Cath Lab Spotlight

Bay Medical Cath Lab

Shirley Goodman, RN, BSN
Shirley Goodman, RN, BSN
What types of procedures are performed at your facility? Bay Medical performs diagnostic right and left heart catheterizations, coronary percutaneous transluminal coronary angioplasty (PTCA) and stent placement, permanent pacemakers, implantable cardiac defibrillators (ICDs), peripheral angiograms, angioplasty and stent placement, the Safe-Cross® Radio Frequency system (Intraluminal Therapeutics, Inc., Carlsbad, California) for crossing total occlusions, the SilverHawk atherectomy device (FoxHollow Technologies, Menlo Park, California) to excise large volumes of plaque from peripheral lesions and laser atherectomy are all performed at our facility. We also perform electrophysiology studies and ablations. Last fiscal year we performed 6,491 procedures, of which there were: 3,723 diagnostic examinations 1,547 interventions 172 electrophysiology studies 283 pacemaker insertions 294 ICD implants 472 other procedures For the fiscal year 2005, Bay Medical estimates that it will perform approximately 8,020 procedures. Our facility averages 125 to 150 cases per week. How did you begin performing peripheral cases (i.e., who started the process, and what did it involve)? It was a natural transition for us. Dr. Charles Mayes, an interventional cardiologist, is also credentialed to perform peripheral interventions. Since many of the cardiac patients we see also have peripheral disease, it was an easy transition to take care of them in the cath lab as well. The process evolved from the need of the community. It happened at the right time, as we were in the planning stages of constructing a fourth lab and could modify the equipment to meet our needs for a peripheral lab. What specific equipment was instituted and/or dedicated to peripheral cases above and beyond what is used for coronary cases? (Any helpful tricks and tips for labs that might not know about the different equipment?) We installed the Phillips Integris system (Phillips Medical Systems North America Co., Bothell, Washington) last year for our fourth room with full peripheral capabilities. With room number five under construction this year, it will be mirrored with the same equipment as room four, which will give us two rooms to schedule peripheral cases. How is inventory management handled for the peripheral equipment, particularly with the varying lengths and sizes of the stents? Inventory is handled in the same manner for the peripheral equipment as it is for the coronary cases. Some items are kept on consignment, some are bought in bulk and some supplies are owned by our facility. What training is instituted to ensure a competent and skilled staff? Bay Medical has had several opportunities to send staff members to outside seminars. Also, equipment and supply representatives offer in-services for all staff on a regular basis. The physicians have taught us as well. We presently perform scheduled cases for our peripheral lab but are planning, in the future, to begin unscheduled emergency peripheral cases utilizing infusion catheters and the AngioJet® system (Possis Medical, Inc., Minneapolis, Minnesota). Do interventional radiologists and cardiologists perform procedures in the same area? No. Our facility has an interventional radiology department with two rooms located on the first floor of the hospital. Aside from our cardiologists, one of the vascular surgeons has performed cases in our lab. Did your facility need to make any changes to the imaging equipment to accommodate peripheral procedures? Since we were constructing a new lab at the time, we did not have to change any of the existing equipment. Does your cath lab perform primary angioplasty with or without surgical backup? We perform primary angioplasty procedures with surgical backup. For acute myocardial infarctions (AMIs), the surgeon on call is notified as soon as the procedure is started. For all other cases, such as scheduled angioplasty, cases are categorized as Levels I, II, or III. Level I indicates that treatment of the lesion in these patients will result in a high technical success rate and will generally not jeopardize a large amount of myocardial tissue. Standby is not necessary. Level II indicates that the lesions in these patients pose a higher risk, but the procedure is still considered low-risk. A cardiac surgeon, heart team and OR suite will be available within one hour from the start of the procedure. When this is required, we contact the surgeon on call, the OR and the perfusionist to notify them of the procedure’s start time. Level III indicates that a cardiac surgeon, heart team and OR suite are available at the initiation of the procedure due to disease extent, location or severity, and there is a significantly lower chance of initial success. This is generally scheduled the day before the procedure. What procedures do you perform on an outpatient basis? Bay Medical performs diagnostic right and left heart catheterizations, peripheral angiograms, generator replacements and electrophysiology studies, as well as follow-ups on an outpatient basis. What percentage of your patients is female? Thirty-six percent of our patients are female. What percentage of your diagnostic catheterization patients goes on to have an interventional procedure? Twenty-nine percent of our catheterization patients who go on to have an intervention procedure. Who manages your cath lab? Dennis Holloway, BA, CVT, Director of Diagnostic Cardiovascular Services, has worked at our facility for one year. He has worked in the catheterization laboratory arena since 1993 and came to us from Greenville, South Carolina. Shirley Goodman, RN, BSN, Supervisor of the catheterization laboratory, has been on staff for two years. She has worked as a critical care nurse since 1993, and gained some cath lab experience in the past. Dr. Charles Mayes, Medical Director, has been at Bay Medical a little over a year. Does your facility offer cross training? Who scrubs, who circulates and who monitors? All procedural staff, radiology technologists and RNs cross-train to be able to work in the scrub and monitoring positions. The RNs are the only staff members who circulate, as they are responsible for medication administration. Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your catheterization laboratory? Yes, the state of Florida requires that an RT be present in the room for fluoroscopic procedures. Which personnel can operate the X-ray equipment in your catheterization laboratory (position the image intensifier, pan the table, change angles, step on the fluoro pedal)? The staff member who is competent to scrub the case can operate the X-ray equipment, such as positioning the image intensifier, panning the table and changing angles. The physician steps on the fluoro pedal. Does your lab have a clinical ladder? We currently do not have a clinical ladder. We reward and recognize employees who demonstrate a commitment to their area of specialty. Those achieving Registered Cardiovascular Invasive Specialist (RCIS) or Critical Care Registered Nurse (CCRN) credentials in the catheterization laboratory receive a bonus of $1.00 an hour for hours worked. What are some of the new equipment, devices and products introduced to your lab lately? Some of the new products at our facility include: Asahi PTCA guidewires (Abbott Laboratories, Redwood City, California); and the Filterwire EX (Boston Scientific, Maple Grove, Minnesota). We have acquired the SilverHawk atherectomy catheter for use in peripheral angioplasties when we excise large amounts of plaque in arteries, and the Safe-Cross crossing system for total occlusions was introduced in 2004. We also use the Pronto catheter (Vascular Solutions, Minneapolis, Minnesota) for removing thrombus. The most frequently used product introduced in the past year was the StasysPatch (St. Jude Medical, Inc., Minnetonka, Minnesota) for hemostasis after pulling arterial sheaths. Our facility has also acquired the CVX-300® Excimer Laser System (Spectranetics Corporation, Colorado Springs, Colorado). Our newest acquisition was the ACIST angiographic contrast injection device (ACIST Medical Systems, Inc., Eden Prairie, Minnesota) that is installed in two of our rooms. The ACIST device allows for smaller amounts of contrast to be administered to patients. Can you describe the system(s) you utilize and how they work in the cath lab? Our cath lab uses the GE MacLab® system (GE Healthcare Technologies, Waukesha, Wisconsin) for hemodynamic monitoring and recording and the Philips Digital Archiving System. Also, our rooms are equipped with Philips bi-plane LCX systems with coronary and peripheral capabilities. How is coding and coding education handled in your lab? How is coding communication handled with the billing department? Our supervisor, Shirley Goodman, handles charges for the lab. The next day, charges are recorded and checked for accuracy. The billing department lets us know if they have any questions and if they do, then Shirley and the staff involved in the case investigate the chart to ensure accuracy of the charges. We utilize a Master Charge Sheet that accompanies the patient during the procedure. Shirley and Dennis educate all staff on how to correctly charge for the different procedures. How does your lab handle hemostasis? Our cath lab utilizes the StasysPatch (St. Jude Medical, Inc.) for manual pressure. The VasoSeal Elite (Datascope Corporation, Mahwah, New Jersey), Angio-Seal (St. Jude Medical, Inc.), and Perclose® (Abbott Vascular Devices) are the closure devices our facility utilizes. The person who pulls the sheath is responsible for hemostasis. All nurses and technologists are competent to pull sheaths and hold manual pressure. Each individual is taught and credentialed by the representative of each closure device before they are able to perform these functions in our lab. All diagnostic procedure sheaths are pulled on the procedure table. The patients requiring interventions go to our recovery area where a staff member pulls the sheath at a later time, and then the patients go to the telemetry floor, or in some cases may be admitted to the ICU. All of our outpatients go to the recovery area and are discharged home later in the day. Does your lab have a hematoma management policy? We do not have a hematoma policy. Hematomas are a very rare occurrence from our catheterization procedures. We use 4 French catheters for most diagnostic examinations. All patients phoned daily for follow-up groin management and to check on how they are doing. How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies? Bay Medical just acquired a full-time inventory technologist who manages the cath lab’s inventory. Par levels and reorder levels are applied to aid in our inventory control. The installation of a Pyxis system (Cardinal Health, San Diego, California) is underway to make the process easier and more accurate. Our coordinator, Kelly Cook, orders supplies, while the purchasing of equipment is initiated by our director, Dennis Holloway. Has your cath lab recently expanded in size and patient volume, or will it in the near future? Our lab has come a long way in the last 27 years. Dr. James T. Cook, III, our past Medical Director, started the cath lab in 1978. He performed our first angioplasty in 1981. Dr. Maher Ayoubi placed the first coronary stent in 1994. Bay Medical’s catheterization facility grew from one room to two rooms in 1986, and added a third room (a mobile lab) in 1998. When Bay Medical added the West Tower in 2002, three permanent rooms were operating, with further room to grow. In 2004, a fourth room was opened, and in 2005 we will open our fifth room. Bay Medical currently has ten cardiologists who perform procedures in the catheterization lab, and our volume continues to grow from 4,379 procedures in 2002, to a projected volume of 8,020 procedures in 2005. Is your cath lab involved in clinical research? We are presently involved in the Aventis Sepia PCI Trial, which will compare the direct FXa inhibitor otamixaban with unfractionated heparin in patients undergoing nonurgent PCI. Dr. Charles Mayes, our medical director, is responsible for getting Bay Medical involved in the research trial and we are very excited to be one of the sites chosen. Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? Bay Medical has experienced only one complication in the past year requiring emergent cardiac surgery. What other modalities do you use to assess stenosis? We frequently use intravascular ultrasound (IVUS) to assess stenosis size. What measures has your cath lab implemented to cut or contain costs? Several staff members serve on our Value Analysis Team whose job is to evaluate the function of products, services and processes in order to provide an equivalent or better performance of a required product at the lowest possible cost. A staff member from materials management and a representative from VHA also serve on the team. This process has enabled us to save over $200,000 this year. The team meets monthly and continues to work on cost-saving strategies. Examples of the team’s work include revamping catheterization packs, pacer packs and eliminating small bottles of contrast, as well as conducting ongoing negotiations with vendors to obtain price reductions. What type of quality control/quality assurance measures are practiced in your cath lab? Bay Medical’s cath lab participates in the American College of Cardiology NCDR database. We also have a Heart Improvement Team that meets monthly to monitor performance improvement. Our department utilizes a documentation tool to monitor quality indicators outlined by JCAHO such as conscious sedation, time out, smoking cessation education, patient education, pre- and postprocedure pain management, pre- and postprocedure Aldrete scores, and discharge instructions. Our staff members also telephone all patients discharged from the cath lab one to two days postprocedure to see how they are doing and ask if they have any questions or suggestions. Cath lab patients complete a survey upon discharge, and all patients hospital-wide will soon begin participating in Press Ganey Scores. Our cath lab department has formed two other committees, Staffing and Operations, whose goal is to improve our throughput as we grow in order to continue to offer the best and most comprehensive services. How does your cath lab compete for patients? Has your institution formed an alliance with others in the area? Bay Medical competes for patients by providing quality care with good outcomes. We are the first hospital in Florida to achieve JCAHO Centers of Excellence for AMI and stroke. Bay Medical recently achieved Solucient’s Top 100 list for large community hospitals. We strive to be the best every day. How are new employees oriented and trained at your facility? What licensure is required for all professionals who work in your lab? All new employees attend a general hospital orientation program their first week. Once they start work in the department, they are assigned a preceptor. Progress is noted weekly and goals are set for the following week. There is a checklist of procedures and equipment, and all new staff members must become competent within 90 days. Most new hires are able to start call rotation within four months. Our facility has only one LPN working in the recovery area; the rest of the staff consists of registered nurses and radiology technologists who are also ARRT-certified. One of our nurses is CCRN-certified. What type of continuing education opportunities are provided to staff? There are many opportunities for education. The hospital is presently offering a series of monthly classes on AMI. Furthermore, vendors of equipment, pharmaceuticals and supplies bring seminars to us and provide regular in-services on equipment and supplies. The staff can attend weekly catheterization conferences with the cardiologists and cardiac surgeons. In the catheterization conference, the physicians discuss difficult cases and treatment options. How do you handle vendor visits to your lab? All vendors must check in with the Purchasing Department before coming to the cath lab. Competitive vendors may not visit on the same day, and all must have physician permission to enter the procedure room. How is staff competency evaluated? Competency evaluation is an ongoing process. Many educational opportunities are offered by representatives from companies whose products we use and staff members teach one another. Annually, each staff member is evaluated for competency by the supervisor who uses a checklist. For our low-volume, high-risk procedures, we offer classes each year for staff to maintain competency. Does your lab utilize any alternative therapies (such as guided imagery, etc.)? Living in a coastal environment, we work in a laid-back atmosphere. We do provide music during some cases and a lot of comic relief. Our philosophy is that the patient should be made as comfortable as possible for what is perceived to be a very frightening procedure. How does your lab handle call time for staff members? Is there a particular mix of credentials needed for each call team? Do you have flex time or multiple shifts? Bay Medical’s call team consists of four members who can be comprised of two RNs and two RTs, or three RNs and one RT, or all RNs, since most are cross-trained. We presently work eight-hour shifts, but most staff work overtime. We have tried implementing ten-hour shifts, which the staff loved, and overtime was decreased, but the need to hire additional staff is apparent in order to truly make this option successful. We are working on it! The call schedule averages out to one day a week and every fifth weekend for each staff member. What trends do you see emerging in the practice of invasive cardiology? Based on recent data, the cath lab is moving towards treating more and more patients utilizing less cardiac surgery. Coronary intervention trends show an increase in treatment with angioplasty and stent placement in unprotected left main lesions and bifurcated and trifurcated lesions. Valvular repair, excision of plaque from peripheral arteries and cerebral stents are other emerging areas. Our facility is handling an increasing number of complex cases in the cath lab as opposed to offering these patients medical therapy or sending them to surgery. Has your lab undergone a JCAHO inspection in the past three years? In 2003, Bay Medical underwent a JCAHO inspection and performed very well. Preparing for a JCAHO inspection requires a commitment to do things the right way all the time. Working according to the old saying practice what you preach makes the inspection easy. If the guidelines are followed in everyday practice, then the actual inspection runs smoother. Where is your cath lab located in relation to the OR, ER, and radiology departments? All of these facilities are located in the West Tower of the hospital. ER and Radiology are located on the first floor, OR on the second floor, and the cath lab is located on the fourth floor along with the CVICU. The telemetry unit is located in the same building on the fifth floor. We have easy access to any of the departments just outside the elevator door. Please tell the readers what you consider unique or innovative about your cath lab and its staff. Bay Medical’s cath lab provides a wide range of services and treats many complex patients. Even though we have grown by adding staff, procedure rooms and physicians in the last three years, we continue to operate as an excellent team. We all work together toward the same goals and love what we do. The outcomes experienced in the cath lab make it one of the most gratifying jobs most of us have ever had. Is there a problem or challenge your lab has faced? How was it addressed? Our growth has kept us busy! Bay Medical is equipped with the staff and procedure rooms to keep up with our growing number of cases, but we have discovered that our preparation and recovery area needs to be enlarged. A committee is actively working on our throughput process to utilize space and become more efficient. We are extremely busy in the winter months due to the large volume people who spend their winters here in Florida’s panhandle. What is 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? Panama City Beach is rated one of the world’s most beautiful beaches. We have many seasonal residents who spend the winter here, as well as Spring Breakers who come over a six-week period. Bay County is ranked one of the fastest-growing counties in the United States. SICP spotlight questions: 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? Bay Medical does not require staff to take the registry exam. Staff members are encouraged to take it and a bonus program will be offered later in 2005 for those who pass the exam. 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. Shirley Goodman can be contacted at