Wake Forest University Baptist Medical Center


Sunny Koshy BS, RT(R)(CT)(CV)(CI)(ARRT), CCT, RCIS
Cardiovascular Specialist
Winston-Salem, North Carolina

What is the size of your cath lab facility and number of staff members?

We have five suites with a total of 44 staff members, including technical and nursing staff, support personnel, and students. We only have two credentials in our lab: ARRT-registered radiologic technologist and registered nurse. We have staff members with varied years of experience, ranging from 2 to 30.

What type of procedures are performed at your facility?

We perform diagnostic right and left heart catheterizations, percutaneous coronary interventions, pediatric diagnostic catheterizations, pediatric interventions, PFO/ASD closures, alcohol ablations, coil embolizations, valvuloplasties, aorto-femoral runoffs, aortograms, renal angiograms, etc. We perform approximately 100 procedures per week. We do not perform peripheral interventions at this time but are capable of performing these procedures. Due to referring physician preference, these procedures are currently done by vascular surgeons and interventional radiologists. Electrophysiology is a separate, dedicated department under cardiology diagnostic services.

Does your cath lab perform primary angioplasty with/without surgical backup?

Cardiac surgery is present on site and is available 24 hours a day. Scheduling is on an as-needed basis.

What procedures do you perform on an outpatient basis?

We perform only diagnostic right and left heart catheterizations on an outpatient basis.

What percentage of your patients is female?

Thirty-five to forty percent of our population is female.

What percentage of your diagnostic cath patients go on to have an interventional procedure?

Approximately 75% of diagnostic cath patients go on to have interventional procedures.

Who manages your cath lab?

Our cath lab is managed by D. Page, RT(R)(CV)(ARRT). We also have an assistant nurse manager and an assistant clinical manager.

Do you have cross training? Who scrubs, who circulates and who monitors?

Yes. Our staff is cross-trained to perform all functions except administration of drugs. Only registered nurses are allowed to administer drugs at this time, due to hospital policies.

Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab?

Yes. ARRT-registered radiologic technologists have to be present in the room for all fluoroscopic procedures.

Which personnel can operate the x-ray equipment (position the II, pan the table, change angles, step on the fluoro pedal) in your cath lab?

Only physicians and ARRT-registered radiologic technologists are allowed to operate x-ray equipment.

Does your lab have a clinical ladder?

We do not have a clinical ladder at this time, but we foresee it in the near future. Management has been charged with the task of its creation and implementation.

What are some of the new equipment, devices and products introduced at your lab lately?

New devices that we have utilized include:

Cypher stent (Cordis Corporation, Miami Lakes, FL);

Taxus stent (Boston Scientific, Maple Grove, MN);

Multi-Link Vision stent (Guidant Corporation, Santa Clara, CA);

FilterWire Ex Embolic Protection System (Boston Scientific, Maple Grove, MN);

Duett Pro sealing device (Vascular Solutions, Minneapolis, MN)

Voyager Balloon (Guidant Corporation, Santa Clara, CA);

Pilot Guide Wire (Guidant)

Acist Contrast Management System (Acist Medical, a Bracco Company, Eden Prairie, MN).

Is your cath lab filmless?

Yes. We utilize the Heartlab Encompass system for archiving (Westerly, RI). All rooms are connected to Encompass system. Images from cases are transferred automatically to the system. Images can be accessed hospital-wide as well as from remote locations. It has also made retrieval of previous examinations easier and faster.

How does your lab handle hemostasis?

We utilize a good mix of vascular closure devices and manual pressure for hemostasis. Diagnostic cath patients have their sheath removed by holding room staff. Post intervention patients have their sheath removed by nursing unit staff.

The hemostasis devices we utilize include:

Angio-Seal (St. Jude Medical, Minnetonka, MN);

Perclose® (Abbott Vascular Devices, Redwood City, CA);

VasoSeal® (Datascope Corporation, Mahwah, NJ);

Duett Pro.

Does your lab have a hematoma management policy?

Yes, all hematomas are marked and physicians are notified. Physicians do the follow up. The hospital has nurse data coordinators who track post procedure outcomes on a Lumedx Apollo database (Oakland, CA).

How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies?

Inventory is managed by a dedicated clinical inventory coordinator, T. Fulwood. She also orders our equipment and supplies. Each product in our inventory is stamped with a barcode sticker. Once a product is used, copy of the barcode stickers are sent back to inventory coordinator. The system that we utilize is called PeopleSoft (Pleasanton, CA). Orders are placed by the inventory coordinator depending on need. It has to be approved by the manager of the department, and then the purchasing manager of the hospital places the order for the new products.

How is coding and coding education handled in your lab?

Our manager is trained in all aspects of coding. Communication is handled with the billing department through physician procedure forms.

Has your cath lab recently expanded in size and patient volume, or will it be doing so in the near future?

We recently moved into our new area, which opened in May 2000 and is part of Brenner’s Children Hospital. We occupy the 4th floor along with neurology unit and epilepsy unit. The majority of the floors are occupied by pediatric rooms. Other floors include operating rooms, the respiratory department, etc. Our new location has also resulted in faster patient transfer time from key departments like the emergency department and coronary care unit. As a result, we do not anticipate a need to increase in size for some time. We have budgeted for a moderate patient volume increase this year.

Is your lab involved in clinical research?

Yes. We have a dedicated interventional cardiology research team with four full-time staff members. All five of our interventional cardiologists take part in research. Some of the research studies we’ve been involved with are the PROXIMAL study, TAXUS IV, V (ISR) studies, ENDEAVOR III, PRIDE and several drug studies.

Research staff member credentials include two individuals with bachelor’s degrees, one LPN and an ARRT-registered radiologic technologist who is also a Certified Clinical Research Coordinator (CCRC).

Does your lab perform elective cardiac interventions?

Yes, we perform elective cardiac interventions.

Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery?

Over the past year we had an 0.2% incidence of complications requiring emergent cardiac surgery.

What measures has your cath lab implemented in order to cut or contain costs?

We order supplies on consignment, negotiate prices of equipment and also take advantage of bulk buys. Hospital administrators and physicians meet on a quarterly basis with the vendors to review contracts and usage.

What type of quality control/quality assurance measures are practiced in your cath lab?

We evaluate effectiveness of conscious sedation and compliance by physicians for conscious sedation documentation. We also monitor documentation of LMP for radiation safety and also monitor procedures with greater than 40 minutes of fluoro time.

How does your cath lab compete for patients? Has your institution formed an alliance with others in the area?

We compete for patients through marketing, emphasizing our comprehensive cardiovascular services, and by fostering generative relationships with referring providers. For example, we provide educational programs and resources, or provide added value with our Cardiovascular Access Network (CVAN). This network allows high-speed secure transmission of cath lab images for consultation with physicians and managed care contracting. Our Cardiovascular Access Network was created by the hospital. We utilize software provided by Heartlab and the required hardware is developed by the hospital. This system is also HIPAA-compliant.

How are new employees oriented and trained at your facility?

All employees are assigned a preceptor and undergo orientation for 90 days. They are also given inservices on new equipment before they are introduced in the lab. Staff members have to be registered nurses or ARRT-registered radiologic technologists.

What type of continuing education opportunities are provided to staff members?

Opportunities are provided during in-service education. We also send our staff to cardiovascular-related conferences on a funds-available basis.

How do you handle vendor visits to your lab?

Vendor visits are scheduled in advance. Competing vendors are not allowed on the same day. Vendors are required to check in with materials management and obtain an access badge. They are allowed in patient care areas only if a new product is being utilized. Otherwise, they are limited to non-patient care areas.

How is staff competency evaluated?

We are currently revamping our competency process. Peer review process is a new process which has provided us with a mechanism for staff to be evaluated by their peers. This was implemented to increase accountability to each other.

How does your lab handle call time for staff members?

Staff members are on call once a week and once every six weekends. One RN and one RT are required to be each call team. Other staff members might be either/or. We do not have flextime. We have both eight-hour and ten-hour shifts.

What trends do you see emerging in the practice of invasive cardiology?

Drug-eluting stents will play an important role in invasive cardiology. Flat panel technology will revolutionize the imaging process and cardiovascular MRI will play an important role in the future.

Has your lab has undergone a JCAHO inspection in the past three years?

Yes. We were reaccredited with commendation. Our institution is also a magnet-recognized facility for nursing excellence and was the first in the Carolinas to be awarded this prestigious recognition.

Where is your cath lab located in relation to the OR department, ER, and radiology departments?

We are located five floors above the ER and four floors above the OR. If possible, we would have preferred to be next to the ER.

Please tell readers what you consider unique or innovative about your cath lab and its staff.

Our lab serves as a training lab for our cardiology fellows, cardiovascular technology students from different institutions, and our own cardiovascular technology school. The school currently has 2 students. We have been involved in educating students since September 2000. The program is one year in length and includes didactic as well as clinical components in cardiac catheterization and interventional radiology. The school, located in the cardiac cath lab department, is managed by a dedicated clinical instructor who does the majority of the didactic instruction. Both registered nurses and ARRT-registered radiologic technologists teach classes as needed. Students rotate through clinical areas and are supervised by staff.

Is there a problem or challenge your lab has faced?

The biggest challenge that we have faced in this lab is staffing. We addressed this by implementing creative methods to improve staff morale, including the Fish philosophy [from the book Fish! A Remarkable Way to Boost Morale and Improve Results, S. Lundin, H. Paul, and J Christensen] and a peer review process of performance evaluation. We’ve also increased staff participation in management by the establishment of interview committee, encouraging staff participation in establishment of operating plan, and starting a CVT school.

What’s special about your city or general regional area in comparison to the rest of the U.S.?

Winston Salem is a city where you can experience the 18th century, explore your artistic side or enjoy challenging greens at our golf courses. Old Salem in Winston Salem was one of the earliest planned communities in the U.S. Winston Salem was recently rated as the 12th best city in America to live and work. It also houses the internationally renowned Wake Forest University School of Medicine and nationally renowned Wake Forest University. This helps us to attract some of the best faculty and staff to our institution, and they in turn impact our lab in a positive way.

Questions from the Society of Invasive Cardiovascular Professionals (SICP):

1. Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? Do staff receive an incentive bonus or raise upon passing the exam?

All clinical staff are encouraged to take the registered cardiovascular invasive specialist (RCIS) examination. However, this is not mandatory at this time. Staff is reimbursed the cost of taking the exam if they are successful. All registered radiologic technologists in the department will be required to successfully complete the cardiac interventional (CI) exam offered by the ARRT within two years.

2. Are your clinical and/or managerial team members involved with any professional organizations that support the invasive cardiology service line?

Staff members are encouraged to join professional societies. Most of our radiologic technologists are members of the ASRT. The author is an active member of the Society of Invasive Cardiovascular Professionals (SICP), Alliance of Cardiovascular Professionals (ACVP), American Society of Radiologic Technologists (ASRT), and North Carolina Society of Radiologic Technologists (NCSRT).

Sunny Koshy can be contacted at SKoshy@wfubmc.edu

Staff not pictured in this article:

A. Murray, K. Wells RN, S. Nieves RN, S. Groen RT(R), P. Priddy RN, K. McRoy RN, and B. Rowe RN.


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