Spotlight: Saint Vincent Hospital
Tell us about your facility and cath lab.
Saint Vincent Hospital is located in Erie, Pennsylvania, and is one of 7 hospitals that comprise Allegheny Health Network. Our cath labs are shared between interventional cardiology and vascular surgery. Our department has a 6-bay pre/post unit, 3 procedure rooms, and will utilize a hybrid OR room as necessary. One room is a dedicated cardiac suite, one room can be used for coronary or specials, and the third room is a bi-plane room that can also be used for both procedure types. We employ 16 staff members, including 5 registered nurses (RNs), 8 radiologic technologists (RTs), 1 scrub tech, and 2 secretaries. Staff experience ranges from a modest 39 years, to an RN that just began her cath lab career 3 months ago. Our average service time is 8.5 years.
What procedures are performed in your cath lab?
The Saint Vincent Hospital Cath Lab is a combination cardiac and special procedures unit. Our coronary work includes diagnostic and interventional procedures that include chronic total occlusion (CTO) and patent foramen ovale (PFO) closures.
The specials procedures include carotid angiograms and stents, upper and lower extremity angiograms and interventions, abdominal angiograms and stents or coilings, lumbar kyphoplasties, and cerebral angiograms. We perform about 60 coronary procedures and 30 special procedures per week.
If your cath lab is performing transcatheter aortic valve replacement (TAVR), can you share your experience?
Saint Vincent Hospital has a hybrid OR suite with an Artis zee system (Siemens Healthineers) that is staffed with a combination of cath lab and OR staff members. We performed our first TAVR in April 2013 and have performed nearly 200 since.
Who manages your cath lab?
Charmaine Rohan, RN, is the director of cardiovascular services at Saint Vincent, and Kevin Tobin, RN, RCIS, is the manager.
Do any of your physicians regularly gain access via the radial artery?
All seven of our interventional cardiologists adopted radial access about four years ago and currently, 65% of our diagnostic and ST-elevation myocardial infarction (STEMI) cases are performed via radial access.
If you are performing peripheral vascular procedures, do any operators utilize pedal artery access when appropriate?
Yes, pedal access is used by both the interventional cardiologists and the vascular surgeons when necessary.
What is your percentage of normal diagnostic caths?
Of our yearly total of cases, about 40% require either percutaneous transluminal coronary angioplasty (PTCA)/stent or coronary artery bypass graft (CABG) surgery, which leaves the remaining 60% of our patients either normal or treated medically.
Do you have cross-training? Who scrubs, who circulates and who monitors?
Yes, we try to cross-train all of our RNs and RTs to the scrub position. Each procedure is staffed by the physician, an RN that circulates, a radiologic technologist that monitors, and a scrub. Our scrub position can be an RN, scrub tech, or RT.
Are there licensure laws in Pennsylvania for fluoroscopy?
Baseline training/credentialing is required. A certified RT is present for all procedures and all operating physicians have to have required training.
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?
All of our physicians operate the x-ray equipment for the procedures. If an RT is scrubbed in, then he/she is allowed to assist with the x-ray equipment.
How does your cath lab handle radiation protection for the physicians and staff?
All of our staff are given personal lead aprons and lead glasses. All staff are required to wear a dosimetry badges that are analyzed quarterly. Michelle Drexel, RT, is the radiation safety officer for the cath lab and she speaks to each new employee about proper techniques for reducing radiation doses.
What are some of the new equipment, devices and products recently introduced at your lab?
We have recently introduced Opsens’ Optowire Pd/Pa wire, Osprey Medical’s DyeVert Plus System, and have instituted a Pulmonary Embolism Response Team using EKOS catheters.
How does your lab communicate information to staff and physicians to stay organized and on top of change?
The manager and director meet with the interventional cardiologists on a monthly basis to go over any issues within the labs or information that they want passed onto the staff, along with a presentation of lab metrics. The manager and director also meet with the staff once a month at a unit conference, to go over new policies or procedures, and other importation communications. There are daily huddles with the staff each morning to go over the flow for the day and any potential issues that are foreseen. The staff also utilizes a dry erase “communication board” in our breakroom to notify each other of important information or physician requests.
How is coding and coding education handled in your lab?
Matt Billingsley, RT, handles all coding and charging on the front end of our procedures and a certified coder reviews all charges.
Who pulls the sheaths post procedure, both post intervention and diagnostic?
All cath lab staff members are credentialed to pull both post interventional and post diagnostic sheaths. During staff orientation, a new RN or tech is observed pulling a variety of sizes and insertion site locations.
Where are patients prepped and recovered (post sheath removal)?
We have a 7-bay pre/post area (holding area) to which our patients are brought from the floors. The unstable patients or any patient on a ventilator go straight to the procedure rooms, but all other patients stop in the holding area for a quick assessment and chart review. Post procedure, we have the ability for manual compression or closure devices based on physician preference and patient anatomy. Depending on the anticoagulated state of the patient, the sheath can be removed in the holding area post procedure or the patient can be sent to the telemetry or critical care floors and have the sheaths pulled later. An activated clotting time (ACT) level of less than 150 seconds is used as a level to remove femoral arterial sheaths. For pedal or radial sheaths, we use an ACT level of less than 200 seconds for pull criteria. For closure devices, we use the TR Band (Terumo) for radial compression, and also have Angio-Seal (Terumo), MynxGrip (Cardinal Health), and Perclose ProGlide (Abbott Vascular).
How is inventory managed at your cath lab?
We have a hospital staff member that manages the inventory and scans product usage each day. As a product is used during a procedure, the staff leave a product card that has a barcode on it in a collection bin. The cards are then scanned and orders are placed automatically through our purchasing interface. Allegheny Health Network has a group purchasing organization (GPO) that handles all new contracts and purchases. The unit manager is responsible for monthly usage and budget expenditures.
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?
Saint Vincent Hospital’s average D2B time for the last year was 57 minutes. Over the past few years, we have worked closely with area emergency medical services (EMS) and our emergency department (ED), and have implemented EMS-allowed activation of the cath lab STEMI team. Our on-call STEMI team does not remain in house on off-hours and weekends, so having EMS start the cath lab team responding prior to the patient actually arriving in the ED has shortened our times. We are Mission: Lifeline accredited with the American Heart Association (AHA) and we are currently working on Chest Pain Center Accreditation through the American College of Cardiology (ACC).
Who transports the STEMI patient to the cath lab during regular and off hours?
All STEMI patients are picked up by the cath lab RN and another team member. During off hours, once the team assembles in the room, the RN will go over to the ED or coronary care unit (CCU) to start getting the patient ready for transport. Once the scrub is finished setting up the procedure table, he/she will go and help the RN transport.
What do you do when the call team is already busy doing a procedure and a STEMI comes into the ED?
The on-call team has the ability to alert the in-house manager of operations who will come down to the cath lab and page the other off-duty staff in order to pull a second team together. If, by chance, a second team cannot be formed, we will utilize an “In-house Cardiac Thrombolysis Protocol” and the patient can be given tPA by the ED physician.
What measures has your cath lab implemented in order to cut or contain costs?
The Allegheny Health Network has worked diligently with multiple vendors to get the best pricing possible. We have also demoed various competitors to try to find the best pricing while still providing safe care.
What quality control measures are practiced in your cath lab?
Monthly, we review D2B times along with the cardiologists, ED physicians, and ED leadership. Quarterly, we sit down with the quality department to review acute kidney injury (AKI) rates, and mortality and bleeding rates.
How do you determine contrast dose delivered to the patient during an angiographic procedure?
For every procedure that we perform, a MACD (max allowable contrast dose) is calculated prior to the procedure and is part of the pre-procedure time-out. The MACD is calculated using the patient’s creatinine, body weight, and contrast concentration. For patients with a low MACD, the physician has the ability to utilize Osprey Medical’s DyeVert contrast reduction system.
How are you recording fluoroscopy times/dosages?
Our Philips rooms calculate fluoro times and dose area product (DAP), and then this information is documented in the patient’s chart.
What is the process that occurs if a patient receives a higher than normal amount of radiation exposure?
Our Philips equipment calculates radiation dosage and we have a policy in place that any patient receiving over 5000 mGy is seen in follow-up by the performing cardiologist. During the procedure, the RT will document the mGy dose for every patient, and if a patient reaches the 5000 mGy threshold, then the performing physician’s office nurse will be notified. The nurse will call the patient to schedule a follow-up appointment for a skin check.
Who documents medication administration during the case?
Medications are documented by a combination of the circulating RN and the monitoring RT. Any meds that the RN gives to the patient are documented by the RN. Any meds that are given on the procedure table by the physician are documented by the RT.
Are your physicians dictating their cath procedure reports, or do they use a structured reporting tool?
Our physicians use the structured reporting tool in the Epic electronic medical record (EMR) for the coronary procedures, but the majority of our peripheral cases have the notes dictated into Epic.
Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) or any other outside data collection registry?
Yes, some data points from our Epic EMR system flow automatically into the registry, but we also have a dedicated cardiology abstractor (a former cath/electrophysiology RN) in our quality department who handles data collection for the hospital.
How does your cath lab compete for patients? Has your institution formed an alliance with others in the area?
We have always stuck with the mantra that “our patients are our best marketing tool”, providing each and every patient with a safe and comfortable experience. We care for each patient as if they were one of our family members. Having these patients out in community speaking positively about our lab and hospital brings us additional patients.
How are new employees oriented and trained at your facility?
New employees will go through a house-wide orientation day on their first day of work. The hospital budgets an orientation period of 8 weeks for a new hire. The orientation process for nurses and RTs in the lab itself runs between 8-10 weeks, depending on the individual’s past experience, and the orientation for a new scrub takes close to 6 months. Each new staff member is given two preceptors who are by their side for the early stages and then act as a resource as the new member progresses. For on-call orientation, the new employee is paired up with a senior staff member for between 6 and 10 months. Weekly check-ins are performed between the orientee, the preceptor, and the unit manager, and the physicians give feedback on a monthly basis.
What continuing education opportunities are provided tostaff members?
The hospital educators put on monthly seminars and different physicians will speak during “Grand Rounds” where a different topic is presented. We also have great support from our vendors, who are always willing to put on educational lectures or demonstrations for the staff. Staff are made aware of national conferences that are available.
How do you handle vendor visits to your lab?
Vendors must schedule visits with the unit manager. The hospital then has a check-in system for the vendor each time they visit, which logs them in and produces a visitor badge for that day. The number of vendors each day is controlled as to not disrupt the care that is provided to our patients.
How is staff competency evaluated?
Staff perform annual competencies on most of the equipment used in the cath lab. We focus on the low-frequency/high-risk equipment first and then complete other competencies as the year goes on. Each staff member is signed off by the manager or a senior staff member.
Does your lab have a clinical ladder?
The hospital has a clinical ladder for the nursing staff and we are looking into the structure of a clinical ladder for the technologists and ancillary staff.
Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)?
We currently do not require the staff to have RCIS, even though it is strongly recommended. Last fall, our director, with some support, brought in a nationally recognized program to put on the RCIS exam review course. Hopefully, this year more of our staff will be sitting for the RCIS exam.
What do you like about the physical space in which you work?
All three cath lab rooms are very spacious. It gives us a lot of freedom to move around the room, especially in the unfortunate circumstance when a case deteriorates.
How does your lab schedule team members for call?
Prior to the beginning of each month, the individual groups (circulators, scrubs, and RTs) sit down together and get to pick their call days for the month. As long as all members take their fair share of days, then this process works. If there is a dispute with call days then the manager reserves the right to assign the days.
Within what time period are call team members expected to arrive to the lab after being paged?
Our staff members are expected to arrive in the lab within 25 minutes
Are staff permitted to leave early or start later after a night of on-call?
After an on-call shift, the call team members are given the first option of leaving early as long as the case load allows it.
Do you have flextime or multiple shifts? How do you handle slow periods?
The majority of our staff members work 8-hour shifts. We do have one team of individuals that works 10-hour shifts to help finish cases at the end of the day. Staff education is always the priority when we get slow periods. With new technology always coming out, as well as newer staff members, down time can always be utilized to improve the staff.
Has your lab recently undergone a national accrediting agency inspection?
Last year, our hospital went through Joint Commission accreditation and our biggest recommendation is just to have everything in place and done properly as your daily routine.
What trends have you seen in your procedures and/or patient population?
Peripheral work and the growth of structural heart procedures has become a large focus and volume for us.
What is unique or innovative about your cath lab and staff?
Our nursing staff comes from a variety of backgrounds: emergency care, intensive care, cardiac telemetry, step down, and med surg. Our technologists come from just as diverse a background, from 39 years of experience in the cath lab to members who have done OR work, office work, and mobile studies. This brings a robust and dynamic view of patient care and treatment.
Is there a problem or challenge your lab has faced?
Staffing and education of staff are the major issues. It has been difficult to find staff that can accept taking call and have the personality to be cath lab staff. Once you are short-handed, it then becomes difficult to provide quality, in-depth training to newer staff, which can cause them to feel overwhelmed. Providing the best possible environment for the staff is our main focus for staff retention. We try to accomplish this through daily huddles with the staff, timely positive feedback, addressing staff issues, and providing vendor-sponsored education.
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”?
It usually starts snowing in Erie around November and doesn’t let up until April. We are always guaranteed at least a couple of STEMIs with the first snowfall of the year. This past year, the City of Erie and Saint Vincent Hospital made national news for a record snowfall around Christmas that dumped nearly 84 inches of snow over 6 days. This tends to lead to quite a bit of cabin fever come March and April, so keeping the staff motivated and positive becomes especially important.
A question from the American
College of Cardiology’s National Cardiovascular Data Registry:
How do you use the NCDR Outcome Reports to drive QI initiatives at your facility?
In 2013, we noticed that our AKI rate was higher than the benchmark, so we developed a pre and post hydration protocol, and we have also brought in contrast reduction equipment.
Kevin Tobin, RN, RCIS, Manager Heart and Vascular Center, can be contacted at firstname.lastname@example.org