Tell us about your cath lab. Is it part of a cardiovascular service line?
Dr. Katzen: One of the things that is unique about Miami Cardiac & Vascular Institute is that we are responsible for the entire service line of cardiac and vascular care at Baptist Health South Florida. Starting 30 years ago, the Institute became the model for integrating all technology, equipment and medical disciplines that relate to cardiac and vascular disease, both organizationally and architecturally. This also helps us to achieve economic benefits by eliminating redundancy in disposable inventory and imaging equipment. Miami Cardiac & Vascular Institute is the largest and most comprehensive cardiovascular facility in the South Florida region. The Institute is responsible for all cardiology, vascular and electrophysiology services. Our team of multilingual, multidisciplinary specialists are pioneers in the development of minimally invasive techniques used to treat occlusive arterial disease throughout the body, aneurysms wherever they occur, and structural heart disease.
The benefits to patient care are that all physicians involved in invasive therapy are working side-by-side. Literally. We don’t have barriers. If there is a problem with a patient, we have incredible human professional resources here to help solve the problem. Our physicians benefit from the satisfaction of working in a super sophisticated environment with all the technology in one place.
Two hospitals house our cath lab facilities, where physicians are credentialed to schedule and perform procedures.
What is the size of your cath lab facility and number of staff members?
The Miami Cardiac & Vascular Institute cath labs are located at Baptist Hospital of Miami and South Miami Hospital. Both settings have what we call interventional suites, where cath labs are interspersed among interventional radiology and endovascular labs to foster the model of collaboration and integration of the specialties. These types of environments don’t exist in general operating rooms at Baptist Health.
At Baptist Hospital, there are 15 interventional suites for procedures and diagnostics:
- 3 cardiac cath labs including one lab with robotics for coronary intervention;
- 2 electrophysiology (EP) labs;
- 2 interventional neurovascular labs;
- 4 interventional radiology and vascular labs;
- 2 advanced endovascular suites for structural heart and endovascular procedure suites that are fully hybrid, which allows us to bring physicians from different disciplines together to perform both catheter-based procedures and surgical approaches to provide the best solution for the patient;
- 2 cardiovascular imaging environments, one for MR and one CT scanner dedicated to image-guided interventional work.
At the Baptist Hospital cath lab, our staff consists of:
- 9 RNs and 9 cardiovascular technologists (CVTs) or radiologic technologists (RTs) in the cath labs;
- 2 RNs and 5 CVTs in the EP labs.
The Baptist Hospital endovascular and interventional radiology lab staff consists of 11 RNs and 15 RTs.
The Baptist Hospital CT/MR staff consists of 4 RTs (CT)(MR).
The Baptist Hospital Cardiovascular Care Unit (CVCU) staff is 32 RNs, 4 ARNPs, and 15 ancillary and support staff.
Several members of the team have more than 15 years of service. Others range from one to 15 years, including those who left and came back to rejoin the team.
The South Miami Hospital facility has 6 interventional suites:
- 3 cardiac cath labs: two rooms for cardiac diagnostic and interventional procedures; one for EP procedures;
- 3 rooms are for vascular, endovascular and interventional radiology cath labs.
The South Miami Hospital staff consists of 8 RNs and eight CVTs for the 3 cardiac cath labs.
Half of our South Miami Hospital staff members have been “in residence” for an average of 20 years, while the other half for an average of six years.
What procedures are performed?
Comprehensive coronary intervention, structural heart, and vascular and non-vascular procedures are performed at both Baptist Hospital of Miami and South Miami Hospital. The average weekly volume for cath and EP labs at Baptist Hospital is 70 to 80 cases. The average weekly volume for the South Miami Hospital labs is 30 to 40 cases. At this time, transcatheter aortic valve replacement (TAVR) procedures are done at the Baptist Hospital facility.
Can you share more about your experience with TAVR?
We were early adopters of TAVR and the first in South Florida to perform TAVR outside of a research trial. Because our fundamental infrastructure involves multidisciplinary collaboration, we were sitting with the heart teams and valve teams in place when TAVR was approved. Our TAVR program has grown consistently, and now we are doing about 100 a year. Two additional interventional cardiologists recently were approved to become part of the TAVR team as a result of volume growth. We have a process in place to increase the number of TAVR-credentialed interventional cardiologists, based on both credentialing criteria and an onboarding process to make sure they become part of the team as opposed to independent operators.
Has your cath lab recently expanded in size and patient volume, or will it be in the near future?
Dr. Katzen: Yes, we recently completed a $120 million expansion and renovation that nearly doubled the Institute’s size in anticipation of an increase in volume for both cardiac and vascular patients and procedures.
Is your lab involved in clinical research?
We participate in clinical research across the board that includes vascular, neuro, and cardiac trials. Our clinical research and outcomes infrastructure includes a dedicated research director who is a clinical cardiologist by training. I provide physician leadership and oversight, and a significant number of incredible research coordinators and regulatory people round out the coordination.
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?
Many hospital personnel and departments are involved in expediting ST-elevation myocardial infarction (STEMI) care, from emergency services, the transfer center and registration to the operators and the security department. Physicians and staff are activated and arrive within 30 minutes. Some team members go to the cath lab to set up and some go to the emergency department (ED) to meet the patient. The collaborative team effort is the key to our great D2B times, currently averaging 57 and 58 minutes.
If you are performing peripheral vascular procedures, do any operators utilize pedal artery access when appropriate?
Dr. Katzen: Yes, the interventional radiologists and vascular surgeons go a good amount of pedal artery access.
Are you registered with the American Heart Association’s Mission: Lifeline or the American College of Cardiology’s D2B Alliance?
Dr. Katzen: Both Baptist Hospital and South Miami Hospital are accredited by the Accreditation for Cardiovascular Excellence (ACP) organization for our Cath/PCI programs.
How does your cath lab compete for patients? Has your institution formed an alliance with others in the area?
Dr. Katzen: We compete for patients on several grounds. One is by establishing clinical and patient service excellence, and raising awareness within the general public and physician peers.
Second, we compete by having innovative solutions for patients who previously were told that surgery is the only solution, which relates specifically to our complex chronic total occlusion (CTO) program. On the vascular side, by participating in innovation, we attract patients who, again, had been denied less invasive therapy for aneurysms and other areas that are part of our standards of excellence. Third, our demographic practice base is increasing. Miami Cardiac & Vascular Institute delivers cardiovascular care at 7 hospitals and 25 outpatient centers within our rapidly expanding Baptist Health system, which has become a regional enterprise extending from Palm Beach to the Florida Keys, a large geographic area.
In addition, we support other aligned organizations and are actively involved in the American Heart Association in the community, leading the annual Heart Walk and Heart Ball in the region.
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”?
Dr. Katzen: South Florida is a melting pot, and often you will have patients who feel more comfortable being cared for by people who are from their own culture. This includes different Hispanic cultures from Central and South America. Other cultures originate from the Caribbean and Europe. Many patients come from Brazil and Asia. So, you can see we live in a unique environment. The majority of patients in South Florida have a Hispanic background, which means that Spanish language is important. We meld all of this into how we take care of patients. At Miami Cardiac & Vascular Institute, we are a multi-cultural organization that appreciates and incorporates diversity into how we deliver care. We need to make patients, regardless of their culture and language, feel comfortable in their time of illness. It doesn’t mean that everybody who works here has to be bilingual, but we have that as a resource as an integral part of our teamwork. It layers with our everyday employee culture of caring for one another, making eye contact when speaking to others, smiling, making sure you are concerned for the other person, and if you see a problem, you own it.
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?
Dr. Katzen: Our CVTs and RTs must be RCIS- or registered cardiac electrophysiology specialist (RCES)-eligible upon hire, and achieve certification within one year of employment. The exam is reimbursed upon passing. Those certified are eligible to advance to a higher level in the career advancement program, which offers a pay increase for advancing to the senior (advanced) and specialist (expert) levels.
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) or regional organizations?
Dr. Katzen: Various team members belong to the ACVP. Staff participates as educators as well as registrants in a number of meetings such as the International Symposium on Endovascular Therapy (ISET), Society for Cardiovascular Angiography and Interventions (SCAI), Cardiovascular Research Technologies (CRT), and the American College of Cardiology (ACC).
How do you use the ACC’s National Cardiovascular Data Registry (NCDR) outcome reports to drive quality improvement initiatives at your facility?
Dr. Katzen: We are part of several of the registries, and we use them to fill out our metrics of performance and dashboards. Established within our management company model here at Miami Cardiac & Vascular Institute, which is 50 percent owned by physicians and 50 percent owned by Baptist Health, are financial incentives associated with quality metrics required from a number of registries, including the NCDR. Therefore, a monetary incentive is built in to achieving high quality standards.
Do you regularly gain access via the radial artery?
Dr. Krauthamer: More than 50 percent of the cardiac catheterization cases are performed through the radial artery at Miami Cardiac & Vascular Institute. We were one of the first centers to use the procedure when it was introduced in the United States. I will use the transradial approach for certain indications, such as when a patient is morbidly obese or has peripheral vascular disease. But I prefer to use transfemoral catheterization for about 80 percent of my cases. Almost all of them end with a closure device, and the patient will be ambulatory within two or three hours. Perhaps it is a comfort level after more than 30 years of experience with femoral access. Both access points have their advantages and risks, depending on the condition of the patient.
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?
Dr. Krauthamer: Usually the doctor performing the procedure in our catheterization labs operates all the x-ray equipment. There are some doctors who have a CVT perform the panning, but the great majority of us do it ourselves. Some doctors compensate by using lower magnification so they will not have to do any panning. The advanced x-ray equipment in our labs allows us to process the images later and to magnify if needed. For me, I do everything myself, and I magnify. In the vascular and IR labs, this is done by the physician.
How is coding and coding education handled in your lab?
Dr. Krauthamer: In our lab, we have a registered nurse whose only job is to perform the coding. She captures the list of devices and supplies used during a procedure by reviewing a physician’s dictation and the records kept by the CVT.
What measures has your cath lab implemented in order to cut or contain costs?
Dr. Krauthamer: There are many ways to cut costs. Our committees for cost containment and interventional cardiology meet frequently to review pricing. Final decisions are made by the Interventional Cardiology Committee. We meet with cath lab administrators to go over supplies that could be substituted to contain costs. We work closely with the purchasing department, which negotiates supply contracts on our behalf. In one instance, we limited the number of stents we use to two brands in order to get a better price. On another occasion, we found a company that sold its J-wire for $10 less than we had been paying. For us, a wire is a wire. We gave it a trial period for a month, it worked fine, and we switched. Yet there are some items we can’t compromise on, and when we can’t compromise, we try to save by buying volume.
Who documents medication administration during the case?
Dr. Krauthamer: A cath lab nurse is in the room for every procedure, and that’s the person who documents the medications in the computer.
What trends have you seen in your procedures and/or patient population?
Dr. Krauthamer: The overall population in Miami-Dade County has doubled in the past 20 years, yet the number of coronary intervention procedures we do has remained steady. The reason? People are healthier now. They take better care of themselves. They exercise. They take medications that are more effective in controlling cholesterol. Therefore, the way we grow is by doing more complex cases that previously were treated with open-heart surgery or were too high risk for coronary intervention altogether. Technological advancements have given us the ability to perform more percutaneously complex procedures. For example, we are able to treat patients with multiple coronary artery obstructions with drug-eluting stents that minimize renstenosis. We can treat patients with diffuse and calcific coronary artery disease and chronic total occlusions, because we have better wires and devices. We do more high-risk coronary interventions in place of bypass surgery. Whereas 20 years ago coronary procedures dominated, you are seeing electrophysiology and structural heart procedures being done today.
Does your cath lab perform primary angioplasty without surgical backup on site?
Dr. St. John: No. We are a tertiary facility with a very well established and robust cardiac surgery program where surgical backup is always available.
Do you have cross-training? Who scrubs, who circulates and who monitors?
Dr. St. John: We have cross-training, but with certain limits. The typical team for a catheterization case is two RNs, and two either CVRTs or RTs. The nurses administer medications and act as circulators to help set up the table and be an extra set of hands. The technologists monitor and document in real-time everything we do. They also circulate and scrub the case with the interventional cardiologist.
How does your cath lab handle radiation protection for the physicians and staff?
Dr. St. John: Radiation safety has undergone a resurgence of interest because of increased risk to interventional radiologists and cardiologists for certain types of malignancies. It is something we all think about and take quite seriously. Our physicians and staff remind one another to be protected during each procedure. Everyone has custom-fit lead aprons and lead glasses. We have also started using lightweight lead aprons that I think will help reduce orthopedic problems. Imaging systems in our cath labs have radiation reduction software that cuts exposure by up to 70 percent. In addition, a variety of aerial and rolling shields screen the staff and physicians. We use the Philips DoseAware System that alerts the person wearing it to know when they have entered a high radiation zone. It is effective in training the staff and physicians to find the best place to stand. We are evolving in our use of robotic percutaneous coronary intervention, which lets the operator be completely shielded. At least once a year, we receive radiation safety education updates. We currently have a Miami Cardiac & Vascular system-wide radiation reduction committee, which is looking at standardizing reporting from various machines and deploying uniform radiation protection protocols, as well as optimizing performance of the technology.
What are some of the new equipment, devices and products recently introduced at your lab?
Dr. St. John: We have most of the up-to-date tools that any modern cath lab should have. We have recently updated the fractional flow reserve (FFR) that incorporates instantaneous wave-free ratio (iFR) technology. We have optical coherence tomography (OCT) intravascular ultrasound devices. We have several image applications, such as Philips’ StentBoost that lets you see the stents more clearly when you deploy them and a program that allows you to overlay CT images with coronary angiograms in real time to help with both the planning and performance of complex interventions. There also are behind-the-scenes software applications that improve the image quality and, in some cases, can help guide decision making and appropriateness. In addition to the latest imaging technology, we constantly evaluate new products that can improve patient care. We are developing a protocol for a product called DyeVert (Osprey Medical) that reduces contrast utilization in patients who are at particularly high risk for contrast-induced nephropathy.
Who pulls the sheaths post procedure, both post intervention and diagnostic? What kind of training is mandated before someone can pull a sheath?
Dr. St. John: In the interventional cardiology labs, the technologists and the nurses are both trained to pull the sheaths both post intervention and diagnostic. The nurses and technologists learn the skill in a competency-based program that requires them to do 10 sheath pulls under direct supervision before they do the procedure on their own. We have recurrent inservices on sheath pulling and groin management to make sure everyone is doing it properly. In the vascular and IR suites, generally physician fellows pull the lines with completion by the technologists.
Where are patients prepped and recovered (post sheath removal)?
Dr. St. John: The Cardiovascular Care Unit (CVCU) is our dedicated recovery area. We do a lot of radial approaches that usually require just a short period of manual compression, or more commonly a HemoBand that is applied to the wrist. For a femoral approach, many of us use closure devices. Cases that require manual compression are done by a properly trained nurse or technologist. We encourage a minimum hold time of 20 minutes. If the procedure is diagnostic without anticoagulation, the sheaths are pulled immediately in the procedure room. Otherwise, the sheath pulling and compression are done in the CVCU.
Who transports the STEMI patient to the cath lab during regular and off hours?
Dr. St. John: During regular and off hours, a catheterization team goes down to the ED to meet the patient. The team that wheels the stretcher back upstairs includes the interventional cardiologist, the room nurse, and generally speaking, a nurse or technologist from the emergency department. The circulators are in the room getting the table ready. When we have STEMI alerts, the security department also is notified. Their role is to make sure all doors and hallways are clear, and the elevator is waiting for us. Those little things help ease the transfer of the patient from the ED to the cath lab and shave off a few minutes from our door-to-balloon time.
What do you do when the call team is already busy doing a procedure and a STEMI comes into the ED?
Dr. St. John: During regular hours, there are enough teams and enough rooms that even if the call team is tied up doing a case, another team and another doctor will jump in and manage the patient. Sometimes during off hours, it can happen that two cases arrive in close proximity. Depending on the timing, the patient might need to be stabilized in the ED while the team finishes the case on the table. We would prefer the new patient receives primary angioplasty rather than go with thrombolytics, because even a complex case underway will usually be done within an hour or two — a window of time in which primary angioplasty usually still offers more benefits than thrombolysis. It is a stressful scenario that fortunately does not happen very often.
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?
Dr. St. John: As the complexity of the cases increase, and therefore the length of the procedures, we are acutely aware of radiation exposure to patients. The threshold for when we monitor patients for radiation damage post procedure is 5 gray (Gy). Thankfully, it is not a protocol that we have to use very often. Should we reach that threshold, however, I would have a conversation with the patient, or a family member, right after the case. It is important for patients to be made aware should a lot of radiation occur for their procedure and for them to take proper care should they see changes to their skin. We also inform the follow-up cardiologist if they aren’t part of the team. If a patient did develop a radiation injury or burn, it would be important for them to be seen by a dermatologist who understands what they are looking at and not treat it as something else. Frankly, I can’t remember the last time we had such a case.
Are your physicians dictating their cath procedure reports, or do they use a structured reporting tool?
Dr. St. John: Our new structured reporting tool is in development in conjunction with the Philips XPER and Xcelera systems. At this point, we follow a dictation template to ensure we are including all the required elements.
Where is your cath lab located in relation to the operating room (OR) and ED?
Dr. St. John: Our cath labs at the Baptist Hospital campus are located on the third floor and the general OR is on the first floor. The ED is in a different building altogether on the first floor. The cath labs have 2 advanced endovascular suites — or hybrid rooms — which can serve as operating rooms, especially when we do very advanced endovascular procedures or structural heart procedures. So technically, we do have two operating rooms in the cath lab.
What is unique or innovative about your cath lab and staff?
Dr. St. John: The unique thing about Miami Cardiac & Vascular Institute, which was founded in 1987, is that from the very beginning, it was committed to less invasive therapy and focused on collaborative, multidisciplinary care in an environment of transparency. I think one of the things you would see when you walk into our cath lab is that transparency is not just a metaphor; it is a way of life. The whole place is made of glass so that from the center of the cath lab, which is shaped like a horseshoe, you can see what is going on in each of the surrounding rooms. Indeed, there are seats outside the Advanced Endovascular Suite to allow viewing of live cases. This transparency has many benefits. It fosters a great deal of collaboration, but also encourages you to practice at your best. When complications happen, and they will, specialists from all across the spectrum are there to jump in to help. Say there is a vascular access complication — the interventional radiologist can lend support. Conversely, if there are cardiac issues or arrhythmias that develop in an IVR procedure, there will be a cardiologist who can jump in and offer advice. Vascular surgeons, cardiac surgeons, interventional radiologists, and cardiologists are all working in tandem for the best care of the patient. That is what sets us apart and is one of our main advantages.
What is your percentage of normal diagnostic caths?
Kiah and John: We are at 22 percent, which is consistent with the national rate of normal diagnostic catheterizations.
Who manages your cath lab?
Kiah: The leadership and management structure includes medical directors of Interventional Cardiology, Structural Heart Therapy, Electrophysiology, Interventional Radiology, and Neuroradiology. There is a team of Registered Nurse and Technologist Supervisors, an Operations Manager, and Director of Invasive Services. The executive team includes Founder and Chief Medical Executive of the Institute, Barry T. Katzen, MD, Chief Operating Officer, Carol Melvin, and Vice Presidents Harold Girado at Baptist Hospital and Carol Biggs at South Miami Hospital.
How does your lab communicate information to staff and physicians to stay organized and on top of change?
Kiah and John: One of the core philosophies of the Institute is multidisciplinary, multispecialty collaboration. Staff and physicians participate together in meetings and work groups for collaborative improvement efforts and shared decision making. We also communicate at meetings, group huddles, and through emails.
How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies?
Kiah and John: Inventory is managed by a team of inventory technicians and a manager, who order and receive stock into a general location. They manage items to maintain the integrity of the packaging, review utilization for increases or decreases, and rotate stock to avoid expiration. Lab staff stocks the rooms to set par levels, and scans supplies when used for billing and reordering.
What quality control measures are practiced in your cath lab?
Kiah and John: We maintain Association of periOperative Registered Nurses (AORN) standards, including mandatory surgical attire. Time out procedures, equipment checks, and room readiness are audited for effectiveness and compliance. Radiation and fluoro time are monitored, and physicians are alerted at increasing levels. “Not-to-exceed” safe contrast doses are calculated for each patient based on individual risk factors. These are just some of the many measures we take for high quality and safety.
How are you recording fluoroscopy times/dosages?
Kiah and John: Fluoro times and radiation dosages are documented in the patient’s medical record and on the procedure record, and images stored in the PACS image archiving system.
How are you populating registry data records?
Kiah and John: We participate in the ACC-NCDR’s Cath/PCI and PVI NCDR registries. We enter some of the data into the Philips XPER electronic medical record, which integrates with a third-party vendor for NCDR data collection. A dedicated research and outcome team of abstractors collect and enter remaining elements, review the integrity and completeness, and submit the data for reporting and benchmarking.
How are new employees oriented and trained at your facility?
Kiah and John: We have a Versant Nursing Residency program for new and transitioning nurses. Lab training is facilitated by clinical educators and staff preceptors guided by a comprehensive, competency-based orientation checklist that has to be completed successfully. A new model will be adding a physician preceptor to the mix.
What continuing education opportunities are provided to staff members?
Kiah and John: Staff is encouraged to attend the monthly Cath Lab Conference, Grand Round lectures, and special guest lectures. Physicians conduct monthly “Know-on-the-Go” sessions for focused topic training. Clinical educators, peers and vendors provide education and training sessions on pertinent topics or devices and equipment. Education conferences sponsored by Baptist Health South Florida are available at no charge to all employees and learning modules are available on the hospital intranet, Baptist Health University. Staff is also encouraged to attend the annual International Symposium for Endovascular Therapy (ISET), a world-renowned educational conference for medical and allied health, which is directed by Miami Cardiac & Vascular Institute medical staff and sponsored by the Institute. The team also participates in live case presentations to international conferences throughout the year.
How is staff competency evaluated?
Kiah and John: Evaluations are based on competency checklists, and clinical educators and preceptors teach and observe return demonstrations. Physicians also evaluate competency and provide feedback.
Does your lab have a clinical ladder?
Kiah and John: Yes, we have a Clinical Advancement Program for both nurses and technologists that is based on Pat Benner and the Dreyfus model of skill acquisition and competency. There are four levels: novice, proficient, advanced, and expert.
How does your lab handle call time for staff members?
Kiah and John: Two RNs and two technologists are on call for off hours. The teams are permitted up to seven hours from the end of a call case after a night or weekend on call to return to a scheduled shift.
Within what time period are call team members expected to arrive to the lab after being paged?
Kiah and John: The team must arrive in 30 minutes or less for a call case.
Do you have flextime or multiple shifts? How do you handle slow periods?
Kiah and John: Staff works four 10-hour shifts a week. Flextime is managed on an individual basis. Team members are reassigned to other specialties such as EP, IR, the prep and recovery area, or assigned to special projects when the need exists. At times, they are relieved from duty when volume is low.
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