Cath Lab Spotlight

Spotlight: Tallahassee Memorial HealthCare

Thomas Noel, MD, FACC, Interventional Cardiologist, 
Tallahassee Memorial HealthCare, Tallahassee, Florida

Thomas Noel, MD, FACC, Interventional Cardiologist, 
Tallahassee Memorial HealthCare, Tallahassee, Florida

About Tallahassee Memorial HealthCare:

Founded in 1948, Tallahassee Memorial HealthCare (TMH) is a private, not-for-profit community healthcare system committed to transforming care, advancing health, and improving lives, with an ultimate vision of leading the community to be the healthiest in the nation. Serving a 17-county region in North Florida and South Georgia, TMH is comprised of a 772-bed acute care hospital, a psychiatric hospital, multiple specialty care centers, three residency programs, 31 affiliated physician practices and partnerships with Doctors’ Memorial Hospital, Florida State University College of Medicine, University of Florida Health, Weems Memorial Hospital and Wolfson Children’s Hospital.

About the Tallahassee Memorial Heart & Vascular Center:

The Tallahassee Memorial Heart & Vascular Center is a leader in the Southeast for advanced heart care and research. We are the first hospital in Florida to offer the Absorb BVS (Abbott Vascular). Our Heart & Vascular Center is as home to an accredited chest pain center with percutaneous coronary intervention (PCI) and the area’s only certified atrial fibrillation program. 

With an expert team of cardiologists and surgeons, we provide exceptional heart and vascular care for our patients. In fact, our physicians perform more clinical research and advanced procedures than any other program in the North Florida and South Georgia region.

What is the size of your cath lab facility and number of staff members? 

We currently have one cath lab, two hybrid cardiac/vascular suites, and a biplane neurovascular suite. There are currently 22 positions with 13 registered nurses (RNs), 7 radiologic technologists (RTs), and 2 cardiovascular technologists (CVTs) with an average “in residence” time of 10 years. 

What procedures are performed in your cath lab? 

We provide comprehensive cardiac diagnostic and interventional services, performing 2,500 diagnostic caths and 800 cardiac interventions annually. We have a robust structural heart program that includes transcatheter aortic valve replacement (TAVR), MitraClip (Abbott Vascular), and Watchman (Boston Scientific) devices. Our team performs a variety of complex peripheral endovascular procedures and aortic endografts. We have a full arsenal of circulatory support technology, including intra-aortic balloon pumps (IABPs), Impella (Abiomed), and CardioHelp (Maquet). We provide urgent intervention for pulmonary embolism using the EkoSonic Endovascular System (EKOS Corporation, a BTG International group company). TMH is a Comprehensive Stroke Center, providing acute intervention in our neurovascular suite, and the cath lab program supports a growing volume of elective and urgent endovascular neurosurgery procedures, including angiography, coiling, stenting, and clot retrieval. In addition to our tertiary-level services, the Heart & Vascular Center partners with Tallahassee Research Institute (TRI) in bringing advanced clinical research trials, with the cardiac cath lab service supporting many of those studies. 

If your cath lab is performing transcatheter aortic valve replacement (TAVR), can you share your experience? 

TMH has a comprehensive, multidisciplinary structural heart program. The service began in 2012 and has grown into a regional referral center for tertiary-level services. Our two hybrid labs support transcatheter aortic and mitral valve procedures, with 1-2 days per week primarily devoted to structural heart procedures. As many of our structural heart cases have transitioned to percutaneous access with conscious sedation, we have improved efficiency by “flipping” rooms, and recovering these patients on our pre/post-procedural care unit. A majority of our structural heart patients do not require intensive care unit (ICU) admission, reducing length of stay and improving patient satisfaction. 

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

Between 60-65% of our diagnostic and interventional procedures are via radial access. 

Who manages your cath lab? 

Our cath lab manager is a licensed RT who has been with our lab for over 30 years. 

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

We cross train for all positions, scrub, circulator, and monitoring/recording. RNs administer medications.

Who documents medication administration during the case?

The colleague at the recorder position repeats back, then documents medication administration in the case record, at the direction of the nurse administering the medication.

What percentage of your diagnostic caths are normal?

We are at the 50th percentile of the National Cardiovascular Data Registry (NCDR) CathPCI registry in this outcome.

Which personnel can operate the x-ray equipment (position the image intensifier [II], pan the table, change angles, step on the fluoro pedal) in your cath lab? 

Physicians and RTs may step on fluoro; however, any of the colleagues may pan the table. The physician primarily positions the II during the procedure.

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

Colleagues receive annual education regarding radiation safety. Monthly monitoring of film badges keeps us mindful of physician and colleague exposure. We have recently updated some of our equipment with radiation reduction software, which allows for quality images at reduced radiation doses.

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

At TMH, participating in clinical research with our physician partners lays the foundation for early adoption of new technology. Most recently, our program was the first commercial site in the state of Florida, second in the Southeast and sixth in the country to implant the Absorb BVS. Our program was the third in the nation and first in the Southeast to offer the Watchman device commercially.

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

We have 5 clinical co-management councils that meet monthly, and are led by cardiologist-administrator dyads. We hold monthly meetings with our colleagues. Our manager, our clinical educator, and our performance improvement (PI) advisor work as a team to facilitate communication to keep colleagues involved in and abreast of change.

How is coding and coding education handled in your lab? 

We have a reimbursement/charge capture analyst who tracks documentation, coding, and reimbursement for our Heart & Vascular Center. We have a contractual partnership with a specialty service to provide coding education and assist us with assuring the accuracy of our coding and billing; we have recently expanded that agreement to include specialty coding for high dollar, new technology accounts. 

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

The majority of the sheaths are pulled by nurses in the post-procedure care area. We have a formal preceptor training process for sheath pull and access site management.

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

Patients are prepped and recovered in our procedural care area. Due to the broad range and complexity of our services, hemostasis is highly individualized, and we utilize both manual compression and closure devices.

How is inventory managed at your cath lab? 

Inventory management is handled by our cath lab manager. Purchasing of equipment and supplies is reviewed through a value analysis agenda in our co-management meetings. Our materials management team reviews all requests and provides details to the councils so informed decisions can be made.

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

Our biplane neurovascular suite will move to a new surgical/intensive care tower when it opens, and that lab space will be repurposed as a third structural heart/vascular suite. We plan to open a third EP lab in the next 1-2 years.

Can you tell us more about your involvement in clinical research?

Tallahassee Memorial HealthCare, Southern Medical Group, and Tallahassee Research Institute collaborate regularly to bring new clinical cardiovascular research to our area, with as many as 20 open research studies at any given time. Through this relationship, our labs have been included in many research trials, such as ABSORB, which allowed us to be one of the first programs in the country to offer the technology to our patients.

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 D2B time is under 60 minutes. We are accredited by the Society for Cardiovascular Patient Care as a Chest Pain Center with PCI, and we are seeking accreditation as a Chest Pain Center with PCI and Resuscitation in the Cycle V accreditation process. Our Chest Pain Center coordinator tracks ST-elevation myocardial infarction (STEMI) times in real time and provides immediate feedback to EMS, our emergency centers, the STEMI team, and our physicians. We hold a monthly multi-disciplinary meeting to review all STEMI cases, discuss strategies to continually reduce time, and also to celebrate successes. 

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

Cath lab colleagues escort the STEMI patient to the lab in all cases.

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

STEMI call, stroke call, vascular call, and acute pulmonary embolism (PE) call all fall within the cardiac cath lab service, and we provide response times within 30 minutes. As services have expanded, we have built redundancies into our call team strategies to accommodate the potential for multiple case demand — it takes a dedicated team and flexibility. There are 6 labs in the Heart & Vascular Center, all capable of accommodating a STEMI case, and our team works hard to ensure we can get our emergency cases on a table without delay. In the very rare circumstance that we could not accommodate a STEMI patient, our emergency centers are prepared to provide thrombolytic therapy.

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

Our co-management program and value analysis process are highly effective in managing costs, and our lab colleagues are very engaged in charge capture accuracy and in helping the organization manage costs.

Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) or any other outside data collection registry?

We participate in the ACC-NCDR CathPCI registry, Society of Thoracic Surgeons (STS)/ACC TVT (Transcatheter Valve Therapy) registry, Watchman registry, and ICD (Implantable Cardioverter Defibrillator) registry. These data are used in assessing and improving our outcomes.

How are new employees oriented and trained at your facility? 

Hospital and clinical orientation is 5 days. We have developed a formal cardiac cath lab orientation program with a 90-day competency plan, and a 6- to 9-month competency plan, which is tailored to the new colleague’s clinical experience prior to joining our team. Our clinical educator coordinates and oversees the orientation plan with the cath lab manager and preceptors within the service. The cardiologists have partnered in colleague education and competency, which has increased cath lab staff and physician satisfaction. 

How do you handle vendor visits to your lab? 

Vendors coordinate their visit to the lab with the cath lab manager and are required to check in through the VendorMate system in materials management prior to reporting to the lab.

How is staff competency evaluated? 

After orientation is successfully completed, we evaluate ongoing competencies through assessing annual case volumes at all positions, the use of a colleague skills self-assessment, and feedback from peers and from cardiologists.

How does your lab handle call time for staff members? 

We have a mix of 2 nurses and 2 technologists, and we have additional competency requirements related to acute stroke call.

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

Colleagues are required to arrive within 30 minutes.

Do you have flextime or multiple shifts? 

We have staggered shifts starting at 7:00 am, with the last shift arriving at 10:00 am.

Do you have any recommendations or advice for labs about to undergo a national accrediting agency inspection?

Remain ready at all times. We do monthly patient tracers and weekly environment of care rounds within the department. Leadership rounds are performed on a monthly basis.

Where is your cath lab located in relation to the OR and ED? 

The OR is located directly below us and we have a dedicated elevator between our 2 floors. The ER is located in an adjacent building with a crosswalk.

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

Over the past five years, we have experienced a rapid, dynamic increase in technology and in the complexity of patient population. Our team has been very engaged and progressive in adapting to these changes and we are actively seeking colleagues who want to be a part of our exciting growth!

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

Our physicians and cath lab staff are innovative in trying to improve the patient experience from the moment of admission to the time of discharge. This patient-centered approach has required significant change in practice by both physicians and the cath lab, but has improved patient outcomes and satisfaction.  

How does your facility handle the challenges of operating a cath lab that inevitably crop up on a regular basis?

Our clinical co-management program, which started in 2013, has evolved into a very effective structure for managing challenges within the program.

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”?

Tallahassee is one of the most educated cities in the country and is Florida’s capital, placing us in the spotlight for new programs, research, and policies. With three major higher education institutes, Tallahassee is retaining a growing population of young professionals. Pair the city’s cultural boom with the beautiful parks, excellent schools, and mild year-round weather, we find that more and more people are eager to move to our capital city. Our cath lab team is a reflection of our dynamic city, creating a culture dedicated to advancing research and technology, and providing to excellent care for the entire region.

The Society of Invasive Cardiovascular Professionals (SICP) has added a question to our spotlight:

Does staff receive an incentive bonus or raise upon passing the registered cardiovascular invasive specialist (RCIS) exam?

We do offer additional compensation for registry.

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?

We have developed executive snapshot reports for all registries that are reviewed with each quarter release. The registry outcomes are an important source for monitoring and improving performance and outcomes in the CathPCI, ICD, transcatheter valve, and Watchman patient populations.