Winter Haven Hospital Cardiac Catheterization Laboratory

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Author(s): 

Donald Whatley, RN, CCRN, Cardiac Catheterization Laboratory Manager, Winter Haven Hospital, Bostick Heart Center, Winter Haven, Florida

Tell us about your cath lab.

Winter Haven Hospital is a 527-bed facility located in central Florida. We are the only Magnet-accredited hospital in Polk County. We currently have three labs utilized for coronary, peripheral, and electrophysiology (EP) procedures. In addition to serving the local community, we conduct a number of training courses for physicians, including a hands-on radial course, laser atherectomy, rotational atherectomy and orbital atherectomy. We also participate in a number of clinical trials.

Our department consists of 26 total staff members, with an average of six years of experience in cardiac catheterization. Among them are eight registered nurses (RNs); all are eligible to have their critical care registered nurse (CCRN) certification. Four of our RNs have bachelor of science in nursing (BSN)-level educations. We have 12 technologists of varying backgrounds, including radiology, respiratory, and cardiovascular, 100% of whom are registered cardiovascular invasive specialist (RCIS)-certified. The additional six staff members are support staff: our secretary, financial coding analyst, licensed practical nurse (LPN), transporter, and tech assistants. This staff works among three procedure rooms and one three-bay holding area.

What procedures are performed in your cath lab?  

We are a fully invasive cardiac catheterization lab, capable of performing essentially all procedures, with the exception of transcatheter aortic valve replacement (TAVR); however, there are plans to incorporate TAVR in the near future. We perform approximately 80 procedures per week. Since 2008, we have transitioned to a “radial-first” mentality and now perform approximately 75% of our coronary procedures via the radial approach. We perform the following procedures:

  • Invasive cardiac procedures:  Left and right heart catheterization, percutaneous coronary intervention (PCI) including Impella (Abiomed)-supported procedures and chronic total occlusions (CTOs), rotational and orbital atherectomy, laser atherectomy, AngioJet thrombectomy, aortic balloon valvuloplasty, pericardiocentesis, and intra-aortic balloon pump.  
  • Rhythm therapy procedures:  Bi-ventricular automatic internal cardiac defibrillators (AICDs), pacemaker and loop recorder devices. We also have a budding EP program in which we perform EP studies and atrioventricular  node/atrial flutter ablations.
  • Non-invasive cardiac procedures:  Transesophageal echocardiogram, tilt table testing, cardioversions and non-invasive programmed stimulation procedures.
  • Peripheral procedures: Abdominal angiography, peripheral digital subtraction angiography, percutaneous transluminal angioplasty of the peripheral vessels utilizing laser, orbital and rotational atherectomy, and including lesions considered to be CTOs, critical limb ischemia, limb salvage procedures, carotid angiography and stenting, and inferior vena cava filter insertions/removals.

Can you share more about your planning for TAVR procedures?

We are currently budgeted for a new hybrid procedure room to facilitate the performance of TAVR as well as other structural heart procedures, aortic endografts, etc. Construction should begin in early 2013.

Does your cath lab perform primary angioplasty without surgical backup on site? 

Winter Haven Hospital has cardiovascular surgeons on call at all times, providing our facility with full surgical backup. We also serve as an emergency backup site for a few nearby facilities without surgical backup.

What percentage of your diagnostic caths is normal?

Over half of our diagnostic procedures yield positive results that may warrant some form of revascularization therapy (PCI or bypass). Our lab practice is largely evidence-based; therefore, we utilize a good deal of intravascular ultrasound (IVUS, Boston Scientific and Volcano) and fractional flow reserve (FFR) (Volcano, Inc.), particularly with intermediate angiographic lesions. We also try to utilize a heart team approach when choosing a revascularization strategy in complex anatomy.

Winter Haven has a strong radial access program. Can you tell us more?

We have a total of seven cathing physicians that work in our lab, four of whom are interventionalists. Six are competent in and regularly utilize the radial artery access site.  Zaheed Tai, DO, is the course director for our Terumo transradial course, conducted on a monthly basis. This is a “hands on” training course for physicians seeking initial or additional training in transradial procedures. Our facility is also featured regularly in Cath Lab Digest in a column presenting transradial catheterization cases (Ask the Transradial Expert, with Dr. Tai and Orlando Marrero, RCIS).

Who manages your cath lab? 

Donald Whatley, RN, CCRN is our acting manager. He oversees the day-to-day operation of the department in addition to balancing the administrative duties that come with the job. Danny Lopez, registered respiratory therapist (RRT), RCIS, is second in command and is in charge of the daily room scheduling for staff members, as well as the flow and efficiency of the department.

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

We have a very eager and ambitious staff that is in the process of achieving 100% cross training. Currently, only RNs are able to administer medications. Technologists have the primary responsibility of scrubbing, but most of our RNs are currently in the training stages of scrubbing procedures. Both RNs and techs are capable of monitoring all procedures, as well as being well-versed on all of the support equipment we use.

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

An RT is not required as long as a physician is present in the room during fluoroscopic procedures. However, we do have four RTs on staff and available.

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? 

All staff members are capable of positioning the II, panning the table, and changing angles. However, only physicians and RTs may step on the fluoro pedal to produce images.

How does your cath lab handle radiation protection for the physicians and staff?

All staff is encouraged to practice the time, distance, and shielding method for radiation safety. In addition, we also do monthly film badge monitoring to check radiation levels for each staff member and physician.

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

As a lab, we constantly embrace the latest technology and products. Some of our new equipment utilized on a regular basis includes: the Impella left ventricular assist device, FFR, IVUS, the Stealth 360° Orbital PAD system (CSI), ClearWay OTW Local Therapeutic Infusion catheter (Atrium Medical), and Wildcat CTO catheter (Avinger). We are often one of the first sites chosen for product launches for many different companies. For example, we were one of the initial sites chosen for the  Coyote peripheral balloon (Boston Scientific), Emerge coronary balloon (Boston Scientific), Promus Element drug-eluting stent (DES) (Boston Scientific), Resolute DES (Medtronic), GuideLiner catheter (Vascular Solutions), and AngioSculpt scoring balloon catheter (AngioScore), among others.

 

How does your lab communicate information to staff and physicians to stay organized and on top of change?

We have staff meetings on a monthly basis, as well as a weekly cath conference for physicians which all staff members are encouraged to attend. We also send several staff members to various conferences throughout the year to keep up with recent trends.

How is coding and coding education handled in your lab? 

We recently hired a financial coding analyst to achieve optimal charge capture.

Who pulls the sheaths post procedure, both post intervention and diagnostic? 

Due to our radial-first approach, most sheaths are pulled on the table by the scrub tech using a TR Band (Terumo) immediately after the procedure, regardless whether it is diagnostic or PCI. On the occasions in which we use the femoral approach, diagnostic sheaths are pulled in the holding area when a closure device is not utilized. Interventional sheaths are pulled in the Cardiac Intensive Care Unit (CICU) by CICU nurses at the appropriate time. Staff members in both the cath lab and CICU are trained in sheath pulls and site maintenance, and are signed off as competent after ten successful pulls under experienced supervision.  

Where are patients prepped and recovered (post sheath removal)? 

Outpatients are prepped in our Ambulatory Care Unit and return there following diagnostic procedures. Inpatients are prepped throughout the hospital, depending on where they are prior to cath. Since the majority of our cases are performed via the radial approach, hemostasis is achieved in the lab by the scrub tech. Our closure devices of choice are the Perclose (Abbott) and Angio-Seal (St. Jude Medical) for our femoral cases.


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