The cath lab at Jupiter Medical Center opened in March 2011 and has grown exponentially ever since. The lab has been doing emergent ST-elevation myocardial infarction (STEMI) since June 2014 and elective percutaneous coronary intervention (PCI) since November 2014. We also perform diagnostic and interventional peripheral procedures, pacemaker/defibrillator implants, and loop recorder implant/explant on an inpatient and outpatient basis. There are 10 full-time team members who handle our pre, intra, and post procedural care. Our department shares a space with the cardiology department, so most of our cath lab nursing team has been cross-trained to perform transesophageal echocardiography (TEE)/cardioversion, tilt table tests, and stress tests. We are fortunate to be located in Jupiter, Florida, just north of West Palm Beach. The community has a close relationship with the hospital and has been very active in developing all service lines. The hospital was actually built based on demand and with support from the local community in the 1970’s. We are a not-for-profit 327-bed regional medical center consisting of 207 private acute-care hospital beds and 120 long-term care, sub-acute rehabilitation, and hospice beds. We provide a broad range of services with specialty concentrations in cardiology, oncology, imaging, orthopedics and spine, digestive health, emergency services, lung and thoracic, women’s health, weight management, and men’s health. In February 2016, we opened the De George pediatric inpatient unit.
The hospital and cath lab continue to receive support through generous donations from the surrounding community. The cath lab owes its existence to the support of the Jupiter community, and the dedication and vision of our senior leadership team, led by CEO John Couris, the board of directors, and our team members. Our cardiology department, which includes the cath lab, is ranked in the 90th percentile for likelihood to recommend for Palm Beach and Martin Counties.
In order to grow our cardiology program, Jupiter Medical Center recently entered into an exciting partnership with Mount Sinai Heart New York. We are working toward beginning an open heart program within the next two years and are increasing steadily in volume to accomplish that goal.
What is the size of your cath lab and number of staff members?
The department consists of 2 cardiac cath labs (Room 1 is a Philips FD10 and Room 2 is a Philips Allura FD20), and there are 10 holding beds for pre and post recovery. Presently, there are 10 total team members during the off-season and supplemental seasonal employees are hired for our winter season. We have 4 registered nurses (RNs) and 4 cardiovascular technologist (CVT) team members. Since our lab has only been open for elective PCI since November 2014, most of the team has been employed here for less than 2 years. The majority of our team has been working in a cath lab for greater than 20 years.
What procedures are performed in your cath lab?
Procedures performed in our lab include diagnostic right and left cardiac catheterizations, intravascular ultrasound (IVUS), fractional flow reserve (FFR), optical coherence tomography (OCT), PCI, and peripheral diagnostic and interventional procedures. We also implant pacemakers, defibrillators, and loop recorders. We have seen tremendous growth in the past year and presently perform an average of 15-20 procedures per week.
Does your cath lab perform primary angioplasty without surgical backup on site?
Yes, we have been performing primary angioplasty without surgical backup on site since June 2014. At the present time, we have performed over 400 PCI cases.
How many of your diagnostic caths are normal?
According to our data obtained from National Cardiovascular Data Registry (NCDR), at least 40.2% have non-obstructive coronary artery disease (CAD) not requiring PCI.
Do any of your physicians regularly gain access via the radial artery?
Our physicians use radial access 40-50% of the time.
Who manages your cath lab?
Our day-to-day operations are overseen by the assistant clinical manager, Sara Gelo, RN, BSN, CVRN-BC, who reports directly to the director of the cardiovascular service line, Barbara Lamia, RN, MSN, CCRN.
Do you have cross-training? Who scrubs, who circulates and who monitors?
Because of the size of our team, cross-training is a necessity. We have 4 CVTs who scrub and monitor. All RN team members are cross-training to circulate and monitor.
Which personnel can operate the x-ray equipment (position the image intensifier, pan the table, change angles, step on the fluoro pedal) in your cath lab?
Most of our physicians pan the table, change angles, and fluoro during the procedures. Our scrub staff (CVT or RN) is also trained to pan and move the table as needed during the case. We work with a dozen physicians, and everyone has a different workflow. Our team is capable of accommodating the preferences of the physicians. It truly is a collaborative effort between the interventionalist and the scrub person, which makes for an engaging and rewarding work environment.
How does your cath lab handle radiation protection for the physicians and staff?
We have a radiation safety officer for the hospital. A radiation committee oversees our practice, and monitors the safety of team members and patients. Quarterly meetings keep everyone current with the safest recommendations. X-ray badges are worn by all team members and physicians. Logs are reviewed by the safety officer. A quarterly report is kept in the lab so that everyone can see their own dose amounts. Vendors also give radiation safety lectures.
What are some of the new equipment, devices and products recently introduced at your lab?
We were excited to bring St. Jude Medical’s OCT technology into our lab, which allows us to be prepared for new advancements (i.e., bioresorbable stent technology). We recently added ceiling-mounted, zero-gravity lead protection systems (CFI Medical, a TIDI Products Company) to both rooms in response to physician requests. We are in the process of training team members and physicians. As our program grows, we look forward to expanding our peripheral vascular procedures and our use of drug-eluting balloons.
How does your lab communicate information to staff and physicians to stay organized and on top of change?
Communication is important in any cath lab. We communicate by having monthly team meetings, emails, and quarterly town hall meetings, which are led by our CEO. The unit-based council sets up “lunch and learns” to communicate changes within the industry. The goals of our facility are displayed on our organizational action plan board, which is updated quarterly. There are quarterly division of cardiology meetings to keep physicians abreast of any new information and changes.
How is coding and coding education handled in your lab?
We have an excellent relationship with our billers and coders. We work as a team to update and maintain our procedure charges. We have successfully implemented our ICD-10 conversion. Ana Balensiefer, CVT, handles the Charge Master. She informs the cath lab team members of any updates.
Charges are entered in the Horizon Cardiology Hemodynamic billing module (McKesson) and all CPT codes are attached to the charges. Procedure charges are entered at the completion of cases and reviewed the next morning for accuracy. If a modifier needs to be added, Ana works with the coders to complete the chart.
Who pulls the sheaths post procedure, both post intervention and diagnostic?
All team members are trained and competent to pull sheaths, and during business hours, sheaths are pulled by the cath lab team. After hours, we are currently training intensive care unit (ICU) and progressive care unit (PCU) team members to pull sheaths and manage TR Bands (Terumo) in order to improve patient flow and experience, and allow the call team to leave upon completion of the procedure.
All new team members are trained by first watching videos on how to pull sheaths or remove a TR Band. Next, they observe the procedure being performed, and then they must demonstrate competency before they are allowed to proceed without supervision.
Where are patients prepped and recovered (post sheath removal)?
Patients are prepped and recovered in our 10-bed cath holding area during business hours. Emergency cases usually are recovered in the ICU. We use vascular closure devices and manually remove sheaths.
How is inventory managed at your cath lab?
We use a combination of Horizon Cardiology Inventory modules and manual counting to manage our supplies. Ana is primarily in charge of reordering supplies and maintaining vendor relationships, but a group effort is required to check expiration dates and supply levels.
We have a large consignment inventory for our coronary interventional needs. We work with Boston Scientific and Abbott to allow for physician preferences and requirements. Jupiter Medical Center is part of the SCMA Alliance (a regional purchasing organization). We use products that the alliance has approved. We stock, order, and adjust our par levels as needed. We are fortunate to work with an outstanding materials management department, and enjoy an excellent working relationship with our buyers and vendors.
Has your cath lab recently expanded in size and patient volume, or will it be in the near future?
In 2011, the lab opened, and only offered diagnostic caths and implants. In 2014, Jupiter Medical Center started performing emergent and elective PCI. Due to our growth, volume has increased 177% since 2014. We anticipate further growth and expansion of our program.
Is your lab involved in clinical research?
Not at the present time. We are presently working through our affiliation with Mount Sinai Heart New York. We hope to participate as our program expands.
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?
Jupiter Medical Center’s D2B median time is currently at 59 minutes. We have collaborated in setting up a protocol in transmitting electrocardiograms (EKGs) via Lifenet (Physio Control) from emergency medical services (EMS) to the emergency department (ED). The ED physician will determine if it is a ST-elevation myocardial infarction (STEMI) and contacts the interventionalist on call. The call team is notified by the nursing supervisor by phone and must respond within 30 minutes.
The ED, cath lab, ICU and telemetry floor directors/managers meet bi-monthly with the medical directors of the ED, cath lab, and the Mount Sinai Heart New York Program. All STEMI cases are presented for D2B or door-to-door (D2D) time. We review our quarterly reports from the American College of Cardiology’s NCDR PCI registry at each meeting. Accomplishments and areas of opportunity are discussed. Changes are put into effect immediately in order to continually work on improvements in the program.
Who transports the STEMI patient to the cath lab during regular and off hours?
The cath lab RN will go to the ED, receive a hand-off report, and transport the patient back to the cath lab on one of our monitor/defibrillators. Depending on patient situation, another cath lab team member, respiratory therapist, or the ED RN will assist with patient transport. This process is used 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?
After being notified of the STEMI by the ED or the nursing supervisor, the STEMI will take precedence over elective procedures. We make every effort to have two teams available during regular hours for this reason. After 5 pm, we make every attempt to limit elective procedures in order to have the call team available for STEMI patients.
What measures has your cath lab implemented in order to cut or contain costs?
Being part of the SCMA Alliance is our best measure for containing costs, as they are able to negotiate the best contract prices. We carry most of our supply on consignment and work closely with our physicians to only carry what they prefer to use to avoid product sitting on our shelves. Every team member is mindful of waste and checks expiration dates, rotates, and stocks supplies as needed. In order to control costs and curb waste, ordering supplies is limited to 2 people. The facility works with MedAssets and Truven Health Analytics to manage labor productivity.
What quality control/quality assurance measures are practiced in your cath lab?
Quality and safety are a huge priority for our cath lab. We are diligent with hand hygiene, minimizing contrast utilization, radiation safety, accurate point-of-care testing, “time outs” and universal protocol. Our implants follow the operating room standards, and include the need for accurate instrument and sponge counts before and after procedures.
Are you recording fluoroscopy times/dosages?
This is a mandatory field for our hemodynamic report for each patient. We also report on a quarterly basis to our radiation safety officer.
Who documents medication administration during the case?
Medication administration is documented primarily by the RN administering medication in the room. The recorder does assist in the medication administration documentation during emergent cases, which is then reviewed by the RN.
Are your physicians dictating their cath procedure reports, or do they use a structured reporting tool?
We have a reporting system through the McKesson Cardiology monitoring system. Most of the cardiologists utilize the structured report; others will still dictate their report.
Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) or any other outside data collection registry?
We submit to the ACC-NCDR’s PCI registry and the Implantable Cardioverter Defibrillator (ICD) registry.
How does your cath lab compete for patients?
Jupiter Medical Center provides the world-class care that you would find at a large institution, with the concierge-style, individualized care you’d expect from a community hospital. We know our patients have a choice, and we have been told time and time again by our patients that they specifically choose to come to Jupiter Medical Center, even when coming from surrounding counties.
Our partnership with Mount Sinai Heart in New York is another unique aspect of the cath lab. It allows our physicians to access the resources of a world-renowned institution and research facility to deliver the best possible care to our patients. This also allows our patients a choice to receive care at Mount Sinai Heart in New York. Locally, we have transfer agreements in place with a facility that has an on-site open heart program.
How are new employees oriented and trained at your facility?
Our new employees undergo didactic and practical orientation. We have developed a manual to aid in the training of our new team members. The time period of the orientation is individualized on new employee’s needs. The entire team is involved in training of new team members.
What continuing education opportunities are provided to staff members?
There is ongoing continuing education presented to the team in a variety of ways. Hospital classes and seminars are offered through our education department. Vendors provide seminars in the area all year long. Three team members attended last summer’s Cardiac Symposium at Mount Sinai in New York City. The team has access to modules on our HealthStream educational site, as well as many CEU opportunities through CE Direct. Our physicians are always happy to educate cath lab team members.
How do you handle vendor visits to your lab?
Vendors make appointments to visit the lab and sign in through the materials management department.
How is staff competency evaluated?
Our yearly employee education is managed online through HealthStream. Unit-specific competencies are done peer-to-peer through verbal instruction and return demonstration.
Does your lab have a clinical ladder?
At the present time, the clinical ladder program is available to RNs only. As our lab grows, our goal is to implement the program to all team members.
How does your lab handle call time for staff members?
There is no particular mix of credentials. It is a 4-person team consisting of RN and CVT personnel. Since there is a small team who supports the 24/7 requirements of call, there are many combinations.
Within what time period are call team members expected to arrive to the lab after being paged?
The team is required to report to the hospital within 30 minutes of receiving a call from the nursing supervisor. We do not use a paging system.
Do you have flextime or multiple shifts?
At Jupiter Medical Center, we have a team arrive at 0600 and a second team at 0700. We will flex and start call early during slower times. We look on a day-to-day basis to ascertain the next day’s caseload. All team members are flexible to meet the next day’s demands. During the busier months of our winter season, we stagger the 2 shifts to accommodate the longer days.
Has your lab recently undergone a national accrediting agency inspection?
The Joint Commission visited Jupiter Medical Center in July 2015. The surveyors were very complimentary on our lab and our progress. Our recommendations are to always be prepared. Follow the guidelines made by the surveyors and stay abreast of recommendations made by your quality department. Implement changes as soon as you are made aware of them and there will be no surprises.
Where is your cath lab located in relation to the operating room (OR) and ED?
The OR is on the second floor. The cath lab procedural areas are on the first floor, adjacent to the ED. We are located close to 3 elevators and are able to move from floor to floor fairly rapidly, which will benefit us when we begin our open heart program. Currently, open heart surgery is not available at Jupiter Medical Center. We are striving to obtain state approval within the next two years.
What trends have you seen in your procedures and/or patient population?
In terms of population, Jupiter, Florida, is fairly homogenous. Our patient population is primarily composed of a mix of seasonal and annual patients who tend to be 50 and older. As a lab, we do a fairly even mix of in and outpatient procedures, with diagnostic or interventional cardiac catheterization procedures being the bulk of our volume. We have seen more local physicians start to prefer radial access, and in accordance with evidence-based practice, use FFR, IVUS, or OCT to determine interventional necessity.
What is unique or innovative about your cath lab and staff?
Our cath lab does pre-cath, procedure, and post-cath care. We are comprised of 8 cath lab team members, 2 other RNs and a few per diem team members who help during busy times. Because of the small team, and proximity to our cardiology procedural area and interventional radiology department, our team’s skill set is diversified, and we collaborate between departments to share team members and resources.
Is there a problem or challenge your lab has faced?
Our challenge has been developing and implementing our program without on-site open heart surgery. We have addressed it by having an experienced, dedicated team and excellent outcomes. All of our cardiologists are self-employed private practice physicians. We have worked continually to show them that our approach to quality drives us to be the best. We are becoming very busy and growing daily, but we remain focused on quality. This has helped us to become recognized for excellence by our physicians and the community.
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”?
Jupiter, Florida is located in northern Palm Beach County. It is an idyllic waterfront community located less than 2.5 miles from the Atlantic Ocean and is known for its iconic red lighthouse that was built in the 1860s. In the winter season, the average temperature is 70 to 80 degrees Fahrenheit. The area becomes very busy around November, due to the seasonal population arriving from all over to retreat for the winter.
Something unique about this community in particular is its overwhelming support for the medical center and our presence in the community. Jupiter Medical Center is also unique for its upstream thinking in regards to community health, and it dedicates many resources to the community to detect conditions such as heart disease, breast cancer, and diabetes, and works hard to keep patients with chronic health problems out of the ED. Resources such as the wellness bus, cardiac risk screenings by our cardiac nurse navigator, outpatient clinics in several residential developments, urgent care centers, frequent health fairs, and a presence at the local Mandel Jewish Community Center allow Jupiter residents to access world-class care without ever needing to step foot in the hospital. There are also exciting partnerships beyond Mount Sinai Heart New York with Nicklaus Children’s Hospital, the Mandel Jewish Community Center, and the Joe Namath Neurological Research Institute, which afford Jupiter residents comprehensive care from birth through their golden years. The hospital truly collaborates with and advocates for the health of the community.
The authors can be contacted via Barbara Lamia, RN, MSN, at firstname.lastname@example.org.
Questions from the Society of Invasive Cardiovascular Specialists (SICP):
1. 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?
Since we are a new program, at this time, we have not required our team members to be credentialed. Our team members with the RCIS credential currently do not receive compensation for this certification.
2. Are your clinical and/or managerial team members involved with any professional organizations that support the invasive cardiology service line, such as the SICP, ACVP, or regional organizations?
Not at the present time.
A question from the American College of Cardiology’s National Cardiovascular Data Registry:
How do you use the NCDR Outcome Reports to drive quality improvement (QI) initiatives at your facility?
In the past 2 quarters, our volume has increased. Having a larger volume of patients has allowed us to review our results in order to identify trends and benchmark ourselves. We will be using Q3 results to drive QI initiatives moving forward.
Mount Sinai Heart New York’s Partnership with Jupiter Medical Center
Talking with Samin K. Sharma, MD, FSCAI, FACC, Director, Clinical & Interventional Cardiology, President, Mount Sinai Heart Network, Dean, International Clinical Affiliations, Zena & Michael A. Wiener Professor of Medicine, The Mount Sinai Hospital, New York, New York.
Can you tell us about the partnership?
Mount Sinai Heart New York’s affiliation with Jupiter Medical Center started a few years ago, with a single purpose — providing the best patient care and research in south Florida. Mount Sinai has many affiliations with other countries, but outside of the boroughs of New York, Jupiter Medical Center is our first trans-state affiliation for cardiology services. Jupiter Medical Center is a reputable center with excellent, experienced cardiologists, but there are a few complex diseases that cannot be taken care of there, such as complex coronary interventions, transcatheter aortic valve replacement (TAVR), and cardiac surgeries. The ultimate goal is to empower Jupiter Medical Center to have the cardiac surgical program on site at the local level. Also, under our affiliation, Jupiter physicians have visited us frequently and their cath lab staff attended our Nurse and Technologist education sessions at our annual symposium in June 2016. It has been very useful. The goal is to improve knowledge and participation in research, and extend all the clinical care available at Mount Sinai Hospital, and they are on the right track.
Your lab is well known for establishing protocols. Have those also been shared with Jupiter Medical Center?
Yes, Mount Sinai’s protocols are also being extended to Jupiter Medical Center. They get the benefit of academically and clinically tested protocols to improve patient care and also identify patients who need advanced care. Jupiter Medical Center now offers a clear-cut referral pattern to Mount Sinai Hospital for advanced care. At Mount Sinai, we have access to Jupiter Medical Center patients’ electronic medical records. Jupiter physicians refer patients needing advanced care to Mount Sinai New York, and they also can look at the patient’s record, angiogram, anything being done here. It is a great step. We have found that unless a formal relationship has been established, patients are reluctant to pursue advanced care outside their locality. But if a system has been created, patients are much more receptive to travel for advanced care, and this has been proven in the last 2 years of our relationship. Patients seen at Jupiter Medical Center who require advanced care are now routinely coming to Mount Sinai New York. Also, many of our patients who also live in Florida are being taken care of by Jupiter Medical Center doctors.
Any final thoughts?
Eradication of cardiac disease may be an impossible goal, but at Mount Sinai, we are seeking to improve cardiac care globally. Our relationship with Jupiter Medical Center is one step toward this goal. Mount Sinai has been a leading center in providing care to the patients in New York State, and now we are branching out nationally, as well as globally. This process has accelerated recently under leadership of our network president, Dr. Arthur Klein, and we are considering how we can go further to improve relationships with both patients and medical centers in offering global cardiovascular care.