Cath Lab Spotlight

Deborah Heart and Lung Center Cardiac Catheterization Laboratory

Jon C. George, MD, Attending, Interventional Cardiology and Endovascular Medicine, Director of Clinical Research; and Valerie Harris, RN, Interim Nurse Manager and Department Head, Adult Cardiac Catheterization Laboratory, Browns Mills, New Jersey

Jon C. George, MD, Attending, Interventional Cardiology and Endovascular Medicine, Director of Clinical Research; and Valerie Harris, RN, Interim Nurse Manager and Department Head, Adult Cardiac Catheterization Laboratory, Browns Mills, New Jersey

Can you tell us about your cath lab?  

Deborah Heart and Lung Center (DHLC) has a longstanding history of being a leader dedicated to cardiovascular care. Our cath facility consists of four labs: one biplane lab, one single-plane lab formerly used as a pediatric lab and now being renovated for dual use as a peripheral and coronary lab, and two single-plane adult labs. In addition, there is an endovascular lab, shared by interventional cardiology and vascular surgery, fully equipped for peripheral angiograms and interventions. We have 16 staff members who support both our holding area and the labs. They comprise an experienced clinical team of eight full-time registered nurses (RN) and five full-time radiologic technologists [RT(R), CI, CV]. Our clinical team’s experience ranges from 5 to 20 years in cardiac catheterization, interventional radiology or critical care. We also have two cath lab assistants who work both in the holding area and manage inventory for the labs. There is a unit coordinator that manages daily clerical needs, and a team of office coordinators that overlook scheduling and follow up. The physician team includes 4 board-certified interventional cardiologists that are fellowship-trained in coronary, structural, and endovascular medicine.

What procedures are done at your lab? 

We perform the entire spectrum of diagnostic and interventional coronary, structural, and peripheral procedures. Procedures include radial, brachial, and femoral access; right and left heart catheterization; coronary angiography; balloon angioplasty and stenting; rotational and laser atherectomy; cutting and scoring balloon angioplasty; rheolytic and mechanical thrombectomy; intravascular ultrasound (IVUS) and fractional flow reserve (FFR); intra-aortic balloon pump and percutaneous ventricular assist device; pericardiocentesis; percutaneous closure of atrial septal defect (ASD), patent foramen ovale (PFO), and patent ductus arteriosus (PDA); alcohol septal ablation; aortic and mitral valvuloplasty; peripheral arterial angioplasty and stenting of carotid, upper extremity, aortic, renal, mesenteric and lower extremity vascular beds; and peripheral atherectomy and angioplasty for limb salvage. We perform approximately 75 procedures per week, inclusive of diagnostic and interventional cases.

Does your cath lab perform primary angioplasty with surgical backup on site?

Our facility provides a full spectrum of on-site surgical backup to all our interventional cardiologists. 

What percentage of your patients is female?

About 40% of the patients our laboratory encounters are female.

What percentage of your diagnostic cath patients goes on to have an interventional procedure?

Almost 40% of our diagnostic cath patients go on to have an interventional procedure. Less than 20% of our diagnostic caths are normal.

Do any of your physicians routinely utilize transradial access?

Access is determined primarily on a case-by-case basis, specifically catering to the patient’s needs, requests, and best outcome. Our physicians have and continue to use radial artery for both diagnostic and interventional procedures with excellent results.  

Who manages your cath lab?

Our cath lab is managed by a collaborative team of physicians and the nurse manager. The nurse manager of the cath lab oversees all activities in the lab and recovery unit. She handles all the day-to-day issues and concerns. The cath lab has a medical director, who works closely with the nurse manager and with the support of the staff interventionalists to handle all administrative issues.  

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

All RNs and RTs cross-train for scrub and monitoring roles. Only the circulating role, for patient assessment and medication administration, is held solely by the RN staff.

Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab?

A radiologic technologist (RT) is present in the department during all fluoroscopy procedures.

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 are able to perform all tasks with the x-ray equipment. In our lab, both RNs and RTs act as scrub assistants; however, only RTs and physicians are allowed to step on the fluoro/cine pedal during a procedure. Since DHLC is a teaching institution with 15 general cardiology fellows and 3 interventional fellows, most of the x-ray equipment tends to be operated by the fellow in training or the attending.

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

Film badges and rings are worn by all clinical staff members, physicians and fellows. These devices are changed and dosage reported monthly through our radiation safety committee, in addition to routine area monitoring and inspection. Everyone present in the procedure room during fluoroscopy use is provided with lead aprons, thyroid collars, and lead glasses as needed. Each room has an adjustable lead shield on the boom and a portable lead skirt for use at the table. Portable lead shields are also present for use by the circulating RN.

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

In the last few years, we upgraded our hemodynamic monitoring system to the Siemens Sensis (Malvern, Penn.). We have maintained our position at the forefront of cutting-edge technology with the introduction of the Impella 2.5 percutaneous left ventricular assist device (Abiomed, Danvers, Mass.) for high-risk interventions and are currently in pursuit of optical coherence tomography (OCT) for intravascular imaging. We are in the process of creating a hybrid lab equipped for surgical and percutaneous/endovascular procedures in anticipation of recognition as a site for placement of percutaneous aortic valves. We have upgraded our FFR and IVUS systems with the expectation of shortly having table-mounted FFR/IVUS systems. Our array of new endovascular devices is comprised of the Frontrunner (Cordis Corp., Miami, Fl.), Crosser (FlowCardia, Inc., Sunnyvale, CA) and Wildcat (Avinger, Redwood City, CA) chronic total occlusion (CTO) devices; Turbohawk (ev3, Plymouth, Minn.), Diamondback 360 (Cardiovascular Systems Inc., St. Paul, Minn.), Pathway (Pathway Medical Technologies Inc., Kirkland, Wash.), and laser atherectomy devices; Proteus embolic protection angioplasty balloons (Angioslide, Inc., Minneapolis, Minn.), and is soon to include drug-eluting balloons.

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

Technology is ever-changing, with outpouring of new data from constantly emerging clinical trials. Communication is vital in order to stay abreast of emerging data for maintaining quality patient care. In addition to weekly cath and vascular conferences for clinical discussions, monthly cath lab staff meetings are held to discuss any current issues and to share monthly statistics. We currently use a “read and sign” communication book for memos, updates, reviews, and pertinent journal articles. Minutes from the monthly meetings are posted in the communication book and any staff member that was not present is required to read and sign the minutes. Information that needs to be transmitted urgently is posted on a central board at the unit coordinator’s desk and communicated via e-mail.

How is coding and coding education handled in your lab?

While all lab staff members are trained to code procedures for accurate documentation, final coding is primarily handled by the billing department. In addition, the billing department organizes educational sessions for updates as needed.

How does your lab handle hemostasis?

We currently offer Angio-Seal (St. Jude Medical, Minnetonka, Minn.), Perclose (Abbott Vascular, Redwood City, Calif.) and Mynx (AccessClosure, Mountain View, Calif.) as vascular closure device choices for the femoral artery and the RadAR band (Advanced Vascular Dynamics, Portland, Oregon) for the radial artery. Vascular closure devices are used for majority of the cases. When needed, manual compression is performed in our holding area by cath assistants and trained cath lab staff. Post-intervention patients are transferred with sutured sheaths or vascular closure devices to our interventional unit for overnight stay. Our interventional unit staff is also trained for sheath pulls and can be utilized when needed.

What is your lab’s hematoma management policy?

Hematomas are addressed as soon as they are recognized. Expanding hematomas immediately receive manual compression and reversal of any anticoagulation until hemostasis is achieved.

How is inventory managed at your cath lab?

Inventory is maintained by our cath lab assistants, who monitor the use of products in the cath lab. All equipment and supplies are re-ordered as soon as they are used to maintain a pre-determined par level for each product.

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

DHLC is one of the few remaining non-profit hospitals in the area. We previously relied solely on walk-ins, clinics, and transfers for patients. However, we have recently partnered with a local area hospital, Our Lady of Lourdes Medical Center, to open a satellite emergency department on our premises. This recent addition, since March 2010, has significantly increased cath lab and inpatient volumes at our institution. Plans are now underway to convert our oldest lab to function as a swing lab to perform cardiac and peripheral procedures in the near future.

Is your lab involved in clinical research?

DHLC continues to be at the cutting edge of research and science for patient care by participating in a variety of clinical trials. We are currently enrolling for a total of 24 trials, involving both drugs and devices. The clinical research department is in the process of transitioning to a new business plan and model, establishing DHLC as a research institute in order to continue the delivery of advanced care for our patients.

Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery?

There were no cath lab-related complications in the past year that required emergent cardiac surgery.

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

As mandated by the state of New Jersey, we participate in the New Jersey Cardiac Catheterization Data Registry. The data elements and definitions of this registry, however, are based on the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR).

The New Jersey Department of Health Services provides an annual Catheterization Report based on the data submission to the New Jersey Cardiac Catheterization Data Registry. This report will assess the risk-adjusted outcome measures by hospital, cardiologist, and for the state. These outcome reports are then utilized to develop quality improvement initiatives at DHLC, based on any deficiencies in the report.

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 cath lab’s average D2B times are re-assessed every quarter and have been consistently under 90 minutes. Our staff and physicians are encouraged to be in close proximity to the hospital during call, with the provision of on-site housing, in order to maintain our D2B times.

What other modalities do you use to verify stenosis?

We use fractional flow reserve (FFR) for physiological assessment and intravascular ultrasound (IVUS) for anatomical assessment of lesions. We are also in the process of procuring an optical coherence tomography (OCT) unit.

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

Cath lab equipment and supplies are maintained on consignment agreements with vendors in order to contain costs as much as possible. 

What quality control/quality assurance measures are practiced in your cath lab?

We conduct monthly morbidity and mortality conferences for continued medical education, to limit iatrogenic errors, and to effect changes in systems to improve quality of care.

How does your cath lab compete for patients? Has your institution formed an alliance with others in the area?

The presence of surgical back up at DHLC has allowed for us to partner with various cath labs in the region that are unable to perform high-risk interventions. Moreover, our physicians participate in acute MI calls at other cath labs to allow for referral of patients to our hospital. DHLC has maintained a reputation for performing complex procedures with excellent clinical outcomes, which has led to increasing cath lab volumes despite increasing competition in the area. Finally, the addition of the satellite emergency department in partnership with Our Lady of Lourdes Medical Center has significantly contributed to the increase in patient volume. Likewise, the recognition of DHLC as a Joslin Diabetes Center Affiliate and the establishment of a wound care center at DHLC during the upcoming year are expected to effect similar outcomes.

How are new employees oriented and trained at your facility?

All staff members in the cath lab are formally trained and licensed for their respective positions. We currently have RN, RT, and registered cardiovascular invasive specialist (RCIS) certifications. We require basic life support (BLS) training for all staff members and additional advanced cardiac life support (ACLS) training for all RNs. None of our staff members have less than 2 years of experience in the cath lab. Moreover, RNs are required to have at least 2 years of critical care experience. The majority of our staff have been longstanding DHLC employees or have come from surrounding area hospitals, with diverse backgrounds in an emergency department, operating room, intensive care unit, or interventional radiology. New cath lab staff are proctored by senior members of the department and follow a formal preceptorship pathway. This involves a competency-based orientation that lasts 3–6 months. An orientee is assigned to a preceptor who provides one-on-one teaching and training during cases. The preceptor provides educational resources and works with the manager to schedule necessary educational sessions. Upon completion of the orientation period, each new staff member is given a few months on their own before initiating weekly call rotation, scheduled specifically with their assigned preceptor. 

What continuing education opportunities are provided to staff members?

Continuing education opportunities are provided in the form of hospital-based conferences and meetings at local and national settings. DHLC budgets a yearly stipend for all staff members to utilize for registration and travel for educational conferences. 

How do you handle vendor visits to your lab?

Vendors are required to pre-schedule a visit to the lab through our cath lab nurse manager who assigns no more than one vendor visit per day. In addition, all vendors are required to carry identification badges from hospital registration and are limited to the cath lab floor.

How is staff competency evaluated?

New staff members must complete a competency checklist prior to completing orientation. Staff competency is evaluated yearly by the nurse manager via peer reviews and feedback from attending physicians. In addition, there are quarterly hospital-based test modules that all staff members are required to complete. Subsequent deficiencies and focus areas are addressed in one-on-one preceptor sessions, as determined by the nurse manager.

Does your lab have a clinical ladder?

The cath lab does have a clinical ladder. Currently there is a pending addition of RN and RT team leaders. Any issues in the cath lab could then be directed from a staff member to the clinical team leader and onward to the nurse manager or medical director of the cath lab.

How does your lab handle call time for staff members?

Our cath lab call team is assigned one week of call every 4–6 weeks. The call team typically is comprised of an RT, RN, float (RT or RN), fellow, and attending.

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

The call team, including the attending (who is not always on-site), is expected to arrive to the lab within 30 minutes of being paged.

Do you have flextime or multiple shifts?

We do not offer flextime, but maintain 2 ten-hour shifts to ensure adequate staff coverage for the early and late cases. The regular shift starts at 7 am and the next shift at 8 am. The on-call team starts at 10 am and finishes up when all cases are done.

Has your lab has undergone a Joint Commission inspection in the past three years?

Our cath lab recently underwent a Joint Commission inspection and passed review with flying colors. Routine areas of focus in the cath lab are accurate documentation with dated and timed notes, properly managed pre-procedural time-outs, and labeling of all fluids and medications on the sterile field.

Where is your cath lab located in relation to the operating room and emergency department?

The cath lab is within close proximity of the emergency department (ED) and the operating room (OR), which allows for the expeditious transfer of patients. The ED is located on the first floor, the OR on the second floor, and the cath lab on the fifth floor.

How do you see your cardiac catheterization laboratory changing over the next few years?

We anticipate the addition of a swing lab for both coronary and peripheral use in the setting of increasing volumes, along with systematic upgrades of the present labs. Moreover, we are currently planning the installation of a hybrid suite with surgical and endovascular capabilities with the intention of pursuing percutaneous valve replacement technology. Our renovations will also include a larger patient holding area, a conference room, and a comfortable patient family waiting area.  The current space is limited until completion of the renovation.

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

Our cath lab is an extremely cohesive and collaborative group that fosters an environment of education for fellows and trainees, development of junior faculty, nurturing of research interests, and mutual respect of team members.

Is there a problem or challenge your lab has faced?

The biggest challenge the lab has recently faced was 2 years ago when the preceding cath lab director left DHLC to take on a new position at another institution. This led to the simultaneous departure of the entire veteran DHLC cath lab physician team and the influx of an entirely new physician team from various medical centers without the prior familiarity of working together. However, the cohesive bond of the cath lab staff maintained the unity of the group and welcomed the new team. This encouraged the seamless integration of all the individual physicians and paved the way to our lab’s present success and productivity.

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”?

DHLC is located in the city of Browns Mills, which is a small town in Southern New Jersey with a population of under 12,000 people. However, it has a rich history in the area, having been established as a tuberculosis (TB) sanitarium in 1922. With the advent of antibiotics and the eradication of TB, Deborah expanded its focus to other chest diseases, with its first heart surgery performed in 1958. Since then, Deborah has maintained its position as a pioneer in the treatment of cardiovascular and pulmonary disease, which has led to its growing referral base and increasing experience of the cath lab staff in complex cutting-edge interventions.

The Society of Invasive Cardiovascular Professionals (SICP) has added two questions to our spotlight:

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?

The clinical staff members are currently not required to take the RCIS exam. However, incentives for certification are currently being proposed, including subsidized registration and stipends for courses and study materials.

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?

All managerial team members are encouraged to be involved in the SICP, SCAI, AHA, and ACC at the local, regional, and national stages.

The authors can be contacted at jcgeorgemd@hotmail.com