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Email Discussion Group: Scheduling, Surgical Backup, & Organization

(Thank you to Bob Cole, St. Edward Mercy Medical Center, Fort Smith, Arkansas, for last month’s discussion group question, above). 10 cath labs responded to the question above, and emails are included for any questions readers may have regarding a particular lab’s policies. If you’d like to join our group, please send an email to cathlabdigest@aol.com The entire daily schedule is divided as equally as possible among our three cath labs. But if one case takes a long time, we are flexible, moving cases around from room to room. We have a flow coordinator based in our prep/recovery area, who sends for patients, keeps things moving and moves cases around as needed. Do you have scheduled surgical backup for interventions at different levels? We have three cardiac surgeons and three dedicated OR rooms, so the cath lab proceeds as if we always have a room/surgeon available, even though in actuality it may be a little while before an OR table is empty. We always know at least 45 minutes ahead if we will need OR, since we always try to rescue patients first. (Only 1 or 2 cases per year actually go to emergency bypass from failed intervention.) Organization to blur the nurse-tech line: We may be the only cath lab left in the world that reports to the Director of Radiology! But he was once over the cath lab, so it has helped us many times since he is so familiar. We have a manager whom everyone else (nurses, techs, aides [transporters], clerks) reports to. We cover three cath labs and a prep/recovery room, and perform about 3800 procedures per year, including 900 interventions and 100 permanent pacers (just started these on Oct 1). No EP, no peripherals. I am trying to implement a unified scope of practice for nurses and techs so they will all be under one job description/pay grade. It is difficult, but I think will substantially blur the line between nurses and techs. From: jparham@armc.org I can’t help with the first 2 questions we’re a single lab without OR. Organization to blur the nurse-tech line: I have a Charge Tech (RCIS) over the cath lab and holding area who is directly in charge of those employees (techs, RNs and paramedics). I have a supervisor in charge of the diagnostic cardiology and vascular lab (echo-qualified). Both answer to me (Manager of Cardiac Services). I answer to the Regional Director of Cardiovascular Services for 3 hospitals, who reports directly to the CEO at our facility and to the regional CEO. From: pam_ragland@bshsi.com A designated charge person handles the minute-by-minute action for the day. They are guided by the area supervisor. Do you have scheduled surgical backup for interventions at different levels? We have two levels. Surgeon Alert is enacted by notifying a CV surgeon of an intervention in the cath lab, verifying their status of availability, and giving them a heads up that something more than a routine intervention is about to begin. Full standby involves the OR team, CV surgeon, anesthesia and perfusion. This calls for all personnel to be immediately available. Organization to blur the nurse-tech line: We have a V.P. of Professional Services, Director of Medical Imaging, Supervisor of Cath Lab/EP/MIS Nursing, charge personnel, staff. From: JJenisch@rcrh.org We currently have two rooms. We schedule 90-minute time slots in each room. Each room has a team leader to make decisions on cases going early or running late. A rule has been set that we go in chronological order as to who can go next. Do you have scheduled surgical backup for interventions at different levels? We used to have backup on all interventional cases. We got rid of that about 6 years ago. A study was done on the usage of the surgery suite and it was determined that it was not being utilized properly. If a physician requests surgical backup, then we can arrange it. Organization to blur the nurse-tech line: We have a V.P., director, manager and two team leaders. Everyone here is created equal (both team leaders are actually techs). From: lranney@seton.org The team leader assigns the cases to each room. We have four labs. The assignment is usually by physician block. Do you have scheduled surgical backup for interventions at different levels? We no longer have scheduled surgical backup we call if we need them. Very few cases go emergently to the OR anymore. With three cardiac ORs, we stagger case starts in the OR so that a room would be available within 30 minutes. Organization to blur the nurse-tech line: We are a large facility organized in the cardiac service line. There is a V.P., Director Invasive Cardiology, Director Noninvasive Cardiology, and Director of Inpatient Cardiology. There is a cath lab manager, an echo, EKG manager, and each of the inpatient units has a manager. There are team leaders in the cath lab, CSOR, EP Lab, and on the inpatient units. From: ccole@carilion.com We have 5 labs and a 17-bed outpatient unit, which I oversee. I coordinate the flow of patients in the cath lab, scheduling in a first come, first serve format and placing patients to follow in the next available room. As the team leader, I do much of the transport to decrease turnaround time. Do you have scheduled surgical backup for interventions at different levels? Backup is required to have a 30-minute response time. It is not scheduled and does not have a categorized level. Organization to blur the nurse-tech line: We are a very lean organization structure with little division. In addition to cath lab responsibilities, I also have outpatient, which is all RNs and I’m a tech as their supervisor. We cross-train in the cath lab to the degree that our state board allows. From: judy.gately@medcath.com Cases are assigned to whichever room is opened first. We have two labs, one older and one very new lab. Some docs request the new lab. That is fine, though they understand they may have to wait. The newer lab is also set up for peripheral work so all those cases must be scheduled in that specific lab. Staff attach themselves to any open case. We will check to see who is doing what and what needs to be done. Do you have scheduled surgical backup for interventions at different levels? We used to use surgical standby. Now it is rarely used. If a real bad case comes in, the cardiologist may have us call the surgeon to give him a heads up. In even rarer cases, the surgical team will be called in on standby. This happens 1-2 times per year. We do over 700 interventions annually. Organization to blur the nurse-tech line: Corporate structure is as follows: 3 managers over corporate Cardio-Pulmonary Services, one for each facility. The manager for our main facility has final say at the corporate level. One facility has a single supervisor over invasive and non-invasive cardiology, one for respiratory therapy, one for critical care and one for telemetry (step down unit). The other two facilities have the same structure, with one or more people in each facility covering areas in both facilities as follows: Invasive cardiology 1 supervisor; Noninvasive cardiology  1 supervisor; Respiratory therapy 1 supervisor; Critical care 1 supervisor at each facility; Telemetry 3 supervisors covering both facilities. From: rhood@communitymedical.org We currently have 2 cath labs and are in the process of building our 3rd, with a 4th not far behind. We have block times for our docs each day, so each doc has an am or pm block time to do cases. Any non-emergent cases go on at the end of the day. Of course, emergency cases are given priority and are done in whichever lab is available first, regardless of the doc. Do you have scheduled surgical backup for interventions at different levels? We do have surgical standby for interventions. Our surgeons and scheduler work closely so we know when and who is available to cover our interventions. We have a cath lab manager who coordinates the day’s activities. He also fills in for a nurse or tech if needed. With our numbers increasing so much, he has plans for a charge person for the cath lab, and one for our prep/rec area to make things move smoothly. We work 10-hour shifts, with the call people taking over at 5pm. We also go down to one cath lab at that time to finish cases. Our renovation is scheduled to be complete in April, so I’m expecting to see a lot more changes in the future. From: markscvl@aol.com, N. Marks, Lakeland Medical Center, St. Joseph, MI. We have a designated person who is the lead for the day. They run the board, add on emergency cases, deal with MDs, etc. This person does get a differential on that day’s pay for performing this role. Do you have scheduled surgical backup for interventions at different levels? We have classes of interventions: Class 1: OR backup is in the cath lab with cps standby Class 2: OR backup is available with an available OR room Class 3: no OR backup is required. Organization to blur the nurse-tech line: We have a director. She is over radiology, pulmonary, cath lab, non-invasive lab. Under her, each department has a manager. In the cath lab, we have a lead assigned daily for running the board and the case flow. From: annie.ruppert@sharp.com We have two rooms and they communicate between themselves fairly well. We do seem to have some issues with the physicians being able to get hold of someone or information not getting passed on. We are going to get a mobile phone so that there will be one line of communication. One person will carry it and manipulate the schedule. Most days this will be the Team Leader. Do you have scheduled surgical backup for interventions at different levels? All interventional cases are backed up by surgery. We are in a rural area and have one cardiovascular surgeon and one perfusionist. We have discussed, multiple times, about rating cases and have always gone back to handling it the same way. Organization to blur the nurse-tech line: Previously we fell under radiology and everyone in the lab was equal. We were a harmonious group. The organization as a whole underwent some changes and we were put under Nursing. The nurses were moved to a higher level and the techs were left where they were. Not a good thing. We tried to work as a team, but there were some underlying animosities. When you mess with people’s pocket book, they are not happy campers. Currently, I am under the AVP of Perioperative Services, which is under Nursing. I am called the Cath Lab Team Leader. I am an x-ray tech. Under me I have charge nurses, who in my absence run the labs. We recently have had a change that I hope will smooth out some of the lines. I now have charge techs. When I am absent, either a nurse or a tech will be in charge and they are over the whole lab, not separated into fields. We are cross-trained as much as the law allows. We respect and value each others’ differences. We do not work in an environment of ˜that’s not my job.’ We are a team and any other attitude is not tolerated. From: M.P., cathlabdigest@aol.com Daily QA on Imaging Equipment: Our Next Email Discussion Group Question (We need your responses!) How are the personnel in completely cineless cath labs doing daily QA on their imaging equipment? Prior to the CD ROM systems, QA was done on processing equipment and on imaging equipment. The primary reasons were to detect any changes in the cineradiographic equipment for radiation safety guidelines. I spoke with our medical physicist, who checks the dosage levels once a year. He understood how a daily QA program is needed. If there is a shift in radiation dosage levels, the end result is unnecessary direct ionizing radiation exposure to the patient and unnecessary radiation exposure to all personnel. And the concern is that if the dose did change, it could go undetected for a year. How many people can quote the amount of radiation per cine frame on each image intensification mode and how many can recite the fluoroscopic dose levels in the different II modes? What is the maximum R/min for fluoroscopy? I recently read an article on radiation safety in a northeastern U.S. cath lab. Their policy is to check all patients who have had 20 minutes or more of fluoroscopy during an invasive (interventional) cardiology procedure for any evidence of radiation burns. The article did not mention the latent time intervals. In my discussion with our physicist, the fluoroscopic dose level on a patient; if the dose per minute was 4 R., the total dose to the immediate back of the table before entering the patient’s thorax would be 240 R. (240,000 mR). This would be 2400 Gy. This is ten times what we use to treat a 3.0 X 40mm in-stent restenosed vessel with beta radiation, and the skin area during fluoroscopy and cineradiography is much larger. If anyone has any policies and procedures on quality assurance of filmless cinefluoroscopic equipment, please consider sharing them. From: Chuck Williams RT(R)(CV),RCIS,CPFT, RPA Student Weber State University, Radiologic Sciences, Ogden, Utah Email your response to: CathLabDigest@hotmail.com COMING IN JUNE…Excerpts from a country-wide discussion on cross-training.

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