Cath Lab Spotlight

Spotlight: Invasive Cardiology Unit, UHS Wilson Medical Center

Mary Farley, RN, BSN, Nurse Manager Invasive Cardiology
Alon Yarkoni, MD, FACC, Director, Structural Heart Program 
Johnson City, New York

Mary Farley, RN, BSN, Nurse Manager Invasive Cardiology
Alon Yarkoni, MD, FACC, Director, Structural Heart Program 
Johnson City, New York

Tell us about your cath lab. 

Our cath/electrophysiology (EP) labs are part of the UHS Heart and Vascular Institute, which is an all-encompassing cardiovascular service line. We have 2 cath labs, 1 EP lab, and a coronary ambulatory care unit. We currently employ 32 staff members, including 21 registered nurses (RNs) and 6 radiologic technologists (RTs). We have a mix of new staff members, staff that have been here from 3 to 7 years, and long-term staff that have worked in invasive cardiology for more than 15 years.

What procedures are performed in your cath lab?   

Cath lab procedures include right and left heart catheterizations, percutaneous coronary intervention (PCI)/stenting, intra-aortic balloon pump (IABP), Impella (Abiomed), intravascular ultrasound (IVUS), balloon aortic valvuloplasty (BAV), transcatheter aortic valve replacement (TAVR), alcohol septal ablations, and patent foramen ovale (PFO) closures. We average approximately 40-45 procedures per week. 

Can you share your experience with TAVR?

Dr. Yarkoni joined our team in July 2014, after completing a structural heart fellowship at Henry Ford in Detroit. Under his guidance, we spent 6 months building a TAVR program, including acquiring the necessary equipment, training physicians and staff, creating policies, and, most importantly, evolving a collaborative team between the operating room (OR) and cath lab staff. Our first TAVR cases were performed on December 9, 2014, and we have successfully performed over 100 to date. It has been inspiring to see the cath lab and surgical teams come together for this phenomenal procedural process. [Editor’s note: CLD interviewed Dr. Yarkoni about the UHS TAVR program in the June 2016 issue. Read more at http://www.cathlabdigest.com/article/TAVR-UHS-Structural-Heart-Valve-Center.]

What is your percentage of normal diagnostic caths?

We have averaged between 24-25% normal diagnostic caths in the last two years, with normal defined as <50% lesions, patent grafts, and no significant valvular disease. This is slightly higher than the state average. We are currently working on a quality improvement process to address this and believe that proper documentation of case indication and findings is primarily responsible.

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

Yes, three of our six full-time interventional cardiologists routinely perform radial access. We also perform right heart catheterizations utilizing the brachial vein. Together, these two methods of access have drastically reduced our patient recovery times and increased patient satisfaction. We have seen, as have other sites across the country, a reduction in the use of vascular closure devices and vascular complications as a result. 

Are you performing peripheral vascular procedures? Do any operators utilize pedal artery access when appropriate?

We do not perform peripheral vascular procedures on a regular basis, but with the recent opening of our hybrid room, we hope to perform more in the future. We recently had a very challenging case of chronic total superficial femoral artery (SFA) occlusion that could not be cannulated antegrade due to a large collateral. The team utilized ultrasound-guided pedal access, successfully crossed the lesion, and snared the wire with an excellent result. We were very proud to see how the team approached the case using the most advanced techniques and devices.

Who manages your cath lab? 

The cath lab is managed by the nurse manager, along with the medical and the service line directors.

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

We currently cross-train our RNs with our CACU (coronary ambulatory care unit). RNs circulate and monitor, and RTs scrub.

Who documents medication administration during the case?

The monitoring and/or circulating RNs.

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? 

Our physicians and RTs are credentialed to perform all of the above functions.

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

We recently renovated and expanded one cath and EP lab. The cath lab was built for use as a hybrid interventional lab, and in both rooms, we installed state-of-the-art equipment. We recently upgraded our fractional flow reserve (FFR), IVUS, and vascular ultrasound equipment with the newest technology. We also introduced Impella when we started the TAVR process two years ago and have expanded its use to high-risk PCI cases.

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

We communicate through various methods, including service line meetings, staff meetings, staff “Weekly Wrap” emails, etc.

How is coding and coding education handled in your lab? 

Coding is handled by assigned coders within the UHS HIM/coding department. 

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

Most of our access sites are sealed with closure devices. If, however, a sheath needs to be pulled, it will be done by either trained staff or a physician.

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

A minimum of 10 arterial sheaths must be pulled with direct observation to be considered competent.

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

Outpatients are prepped and recovered in our coronary ambulatory care unit by the CACU RNs. Inpatients are prepped and recovered on our telemetry or the cardiac intensive care floors.

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

We have an inventory technologist that is responsible for most of our inventory. This individual orders, stocks, and manages outdates. To ensure best pricing, new product must be approved by our value analysis team prior to purchase. Capital purchases are handled by our service line director and the nurse manager.

Is your lab involved in clinical research?

There are no people currently enrolled in ongoing trials. We have done a number of IVUS arms of drug trials over the past ten years.

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 2016 D2B time was 61 minutes. We have evolved a multidisciplinary approach, including our system-wide clinical staff and providers, Emergency Medical Services (EMS), and our regional healthcare partners in the ST-elevation myocardial infarction (STEMI) process to assure the most efficient approach to D2B time.

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

A combination of cath lab RN and emergency department (ED) RNs transport STEMI patients during both on and off hours.

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

The on-call cardiologist, interventionalist, and ED physician agree on a plan of action, which may include triaging patients or considering the use of thrombolytic therapy.

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

We are part of a system-wide value analysis team that looks at the best pricing opportunities for all products.

What quality assurance (QA) measures are practiced in your cath lab?

We are involved with the New York State (NYS) Percutaneous Coronary Interventions Reporting System (PCIRS) reporting process. We hold a weekly cath conference and monthly CVPI (CardioVascular Process Improvement) meetings that involve case review and NYS/Centers for Medicare & Medicaid (CMS) data review. Each cardiologist also performs blinded case reviews that are part of our QA process.

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

We perform annual, mandatory radiation safety education. We have a very active radiation safety committee that oversees and performs quality checks on the equipment and lead, as well as monitoring radiation exposure to patients/staff.                    

How are you recording fluoroscopy times/dosages? 

We document fluoro time and dose area product (DAP) for each case in our electronic medical record (EMR). Our organization recently installed DoseWatch (GE Healthcare), which captures all exposures for each patient and keeps a lifetime exposure record.

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

Our process with high exposure cases involves sending a letter, within 48 hours of the case, to the patient’s provider, alerting them of the exposure and possible effects. The letter also includes a contact number should the provider/patient have questions. A copy of this letter is also sent to our radiation safety department and the information is placed into a database for tracking. Any trends or issues are shared with the department at the quarterly radiation safety meeting.

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

Our physicians are currently dictating all cath reports.

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

In our area, there is very little competition from nearby institutions. There are two main hospital systems in this area, UHS and Lourdes Catholic Health System. We are the only hospital in the area with cath lab capability. We have a good working relationship with the cardiology services at Lourdes Hospital and facilitate cath lab transfers on a regular basis.

How are new employees oriented and trained at your facility?  

New employees are oriented through our corporate training first and then spend approximately six months undergoing on-unit training.

What continuing education opportunities are provided to staff members?

We arrange clinical vendor educational sessions throughout the year. We also attend a yearly cardiac teaching day each fall.

How do you handle vendor visits to your lab? 

We allow vendors in the lab on a prescheduled appointment day. They must have badged in prior to entering the lab and are required to wear hospital scrubs if they enter a procedural area. All procedural product must be inspected, opened and handed off by hospital staff members only.

How is staff competency evaluated? 

We have an annual credentialing process that includes direct observation and formal educational sessions throughout the year.

Does your lab have a clinical ladder? 

Yes. RNs have a clinical ladder that is based on education, national credentialing, and organizational involvement.

How does your lab handle call time for staff members? 

Our call teams consist of two RNs and one RT. Minimum call expectation is currently 1-2 nights a week and every 4th weekend. To ensure staff and patient safety, we allow call personnel who have worked the night before to come in later or leave early.

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

Thirty minutes.

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

We staff with rotating, staggered start times and we try to use slow periods to provide the time for learning and credentialing opportunities for staff. We also occasionally place staff on call during these slow periods. 

Where is your cath lab located in relation to the operating room (OR) and emergency department (ED)? 

Our cath lab is located on the second floor down the hall from the OR and just above the first floor ED. This convenient location helps shorten our patient transport times in emergent cases.

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

In the last few years, we have seen approximately a 5% drop in STEMI cases. Likewise, we have seen a decrease in the number of elective outpatient PCIs. However, the number of inpatient non-STEMI and valve cases has increased. This correlates with the national trends.    

Is there a problem or challenge your lab has faced? 

While our EP and hybrid labs were under construction, we were down to one functioning cath lab from March 2016 to September 2016. During this period, we employed an early and a late shift for staff. We also retrofitted two OR rooms and an interventional radiology room to use for EP device implants. Our physicians had to change their schedules to allow for procedures to start at 7am and as late as 10pm. We performed outpatients and urgent cases first, followed by non-urgent inpatients. While this posed some inconveniences to our patients and staff, we were able to maintain the same case volume and quality outcomes as before.

What’s special about your city or general regional area in comparison to the rest of the U.S.?  

Binghamton, New York is located in the southern tier of upstate New York. We are a three-hour drive from New York City, a two-hour drive from Albany, and one hour from Syracuse. This area is best known for being the birthplace of the IBM corporation (Endicott, New York) and the home of Binghamton University. Our patients vary from small-town farmers to university professors and retired executives. Our physicians are very dedicated to the community, some having practiced here for more than thirty years. We try to always do what is right for the patient and stay within our comfort zone. We are fortunate to be in close driving distance to some of the nation’s most highly respected healthcare organizations. When we are not able to provide a service locally, we refer that patient to a more capable facility. 

The authors can be contacted via Mary Farley, RN, BSN, Nurse Manager Invasive Cardiology, at mary_farley@uhs.org.