Cath Lab Spotlight

Cardiovascular Interventional Lab (CVIL) at Tampa General Hospital

Louise Stevenson, BSN, RN, CVRN, IR Clinical Nurse, Jamie Carden, BSN, RN, Cath Lab Clinical Nurse, Charity Kanuck, BSN, RN, CVRN, Cath Lab Clinical Nurse, and Gordon Hackstaff RT(R)(CV)(AART), Tampa, Florida

Contributors for this article:
Maureen Ogden, MHA, RN, Vice President of Cardiovascular Services; 
Denise Vander Werf, MHA, BSR, RT(R), Director of Cardiovascular Center, 
Imaging and Cancer Center; Heleomar Zanga, MSN, RN, NMF, CNML, 
Nurse Manager Cardiovascular Interventional Lab; Ryan Mehuron, MHA, Business Operations Manager Cardiovascular Center; Dorothy Beck, BSN, RN, CVRN, Clinical Educator Cardiovascular Interventional Lab; JoAnn Green, MSN, RN, CCRN, Cardiovascular Divisional Educator; Rod L. Atkins, MSN, ARNP; 
Fred Webster, RT(R), RCIS, Team Leader Cath Lab; Carol Shakoori-Naminy, BSN, RN, CRIN, Clinical Nurse; Angela Leland, BSN, RN, CVRN, Cath Lab Clinician; Haydy Rojas, BSN, RN, Clinical Research; and Heather Bidlack, BSN, RN, PCCN, CVRN, EP Clinician Nurse

Louise Stevenson, BSN, RN, CVRN, IR Clinical Nurse, Jamie Carden, BSN, RN, Cath Lab Clinical Nurse, Charity Kanuck, BSN, RN, CVRN, Cath Lab Clinical Nurse, and Gordon Hackstaff RT(R)(CV)(AART), Tampa, Florida

Contributors for this article:
Maureen Ogden, MHA, RN, Vice President of Cardiovascular Services; 
Denise Vander Werf, MHA, BSR, RT(R), Director of Cardiovascular Center, 
Imaging and Cancer Center; Heleomar Zanga, MSN, RN, NMF, CNML, 
Nurse Manager Cardiovascular Interventional Lab; Ryan Mehuron, MHA, Business Operations Manager Cardiovascular Center; Dorothy Beck, BSN, RN, CVRN, Clinical Educator Cardiovascular Interventional Lab; JoAnn Green, MSN, RN, CCRN, Cardiovascular Divisional Educator; Rod L. Atkins, MSN, ARNP; 
Fred Webster, RT(R), RCIS, Team Leader Cath Lab; Carol Shakoori-Naminy, BSN, RN, CRIN, Clinical Nurse; Angela Leland, BSN, RN, CVRN, Cath Lab Clinician; Haydy Rojas, BSN, RN, Clinical Research; and Heather Bidlack, BSN, RN, PCCN, CVRN, EP Clinician Nurse

CVIL Vision: To achieve excellence in health care through ongoing education, research, integrity, dedication and teamwork. 

CVIL Mission: The Cardiovascular and Interventional Radiology labs are committed to providing competent and compassionate patient-centered care with integrity and trust.

Tell us about your facility and the Cardiovascular Interventional Lab (CVIL).

Tampa General Hospital (TGH) is a 1,018-bed private, not-for-profit, level I trauma center in west central Florida. Tampa General offers a variety of services, including a children’s medical center and state-verified regional burn center, and is one of the busiest adult solid organ transplant centers in the country. The facility serves a dozen counties with a population in excess of 4 million. TGH is a certified comprehensive stroke center, a cardiovascular and orthopedic center, and is the region’s safety net hospital. Tampa General Hospital is the primary teaching hospital for the University of South Florida (USF) Health Morsani College of Medicine.  

TGH’s Cardiovascular Interventional Lab (CVIL) consists of four cardiac catheterization labs, two electrophysiology (EP) labs and six interventional radiology (IR) labs, including two neuro-interventional labs.  The CVIL cares for more than 11,000 patients a year and has a staff of 90 that includes registered nurses (RNs), registered radiology technologists (RT[R]s), registered cardiovascular invasive specialists (CVISs and RCISs), nurse practitioners (ARNPs), physician assistants (PAs), management team, transporters, and an administrative assistant. The average length of employment for the department is greater than 4 years.

How is TGH’s Cardiovascular Center Unique?

The CVIL employs a multidisciplinary approach. Cardiologists, interventional radiologists, vascular surgeons, and neuro-interventionists work collaboratively to perform a multitude of procedures. Our center has the ability to perform procedures in a timely manner while maintaining the capability to provide emergent care for the critically ill. 

What procedures are performed in your Cardiovascular Center (CVC)?

The CVC offers both inpatient and outpatient services, including diagnostic and interventional procedures. Our cardiovascular procedures include: ST-elevation myocardial infarction (STEMI) interventions, right and left heart catheterizations, heart biopsies, and septal closures. Percutaneous coronary interventions include balloon angioplasty and stenting. The EP lab performs ventricular tachycardia, atrial fibrillation and atrial flutter ablations, pacemaker implants, and device changes. IR procedures include dialysis access plus fistulagrams, embolizations, transarterial chemoembolization (TACE), biopsies, nephrostomy tubes, biliary tubes and Y-90s. Neuro-interventionalists treat strokes and perform aneurysm treatments including coilings, stent placements, and flow diverters (including the Pipeline Embolization Device [Medtronic], Surpass Streamline Flow Diverter [Stryker], and Flow Re-Direction Endoluminal Device [FRED] [MicroVention]), as well as carotid stenting and arteriovenous malformation (AVM) embolizations.

Does your lab have a hybrid room?

Our hybrid room is equipped to perform transcatheter aortic valve replacements (TAVRs) and placenta accreta procedures. The hybrid room is in the cardiovascular surgical department, only a few steps away from the CVIL. Cath lab staff collaborates with the TAVR team in every TAVR case. The cath lab has a designated TAVR team consisting of two CVISs, one RN, and one team leader. In addition, the team performs endografts, “snorkels” for endovascular aneurysm repair (EVAR), and stents for aortic aneurysms.  

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

Approximately 42 percent of our interventional cardiologists use radial access, while the interventional radiologists use a variety of arterial access methods, including radial access. Physicians have performed 388 radial access procedures in the CVIL thus far in 2015.

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

We have several new products, including:

  • Optical coherence tomography (OCT) is used in the cardiac cath lab to verify proper stent placement. 
  • Thrombix (Vascular Solutions), a powerful hemostatic dressing, has been initiated in the cath lab for temporary control of moderate to severe, post-sheath, removal bleeding.  
  • ViewMate ultrasound (St. Jude Medical) is used in EP for advanced, real-time, intra-cardiac echo imaging. 
  • AngioVac (AngioDynamics) is used in IR procedures that require evacuation of large fresh thrombus through a cardiac perfusion flow pump. 
  • Flow diverters, including the Pipeline, Surpass and FRED, are being used in neuro IR to repair aneurysms.

Who manages your lab?

The management team reports to a senior vice president, the medical directors for EP, cath lab, and IR, and an administrative director. We employ a synergistic approach that involves the clinical nurse manager of the CVIL and a business manager. We also have a frontline management team of six staff that includes an IR team leader and nurse clinician, cath lab team leader, cath lab nurse clinician, EP nurse clinician, and a unit-based educator. The CVIL management team recently added a shared governance council structured with five departmental- based committees. 

The CVIL clinical nurse manager has over fourteen years of nursing experience with ten years of management.  She has been in her current position for more than a year. This nurse manager has received awards including: Leadership of the Month February 2010 and Nurse Manager of the Year 2010, and recently completed AONE Fellowship. The nurse manager has completed her master’s degree in nursing and is currently enrolled in the Doctorate in Nursing Program (DNP). She previously led different nursing units at TGH and has a cardiac and transplant background. The nurse manager is accountable to the senior VP of Cardiovascular Services and the director of imaging, CV Center, and Cancer Center. 

The CVIL business manager has a master’s degree in hospital administration and has served the department for more than three years. Responsibilities include planning and procurement of material components to minimize obsolescence and overstock situations while achieving maximum customer service levels. He is responsible for the management of material inventory levels to ensure that equipment and supplies are available when needed to satisfy department requirements. The business manager also develops and implements budgets, prepares reports for senior management, and ensures the department meets financial goals. He collaborates with the nurse manager and evaluates employee performance.  

All seven management team members of the CVIL were promoted from existing staff. The daily operations are a collaboration of staff, clinicians, team leaders, the educator, and the nurse manager. The IR and cath lab team leaders have been in their positions for more than 10 years. Each member of the management team has had extensive training and preceptorship with another experienced clinician, team leader, or unit-based educator. The management team meets twice a year for a strategic planning. The meeting is designed to set goals and to make new plans and/or modify existing ones. Additionally, the chair of the shared governance council attends these meetings and is very involved in strategic planning. Each member of the management team sponsors one of the unit-based shared governance committees. The CVIL shared governance council consists of the Recruitment and Retention Committee, Safety/Quality Control Committee, Patient Satisfaction Committee, Efficiency, and the Education Committee.  

Who scrubs, who circulates, and who monitors? 

CVIS staff members are cross-trained to monitor and scrub on a variety of cases. The RNs circulate and monitor patients. The RNs and CVIS are trained to operate the EP lab stimulator. In the IR labs, the IR technologist (IRT) circulates and scrubs, while the RN is responsible for sedating and monitoring the patient. Some staff members are cross-trained to work in more than one area in the CVIL.

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

CVIS are trained to change the angles in our labs. The fluoroscope is controlled by physicians who are licensed and certified by the National Radiological Commission (NRC). For IR procedures, the IRTs obtain angles for the procedures and are certified to operate fluoroscopy.

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

All staff and physicians are fitted and assigned a lead apron, including a thyroid shield. All lead items are inspected annually, dated, and coded to allow for identification. If compromised, the lead is removed from use. Protective lead eyeglasses, lead drapes, and free-standing lead shields are available to staff and physicians.  Radiation badges are assigned to each staff member and are monitored monthly for radiation doses. Staff receives required annual training on radiation safety.

How does your lab communicate information to staff and physicians?

Departmental communication is dynamic and provided through a variety of methods, including written notes, meetings, and in lectures. Our unit-based educator, clinicians, and team leaders distribute information through email, which is reinforced in weekly meetings. Bi-monthly staff meetings focus on departmental goals and highlight ongoing areas of improvement. Our clinical unit-based educator updates and provides current information regarding education and safety concerns. Minutes from the shared governance meetings are posted on the department website.

The three medical directors meet monthly with the management team and senior leadership. The meetings serve as an open forum for decision making and information sharing. Most physicians serving the CVIL and all three medical directors receive a weekly e-mail titled “Friday Updates”, containing a brief summary of the weekly face-to-face meeting, important announcements, quality data, and lessons learned. 

Who pulls sheaths post procedure?

When procedures are completed, sheaths are removed by an IRT, CVIS, or nurse, using manual pressure. It is common practice for the CVIL physician to use a closure device for sheath removal to reduce recovery time and aid in patient comfort. Sheaths may also be left in place and patients sent to our post-procedure recovery rooms for care. The post-procedure areas have highly trained intensive care unit (ICU) nurses that are qualified to remove the sheaths and assess for signs of complications.

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

Patients are prepped in the 47-bed pre-and post-procedure area. Once the procedure is complete, the patient returns to this area for recovery. Most outpatients are discharged home on the same day after their interventional procedure following the appropriate recovery time. 

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

Inventory is managed by the CVIL business manager, as well as by three dedicated inventory specialists. We use Qsight (Owens & Minor), an electronic inventory control system which interfaces with EPIC, our electronic medical record (EMR), and McKesson system. This system increases traceability using lot numbers, expiration dates and product recalls, which increases patient safety, reduces inventory, and limits supplies to a just-in-time basis. During a case, the product is opened and then immediately scanned, which impacts par levels and ordering status. The CVIL (IR and cath lab) have a combined inventory.

The CVIL utilizes a value analysis model to evaluate new products and implement cost-saving initiatives. The CVIL has its own committee, but can refer large-scale items to an executive committee if necessary. 

How do you handle vendor visits to your lab?

Vendors may request an appointment through RepConnect (Medical Rep Connect), a computer-based calendar. Some vendors will pre-schedule with a particular physician for a case and in those instances, the vendors deal directly with the physicians. Before going into any labs, vendors must check in with the business operations manager, change into appropriate scrubs, and have their credentials verified. Vendors are required to wear proper identification at all times, and follow hospital policies and procedures. 

Has your lab recently expanded in size?

In 2008, the CVIL expanded from 8 to 12 rooms, and added the hybrid OR. 

Is your lab involved in clinical research?

TGH is affiliated with the University Of South Florida Morsani College Of Medicine. Currently, the cath lab has several research projects:

  • ABSORB III – a bio-absorbable stent (Abbott Vascular);
  • ABSORB Imaging – bio-    absorbable stent with intravascular ultrasound (IVUS)/OCT;
  • ABSORB IV – bio-absorbable stent with a computed tomography (CT) scan post-placement;
  • CAIN – IVUS of the vessels to correlate progression of carotid disease with coronary artery disease (Canadian Atherosclerosis Imaging Network);
  • SYMPLICITY HTN-3 – renal denervation for patients with uncontrolled hypertension (Medtronic);
  • COAPT – mitral valve clip study for percutaneous mitral valve repair (Abbott Vascular).

The IR lab has the following research studies underway: 

  • BEST – embolization for prostates;
  • TGH BHP – embolization for prostates larger than 90 grams;
  • HIQ – embolization of liver tumors;
  • ACE – coiling of aneurysms;
  • Penumbra 3D stroke trial (Penumbra);
  • SCENT – Surpass device for aneurysms (Stryker)
  • PREMIER – Pipeline device for aneurysms (Medtronic).

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

The average D2B time in 2014 was 64 minutes. The target time for D2B is less than 90 minutes. From door to electrocardiogram (ECG), the goal is less than 10 minutes. From door to decision, the goal is less than 15 minutes. From cath lab door to actual time when the procedure begins, the goal is 10 minutes. The emergency department (ED) STEMI doctor on call and the cath lab staff work collaboratively to achieve these goals.  

Who transports the STEMI patient to the cath lab during regular and off hours?

During regular and off hours, STEMI patients are transported by two staff members, one of whom must be a registered nurse or physician. All the patients are transported on a cardiac monitor with defibrillator.

What do you do when the call team is already doing a procedure and a STEMI comes into the ED?

If a STEMI occurs during regular business hours, the first available cath lab would accommodate the STEMI. The staff at the main control desk assigns cath lab cases keeping the need for emergent caths and STEMIs in mind. Procedure assignments are placed so that there is always a lab available for emergencies. In case of multiple emergencies and STEMIs resulting in all labs doing procedures, the patient will be taken to the next available CV surgical room. 

If a STEMI occurs during off hours when the call team is already on a case, the call team will request an additional team. If it is not possible to get an extra complete team, the rapid response team assists with monitoring, turnover, and transport. 

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

We have implemented staggered shifts to align staffing with peak volumes. This evidence-based process has decreased overtime. We recently switched to the Qsight inventory system, which has helped streamline inventory and cut waste by $1.5 million. We also analyzed patient schedules and workflow, and reinforced prompt staff arrival times and attendance. All together, the CVIL reduced operating costs by 6% last year.

Tell us about the quality control (QC)/quality assurance (QA) measures practiced in your lab.

We continually monitor STEMI times to adhere to the American College of Cardiology Guidelines, and stroke times to retain our National Stroke Certification. 

Time-out audits ensure all the safety steps are being followed before a procedure is started. We monitor hand hygiene when staff enter and exit the procedural rooms. We also perform random chart audits to ensure compliance with benchmarking and regulatory agencies.  

The unit-based quality and safety committee recently revised the Peer Audit Tool, which is utilized by all staff members. Peer Audit Tool compliance is monitored by the management team. The data from the peer audit is posted on the department quality bulletin board. Areas in need of improvement are discussed at committee meetings and communicated to all staff members.

Are you recording fluoroscopy times/dosages?

We record total minutes in Air Karma and in the cath report. 

Who documents medication administration during the case?

The RN is responsible for documenting medications given during the procedure in the EMR.

How are new employees oriented and trained at your facility?

All new employees receive an orientation to their work area prior to the delivery of patient care or performance of new job functions. A detailed orientation tool is used and an experienced team member is chosen as a preceptor to work with the employee and monitor progress towards their training goals. Orientation starts with a full day of on-boarding activities provided by the organizational development department. Clinical orientation includes safe patient handling and electronic medical record training. A unit-based educator provides new hires with a unit-specific orientation during the first week. New staff will provide copies of licenses and certifications, and review both the unit and divisional orientation booklets, followed by a department tour. A competency-based orientation (CBO) evaluation is provided to every new staff member. Staff documents validation of competencies on this form as learning competencies are completed. We also utilize an orientation progress record to monitor individual progress and identify learning goals. The length of orientation is based on the employee’s level of knowledge and experience. The manager or unit-based educator conducts formal/informal new employee onboarding meetings to get feedback regarding orientation. The goal of each meeting is to determine if new staff feel welcomed and are receiving proper orientation/training. 

What continuing education opportunities are provided to staff members?

Continuing education is provided to all levels of staff and in various settings around the hospital. Education is also provided at the division and unit level. These include monthly department continuing education unit (CEU) presentations, in which the speakers are staff physicians, volunteer clinical ladder nurses, advanced registries, CVISs, and IRTs. Staff members are encouraged to attend the annual Cardiovascular Symposium and hospital-based, instructor-led training classes. Most of our mandatory education programs are provided electronically. Mindlab is our electronic education software that awards continuing education credits upon successful completion of modules. Tampa General also offers Continuing Education (CE) Direct. CE Direct provides online, nationally accredited, and Florida-required CE courses, webinars, and certification review modules for access at work or home.

Tampa General offers all full- and part-time employees tuition assistance for continuing education. Full-time employees may receive up to $16,000 towards continuing education, and part-time employees up to $8,000. TGH also sponsors selected IRTs, CVISs, and nurses for attendance at national conferences and professional organization meetings every year.

How is staff competency evaluated?

Our organizational development department plans and implements educational programs based on assessments of employees’ learning needs, using adult learning theory. In addition, an online survey is sent out to all clinical employees to assess each individual’s learning needs. The TGH Competency Assessment Program (CAP) assesses job-related skills, and addresses changes in practice, policy and knowledge. CAPS is used to assess, validate, and document job performance competencies for clinical and non-clinical staff. Unit-specific CAPs are identified through low-volume, high-risk cases, quality improvement data, incident reports, staff feedback and direct observation. CAPS were designed to improve patient care outcomes.

Does your lab have clinical ladder?

Clinical nurses working in our labs are eligible to participate in the RN clinical ladder program. The program was developed in 1999. The ladder recognizes and rewards the application of clinical nursing expertise in direct patient care. Eligibility requirements must be met to submit an application. Nurses can apply for one of the four ladder levels, based on meeting specific criteria. A paid hourly differential is attached to the clinical ladder levels, ranging from 4% to 16% of the base hourly wage. Clinical ladder nurses must meet renewal criteria every two years, and re-apply at that time in order to continue or raise their clinical ladder level. 

Our IRTs and CVISs have a similar professional development matrix. The matrix has three levels: entry level I, staff level II, senior level III. The levels are based on education, certification, experience, and specific skill sets. Unlike clinical ladder nurses, the IRTs and CVISs do not need to renew their level every 2 years. Advanced certification in their given specialties is required to stay on their current levels. This is considered a promotion for our IRTs and CVISs.

How does your lab handle call time for staff members?

Call is mandatory for all staff members and is evenly distributed. Staff members are permitted to exchange shifts with manager approval.

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

All team members are expected to arrive to the cath lab within 30 minutes for STEMIs and 45 minutes for in-house emergencies. The IR lab on call staff is expected to arrive within an hour for strokes and emergent IR procedures.

Do you have flexible or multiple shifts?

With staggered shifts, the first shift begins at 07:00, the on-call staff follows at 07:30, and the stay-late teams come in at 08:00. Typically, the first cases begin at 08:00 and last cases finish at 18:00. The labs operate 5 days a week. There is one call team in the cath lab 24/7 and one on-call team for IR Monday through Friday. On the weekends, there are two on-call teams to cover stroke and trauma in IR.

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

The CVIL has seen an increase in volume in the past few years. Cardiac patients appear to be getting younger, with a far greater percentage of coronary artery disease. The number of cardiomyopathy cases has also increased. TGH is one of the nation’s busiest transplant centers, so there is an increased need for performing biopsies. EP studies and ablations used to treat abnormal heart rhythms or arrhythmias have also increased due to the rise in heart disease.

The IR labs have noted an increase in dialysis patients who have complications from long-term dialysis. Other procedures such as embolization and stroke interventions have markedly increased.

Is there a problem or challenge your lab has faced?

Door-to-device times for STEMI and stroke will always be a challenge. Many elements beyond our control, such as weather and traffic, can be very challenging. Together with the shared governance council and the various committees, including quality, education and efficiency committees, we continually strive to identify ways to meet target times to achieve desired patient outcomes.  

Has your lab recently undergone a national accrediting agency inspection?

TGH has undergone the following agency inspections: The Joint Commission, Magnet re-designation, Comprehensive Stroke Center status, and Society of Cardiovascular Patient Care Heart Failure accreditation.  

What’s special about your city or general regional area in comparison to the rest of the United States? How does it affect your CV lab “culture”?

For almost 80 years, Tampa General Hospital has been a source of pride to residents of Hillsborough and surrounding counties. Located on Davis Islands in the city of Tampa, TGH is easily accessible to the entire region via interstates 75 and 4, and a variety of surface roads. Warm winters, access to the Gulf of Mexico, and a thriving economy make the west coast of Florida popular for companies looking to relocate, as well as retirees. 

Our partnership with the University of South Florida sets us apart from all other local hospitals. We are the region’s safety net hospital, whose mission is to provide excellent and compassionate health care to the residents of west central Florida, from the simplest to the most complex medical services. 

The geographic location and the diverse patient population drive the CVIL to create a unique culture where interventional cardiology, electrophysiology, vascular, and neurology are combined. We are integrated, sharing supplies, resources, and staff.  

Read an excerpt about the pulmonary embolism program with Samuel A. Shube, MD, Tampa General Hospital, Tampa, Florida.