Lee Memorial Health System

What is the size of your cath lab facility and number of staff members? Lee Memorial Health System has three locations in southwest Florida: HealthPark Medical Center in Fort Myers, Lee Memorial Hospital in Fort Myers, and Cape Coral Hospital in Cape Coral. HealthPark Medical Center has a total of three interventional cath labs equipped with Philips Integris Allura x-ray equipment (Philips Medical Systems, Bothell, WA) and Mennen hemodynamic monitoring systems (Mennen Medical Corporation, Trevose, PA), as well as one electrophysiology (EP) lab, and one pacer/defib implant room. Cape Coral Hospital has a diagnostic lab equipped with a single-plane Poly Diagnost C x-ray tube and a Mennen hemodynamic monitoring system. Our labs provide service to 6 invasive cardiologists, 16 interventional cardiologists, and 3 electrophysiologists. The cath lab staff at HealthPark Medical Center consists of 24 full-time employees, 1 part-time employee and 6 PRNs. The Cape Coral cath lab staff consists of 5 full-time employees. Included in HealthPark’s staff mix is one director who oversees both labs, one supervisor, one educator, one EP coordinator, two unit clerks, 9 registered nurses, 1 registered respiratory therapist, and 15 registered cardiovascular invasive specialists (RCISs). Cape Coral’s staff mix includes 3 RCISs and two registered nurses. Total, we have 5 staff members with over 16 years of experience, 7 staff with over 10 years of experience and 7 members with 5 years of experience in the cath lab. What type of procedures are performed at your facility? Does your lab perform peripheral interventions? Our procedure mix includes: Right and left diagnostic heart caths Coronary angioplasty Coronary stent placement Cutting Balloon (Boston Scientific Corporation, Maple Grove, MN) Valvuloplasty Arm cases (both brachial and radial, percutaneous and cut down) Transseptal procedures Intra-aortic balloon pump insertions Intravascular ultrasound Rotational atherectomy AngioJet® (Possis Medical Inc., Minneapolis, MN) FilterWire EX (Boston Scientific Corporation) Pericardiocentesis Myocardial biopsy Temporary and permanent pacer insertions Peripheral diagnostic and interventional procedures Our EP procedures include diagnostic EP studies, radiofrequency (RF) ablation and cryo-ablations, implantable cardioverter defibrillator (ICD) insertions, automatic ICDs (AICDs), biventricular pacers and AICDs, intra-cardiac echocardiography, and intra-cardiac mapping. We performed 1663 diagnostic procedures, 1059 interventions, and 830 total EP procedures in 2004. Does your cath lab perform primary angioplasty with surgical backup? We do have open heart surgery at Healthpark Medical Center; however, we perform our angioplasties without surgical backup. If we do need surgical backup for open-heart surgery, our ORs are ready to receive patients with a maximum of a half hour notice. What procedures do you perform on an outpatient basis? Our cardiac observation unit cares for all cath and EP outpatients (OP), pre- and post-procedure. Those include diagnostic caths, pulse generator changes, ICD restudy, peripheral intervention, renal studies, and EPS and ablations. The cardiac observation area also performs elective cardioversions and transesophageal echos. What percentage of your patients are female? Female patients are approximately 37% of our total patients. What percentage of your diagnostic cath patients go on to have an interventional procedure? Approximately 32% of our diagnostic patients go on to have interventions. Who manages your cath lab? Lee Memorial Health System has implemented a service line management concept, which provides continuity of care within each service line across the health system. Kathy Shierling, RN, MS, CNAA, BC, is the Executive Director of Lee Cardiac Care. Beth Moss, RN, MA is the Director of Interventional Cardiovascular Services. She is responsible for the budget, capital planning and strategic planning. Joe Papp, RCIS, is the supervisor. He is responsible for the daily operations and staffing of the labs. Do you have cross-training? Who scrubs, who circulates and who monitors? Yes, all staff are completely cross-trained to rotate through each of the three positions independently (scrub, circulate, record). The physicians control the x-ray camera. The controls are located on the side of the table. Every staff member is required to have BLS and ACLS. Our staff is also cross-trained for the cardiac observation unit and the cardiac holding area. Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab? No, a RT does not have to be present in the rooms during procedures. 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? During all our procedures, the physician positions the II, pans the table, moves the x-ray camera to the different views, and steps on the fluoro pedal. The scrub tech is responsible for performing all the hand injections. Does your lab have a clinical ladder? The hospital has a professional nursing advancement program in place to recognize and reward the clinical expertise, contributions and professional career advancement of registered nurses. Three levels of clinical practice have been defined. Level I demonstrates competent practice based on education and experience. Level II demonstrates advanced practice based on education and experience. Level III demonstrates expert practice based on education and experience. Level III candidates must have a BSN or be actively pursuing a BS/BA. Level II candidates are eligible for a monetary award of $2500. Level III candidates are eligible for a monetary award of $5000. Cath lab nurses are able to participate in this program. The cath lab has had two nurses receive the Level II and two nurses receive Level III recognition. The cardiac cath lab is currently looking into a similar advancement program for the cardiovascular technologist. What are some of the new equipment, devices and products introduced at your lab lately? During the last two years, we have started using the AngioJet 3000A rapid thrombectomy device, the paclitaxel-eluting Taxus® stent (Boston Scientific Corporation) and Filterwire EX (Boston Scientific Corp.) and the Cypher® sirolimus-eluting stent (Cordis Corporation, Miami Lakes, FL). We also recently did our first peripheral cryoplasty with the PolarCath system (Cryovascular Systems, Inc., Los Gatos, CA). Can you describe the system(s) you utilize and how they work in cath lab daily life? We went filmless in 2002. HealthPark and Cape Coral Hospital both use Heartlab’s acquisition and archiving system (Westerly, RI), which interfaces with our Philips x-ray equipment. Cardiologists at HealthPark are able to view a patient’s angiograms before the patient is even off the table at Cape Coral Hospital. This helps the interventional cardiologist in his diagnosis of whether the patient needs to be sent to HealthPark for intervention or bypass. How is coding and coding education handled in your lab? Coding for procedures is "hard-coded," meaning our procedures with their respective charges are set up on the chargemaster. The supervisor marks the charge sheet and the unit clerk enters the charges. The procedures are coded based on what is entered. That is why it is critical the charges are correct (that and reimbursement, of course). This is for inpatient (IP) and OP costs. For IP, the coders also do their normal coding based on the hard chart. Coding education has been handled by a finance person in the past (from the reimbursement area of finance), meeting with the Director/Supervisor to determine two things: 1) How much labor, supplies, and time is involved, so a fair price/charge can be determined for each procedure. 2) Finance also kept the Director/ Supervisor up-to-date on changes in reimbursement law and/or rules that may add or delete procedures from being charged. As of October 1, 2003, the Finance Department opened three new positions, called ChargeMaster/APC Specialists. These individuals have a vast amount of clinical experience in their respective areas, and it was felt that reimbursement possibilities would increase, based on these specialists’ working knowledge of their respective departments and the different procedures. Finance projected that in the first year, the three ChargeMaster/APC Specialists would collectively find/increase reimbursement by $333,000 per year. In the first quarter, they collectively found $281,649 in reimbursement. There is a ChargeMaster/APC Specialist in radiology, the emergency room, and in invasive cardiology. Our ChargeMaster has found $130,000 since her hire. ChargeMaster responsibilities include, but are not limited to: Educating the department on what procedures can be charged; Constantly investigating and updating reimbursement changes as designated by Center for Medicare/Medicaid and other payers; Auditing the chart and bill on every patient done in CCL/ EP/Implant for correct coding and charges; Acting as a liaison between the clinical environment and finance department; Maintaining direct contact with the coders based on chart findings; Maintaining direct contact with the billing department to remedy errors in charges. How does your lab achieve hemostasis? We achieve hemostasis in several ways. Some physicians use hemostasis devices, while others prefer natural hemostasis. For natural hemostasis, we use manual pressure or the CompressAR® (Advanced Vascular Dynamics, A Semler Technologies Company, Portland, Oregon) clamp. We use a Hemoband (HemoBand Corporation, Portland, OR) for the few radial artery access cases we get. External vascular hemostasis devices (ie, D-Stat Dry, Vascular Solutions, Minneapolis, MN) are used on patients that are not candidates for invasive sealing devices or by physician preference. These devices can be used in the angioplasty suite and cath lab holding area. For invasive hemostasis devices, we are currently using Angio-Seal (St. Jude Medical, Minnetonka, MN), Perclose® (Abbott Vascular Devices, Redwood City, CA), and Duett (Vascular Solutions) in the cath lab. When natural hemostasis is to be obtained, the patient is brought to our holding area where the sheath is removed and hemostasis is achieved either manually or with a CompressAR clamp. Immediately after hemostasis is obtained, the patient goes to the outpatient cardiac observation unit or back to the appropriate inpatient nursing unit. Patients who were transferred here from other hospitals in our system may be transferred back to their original hospital if no intervention is needed. PCI patients who are not sealed usually go back to the angioplasty suite. All staff in the angioplasty suite is trained in sheath pulling. The sheaths are pulled there when the appropriate parameters are met. Does your lab have a hematoma management policy? Yes, we have incorporated our hematoma management policy into our arterial and venous sheath removal, post cardiac catheterization/angioplasty policy. How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies? Everyone participates with inventory management. One person is in charge of daily orders, setting par levels and managing low-cost, high-use items like diagnostic catheters, wires and needles. Other staff members count high-price items, such as balloons, stents and percutaneous transluminal coronary rotational atherectomy (PTCRA), in order to keep low-use sizes within par level and prevent waste due to expiration. We have two clipboards in our clean utility room. When we restock post-procedure, we write it on the reorder clipboard. If it cannot be restocked, we write it on the to be stocked in lab clipboard. When the product arrives, we then know to place it in the lab. We order daily, with overnight delivery. We have tried various ways of keeping supply costs down, like bulk buying and capitation programs, and are now involved in a co-op with another not-for-profit hospital. Has your cath lab recently expanded in size and patient volume, or will it be in the near future? Yes, HealthPark Medical Center recently added a third interventional lab. Our cath procedures have increased for fiscal year 2004. Diagnostic procedures increased 14% in the first five months of opening our third lab. We have also increased our interventions by 12% over last year’s figures. We are currently looking into opening a peripheral vascular lab by the end of 2005. Is your lab involved in clinical research? Our EP Lab is often involved in research projects, the result of a relationship with a large cardiology group. We have done device studies and are currently involved in an atrial flutter ablation study. Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? The incidence of cath lab-related complications is minimal. Our percentage of patients that require emergent cardiac surgery is What measures has your cath lab implemented in order to cut or contain costs? The cath lab has implemented 10-hour shifts and staggered start times to help reduce overtime at the end of the day. Due to an increase in after-hours callback for direct PCI, we have implemented an on-call incentive program. This person takes call every night (5pm“7am) for one week and is paid a flat rate of 40 hours (no call pay or overtime). We rotate through all interested full-time employees. We have a pool of PRN staff that is not used when caseload is low, and are under no obligation to provide a certain number of hours to these PRN staff. We also work with our co-op purchasing agent to negotiate the best pricing on stents and devices. We participate in bulk purchases for our pacemakers and ICDs. What type of quality control (QC)/quality assurance (QA) measures are practiced in your cath lab? Our cath lab monitors all interventions and tracks both major and minor complications based on American College of Cardiology guidelines. We also monitor all our direct PCI patients for door-to-first-balloon-inflation time. We are doing manual and computer calculations for all valve cases as a comparison. We QC our x-ray every morning, and perform chart audits for appropriate documentation of time out and sedation for procedure protocols. How does your cath lab compete for patients? Has your institution formed an alliance with others in the area? We are the largest hospital system in Lee County, with an excellent reputation for cardiovascular care. We work very closely with all of our cardiologists and have developed creative scheduling strategies that work to their benefit as well as the patients. Our marketing campaign has focused on advanced technology, pointing out that our cath labs are the most advanced in the area. Part of our marketing campaign includes billboards throughout southwest Florida, newsletters circulated within local newspapers, and segments on the local news highlighting new equipment and procedures. Our staff also volunteers at community health fairs. How are new employees oriented and trained at your facility? What licensure is required for all professionals who work in your lab? First, new employees for the cardiac cath lab go through a two-day hospital orientation, then they go through a cath lab orientation process. We give them a departmental checklist that needs to be completed by their 90-day evaluation. The employee is paired with a preceptor, who works side-by-side with them to ensure the new employee demonstrates an adequate skill level and knowledge base. The department educator is responsible for setting up the cath lab orientation process. New employees are required to complete all hospital mandatory education and all department-specific mandatory educations. Currently, Lee Memorial only hires RCISs and RNs to the cath lab. Cardiovascular technologists are registered through Cardiovascular Credentialing International (CCI). Nurses are registered and have a current license. RNs must have a minimum of 1 year critical care experience or previous cath lab experience. Everyone is required to have a current BLS and ACLS card. What type of continuing education opportunities are provided to staff members? In 2004, we started to offer the cath lab staff one CEU per month. If the staff attend all CEU programs, they will have fulfilled their CCI requirements of 12 CEUs per year. We have teamed up with our local vendors to offer these CEUs, which are related specifically to the cath lab. The Lee Memorial Health System also offers a variety of CEU programs throughout the year to its employees. For the past two years, Lee Cardiac Care has sponsored a National Heart Care Symposium. The hospital also offers a tuition reimbursement program for anyone wanting to continue his or her education. How do you handle vendor visits to your lab? Vendors must be pre-scheduled with the supervisor. The only exceptions are the EP lab vendors needed for implant cases. Our system currently has a vendor visitation policy that addresses proper identification and verification of experience for all vendors. How is staff competency evaluated? Every year, each staff member has to complete an annual competency exam with regards to all equipment and medications used in the cath lab. The hospital puts on a skills validation fair that all clinical personnel are required to attend. The employee must come prepared to demonstrate the skills outlined in a checklist that they receive with the learning module. If employees are not able to successfully demonstrate the critical skills identified by the educators, they will not pass. Once the employee has completed all of their competencies, they will go to a group of outgoing educators. These educators will collect the competency checklists and review them for any competencies that the employee did not pass. A Recommendation for Development will be given to the any employee who has not passed one or more competencies. A duplicate development plan will be attached to the employee’s packet, then sent to the directors. The employee is expected to meet with their educator, supervisor, and director within a three-week period of the fair to receive additional education on the competency not met. That specific skill will then be reevaluated at the unit level. Does your lab utilize any alternative therapies (such as guided imagery, etc.)? No, we do not use any alternative therapies. How does your lab manage call time for staff members? We currently have multiple shifts to accommodate staggered procedures. We have one group that works 10 hours (7:00 am-5:30 pm), another group that works 8 hours (7:30 am -4:00 pm), and another 8-hour shift that works 8:30 am-5:00 pm. We start our first case at 7:00 am, with second starting at 7:30 am, and the third starting at 9:00 am. Our call teams consist of 4 people: one RN and three RCISs. We rotate the call to fit the schedule. Due to an increase in after-hours callback for direct PCI, we implemented the previously mentioned on-call incentive program [this person takes call every night 5 pm-7 am for one week and is paid a flat rate of 40 hours (no call pay or overtime)]. We also require a nurse to be scheduled and present for every cath lab procedure. What trends do you see emerging in the practice of invasive cardiology? I see a continuation of drug-eluting stent (DES) usage, with migration toward previously untreated lesions. The coronary artery bypass graft world will shrink, with the patients treated having more complex disease and fewer options. New treatment options will continue to evolve for valve disease in the cath lab. The CHF patient will be the new "boondoggle" for surgeons and EP physicians alike, as the number of CHF patients continue to grow and treatment options expand via the remodeling of the ventricle or implant devices. Has your lab has undergone a JCAHO inspection in the past three years? We just had a visit in March of 2005 and passed with accreditation. We continue to ensure that all staff complies with JCAHO National Patient Safety Goals. Where is your cath lab located in relation to the OR department, ER, and radiology departments? Our cath lab is located on the third floor, just opposite of the OR department. This makes it very convenient when we have to transport a patient to the OR for an emergency. The ER is located on the first floor. The hospital is currently installing an express elevator that will be used by the ER to transport patients to the cath lab. The radiology department is located on the second floor of the hospital. Please tell readers what you consider unique or innovative about your cath lab and its staff. We have amazing teamwork, seen especially during times of emergency. We also have very good cross-training with the EP lab, Cape Coral cath lab, cardiac holding area, and the cardiac observation unit. Staff is very adaptable in flexing their schedules according to patient census and timing of cases. Our staff are also very willing to help other departments, such as the ERs and ICUs, during times of census crisis. We also provide community services like health fairs and health screenings. Is there a problem or challenge your lab has faced? We currently have been focusing on sedation for procedure issues. We have recently revised our policy and procedures and deleted our standing orders to better comply with JCAHO standards. We have also implemented a time-out to verify correct patient and procedure before the start of each procedure, again to comply with JCAHO. 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? Lee Memorial is located in southwest Florida, where we have some of the most beautiful beaches in the country. We also have professional and semi-pro hockey, baseball and basketball teams. Fort Myers is also the winter training home to the Boston Red Sox and Minnesota Twins. There are many historic sites to visit, including Thomas Edison’s and Henry Ford’s winter homes, museums, charming Old Florida architecture, Indian shell mounds, and historic buildings. We have a large population of seniors that live in our area, and during the winter months, this number triples. Floridians call this population Snow Birds. This increase in population is reflective in our caseload. We generally have a 40-50% increase in caseload during the winter months. There is also a growing Hispanic population in southwest Florida. We have seen the number of Spanish-speaking people increase over the years. SICP QUESTIONS: 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? No, only cardiovascular techs are required to take the registry exam. Nurses are not required to take this exam. We are currently looking into having all of our nurses take the registered exam. We do not offer any incentive bonus or raise upon passing the exam. However, once passing the exam and completing one year in the lab, the RCIS will progress to level II, which is a higher pay grade. 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 management team is involved with SICP, Alliance of Cardiovascular Professionals (ACVP), and Adult Congenital Heart Association (ACHA). Various staff members are involved with SICP. Email: Brian.Crosby@LeeMemorial.org

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