Tell us about your cath lab.
The Indiana University (IU) Health North Hospital is a 189-bed, full-service hospital. Our cardiovascular lab has three Artis suites (Siemens Medical). Our lab is a combination of cardio/peripheral vascular and interventional radiology. Each lab is equipped to function in either area.
Our cath lab staff includes five technologists and four registered nurses (RNs). There are four full-time RNs in our pre/post op area.
What procedures are performed in your cath lab?
We do diagnostic caths, percutaneous coronary interventions (PCIs), peripheral interventions, cardioversions, transesophageal echocardiograms (TEEs) and insert permanent pacemakers. In addition, we perform interventional radiology procedures including uterine fibroid embolizations, G-tube and port placements, and vertebroplasty.
Does your cath lab perform primary angioplasty without surgical backup on site?
Yes, we do perform primary angioplasty without surgical backup on site. If a patient requires emergent surgical intervention, they are transferred to one of IU Health’s local partnering hospitals where a cardiothoracic team is readily available.
What percentage of your patients is female?
Forty-four percent of our patient population is female.
What percentage of your diagnostic caths is normal?
Twenty-seven percent of our cases are considered normal, based on the American College of Cardiology’s National Cardiovascular Data Registry (ACC-NCDR) CathPCI Registry.
Do any of your physicians regularly gain access via the radial artery?
We have two interventional cardiologists who regularly gain access via the radial artery. There are also diagnostic physicians who are trained in radial techniques.
Who manages your cath lab?
Our cardiovascular lab is managed by a collaborative group: Toni Beymer, MSN, RN, NE-BE, Director Cardiovascular and Critical Care Services; Dianna Cobb, RN, BSN, Manager Cath Lab/Interventional Radiology; Angie Bolinger, RN Clinical Coordinator Cath Lab/Interventional Radiology; Jessica Schultz, RT Cath Lab Team Lead; and Andrea Ruffer, RN, CCRN-CMC, Charge Nurse.
Do you have cross-training? Who scrubs, who circulates and who monitors?
All of our nurses circulate and a few also scrub. Our radiologic technologists (RTs) and cardiovascular technologists (CVTs) scrub, and all staff are trained to monitor.
Who documents medication administration during the case?
Our nurses document medication administration and are required to take an annual conscious sedation competency exam.
Does an RT have to be present in the room for all fluoroscopic procedures in your cath lab?
Yes, we require an RT to be in the room.
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?
Physicians primarily control the fluoro/cine pedal during procedures, and the RT or scrub nurse performs the other operations of the x-ray equipment. RTs are able to perform all controls.
How does your cath lab handle radiation protection for physicians and staff?
We have monthly monitoring of dosimeter badges, and staff’s lead aprons are checked annually by our RTs. Other safety equipment includes the RadPad for scatter radiation (Worldwide Innovations & Technologies, Inc.), radiation safety goggles, and lead shields.
Are you recording fluoroscopy times/dosages?
Our patient documentation system (Axiom Sensis, Siemens) automatically imports fluoro times and dosages into the patient’s chart.
What are some of the new equipment, devices and products recently introduced at your lab?
We recently purchased the Fuji PACS reviewing system and the Impella left ventricular assist device (Abiomed).
How does your lab communicate information to staff and physicians to stay organized and on top of change?
In our lab, we have a designated team of charge nurses/traffic who are in charge of the daily schedule. Any additional cases added on by the physicians are filtered through the charge nurse/traffic coordinator and added to the patient schedule. The charge nurse/traffic coordinator is responsible for maintaining efficient flow throughout the day.
How is coding and coding education handled in your lab?
We have a unit-based charge audit coordinator who reviews all cases and assigns the appropriate CPT codes prior to the charges going to HIM (Health Information Management). Unit-based education is provided by the charge audit coordinator in collaboration with revenue cycle. Our charge audit coordinator also introduces a product highlight bi-weekly to educate staff on equipment usage.
Who pulls the sheaths post procedure, both post intervention and diagnostic?
Our pre/post op RNs pull sheaths post procedure. We also have an RT in our post op/recovery area that pulls sheaths. Staff has been trained on evidenced-based best practices for sheath removal and maintains annual competencies.
Where are patients prepped and recovered (post sheath removal)?
Our patients are prepped and recovered in one of our 10 private patient rooms in our observation/pre and post op area. We use a combination of manual and vascular closure devices, depending on physician preference and patient status. For our radial cases, we use TR Bands (Terumo). We have had good success with Angio-Seal (St. Jude Medical).
What is your lab’s hematoma management policy?
Once a hematoma is noted, an assessment is made (size and location), the physician is notified, and manual compression is held immediately. Cath lab staff members always make themselves available for groin management issues. Any time a staff member of our lab assists in the care of a patient regarding groin management, a note is documented in the patient’s chart. Our quality department is also notified for the purposes of ongoing quality assurance.
How is inventory managed at your cath lab?
We have a full-time logistics specialist who manages our inventory based on usage and physician requests. Our products team meets bi-weekly to review products, and monthly with our statewide affiliates.
Has your cath lab recently expanded in size and patient volume?
Within the last five years, we expanded our pre/post op area and added ten private patient rooms. We also added a third lab.
Do you have a hybrid cath lab?
Not at this time.
Is your lab involved in clinical research?
We have been involved with numerous clinical research studies. We are currently participating in the TRANSLATE-ACS study [Treatment With Adenosine Diphosphate (ADP) Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events After Acute Coronary Syndrome, https://www.translate-acs.org].
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?
Our average D2B time is 67 minutes. We have established a multi-disciplinary team to streamline our patient transfer to the cath lab. The team consists of our in-house emergency response team, physicians, associate administrators, protective services, and the cath lab team. Our lab also works closely with our local emergency medical services (EMS) and has set up local EMS training events. We have a case review after each ST-elevation myocardial infarction (STEMI) for quality assurance. We are registered with the ACC-NCDR and Acute Myocardial Infarction (AMI) Quality Measures.
Who transports the STEMI patient to the cath lab during regular and off hours?
During regular hours, cath lab staff transports the STEMI patient. During off hours, our bedside assessment team (BAT) initiates transporting the patient to reduce delays. We have noticed an improvement in our D2B times since implementing this process.
What do you do when the call team is already busy doing a procedure and a STEMI comes into the emergency department (ED)?
The primary cath lab person will secure the needed staff. If the primary person is unable to fulfill this role due to patient treatment demand, they will page the cath lab manager to secure staff.
What other modalities do you use to verify stenosis?
The lab possesses an S5i for intravascular ultrasound (IVUS) imaging (Volcano Corporation), and also uses fractional flow reserve (FFR) (St. Jude Medical).
What measures has your cath lab implemented in order to cut or contain costs?
There is ongoing, careful review of our inventory to ensure up-to-date and accurate pricing for equipment and procedures. The lab has renegotiated pricing agreements and consignment inventory to reduce costs. Some equipment has been eliminated or downsized due to consistent product management. We also have a designated Logistics Specialist who audits our inventory after each case.
What quality control/quality assurance measures are practiced in your cath lab?
We participate in the Quality and Safety Measurement Panel. One key goal of the Quality Panel is to improve patient care and outcomes through alignment with national quality programs, including those through Centers for Medicare & Medicaid Services (CMS), value-based purchasing (VBP) and the Anthem Q-HIP® program. The hospital uses Lean Six Sigma for process improvement initiatives. Our hospital is also accredited by the Society of Chest Pain Centers and The Joint Commission. Any quality standards inherent to these accrediting bodies are implemented.
How are new employees oriented and trained at your facility?
New employees follow a set schedule of competencies and are assigned a preceptor to mentor them. During hospital orientation, the new employee completes a questionnaire that includes an assessment of the orientee’s learning style. We make an effort to couple the new employee’s learning style with the teaching style of their preceptor. Each week, the preceptor and orientee review their weekly goals and determine a level of competency for each skill. The length of orientation depends on the level of experience when hired.
What continuing education opportunities are provided to staff members?
IU Health offers a career advancement program to all of our nurses. There is also a cohort with University of Indianapolis that offers a bachelor of science in nursing (BSN) program and BSN-to-master’s in nursing (MSN) track. In addition, IU Health offers a competitive tuition assistance program, as well as in-house continuing education opportunities.
How do you handle vendor visits to your lab?
Vendors must have an appointment to visit. We use Vendormate to properly credential representatives. Vendors are required to sign in and wear a badge from the hospital’s protective services. They are only allowed in the lab if invited by the physician.
How is staff competency evaluated?
Staff is required to complete annual competencies. There are also training opportunities that offer continuing education units (CEUs). In addition, we have a unit-based educator who manages competencies and informs staff of available evidence-based training.
Does your lab have a clinical ladder?
No, but there are advancement opportunities available through our career advancement program.
How does your lab handle call time for staff members?
On-call shifts are from 5:00 pm to 6:30 am, 7 days a week. Team members are on call one to two weekdays per week and one weekend every five to six weeks. Our call team is comprised of a total of three team members; a combination of at least one RT and one RN.
Within what time period are call team members expected to arrive to the lab after being paged?
Call team members are to be clocked in within 30 minutes of being paged.
Do you have flextime or multiple shifts?
We offer multiple shifts (Monday through Friday) and our on call team is available after hours and on weekends. We have teams of eight-hour and ten-hour staff. We also have a weekend option shift. Regular day shift times start at 6:30 am and end at 5:00 pm, with call starting after 5:00 pm.
Has your lab recently undergone a national accrediting agency inspection?
We recently received full Chest Pain Center accreditation from the Society of Chest Pain Centers (SCPC). Through this accreditation process, the SCPC evaluates the care surrounding the treatment of patients who present with symptoms of a heart attack. We are committed to ensuring that our facility meets or exceeds measures based on improving the process for the care of the acute coronary syndrome (ACS) patient, which supports the SCPC in their mission to reduce heart attack deaths.
In the beginning, we would recommend taking some time to get organized. Start with an assessment of items that you can easily put your hands on and start a file (either electronic or paper). Start by outlining each of the milestones and list the supportive documents (how you meet and/or exceed the expectation of each milestone). Make each milestone submission completely transparent to the reader. Leave nothing to the imagination. Take time to explain what you are submitting.
Where is your cath lab located in relation to the ED?
Our cath lab and ED are on the same floor, located down the hall from each other, so access either way is easy.
What trends have you seen in your procedures and/or patient population?
As the transradial approach gains popularity and has been featured in the press, we have seen more patients request a cath via this approach.
What is unique or innovative about your cath lab and staff?
We have a diverse group, with varying ages and backgrounds. Our culture is built on displaying IU Health North Hospital’s 5 maxims: doing more, showing kindness, connecting fully, taking ownership and creating joy. Our favorable patient satisfaction scores reflect that.
Is there a problem or challenge your lab has faced?
The biggest challenge we faced was the morale of our team. Within the past year, we have undergone turnover. We have worked hard to build a cohesive family of committed and engaged team members who are dedicated to the overall success of our department. Through recognition, coaching and staff development, we have one of the most skilled and loyal cath lab teams!
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”?
Located immediately north of Indianapolis, Carmel is one of the fastest-growing cities in Indiana and was voted one of the “best cities to relocate to in America” by CNBC. We serve a diverse mix of patients, including professional athletes, local business owners and community service providers. Because of our often well-known patient population, we must always ensure patient privacy.
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 it, but encourage all of our staff to obtain certification.
Are your clinical 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 cath lab manager is a member of the SICP.
The authors can be contacted via Dianna Cobb at dcobb@IUHealth.org .