Yale-New Haven Hospital
- Volume 20 - Issue 11 - November 2012
- Posted on: 11/6/12
- 0 Comments
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Founded in 1826, Yale-New Haven Hospital (YNHH) is a non-profit, 1,008-bed tertiary care hospital that receives national and international referrals. The hospital includes Smilow Cancer Hospital at Yale-New Haven, Yale-New Haven Children’s Hospital and Yale-New Haven Psychiatric Hospital. An article released by U.S. News & World Report, “America’s Best Hospitals”, ranked YNHH among the best hospitals in the United States. The hospital is accredited by The Joint Commission and in May of 2011, the American Nurses Credentialing Center granted YNHH Magnet Recognition, which signifies nursing excellence and recognized collaboration between nurses and members of the healthcare team. Only six percent of American hospitals have received this honor. YNHH prides itself on its mission, which focuses on community service, teaching, research and patient care. In addition to providing quality medical care to patients and families, YNHH is the second largest employer in the New Haven area, relying on the skills of nearly 9,000 employees and a combined medical staff of about 3,600 university and community physicians practicing in more than 100 specialties.
YNHH’s Heart and Vascular Center offers a wide range of procedures for cardiovascular conditions, and is consistently ranked among the best in the nation by U.S. News & World Report. Services include diagnostic and interventional procedures, cardiothoracic surgery, electrophysiology and interventional radiology. The Heart and Vascular Center (HVC) includes a women’s heart program, a non-invasive cardiovascular imaging department, a cardiac rehabilitation program and five inpatient units:
- A 14-bed cardiac intensive care unit;
- An 18-bed cardiothoracic intensive care unit;
- A 14-bed cardiac surgical step-down unit;
- A 26-bed medical cardiology unit, and;
- A 25-bed progressive care unit.
The Heart and Vascular Center also includes six interventional labs, three state-of-the-art electrophysiology (EP) labs, including two biplane fluoroscopy rooms, and pre-procedure and post-procedure recovery areas. Five operating room suites are designated for cardiac use.
The cardiac cath lab features five procedure rooms, including a Philips pediatric hybrid lab and a Siemens Artis Zeego Multiaxis Robotic System.
HVC procedural area staff, composed of the cath lab, EP lab and interventional radiology (IR) lab, includes:
- Six advanced practice registered nurses (APRNs);
- Two physician assistants (PAs);
- A service line educator;
- A scrub educator;
- 67 registered nurses (RNs);
- 39 radiologic technologists (RT[R]s);
- Three clinical service associates (CSAs), who schedule all out-patient cardiac cath, EP and IR procedures;
- Two patient care associates (PCAs);
- Two operating room aides (ORAs);
- An inventory control lead – a shared position between the Cath/EP/IR labs.
Staff experience ranges from one to 40 years. There are 24 attending physicians, three interventional fellows and a number of cardiology fellows who rotate monthly in the cath lab. A practice manager, who is an RN, oversees the entire procedural area. One manager is in charge of clinical operations for the cath and EP labs, and another manager heads IR operations. An assistant patient services manager is in charge of nursing for the entire HVC procedural area. As one of the nation’s leading providers of heart and vascular health services, YNHH’s Heart and Vascular Center is a national pioneer in developing new heart treatments and therapies. Our reputation is one of the reasons that we are consistently ranked among the top 100 hospitals for cardiac care in the nation.
What procedures are performed in your cath lab?
The HVC cath lab performs diagnostic and interventional procedures. In 2011, the cath lab performed:
- 3,166 cardiac caths (adult and pediatric) procedures;
- 1,360 angioplasties;
- 268 cardiac biopsies;
- 337 peripheral vascular procedures (diagnostic/therapeutic procedures for iliac, superficial femoral, renal, carotid and subclavian artery disease);
- nine percutaneous valve replacements.
Intra-aortic balloon pumps (IABP), transvenous temporary pacemakers and pericardial taps are also performed. Pressure wires are used in performing fractional flow reserve (FFR), and intravascular ultrasound (IVUS), thrombectomy, and rotational artherectomy are also utilized by the HVC.
What percentage of your patients is female?
Thirty-five percent of the patients are female.
What percentage of your diagnostic caths is normal?
Twenty-four percent of the diagnostic cardiac caths are normal, meaning less than a 10 percent occlusion.
Do any of your physicians regularly gain access via the radial artery?
Yes, physicians regularly gain radial access. Approximately 40 percent of the cases are performed via radial access.
Who manages your cath lab?
The cath lab is run by Senior Manager Marcie Scalia, RT(R), BS. Marcie oversees the daily operations and budgets of both the cardiac cath and electrophysiology labs. Michael Cleman, MD, and Craig Thompson, MD, serve as medical directors of the adult cath labs. Jeremy Asnes, MD, is the director of the pediatric cath lab.
Do you have cross-training? Who scrubs, who circulates and who monitors?
Yes, we have cross-training in our labs. Cardiac fellows scrub in and specially scrub trained technologists and nurses assist in procedures as well. Both RNs and technologists circulate. RTs obtain and set up equipment, and RNs monitor and document the procedures. Some technologists are trained to assist with documentation. An RN reviews all documentation prior to the conclusion of the case.
Does an RT have to be present in the room for all fluoroscopic procedures in your cath lab?
In all of our cath labs, an RT is present during fluoroscopic procedures.
Which personnel can operate the x-ray equipment (position the II, pan the table, change angles, step on fluoro pedal) in your cath lab?
The RTs in the cath lab position the II, pan the table, change angles and step on the fluoro pedal. At times, physicians control the fluoro pedal during lengthy procedures, such as chronic total occlusions (CTOs), so that the technologist can get any additional equipment needed for the procedure.
How does your cath lab handle radiation protection for the physicians and staff?
All staff hired to work in the cath lab are required to take a radiation safety class and pass a written test during their orientation. Annually, technologists and nursing staff must complete an on-line training course on radiation protection. Periodic lectures are also given to the cath lab staff by the YNHH radiation safety officer. All staff working in the cath labs wear radiation safety badges, which are exchanged monthly and monitored by the YNHH radiation safety department. Monthly dosimetry reports are posted for all to view.
What are some of the new equipment, devices and products introduced at your lab lately?
In March 2011, YNHH installed two new Siemens Artis Zee ceiling-mounted cath labs. In April 2012, a new Siemens Zeego system was installed. The Zeego incorporates an industrial robot that allows the operator to move the C-arm to almost any position around the patient.
New products include: Medtronic’s Resolute Integrity drug-eluting coronary stents, Abbott’s Prime drug-eluting Xience coronary stents, Bard’s Ultraverse .014 peripheral balloons, and Abbott’s Armada .014 and .035 peripheral balloons. New devices include: Gore’s Flow Reversal System for carotid stenting and the EKOS (EkoSonic Endovascular System), used for clot-busting in peripheral and pulmonary arteries. The HVC is currently trialing the Exoseal, a vascular closure device by Cordis, and is also implanting Edwards’ Sapien, and Medtronic’s Melody and CoreValve percutaneous valves.
How does your lab communicate information to staff and physicians to stay organized and on top of change?
HVC Procedures has daily morning safety huddles where managers inform and review the schedule, staffing and important updates with all staff. In addition to huddle, there are monthly staff meetings and daily email communications. The service line educator keeps staff informed of any new hospital-wide or HVC policy changes, and new equipment trials. Physicians, leadership, managers and staff attend a monthly HVC Operations Council meeting to review, plan and implement current and future initiatives.
How is coding and coding education handled in your lab?
The cath lab manager is responsible for ensuring that there are appropriate billing codes for procedures. The coding department at Yale-New Haven Hospital notifies the section manager of CPT code changes and revisions on a regular basis. Technologists use a detailed encounter form that they helped design to check off procedures performed in the cath labs so that they can be billed appropriately. A dedicated coding expert reviews each encounter form prior to billing to ensure accuracy.
Who pulls the sheaths post procedure, both post intervention and diagnostic?
A physician, either an attending or a fellow, pulls the sheaths in the cath lab. On the recovery or patient care units, a cardiology fellow pulls the sheaths.
Where are patients prepped and recovered (post sheath removal)?
Inpatients are usually prepped and recovered on their units by their nurses. Outpatients are prepped in the HVC pre-procedure area.
After the procedures, patients who are being discharged or who are awaiting for an admission bed are transported to the HVC post-procedure recovery area. Any patient who has received an intervention is admitted to a telemetry unit overnight. Both the pre- and post-procedure areas are shared with EP and IR patients, and are run by HVC procedural nurses and PCAs.