Cath Lab Spotlight

Spotlight: Baystate Medical Center

Bob LaBonte, Heart & Vascular (H&V) Tech IV, Maria O’Reilly, RN, Janette Walker, H&V Tech IV, Debra Bailey, H&V Tech IV, Courtney Charland, RN, STEMI Coordinator, Peggie Simeoli, RN, Gordon Carr, RN, Donna Smolen, RN, Corey McKinstry, Manager, Springfield, Massachusetts

Bob LaBonte, Heart & Vascular (H&V) Tech IV, Maria O’Reilly, RN, Janette Walker, H&V Tech IV, Debra Bailey, H&V Tech IV, Courtney Charland, RN, STEMI Coordinator, Peggie Simeoli, RN, Gordon Carr, RN, Donna Smolen, RN, Corey McKinstry, Manager, Springfield, Massachusetts

Tell us about your cath lab.

We currently have four cath labs staffed with registered nurses (RNs), technologists, and technical associates. Staff longevity ranges from two months to 27 years, with an average of about 12 years. We have several advanced-level certified team members: an RN and registered cardiovascular invasive specialist (RCIS), two certified emergency nurses (CENs), three critical care registered nurses (CCRNs), an American Association of Moderate Sedation Nurse (AAMSN) and one registered radiologic technologist (RT[R]). We have two Philips and two Siemens rooms. We added a biplane system about 2 years ago that is used for both neuro and peripheral procedures. Every staff member has certification with the National Institutes of Health Stroke Scale (NIHSS) to support our neuro interventional and BAT (Brain Attack Team) team role.

We proudly celebrated the completion of our 100,000th procedure this past winter. The first coronary angioplasty at Baystate was performed in 1981 by Dr. Marc Schweiger. Our primary PCI program includes 12 interventional cardiologists who belong to three distinct groups. They share the interventional call responsibilities equally and work in a collaborative manner. Baystate received the American Heart Association’s Mission:Lifeline Silver Plus award this year for quality outcomes in ST-elevation myocardial infarction (STEMI) patients.

What procedures are done in your cath lab?

Procedures done in the lab include:

  • Left and right diagnostic catheterization;
  • Percutaneous coronary intervention (PCI), which may include the use of intravascular ultrasound (IVUS), fractional flow reserve (FFR), iFR (instant wave-free ratio), AngioJet (Boston Scientific) and Rotoblator (Boston Scientific);
  • Device implants, intra-aortic balloon pump (IABP), Impella (Abiomed);
  • Peripheral diagnostic and interventional cases (interventional cases may include use of the Diamondback 360 orbital atherectomy device [CSI]);
  • Aortic angiography, carotid angiography and stenting;
  • Visceral angiography and interventions;
  • Structural heart procedures such as patent foramen ovale (PFO)/atrial septal defect (ASD) closure, and valvuloplasty;
  • Kyphoplasty and vertebroplasty;
  • Neurovascular angiography and interventions (coiling, stenting, and embolization [arteriovenous malformation (AVM)]).

We have 24-hour, seven days/week call for both the cardiac STEMI team and neuro BAT team. We perform 295 cases/month, averaging about 75 cases per week. Of these cases, 250 monthly are cardiac catheterizations. Each quarter, we perform anywhere from 280-325 PCIs. Our neuro interventions are rapidly increasing with the recent studies in favor of endovascular treatment for stroke.

Do you perform transcatheter aortic valve replacement (TAVR)?

We have been performing TAVR for approximately two years. TAVRs are conducted in our Heart & Vascular endovascular suites, designed specifically for hybrid procedures. Our team consists of cardiac surgeons, interventional cardiologists, and cath lab and OR staff. We have completed over 80 cases to date.

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

More than half our physicians perform radial procedures. About 20% of our caths are performed via radial access. 

Who manages your cath lab? 

The manager of our cath lab is Corey McKinstry, cardiovascular technologist (CVT). She is a retired Air Force veteran of 21 years. Corey worked in the lab as a cardiovascular technologist for 10 years and became the manager in 2012. The cath lab medical director is Dr. Greg Giugliano, who has been at Baystate since 2003 and is a practicing interventionalist. They work together and collaborate across the Heart & Vascular Center with the HVOR, cardiothoracic surgeons, vascular surgeons, and interventional radiologists, to manage inventory and achieve a common set of goals.    

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

Our lab always maintains a team approach. All the members of this team train and are competent in all roles. Everyone monitors, circulates and scrubs for the cases. Only the RN administers medications, conducts patient assessment, and provides moderate sedation. This provides flexibility for staffing and schedule changes. 

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

According to the Massachusetts state law, only radiologic technologists, physicians, and physician assistants with training are permitted to operate the x-ray equipment. Our physicians manage the pedal and maneuver the table.

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

Our department supplies all staff and physicians with lead vests and skirts or aprons, which are inspected annually by our radiation safety department. Our department also supplies each employee with his/her own pair of radiation protective glasses, as well as lead scrub caps for the physicians. In addition to the protective equipment, we wear dosimeters that are collected monthly and analyzed to monitor exposure. Each procedure room has lead aprons mounted to the bottom of the procedure table to protect the lower section of the body and lead shields to protect the upper section of the body. We have a daily radiation reporting system to monitor patients who receive a high fluoroscopy doses. In those particular patients who have received a dose above our radiation threshold, the medical director notifies the performing physician, radiation safety department, and the patient by formal letter. The clinical follow-up is subsequently arranged to identify both early and late sequelae.

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

We recently updated to a new IVUS/FFR/iFR system from Volcano. We have upgraded to the Impella CP system for left ventricular assistance, as well as the Pipeline embolization device (Covidien) and Solitaire thrombectomy device (Covidien) for our neuro service line. We also have peripheral drug-eluting balloons and stents.

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

We have staff meetings monthly, educational inservices, and email frequently. We have a Facebook page and also use an internal social media website.

How is coding and coding education handled in your lab? 

We use the Horizon Cardiology Charge manager (McKesson). Procedures are chosen and procedure codes are attached. Supplies are scanned. We have a comment area in the charge worksheet online to which the coders have access. The staff can leave notes if they are unsure what to choose, or want to explain complexity or special events such as aborting a procedure. The coders review all cases and ensure proper coding before charges are submitted. We also developed a post-procedure checklist that is completed in the recovery room. High interest areas are addressed to avoid errors and rework. 

Can you describe the path to hemostasis for both interventional and diagnostic procedures? 

Whether an interventional or diagnostic procedure, our physicians may utilize a closure device. If a closure device is not used, sheaths are removed in the recovery room. Hemostasis is achieved by manual pressure if the activated clotting time (ACT) is <180 seconds. If sheaths are sutured in place, patients are returned to their nursing unit after recovering for a minimum of 30 minutes. Sheaths are pulled by cath lab staff, certified floor staff or cardiology fellows two hours after an interventional procedure. 

What kind of training is mandated before someone can pull a sheath?

During orientation, staff is instructed in proper sheath removal and hemostasis. Each orientee must successfully remove 12 sheaths and achieve hemostasis in preparation to perform this task. Upon completion of orientation, staff members are required to remove 10 sheaths per year with successful hemostasis in order to maintain competency.    

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

Patients arrive to the lab with groin or radial sites clipped. Patients are then placed on the procedure table, and access sites are prepped, scrubbed, and draped by an RN or CVT assigned as scrub staff per case. Post procedure, patients are recovered in our four-bed recovery area. If no closure device is used, the sheaths are pulled by recovery area staff. If a closure device is used, the sheath is pulled by the fellow or attending physician prior to closure device deployment.

How is inventory managed at your cath lab? 

Our inventory technician works for the manager of the lab. He uses Vuemed/Lawson to order and keep track of stock levels. A Heart & Vascular Value Analysis team reviews and evaluates requests for new equipment. An e-requisition application was recently implemented to allow for electronic approval with set approval levels.    

Is your lab involved in clinical research? 

Baystate Medical Center Heart & Vascular has an active research department. We have been involved in many clinical research trials, including investigational pharmaceuticals and device trials. Recently we completed enrollment in the worldwide EXCEL study that randomized patients with left main disease to coronary artery bypass graft surgery (CABG) or PCI. Currently, we are participating in the Multi-center Prospective Study to Evaluate Outcomes of the Moderate to Severely Calcified Coronary Lesions (MACE trial). This is a CSI-sponsored, real-world study to determine if increasing severity of calcification within coronary arteries can be correlated with outcomes.

Who handles relevant data and its entry into the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR)?

Our physicians enter the pre-procedural information into our McKesson hemodynamic reporting system. This information is double-checked by the cath lab staff both before and after the procedure. We have a dedicated Heart & Vascular Quality Outcomes Department that is then responsible for data collection and reporting outcomes for cath/PCI.

Can you tell us about your STEMI program?  

Baystate Medical Center is involved with the American Heart Association’s Mission:Lifeline, a program designed to enhance national STEMI care, and American College of Cardiology’s D2B Alliance. Mission:Lifeline has over 900 hospitals that perform emergency coronary angioplasty. Baystate Medical Center is the 6th highest volume program across the nation. Our average door-to-balloon time is 57 minutes. During regular hours of 7:00am to 7:30pm, our average door-to-balloon time is 50 minutes. During off hours of 7:30pm to 7:00am, our average door-to-balloon time is 60 minutes. We have the highest volume of STEMI patients within the Commonwealth of Massachusetts. All of our referring hospitals, emergency medical services (EMS), and hospital staff contribute to the positive outcomes and receive feedback from the regional STEMI coordinator. 

When do you start the “clock” for door-to-balloon times?

We use the earliest documented time in patient’s medical record to determine the start time. This may be the triage time or the time of the first electrocardiogram (ECG).

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

Due to our unique geographic regions, we are challenged with time and distance when caring for a critical STEMI patient. All STEMI patients at non-PCI hospitals with anticipated long transfer delays will receive fibrinolytic therapy (if not contraindicated) and then be transferred to Baystate Medical Center for a cardiac catheterization. When a STEMI patient is admitted directly to Baystate Medical Center Emergency Department (ED) transported via EMS, the 12-lead ECG is transmitted to the ED staff and the cath lab from the field. The ED communicates with the cath lab and the patient is evaluated by the cardiology fellow and/or the interventional cardiologist in the ED on regular hours. The patient is then transported to the cath lab with the nurse, nursing support, and the cardiology fellow. If the cath lab team is ready and waiting both during regular and off hours, EMS will transport the STEMI patient directly to the cath lab if there is no reason to be evaluated in the ED. If the cath team is not readily available when the patient arrives from a referring hospital, the patient is assessed in the ED and then transported by the ED staff caring for the patient.

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

When a STEMI arises during the hours of 7:00am to 5:30pm, we assess the progress of all four rooms and the first room that has the best opportunity for starting or stopping takes the case. The flow coordinator collaborates with the on-call physician to identify who will perform the case. During off hours, if an emergency patient is undergoing a cardiac cath and another STEMI presents to the ED, an available cardiology fellow/physician assistant (PA) will evaluate the patient. Depending on the progress of the STEMI patient on the table, we will either call for the patient as soon as possible or the patient will be treated with lytic therapy. The patient will either be monitored in the ED or Heart & Vascular Critical Care (HVCC). Under rare circumstances, we will ask the HVCC nurse to transport the completed STEMI case, so that the cath lab team can turn the room over and proceed with the next emergent case.

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

We have many quality improvement committees and programs. The staff participates in collecting the data and it is reviewed during Heart & Vascular Performance Improvement committee meetings. We also have a quality program for our point of care. This is managed by the hospital reference lab and maintained by a CVT in the cath lab.

Who documents medication administration during the case? 

Horizon Cardiology is our documentation and reporting system. The monitor role documents all events during the case, including medication administration. A procedural report is printed at the end of the case and transported to the floor with the patient. This tool is used for handover and then scanned in the electronic medical record (EMR).

How do you handle vendor visits to your lab?

Vendors use a program called Reptrax. They must have an appointment to be in the lab and cannot go into a procedure unless they have been asked to support a specific case.  Our vendors must wear red scrub hats in the clinical area.

How are new employees oriented and trained at your facility? 

New employees start with a hospital orientation to review hospital-wide applications and programs. Upon arrival to the cardiac cath lab, they are assigned a preceptor and are guided by an extensive checklist. At the end of their training, they begin “buddy call” to familiarize themselves with the nuances of STEMI call after hours.      

What continuing education opportunities are provided to staff members?

Twice a week, we have 1 hour of in-service. Classes are arranged to provide education on new equipment and procedures, required re-occurring training, and special areas of interest. Staff, physicians and manufacturers’ clinical specialists present the information.  Also, we have hospital symposiums. Specialty associations provide CEU (continuing education unit) opportunities. On occasion, staff is chosen to attend regional conferences.  

How is staff competency evaluated? 

Once a year we have a mandatory skills night. We have stations for equipment, where information and procedures are reviewed. Staff has hands-on practice and the ability to ask questions. A checklist must be completed. Food is provided and it is a rare opportunity for the entire staff to be together without the pressure of workload requirements.

Does your lab have a clinical ladder? 

Career development is an important facet of our cath lab. Personal and professional growth is encouraged. RNs participate in the Hospital Nursing Clinical Recognition Program, or “clinical ladder”. This ladder consists of four levels of professional expertise based on Patricia Benner’s work, From Novice to Expert. We have adapted this to provide a clinical ladder for our cardiovascular technologists.

Each level is awarded a wage increase and requires an increase in responsibility and building of leadership behaviors. Annual performance evaluations include a revalidation of each individual’s maintenance of the standards required for their clinical level.

Initial and maintenance documentation include a resume, a detailed self-assessment, clinical narratives, and peer and manager evaluations.

Movement on the clinical ladder is based on clinical competence, pertinent knowledge base, education, professional development, participation in institutional programs and initiatives, and specialty certifications. A one-time bonus is awarded when the first specialty certification is achieved. Currently, RCIS certification is required for CVTs to advance to Level IV.

Maintenance of higher levels results from consideration of: participation in cath lab projects, quality assurance, precepting new employees, providing in-service education, maintaining unit-based competencies, and completing required hospital-wide, web-based training. Becoming a super-user, project champion, lead trainer, room lead, and patient flow coordinator are also considerations.

The clinical ladder encourages individuals to consistently evaluate their clinical practice and professional growth. It also fosters an attitude that keeps us flexible and ready to take on new procedures and challenges.    

How does your lab handle call time for staff members? 

The call teams are developed at the beginning of the year and the calendar is posted independently from the daily schedule. A STEMI team is comprised of 3 people. At a minimum, one must be a nurse. Our BAT team is a hybrid team, which has minimum of an RN, one CVT/RN and one RT(R).    

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

We have a 30-minute response time for both teams.   

Do you have flextime or multiple shifts? 

We have multiple shifts to adjust to fluctuations in volume: 12-, 10-, and 8-hour shifts keep the lab open from 7am until 7:30pm.    

Has your lab recently undergone an accrediting agency inspection? 

We had 3 visits in one year from The Joint Commission, Massachusetts Department of Public Health (DPH) and DPH for Radiation Safety. Contrast and warmers, tracking lead inspections, and labeling trays were some of the items that were highlighted. 

Where is your cath lab located in relation to the OR and ED? 

The Emergency Department is located on the ground floor of the Davis Family Heart & Vascular Center. The Heart & Vascular endovascular suites that specialize in cardiac and vascular surgical procedures (HVOR) are located on the second floor. It takes under 3.5 minutes to get to the HVOR and from the ED to the cath lab. Our future home in the Davis Family Heart & Vascular Center was designed to have direct elevator access to the helicopter pad, HVOR, and ED. 

Is there a current challenge faced by your lab?

The most challenging problem is being fiscally responsible while responding to the unpredictable volume. We have sampled different work schedules and work flows to best meet the needs of the patient while still striving to be efficient. Dedicated staff has been the key to our success.

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”? 

Baystate is the only PCI receiving center in Western Massachusetts. We have 10 referring non-PCI hospitals as part of our regional STEMI program. We have a very diverse patient population that may live in rural towns over 2 hours away or come from the inner city of Springfield. We have the busiest emergency room in the state of Massachusetts and treat more patients with STEMI than any other hospital in the state. We serve a large minority population in Springfield that is primarily Hispanic. Our staff adjusts their approach to patient care to provide an individual experience to suit the patient’s needs. 

A question from the Society of Invasive Cardiovascular Professionals (SICP):

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? 

To receive a Level 4 as a Heart & Vascular Tech, you must have your RCIS. The RCIS is credential is one of several options for the Clinical Level 4 RNs. We have partnered with the Hoffman Heart Institute and are a clinical site for their RCIS program. A study program was conducted during our weekly in-services and there are several staff currently scheduled to take the RCIS certification exam. Upon successful certification, all staff is reimbursed for the test and receives a monetary bonus. 

A question from the American College of Cardiology’s National Cardiovascular Data Registry:     

How do you use the NCDR Outcome Reports to drive QI initiatives at your facility?

We report to the national ACC-NCDR registry in addition to the Massachusetts PCI registry. The interventional cardiologists review outcomes data collected by our cardiovascular outcomes department to verify the information on a quarterly basis prior to submission to these groups. We evaluate how we compare to the rest of the country to identify areas for improvement. For example, about a decade ago, we used this data to identify an area for improvement with regard to vascular complication rates and initiated multiple changes that resulted in a dramatic reduction in vascular bleeding.