Cath Lab Spotlight

Chicago Healthcare System, Lakeside Division

Bernadette Speiser, Cardiac Cath Lab, BSN, MSN, CCRN
Bernadette Speiser, Cardiac Cath Lab, BSN, MSN, CCRN
What is the size of your facility and number of staff members? We have a single digital cath lab and just opened up a second lab dedicated to EP. We have a total of three employees: 1 BSN-prepared RN 1 MSN-prepared RN 1 radiology technologist. Lakeside VA is a teaching hospital affiliated with Northwestern University Hospital. We share our attending cardiologists (4) and have a cardiology fellowship program. This affiliation (between the Chicago VA and Northwestern Medical School) is the oldest in the nation, and was established by Omar Bradley ([1893-1981], best known as an American general during World War II). What type of procedures are performed at your facility? We perform (yearly): Over 600 diagnostic left and right heart caths 168 angioplasties 160 intracoronary stent placements Intra-aortic balloon pump (IABP) placements Intravascular ultrasound (IVUS) Rotational atherectomy Temporary pacemaker placement Pericardiocentesis Cutting Balloon interventions (Boston Scientific, Maple Grove, MN), and PercuSurge® (Medtronic, Inc., Minneapolis, MN) procedures. We started a peripheral vascular interventional program in 2001 to perform vascular diagnostic and interventional procedures as well as stent placement. It is staffed by a cardiologist who obtained special training and credentialing in this area. We just started doing carotid angiograms and are awaiting our first carotid stent placement. In establishing this peripheral program, we worked collaboratively with the peripheral vascular surgery department. The marriage of these two departments provides a well-rounded approach to vascular treatments. We opened up a second room in March 2002 for diagnostic electrophysiology (EP) procedures, with a plan to expand to implantation of permanent pacemakers/defibrillators as well as ablations. We do not do call. Does your cath lab perform primary angioplasty in acute MI with /without surgical backup? We do perform primary angioplasties in acute MI with surgical backup. Northwestern Hospital and the Lakeside VA share a physical space in the form of a sky bridge that connects both facilities over the street level. If a patient needs emergency surgery, a simple phone call is made and the process is put into place. After the immediate surgery period, our patients return to the VA for completion of their recovery process. We are extremely lucky to have developed this contingency plan for the treatment of acute patients requiring immediate surgical intervention. How is your cath lab managed? Our cath lab has a duel management philosophy: the technologist and physicians report to the cardiology department, which is under the direction of Dr. James Rosenthal. Our cath lab medical director is Dr. Nirat Beohar. The RNs report to the coronary care unit manager, Normalinda Cabusao, RN. The cath lab staff have a great deal of autonomy. The staff developed our Quality Assurance Monitors and Manual and the policies and procedures for the cath lab, as well as handling daily functioning. The administrative staff rely on the cath lab staff to function independently as much as possible. Our three staff members work very well together and share duties, utilizing individual strengths to get the tremendous amount of work completed. Do you have cross-training in the cath lab? We are all cross-trained to do each other’s job with the exception of conscious sedation medication administration and monitoring (only the RNs). This allows for enhanced flexibility and efficiency. Also, with limited staffing, cross-training allows for work to continue uninterrupted when vacations occur. The RT routinely does the hemodynamic monitoring, records for the case, is responsible for the imaging equipment, inputs ICD-9 and CPT codes for billing, and orders our supplies. The RNs routinely do the prepping, circulating, medication administration, sheath removal and recovery (outside the cath lab), pre and post teaching, post cath follow-up, statistics, and quality assurance data collection. After the initial sterile set-up is completed, the RN/RT breaks scrub. The attending and fellow are scrubbed during the completion of the case. What are some of the new equipment, devices and products introduced at your lab lately? We have the new access closure devices. We are also using the Cutting Balloon, PercuSurge, and have purchased a new Hemochron® Jr. for ACT testing (International Technidyne Corporation, Edison, NJ). Is your cath lab filmless? We are filmless and utilize a digital GE single plane system. Our RT is responsible for burning CDs for every patient. We are currently looking into piggybacking into the PACS VA system. How does your lab handle hemostasis? We use C-clamps (or fingers) for manual closure, SyvekPatch® (Marine Polymer Technologies, Danvers, MA) and we use the Angio-Seal (St. Jude Medical, St. Paul, MN). Patients are recovered in the coronary care unit post cath or in the recovery room (PACU) if no beds are available in the CCU. The cath lab RN is responsible for sheath removal and hemostasis. The PACU or CCU RN is responsible for conscious sedation monitoring and post procedure vital sign documentation. Post PTCA (for manual removal), the sheath is pulled in the CCU by the cath lab RN after the ACT is below 180 and either a FemoStop® (RADI Medical Systems, Inc., Reading, MA), C-clamp, SyvekPatch, or manual pressure is utilized at the discretion of the cath lab RN or physician. The cardiology fellows are also trained in hemostasis and assist as needed. Does your lab have a hematoma management policy? We have a quality assurance program in the cath lab. Part of our performance improvement is post cath follow-up. Every patient’s groin is assessed the following day after the cath (inpatients) or later in the procedure day (outpatients). Documentation of any hematoma or bruising and the size is recorded, as well as post-procedure WBC, Hgb, and creatinine. Outpatients are called at home by the cath RNs within 24 hours post cath. On Saturdays, the CCU staff call our outpatients at home to ensure the same level of care is being provided per JCAHO standards. Our QA program also collects information on patient satisfaction and areas to improve upon. For those patients with CAD, the RNs make follow-up appointments with the appropriate cardiology clinics to ensure proper patient care is maintained. How is inventory managed at your cath lab? Our cardiac cath lab has an individual budget. Our RT does the majority of inventory ordering, including expendable supplies and equipment for the lab. The RNs are responsible for ordering and stocking medication. If supplies are low, a note is made to reorder. The cath lab also has a consignment contract for PTCA balloons, guiding catheters, and stents. Has your cath lab recently expanded in size and patient volume? We just expanded to a second room, dedicated for EP. The two cath RNs are already cross-covering dobutamine stress testing, tilt table testing, Definity and Optison ECHO imaging enhancement (Mallinckrodt, Inc., St. Louis, MO), transesophageal echocardiography (TEE), and occasional cardioversions. We are concerned about the coordination of yet another area, but EP is a necessity for a full-service cardiology program. Our cath lab clientele has grown over 200% in the last 4 years. This is due in part to our aging veteran population as well as decreasing medical benefits in the private sector for males 40-80 years of age. Is your cath lab involved in clinical research? Our facility is involved with the research programs at Northwestern University and the many governmental studies being conducted in the 171 VA hospitals nationwide. We are currently active in the BARI 2D trials (Bypass Angioplasty Revascularization Investigation 2 Diabetes). Does your lab perform elective cardiac interventions? We do perform elective cardiac interventions. We don’t have a scheduling clerk, so we utilize a computerized consult package for both our internal and external physicians (in satellite VA clinics). Requesting physicians send a computerized consult to our lab. The patients are screened and scheduled. Also, we have phone access for direct calls for scheduling both inpatients and outpatients. Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? We have not had any emergent CABG for failed PTCA/stents in the last year. However, we have sent patients directly from the cath lab with IABP support to open heart surgery for left main disease, etc. What measures has your cath lab implemented to cut or contain costs? We have vendor consignment for interventional supplies, i.e., stents, guides, and PTCA balloons. This helps control costs as well as keeping supplies up to date. We have also identified a primary vendor to reduce overall costs in our VA region (a VA directive). Within the VA, the medical model for cardiac cath has shifted from inpatient setting to outpatient setting. The majority of our cases are handled on an outpatient basis. We try to be flexible with our time schedules to best address daily staffing needs. How does your cath lab compete for patients? We compete with three other VAs in the Chicago area for patients. Our patients primarily come from VA clinics associated with the Lakeside VA in downtown Chicago. We also receive a large number of patients from our satellite VA clinic in Crown Point, Indiana. Our patients are military, either veterans or active duty. Our VA has combined with the Westside VA to become the Chicago Health Care System. We have developed an alliance with Northwestern Hospital for brachytherapy patients as well as an after-hours emergency cardiac cath contract. Can you describe your outpatient program? Our cardiac cath lab works with the same day surgery program in the performance of outpatient cardiac cath procedures. We only do diagnostic cardiac caths as an outpatient procedure. (Interventional cath clients remain in-house overnight post intervention.) Discharge criteria must be met following same day surgery guidelines prior to discharge. The cath lab staff was instrumental in the implementation of a Hoptel (Hotel bed inside the hospital) where patients can come and stay the night before their procedure. The VA facility takes numerous clients outside the Chicago area, who often travel 2-3 hours to reach the hospital. Many of these clients do not drive, do not have families to accompany them, do not have access to transportation at 0500, or have underlying lab abnormalities, i.e. creatinine 2.2, etc. The Hoptel allows for patients to come and have any last minute blood draws, EKGs, IV fluid administration, etc., completed by the cath lab team. The patient then stays overnight in the Hoptel prior to their cath the next a.m. The Hoptel prevents inappropriate admissions prior to the procedure, thus reducing bed days of care. The Hoptel was created from converted medical ward space. How are new employees oriented at your facility? Our current staff have been at the LSVA for over 3 years. We do have a hospital-wide orientation program that includes emergency preparedness, infection control, information management, patient confidentiality, sexual harassment, and customer service. The VA has Functional Statements for individualized positions as well as individual orientation plans to the clinical areas. If we had new employees, they would be orientated to the area by a cath lab preceptor and a competency orientation would be completed. What type of continuing education opportunities are provided to staff members? We have continuing educational programs on the unit and in conjunction with the ICU. These include new drug therapies, IABP competency, mandatory hospital education, EKG analysis, hemodynamic monitoring, new equipment and supplies. We also attend outside training opportunities such as Cardiac Cath 2002, and programs sponsored by other hospitals or private companies. A weekly cath lab conference with Northwestern University is available as well. To maintain CCRN status, continuing education hours are a must. The RNs are also ACLS certified. The cath lab has a minimum of one continuing education program per month. How is staff competency evaluated? We have competency evaluation criteria that is maintained by the nurse manager, the Department of Medicine, and Hospital Education. The competency is evaluated yearly with a checklist for each position description. We work closely with the Nursing Education Clinical Specialist for Critical Care. Does your cath lab utilize alternative therapies? We do not utilize alternative therapies. However, we do have background music in our cath lab procedure room to assist in soothing patients. What type of quality assurance measures are practiced in your cath lab? We have a comprehensive Quality Assurance Program. We have generic and unit-specific monitors. Our generic monitors include: Standard Precautions Cardiac Arrests Emergency Preparedness Unit Safety Skin Care Our unit-specific monitors include: ACT Testing Cardiac Cath Lab Procedure Access Care Post Procedure Follow-up Care Conscious Sedation Complication Monitor Radiation Safety Patient Satisfaction Post Interventional Plavix Administration/Teaching We hold monthly QA meetings along with staff meetings. We also monitor radiation exposure, contrast dye load, and complication rates on a yearly basis (physician-specific). We send all of our patients a thank you letter at home, letting them know how happy we were to care for them. What measures has your cath lab employed to improve efficiencies in patient throughput, etc.? We work very closely with non-invasive cardiology testing (stress testing) and the cardiology clinics. If a physician in the cardiology clinic has a patient they want to cath, they call or bring the patient directly over to the cath lab waiting area for the cath team to interview and set up necessary blood work. This streamlined approach allows the referring physician immediate feedback. We have computerized charting throughout the facility, so that requests, email, and medical records are electronic, thus instant. All the fellows are given an orientation in the lab so they understand how the unit functions and their role. When the new peripheral vascular program and EP program were started, flyers were put in all the clinical areas throughout the facility and a computerized note sent to all employees. The cath reports are completed immediately post procedure and sent with the patient. Also, the reports are placed in the hospital computer system for access for those practitioners that do not have access to the paper chart. The cath team works great together in terms of moving patients through the lab. As two staff members are performing a cath, the additional staff member prepares the next patient going into the lab to maintain a steady flow at all times. Sheaths are pulled outside the cath area to enhance turnover. Angio-Seal reduces hemostasis time and is used as indicated. We send most of our CABG clients to the VA in Milwaukee, Wisconsin. The coordination between the two facilities was developed by the cath lab staff at Chicago and the nurse practitioner, Kathy Epping, at the Milwaukee, Wisconsin VA. Shuffling patients between hospitals and departments (cardiology and cardiothoracic surgery) is a tedious job. Collaboration between these two cities has been excellent. When a patient is deemed in need of CABG, the records and CD are copied by the cath lab team and Fedexed to Milwaukee overnight. The surgeons in Milwaukee review the films the next day and an answer for the patient is provided within 24 hours. Once the surgery has been completed, the CV team from Milwaukee will coordinate follow-up care with the Lakeside cath team. We have maintained continuity of care and fostered a healthy system that shares clients. What trends do you see emerging in the practice of invasive cardiology? We see more peripheral vascular lesions addressed like coronary interventions, i.e., angioplasties and stent placements. We also see intravascular surgery procedures (endovascular AAA repair) performed in a cath lab/interventional radiology suite versus a surgical suite. Can you share your lab’s layout and floor plan? The cath lab room is 20 x 24 feet. The control room is 9 x 15 feet. The EP lab is 17 x 15 feet. Our supply rooms are on the outside quarter of the cath/EP labs. We wish our labs had internal storage space allocated in some fashion. We also wish we had a dedicated prepping/recovery area. Has your lab has undergone a JCAHO inspection in the past three years? Yes, we underwent JCAHO in the past three years. We did not receive any deficiencies and our facility score was a 96%. Please tell the readers what you consider unique or innovative about your cath lab and its staff. We are unusual because we handle all areas of cardiology, not just the cath lab. We handle the patient from the physician phone call (or computer consult), to the scheduling, to the CPT coding, to post discharge from the facility. The cath lab team makes the complete circle with VERY limited resources. We believe we are able to accomplish all these duties because we communicate with each other and with our physicians. Organization is truly our first name! We are extremely self sufficient and resourceful. We are also special because we are cross trained to handle non-invasive cardiology needs. We understand the importance of a global approach to cardiology. We are willing to trial new computer programs, new products, new methods of health care. Keeping an open mind on change is an important step to surviving in the shrinking health care system. We also think that we are easily accessible to our internal and external customers. Our referring physicians believe us to be the link to the continuity of care and our patients really enjoy the special touches we provide like their thank-you notes. We assist in the coordination of CABG surgery locally and outside our state. We have numerous without compensation (no pay) hours dedicated by our cardiologists from Northwestern Hospital to the Veteran patient. Is there a problem or challenge your lab faces? The ongoing problem in hospitals in the allocation of more staff. This is also an issue in our setting. Currently, the VA VISN has a hiring freeze for the area and the Lakeside VA is due for possible closure of the inpatient setting by 2010. The Lakeside Hospital employees and Northwestern Hospital have been lobbying Congress for a change in this directive. Enhancement of the same day surgery preparation of cath clients and the same day surgery hours of operation (current hours are 6:30 a.m. to 4:30 p.m.) impact on the cath lab team and patients. A mini survey was done to determine the support at other facilities and a literature search was completed. This is pending resolution. A 23-hour observation unit would also be helpful or a dedicated unit for cardiac cath recovery. 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? We are one of the largest cities in the U.S. and our facility is located in the heart of the city. Our patients tend to be more transient that the rural or suburban hospitals. We also have many clients that lack adequate family support systems. Our patients are primarily male and many have war-related injuries. They travel a great distance to receive their care at a VA Hospital. They utilize public transportation to travel to the VA due to the limited/high cost of parking in downtown Chicago.