Tell us about your institution and cath lab.
Our department contains three cardiac cath labs (diagnostic and interventional), one electrophysiology (EP) lab, a non-invasive area, a dedicated cardiac prep and recovery unit (CPRU), a hybrid OR for structural heart procedures (transcatheter aortic valve replacement [TAVR] and WATCHMAN left atrial appendage procedures [Boston Scientific]), cardiac surgery, and a coronary care unit (CCU). In addition to diagnostic and interventional heart catheterizations, we perform peripheral diagnostic and interventional procedures, pacemaker, and generator implant procedures. We began performing TAVRs in July 2016, and recently performed our 50th TAVR case. We will perform our first WATCHMAN procedures this July.
We built a specific hybrid room, OR 12, for TAVR. Interventional radiology also uses that room. In addition, two of the three cath rooms in our department are brand new Siemens labs. Bon Secours St. Francis Health System has invested a lot of capital into our cardiac services in the last 12-15 months, which we are very excited about.
Our facility is located in downtown Greenville. Recently Greenville, South Carolina, was listed as the fourth largest growing city in the United States. Our city has a tremendous amount to offer individuals and families moving into the area.
As a healthcare provider, we have responded to that growth in our market accordingly, and our cardiac department has specifically benefited from that growth. Our catheterization volume is growing at 4-6% annually. The use of lean processes has made our service line very safe and efficient, allowing us to offer our services to more patients in the region.
Can you tell us about the physicians and staff at your lab?
Upstate Cardiology is a phenomenal group of cardiologists and physicians with 18 interventionalists working in our lab. We have approximately 26 staff members assigned and dedicated to the cath lab, with 9 prep and recovery RNs and 5 EP staff. Among the cath staff, we have 5 dedicated call teams. In addition to RNs, we have registered radiologic technologists (RT[R]s), and 3 registered cardiovascular invasive specialist (RCIS) credentialed staff currently in our department. The average length of stay in our department is more than 7 years, with some staff members that have more than 11 years. If you look at the industry standard, that far exceeds the stay expectancy at most departments. We “hire to retire”. Our retention is a result of the culture at St. Francis, a culture that starts with our CEO and works its way throughout the organization. It is a culture upheld by our director, DeAna Simpson, BSN. Our department offers a very family-oriented environment and we are a close-knit group. Our physicians value and respect what we do as staff to support their services as cardiologists.
Can you tell us more about the management team at your lab?
Ron Spencer is the administration director, and is in charge of both invasive and non-invasive cardiology. Our invasive cardiology director is DeAna Simpson, BSN, and the cath lab charge nurse is Barney Wasson, RN.
Do you have cross-training? Who scrubs, who circulates and who monitors?
Cross-training is one of the core expectations of the department. We are blessed to have a talented group of professionals that have a desire to learn all aspects of our department and within our organization.
What is the percentage of radial procedures at your lab?
Our cardiology group performs more than 85% of cases via the radial approach. The radial program is one of the jewels in the Bon Secours St. Francis Health System crown. The entire lab is oriented towards radial access and our same-day discharge program. We are one of the few labs in upstate South Carolina that offer a dedicated radial lounge approach with an emphasis on same-day discharge. As a matter of fact, the majority of our ST-elevation myocardial infarction (STEMI) procedures are done via the radial approach, whether left or right radial.
When I arrived at the Bon Secours St. Francis cath lab in May 2010, less than 10% of cases were done radially. Dr. Mathew Nessmith is an Upstate Cardiology interventionalist who was formally trained in Georgia as a radialist. Dr. Nessmith and some of his fellow interventionalists wanted us to do more radial cases. At Dr. Nessmith’s request, and with his and Barney Wasson’s support, I worked to create a radial board called the Cardio-TRAP (Cardiovascular Trans-Radial Access Platform) (Trans-Radial Solutions LLC), which helped usher in our ability to provide a same-day discharge program and a radial lounge atmosphere. We actively market that atmosphere to our patients. Patients are far more educated now than they were 7-8 years ago, and come in asking for radial access for their procedures.
Can you share more of the story behind the creation of the Cardio-TRAP?
Prior to the board’s creation, about 10% of our cases were being done radially and neither the physicians nor the staff felt comfortable in being able to set the patient up properly for the procedure. We lacked a proper access platform. Knowing my entrepreneurial side, Dr. Nessmith asked me if I could develop a radial access platform. I spent four to five weeks looking at some potential constructs and configurations, and I developed the first radial board in the fall of 2010. That device went through four generational changes to what we currently use in the lab today, the Cardio-TRAP. Dr. Nessmith requested that we find a more efficient, safe way to perform radial access, and part of the culture at St. Francis that I enjoy, and I think our staff also enjoys, is that the hospital encourages us to think outside the box. When we see a problem or opportunity, they want us to bring ideas and concepts forward. It brings value to the organization and value to our patients.
So the administration was aware of the work you were doing?
Yes. The hospital promotes this kind of innovation and it is a theme that runs all the way through our organization, whether ideas come from somebody in the cath lab, the OR, or in transportation. Our organization promotes innovative thinking.
What has been the impact of the Cardio-TRAP?
It affects the entire department. We use the platform on every radial case. Because we have a very competent radial access platform, we are able to offer same-day discharge. It allows us to turn the rooms over much quicker. Prior to the board, if the patient had bypass surgery, we would have to convert the room to a left room setup, which was time consuming. Use of the board has made the department more efficient and increased our ability to treat more patients. It provides us with the ability to perform more radial cases. The Cardio-TRAP has become an important part of our same-day discharge program. Same-day discharge is important to the patient. To come in and have a diagnostic heart cath, or even have a stent placed, and meet certain qualifications to be able to go home the same day is of enormous value to our patients. It is also of enormous competitive value when competitors in the same market don’t offer those benefits.
What were some of the challenges you faced in designing the Cardio-TRAP?
The platform had to be utilized in the cath lab, so it had to be radiolucent, and it had to be a material that would not absorb body fluids and create a contamination or sterility issues. That was the easy part. The hard part was in developing the overall design as to how staff would articulate the device. In terms of mechanics, what I think is easy someone else may not. There is a wide, diverse group of individuals that work with the platform. When any new device comes into the cath lab, companies recognize the value in staff being very comfortable with their device in order for that product to be successful. So we were fortunate in being able to get the staff involvement in the evolution of the Cardio-TRAP. It was important to get their buy in, as they are the ones using and working with the device. It has to be comfortable, and it has to be quick and efficient to install and take away after the procedure. It took about 18 months of changes and modifications until we got to where the final product is now.
However, the Cardio-TRAP is a small part of all that is required to put together a same-day discharge program and a radial lounge environment, although it definitely assisted in that process. It is always a goal of St. Francis to provide value to our patient and have a competitive edge in the market. We saw the trend of same-day discharge and a radial lounge atmosphere in other facilities, especially in the northeast, where you may have six or seven operators in a four-square-mile radius. We felt our staff could work toward same-day discharge and a radial lounge environment, and the organization was committed in working toward that goal. The radial platform was simply another device, similar to the wires and catheters we use, that came together to allow us to provide that capability to our patients.
It sounds like individuals can take on a high level of responsibility at your facility.
Exactly. We believe in “to whom much is given, much is expected.” We as staff feel empowered, that this is our department and not just the Bon Secours St. Francis cath lab. Our leadership gives us that freedom and flexibility. You never know where a solution is coming from and you never know where that next great idea is coming from. Bon Secours St. Francis Health System recognizes the value and importance of their employees, and that is what makes it a special place. It is not uncommon to walk through the hospital and see the CEO in the hall, and have him come in and talk with us. All senior level administrators hold that attitude of empowering their employees.
Are there licensure laws in your state for fluoroscopy?
Yes. From the South Carolina Department of Health and Environmental Control (DHEC): 18.104.22.168 No person other than a licensed practitioner or a radiologic technologist possessing a current, valid certificate from the South Carolina Radiation Quality Standards Association (SCRQSA) shall use equipment emitting ionizing radiation on humans for diagnostic purposes.
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?
Scrub staff is composed of RT(R)s, RCISs, and RNs. All can pan and drive the table. As per DHEC, only SCRQSA-certified RT(R) and RCIS staff can step on the floor pedal.
How does your cath lab handle radiation protection for the physicians and staff?
We have dedicated RT(R)s that monitor our radiation numbers and scan our lead on a regular basis, and handle the quality control checks for our lead and other radiation control devices. When there is a need in the department, director DeAna Simpson will alert our team, and very often, somebody from within the department will rise to the occasion and take ownership. Fluoro limits are reported in the Mac-Lab, and RT(R) Scott Pinion spends his personal time transferring that data into a separate excel spreadsheet so we can provide daily, weekly, and monthly reports to our health physicist department that show staff and cardiologists’ individual dose limits and radiation numbers. It is something that Scott takes ownership of, because he is interested in doing so. This is just one example of the sense of empowerment and ownership that the hospital creates and that brings value to the department. The Cardio-TRAP offers a radiation protection component as part of the device that also reduces radiation exposure to physicians and cath lab staff.
What is the process that occurs if a patient receives a higher than normal amount of radiation exposure? How is the patient notified and what follow-up do they receive?
We use Quantros, a web-based software to report safety events and unsafe conditions. Patients receiving more than one hour of floor time are logged into our exposure log. A Quantros report is filled out, and a Mac-Lab report is attached with all dosing and angle information. This information is given to the physicist for further calculations to determine if the dose exceeds the threshold (3 Gy) for radiation-induced skin injury. Follow-up, depending on the outcome, is done by the cardiologist per physicist recommendations.
What are some of the new equipment, devices and products recently introduced at your lab?
In addition to our two new Siemens labs, Bon Secours St. Francis Health System recently incorporated the ACIST dedicated contrast injection system.
Are your physicians dictating their cath procedure reports or do they use a structured reporting tool?
Our cath lab physicians dictate their reports and our EP physicians use structured reporting in ConnectCare (Kodak Alaris)
How does your lab communicate information to staff and physicians to stay organized and on top of change?
Our department conducts a morning huddle prior to the start of procedures and has a regular department meeting the second Wednesday of each month. Every staff member is active with organizational email.
Who pulls sheaths post procedure?
All staff is regularly trained and tested on sheath and groin management. We require new staff to watch six sheath pulls, then, under supervision, the staff member will pull an additional six sheaths. The high radial count of our procedures creates an environment in which we deal with very few sheath pulls.
Where are patients prepped and recovered (post sheath removal)?
Our outpatients’ journey starts with our prep department. After the procedure, our recovery department provides patient care. Most of our caseload is performed via the radial approach and we use a TR Band (Terumo) for our radial patients. The few cases that require a femoral approach are closed with Mynx (Cardinal Health), Angio-Seal (Terumo) or Perclose (Abbott Vascular). Our cardiologists make every attempt to access via radial; in the event of femoral access, an emphasis on a closure device is common practice. In the event of a sheath pulls, we have many experienced staff available to pull the sheath.
How do you promote staff education?
Our department educator is Leah Hall. Education is ongoing throughout the year. In-services are provided formally every second Wednesday of the month with CEUs often provided. New products or changes to existing produces are discussed during morning safety huddle in-services. All new procedures require in-servicing and quarterly education is done for high-risk equipment. Training, credentialing, and personal growth are emphasized and are an important part of the culture at Bon Secours St. Francis.
How is inventory managed at your cath lab?
We utilize a web-based inventory system that is managed by a dedicated staff member.
How are your five call teams organized and scheduled?
We use an internet-based software application to notify the call team. Once the notice goes out, staff has 30 minutes to be in the room, ready to perform the procedure. Patients may already be in our ED when we arrive, but often they will come straight from the EMS truck directly into the cath lab. We will send cath lab staff over to meet the EMS or ED staff with the patient. Our door-to-balloon times average 33 minutes.
Our call teams consist of three staff members, with one RN required. In South Carolina, only RNs are allowed to push drugs. All of our RNs are BSNs. There is a program hospital-wide within the hospital to get all non-BSNs credentialed to BSN over a certain timeline. RT(R)s and/or RCISs are the second and third members of the team. During a call weekend, staff can be called upon to do a pacemaker, a heart cath, or an emergent peripheral case.
Barney Wasson is the cath lab charge nurse, and he manages our schedules in eight-week block intervals. We know our days off eight weeks out. We work four days during the week with one day off. The particular day may vary. In an eight-week period, we may get two Fridays off, for example. We are on call one night a week, late stay one night a week, and are assigned weekend call every fifth weekend. It is variable as a result of paid time off, department fluctuations, vacations, sicknesses, and so on. One thing that really makes our department special is how we all support each other if someone needs to change a call weekend, or has a family crisis or a sick child. If I need somebody to pull my call for the night, it is not uncommon to have two or three people volunteer. We are that close as a family. Many times we will pull call two or three nights in a row, if that is what it takes for a fellow co-worker. When we are on call, we are there until the last case is done. On the weekends, call starts on Friday evening from the last case until Monday morning at 7am. Typically, staff will be off after being on call, but this obviously changes as the staff and work volume dictates. We typically park in the emergency department (ED) parking lot, which is right outside the ED. Parking is never an issue.
What do you do when the call team is already busy doing a procedure and a STEMI comes into the ED?
Our department has a call team and a late team, Monday through Friday. Typically, the late team will be on site if we have more than one cardiologist actively performing cases. The late team is required to remain on site up to or after 7pm to ensure that the call team can handle the current caseload. There have been times when more than one team has been required on the weekend or after hours, and many times staff volunteers will respond to handle the additional STEMI event.
What quality control measures are practiced in your cath lab?
Many of the quality controls in the lab are completed by staff. The rooms are checked every day, lead aprons are scanned regularly, and we do systematic and regular scanning for out-of-date products. We employ a system of date checking for cardiac supplies. RNs regularly validate ACT quality control functions. Mac-Lab reports are checked by two separate individuals prior to going to medical records. We take great pride in our quality control process.
How does your cath lab compete for patients?
Bon Secours St. Francis Health System competes against a much larger facility within the Greenville market space. We provide a strong emphasis on patient care in an atmosphere that places a high priority on the patient as a person of value. This hometown, personal touch fosters an atmosphere in which our patients can feel our compassion and interest in their care and recovery.
How are new employees oriented and trained at your facility?
The orientation process is competency based and goal oriented. New employees are assigned a preceptor, but all staff participates in the orientation process. Performance is evaluated and discussed with the new employee, preceptor, educator, and director. Individual competencies and comfort are evaluated weekly. Each new employee begins in the position for which they were hired and then is cross-trained into other responsibilities as their skills advance. Depending on initial skills, the new hire spends twelve weeks orienting to the hired position. New hires take “buddy call” as a fourth person until they are competent to be a third with another technologist or nurse as appropriate.
How is staff competency evaluated?
Staff competency is evaluated and verified on a yearly basis. We currently use the Donna Wright method. The goal of competency assessment is to evaluate individual performance, group performance, meet standards set by regulatory agencies, address problematic or high-risk procedures and equipment, and encourage professional development.
Does your lab have a clinical ladder?
The hospital has a nursing clinical ladder. The cath lab does not have a clinical ladder for technologists at this time. The institution is currently revising the preceptor program to include all staff and align itself with the nursing model, rewarding knowledge, accomplishments, and education.
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, ACTION, ICD, TVT, and upcoming will be the LAAO registry. We have three full-time data extractors who also navigate patients through the health care system. Registry data entry is mostly done manually. Limited data is populated in from GE Mac-Lab reports.
Has your lab recently undergone a national accrediting agency inspection?
Our hospital participates in the Joint Commission inspection. We are due again as early as December.
What are some of the trends you have seen in your patient population?
We are seeing and treating a younger patient population. Greater than 50% of the patients treated last year were less than 64 years old. We are seeing a trend in growth in our structural heart program, from TAVR to WATCHMAN procedures. We have seen an increase in our peripheral volume. Three of our physicians perform peripheral procedures. On average, we are probably doing anywhere from eight to twelve peripheral procedures/month in the cath lab. We are spending more capital to increase our abilities in our same-day discharge program and radial lounge.
You will be working under construction for a while.
Yes, and we have already put in two new rooms. When you are doing nearly 400 cases/month, patient volume doesn’t slow down. We brought in a portable lab to allow us to treat our patients during construction.
Not enough can be said about Ron Spencer and DeAna Simpson’s leadership through that process. As you can imagine, it was an enormous undertaking to change a room out while keeping procedures flowing, but it impacted our department as minimally as possible. We still did the same volume during this period. The first room was done in ten weeks and the second room was completed in a little under nine weeks. There was a great deal of work on the front end to make sure all the details were in place. It is wonderful now to have two new Siemens rooms, which offer us new capabilities and technology. The display screens are amazing. We went from an 18 x 20 monitor to 80 x 60. The doctors are really excited about it and the technology that Siemens brings to the table is just phenomenal.
Can you share more about the culture behind the success of Bon Secours St. Francis Health System?
The story of Bon Secours St. Francis is the culture our organization creates. What we hope will come out of this story is that it is okay to be innovative. Maybe others will see what we have achieved and allow for that atmosphere of innovation to take place in their facilities. When an employee has the ability to think out of the box, and bring forward answers and solutions to problems, it adds enormous value to the department, and it presents enormous value to the patients and organization. The success of our department is the people — the staff and the management. It is the Bon Secours St. Francis family.
To create our same-day discharge program, our director DeAna Simpson gathered eight volunteers from our team and said: Okay, it’s your department. How do you want the same-day discharge program to look? The eight of us looked at related protocols, policies, and procedures, and what other departments in other hospitals were doing. We visited four different facilities in the southeast. Our same-day discharge program was not something that the management created and expected the staff to adhere to. Like many aspects of how our department is governed, our same-day discharge program and radial lounge were put into place by our staff. Our hospital encourages us, as staff, to take ownership of the overall daily functions of the department. You see that in the length of stay of our staff. You see it in what we are able to accomplish. And you see it not just in our department, but throughout the hospital. If we see a problem, we feel very much empowered to not just deal with the problem, but to bring a solution to bear to eliminate that problem. Our staff are known for their resilience and willingness to rise to a challenge and promote the department, not one’s self. We have experienced much change and growth in the last three years. We are proud of our department and coworkers for meeting these goals and challenges while maintaining our family environment.
The author can be contacted via Ashley Taylor at firstname.lastname@example.org.