Cath Lab Spotlight

Governor Juan F. Luis Hospital and Medical Center

Jill Price, RN, Head Nurse Cardiovascular Lab St. Croix, U.S. Virgin Islands
Jill Price, RN, Head Nurse Cardiovascular Lab St. Croix, U.S. Virgin Islands
We have a one-unit diagnostic/interventional lab with 3 RNs, 1 PA and 3 cardiologists (one of whom is an interventional cardiologist). Our Chief of Cardiology is from Detroit and our interventionalist and other cardiologist are both from St. Croix, trained in the States. What type of procedures are performed at your facility? We perform diagnostic cardiac caths, peripheral angiograms, venograms, permanent pacemakers, and intra-aortic balloon pump insertion and coronary intervention. We perform approximately 10 cases per week. We do not perform peripheral interventions. Our lab is primarily an outpatient program. We perform 90% of our procedures on an outpatient basis, including diagnostic caths and peripheral angiograms. Does your cath lab perform primary angioplasty with/without surgical backup? Yes, our cath lab does perform primary and elective angioplasty without surgical backup. We are a small island located in the Caribbean Sea and currently we do not have an open-heart program within our facility. We are working on obtaining that service for the future. We do have a policy in place for surgical backup at a hospital in San Juan, Puerto Rico, which is a 35-minute plane ride over the ocean. When we get an acute myocardial infarction (AMI) that is a candidate for primary percutaneous coronary intervention (PCI), we notify an air ambulance team and Pavia Hospital in San Juan for standby. Who manages your cath lab? Our head of nursing overseen by the department of nursing, manages our cath lab. The head nurse evaluates all nurses that work in the cath lab, holding area, and recovery. The director of the cath lab evaluates our PA, who is under the medical director. Do you have cross-training? Yes, we have cross-training for all nurses. All nurses can scrub, circulate, monitor and take care of patients during holding and recovery. Generally, we have the PA scrub with the cardiologist, an RN monitor, an RN to circulate/conscious sedation and an RN to prepare and recover the additional patients. Does your lab have a clinical ladder? No, we do not have a clinical ladder. All RNs are in a union, which negotiates our salaries regardless of our field of nursing. The PA falls under the physicians’ union. What are some of the new equipment, devices and products introduced at your lab lately? Our lab itself is new. We opened in June 2000 as a diagnostic lab only. Then, in March 2002, we began our interventional program of both primary and elective PCI, which of course entailed the purchase of new equipment, devices, and supplies. Recently, we started using VasoSeal® (Datascope Corporation, Mahwah, NJ) to decrease our recovery time, and it has worked out wonderfully. Is your lab filmless? Yes, we have a digital lab (Toshiba). How does your lab handle hemostasis? We use VasoSeal for our entire outpatient population and SyvekPatch® (Marine Polymer Technologies, Danvers, MA) for our inpatients. Our PA deploys all the VasoSeals and pulls sheaths for both SyvekPatch and straight manual pressure if indicated. We do not use clamps for pressure. All of our inpatients (excluding ICU patients) and outpatients go to our holding and recovery area for at least 2 hours to be recovered and have their groin monitored. From there, patients either go home or back to the medical or surgical floor. Does your lab have a hematoma management policy? We do have guidelines to follow. For example, if there is a hematoma, we monitor its growth, size, and mark and record it. We notify the doctor and record it as a minor complication, which ties into our monthly complication rates. We also assess the reason as to why the hematoma may have occurred (i.e., high blood pressure, movement, coughing, etc.) and try to correct the cause so it does not happen again. How is inventory managed at your cath lab? Our head nurse manages inventory. She handles all product purchasing. All of our angioplasty supplies are on consignment and are counted after every angioplasty so the items can be replaced. How do you handle vendor visits to your lab? All of our vendors go through our material management director upon arrival, where she issues a vendor ID badge. Some vendors travel every Thursday to touch base, (they also sell products to other parts of the hospital). Other vendors (diagnostic and angioplasty supply vendors) visit at least every two months, if not once per month. Most vendors are traveling from Puerto Rico. They are welcome in the lab. If cases are in progress during their visit, then they remain in our control room, without radiation badges issued. Has your cath lab recently expanded in size and patient volume? Yes, our cath lab has expanded in patient volume ever since our interventional cardiologist joined our staff and intervention program. We are also planning to build a new, state-of-the-art cardiovascular center attached to the hospital which will have two cath lab suites, an OR suite, telemetry holding and recovery, and a helicopter pad on the roof. We predict that the project will be completed in about three years and we will hire additional RNs, LPNs, CVTs, and RTs at that time. Is your lab involved in clinical research? No, not currently, but we would like to be in the future. Does your lab perform elective cardiac interventions? Yes, we started performing elective PCI in March 2002 without on-site surgical backup. We have a memorandum of understanding (MOU) established with a hospital in San Juan and an emergency air transport team. As a secluded island in the middle of the Caribbean Sea, we have had to provide this service to the patients in the territory that either could not afford to travel off-island or were dying in the process of trying to get somewhere for intervention. Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? No, we have not had any. What measures has your cath lab implemented in order to cut or contain costs? Our biggest cost-saving strategy has been consignment for our angioplasty supplies. We search a variety of vendors for competitive pricing. We also look for ways to decrease overtime and still maintain quality care. What type of quality control/quality assurance measures are practiced in your cath lab? We monitor flouro time, complications, patient satisfaction surveys and statistics on a monthly basis. We develop a performance improvement design for any new product or program brought into the lab under the claim that it will decrease mortality, decrease off-island travel and contain cost, in order to see if the program/product is worth it. This was the design we originally used to establish a diagnostic cath lab and an angioplasty program. JCAHO loved the plan as it related to the establishment of the diagnostic cath lab. We follow the model PDMAI: (P) Plan, (D) Design, (M) Measure, (A) Assess, (I) Improve. We develop a plan (usually as a result to a problem), have a design, and measure and assess it to see if it will provide improvement. We monitor patient statistics in order to develop a need for future programs (for example, how many patients are still traveling off the island for bypass and is it enough to implement a bypass program on the island). How does your cath lab compete for patients? We are fortunate that we do not have to compete for patients at this time. We are the only hospital on the island of St. Croix, and the population is approximately 55,000. Within the territory, the population is approximately 100,000 plus. We are setting up to receive more patients from other Caribbean islands. Since our primary language is English, the patients are starting to come to St. Croix instead of Puerto Rico, which up until June 2000 was the closet place to go for cardiac care. How are new employees oriented and trained at your facility? All new employees go through a 6-to-8-week orientation period. Since we have all registered nurses in the cath lab, they are each required to have an individual Virgin Islands nursing license. Both the head nurse and the director of the cardiovascular lab train the PA. He is credentialed under the medical director. What type of continuing education opportunities are provided to staff members? All staff members are allowed to attend one off-island conference per year. We do have in-house CEs given through the nursing inservice department, and some topics are lectured on by the cardiologist. During our angioplasty education training and planning of the program, all staff traveled to Mount Sinai in Miami Beach for three months to receive angioplasty training with our interventional cardiologist. The interventional cardiologist and the hospital administration of St. Croix arranged the off-island training. We did not have anyone covering the cath lab at the time, but we also were not performing emergent PCI. We went three different times for one week intervals to Miami Beach. We also attended the TCT 2001 (Washington, D.C.) and the ACC 2002 (Atlanta). Funding through grants and the hospital covered expenses. Our education was obtained primarily through mentoring with our interventional cardiologist, Dr. Kendall Griffith, and lecturing. We gained a lot of knowledge from the cardiac cath lab staff (RCISs, RNs, and attendings) at Mt. Sinai Hospital. In addition, we have all relied on our own reading of Morton Kern’s books and utilization of Wes Todd’s RCIS review CDs and books. How is staff competency evaluated? The head nurse evaluates the RNs yearly through a performance evaluation. The head nurse and the PA are also evaluated yearly by the director of the cardiovascular lab. Does your lab utilize any alternative therapies? No. How does your lab handle call time for staff members? We work 5 days a week, eight hours a day, and we’re on call the rest of the time. Two RNs and the PA are on call at all times. The RNs rotate with two weeks on and one week off. If the PA is off-island, then another cardiologist will scrub in with the attending. If we have to work over 8 hours, we get paid overtime. We do not have flextime or multiple shifts. It is not needed at this time. With our current use of VasoSeal, we have decreased our overtime by 3-4 hours per week. What trends do you see emerging in the practice of invasive cardiology? I see more primary PCI being done without onsite surgical backup and eventually surgical backup eliminated altogether for both primary and elective procedures, especially in rural areas (speaking from experience). Has your lab undergone a JCAHO inspection in the past three years? Yes, our lab underwent a JCAHO inspection after being operational for one year. Our department was the center of attention for the entire survey team, because it was new. We spent several days with the surveyors, answering questions and presenting on the development of the lab and the need to have this service at the hospital. Can you describe the layout of your cath lab? Our cath lab is approximately 460 square feet, including the control room. Obviously, this is a very small, tight-fitting lab. It was designed to fit a pre-existing radiology suite. We recover and hold our patients in another part of the hospital. We do not like the fact that we are growing and the lab still stays the same size. More importantly, we do not like having our patients both wait and recover on another floor, all the way across the hospital. That’s one reason we have plans to build a new center where everything is contained within the same building and we will have a lot more space. Please share what you consider unique or innovative about your cath lab and its staff. I feel we are a very special lab, being so far away from the U.S. mainland, and yet we are able to provide the same quality care to our patients as in the States. We have a lot of challenges, from hurricanes to shipping and receiving supplies. We do not have everything at our beck and call. We have to rely on a lot of off-island team support, from vendors to other physicians and healthcare providers. Our cath lab team is very unique in the fact that we have learned everything from other facilities and physicians to create our own team and cardiovascular lab. None of the staff members, including myself, had any experience in a cath lab, and through dedication and a genuine joy in working in the field of healthcare, we have created something special for our patients. Is there a problem or challenge your lab has faced? Our biggest challenge was creating an angioplasty program and presenting the need to the Hospital Board and Government. Our next challenge was to involve everyone in the community to come together in a collaborative effort to make it happen. It was difficult but successful, and most importantly, today we are saving lives. What’s special about your general regional area in comparison to the rest of the U.S.? Our lab is very special because it is located on a beautiful, tropical U.S. Virgin Island in the middle on the Caribbean Sea. We are JCAHO-accredited and we receive numerous tourist and cruise ships every year. We have created a program that is growing more and more every day to provide Western medical care to cardiac patients who previously would not have received it. In addition, the whole island community has reaped the rewards of having the cath lab, by being able to stay home for treatment and surviving an AMI. The island community tends to be a mixture of different ethnicities and cultures. We have a large percentage of retired (snowbird) population in the November through April months. The island people are strong believers in big families, with average 2 to 5 children per family. The following questions were supplied by the Society of Invasive Cardiovascular Professionals (SICP): Do you require your clinical staff members to take the registry exam for RCIS? If yes, do they receive an incentive bonus or raise upon passing the exam? No, we do not require the exam at this time. However, everyone is currently studying on their own for the RCIS exam. We will not get compensated on passing but we will have the knowledge. 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? Yes, our head nurse is involved with the SICP, and the director is involved in the SCA&I.