Spotlight Interview: Medical Center of the Rockies & Poudre Valley Hospital

Tell us about your cath labs.

[4]Medical Center of the Rockies (MCR) of Loveland, Colorado, a Level II trauma center, and Poudre Valley Hospital (PVH) of Fort Collins, a Level III trauma center, comprise two hospitals in the Poudre Valley Health System. Both hospitals are magnet facilities and have received numerous additional commendations and awards for management and outstanding level of care, such as the 2008 Malcolm Baldrige National Quality Award and Thomson Reuters 15 Top Health Systems in 2012. Our cardiac cath labs service northern Colorado, western Nebraska, and southern Wyoming, a service area of about 50,000 square miles.

The two hospitals have a total of 417 beds with four cardiac/peripheral cath labs and one biplane electrophysiology room. We also have another room available for future expansion. Our cath lab primarily staffs MCR, but we provide 50 regular hours of staffing for PVH during the week. The call team covers both hospitals. The cath lab is made up of 26 registered nurses (RNs), 3 registered cardiovascular invasive specialists (RCISs), 5 dedicated electrophysiology (EP) staff and 24 non-invasive/pre/post RNs. Currently, 80% of our department has certification in our field. Everyone in the cath lab has certification with the exception of our newest members. Our department has very low staff turnover. We have staff members who have worked here as long as 29 years and as little as 18 months.

What procedures does your lab perform?

[5]Our lab performs left and right heart caths, peripheral angiograms, and carotid angiograms, and we utilize both fractional flow reserve (FFR) and intravascular ultrasound (IVUS) in our diagnostics. We perform percutaneous coronary interventions (PCIs), rotablations, atrial septal defect (ASD) and patent foramen ovale (PFO) closures, chronic total occlusions (CTOs), valvuloplasty, trancatheter aortic valve replacement (TAVR), intra-aortic balloon pumps (IABPs), pericardiocentesis, temporary pacing, and high-risk PCI involving Impella (Abiomed) left ventricular device support.

Our EP lab performs rhythm studies and ablations, including supraventricular tachycardia (SVT) ablations, ventricular tachycardia (v-tach) ablations, atrial fibrillation (a-fib) ablations and high-risk EP procedures involving Impella support. They also implant pacemakers, implantable cardiac defibrillators (ICDs), and bi-ventricular devices. 

Our Pre/Post nurses assist our cardiologists in performing treadmill testing, Lexiscans, transesophageal echocardiograms, dobutamine stress echocardiogram/dobutamine stress nuclear tests, tilt table testing, cardioversions and infusions.

Our procedural volume is:

• Coronary procedures: 28/week
• Peripheral procedures: 4/week
• Electrical procedures: 12/week
• Carotid procedures: <1/week
• PFO/ASD procedures: <1/week

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

Yes. We have labs in two different hospitals. Patients at PVH who need emergency cardiac surgery are transported with IABP support via ambulance to MCR, a 20- to 30-minute ride, due to the fact that PVH does not have an open-heart operating room.

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

In the last year, we had one complication that has required emergency cardiac surgery. Our facility has remained under the American College of Cardiology (ACC) average of 0.3% in cath lab-related complications requiring emergency cardiac surgery.

What percentage of your patients is female?

Forty-one percent (41%), including cardiovascular procedures, as documented in our charting system.

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

Diagnostic-to-interventional procedures are 41%, and normal diagnostic caths are 53%.

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

Yes, three out of seven of our interventional cardiologists primarily use radial access. We have several others who use both femoral and radial access, based on what is best for the patient at that time.

Who manages your cath lab?

Carol Mackes, BSN, NE-BC.

Do you have cross training? 

Our cath lab consists of primarily RNs and RCIS-certified techs. RNs are responsible for performing in the scrub, circulator and monitor roles, while our techs are responsible for the scrub and monitor roles. The cath lab staff is able to assist our Pre/Post unit and EP Lab as needed when staffing issues arise.

Who documents medication administration during the case?

The staff member in the monitoring role documents all of the medications administered during the case. If it happens to be a “Code Blue” situation, the monitor person documents all medications that would normally be given during a cath, and the Code Blue recorder documents all of the medication that is normally given during a code.

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

All of our staff can operate the x-ray equipment under the supervision of the physician; however, our physicians are the only ones who step on the fluoro/cine pedal during a case. All staff members in the cath lab are required to successfully complete an annual radiation competency as required by the State of Colorado. Colorado state law does not require an RT to be present.

Are you recording fluoroscopy times/dosages?

We monitor the fluoro dosages on every patient and document them in the medical record. If the specific dosages fall outside of the expected parameters, we have a QA process that documents the over-dosage and notifies both the radiation physicist and the physician so they can monitor the patient for potential adverse effects.

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

[6]Educating staff and physicians is the first and primary way of achieving radiation protection. All of our staff wear radiation badges, lead aprons and adhere to the ALARA (as low as reasonably achievable) principle. We also have moveable leaded glass shields in our rooms for staff to utilize in high dose or long cases. Our scrub staff utilizes collimation and ‘fluoro save’ as much as possible to achieve the lowest radiation scatter possible.

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

The most recent additions to the lab are FFR and the Impella device. Cardiac and peripheral CTO equipment began use in April 2012. The TAVR and valvuloplasty equipment was implemented in May 2012 and cryoablation is slated for November 2012.

Do you have a hybrid cath lab?

[7]Our brand new hybrid lab was completed in May 2012 prior to our first TAVR procedure.

Poudre Valley Health System announced an affiliation with University of Colorado Hospital in Denver earlier this summer. The University of Colorado Hospital in Denver is a Level II trauma facility providing heart transplantation and other advanced cardiac supportive care that will provide our patients with a superior level of continuity of care.  

We converted our largest cath lab into a hybrid lab in preparation for performing transcatheter aortic valve replacement. Dr. Mark Guadagnoli and Dr. Mark Douthit, two of our cardiovascular surgeons, and two of our cardiologists, Dr. Bradley Oldemeyer and Dr. Justin Strote, have overseen the development and success of this program.

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

We have a Pre/Post unit dedicated to the preparation and recovery of patients for most procedures done within the cardiac cath lab. This unit is adjacent to the cath lab for convenience and patient safety.

Patients typically return to the Pre/Post unit for recovery, unless they require transfer to an intensive care unit. Outpatient discharges typically occur within 2-4 hours. Inpatients typically return to their rooms usually within an hour.

Our physicians utilize both vascular closure devices and manual compression, depending upon the specific needs of the patient and the specific situation. We utilize three different closure devices: Starclose (Abbott Vascular), Perclose (Abbott Vascular) and Angio-Seal (St. Jude Medical).

Sheath pulls are done in the cath lab, the Pre/Post unit, our Intermediate Care unit, or the CICU. All staff members in these units must complete a specific competency that demonstrates that they are competent in removing arterial and venous sheaths, and utilizing various hemostatic adjuncts to gain hemostasis. 

What is your lab’s hematoma management policy?

[8]Groin management is part of our yearly competencies. Back-up devices include the Femo-Stop (St. Jude Medical) and the C-clamp. We do not use those devices unless necessary. Our unit assistants are able to help us with sheath pulls when necessary. Patients are ambulated prior to discharge to ensure hemostasis. Regardless of whether manual pressure or a closure device is utilized, if a hematoma develops at the site, immediate manual pressure to the site is applied.

How is inventory managed at your cath lab?

We have a team of three cath lab RNs, under the supervision of the manager, who collaborate with the hospital systems’ purchasing department. The product team handles the daily order entry after all cases and Purchasing completes the order from the different companies. This team works closely with vendors and physicians in acquiring new equipment and setting up contracts with all vendors.

How is coding and coding education handled in your lab?

We have a resource group of staff members that are our “go-to” people for coding questions. The resource group works with a coder who is specifically trained for cath lab coding. The coder will send us resources for FAQs and helpful hints that are shared among the resource group.

Has your lab recently expanded in size and patient volume?

No, but we have a shelled space in our lab for future expansion.

Is your lab involved in clinical research?

Dr. Gary Luckasen has assumed leadership of the Cardiac Research Department. We have a very active research program and have been involved in many studies. PVHS was first to place a platinum stent in a previous study program. 

Can you share your lab’s average door-to-balloon (D2B) times?

[9]Our lab’s average door-to-balloon time is 38 minutes. Our average E2B (EMS-to-balloon time) is 60 minutes. We have achieved low D2B times by utilizing a committee comprised of cardiologists, emergency room (ER) physicians, cath lab staff, nursing supervisors, quality assurance staff, and EMS staff. They work together to eliminate obstacles and continually troubleshoot problems. MCR is registered with the ACC D2B Alliance initiative, as well as the ACC National Cardiovascular Database Registry (NCDR) and ACTION Registry.

The cath lab, in conjunction with the emergency departments at both facilities, has just instituted an evidence-based “Acute MI Protocol.” The goal is to provide a more efficient and standardized treatment process for patients experiencing STEMIs. Either the ER physician or cardiologist can initiate the protocol after assessing the patient. If the patient meets the specific criteria, bivalirudin and a thienopyridine (primarily prasugrel) are administered prior to the patient’s transfer to the cath lab.  

Who transports STEMI patients to the cath lab?

Our STEMI patients are brought directly to the lab from the ED by the ED staff and/or the EMS staff. If a STEMI patient is already in the hospital, the cath lab team transports the patient to the cath lab emergently. We follow the same procedure during off hours.

What do you do when the call team is already busy doing a procedure and a STEMI patient arrives?

If a STEMI patient comes in during call hours and the team is already in a procedure, the house supervisor is notified and the patient is kept in the ED. Our ED staff has been trained in our MI protocol and it would be immediately initiated. If the patient is from an outlying facility, lytics are typically given prior to transferring to our facility. In the meantime, one member of the call team would get our second room prepped and ready to receive the patient. Often, our second MD on call would go to the ED to see the patient.  As soon as the first procedure is completed, one call staff member would take the patient to the appropriate unit for recovery while the remainder of the team starts the second procedure.

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

Our staff is receptive to volunteering to leave work early if not busy. We have had a reverse auctionwith our vendors to decrease product cost to the hospital. RFPs and bulk orders are occasionally placed on frequently used supplies. We are very proactive in contract product negotiations with our vendors. The bulk our equipment in the lab is on consignment instead of being purchased. We reprocess much of our EP equipment to help contain costs. The tips of our interventional wires are sent for metal recycling.

What quality control (QC)/quality assurance (QA) measures are practiced in your lab?

Our lab is involved in many quality control measures. We currently do QA on our equipment, such as Philips, IABP units, and the Hemochron. We also do QA on our charting, hand washing techniques, sterile technique, radiation dosing, lead quality, and nursing quality improvements.

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

[10]Our facilities are in a unique niche area, in that we are considered a regional hub and our services extend out to three states (Northern Colorado, Wyoming and Nebraska). We compete with other hospitals in our area through excellence in patient care. Thomson Reuters named PVHS one of the nation’s top 15 health systems for 2012.  PVH has been a “Top 100 Hospital” for over 5 years, obtained Magnet Hospital status for both facilities, received the Malcolm Baldrige Award in 2011, and has met an Avatar patient satisfaction score of 80.9. We have formed an alliance with Scottsbluff Nebraska and recently with the University Hospital in Denver, Colorado. We are currently developing a relationship with Memorial Hospital in Colorado Springs, Colorado.

How are new employees oriented and trained at your facility? 

New employees go through an interview process that incorporates at least three of our current staff members. Once hired, they are required to go through a week of house-wide training before they actually start orientation on the unit. Once they get through the hospital-wide training, they are paired up with one or two staff members that remain with them throughout their unit-specific orientation process. This process is individually tailored, depending on the needs of the new hire. The average orientation process takes approximately three months. They are required to complete testing and comps that are both house-wide and unit-specific. If a new hire feels that their orientation is not complete and they do not feel comfortable going out on the unit on their own, they can ask for an extension of their orientation.

How many staff members do you have now with less than a year’s experience in the cath lab?

We do not currently have any staff members with less than one year of cath lab experience. Our staff has a varied background, including ICU, ED, telemetry, OR, dialysis and obstetrics. A current Colorado or compact state licensure is required of all our RNs and all cardiovascular technologists are required to be RCIS-certified within 18 months of hire.

What continuing education opportunities are provided to staff members? 

[11]We have many company representatives who provide educational in-services carrying CEU credits. We met our 2011 goal of sponsoring a two-day review course and exam for the CVRN certification. We will be hosting a registered cardiac electrophysiology specialist (RCES) review course at Medical Center of the Rockies on April 12-13, 2012, which will be the first time a course like this has been offered west of the Mississippi. The staff is encouraged to participate in both in-house and outside educational opportunities.

How do you handle vendor visits to your lab?

Vendors are offered scheduling once a quarter. They may provide in-services in our staff lounge, but must be invited to observe in our cath lab rooms by the physician. 

All vendors much check in and we use the services of Reptrax. 

How is staff competency evaluated?

We have several annual house-wide competencies that specifically meet the regulatory needs of the hospital. We also have unit-specific competencies. Our 2011 unit-specific competencies included rotablations, the Impella device, FFR, IVUS, methohemoglobinemia, radial artery catheterizations, and our new acute MI protocol. In 2012, we have had the following competencies: adenosine in the cath lab, pseudo-aneurysms and thrombin injections, CTOs, amd circulating within the electrophysiology lab.

Does your lab have a clinical ladder? 

We do not currently incorporate a clinical ladder in our facility.

Does your lab utilize any relaxation techniques for patients?

We provide music for our patients to listen to during a cath procedure. In the non-invasive areas, such as infusions, we provide our patients with magazines and TVs.

How does your lab handle call times for staff members?

Our lab hours are Monday to Friday, 06:00 to 16:30. The call team consists of four staff members with a 30-minute response time to either hospital. We cover call 365 days a year. Staff members sign up for nights and weekends a couple of weeks ahead of the new schedule. The average requirement for call is about one night of call per week and one weekend every five weeks. There is not an attending cardiologist required to be on site but the 30-minute response time remains in effect.

Do you have flex-time or multiple shifts?

We have 10-hour shifts with some staff flexing in 6-hour shifts during our busiest hours. 

The Pre/Post unit is open from 5:30 am to 19:00,with 8- and 12-hour shifts. We have five different shifts flexing in/out throughout the day, maintaining a 2:1 patient-to-nurse ratio. 

Has your lab undergone a Joint Commission or accrediting agency inspection in the past three years?

Yes, our lab underwent a Joint Commission inspection in 2010. Our lab did not receive any recommendations at this inspection. Our advice to others is to diligently work to follow the Joint Commission guidelines and to practice mock inspections to see where you might need to make corrections.

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

We have monthly mandatory staff meetings, e-mails, bulletin boards, “Over the Wire”, a weekly newsletter for the cath lab, and have just added a new wiki space (our own cath lab website). Monthly in-services are scheduled by our representatives to keep us abreast of changes in products.

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

All of our cath labs are right next door to the OR, with the exception of our hybrid lab. The emergency department is just down the hall from the cath lab at Poudre Valley Hospital and is one level down from the cath lab at Medical Center of the Rockies.

How do you see your cath lab changing over the next few years?

Our lab is expanding on the services we will be providing to our patients. The new services for 2012 will be same-day discharge for PCI, cryoablations, TAVR, and CTO procedures. Our facility is also merging with University of Colorado Hospital and potentially, Memorial Hospital, to provide a broader range of services to a greater population.

What is unique about your cath lab and staff?

[12]Our lab is unique in the fact that our staff works and covers call for two separate hospitals. MCR and PVH are considered sister facilities, under the heading of Poudre Valley Health Systems, but both facilities operate as its own separate entity. Our lab is also unique in the fact that the majority of our staff is RNs and we are all cross-trained to do all tasks within the lab. 

Every fall, our lab sponsors a “Duck Race.” All of the money raised is then donated to the hospital foundation and distributed to employees in need.

Is there a problem or challenge your lab has faced?

The biggest problem we have faced is our staff floating between and covering two separate facilities. The challenge comes when simultaneous cardiac alerts take place at both facilities with one call team. The solution has been to take a multi-disciplinary approach, involving input from EMS, ED, house supervisors, cardiologists, and cath lab staff.

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

PVHS covers a demographically diverse patient population in Northern Colorado, Wyoming and Nebraska. Our patient population is comprised of farmers, students, mountain vacationers, migrant workers, and a large retirement community. Being on the Front Range also serves as a challenge, due to the fact many of our patients must be sent by helicopter from the mountains and outlying small communities from other states.

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 any bonus, raise or incentive for passing the exam?

RCIS certification is a requirement for our CV techs. Certification is not a requirement for the remainder of our staff. We encourage RCIS, CVN, CVRN, PCCN or CCRN certification. PVHS offers an annual monetary bonus for certifications achieved beyond job requirements.

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?

Many of our staff members are involved in the following professional organizations: the Heart Rhythm Society, ARNP, ANA, ACCN, and SICP. 

The authors can be contacted via Kristi Ramsey at kdr@pvhs.org [13].