Cath Lab Spotlight

Holston Valley Medical Center: Kingsport, Tennessee

Rebecca D. Holt, RN, Director of Invasive Cardiovascular Services, with contributions from Adam Light, RT(R), RCIS; Elizabeth Potter, RCIS; Leslie Bishop, RT(R), RCIS; Kingsport, Tennessee
Rebecca D. Holt, RN, Director of Invasive Cardiovascular Services, with contributions from Adam Light, RT(R), RCIS; Elizabeth Potter, RCIS; Leslie Bishop, RT(R), RCIS; Kingsport, Tennessee
What is the size of your cath lab facility and number of staff members? Holston Valley Medical Center (HVMC), a member of the Wellmont Health System, is a 544-bed facility located in Kingsport, Tennessee. In 2005, and again in 2007, Holston Valley was named one of the nation’s top 100 hospitals for cardiac care by an independent, nationally recognized healthcare information company. Holston Valley is just one of four Tennessee hospitals recognized in Thomson’s 2007 100 Top Hospitals: Cardiovascular Benchmarks for Success. Holston Valley also houses one of only six Level I trauma centers in Tennessee, and is equipped to care for the most critically ill and injured patients. HVMC has entered into a partnership with Cardiovascular Associates (CVA). Through this partnership, Holston Valley Heart Institute was formed. Consisting of approximately 30 physicians, the CVA group is able to provide non-invasive, invasive and surgical services to the in-patient units and cath/electrophysiology (EP) lab. There are sixty (60) inpatient beds and 13 outpatient beds within HVHI. HVHI has approximately 260 employees, 43 of whom are employed in the cardiac cath/EP lab. Our lab staff is comprised of: • 21 registered nurses (RNs); • 7 registered cardiovascular invasive specialists (RCISs); • 4 registered radiologic technologists (RT[R]s); • 3 cardiovascular technologists (CVTs); • 2 patient care technicians (PCTs); • 2 unit secretaries (USs); • 2 transcriptionists; • 1 patient liaison, and; • 1 supply manager. The cath/EP lab consists of a 13-bed cardiovascular admission recovery and evaluation (CARE) unit, 1 EP lab, 1 coronary lab, 2 coronary/peripheral labs, a large reading room, and administrative offices. The CARE unit is staffed with 10 RNs, 2 PCTs, 2 USs, and a patient liaison. We staff the unit with flexed 8- and 12-hour shifts. The administrative offices are staffed with database, transcription, and a care coordinator. We have 4 RNs, 1 RT(R) RCIS and 1 secretary to support the database. Three of the 6 employees work part-time, and all 6 employees have cath/EP lab experience. These 6 employees flex their schedule to meet American College of Cardiology (ACC) and Society of Thoracic Surgeons (STS) database deadlines. Transcription is supported by two full-time employees working 8-hour shifts. They are able to complete dictated reports within 30 minutes. The reports are added to the electronic medical record and are readily available to the physician’s office. The cath lab coordinator directs patient flow throughout the day and is responsible for staff scheduling. The supply manager stocks, orders and manages all equipment and supplies for the cath/EP lab. The EP lab is staffed with two RNs, one RT(R) and two CVTs; they work flexed 8- and 10-hour shifts to provide coverage. The staff is dedicated to the EP room and does not participate in the on-call schedule. However, these five staff members are committed to and responsible for completing scheduled EP cases each day. The coronary/peripheral labs are staffed with six RNs, eight RCISs, and two RT(R)s. The staff works flexed 8- and 10-hour shifts and participates in a call rotation to provide 24-hour/7-day-a-week ST-elevation myocardial infarction (STEMI) call coverage. What type of procedures are performed at your facility? The coronary/peripheral labs perform diagnostic and interventional coronary and peripheral procedures, including carotid stenting. Electrophysiological studies, ablations, and device implants are done in the EP lab. Tilt test, cardioversion and transesophageal echocardiograms (TEE) are performed in the CARE unit. Our lab performs approximately 50 coronary procedures, 10 peripheral procedures, 15 EP/ablation procedures, and 12 device implants per week. Does your cath lab perform primary angioplasty with surgical backup on-site? Yes, our CVOR team is in-house and the surgical suite can be ready within one hour. In addition, the CVOR team is on call 24 hours, 7 days a week. What procedures do you perform on an outpatient basis? We perform diagnostic coronary and peripheral procedures on an outpatient basis. If a coronary intervention is performed, the patient is required to stay overnight. Peripheral interventions are treated on a case-by-case basis, and the physician decides what type of stay will be required. What percentage of your patients is female? Approximately 30% of our patients are female. What percentage of your diagnostic cath patients go on to have an interventional procedure and what percentage of your diagnostic caths are normal? Currently, 75% of all diagnostic cath patients receive an intervention of some degree. Although this number is higher than the national average, the Cardiovascular Associates office has a diagnostic lab on-site. This office lab completes a majority of our diagnostic procedures. When these patients require an intervention, they are sent to our lab to complete the procedure. Approximately 10% of our cardiac caths are normal. Who manages your cath lab? Rebecca Holt, RN, is the director of invasive cardiovascular services. She is responsible for the coverage of HVHI Invasive Services around the clock and coordinates the department’s direction to achieve its goals in accordance with the division of patient care services philosophy. Rebecca is responsible for developing patient care service goals, standards of performance, policies and procedures, and departmental organization in accordance with Holston Valley and Wellmont Health System’s mission, vision and values. In addition, she ensures the invasive cardiovascular services lab meets the legal, organizational and medical staff guidelines. Rebecca directs, supervises and ensures compliance with the Standards of Nursing Practice and the Cardiac Catheterization/EP Lab Policy and Procedures which promote optimum health care delivery. Do you have cross-training? Who scrubs, who circulates and who monitors? In our facility, all personnel are expected to be able to scrub, monitor and circulate all cases. The only exception is that an RN must be present to circulate and give meds. We have a dedicated EP staff and a dedicated cath lab staff, but at any given time each can help the other. We also have a local community college with a registered cardiovascular invasive specialist program. Therefore, we regularly have students graduating from the college who are ready to enter the workforce. We have also implemented an RCIS extern position where one student is selected and is given a position at the hospital, allowing the student extra career training. Does an RT have to be present in the room for all fluoroscopic procedures in your cath lab? All of our cardiologists are fluoroscopic-certified. The physician is responsible for the radiologic equipment and fluoro exposure during the procedure. Radiologic technologists are readily available for troubleshooting and professional questions. 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? We have four radiologic technologists in our lab. In Tennessee, however, if a cardiologist is a fluoroscopic- certified physician and is present in the lab, an RN or RCIS tech may pan the table, position the II, change angles and step on the fluoro pedal. If your lab performs peripheral interventions, what disciplines are involved? Peripheral and carotid interventions are performed on a daily basis; however, only cardiologists perform procedures in our lab. Surgeons, radiologists and other physicians are consulted for opinions on a regular basis. What are some of the new equipment, devices and products introduced at your lab lately? We have the Silverhawk (ev3, Plymouth, MN), excimer laser (Spectranetics Corp., Colorado Springs, CO), cryoplasty (Boston Scientific, Natick, MA), Proxis embolic protection system (St. Jude Medical, Minnetonka, MN), Angiosculpt scoring balloon catheter (AngioScore, Inc., Fremont, CA) and intravascular ultrasound (IVUS) (Volcano, Rancho Cordova, CA) technologies available in our department. We participate in multiple drug, device and technology studies. We were the first in the United States to use the ev3 Spider Distal Protection device during a carotid intervention. We just completed the Acute Myocardial Infarction with Hyperoxemic Therapy (AMIHOT) trial. We are currently participating in 21 research studies, involving coronary, EP, peripheral, carotid and renal procedures. Can you describe the system(s) you utilize and how they work in cath lab daily life? Emageon HeartSuite (Birmingham, AL) is used for our hemodynamic and procedural monitoring. We have Philips radiography equipment from the Integris to the FD-20 series (Bothell, WA). We also use Philips Xcelera archival system. The cath lab utilizes the Pyxis system (Cardinal Health, Dublin, OH) for medical and supply management. How is coding and coding education handled in your lab? Staff members have received education related to appropriate patient charging. The procedure room staff completes the charge sheet. The charges are compared to the physician’s dictation to ensure accuracy. The chargemaster has coding hardwired to related procedure charges. The patient’s account is reviewed post procedure to ensure the right charges are applied to the correct account. How does your lab handle hemostasis? Our lab uses Angio-Seal (St. Jude Medical), Starclose (Abbott Vascular, Redwood City, CA), Perclose (Abbott) and conventional manual pressure utilizing D-Stat (Vascular Solutions, Minneapolis, MN) hemostasis patch. After one year of employment and completion of a closure device class, staffs are allowed to train to deploy closure devices. If manual pressure is used to achieve hemostasis, the patient is transferred to the CARE unit. The continued hemostasis is monitored and patient is moved to an inpatient room or discharged home. What is your lab’s hematoma management policy? If a hematoma develops, manual pressure is applied until hemostasis is achieved. The access site is monitored until the patient is transferred to an inpatient unit where continuous monitoring occurs. The database staff documents all access site complications. The complications are reported in the American College of Cardiology (ACC) percutaneous coronary intervention (PCI) Registry, providing benchmark data with other labs across the country. How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies? The Pyxis system is used to manage inventory and order daily supplies. New equipment and technology is discussed with the physicians regarding clinical-related needs. The director of invasive cardiovascular services, executive director of cardiology, cardiac cath lab medical director and medical director of HVHI, electrophysiology lab medical director and the director of supply chain discuss needs related to budget and growth. Has your cath lab recently expanded in size and patient volume? Within the past 18 months, we added a combo suite (cath/periph) and built a new 13-bed CARE area. The CARE unit allows for the acceptance of cardiac transfer patients, who were previously housed in the emergency department (ED). The arrival of direct admissions keeps the ED focused on emergency care and provides a central location for all cardiac transfer patients to be evaluated. In addition, a Philips FD-20 with a 19-inch II and the Xcelera System were installed in January 2007. We also have upgraded our primary coronary room to the Philips FD-10 system with integrated IVUS (Volcano). Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? In 2008, we performed 2,450 procedures, and only two patients required emergency surgery related to procedure complications. Can you share your lab’s average door-to-balloon (DTB) times and some of the ways employees at your facility have worked together to keep DTB times under the mandated 90 minutes? Our improvement in door-to-balloon performance is one of Wellmont Health System’s greatest success stories over the past year, and it came about through a concerted, determined team effort. In July 2006, we began a D2B Performance Improvement Project to improve our D2B times. Our median average for D2B times over 2005 was 111 minutes. The team included ED physicians, cardiologists, ED staff, cath lab staff, administration, database managers, quality and local EMS. Collaboratively, we made the following process improvements: 1) The ED physician calls the STEMI code (the most significant step). 2) ED transports patient to cath lab. 3) A pre-procedure check list was developed. 4) Revised physician orders streamline the ED/cath lab admission process. 5) A feedback tool is sent via email to all ED physicians, cardiologists, and team members who participated in the patient’s care. 6) An interactive root cause analysis is performed by the ED and cath lab with input from all staff. 7) Outliers are identified, and new intervention strategies are discussed and implemented on a continuing basis. 8) A feedback tool is posted in a visible area that shows how each case went and which team members were involved. We are very proud that our D2B time for Quarter 3 and Quarter 4 2008 were 65 minutes and 66 minutes, respectively. Eighty-two percent of our patients received D2B times of ≤90 minutes in Quarter 4 2008. What other modalities do you use to verify stenosis? We currently use intracoronary ultrasound to verify stenosis. What measures has your cath lab implemented in order to cut or contain costs? The Pyxis system helps to maintain inventory, making sure products and medications are charged correctly to the patient’s account. Recently we eliminated 500cc bottles of contrast due to product waste. We continuously renegotiate vendor contracts in an attempt to consign products on our shelves. HVMC underwent an evaluation with ZHealth Publishing (Brentwood, TN) with training on appropriate procedural charges. What type of quality control/quality assurance measures are practiced in your cath lab? We have several different employees who are responsible for QA and QC. Weekly and bi-annually, Avoximeter controls are performed. Hemochron controls are completed every 8 hours. The cinical engineering department maintains all radiologic equipment assurance requirements. Monthly controls are performed on the Datascope intra-aortic balloon pumps (IABPs) (Fairfield, NJ); annual maintenance is performed by the company. Daily room checks are required to assure all equipment is working correctly and is readily available. How does your cath lab compete for patients? Has your institution formed an alliance with others in the area? Our facility has a 23-county referral area and accepts transfers daily. We participate in Press-Ganey surveys, and review feedback and adjust processes to meet patient needs. We focus on quality care, reviewing outcomes and changing practices to ensure our patients get the best care. As a result, we were selected as one of the nation’s top 100 heart hospitals for two out of three years. How are new employees oriented and trained at your facility? New staff members are assigned a preceptor until all orientation objectives are met. We have 4 staff members with less than a year’s experience. All of our nurses are required to have critical care experience and we have recent Northeast State Technical Community College’s RCIS program graduates. The staff must have one of the following: RN, RT(R) or RCIS. What type of continuing education opportunities are provided to staff members? We have “lunch and learn” opportunities offered by various vendors. In addition, we have a Cardiac Foundation which supports educational grants for off-campus seminars. How do you handle vendor visits to your lab? Vendors are allowed into the lab by appointment only, and we schedule only two vendors daily. They are required to attend a supply chain-sponsored training class to ensure they follow hospital and cath lab policies. How is staff competency evaluated? All employees are responsible for keeping their required certifications. Staff participates in four peer reviews annually. The director then reviews results and provides additional input with each lab member. Does your lab have a clinical ladder? The RN staff has a hospital-wide clinical ladder called CAP (Clinical Achievement Program). A recently developed ladder for RCIS staff has been presented to Human Resources for final approval. These ladders include community service, participation in process improvement and continuing education. Does your lab utilize any alternative therapies (such as guided imagery)? The rooms are equipped with stereo systems. A variety of music genres are available for the patient’s selection. How does your lab handle call time for staff members? Each call team must consist of three members. There must be one RN and one RCIS/RT(R). The call schedule is equally divided between all members of the cath lab staff. We currently have a late team which is responsible for staying with the call team until the lab is down to its last case of the day. Within what time period are call team members expected to arrive to the lab after being paged? Call team members and the cardiologist must arrive within 30 minutes. Do you have flex time or multiple shifts? Currently, our employees work eight- and ten-hour shifts. The cath/EP lab staff work multiple shifts, and are responsible for call and late day coverage. Does your cath lab do electives on weekends and or holidays? We do not routinely perform elective cases on the weekend or holidays. Has your lab has undergone a Joint Commission inspection in the past three years? HVMC underwent a Joint Commission inspection in 2006. We try to keep our cath lab ready for inspection at all times, using tracer methodology with monthly tracers by hospital employees. Where is your cath lab located in relation to the operating room (OR) and emergency room (ER)? The cath lab is located directly above our emergency room. Our location provides for fast transport, leading to quicker reperfusion times. Our cardiac/thoracic OR is located adjacent to our department, again allowing for fast transport in the case of an emergency. How do you see your cardiac catheterization laboratory changing over the next decade? Our vision for the future is a continued strong relationship between Cardiovascular Associates and Holston Valley Medical Center. Our focus will remain on providing quality-driven, innovative care to the residents of the 23 counties surrounding Kingsport. We will continue to foster professional growth by providing educational opportunities for all staff members. We plan to continue with staff retreats and an active Clinical Practice Committee to further develop cohesive staff relationships. What do you consider unique or innovative about your cath lab and staff? We have implemented several projects to help improve our working environment which has enhanced our performance. Each staff member is responsible to help with staff education by presenting PowerPoint presentations related to our identified needs. We have also been given the opportunity to streamline the patient charging/ billing process. Is there a problem or challenge your lab has faced? How was it addressed? The position of director of invasive cardiovascular services remained vacant for several months, leading to unresolved situations. Rebecca Holt, RN, has taken the director position and we are resolving educational, supply chain, staffing and charging/ billing issues. 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”? Kingsport is surrounded by beautiful mountains and the Holston River. There are abundant outdoor activities, including, fishing, hunting, hiking and skiing. Kingsport also has a rich historical background that draws heavily from its history as a former port for riverboat commerce through the mid-1800s, and then, in 1917, from its rebirth as a hub for industry and commerce. Within the city are several historical sites of interest — the 200-mile Daniel Boone Wilderness Trail starts in Kingsport, an ode to the fact that Boone and his men frequented what was then the boatyard district in the city, prior to blazing a wilderness trail that pioneer settlers would follow from Kingsport to the Cumberland Gap. Also of note is the historic Netherland Inn, a well-preserved landmark where visitors can see a former lodging place that provided accommodations for three U.S. presidents. Kingsport is a great place to raise a family, enjoy the outdoors or to bring the kids for an educational trip. The most-visited state park in Tennessee, Warriors Path State Park, is located near the city. The city is also home to Bays Mountain Park, a 3,500-acre nature preserve that is the nation’s largest municipally-owned park. It features 22 miles of hiking and biking trails, a planetarium and native wildlife habitats. Our cath lab has a very relaxed and family atmosphere. We all love what we do and are committed to providing patients throughout the tri-state region we serve — which includes residents in northeast Tennessee, southwest Virginia and southeast Kentucky —with the best possible cardiac care. 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)? Does staff receive an incentive bonus or raise upon passing the exam? The RCIS credential is not required, but is highly recommended. We do provide an hourly differential related to additional licensure, such as CCRN. 2. 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? We currently do not participate with the SICP or ACVP. The authors can be contacted at