Cath Lab Spotlight

Stamford Hospital Cardiac Cath Lab

Rebecca Miller, RN, BSN, Angioplasty Nurse Specialist, Jo-Ann Memale, RN, ASN, Angioplasty Nurse Specialist, William Drago, RT(R), Lead Cardiovascular Technologist, Stamford, Connecticut

Rebecca Miller, RN, BSN, Angioplasty Nurse Specialist, Jo-Ann Memale, RN, ASN, Angioplasty Nurse Specialist, William Drago, RT(R), Lead Cardiovascular Technologist, Stamford, Connecticut

Tell us about your cath lab.

The cardiac cath lab at Stamford Hospital consists of 1 director, 1 nurse manager, 1 clinical coordinator, 5 technologists, 2 advanced practice registered nurses (APRN), 1 physician assistant (PA), 1 scheduler, 1 unit coordinator, and 20 RNs. We have 3 labs. One lab is designated for electrophysiology (EP) studies and ablations, and device implants, one lab is for cardiac catheterization procedures, and one lab is for vascular interventional radiology procedures. We have dedicated staff for both EP and cardiac procedures. Our nurses have a variety of credentials: we have bachelor degree nurses, associate degree nurses, and a diploma nurse. We have staff members that have been working in this lab for over 15 years.

What procedures are performed in your cath lab? 

A variety of procedures are performed on a daily basis, including but not limited to: diagnostic heart caths, with possible angioplasty and stenting, chronic total occlusions (CTOs), ST-elevation myocardial infarctions (STEMIs), lower extremity angiograms with interventions, pacemaker/implantable cardiac defibrillator (ICD) implants, paravalvular leak repair, balloon aortic valvuloplasty (BAVs), transcatheter aortic valve replacement (TAVR), CardioMEMS implant (St. Jude Medical), EP studies with various ablations, pericardiocentesis, temporary pacemaker insertions, transesophageal echocardiograms (TEEs),g Impella insertions (Abiomed), Rotoblator (Boston Scientific), intra-aortic balloon pump (IABP) insertions, cardioversions, convergent ablations, and LINQ insertions (Medtronic). Approximately 35 procedures are performed in our lab each week.

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

We do have a hybrid operating room (OR) that was recently built to perform these procedures. We performed our first TAVR procedure in April 2015 and continue to grow this service. At this time, we have completed 17 TAVR procedures.

What percentage of your diagnostic caths is normal?

Approximately 60% of our heart caths are normal.

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

Radial access is utilized in approximately 80-90% of our cases.

Who manages your cath lab?

We have 1 director and 1 nurse manger managing our cath lab.

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

We do not have cross training in our cath lab. However we are looking into this route. Currently, our technologists scrub with the cardiologist, 1 RN circulates, and 1 RN monitors each case. 

Which personnel can operate the x-ray equipment in your cath lab? 

In the state of Connecticut, only the physician or the technologist can use the fluoroscopy. Similarly, in our cath lab, only the physician or the technologist can operate the x-ray equipment. This includes positioning the C-arm, panning the table, changing the angles, and stepping on the fluoro pedal.

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

We are provided with lead aprons, thyroid shields, stand up and rolling lead shields, dosimetry monitors that are read monthly, and we have routine check of lead aprons under fluoro. We also have a radiation safety officer who oversees the radiology department.

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

We have been using new radial compression devices. We currently have 3 vendors for stents and balloons. We have an optical coherence tomography (OCT) system and the Impella device. We also have been implanting CardioMEMS devices to monitor pulmonary artery pressures to prevent/reduce heart failure hospitalizations. Our staff is independent using all of these technologies. Both the Impella and OCT systems have representatives who have been very helpful and available for any questions.

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

In our lab, our manager communicates via email and monthly staff meetings, which are usually attended by our physician director and nursing director. Occasionally, we will have “huddles” for important announcements. 

How is coding and coding education handled in your lab?

We have a lead technologist who handles coding and billing. Prior to each case, we have the ability to scan all equipment used, which is then printed for billing purposes at the end of the case.

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

All of our technologists, our physician assistant, and our nurse practitioners have the ability to pull sheaths, both diagnostic as well as interventional. The EP nurses have also completed competencies to pull venous sheaths. In many cases, we do utilize a closure device, placed by the physician at the end of the procedure. The physician, PA, or APRN will work with our technologists to teach them the proper process for pulling sheaths. Staff is required to pull a certain amount of sheaths supervised before they are “signed off”.

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

Our patients come to our holding room prior to each procedure (with the exception of the STEMI patients, who go directly to the lab from the emergency department [ED]). In the holding room, the patients are prepped and screened by 2 RNs, the APRN or PA, and are also seen by the physician before going into the lab. Post procedure, if the sheath is still in place, we will keep the patient in the holding room, monitored by one RN, until the sheath is pulled.  

How is inventory managed at your cath lab? 

Our lead technologist manages and performs the purchasing of our supplies, which is overseen by our manager and director. We scan all equipment for each case, which generates a detailed inventory report.

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

From fiscal years 2013 and 2014, our volume has increased by 23%. In 2015, we were targeted to do 787 procedures, and we actually completed 851 procedures. A new hospital is currently under construction and on schedule to open in late summer 2016. Our expanded Heart & Vascular Institute will have 2 EP rooms and 3 cardiac cath rooms. At that time, the non-invasive cardiac procedures, such as TEEs and cardioversions, will be managed separately from the invasive team by the cardiology department.

Is your lab involved in clinical research?

At times, we have patients who are involved in a clinical research study through their private physicians. We are currently in the process of developing our first nursing clinical research project for same-day radial access cardiac cath discharge. At this time we have completed 3 with great success, as we only began this past December.

Can you share your lab’s average door-to-balloon (D2B) times and some of the ways employees in your facility have worked together to keep D2B times under 90 minutes? 

Our average D2B time was 62 minutes in the last quarter of 2014. We have been 100% compliant for D2B time for 17 quarters. Our STEMI team is extremely diligent. We are always here within the 30-minute timeframe; however, most of the time we are here well before the 30-minute timeframe. Our lab is registered with the American Heart Association’s Mission: Lifeline and the American College of Cardiology’s D2B Alliance.

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

Our STEMI patients are brought from the emergency room with the ED physician or the intensive care unit (ICU) resident, who will accompany the patient to the cath lab along with the ED nurse and the hospital resource nurse. At times, the STEMI physician will make a determination to bring the patient directly to the cath lab and bypass the emergency room.

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

During regular hours, another cath lab team will set up in another room to do the STEMI. During off hours, if our call team is in a procedure, they will contact the nursing supervisor to facilitate the next STEMI patient getting to the room. The nursing supervisor and resource nurse will need to help transport patient out of the lab in order to get in the next patient. The call team will work quickly to finish the procedure in order to see to the next patient.

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

We scan equipment for every case and most physicians are very diligent about not using excess equipment. Our lead technologist works with the vendors to achieve quality control and utilization in an effort to contain costs. We have implemented quantity purchases for devices to decrease cost. We have also created staggered shifts to keep labor costs down.

What quality control/quality assurance (QC/QA) measures are practiced in your cath lab?

We do daily room and equipment checks, and monthly QC checks to ensure QA. We monitor first case start time, cost per case, universal protocol, pain assessment, and use a pre-op checklist to ensure high quality, safe patient care. We also do antibiotic timing for device implants.

Are you recording fluoroscopy times/dosages? 

We document fluoroscopy dosages in our lab-documenting program for each case. It also is documented in our national registry information. 

Who documents medication administration during the case?

During each case, the RN monitoring will document medication administration.  After the procedure, the physician and both RNs will electronically approve the entire report.

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

Our physicians dictate after each procedure via telephone, which is then typed by a service within the hospital. They also dictate using a structured reporting tool that is contained in our documenting system.

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

We currently use the ACC-NCDR to report cardiac cath procedures. We also use the NCDR-ICD registry for any implants.

How does your cath lab compete for patients? 

We maintain our patient population through physician referrals. Additionally, we are a member of the New York-Presbyterian Healthcare System and an affiliate of the Columbia University College of Physician & Surgeons. We also get patients via word of mouth from other patients. We are the only hospital in Lower Fairfield County with the ability to perform elective angioplasty and stenting, which increases our patient population. 

How are new employees oriented and trained at your facility?

New employees complete an 8- to 12-week orientation where they are partnered with a seasoned cath lab nurse. During this orientation process, we have a competency program where steps are checked and reviewed with the orientee, preceptor, and manager on a weekly basis. We provide a 6-8 week shadow STEMI call period.

What continuing education opportunities are provided to staff?

We have monthly education by vendors and representatives for products and equipment. We also complete a yearly competency hands-on program specialized to our unit and our equipment. At times, outside education opportunities are provided by vendors. Each year, we have money set aside in our budget for staff to attend national and local conferences.

How do you handle vendor visits to your lab? 

Vendors are required to sign in with materials management, provided a photo ID badge, and sign in with security. Vendors coordinate with our unit coordinator and lead technologist to plan visits on certain available days.

How is staff competency evaluated?

Staff competency is evaluated each year by performance reviews with our manager. We also have modules to complete on the computer on an annual basis, along with an annual hands-on competency program. 

Does your lab have a clinical ladder?

We do have a clinical ladder within our hospital. It is a hospital-wide nursing program designed to engage nurses in expanding and improving their professional development.

How does your lab handle call time for staff members? 

During off hours, we have 2 RNs and 1 technologist on call. Off hours include 5pm-7am, the weekend hours, as well as holidays.

Do you have flextime or multiple shifts?

We do have flexible shifts to accommodate our patient population. These include 6:30am-4:30pm, 7am-5pm, 8am-6pm, and 7am-8pm.

Has your lab recently undergone a national accrediting agency inspection? 

Our lab has not undergone any national accrediting agency inspection. We are currently looking into national accreditation. We are subject to routine visits from The Joint Commission and the Department of Health, as are many other facilities. Our hospital recently applied for Magnet status with a site visit planned for early February 2016.

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

Our cath lab is currently on the ground floor, down the hall from the emergency room. The operating room is currently on the second floor, directly above the cath lab. However, with the advent of the new hospital, this layout will change.

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

One trend we have seen in our procedures includes the change from femoral access with no closure device to radial access with the use of compression devices. This has made it more comfortable and safer for the patient, and can expedite a faster discharge time. In regard to our patient population, we have been seeing an aging population who need interventions.

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

The staff in our cath lab is very close knit. We are like a family. Everyone gets along; we even get together outside of work regularly. We share lots of laughs and good times. Our staff is consistently working towards the best interest of the patient, as well as the safety of our patients.

Is there a problem or challenge your lab has faced?

One challenge our lab has faced is regarding on-time starts. We collected data that included patient arrival time, patient prep time, and physician arrival time. We presented this data to the staff and physicians. We have made some previsions regarding room turnover and patient prep practices, and have since had much better results. We went from 0% compliance for on-time start in 12/2013 to 60-70% compliance in 12/2014. We are currently at 100% compliance for on-time start over the past 2 months.

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”?

Lower Fairfield County is a highly populated area. We are the only hospital in Lower Fairfield County that provides elective angioplasty. There are many large corporations in Lower Fairfield County that bring people from outside areas to work, thus increasing our population, especially during the week. 

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 rise upon passing the exam?

Our lab currently does not require clinical staff members to take the registry exam for the RCIS. We do have one technologist and one RN with the RCIS certification. The RCIS credential is something we are currently looking into for our lab and there are additional people who are interested in getting this certification. Our manager will reimburse staff for the cost of the exam if a passing grade is achieved. 

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 organization?   

Our manager and clinical coordinator are members of the Society for Cardiovascular Angiography and Interventions (SCAI).

A question from the American College of Cardiology’s National Cardiovascular Data Registry:    

How do you use the NDR Outcome Reports to drive quality improvement (QI) initiatives at your facility?

We use the NCDR Outcome Reports to drive QI initiatives such as cardiac rehab referrals. Over the past year, our cath lab operations group has been revamped as an operational working group. The data coordinator brings back the information gathered to improve our measures regarding cardiac rehab referrals and we are now at over 90%.