Spotlight Interview: Metro Health Hospital Cardiovascular Lab

Can you give us an overview of your cath lab?

[4]The Metro Health Hospital Cardiovascular Laboratory consists of two cardiovascular labs and one interventional lab, with a 12-bed pre/post care area. The staffing matrix consists of thirteen registered nurses (RNs) and seven registered radiology technologists (RT[R]s) in both full and part-time roles. Staff longevity ranges from one to twenty-plus years, with almost 50% of staff serving five years or more.

What procedures are performed in your cath lab? 

We perform:

• Left and right heart catheterization
• Emergent coronary angioplasty
• Peripheral vascular angiography and interventions
• Devices including loop recorders, pacemakers, implantable cardioverter-defibrillator (ICD)s, and bi-ventricular ICDs
• Myocardial biopsy and pericardiocentesis

We average from twelve to fifteen procedures a day.

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

Yes, we perform primary coronary angioplasty without surgical backup. We were the first hospital in the state of Michigan to go live with this program seven years ago.

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

No. In fact, in the seven years that we have been doing primary percutaneous coronary intervention for ST-elevation myocardial infarctions (STEMIs), we have never needed emergent cardiac surgery due to complications from an intervention.

What percentage of your patients is female? 

Forty-three percent (43%) of our patients are female.

How many of your diagnostic cath patients go on to have an interventional procedure and how many diagnostic caths are normal?

The approximate percentage of diagnostic catheterizations that evolve into an intervention is between 27 and 30%. The percentage of diagnostic catheterizations that are normal is between 10 and 15%.

Do any of your physicians regularly gain access via the radial artery?

We have 6 physicians (out of 10) that perform radial access on a consistent basis.

Who manages your cath lab?

Philip Pascucci, RN, our cardiovascular lab manager, has 8 years of cardiovascular experience and 12 years of emergency room experience.

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

The staff is cross-trained to the fullest extent by licensure. RNs perform in all roles in the cardiovascular lab and pre/post care area. The RT(R)s perform in all roles except the nursing role.

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

Yes, though our physicians primarily operate the equipment, an RT is present. In the cardiovascular lab, only the physician pans the table, manipulates the flat detector and controls fluoroscopy. 

How does your cath lab handle radiation protection for the physicians and staff that are in the lab day after day?

[5]An RT(R) assists in the handling of radiation protection. This includes annual lead checks, monitoring of radiation badges, and radiation safety education upon orientation.

Our staff rotates positions, so on a weekly basis, staff is in the pre/post care area some days and in the actual labs on other days. We also rotate in the lab itself, so staff is out of the field of radiation while recording the case.

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

We have started an extensive peripheral vascular program, and are very busy with chronic total occlusions and below-the-knee intervention as part of our amputation prevention program. Some of our new equipment includes the excimer laser (Spectranetics), the Crosser total occlusion crossing device, the Diamondback 360˚ atherectomy device (Cardiovascular Systems Inc.), and optical coherence tomography (OCT) along with standard intravascular ultrasound (IVUS). Due to our physicians’ expertise in this field, we have many vendors that bring in new, FDA-approved equipment for our physicians to trial.

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

[6]This is a very challenging area. We are at the size where we are big enough that you can’t just catch people in the hall, but not big enough to keep the labs running while you have staff meetings. We do much of our communication by e-mail.

As a manager, I spend about 30% of my time in the labs working, so I see many of our needs firsthand.

We have monthly lunch meetings; providing dessert assures attendance. I will also round (one-on-one talk with each person on staff) at least quarterly so they can share their views on what is working, what is not, and equipment needs.

Hospital events are posted on a communication board located in our locker room.

We have an information technology expert (a CVL nurse with computer training) that can manipulate our electronic medical record to meet our needs. She can communicate any changes to the staff directly and be there for staff support.

We do not have an educator dedicated to our area, so we have two experienced staff members that help coordinate education. We have just started a 2-tier education system, dividing up cardiac and peripheral training. These educators keep our information standardized and current, and since they work in the labs, are easily accessible.

How is coding and coding education handled in your lab?

Staff inputs charges when the procedure is performed. Staff is educated on changes to codes and billing via our (cardiology-specific) billing coordinator. A supply coordinator and then the billing coordinator review charges. The billing coordinator has the luxury of seeing the physician’s dictation to assure all charges are captured; she then releases it to the hospital coders.

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

Our 12-bay pre/post op holding area has private bays. Prep and recovery is done by the nursing staff. Sheaths are pulled in the recovery area 90 % of the time. If the patient is going to receive a vascular closure device (approximately 10% of our patients), they are placed in the procedure labs. Outpatients recover in the pre/post area. Inpatients are placed in their bed from the floor and returned to their inpatient area 30 minutes after hemostasis. Nursing staff accompanies any critical patient or patients that have experienced bleeding or have a hematoma to make sure the floor staff views the site and therefore are quicker to notice changes.

What is your lab’s hematoma management policy?

Most hematomas appear in the lab or within the first 30 minutes of the pull. They are manually compressed and a physician is notified. Physicians may choose to order an ultrasound of the area. On rare occasion, a patient may be moved back into a lab for angiography if retroperitoneal bleeding is suspected. Depending on the severity, the physician may choose longer bedrest times, serial labs, and/or an overnight stay.

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

Inventory is managed on two levels. We have a hospital materials management system that supplies us with all of our daily use items. Staff will note needs of which they are aware on an inventory board. These items can also be ordered throughout the day, as they are kept on site.

We also have a supply coordinator that splits her time between inventory management and working in the labs. She is responsible for all special-order items such as catheters, balloons and stents. She keeps a par level and reorders as we use items. Also, she works with the company representatives to handle new products and coordinate replacement of expiring products. She also adds all products to our computer system for billing.

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

We are planning to install a third cardiovascular lab in the near future. This is in response to growth rates of 10% yearly, a surge in peripheral vascular business,  and the addition of three interventional cardiologists. With this expansion, we also will be adding some additional post care beds.

Do you have a hybrid cath lab, or are you planning to build one?

We currently do not have a hybrid lab. We have discussed it with surgery. Most likely, the space would be in the surgical suite. Since we currently do not do open-heart surgery, this project is still in the early stages.

Is your lab involved in clinical research?

Our lab is involved in clinical research. We are primarily involved in electrophysiology and peripheral vascular device trials. The cath lab staff works collaboratively with our institution’s dedicated clinical research coordinators to ensure compliance with research protocol requirements and to support best patient experiences.

Can you share your lab’s average door-to-balloon (D2B) times and some of the ways employees at your facility have worked together to keep D2B times under the mandated 90 minutes?

[7]Our door-to-balloon times have averaged 67 minutes over the last year. Since we are a smaller hospital, everyone is acutely aware of how important their role is in this process. We ask our emergency department (ED) physicians to activate the call team prior to ambulance arrival. We have a chest pain coordinator and committee encompassing all areas from the ED to the floors that help coordinate change to keep our system efficient. Our goal for ECG times for “chest pain” patients is in less than ten minutes. This is an important factor in meeting the 90-minute D2B goal. We anticipate receiving our designation of Chest Pain center - PCI  with the Society of Chest Pain Centers and we are registered with the American Heart Association (AHA)’s Mission: Lifeline. We also belong to the American College of Cardiology National Cardiovascular Database (ACC-NCDR) ACTION Registry, CathPCI Registry and the Blue Cross/Blue Shield of Michigan Cardiovascular Consortium (BMC2).

What other modalities do you use to verify stenosis?

We have IVUS, OCT, and fractional flow reserve (FFR) available to our physicians; we also use the plain old pull back method across some peripheral stenoses. 

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

Communication. We let the physicians and staff know how much products cost and which companies are competitive. Staff gets information on what they charted (charged) versus what was used in the case. This requires a double check by our supply coordinator, but assures accuracy and charge capture. We also educate staff on the cost of dropped or “open and unused” equipment monthly. Inventory volumes are tightly controlled and product that is close to its expiration will be exchanged by the company representatives for new product. We also ask our physicians and sales representatives to do a product trial and determine estimated usage before we will stock it.

Our hospital has also joined an alliance to secure better pricing on all of our standard supplies.

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

[8]We belong to several registries, including the ACC NCDR ACTION, ICD, and CathPCI registries, the Michigan Blue Cross/Blue Shield consortium, and AHA’s Mission: Lifeline. We also belong to the Leapfrog Group. This data is pored over by our quality department and feedback comes to the quality committee (made up of physicians and management) monthly. The department also has a yearly quality plan that rolls down to the staff. Many suggestions are made by staff during staff meetings or during one-on-one rounding; these are enacted in a PDSA (plan/do/study/act) format, because we are still small enough to make changes quickly.

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

We have eleven neighborhood outreach centers that refer back to our cardiology group. We have four cardiology locations to make it easier for patients to visit their physician. We are located in the southern part of Grand Rapids, so geographically, we attract certain patients as a result. Our peripheral program has a renowned physician that speaks at many of the national conferences, so we also get international referrals to our amputation prevention program. Our alliances include a location to train our staff for PCI and a location to which we send our patients that need open-heart surgery.

How are new employees oriented and trained at your facility?

We have all licensed staff, either registered radiology technologist or registered nurse. Most of our RN staff comes from internal transfers from the ED, ICU or telemetry. Staff is cross-trained to operate to the fullest extent of their license. Education was originally handled by the cath lab manager, but has recently been assigned to two senior staff members. We have divided our education into two phases: coronary and peripheral. Coronary training includes pre/post area training, electrophysiology training, and scrub/circ/record basic cases, and lasts three months. Peripheral training starts at six months and lasts approximately 6-8 weeks. To scrub PCIs, we have to send our staff to an open-heart facility for education (state mandated). We always warn people interested in working in our cath lab that it will take at least a year to be comfortable.

What continuing education opportunities are provided to staff?

Our physicians are very active with the staff and arrange for company representatives to come in and educate us on their equipment. Other facilities offer several training sessions that we also send our staff to attend. We have instituted a staff education day, where staff comes in on a Saturday to go over low-use, high-risk equipment and cover any new equipment. One of our physicians has started a journal club for the staff. As with most institutions, our travel budgets continue to decline, so we are finding more creative ways to educate. We receive several professional journals, and the internet, of course, provides a great deal of quality information.

How do you handle vendor visits to your lab?

[9]Vendors are a great resource for education. Vendors also want to sell you their product. They do have to register with Reptrax before they can enter our area. We have instituted a sign-in sheet for vendors, so they sign in and then have to go to the lobby or cafeteria. The physician is advised on which representatives are present. If they need that vendor to be in a case, we will page them. If the physician would like one-on-one time with a vendor, then they can meet between cases in the reading rooms. We do have course days that are sponsored by vendors and they bring in people from other cities, states, or even countries to observe our physicians. We hold a conference room open on these days to accommodate our guests. We have recently purchased a video system so we can transmit cases to our conference rooms, webcast, or give live presentations at conferences. It has full audio capabilities with two-way communication so the visiting physicians can ask questions and actually see the cases better.

How is staff competency evaluated?

All competencies are on a checklist, and are verified by the preceptor and physician.

Does your lab have a clinical ladder?

Not at this time.

How does your lab handle call time for staff members?

Call is evenly distributed to all members of the team. Each member is assigned one day per week and every 5th weekend (Friday night through Monday morning) Trading call is permitted as long as the team has one RN (for conscious sedation). We have a four-person call team on weekdays to handle late cases that may still have a patient in the holding area and a three-person team on the weekends.

Within what time period are call team members expected to arrive to the lab after being paged?

Both the interventional cardiologist and the call team are expected to be in the lab within 30 minutes of being paged.

Do you have flextime or multiple shifts?

We are “open” 7 am to 5 pm, but anyone who works in a lab knows that nothing goes as planned and sick people don’t wear watches. We flex staff from 6:30 am until 6 pm, and then it is the responsibility of the call members to finish any late cases and recovery. We do have some part-time staff that flex their hours if we know we will have a late day.

Has your lab recently undergone a national accrediting agency inspection?

We had our HFAP (Healthcare Facilities Accreditation Program) inspection. We are recently had our Society of Chest Pain Center accreditation inspection. My best advice is to not change your practice habits “for inspections.” Set good work habits and practice within the guidelines all of the time. If you see a work around, fix it before it becomes a bad habit. It really doesn’t take any more work to do a job correctly the first time; it takes a ton of work to get people to change after they have been doing it wrong.

Where is your cath lab located in relation to the operating room (OR) and emergency department (ED)?

Our lab is located on the same floor and in between the ED and OR. We are literally 100 feet from the ED and during the day will bypass our ED with STEMI patients.

What trends have you seen in your procedures and/or patient population?

We are experiencing a dramatic increase in peripheral vascular work. Patients are being referred to us from all over Michigan and internationally for our amputation prevention program. Our program has had a 96% success rate in either preventing amputation or decreasing the level of amputation.

What is unique or innovative about your cath lab and staff?   

It is very much a family here. These people work together and play together. They celebrate and suffer loss together. A close-knit team means they will cover each others’ call on short notice and pick each other up when someone stumbles. We have been through several growth spurts and the team always works to get through the long hours and impossible schedules to get to the next staffing level. To get hired, you interview with the manager, a peer team, and then shadow so everyone gets to meet you and everyone helps make the decision.

Is there a problem or challenge your lab has faced?

We have been through several challenges. At one time, we were on call every other day and every other weekend. Currently we are facing longer days due to increasing patient needs. Two things seem to get us through. First is the strong team and second is communication. This communication needs to come from many levels. The manager is on the front lines and should communicate daily, but it helps to have the support of your director/VP or CEO. I like to have the physicians talk with staff. They need to let the staff know that they are aware of the struggle and are working toward solutions. It’s always a compromise; no one gets the best pay for the least amount of work, but if everyone talks it through and understands the others point of view, no one feels cheated.

What’s special about your city or general regional area in comparison to the rest of the U.S.? How does it affect your “cath lab culture”?

We are a 208 bed acute care osteopathic teaching hospital. We are one of three high-quality facilities in the highly competitive Grand Rapids market. There is a group called the Alliance for Health that is made up of business leaders in our community. If you wish to expand your service line or move into new areas of service, it is helpful to have their blessing. We are also a CON (certificate of need) state, which means you also have to demonstrate need to the state. This can present cumbersome hurdles to growth in our area. As an example, our surrounding area has only one open-heart program to service 1,000,000 people, but the CON is very difficult to obtain as it is currently written.

The Society of Invasive Cardiovascular Professionals (SICP) has added two questions to our spotlight:

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

We do not require RCIS certification, our hospital does support continuing education and pays for certification classes, books and exams. There is no increase in pay based on certification, but it would be considered at performance evaluations.

Are your clinical and/or managerial team members involved with any professional organizations that support the invasive cardiology service line, such as the SICP, ACVP, or regional organizations?

Our director is a member of the American College of Cardiovascular Administrators and the Cardiovascular Roundtable.

Philip Pasucci can be contacted at philip.pascucci@metrogr.org [10].