West Hills Hospital is nestled deep in the San Fernando Valley, offering evidence-based medicine close to home for our patients. Our cath lab is part of our division’s cardiovascular service line strategy. We align our services with our sister hospital in the market, and share best practice and learning across eight hospitals in the HCA system. It is a great model because of the multiple resources readily available.
What is the size of your lab and number of staff members?
We currently have 2 labs, with a third planned for construction in the near future. We have 5 full-time registered nurses (RNs), one part-time RN, 2 PRN RNs, 3 full-time technologist, and one PRN technologist. The techs are all cardiac interventional (CI) radiography licensed, and 2 of the nurses are critical care (CCRN) certified. One of our nurses has been with the HCA system for over 30 years. Our longest in-resident nurse has been in the cath lab for 17 years.
What procedures are performed in your cath lab?
We perform both coronary and peripheral angiograms and interventions, including percutaneous transluminal coronary angioplasty and stenting. Available technologies include intravascular ultrasound (IVUS), fractional flow reserve (FFR), rotational atherectomy, intra-aortic balloon pump (IABP), and Impella (Abiomed). We also do implants of cardiac rhythm management (CRM) devices and loop recorders, electrophysiology studies and ablations, and tilt tests.
R4Q ending 2Q2017, only 88/209 of our elective patients were diagnostic.
Do any of your physicians regularly gain access via the radial artery?
Yes. All of our cases are planned via radial access unless they have a limiting factor (R4Q ending 2Q2017, 475/937 = 50.67%).
Who manages your cath lab?
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?
Radiologic technologists (RTs) and physicians can perform these duties.
How does your cath lab handle radiation protection for the physicians and staff?
What are some of the new equipment, devices and products recently introduced at your lab?
- Tryton Bifucation Stent (Cardinal Health);
- Jetstream Atherectomy System (Boston Scientific);
- Micra Transcatheter Pacing System (Medtronic).
How does your lab communicate information to staff and physicians to stay organized and on top of change?
How is coding and coding education handled in your lab?
Coding is performed by our health information management (HIM) department. The lab reconciles all charges and recommends coding modifications.
Who pulls the sheaths post procedure, both post intervention and diagnostic?
RTs pull the great majority of the sheaths; however, nurses are trained and competent as well, both in the cath lab and in our post cath departments. We have annual skills labs and competencies that cover sheath removals.
Where are patients prepped and recovered (post sheath removal)? How does your lab handle hemostasis?
Patients are prepped prior to arriving to the cath lab by their admitting nurse on the floor (either same-day surgery or in patient room). Radial patients are managed with radial bands applied by the RTs prior to patient leaving the cath lab. Femoral access is usually Angio-Seal (Abbott Vascular) placed by the RT or we occasionally use Perclose (Abbott Vascular). Manual pressure is also used as needed by the RTs and/or the nurse on the floor. Our post-op patients go to the recovery room, and ST-elevation myocardial infarction (STEMI) patients go to the intensive care unit (ICU). After the recovery room, patients go to either outpatient for discharge or the step down unit for management and care.
How is inventory managed at your cath lab?
Has your cath lab recently expanded in size and patient volume, or will it be in the near future?
Plans are underway to expand our capacity and also include more advanced procedures.
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?
We rock! Our average D2B is 42 minutes (2Q2017). For a period of time last year, we were the number-one STEMI receiving center for D2B in all of Los Angeles county. We also became the number-one hospital in the HCA system for consistently having our D2B time under 90 minutes. Our team is dedicated to working together with emergency medical services (EMS), the emergency department (ED), cardiology, quality, and physicians to achieve the best outcomes for our patients. We have multidisciplinary weekly case reviews for our STEMI patients.
Who transports the STEMI patient to the cath lab during regular and off hours?
The ED team usually bring the patients up to the cath lab. The cath lab team will help as needed.
What do you do when the call team is already busy doing a procedure and a STEMI comes into the ED?
The STEMI doctor, ED doctor, and the cath lab team triage patients if a second room, team, and doctor are not available. If necessary, the patient on the table will be moved and held in the recovery room temporarily until their case can be completed.
What measures has your cath lab implemented in order to cut or contain costs?
Bulk purchases for supplies and consignment. Our staff is cross-trained and handles multiple responsibilities including stocking, purchasing, transporting, and billing.
What quality control measures are practiced in your cath lab?
We perform STEMI reviews, use DoseWatch (GE Healthcare) for radiation monitoring, and monitor achievement of the hospital’s core measures. We also follow-up with our patients post-op by rounding while they are at the facility and with a phone call after discharge.
How do you determine contrast dose delivered to the patient during an angiographic procedure?
We use the maximum allowable contrast dose (MACD) equation to prevent acute kidney injury (AKI): patient weight in kilograms x 5, divided by creatine.
Are you tracking the incidence of contrast-induced AKI in patients?
Yes, through the American College of Cardiology’s National Cardiovascular Data Registry (ACC-NCDR). The information is shared with our physicians and staff, and is also tracked internally.
How are you recording fluoroscopy times/dosages?
In our Mac-Lab reports (GE Healthcare), our department log book, and DoseWatch.
What is the process that occurs if a patient receives a higher than normal amount of radiation exposure?
An incident report is filed. The radiation safety officer reviews the case. Follow-up is completed by the cardiac cath lab team.
Who documents medication administration during the case?
Medications are documented in both the patient’s electronic medical record by the administering RN and in the Mac-Lab report, which is done by either an RN or RT.
Are your physicians dictating their cath procedure reports, or do they use a structured reporting tool?
Doctors dictate in addition to the detailed cath lab report that is in the patient’s chart.
How are you populating registry data records?
Our cath lab staff enter some information in the Mac-Lab report. Other information is entered by our quality department as abstracted from the patient’s medical record.
How does your cath lab compete for patients? Has your institution formed an alliance with others in the area?
We have arrangements with local hospitals to care for their STEMI patients and our hospital is a participant in the county-wide EMS STEMI receiving program.
How are new employees oriented and trained at your facility?
We use an on-the-job “buddy system” to orient new employees. They are proctored with experienced staff until they display the competencies required.
What continuing education opportunities are provided to staff members?
We provide in-services and vendor-sponsored/provided training opportunities and classes, along with regular cath conferences.
How do you handle vendor visits to your lab?
Vendors are managed through an internal process called DHP. They must be preapproved and badged every time they visit the facility. They can only visit the department they have been cleared/badged for.
How is staff competency evaluated?
Competency is evaluated annually using vendors/representatives, in-house education, and a skills lab.
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?
No, it is not required. There is no bonus/raise.
Does your lab have any physical (layout) bottlenecks or limitations?
We are experiencing growing pains. Inventory and storage are dynamic challenges.
What do you like about your physical workspace?
What we like most about our space is the people in it. It takes an amazing, dedicated team to perform consistently at our level and this dedication is infectious. I am privileged to be part of such an amazing group of staff and physicians.
How does your lab handle call time for staff members?
All team members take call, and each team has 2 RNs and one RT at all times. We have language in our nursing contract to allow staff to leave early or call off if they feel they aren’t safe to work after callbacks.
How does your lab schedule team members for call?
We do self-scheduling for call. We have 2 RNs and 1 RT on call. Call is divided up equally amongst the staff. We use a rotating schedule of who gets first choice in their call days.
Within what time period are call team members expected to arrive to the lab after being paged?
The team has a 30-minute response time. In light of the Los Angeles traffic and our current D2B performance, it is a testament to our team’s commitment.
Do you have flextime or multiple shifts? How do you handle slow periods?
We have one shift from 6:30am to 3pm, Monday to Friday. We use the slow times to catch up on education, stocking, inventory, patient rounding and follow-up. Staff also get cancelled and flexed as needed by the department.
Has your lab recently undergone a national accrediting agency inspection?
We currently have our Society of Cardiovascular Patient Care (SCPC) certification and we are preparing for The Joint Commission accreditation for chest pain.
What trends have you seen in your procedures and/or patient population?
Radial access allows for quicker recovery and discharge of patients.
What is unique or innovative about your cath lab and staff?
We are a small team committed to patient outcomes, cross-trained and fully functional to handle multiple responsibilities in our lab.
Is there a problem or challenge your lab has faced?
Problems and challenges are faced in many ways, depending on what it is. Policy, practice, and quality issues are handled through the CVOIC (Cardiovascular Operations Improvement Committee). We take challenges on as a team and grow together.
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 use the NCDR CathPCI reg- istry to help drive quality initiatives, which in turn helps improve patient care. We look closely at our door- to-balloon times, mortality, AKI, and bleeding, to name a few. For exam- ple, D2B in 2Q2017 = 42 min and 3Q2017 = 46 min. We have been in the top 90th percentile for 2 quarters in a row! Immediate percutaneous coro- nary intervention within 90 min = all of 2015,2016,and the first 3 quarters in 2017 = 11 straight quarters!