Cath Lab Spotlight

Kaiser San Rafael Medical Center

Peter Alt, RN, San Rafael, California
Peter Alt, RN, San Rafael, California

What is the size of your cath lab facility and number of staff members?
Our facility has 1 dual-use lab. It functions both as a cardiac cath lab and an interventional radiology (IR) lab. Currently, our staff consists of:
• 8 part time registered nurses (RNs)
• 3 radiology technologists (RTs)
• 1 nurse practitioner (NP)
• 4 diagnostic cardiologists on a rotating basis (in-house)
• 7 interventional cardiologists on a rotating basis (from San Francisco Kaiser)
• 1 full-time interventional radiologist (in-house)
• 1 vascular surgeon who also does frequent IR procedures (in-house)

Our pre-op/recovery area has two beds and is staffed by the same staff.
Our lab opened in October 2005. The staff had critical care and/or emergency department backgrounds. All staff was required to complete extensive training in San Francisco Kaiser’s high-volume cath lab.

What procedures are performed at your facility?

A wide array of procedures are performed at our facility, both cardiac and IR, including:
• Bilateral cardiac catheterizations
• Primary angioplasty and stenting on an emergent basis
• Intra-aortic balloon pump insertions
• Temporary pacer wire insertion
• Pericardiocentesis
• Peripheral artery angiograms and stenting
• Peripheral and coronary atherectomy
• Peripherally inserted central catheter (PICC) line insertion by MDs and RNs
• Hepatic, lung and renal biopsies
• Ablation of hepatic and gastrointestinal bleeds
• Dobutamine stress tests
• Insertion of varicocele coils
• Drain placement
• Tunnel catheter placement
• Fistulagrams and declots
• Renal stenting
• Vein closure
• Carotid and cerebral angiography
• Transjugular intrahepatic portosystemic shunts (TIPS)
• Uterine fibroid embolization (UFE)
• Chemo radio frequency ablation (RFA)
• Kyphoplasty
• Elective cardioversions
• Transesophageal echocardiograms (TEE)

We average 25-30 IR procedures and 6-10 diagnostic cardiac caths per week, along with 4-6 non-invasive cardiac studies per week.

Since you are a single-lab facility, can you describe how interventional radiologists and cardiologists perform procedures in the same area?
The cardiologists and interventional radiologists all share the same space and staff. IR days are Monday, Tuesday and Thursdays. Cardiac days are Wednesday and Fridays, though in practice, IR days can be a mix of both. We have become adept at switching between cardiac and IR procedures.

Does your cath lab perform primary angioplasty with surgical backup on site?
Since March of 2006, we have provided primary emergent angioplasties for acute ST-elevation myocardial infarction (STEMI) patients without cardiovascular surgical backup. If, during the diagnostic phase of an emergent cath for STEMI, it is ascertained that the case is unsuitable for angioplasty/stenting, the patient is stabilized and transported to Kaiser Permanente’s main cardiac surgery facility in San Francisco — Geary St campus. We can transport with a balloon pump if needed. This routine is facilitated by our Heart Alert algorithm, which places a critical care-equipped ambulance at our facility during the alert. Our cardiologist will accompany the Critical Care Transport (CCT) team to the city and if the patient has a balloon pump or is unstable, with one of the cardiac cath team RNs.

What procedures do you perform on an outpatient basis?
All of our procedures are performed on an outpatient basis, but some are admitted if they will require an extended recovery period.

What percentage of your patients is female?
Using available data, 44 percent.

What percentage of your diagnostic cath patients go on to have an interventional procedure?
Our data shows the following patient treatment breakdown.
• True cardiac emergent cases – 10%
• Cardiac cases that go on to elective stenting – 17%
• Cardiac cases requiring valve repair – 11%
• Other modalities (med Rx, pericardiocentesis, etc) and normals – 63%

Who manages your cath lab?
The cath lab management team consists of our Assistant Medical Group Administrator and Director of Outpatient Nursing, Vincent Reed, RN, the Lab Manager, Vicki Miller, RN, an Assistant Manager, Virginia Vivian, a Charge Nurse, Inger Alt, RN, a Senior Staff Specialist, Trevor Cost and a Perioperative Specialist, Colleen Cerda.

Do you have cross-training? Who scrubs, who circulates and who monitors?
We have designated staff for the cardiac cath lab and IR. Everyone in the cath lab is cross-trained within their license. RNs are trained to circulate and monitor all cases, and scrub training will begin shortly. RTs are trained to scrub, monitor, and circulate cases (excluding giving medications and pulling of arterial/venous sheaths). At least 1 RN is assigned to circulate any case.

Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab?
Some minor cases may be performed with only a physician (who is fluoro-certified) and an RN. These cases usually only require a single fluoro shot or minimal runs, but a certified RT is always in the area if needed to assist the MD in managing the fluoro table.

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?
Only a physician with a fluoro license and certified RTs are permitted by California law to perform these functions.

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

We use an Allura Philips PT 20 large format image C-arm (Bothell, WA), and McKesson’s Horizon Cardiology Hemodynamic and Cath charting software (San Francisco, CA). All our monitors are high-resolution flat panels.
In the next two months, the radiology department will acquire a 64-slice CT scanner, which will enable less invasive rule-outs.

Can you describe your STEMI program?
Kaiser Permanente envisioned a system in which our department would expedite emergent angioplasty and stenting to the county residents and Kaiser Members of the North Bay Area. We received overwhelming support from our local emergency medical (EMS) agencies and other departments within our Kaiser facility that have assisted us in meeting the majority of our door-to-balloon times (DTBT) under 90 minutes. Due to the success of our lab, other small dual-use labs are being built and designed to model our suite at other Kaiser facilities around the Bay Area.
Our emergent heart alert program (designed to reduce our DTBT) has been effective due to the collaboration of local EMS agencies. All local EMS paramedics are trained by local EMS medical directors with our attending cardiologists to rapidly recognize STEMIs in the field. The EMS paramedics are authorized to initiate the Emergent Heart Alert through the emergency department (ED) without a cardiologist’s verification. The cath team on standby is paged and many times has met the ambulance rig and the patient at the ED door, ready to take the patient directly into the cath lab. All ambulance rigs in Marin County have 12-lead EKG capabilities. The County of Marin EMS, representatives from local EMS departments and both receiving hospitals meets bi-annually to review the quality of transport and EKG interpretation of emergent STEMI patients transported to our labs.
Our Emergent Heart Alert algorithm can actually be initiated by a paramedic in the field — in fact, fully 30% of our STEMI patients are called in the field. This has greatly reduced our DTBT. It can also mean the patient can be expeditiously triaged in the ED and go straight to the cath lab.
Every Emergent Heart Alert post procedure is debriefed with the physicians and staff immediately to discuss what we can do better and what we did well. We have formulated tools that have shaved minutes off from our already excellent times.
The ED has a run review every other month with ED RNs, ED physicians, paramedics and EMTs to discuss recent ED cases. We have designated RNs who are available to attend those meetings to present current DTBTs and receive feedback about recent Emergent Heart Alert cases. Also, our medical director, Dr. John Kennedy, is committed to facilitating educational inservices during run reviews.

How is coding and coding education handled in your lab? How is coding communication handled with the billing deptartment?
As a Kaiser member, the patient pays only co-pay, based on their chosen benefit, when they are admitted for the procedure. The staff enters the CPT codes into our computer system, for tracking purposes and Medicare reimbursement. Our Kaiser patients don’t have any other charges outside of their co-pay. A non-member’s insurance will be billed for any procedures done.

How does your lab handle hemostasis?
Most groin sheath removal is done with manual holds. Some cardiologists will use the Angio-Seal device (St. Jude Medical, Minnetonka, MN) to close. Our vascular surgeon will use the Starclose device (Abbott Vascular, Redwood City, CA) to close. The interventional radiologists prefer a manual hold in the recovery area. Only RNs are designated by the Department of Health in California to be able to pull the sheath. RNs and RTs can hold. The lab staff is responsible for obtaining hemostasis prior to transfer to PACU (Post Anesthesia Care Unit) or the telemetry floor.
Our nurse practitioner, Lance Benedict, NP, follows up with each cardiac patient once they arrive to the telemetry floor. He provides education prior to admission and follows up after discharge with a phone call and follow-up clinic appointment. He is also a great resource for the staff.
Our lab staff follows up with all IR patients to review access site/s status within 72 hours to follow up on patient well-being and ensure that all instructions were understood.

Does your lab have a hematoma management policy?
Yes. Our facility has developed a standard of care for arterial and venous sheath and groin management. When pulling any sheath, our standard of care is to have the FemoStop device (Radi Medical Systems, Wilmington, MA) available, though it is infrequently needed.

How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies?
The Pyxis system (Cardinal Health, San Diego, CA) is used for all medications and par levels are maintained by our pharmacy. We have a perioperative specialist, Colleen Cerda, who orders and maintains stock levels for most other consumables, including stent stock. We have dedicated materials management personnel who stock all general supplies. All inventory par levels for wires, balloons and catheters are tracked by the Spacetrax inventory management system (InnerSpace Corporation, Grand Rapids, MI). Spacetrax creates a detailed case report inclusive of CPT coding, procedure time, staff list and all equipment and devices utilized.
However, general inventory is the responsibility of everyone in the lab. Product rotation and expiration control is performed by all staff members and cross-checked by the Spacetrax system, which is controlled and maintained by the department’s perioperative specialist. Capital cost items are purchased through our yearly capital equipment budget.

Has your cath lab recently expanded in size and patient volume, or will it be in the near future?

Our STEMI cardiac patients come from Marin County. Currently, the policies and procedures in place for the paramedics in surrounding counties limit them from crossing county lines for an emergent STEMI.
Our department’s IR caseloads have doubled in the past 6 months, due to the diverse range of procedures done by our new interventional radiologist, Naveen Kumar, MD and vascular surgeon, Jeffry D. Cardneau, MD, FACS.
As a result of the increase in referrals, we have instituted a new 10-hour shift, to assure that our patients and their families are cared during an expanded schedule. The longer work shift has provided time for the RNs in the department to call past and future patients, and for the team, the capability of meeting our 30-minutes arrival time for emergency STEMI procedures during peak traffic periods.

Is your lab involved in clinical research?
Not at this time, although we are doing an informal study with guided imagery.

Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery?
Fortunately, no atypical complications requiring emergent surgery presented in the past year. All of our procedures are reviewed in during our quarterly cardiac cath lab morbidity and mortality (M&M) meetings and by our facility’s quality department.

What other modalities do you use to verify stenosis?
At this time we utilize imaging only for lesion assessment. We will be using intravascular ultrasound starting in January 2009.

What measures has your cath lab implemented in order to cut or contain costs?
We work closely with the physicians from both departments to share equipment used in the IR and cardiac caths. This is mainly for space containment, not necessarily cost containment. We are committed to providing state-of-the-art equipment for our operating physicians and our members.
Running an interventional radiology department promotes overtime. Knowing that add-on procedures are the norm, which will result in extended days, this promoted our 10-hour shifts followed by the “Standby Team” if procedures are running late.

What type of quality control/quality assurance (QC/QA) measures are practiced in your cath lab?
Our most important measure of QC/QA is reporting to the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR).
Our cardiologists host an open community forum with the EMS agencies four times a year.
Quarterly, our lab participates in a M&M forum, where selected cases are presented for informational and educational purposes. This forum is open to anyone in the hospital, including the EMS agencies, to attend.
We also have cath-ops meetings and IR-ops meetings, each held every other month. During these meetings we discuss how the workflow can be improved. It is a multidisciplinary effort, involving management, staff from our department, plus telemetry staff, guest speakers and physicians.
Our DTBT has been segmented into tasks, with each taking an allotted time frame. This enables us to zero in on bottlenecks and facilitate teaching to improve our already excellent times.
Each chart is subjected to independent review for completeness and accuracy of documentation. A monthly meeting is scheduled for feedback with each staff member who charts, so charting can be consistent and accurate. Monthly tracers are utilized that monitor 9 safety metrics implemented by Kaiser Permanente system-wide.
We also run weekly QC for our I-Stat machines (Abbott Laboratories, Abbott Park, IL) for arterial blood gas (ABG), activated clotting time (ACT) and creatinine, and our glucometer, all validated by our clinical laboratory personnel.

How does your lab handle radiation protection for the physicians and staff that are in the lab day after day?
All staff are fitted with customized lead aprons. Each staff member was both an apron and collar dosimeter badge which is read and reported monthly to Landauer (Glenwood, IL). Those radiation reports are verified by our facility’s radiation safety committee and radiation safety officer. We report dose-area product (DAP) on all procedures. The procedure room staff is rotated every other case to limit and monitor the amount of fluoro time exposure in the room.

How does your cath lab compete for patients? Has your institution formed an alliance with others in the area?
Our lab does not really compete for patients. We are relatively centrally located in Marin County, where approximately 45% of the population is a Kaiser member. As part of the Kaiser system, other Kaiser facilities can book plan members in their area for procedures at our facility (as well as servicing our own local patient pool) for both cardiology and interventional radiology. As for emergent angioplasties/stenting, we are one of only two Marin County facilities that perform this procedure. The County of Marin, EMT companies and the other county non-Kaiser medical facility are following the County EMS 12-lead protocol, which states that any in-field STEMIs are to be taken to the nearest (or shortest access time due to traffic) hospital regardless of plan coverage. In keeping with best practices, this provides the fastest DTBT for all residents of Marin and southern Sonoma County.

How are new employees oriented and trained at your facility? What licensure is required for all professionals who work in your lab?
Our new employees are placed with a primary preceptor for a period from 4 to 6 months, and then move on to autonomous practice. During this period, they are subjected to the most valuable learning cases to assure competency. After an initial 4 to 6 weeks in our facility, they transfer to the cardiac cath and interventions side of their job description at the Kaiser Permanente San Francisco campus (the main Kaiser Permanente facility for the San Francisco Bay Area). This facility provides a large portion of the training for new staff at all of the satellite labs in the Bay Area, and should be recognized for the valuable contributions they provide to the success of Kaiser Permanente’s Emergent Cardiac Intervention program.
All RNs are required to be both BLS- and ACLS-certified, as well as having at least 1 year experience in a critical care or emergency department specialty area. Our radiologic technologists were all trained on the job at Kaiser Permanente San Francisco, as well as attending selected seminars and lectures, but all had a medical background. All RTs must also have BLS/ACLS certification. Our management team is flexible in scheduling to allow the use of education leave.

What type of continuing education opportunities are provided to staff members?
Continuing education is encouraged in a daily basis. We have a monthly staff meeting at which one of our cardiologists or interventional radiologists will lecture us on a topical subject. Also, our vendors are excellent sources of information.

How do you handle vendor visits?
Vendor visits are usually by appointment, but if they are restocking consignment items (e.g., stents) then they usually come once a week. We may have more than one vendor representative per day, but they cannot be from competing companies. All must wear appropriate hospital-issued identification. Some of our vendors are ex-cath lab personnel and have been invaluable for educational purposes.

How is staff competency evaluated?
Staff competency is evaluated by our manager on an annual basis. Some competencies are required by the hospital, also on an annual basis, and are covered in our yearly safety fair; others, specific to our lab, are done by a ‘super-user’. The charge RN, the medical director or a person from the hospital laboratory can also do proficiency testing.

Does your lab have a clinical ladder?
The RN and RT clinical ladders are a negotiated contact between Kaiser Permanente, United Health Workers and the California Nurses Association. The steps and pay scales are for any RN or RT working in the northern California region, not specifically in the cath lab.

Does your lab utilize any alternative therapies?
We have recently started a guided imagery program for our patients. Our cardiac cath lab director, John Kennedy, MD, with Lance Benedict, Cardiac RNP, have written a guided imagery program, “Healing Your Heart from Inside Out,” which is specifically for cardiac patients. Many studies show that it can be used to reduce anxiety, pain, enhance patient participation, improve quality and patient/family satisfaction, as well as reduce length of stay.
This program is a pilot for Kaiser Permanente. It has required the input and cooperation of staff from the cath lab, the telemetry floor, and ICU. Hopefully, with the data acquired, it may be instituted in other Kaiser Permanente labs.
We believe that we are the only lab in the country using a guided imagery program specifically tailored to cardiac cases.

How does your lab handle call time for staff members? Is there a particular mix of credentials needed for each call team?
Call time is shared equally among the staff. Our call team consists for 4 staff members, where at least 1 is an RT and at least 2 are RNs. Spare shifts are allocated on a seniority basis. We always have 2 RNs circulating and an RT scrubbed in, and the monitor person can be either a RT or RN.

Within what time period are call team members expected to arrive to the lab after being paged?
We are expected to arrive within 30 minutes of being paged, but most of the time we are there within 20 minutes. We are fortunate to have several staff members who live close to the hospital who can open the lab and start the set up soon after the page.

Is an attending cardiologist always on-site? If not, what is their expectation to arrive after being paged?
During office hours the cardiologists are on site. They, too, are expected to be at the facility within 20-30 minutes when paged emergently during after hours.

Do you have flex time or multiple shifts?
The lab hours are 6:30am to 5:00pm. Our standby team is available after 4:30pm for any urgent or emergent cases needing to be completed.

Does your cath lab do electives on weekends and or holidays?
At this time we do not perform electives on weekends and holidays, only emergent cases.

Has your lab has undergone a Joint Commission inspection in the past three years?
Do you have any recommendations or advice for labs which are about to undergo this inspection? Joint Commission visited our facility in November 2007 and recertified Kaiser Permanente San Rafael Medical Center for 3 more years. In preparation for our survey, our facility has provided frequent in-services and patient safety awareness training. All of our safety tasks are audited, and a “timeout” line has been added to our charting system, to be checked for every patient. We make a concerted effort to be ready at all times, and work as if an inspection is imminent all year round.

What trends do you see emerging in the practice of invasive cardiology?
We have most recently seen a reduction in diagnostic cardiac caths, possibly related to the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial. Many members are electing to trial medications and exercise prior to any invasive procedure. Though COURAGE looked at stable angina patients, which is not the population we traditionally service, it is having an impact on patient decision-making. We have also seen a reduction in the number of diagnostic caths with the addition of the 64-slice CT scanner.
Our lab has seen an increase in the range and scope of IR procedures as new techniques develop.

Please tell the readers what you consider unique or innovative about your cath lab and its staff.
Our ability to perform emergent interventional cardiac caths without cardiac surgical backup on site is a somewhat new innovation in treatment, though possibly not unique. Our heart alert system, where paramedics can call in STEMIs from the field, we believe is unique.
Also unique is our dual-use lab and cross-trained staff.
The most unique element in our lab is the mix of our staff and their ‘can do’ attitude to the department. Each one of us, without exception, ‘owns’ the lab and is truly committed to having the very best working environment and commitment to excellence that can be provided. No one in our lab had cardiac cath experience. We started a new and unrecognized lab from literally nothing — not only the physical lab, but the very systems and paperwork that enable it to work — a daunting challenge, to say the least. The electronic charting system instituted in our lab at the beginning was new and untried, not only to us, but the entire Kaiser Permanente system. After trialing and streamlining in our facility, this system is now being instituted in all Kaiser Permanente cath lab facilities system-wide. ‘Change’ is almost an everyday word in our lab, and, by virtue of having a small staff, can be implemented, embraced, encouraged and adapted to with minimal interruption to the daily lab workflow. Even during the writing of this article, a number of revisions were required due to changes that had occurred in our lab. We are all totally committed to the success of our lab, from lab staff to upper management.

Is there a problem or challenge your lab has faced that you’d like to share?
Along with the myriad problems faced by our staff in establishing a new lab from the ground up, the biggest ongoing challenge is the ability to move patients out of our small recovery area to beds within the hospital. Often, due to census and staffing constraints, we are unable to move patients to other areas for recovery. This immediately impacts our workflow due to our limited capacity to hold patients. With collaboration from hospital management, PACU, telemetry, and medical floors, we are usually able to secure beds for recovery at the start of the day, although of course circumstances may change. Our facility’s ‘Commitment to Excellence’ shows in the lengths that other areas will strive to go to in order to accommodate our patients.

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”?
The area that our patient population is drawn from is mainly Marin county, but also from Contra Costa county and Sonoma county. The lab is located centrally in Marin. Marin is one of the most affluent counties in the U.S., and has a high standard of living. Its residents are also generally well informed concerning health issues. The Golden Gate Bridge is 10 miles south of us, and we have a (relatively) easy drive to all the attractions of the Bay Area. North of us are the famous wineries of Napa and Sonoma counties. All in all, a great place to live!

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 the Registered Cardiovascular Invasive Specialist (RCIS)? At this time, there is no requirement to have our staff to take this certification. This year we as a facility will be strongly encouraging our staff to become RCIS certified.

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? Not at this time. We do read Cath Lab Digest!