Cath Lab Spotlight

Lehigh Valley Hospital and Health Network

Lee Phillips, RN, Director of Invasive Cardiology Allentown, Pennsylvania
Lee Phillips, RN, Director of Invasive Cardiology Allentown, Pennsylvania
What type of procedures are performed at your facility? Our cath lab performs all types of diagnostic and interventional procedures. We use all of the diagnostic technology available, including IVUS. We perform interventional procedures, including PTCA/stenting, Rotablator® (Boston Scientific, Maple Grove, MN), DCA, brachytherapy, aortic and mitral valvuloplasty, coronary thrombectomy, and transcatheter defect occlusion. We perform anywhere from 75 to 125 scheduled cases per week. In addition, we usually manage about 5-8 acute myocardial infarctions per week as well. We began our peripheral program about 3 years ago. In our new lab, which we just opened in November 2002, we installed a GE Advantix LCV unit (GE Medical Systems, Waukesha, WI) with full peripheral capability, so that we can continue to grow this area of our department. Since the November opening, our volume has seen a steady increase to about 50 diagnostic and 10 interventional peripheral cases per month. Has your procedure volume been increasing? Our volume has consistently been increasing, although competition in the area is an ever-present concern. We built a shell in our new lab that will give us the ability to expand in the future if needed. Does your cath lab perform primary angioplasty with or without surgical backup? We have a surgeon assigned to us on a daily basis. The surgeon is available to handle emergencies or consult with our cardiologists at the time of the procedure if warranted. What procedures do you perform on an outpatient basis? We only perform diagnostic cases on an outpatient basis. All of our interventional patients spend at least one night in the hospital post-procedure. Who manages your cath lab? We fall under the Department of Medicine. We have two Coordinators who report to the Invasive Cardiology Director. The Director then reports to the Administrator for the Department of Medicine, who ultimately reports to the Chair of Medicine. There is also a physician Medical Director. Do you have cross-training? Who scrubs, who circulates and who monitors? All of our staff are cross-trained to perform any function, with the exception of administering IV meds, which is done by the RNs only. We do have some core teams of staff who are trained to perform some of our less frequent procedures, such as transcatheter defect occlusion. Does your lab have a clinical ladder? We currently do not have a clinical ladder. What are some of the new equipment, devices and products introduced at your lab lately? In November 2002, we moved into our new space, which includes all new x-ray equipment. We installed 3 GE Innova labs and the Advantix LCV lab (GE Medical Systems, Waukesha, WI). Being filmless is a wonderful thing! We also replaced our hemodynamic monitoring system last year with the GE Mac-Lab®. How does your lab handle hemostasis? Our diagnostic patients go to our Staging and Recovery unit post procedure where their sheaths are pulled by our trained Technical Partners. Interventional patients go to our Progressive Coronary Care unit post procedure, where the process is the same. We do use closure devices on about 30% of our patients, utilizing: Perclose® (Abbott Vascular Devices, Redwood City, CA); Angio-Seal (St. Jude Medical, Minnetonka, MN), and; SyvekPatch® (Marine Polymer Technologies, Danvers, MA). Does your lab have a hematoma management policy? We used to have a very elaborate process for tracking all of our patients; however, we continued to be well under the national average, and do not follow that process any longer. We do track our patients until discharge, documenting any deviations from normal in our patient’s medical record. How is inventory managed at your cath lab? About three years ago, we started a very long project that looked at how our inventory got into the department and what happened to it once it arrived. It took a very coordinated effort on the part of our management team, cath lab staff and the staff of Materials Management to develop a comprehensive plan for us to follow. We now have very specific guidelines and policies in place so that each of us knows what our role is in the process of inventory management. All of our vendors receive copies of these policies and are expected to follow them without fail. Through these policies, we have been able to get the physicians and the CCL management team out of the chain for pricing negotiation. We leave that up to the experts in Materials Management. This has been a great relief for the physicians, as they were often put in the middle of issues involving cost and choice. The physicians still drive our inventory based upon clinical need, but what happens after that moves behind the scenes and is not visible to them. Our supplies are ordered on a daily basis by our two Buyers, who work for Materials Management. We also have a Contract and Product Manager, also from Materials Management, who constantly assesses our pricing, reviews contracts, negotiates with vendors and researches information. She keeps the CCL management team informed of everything so that we are always in the loop. This project has been enormously successful for us. Is your lab involved in clinical research? Yes. We run our clinical trials through the Department of Medicine research team. We have a full-time Research Coordinator who manages all of our trials. Some of the trials we have been and are involved in are GAMMA I, II and V, GUSTO IV, TAXUS IV, SCORES, SYNERGY, BERLEX, and RESCUE. Does your lab perform elective cardiac interventions? We do, although about 90% of our cases are scheduled as a diagnostic, possible intervention. Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? We usually have about 1 or 2 cases per year, out of 7000, that require an emergent transport down to the OR. What measures has your cath lab implemented in order to cut or contain costs? Our institution has a program called Working Wonders. It provides monetary reward for staff that come up with a cost-saving idea that is implemented. We have several people who have taken advantage of this program and who have submitted really innovative ideas. One example of these ideas was our change from Lidocaine with Epi for subcutaneous injection to plain Lidocaine. This initiative saved the institution several thousand dollars. We also have become very proficient in rebate programs as well as bulk purchasing of high ticket inventory in order to save money. What type of quality control/quality assurance measures are practiced in your cath lab? Our medical staff do monthly case reviews during our Invasive Cardiology Directorship meeting. We also have a Performance Improvement committee that monitors certain quality indicators throughout the year. These vary annually based upon what we may perceive to be problem-prone areas. How does your cath lab compete for patients? Has your institution formed an alliance with others in the area? Several years ago, our institution purchased a community hospital across town. This hospital contained a diagnostic-only single cath lab. Since that purchase, we have expanded the single lab into two labs, initiated an open heart surgery program, and are about to break ground on a new building that will house, in addition to in-patient beds, a new cath lab/EP lab and a Staging and Recovery area. This purchase has successfully allowed us to compete in an area of the community that had previously been difficult to attract. We consistently provide the latest technology at both of our sites and communicate this to our referring physicians. How are new employees oriented and trained at your facility? New staff are assigned a preceptor, and are trained one-on-one for 6 months. Our Education Committee worked very long and hard to establish a comprehensive training manual for new employees. Our staff are either RNs or RCIS. Non-registered techs are required to attain their RCIS within two years of working in the lab. If they are not successful in obtaining the certification, they may still work in the lab, but at a lower grade salary level. What type of continuing education opportunities are provided to staff members? We have a late start every Tuesday, which allows for inservice time, committee work or staff meetings. Our inservice calendar is usually booked a month ahead, by vendors or by required inservices set up by the Education Committee. We also have mandatory hospital inservices that are ongoing. We also send staff every year to TCT. How do you handle vendor visits to your lab? Our Buyers manage the vendor calendar. We only allow two vendors in per day, although this sometimes expands, as we require peripheral and coronary representatives from the same company to schedule on the same day. They must have an appointment or they are asked to leave. Our main vendors are permitted one day per week. Our vendors who do not have as much of a presence are either permitted in the lab twice a month or monthly. Pharmaceutical representatives all have to go through pharmacy to get into the lab, and our pharmacy is fairly restrictive. We recently put a vendor policy into effect which requires representatives to maintain a certain decorum. They must also report to Materials Management for a badge before reporting to the department. How is staff competency evaluated? We have certain core elements that each staff member is evaluated on annually. This is usually done by direct visualization. Does your lab utilize any alternative therapies (such as guided imagery, etc.)? No, although in our new lab we did install lighted murals over each procedure table so the patient has something pretty to look at! How does your lab handle call time for staff members? We have three people on call every night, one of which must be an RN. Our 8-hour call staff come to work at 9:30, but our 10-hour people come in at 7:30. Weekend coverage involves Friday night, Saturday and Sunday. If the call team is in during the night, they are still required to report to work, either at 7:30 or 9:30 the next day for their scheduled shift. We try, as best we can, to let them go home early; however, our staffing needs don’t often allow it. What trends do you see emerging in the practice of invasive cardiology? Certainly, drug-eluting stents have changed the whole landscape of how we may be treating patients. We have spent the last year and a half preparing for this change, but only time will tell as to what it will actually do. Has your lab has undergone a JCAHO inspection in the past three years? We had an inspection in 2000 and are due for one again in December of 2003. We did very well in our last inspection, and had no violations. Since we moved to our new area, and actually created some of the design based upon JCAHO guidelines, we are anticipating that this inspection will go very well also. Can you discuss your cath lab layout? We really were able to blow things up and start over with the design and creation of our new labs. We worked with a wonderful architectural firm, FreemanWhite, from Charlotte, NC. Our staff and physicians helped with the design, and the architects made it a reality. Our cath labs and EP labs revolve around a central inventory space. The rooms are huge (700 square feet) and they give us ample space to work. We decided upon mobile inventory carts versus standing cabinets to give us the ability to clean behind them as well as to limit the amount of space where inventory could be hidden. Our control booths have a separate work-space for our physicians, so that they can dictate and make phone calls out of the way of the staff. The viewing rooms are located at the entrance of the lab so that traffic through the procedure area is limited. The Staging and Recovery area just opened in March of this year, and it is located directly adjacent to the lab area so that transport is minimal. We are so proud of our new area. It is beautiful, and the staff enjoys working here. Our institution is very dedicated to process flow, and the Facilities and Construction department spent a lot of time listening to us and trying to create everything that we wanted. It was a wonderful experience. Where is your cath lab located in relation to the OR department, ER, and radiology departments? We are one floor above all of those units. If we could choose one area to be closer to, it would have to be the ED. We have an MI Alert program, which encourages us to have a door-to-balloon time of under 90 minutes. We do a significant volume of MIs, and it would be great if we didn’t have to wait for an elevator to bring the patients to the lab. Please tell the readers what you consider unique or innovative about your cath lab and its staff. We have such longevity in our staff, and they are so well-trained. I really feel this is something special that sets us apart. We have streamlined our process over the years, based upon the creative ideas of many people. Our physicians are very supportive of the staff, and respect them and their opinions. Our physical environment is now set up so that our work flow is streamlined. We are as flexible as we possibly can be with staff time off, allowing them to have lives outside of work, which is very important in creating job satisfaction. Is there a problem or challenge your lab has faced? Moving an entire lab, both cath and EP, was an enormous challenge. We did it all in a weekend. It took the creative planning of many staff, lots of overtime, and everyone’s organizational skills to get it accomplished. We literally moved out of our old labs on Friday and fired up the new ones on Monday and it all worked! What’s special about your city or general regional area in comparison to the rest of the U.S.? We are really a suburban area, although Allentown is a fairly large city. We have, over the last 10 years, attracted a large population out of New York City, who live here but commute there to work. This has changed the culture somewhat, from an industrial area to a mixture of white- and blue-collar residents. We have also had several industries close in the area, Bethlehem Steel being the largest and one which has affected many people. Our area is a beautiful one to live in, with the Pocono Mountains just north of us and city life, if you want it, 2-3 hours away. We have several festivals each year that feature the arts and music and attract people from far and wide. Author Lee Phillips can be reached at: