Cath Lab Spotlight

Florida Hospital

Barry Egolf, RN, Administrative Nurse Manager, Ron Reynolds, RT(R), RCIS, Daytime Supervisor, Linette Lenker, BSN, Supervisor Pre and Post, Joshua Montemayor, BSN, RRT, Evening Supervisor
Orlando, Florida

Barry Egolf, RN, Administrative Nurse Manager, Ron Reynolds, RT(R), RCIS, Daytime Supervisor, Linette Lenker, BSN, Supervisor Pre and Post, Joshua Montemayor, BSN, RRT, Evening Supervisor
Orlando, Florida

Can you tell us about your cath lab?

Florida Hospital is a 1,400-bed facility. We have:

  • 5 dedicated cardiac cath labs;
  • 1 cardiac/vascular lab;
  • 1 dedicated vascular lab;
  • 2 bi-plane electrophysiology (EP) rooms;
  • 2 single-plane EP rooms;
  • 1 Stereotaxis;
  • 3 shelled-out areas for more rooms.

We have 98 employees, comprised of registered nurses (RNs), registered cardiovascular invasive specialists (RCISs), registered radiologic technologists (RT[R]s), and registered respiratory therapists (RRTs), as well as dual-credential staff.

What procedures are done at your lab? 

We do diagnostic caths, percutaneous coronary interventions (PCIs), implants, peripheral interventions, intra-cardiac biopsies, left ventricular assist (Impella, Abiomed, Danvers, Mass.), valvuloplasties, non-invasive programmed stimulation (NIPS), tilt table testing, and cardioversions. We average approximately 135 procedures per week.

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

Yes, we perform over 2,500 open-heart surgeries a year. On February 4, 2011, Florida Hospital performed the first complete robotic cardiac surgery in central Florida. Dr. Joseph Boyer was the surgeon performing the procedure.

What percentage of your patients is female? 

In 2010, we had a 61% male and 38% female patient population.

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

Thirty percent (30%) of our procedures are crossover, 16% are interventional, and the remaining 54% are diagnostic procedures.

Many of our patients come in for direct intervention, so our diagnostic volume is not large. Physicians in Florida have the ability to do heart cath procedures in their office. Every one of our major physician groups have their own cath lab inside their office where they perform diagnostic heart caths. They also do peripheral interventions. Because of the large number of diagnostics being done in the offices, we have agreed to expedite any patient in need of an intervention from their office. This helps prevent the patient from having the sheath pulled and placed again. Ultimately, this is better service to the physician and better care for the patient.

We handle these “same-day” and “future” scheduling requests through the Apollo scheduling system from Lumedx (Oakland, Calif.), and we use it for all of our clinical documentation as well [Ed. note: See Florida Hospital’s March 2004 article on their Apollo experience, “Managing High-Volume Inventory: Increasing Efficiency, Decreasing Costs at Florida Hospital,” online at http://tinyurl.com/FloridaApollo.].

Do any of your physicians regularly gain access via the radial artery?

Yes. Currently, between 10-12 of our 120 physicians gain access via the radial artery on a fairly routine basis.

Who manages your cath lab?

Barry Egolf, RN, is the administrative nurse manager over the cardiac/vascular and EP labs, as well as the sheath pull team.  

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

All staff working the cardiac cath and vascular labs performs in all three positions, no matter their credentialing background. We find that this makes a stronger team, just from being able to anticipate the needs of the person they are supporting.

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

No, as long as the physician is present and is the actual one producing the x-rays.

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?

All staff is allowed and trained to position the II, pan the table, and operate the C-arm; however, only the physician or a radiologic technologist is allowed to step on the fluoro pedal.

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

Multiple radiation protection measures are provided, including low table-mounted lead aprons, roll-around lead aprons, boom-mounted lead screens, RadPads (Worldwide Innovations & Technologies, Inc., Kansas City, Kansas) (for lengthy cases), lead glasses, lead aprons, and film badge monitoring, processed on a monthly basis.

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

We have the St. Jude Medical fractional flow reserve (FFR)/optical coherence tomography (OCT) combo unit, ILumien (Minnetonka, Minn.), the Femoral Introducer Sheath and Hemostasis Device (FISH, Morris Innovative, Bloomington, Indiana), Boston Scientific’s Coyote peripheral balloon (Natick, Mass.), the Stealth 360° Orbital PAD System by Cardiovascular Systems, Inc. (CSI, St. Paul, Minn.), and Atrium’s new thrombectomy catheter, Xpress-Way (Hudson, New Hampshire).

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

Staff schedules are posted on the hospital’s password-protected website, usually 6 weeks out. A daily “Energizer” meeting is held promptly at 0631 for all team members every morning to discuss the day’s cases, important information, and staff assignments. Email is used extensively to communicate everything from new devices being available to vacation requests. “Texting” has also been a welcomed mode of communication to the staff on off hours. We use email, texting, office managers, and post fliers to communicate with some of our physicians. 

How is coding and coding education handled in your lab?

Coding is done by a dedicated group of two individuals. All coding information is processed via our Apollo documentation system. Monitor techs enter procedures only and the coding is done “behind the scenes.”

Where are patients prepped and recovered (post sheath removal)?

Right now, patients are prepped in our sister unit, the chest pain observation unit, if they are outpatients or from one of our satellite campuses. Inpatients are prepped in our pre area by our staff.

Our main closure device is the FISH. We have had good success with the Fish product. We do use Angio-Seal (St. Jude) and Perclose (Abbott Vascular, Redwood City, Calif.) on occasion, as well as the Terumo TR Bands (Somerset, New Jersey) for the radial cases (about 8-10% of our cases are radials). We also use SyvekPatches and GlykoSL patches (both by Marine Polymer Technologies, Inc., Danvers, Mass.). Our complication rate is < 0.5%.

What is your lab’s hematoma management policy? 

Once a hematoma is noted, an objective assessment (size and location) is made and physician notified. Manual compression is started immediately to stop any further growth, with the option of a FemoStop (St. Jude) if necessary. An echo of the site may be also ordered to rule out a pseudoaneurysm. If one is noted, we use the FemoStop in combination with echo for closure.

How is inventory managed at your cath lab?

Most of our inventory is processed and tracked thru the WaveMark radio-frequency identification (RFID) system (Littleton, Mass.). The inventory is scanned in Apollo for each case. This gives us the ability to associate the inventory with each unique case. Our supply chain and contracting manager, Margarita Rivera, will use the information that is gathered at “Point of Care” and reorder. In addition, having this data at her fingertips helps identify real-time trends across the service lines. This is invaluable when negotiating contracts and anticipating physician practice patterns.

Has your cath lab recently expanded in size and patient volume?

We moved to a new 14-story tower at the end of 2008, with the invasive labs occupying 75% of the second floor. We were previously located in the basement of the main building. Plans are underway to develop our remaining 3 empty rooms for interventional neuroradiology and EP, with the use of hybrid lab technology.

All of our cardiac, vascular and EP labs are located within a “Red Zone,” with each lab having hard deck ceilings and laminar flow-filtered air as well as being equipped with full medical gases. Over half of the rooms come with ceiling-mounted surgical lights, allowing us to convert to an invasive surgical procedure if necessary. This allows any of our egesting rooms to be used as “hybrid” labs.

Is your lab involved in clinical research?

Yes. Our cardiovascular research department is managed by Melissa Leonard, RN, MBA, CCRP. The department consists of 13 team members and is involved with over 50 trials at any given time.

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

With over 7,000 cardiac cath procedures performed each year, we do occasionally have to send a patient to cardiac surgery. 

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? 

In-house ST-elevation myocardial infarction (STEMI) D2B times are consistently at or under 60 minutes, with our current best case at 25 minutes D2B. In addition to receiving STEMIs from our in-house emergency department, we also receive all STEMIs from our 7 outlying satellite campuses. As of June 2011, we average 74 minutes D2B, including patients from the satellite locations. We do struggle with D2B times from one of our furthest satellites. A standalone PCI program is being implemented at this campus in the near future. To expedite communication, all information is routed through our “Emergency Transfer Center.” They are responsible for contacting the cardiologist as well as cath staff. This one “source of truth” is critical when coordinating so many facilities.

What other modalities do you use to verify stenosis?

We use intravascular ultrasound (IVUS), OCT and FFR. We also us the “short vessel and long vessel” stenosis packages within the GE machine (Waukesha, Wisc.).

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

Margarita Rivera, supply chain and contracting manager, has had the biggest impact by negotiating contracts and finding comparable products at a lower cost. Margarita, utilizing the Apollo system, drives all of her recommendations from point-of-care clinical trends. Group purchasing through our corporate alliance has also assisted with larger purchases. With our volume of supplies, even a small savings on each product makes a significant impact in the overall budget.

In addition, having our staff cross-trained in EP, cath and vascular allows us to be more flexible with their hours, based off their ability to work across our entire service line. 

What quality control/quality assurance (QC/QA) measures are practiced in your cath lab?

A set number of mock Joint Commission Surveys (“tracers”) are performed randomly every month to make sure that all policies and procedures are followed before, during, and post cath. We also have annual competency ranging from hands-on to written tests. The best way we find to enhance QA issues is through open communication with the staff. If the understand the rationale behind an initiative, they are more likely to follow it.

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

Yes, we have a registry department that inputs all data for cardiac cath and thoracic surgery.

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

We compete by reassessing what it is we can do better. Being in a very competitive market in central Florida means you don’t get hung up on what the person down the road is doing — otherwise, you will never be the leader. Florida Hospital has to perform every day, because 7 other hospitals depend on us to treat their STEMIs.

What continuing education opportunities are provided to staff members?

Our education coordinator oversees an annual symposium entitled “Emerging Trends,” marketed to the central Florida area. Florida Hospital invasive lab employees attend for free.

Multiple vendors are scheduled every month, presenting classes on new devices, medications, and techniques. The city of Orlando often hosts the American Heart Association and American College of Cardiology annual meetings, allowing our staff attend with minimal travel cost.

We also send our staff to national conferences based on specialty.

How many staff members do you have now with less than a year’s experience in the cath lab?

We currently have 6 employees with less than a year’s experience. New employees are a mix of RRTs, cardiovascular technology (CVT) graduates, and progressive care unit/intensive care unit (PCU/ICU) RNs.

How is staff competency evaluated? 

We have a system-wide annual evaluation that occurs at the same time every year, and we also do a 6-month mini evaluation halfway through the year. As part of the annual evaluation process, the staff can nominate each other for a “model of excellence.” We also solicit active feedback from our physicians and vendors for any observations they have made. We also have a small group of lead techs that help mentor and evaluate new staff members.

Does your lab have a clinical ladder?

We had one in the past that was felt to be much too complicated. We have just completed a new EP clinical ladder and plan to model a ladder for the cath lab on this new version.

How does your lab handle call time for staff members?

On-call shifts are from 6:30 pm to 6:30 am, 7 days a week. Team members are on call 1-2 weekdays per week and 1 weekend every 6 to 7 weeks. We do not staff our call teams with any specific credentialed team members as all members have been cross trained.

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

Call team members are to be clocked in within 30 minutes of being paged. 

Do you have flextime or multiple shifts?

We are staffed 24/7, 365 days a year. Monday thru Friday, we have teams of 8-hour, 10-hour, and 12-hour staff, all starting at 0630, and an evening/night team from 7pm to 7am. Three weekend-only teams are on site, with two teams 7am to 7pm and one team from 7pm to 7am. 

How do you handle vendor visits to your lab?

Vendors must schedule all visits with the supply chain and contracting manager or the education coordinator. Vendors must sign in and wear a badge, and are only allowed in the lab if invited by the physician. A specific area is set up within the central work core for the vendors to set up displays.

Has your lab recently undergone a national accrediting agency inspection?

Not at this time.

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

We are two floors directly above the ED and, although it is some distance away, we are on the same floor as the OR.

What trends have you seen in your procedures and/or patient population? 

We are starting to see more patients with significant disease that are not cardiac surgical candidates. Physicians are starting to elect to use Impella as a supportive device so that they can do multi-vessel stenting, including left main disease. We are also using it for cardiogenic shock with good outcomes.

We are utilizing FFR and OCT more frequently for diagnosis and moving away from IVUS.

In addition, we are seeing a trend of younger patients coming in and some people in their early to mid-20’s with significant disease, although usually with a single-lesion event.

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

Every lab we have has been built to accommodate hybrid procedures. The multipurpose capabilities of our labs are only matched by the versatility of our staff. We have always supported our staff as well as offered opportunities for advancement. Our entire leadership string has attended “Grassroots” leadership courses to assist with communication and expectations of all levels of leadership.

Most recently, we have started an “Innovation Lab” to help break down paradigms that can paralyze a department’s ability to grow.

Is there a problem or challenge your lab has faced?

The biggest challenge we faced has been to change the behavioral culture of the staff. Over the last few years, we have sought to build a cohesive family of dedicated, engaged team members who are respectful to one another. Through education, recognition, people development, attrition and careful hiring, we now have one of the most skilled and caring groups in the nation.

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 located in Orlando, in the self-proclaimed “Tourist Capital of the World.” The central Florida Hospital population mix is extremely diverse. We do have a fair mix of patients that come from up north (the snowbird population), but there are also a lot of Europeans that come to Orlando. The transient population is quite varied. It does present some challenges. On any given day, we may have French Creole, Portugese, German, or Russian patients. It’s not just the Spanish-speaking population you might expect. Also, within the cath lab staff itself, we have team members from all over the world.

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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?

Any CVT graduates are required to pass the RCIS within one year of employment. Any of the other disciplines working in the lab are encouraged to obtain the RCIS credential, but it is not a requirement.

We are working with one of our local community colleges, Valencia Community College, to implement a registered cardiac electrophysiology specialist (RCES) program as well. We have actually been very involved with their RCIS program here in Orlando, and helped co-found it with the Orlando Regional Medical Center. We have quite a few students who come and train at our lab, and have hired some of them. We have several other colleges with whom we are affiliated, and those students who do their clinical rotations here as well.

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.

New! A question from the American College of Cardiology’s National Cardiovascular Data Registry:

How do you use the NCDR Outcome Reports to drive QI initiatives at your facility?

We do look closely at our outcome metrics. We have a very involved physician leadership structure at Florida Hospital and they also review the data. The registries most commonly referenced are the ICD and CathPCI Registry. We are also looking forward to our data from the ACTION Registry-GWTG.

The authors can be contacted via Barry Egolf at barry.egolf@flhosp.org.