Cath Lab Spotlight

Cath Lab Spotlight: Methodist University Hospital

Derrick Bowen, BSN, RN, Team Lead; Roxanne Gardner, RCES, Lead  Invasive Cardio Tech, Angela Knox, MSN, Jason Weatherly, BSN, CCRN

Rami Khouzam, MD, FACC, FACP, FASNC, FASE, FSCAI, Program Director, Interventional Cardiology Fellowship, Vice Chair of Medicine, Associate Chief of Cardiology, Associate Program Director, Cardiology Fellowship; Associate Professor, University of Tennessee Health Science Center; Medical Director, Cardiac Cath Lab, Methodist University Hospital; President, Unified Medical Staff, Methodist Le Bonheur Healthcare, Memphis, Tennessee

Derrick Bowen, BSN, RN, Team Lead; Roxanne Gardner, RCES, Lead  Invasive Cardio Tech, Angela Knox, MSN, Jason Weatherly, BSN, CCRN

Rami Khouzam, MD, FACC, FACP, FASNC, FASE, FSCAI, Program Director, Interventional Cardiology Fellowship, Vice Chair of Medicine, Associate Chief of Cardiology, Associate Program Director, Cardiology Fellowship; Associate Professor, University of Tennessee Health Science Center; Medical Director, Cardiac Cath Lab, Methodist University Hospital; President, Unified Medical Staff, Methodist Le Bonheur Healthcare, Memphis, Tennessee

[Editor's Note: Angela Knox, MSN, and Jason Weatherly, BSN, CCRN, were accidentally left off the author byline for this article. Their names have been added in the online version for readers.]

Tell us about your cath lab. 

Methodist University Cath Lab is part of the Cardiovascular Service Line at Methodist University Hospital (MUH). MUH is a faith-based organization located in the medical district of Memphis, Tennessee, providing high-quality, cost-effective patient- and family-centered care to diverse socioeconomic populations across West Tennessee, North Mississippi, and East Arkansas. MUH is the most comprehensive and largest hospital in the Methodist LeBonheur Healthcare System, with 617 beds. MUH is partnered with the University of Tennessee Health Science, and acts as the major academic campus and principal teaching hospital. MUH is a Joint Commission and DNV-GL Healthcare accredited tertiary referral center with highly specialized healthcare providers.

As a teaching facility, Methodist University Cath Lab serves as a model for the organization in integrating new technology. We place a strong emphasis on service excellence, as well as our values of quality, integrity, teamwork, and innovation. We continually strive to seek out best practices and take ownership for applying them as we focus on comprehensive regional cardiac care.

What is the size of your cath lab facility and number of staff members? 

Our department consists of 6 procedural rooms: two cardiac cath labs (diagnostic and interventional, coronary and peripheral) labs, two electrophysiology labs (EP), one neurovascular lab (diagnostic and interventional), and one hybrid suite, and a dedicated pre and post recovery unit. Diagnostic and interventional cath procedures are performed in the two EP rooms or hybrid suite, as needed.

We have a total of 40 associates working in the cath lab. Twelve associates are assigned and dedicated to cardiac cath and vascular procedures, 7 EP associates, 6 registered nurses (RNs) for pre and post recovery, one certified nursing assistant (CNA), and 10 neurovascular associates. The associates in the cath lab have been in residence anywhere from 3 months to 30 years.

There are two dedicated call teams, one for ST-elevation myocardial infarction (STEMI) and one for stroke. In 2017, we averaged a total of 500 cases per month.

The cardiovascular service line volume is growing in the region. Our cath lab has benefited from that growth, with a 10-12% increase in cases annually. We are very excited that the Methodist LeBonheur Healthcare System has invested capital into our cardiac services. We have 2 new GE rooms and a new Philips room, and we are possibly adding another room in the near future. 

What procedures are performed in your cath lab? 

We have an extensive cardiac, electrophysiology, neurovascular, and vascular program. 

Our lab does comprehensive coronary and vascular diagnostic and intervention procedures. Moreover, we do structural heart procedures, valvuloplasties, pacemakers, defibrillators, endovascular stent grafts, abdominal aortic aneurysm (AAA) repairs, and atrial fibrillation/flutter ablations. We place left ventricle (LV) and right ventricle (RV) supportive devices (Impella, Abiomed). Our neurovascular procedures include complex embolizations (arteriovenous malformation [AVM], arteriovenous fistula, tumor, aneurysms). Neurovascular also does spinal arteriograms, kyphoplasty, venous sinus pressure monitoring, and sclerotherapy procedures. 

Can you share more about your transcatheter aortic valve replacement (TAVR) experience? 

Our lab was performing TAVR from 2013 until March 2017. The program has since moved to our sister facility, Methodist Germantown. We are planning to restart performing these procedures at MUH in the near future.

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

Our lab performs primary complex angioplasties. We have surgical backup on site. MUH has a total of 21 OR suites.

What is your percentage of normal diagnostic caths?

Out of 222 total cardiac cath cases in November 2017, 36.4% of cases required angioplasty. This equates to 81 patients. Of our patients, 63.6% do not require any intervention. 

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

Our cardiology group performs procedures via radial and femoral access. There are two cardiologists that primarily use the radial approach to obtain access, including our cath lab medical director, Dr. Rami Khouzam, who is reinforcing the importance of this safe approach and practice. We have used radial access to perform elective cardiac catheterizations, as well as acute coronary syndromes, both non-ST elevation myocardial infarction and some STEMI procedures. The entire cath lab staff has been educated on the radial program. The number of procedures via radial approach is expected to increase in the upcoming months as this approach is being adopted by more interventionalists. 

If you are performing peripheral vascular procedures, do any operators utilize pedal artery access when appropriate?

Cardiologists and vascular surgeons obtain ultrasound-guided pedal access on complex vascular cases when appropriate.

Who manages your cath lab?

Angela Knox, MSN, RN, is Director, Cardiovascular Services. Rami Khouzam, MD, FACC, FACP, FASNC, FASE, FSCAI is the medical director of the cath lab. He is also the program director for interventional cardiology fellowship training at the University of Tennessee Health Science Center.

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

We have a wide range of experience in our lab. RNs and scrub techologists can circulate, monitor, and scrub. 

Are there licensure laws in your state for fluoroscopy?

On April 20th, 2016, the State of Tennessee passed Senate bill 899 that amended Title 63 Chapter 6 Part 224 in regards to the use of fluoroscopy. It established the baseline credentials needed for licensed personnel to operate radiologic imaging and radiation therapy equipment. It also mandates that each certified individual must also biennially complete twenty hours of continuing education to maintain certification.

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? 

The scrub tech can operate the x-ray equipment (position the II, pan the table, change angles). This includes the RNs, registered cardiovascular invasive specialists (RCISs), and registered radiologic technologists (RT[R]s). RT(R)s and RCISs can step on the fluoro pedal. The physicians can operate the x-ray equipment as well.

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

Lead RT(R) Terence Gaither monitors the radiation numbers and performs quality control inspections of the lead aprons yearly. Physicians and staff are custom-fitted for lead aprons. Eyewear and lead caps are also provided.

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

  • CSI orbital atherectomy for coronary arteries: we were the first lab in West Tennessee to utilize this technology for the coronary arteries in 2013.
  • Instantaneous wave-free ratio (iFR), Opsens fractional flow reserve (FFR), and new intravascular ultrasound (IVUS) devices have been recently purchased.
  • Newest Resolute Onyx stents (Medtronic).
  • New high-resolution ultrasound systems for facilitating pedal access.
  • Optical coherence tomography (OCT) technology for peripheral procedures.
  • We are introducing the WATCHMAN left atrial appendage occlusion device (Boston Scientific) as well.

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

Most of the communication is done through the holding room RN. She keeps the flow of the procedures going by letting the room lead know what is going on. She also communicates any add-on cases to the schedule. The cases are also written on the board in our main hallway, along with room assignments for that day. 

Every morning, our director conducts a daily safety huddle. We have weekly meetings with cath lab staff and management to review policies/procedures, set unit goals, and to stay up-to-date on future unit endeavors. 

How is coding and coding education handled in your lab?

Whitnie Anderson, RCIS, is responsible for cath lab coding and charges. Whitnie does an excellent job ensuring that documentation follows all department, hospital, and regulatory protocols.

Who pulls the sheaths post procedure, both post intervention and diagnostic? 

The techs, nurses, or fellows in training pull the sheaths for both post intervention and diagnostic procedures. There is mandated, regular training to keep our team familiar and competent with manual hemostasis and closure devices, as well as the TR Band (Terumo) for post radial access procedures.

Everyone in the cath lab is trained to pull sheaths, along with groin and wrist management. The patients are transported to our AngioRecovery unit post procedure. If a closure device is not used, the RNs in our angioplasty recovery area will pull the sheaths post procedure for both interventional and diagnostic procedures. 

Before a staff member is able to pull sheaths, they must go through an in-depth training from experienced nurses. Each member must complete a pre-education regarding sheaths. They will then observe multiple sheath removals by an experienced staff member. After all observations have taken place, the staff member will pull 10 sheaths under supervision. Upon completion of supervision, the staff member is able to pull sheaths by themselves. 

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

Inventory specialist David Van Netta’s sole responsibility is to manage our large inventory. It is a daunting task with our plethora of necessary supplies. He is constantly doing inventory and will purchase the required equipment under supervision of our director.

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

Since we are the tertiary care center and hub for West Tennessee, North Mississippi, and East Arkansas, we receive and perform the highest volume of STEMIs in the area. A new cath lab is under construction, with the potential addition of another lab to accommodate the expanding and increasing numbers of procedures.

Is your lab involved in clinical research?

  • Our lab has completed the ARTEMIS trial: Affordability and Real- World AntiPlatelet Treatment Effectiveness After Myocardial Infarction Study. A Prospective, Cluster-Randomized Clinical Trial that Will Evaluate Whether  Patient Copayment Elimination Significantly Influences Antiplatelet Therapy Selection and Long-term Adherence, as well as Patient Outcomes and Overall Cost of Care after Acute Myocardial infarction, where Dr. Khouzam as the principal investigator and a number of fellows in training as sub-investigators.
  • We are currently participating in the UPSTREAM registry: Utilization of Ticagrelor in the Upstream Setting for Non-ST-Segment Elevation Acute Coronary Syndrome (UPSTREAM): An ED-Based Clinical Registry. This is a collaborative, prospective registry with the Hospital Quality Foundation under a grant from Astra Zeneca. It is a Phase IV, post-approval, multicenter, prospective, non-interventional, observational registry of consecutive patients with a working diagnosis of NSTEMI and treatment with an oral antiplatelet agent (ticagrelor, clopidogrel, or prasugrel) 4 to 72 hours upstream of diagnostic angiography. The primary objective of the UPSTREAM registry is to address in detail the data gap regarding the course of NSTEMI between emergency department (ED) arrival and diagnostic angiography, by characterizing and following the ED and peri-ED use of oral antiplatelet agents. Dr. Khouzam is the principal investigator and a number of fellows in training are sub-investigators.
  • We also recently started the Detroit Cardiogenic Shock Initiative, led by Raza Askari, MD. 

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 56 minutes. To keep our D2B times <90 minutes, we have implemented a STEMI Task Force, cross-trained our Chest Pain Neuro Staff in the ED, and patients from the helipad are transported directly to the cath lab if certain criteria are met. We have also implemented a four-person call team. Our lab is registered with the American Heart Association’s Mission: Lifeline and the American College of Cardiology’s D2B Alliance.

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

During regular and after hours, STEMI patients are transported to the cath lab by the Chest Pain Neuro staff.

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

We have a four-person call team. If the physician is finishing the case, one of the call team members prepares another room. The Chest Pain Neuro staff assist the second patient until the cardiovascular intensive care unit (CVICU) staff or medical response team arrives. The CVICU staff and/or the medical response team transport the first patient to the unit. If the second patient meets the criteria to undergo tPA (tissue plasminogen activator), it could be an option to allow time for the previous case to finish. Patient safety is always our priority and we will do whatever is necessary to provide the utmost care for our patients.    

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

We have started only using Omnipaque dye (GE Healthcare) for all procedure vs using Visipaque (GE Healthcare). We also use the ACIST power injector for all of our procedures.  This is very cost efficient in that we are not wasting a lot of contrast.

Also, following recent guidelines, most of our interventionalists have started replacing bivalirudin with heparin during percutaneous coronary and peripheral interventions.

What quality control measures are practiced in your cath lab?

We incorporate Appropriate Use Criteria (AUC). We also use a hydration protocol and calculate the maximum radiographic contrast dose (MRCD) prior to each case.

How do you determine contrast dose delivered to the patient during an angiographic procedure? 

The ACIST power injector allows us to have an exact measurement of the amount of contrast delivered to the patient.

Are you tracking the incidence of contrast-induced acute kidney injury in patients? 

Yes. However, we have implemented a pre and post cath hydration protocol to reduce the incidence of contrast-induced acute kidney injury. Establishing a baseline protocol for proper patient hydration before and after a cardiac catheterization is crucial to avoiding a contrast-induced kidney injury.

How are you recording fluoroscopy times/dosages?

Fluoroscopy times and dosages are documented in the GE Mac-Lab/ CardioLab system. 

We record the fluoro times using equipment from Philips, GE, and Siemens Healthineers.

What is the process that occurs if a patient receives a higher than normal amount of radiation exposure? 

Our policy is to inform the physician when they are getting close to reaching 5 gray (Gy)/60 minutes of fluoro time, and again at 7Gy. If the physician goes over 7Gy, then the physician must provide consultation with the patient before discharge. Also the patient will be given a “Fluoroscopy Exposure Information Sheet” which provides radiation follow-up instructions.

Who documents medication administration during the case?

The monitor tech documents medication administration in the GE Mac-Lab hemodynamics monitoring system during the case. However, the RN documents medication administration in Cerner.

Are your physicians dictating their cath procedure reports, or do they use a structured reporting tool?

The cardiologists dictate their cath procedure report. They also chart an immediate post procedure note in Cerner.

Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) or any other outside data collection registry?

Yes, we participate in the CathPCI registries. Registry data records are populated using the GE Mac-Lab system. We have two full-time data abstractors (Clinical Quality Analysts).

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

MUH cath lab competes with two other hospitals in the greater Memphis metropolitan area. We participate in monthly outreach programs with outlying hospitals.

How are new employees oriented and trained at your facility?

We assign all new employees to a preceptor and depending on their experience in the cath lab, the orientation period can last anywhere from six weeks to six months. 

What continuing education opportunities are provided to staff members?

A great deal of the continuing education comes from vendors. They offer education on their websites where staff can receive continuing education units (CEUs). Vendors can also come in and do training that allows for CEUs. 

How is staff competency evaluated?

A cath lab skills fair is held yearly to evaluate staff competency. The evaluations are based on checklists, direct observation, and written tests. Several vendors are in attendance to assist with evaluating staff. Computer-based learning is also available through Cornerstone.

How do you handle vendor visits to your lab?

Vendors are required to schedule time in advance to visit the lab. They must meet the Reptrax requirements and have a badge on at all times. The vendors are allowed to sit in the staff breakroom unless requested by a physician. They are limited to one visit per week.

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

All cardiovascular technologists are required to take the registry exam for the RCIS within 2 years of their hire date. A raise is received upon passing the exam. 

What do you like about your department’s physical space? 

All the rooms are very spacious and well organized. The layouts are very staff-friendly and make the complex cases easier due to the size of the rooms. 

How does your lab handle call time for staff members? 

We have a cardiac call team and a neuro call team. Both call teams consists of two nurses and two techs, or one nurse and three techs. There must be at least one nurse on call at all times. 

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

The cardiac call team has thirty minutes to arrive after being paged.

Do staff members have any little or big particular perks that you might like to share? 

The associates are permitted to leave early or start later after a night of on-call. Our staff enjoy the fact that they are guaranteed to get their 40 hours a week without having to use their PTO hours. There is also free parking within a covered garage.

Do you have flextime or multiple shifts? How do you handle slow periods?

The teams work four ten-hour shifts. Staffing levels are driven by volume. During low census, staff are offered time off or assigned other duties.

Are your clinical and/or managerial team members involved with any professional organizations that support the invasive cardiology service line, such as the Alliance for Cardiovascular Professionals (ACVP)?

Yes.

Has your lab recently undergone a national accrediting agency inspection? 

Yes, we were recently inspected by DNV-GL Healthcare. Our recommendation would be to treat each day as if you were being inspected at that moment. Make sure you are doing everything the right way every day.

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

We have seen a trend in our patients requiring cardiac services being younger and with several comorbidities. We have also seen an increase in patients requesting radial access for their procedures. Many patients really like this approach because the bedrest is not as long as for procedures with femoral artery access.

Is there a problem or challenge your lab has faced? 

While undergoing renovation, it was necessary to use only one room for cardiology. Our staff and physicians worked very well together to rotate their schedules so that every patient was accounted for in a timely manner. The volume increased 18% during this time.

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

Our cath lab team is a very diverse, with ages ranging from early 20s to late 50s. The background of the team consists of individuals who have worked as first responders, CVICU, ED and telemetry nurses, respiratory therapists, radiologic technologists, and surgical technologists. Our administrative director formerly worked as a police officer for the Memphis Police Department.

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”?

Memphis is located in the southwest portion of Tennessee. We are bordered by eight other states: Kentucky, Virginia, North Carolina, Mississippi, Alabama, Georgia, Arkansas, and Missouri. We can have patients flown to our facility from any of these states. Memphis is known nationally for our barbecue, with the World Championship Barbecue Cooking Contest held every year in May. Our city also hosts the St. Jude Memphis Marathon with thousands of runners yearly. We are home to Elvis Presley’s Graceland, and receive visitors from around the world to see Elvis’ residence. With so much to do in our city, our staff members are well versed in giving out restaurant and entertainment recommendations to our patients and families.  

The authors can be contacted via:

Derrick Bowen, BSN, RN, Team Lead, at derrick.bowen@mlh.org

Roxanne Gardner, RCES, Lead Invasive Cardio Tech, at roxanne.gardner@mlh.org