Cath Lab Spotlight

Eisenhower Medical Center

Dixie Lee Sargent, CVT, RCIS Rancho Mirage, California
Dixie Lee Sargent, CVT, RCIS Rancho Mirage, California
Our cath lab team consists of the following: five RNs, four RT(R)s, one cardiovascular technologist (CVT)/ Registered Cardiovascular Invasive Specialist (RCIS), two clerical/support staff, and one cath lab director. We are under the direction of an administrative and a medical director of the cardiac cath lab. The majority of team members have been working together for over ten years, although one of our registered nurses (RNs), Sue Salimaki, is new to the cath lab environment. At the time of this article’s publication, a new cath lab director, Cindy Olson, RN, will also have joined our team, bringing previous managerial experience. Individually, each staff member has twenty-plus years of experience in his/her specialty. This wealth of experience culminates into a dynamic team and a level of performance excellence that exemplifies what Eisenhower Medical Center is all about. What types of procedures are performed at your facility? Our cath lab performs diagnostic and interventional procedures for coronary and peripheral arteries. Electrophysiology procedures (EP) and pacemakers are performed in a separate department due to the large volumes of these procedures. From the last fiscal year (July 1, 2006 to June 30, 2007), our total number of billed procedures was 3,815. Of that, 561 were peripheral angiograms. What type of peripheral interventions are done at your lab? According to cath lab medical director Dr. Barry Hackshaw, the cardiologist group at Eisenhower was among the first in the state of California to apply for and receive peripheral privileges in the cath lab setting. In our cath lab, we currently perform peripheral interventions of the lower extremities and renal arteries only. We utilize current technologies and equipment for peripheral interventions. Our digital imaging capabilities are outstanding, with the use of the bolus chase functions for runoffs. We use several different products and devices, including devices from FoxHollow Technology (Redwood City, CA) devices, AngioScore (Fremont, CA) balloons, the recently FDA-approved Orbital Arthrectomy System (Cardiovascular Systems, Inc., St. Paul, MN) and stenting. To achieve an optimal result, a patient site access is geared to the lesion location and degree of difficulty. Site access may be traditional and/or antegrade. Our interventional cardiologists are innovative and progressive in their treatment of peripheral vascular disease (PVD). Does your cath lab perform primary angioplasty with surgical backup? Primary angioplasty is performed without scheduled surgical backup. We do have open-heart surgical services available for the rare emergent surgical intervention. What procedures do you perform on an outpatient basis? Outpatient procedures include all diagnostics for cardiac and peripheral. A patient who has a diagnostic procedure that evolves to an intervention is admitted as an inpatient for overnight observation. There are some exceptions. A small population of patients will be same-day discharged post recovery from interventional procedures. What percentage of your patients is female? Available data is for percutaneous coronary intervention (PCI) patients only. We track interventional coronary data for the American College of Cardiology National Cardiovascular Registry (ACC-NCDR). Diagnostic peripheral and diagnostic coronaries are not entered into the ACC database. In 2006, we did 180 PCIs for females. Of the total PCIs, 27.1% were females. (This does not depict peripheral procedures.) What percentage of your diagnostic cath patients go on to have an interventional procedure? In 2006, we did a total of 677 PCIs as entered in the ACC database. We did not distinguish the diagnostic-only procedures (coronary or peripheral) from those that moved into intervention in the database. In the last fiscal year, we billed for 2,123 left heart caths. From the numbers, it is safe to assume that approximately less than one half of diagnostic exams evolve to interventional procedures. Who manages your cath lab? Our cath lab is unique in that many management duties have been handled collaboratively over the past two years. Our cath lab administrative director, Lynn Hart, RN, delegates certain manager duties to the team. She gives us the opportunity to function outside our regular roles to manage supplies, inventory, vendor requests, clinical documentation issues, scheduling and timekeeping. This collaboration has helped our group function at a higher level, creating solid cooperation and a heightened respect for the position of cath lab manager! Do you have cross training? Who scrubs, who circulates and who monitors? All of our RTs can scrub, circulate, and run x-ray equipment. Our RCIS scrubs, monitors, and circulates. All of our RNs monitor and give IV medications, and a few scrub. Does an RT have to be present in the room for all fluoroscopic procedures in your cath lab? In complying with a very strict interpretation of California state regulatory laws, only a licensed x-ray tech or a fluoroscopy-certified physician is able to position the II, pan the table, change angles, and step on fluoro pedal in our cath lab. There is no exception. All certifications must be current or privileges are suspended. We have an RT for each case, in each room, running the x-ray equipment. The RTs also perform required quality control/quality analysis of the x-ray equipment. There is a designated RT (Steve Jones, RT) for the Radiation Safety Committee. What are some of the new equipment, devices and products introduced at your lab lately? Our cath lab frequently participates in new product research, development and market launching. Recently, we launched a newly FDA-approved closure device in our lab. We actually participated in the development and research of this device, called the Mynx Vascular Closure Device (AccessClosure, Inc., Mountain View, CA). One of our cardiologists, Dr. Puneet Khanna, was intimately involved in all phases of this product. Dr. Khanna also involved our lab in a trial for peripheral artherectomy with the Diamondback Orbital Artherectomy System, (Cardiovascular Systems, Inc., St. Paul, MN), recently approved by the FDA. We are hosting a physician training course for this system on January 15, 2008. Dr. Khanna is currently involved in innovative ostial and bifurcation stent development. These stents are just starting trials outside the United States. According to Dr. Khanna, Eisenhower will probably be one of the first U.S sites to trial these stents when available. Can you describe the system(s) you utilize and how they work in cath lab daily life? Our digital imaging equipment is the GE Innova (Waukesha, WI). We get optimal images with this equipment, as well as ease of use for the operator. Our enhanced capabilities for the peripheral runoffs and superb imaging are an asset to patient treatment. The GE Mac-Lab® system for hemodynamic monitoring is used for procedure charting and physician reporting. We have a link to a digital management system (DMS), GE Cardiology Centricity, which is a physician computerized reporting system that provides digital procedural images and integrated patient reporting. All ACC data is also put into this system. The physician reporting system has been a challenge to integrate. The special training for staff and the ongoing training for physicians is a time investment. It also requires a great deal of patience and positive reinforcement for those who are accustomed to using oral dictation reporting. The payoff is excellent patient charting, which is easily available anywhere in the hospital and/or physician office computer systems. Overall, integrating all these systems and modalities has been worth the end result, which is ease of use and a secure source for detailed patient information. We also use the Arrow International AutoCAT Series IABP System (Everett, MA). When you need an IABP in the cath lab setting, chances are that you are too busy to stand by to constantly monitor settings. This balloon pump continuously monitors the patient’s ever-changing parameters and will adjust timing accordingly. This gives us the ability to focus directly on our patients and not on a machine. For emergent vessel clot extraction, we are using the Pronto Catheter (Vascular Solutions, Minneapolis, MN), and the Rinspirator System (FoxHollow Technologies). We have used other systems and devices, but for ease of use and performance, these two have remained in our lab. How is coding handled in your lab? We are still using a hard copy charge system per case. The coding is printed on our charge sheets. These sheets include procedures, imaging and supplies. The case updating department enters all charges, which are reviewed by the hospital coders. The charges then go electronically to the bill. One staff member (Bruce Freiman, RT) is working with the finance department to make our charges more compact. We also use a hospital-wide McKesson (San Francisco, CA) Intellishelf scanning system for supplies. The system can initiate a direct per-patient itemization and track shelf inventory. The cath lab is currently using only the inventory feature for restock purposes. How does your lab handle hemostasis? Hemostasis begins at the moment of access. Meticulous attention is given to groin management from access to discharge. Patient education is reinforced all along the path of patient stay. We have a few cardiologists that prefer a 4Fr sheath for the diagnostic angiogram. These patients will get a manual hold. Most manual holds will also include a D-Stat Dry (Vascular Solutions) pad to enhance the speed of hemostasis. The scrub tech generally does the manual hold. The majority of our patients will have a 6Fr sheath and receive a closure device. Techs or physicians deploy the closures. We usually use Angio-Seal (St. Jude Medical, St. Paul, MN) or Mynx. If there is any oozing at the site, a Safe-Guard dressing (Datascope, Mahwah, NJ) is applied. A sheath left in post procedure is secured with suture, an obturator placed in the shaft of the sheath and a flush device connected. The majority of our patients are transferred to the Cardiac Diagnostic Interventional Unit (CDIU) for recovery and/or transfer to an inpatient room. The RNs in this area monitor groins for hemostasis, do sheath pulls, and reinforce post procedure teaching. We have an excellent hemostasis record that is a result of multi-departmental teamwork. What is your hematoma management policy? Hematomas are charted at the onset. Appropriate compression and hemostasis management is immediately applied. A patient is not transferred out of the cath lab without control of the access site. Continuous monitoring of the site and patient hemodynamics are charted. When a patient is transferred, the recovery RN is given a detailed report in order for him/her to continue observation of the site. How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies? Our sterile processing department (SPD) conducts a computerized daily inventory via the McKesson system. Appropriate supply is restocked and rotated for outdates by the SPD tech (Gus Hernandez) in the early morning, prior to cases. This per-item barcode scanning system is used hospital-wide. Clinical staff requests special order items on a per use basis. Our clerical support (Monica Turner and Frank Zazueta) follows through with an order. This includes stents and special interventional products for both coronary and peripheral procedures. This system allows us to maintain a realistic par level of expensive items on the shelf. It also prevents costly waste of expired items. Our director must approve capital equipment, special orders, and/or new product requests prior to purchase. The hospital new product committee must approve all new product requests before product can be stocked in the lab. A physician, with approval from the director, can initiate specific product/equipment trials. This would include our product research and development items. Overall, we maintain very realistic par levels that keep cost down and ensure no product waste. Has your lab recently expanded in size and patient volume, or will it be in the near future? Our cath lab is located in the Coachella Valley of Riverside County, California. This area is one of the fastest-growing populations in the nation. We have seen a steady increase in patient volume that covers the calendar year, not just the winter months. We are a resort community with a season lasting six to eight months of the year that sees an influx of visitors from all over the world. Each year, increasing numbers of people are becoming full-time residents. Eisenhower Medical Center is currently constructing a new building to open in the summer of 2009 to increase the current 289-bed count to approximately 400 beds. The building is a result of generous gifts from our benefactors. After it is complete, our cath lab will be relocated into the current existing ICU, which will be remodeled for our use. We will have three suites. One suite will be designated as peripheral. This move will consolidate all of Cardiac Services. It is an exciting future of change and growth for the entire hospital. We do expect an increase in acute coronary patients based on our recent designation as one of the ST-elevation MI (STEMI) receiving centers in Riverside County. This designation requires ambulance services to deliver STEMI patients to Eisenhower Medical Center if it is within 30 minutes or less from another receiving center. Based on clinical evidence, patient outcomes are better when paramedics identify and take patients to an advanced cardiac treatment center. Our Emergency Department is currently under major reconstruction and expansion from 27 to 44 beds (to open in winter of 2008) to accommodate our growing patient population. We also expect a large increase in peripheral patients. Dr. Khanna has started an outreach to physician offices to teach diagnostic screening to physicians (i.e., podiatrists and primary care physicians) and their staff. An ankle brachial index (ABI) screening program is an excellent tool to identify frequently missed PVD patients. Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? Our lab sees a high percentage of complex coronary disease due to the older age of our patient population. We do very challenging interventional procedures on patients who have multiple health issues, previous open-heart surgeries, physical inability to have open-heart surgery, age older than seventy-five years, and, in general, have more co-morbidity. Statistically, even though our patient population is one of higher risk, we have excellent outcomes. An emergent surgical call is rare from our lab; we are fortunate to have a highly skilled open-heart team who can respond to the infrequent necessity for surgical intervention. What other modalities do you use to verify stenosis? Cardiologists will first make an educated visual lesion judgment based on coronary angiography. We do have intravascular ultrasound (IVUS) available for use, but do not use it on every interventional case. We do take advantage of IVUS when there is a question of apposition of a stent, to better evaluate an in-stent restenosis concern, to better define a left main stenosis, and whenever a physician has any quandary or concern with respect to a lesion determination. Using IVUS requires opening basic interventional supplies onto the sterile field. At this point, there is no negative financial impact in applying extra diagnostic tools to confirm the physicians’ judgment with respect to a lesion. Our patients deserve the best diagnostic tools available prior to any lesion intervention. What measures has your cath lab implemented in order to cut or contain costs? One measure we have taken is to streamline supplies and do case-pack consolidation. The majority of our physicians agreed on the supplies in our basic case packs. They concur on the basic interventional supplies. This group consensus is a cost saver. Stocking fewer surpluses, consigning high-dollar supplies, consolidating supplies and continually working with vendors for better pricing saves money for our cost center. A second measure is in flex-off time during slow days. We work out among ourselves with respect to who will be off. So far we have not had to enforce a mandatory flex-off schedule. It seems to work out in a fair and equitable way. Our work schedule is staggered ten-hour shifts, four days a week, which covers the busiest time of day. With respect to our caseload versus hours of actual staffing, we have excellent productivity ratings when it comes to reporting statistics. What type of quality control/quality assurance measure is practiced in your cath lab? As noted, RTs perform x-ray machine QC/QA per California state law. They also attend required Radiation Safety Committee meetings. RNs perform QC/QA on lab machines (saturation & ACT) to meet the CLEA (laboratory accreditation) requirements and state certifications. Staff member Kathy Stevens, RN, is our self-appointed coordinator for the ACC-NCDR database. She does an outstanding job investigating and finding pertinent information. All RNs and the RCIS do the daily data input. The ACC-NCDR national database provides statistical and comparative analysis that depicts the performance of the participating cath labs. The cath lab also participates on the hospital acute myocardial infarction (AMI) committee. The committee focus is to improve optimal care for the acute heart attack patient, and to continually improve door-to-balloon time. Statistics are submitted for core measure reporting. Cath lab staff member Mary Jacobs, RN, sits on this committee to represent a cath lab perspective. How does your cath lab compete for patients? Has your institution formed an alliance with others in the area? In 2006, Eisenhower became a certified Chest Pain Center by the Society of Chest Pain Centers (Columbus, OH, www.scpcp.org). In October 2007, the County of Riverside appointed Eisenhower Medical Center as one of the designated STEMI Receiving Centers, as a result of our meeting the standards set by the Society of Chest Pain Centers for timely treatment of patients with acute MI. This relationship with ambulance services will increase the number of STEMI patients admitted via our emergency room for immediate angioplasty. Our door-to-balloon time is continually improving in order to meet and exceed the benchmarks set for maintaining our certification. In the peripheral arena, we are actively increasing our patient load with the ABI Screening program mentioned earlier. This program is in conjunction with FoxHollow Technologies. How are new employees oriented and trained at your facility? We have a core competency program that all new hires must complete within a probationary period to be successful. Long-term employees mentor new hires for the period of time necessary to complete competencies and to be able to participate in the on-call schedule. The mentor process is adjusted to the experience of the new hire with a reasonable expectation timeline for performance. All employees in the cath lab must meet minimum qualifications in order to be hired. RNs must have BLS and ACLS. CVTs must be certified and have RCIS and ACLS. RTs must have California state licensure; preference is a national registry accreditation and BLS. The clerical support staff must also have BLS. What type of continuing education opportunity is provided to staff members? Our cath lab team formed a lunchtime education program where we invite industry representatives to give us accredited inservices. We also have hospital tuition and expense reimbursement available for outside local and national education programs. How do you handle vendor visits to your lab? Vendors must book specific dates via our clerical staff. They are limited to a specific number of visits per month. Only one vendor per day can be in the lab. All vendors must register with Materials Management to receive a name badge. Vendors may not enter the control room or patient area without physician approval. Vendors are not allowed to circulate cases or participate in direct patient care. How is staff competency evaluated? All employees must maintain required certifications in their specialty. Evaluations are set up to occur at the same time of year for all employees. Our lab also uses a peer-assigned competency check-off system to demonstrate our knowledge and performance of what we do on a daily basis. The director then reviews these competencies and schedules individual interviews with each employee. Does your lab have a clinical ladder? To date, our lab does not have a clinical ladder for the technologists. There is a hospital-wide clinical ladder for the RNs. Does your lab utilize alternative therapies? In the past, guided imagery was trialed with patients using a CD. We found that the best therapies are a smile, kind words of reassurance, respect, listening, appropriate pain medication and sedation, and professionalism. These simple acts put patients at ease. How does your lab handle call time for staff members? There must be at least one RN and one RT on the three-person call team. The third person can be an RN, RT or RCIS. The cath lab has coverage twenty-four hours, seven days a week. Call begins at end of scheduled cases with a three-person team. Call is scheduled in advance. It is often traded and bartered for! Weekend call works out to be every third weekend. Since we have a four-day work week (ten-hour shifts), we periodically get four-day weekends. Staff member Cheli Shea, RN, has undertaken the challenge of making our schedules. She does an excellent job in juggling all of our requests while covering the needs of our lab. We appreciate her effort! What time period are call team members expected to arrive to the lab after being paged? In compliance with our Society for Chest Pain Center certification, we must meet a benchmark of ninety minutes or less for door-to-balloon time. We are required to arrive in cath lab within twenty minutes after being paged. Prior to paging cath lab, the goal is for early detection (in the field) of acute MI, and beginning measures to establish coronary blood flow as soon as possible. A paramedic uses a 12-lead EKG to assess a patient in the field. The ER physician interprets the initial 12-lead, the vitals, available history, possible contraindications, etc. Based on the judgment of the ER physician, the cath lab team may be paged prior to the cardiologist assessing the patient. There is not a cardiologist on site 24/7. The ER physician continues with the appropriate emergency algorithm. This process saves minutes for the valuable myocardium. It is vital to the life of our patient that each cath lab and ED team member involved is playing their role full-out, 100% of the time. We each make a difference in the outcome of our patients. Do you have flextime or multiple shifts? We have an informal flextime for slow days. It works well for us and is fair and equitable. Team members communicate with each other with respect to schedule desires. We have found that working ten-hour shifts, four days a week gives our team the greatest flexibility in lab case coverage and in meeting individual needs for time off. Does your cath lab do electives on weekends and or holidays? The emergency call back team is used for non-emergent inpatient cases after hours, weekends, and holidays. Our physicians are our main patient referral bases and it is important to foster good relations by trying to accommodate their scheduling requests. It also serves the hospital by not holding an inpatient bed an extra day solely for scheduling a cath procedure during regular hours. Hospital occupancy is 80-90%, depending on seasonal fluctuations, and available bed space is of utmost importance in serving our community. Has your lab undergone a Joint Commission inspection in the past three years? Our cath lab has passed The Joint Commission inspection in the last three years. The best advice is to keep everything Joint Commission-ready all year. This can become a habit. It also eliminates the drama associated with inspection preparation. Where is your lab located in relation to the operating room (OR), emergency room (ER), and radiology department? We are currently located on the main floor across the hall from the cardiac surgery unit, an intensive care unit for critical heart patients and post open-heart patients. The OR and radiology departments are located down the hall. The ER is one level away. The reason for the location of areas is mainly due to the original design of the hospital structure in 1971. The future move will put us in an ideal proximity to the OR and ER. What trends do you see emerging in the practice of invasive cardiology? According to the medical director of the cardiac cath lab, Dr. Barry Hackshaw, the trend is to apply more medical management as opposed to performing more invasive interventional procedures, especially when considering a patient population that is prone to a greater co-morbidity. Staff cardiologist Dr. Lester Padilla believes the use of statins, hypertension control and anti-platelet therapy is giving a select group of his patients life-sustaining results without a coronary intervention. He believes that the willingness of American society to perform risky invasive procedures on the elderly requires stringent and conscientious medical management for this higher-risk patient population. This is not to say all elderly patients are the same, which is precisely the point. The overall patient health profile must be considered in administering any type of treatment or procedure. Please tell readers what you consider unique or innovative about your cath lab and staff. In having had the opportunity to work in cath labs across the country, from the midwest to the west coast, I conclude that a cath lab is a cath lab, is a cath lab. What makes a cath lab unique or innovative is driven by the culture of the people who work in the lab. It is also driven by the attending physicians’ purpose and/or motivation in his/her practice (i.e., interest in teaching, research, etc.) The general type of patient population treated in the lab also contributes greatly to the atmosphere of the lab. These factors combined create the unique quality of a cath lab. The majority of our cath lab staff has never worked in another cath lab setting. For this reason, there is staunch tradition in practice here. After so many years of working together, this team knows each other very well. This familiarity gives way to a comfortable sense of predictability in each other’s responses and an understanding of one another’s aura of the day, a persistent inside humor, a steadfast loyalty and a familial history that binds them even closer beyond the work door. Since the beginning of this cath lab, the team has evolved through their shared life experiences such as marriage, divorce, pets, children, deaths and illnesses. This mutuality is unique within the fast-paced healthcare field that tends to have constant employee turnover. The number of long-term employees in this lab may be attributed to living the Five Star Values (Integrity, Respect, Honesty, Professionalism, Team Player) that Eisenhower Medical Center has set forth in fulfilling its organizational mission statement. Is there a problem or challenge your lab has faced? For the past few years, this cath lab has been challenged to function without a manager. One staff member, Cheli Shea, RN, has stepped up to bat in a big way to take care of some of the not-so-exciting administrative duties. We can’t convince her to take the position full-time! A former long-term manager (Maureen Lochridge, RT) who now works only as a staff RT, takes care of our computerized time cards. We really appreciate this! Our administrative director, Lynn Hart, RN, has delegated some managerial duties among each staff member as needed. Our team players have collaborated in the execution of these assigned duties. We each have things we excel at and these assigned duties give us the opportunity to shine in a way that may not be within our usual roles. We do have common workplace problems like any other cath lab. We just try hard with one another to work it out. It has been a good measure of our maturity and professionalism. It makes us a better team. What’s special about your city or general regional area in comparison to rest of the U.S.? Rancho Mirage, California, is located in the Coachella Valley, within a unique desert landscape. It is surrounded by three separate mountain ranges. We are approximately 20 miles from central Palm Springs. Our weather is outstanding for the majority of the year. Temperate conditions are an average balmy 85 degrees. Tourists and part-time residents from all over the world flock here for several months out of the year. The summer can reach into dry, scorching triple digits, creating a temporary exodus from our desert oasis. Even though this is primarily a retirement population, it is an outdoor/sports-oriented community. The seniors here are some of the most robust, vital and interesting people you could ever meet. It is a real pleasure to serve such a patient population. And a lesson in trying to keep up with their energy! One can take in the natural desert beauty in a variety of ways. World-class golfing, tennis, hiking in one of the many national parks, swimming, biking and people-watching are just a few of the outdoor activities. To top it off, you can take a ride straight up the snow-capped San Jacinto mountainside on our world-famous gondola. The only other one like it is in the Swiss Alps. To complement this desert terrain, less than two hours away are the Pacific Ocean, Disneyland, and the ski resorts of Big Bear Mountain. We are always in close proximity to interesting outdoor activities. The Palm Springs area has long been a draw for the rich and famous. Rancho Mirage is considered the Playground of the Presidents. Our hospital is named after President Dwight D. Eisenhower, who lived here after his presidency. Comedian Bob Hope and his wife, Dolores, actually donated the land our hospital campus is built upon. Dolores Hope still resides in the area. The late President Gerald R. Ford was a long-term resident here before passing. His wife, Betty, still resides in Rancho Mirage. Our retiree population has molded the character of our community and of our hospital. These active individuals have a wealth of experience that contributes to the success, growth and progressive healthcare we offer at Eisenhower Medical Center. Our 130-acre campus includes Eisenhower Hospital, Barbara Sinatra Children’s Center at Eisenhower, the Betty Ford Center at Eisenhower and the Annenberg Center for Health Sciences at Eisenhower. We are fortunate to attract a level of generous benefactors who care about our community in such a healing way. Our hospital culture is attributed in a very large part to the brigade of Auxiliary volunteers. These men and women assist by raising funds, volunteering assistance to patients and hospital personnel. To have this kind presence within all areas of the campus is a great support, and a constant sense of reassurance to staff, patients and visitors. Our cath lab culture is forged from the incredible community we serve. We are geared to cater to a much older patient population. The average age of our cath lab patient is 70. The greatest numbers of cases are performed on a person 80 years and older. Our lowest number of cases are the 54-and-under age group. We serve a patient who is typically much older, generally sicker and may have recently lost a spouse. Illness and death seem much closer to these individuals. This shapes our language, our listening skills, our level of patience and our real concern for overall patient comfort. Our elderly patients are the most amazing group of people. They are the lifelines of this community. Our individual destinies are truly seen in their expressions, heard in their stories, and felt in their fears and their triumphs. Every day that we get to serve our patients with genuine compassion is a day that we build a bridge of patient satisfaction that crosses over into the community. We have an excellent reputation in this community. It has been earned and must be nurtured by each employee on a daily basis.

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

1. Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? Only the CVT is required to have RCIS credential as a minimal job requirement. There is no monetary incentive bonus for this credential. 2. Are your clinical and/or managerial team members involved with any professional organizations that support the invasive cardiology service line, such as SICP, Alliance of Cardiovascular Professionals (ACVP), or regional organizations? Our RCIS staff member is an active member of SICP and ACVP. All of the RTs are members of ASRT (American Society of Radiologic Technologists). Several of the RNs are affiliated with AACN (American Association of Critical-Care Nurses). Acknowledgement: Thank you to Bruce Freiman and the Eisenhower Medical Center Public Relations Department for taking many of the photographs in this article. Dixie Sargent can be contacted at dsargent@emc.org
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