Cath Lab Spotlight

Spotlight: St. Tammany Parish Hospital

Shane Melder, RT(R), Cath Lab Radiology Supervisor, Sandy Morgan, RT(R), Cath Lab PACS Administrator, Shannon Holley, MBA, RT(R), Cardiovascular Services Department Head, Covington, Louisiana

Shane Melder, RT(R), Cath Lab Radiology Supervisor, Sandy Morgan, RT(R), Cath Lab PACS Administrator, Shannon Holley, MBA, RT(R), Cardiovascular Services Department Head, Covington, Louisiana

The authors can be contacted via Shane Melder, RT(R), Cath Lab Radiology Supervisor, at rmelder@stph.org.

Tell us about your cath lab.

St. Tammany Parish Hospital cath lab has 4 catheterization suites: 2 dedicated cardiac, 1 cardiac/vascular, and 1 electrophysiology (EP) room. We have 21 staff in the cath lab, 

including 5 radiologic technologists (RT[R]s), 

8 registered nurses (RNs), 1 surgical technologist, 

2 assistants, 1 scheduler/clerical, 

1 radiology/technical supervisor, 

1 nurse supervisor, 1 PACS/cardiovascular information systems (CVIS) administrator, and 1 American College of Cardiology (ACC) database abstractor. There are also 7 RNs in our cardiovascular outpatient unit.

What procedures are performed in your cath lab?  

We perform diagnostic coronary catheterizations, percutaneous coronary intervention (PCI), including stents, percutaneous transluminal coronary angioplasty (PTCA), atherectomy,  EP procedures and ablations including afib ablations, bi-ventricular ICD implantations, peripheral vascular diagnostic and intervention, including management of acute and critical leg ischemia, acute and chronic deep vein thrombosis (DVT) interventions, abdominal aortic aneurysm (AAA) repairs, acute and chronic mesenteric ischemia interventions, and carotid stenting. From a structural heart disease standpoint, we perform balloon valvuloplasties and percutaneous atrial septal defect (ASD)/patent foramen ovale (PFO) repair, and mitral balloon valvuloplasty. We perform approximately 50-60 cases per week.

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

At this time, we are at more than 80% radial artery access for coronary catheterization. Improved patient comfort and lower morbidity rates are significant advantages to transradial cardiac catheterization. Even with vascular closure devices, transfemoral cardiac catheterization requires that the patient maintain a supine position for an extended period post procedure when compared to radial access cases. This can be especially uncomfortable in patients with chronic back problems. Transradial catheterization removes the need for postprocedural flat time, and most patients are able to ambulate immediately following the procedure. Transradial catheterization also has the potential to reduce procedural costs. Fewer bleeding complications equate to shorter hospital stays.

Who manages your cath lab? 

We have a department head responsible for all of cardiovascular services, a radiology/technical supervisor, and a nursing supervisor for the cath lab. 

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

Our employees are all cross-trained to accomplish multiple tasks in the cath lab. This helps with room assignments and in continuity of the lab throughout the day. All the technologists are trained to scrub, circulate, and monitor/record. All nurses are trained to circulate, administer conscious sedation and all needed medications, assess the patients before, during, and after the procedure, and monitor/record.

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? 

In Louisiana, only the radiologic technologists and physicians are able to use fluoroscopy. Our radiologic technologists perform all of those tasks, with the physician usually operating the exposure switch/pedal.

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

Along with appropriate radiation protection training, all physicians and staff are equipped with lead aprons and thyroid shields. We also have lead hanging shields in all of the rooms for extra table side protection. We are evaluating the Zero-Gravity system (CFI Medical) to help with radiation protection as well as taking the weight of the lead off of the physicians. Every employee is assigned a radiation badge and is monitored monthly.

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

We have recently begun using the Diamondback 360 coronary orbital atherectomy system (CSI) and the CryoConsole cardiac cryoablation system (Medtronic).

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

We have departmental meetings as well as a cardiovascular committee meeting every other month. We use our email system to communicate important information to all employees. For things on a lighter note, we use our bulletin board to post hospital-wide information as well as information on a wide array of topics.

How is coding handled in your lab? 

Our PACS/CVIS administrator is responsible for setting up and monitoring all of the charges and billing for the cath lab.

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

The radiologic technologist scrubbing in the case will pull sheaths post diagnostic cases. Post intervention, the sheath is pulled in our cardiovascular outpatient unit area by one of the RNs. Training is done during the three-month orientation process through a review of training, demonstrations, and oversight by the senior technologists and nurses.

How is inventory managed at your cath lab? 

We have an inventory management system along with Pyxis supply stations (CareFusion) that help with the inventory process. Our charge tech handles all of the ordering of supplies with communication through the materials management department.

Has your cath lab recently expanded in size and patient volume, or will it be in the near future?

Compared to previous years, we have noticed an increase in patient volume over the past 12 months, resulting from physician alignment, patient population, and the formation of strategic partnerships.  

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? 

For the St. Tammany Parish Hospital year-to-date 2015 acute myocardial infarction (AMI) D2B times, 67% are less than 60 minutes. Our mean time is 56 minutes with a median of 49 minutes. All cath lab staff and cardiologists, along with emergency physicians and staff, are engaged in AMI and D2B quality outcomes.  

Who transports the ST-elevation myocardial infarction (STEMI) patient to the cath lab during regular and off hours? 

The cath lab team always meets the cardiologist performing the PCI in the emergency department (ED) and transports the patient to the cath lab.

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

We try to limit any elective cases done after hours or on the weekend to alleviate this problem. If procedures are going on in the lab during normal hours and there isn’t an available room, the charge tech makes the decision as to which procedure is stopped to make a room available. If a STEMI arrives after hours while the call team is doing another procedure, then the decision is made to bring in another team to assist.

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

All of our employees are very conscious of the reality that cost is a major concern and do everything in their power to keep that a priority. We keep the correct amount of inventory on hand without having to worry about items expiring by using the JIT (just-in-time) ordering system. It enables us to keep less inventory on hand and resupply as needed. Most of our high-dollar items are consigned, removing the burden of being responsible financially for those items going out of date. We continuously work with vendors to get the best pricing possible through various contracting structures.

What quality control/quality assurance measures are practiced in your cath lab?

We use ACC National Cardiovascular Data Registry outcome reports to drive quality. Additionally, we perform patient rounds on post cath patients to discover any potential quality indicators. All complications are also peer reviewed for quality. The hospital’s decision support and process improvement department also monitors several metrics through several benchmarking organizations.  

Are you recording fluoroscopy times/dosages? 

This is automatically recorded and documented in the procedure record via an interface between the x-ray system and the hemodynamic system.

Who documents medication administration during the case?

Medications are recorded in the hemodynamic system (GE Mac-Lab) and Pyxis system by the circulating nurse in the case.

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

The majority of the report is documented throughout the case on the hemodynamic system. At case end, the data is exported to a structured reporting tool (GE Centricity cardiology data management system) in the physician reading room. The physicians will then log in and dictate the indication, findings, recommendations, and conclusions. The report is then electronically signed by the physician and sent to our EMR.

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

Last year, the hospital employed a cardiology practice. We also formed a partnership with Ochsner Health System that is contributing to the growth of our cath volume.    

How are new employees oriented and trained at your facility? 

All new employees have a three-month orientation and training regimen in our facility. After a general hospital orientation, each new staff member is assigned a preceptor for department orientation. Using a skill checklist, new employees are checked off once they are deemed competent for that certain skill. For someone completely new to the cardiac cath lab, orientation can be extended until the employee is competent to take call. 

How do you handle vendor visits to your lab?

We only allow one representative per day. They have to be in good standing with our Reptrax system.    

How is staff competency evaluated? 

Hospital-wide nurse competency requirements are coordinated through the education department. Department-specific competency is evaluated by management, senior personnel, and physician input.

How does your lab handle call time for staff members? 

We have a three-person team that takes call one night a week and one weekend a month. 

What kind of relief is offered to staff after a busy night of call? 

We try to be reasonable in these situations. If the schedule allows, we will definitely send those team members home early if they would like. They do have to use their paid time off for those hours missed.

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

The staff is expected to be here within 30 minutes.

Do you have flextime or multiple shifts? 

All of our shifts are 10 hours (6:30am–5pm).

Has your lab recently undergone a national accrediting agency inspection? 

The hospital recently completed the reaccreditation process with the Society of Cardiovascular Patient Care and was again recognized and accredited as a Chest Pain Center with Primary PCI.  

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

The OR is one the same floor and directly down the hall. Our ED is one floor down in the same building. 

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

We see more and more patients each year coming to the lab with heart disease at a young age, some in their upper 20s and quite a few in their 30s. We are also seeing an increased number of AMIs each year.

What is unique or innovative about your cath lab and staff?    

Our cath lab staff is highly experienced and engaged in their profession. Each holds the others to very high expectations and levels of performance. It is truly a multidisciplinary team that works together for optimal performance and quality outcomes.    

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

As a suburb of New Orleans, the culture of our area is very strong and often diverse. We see patients from varying socioeconomic status levels and our staff is able to respond to each in a professional and caring way. Our work culture is one of dedication and high performance, and one that also likes to have fun both away and at work. We have strong teamwork and trust. 

Learn more about St. Tammany Parish Hospital at stph.org.

Two questions from the Society of Invasive Cardiovascular Professionals (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? 

Not at this time.

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 this time.