Letter from the Editor

Lynchburg General Hospital

Kim Carwile, RT(R)(CV), Whitney Ruggieri, RN III
Kim Carwile, RT(R)(CV), Whitney Ruggieri, RN III
What is the size of your cath lab facility and number of staff members? Our cath lab currently has three patient procedure rooms and a five-bay prep/recovery area. Each lab is equipped to perform cardiac catheterizations and interventions. One room doubles as an EP study/ablation and surgical suite, while another doubles as our peripheral suite. A fourth room shell will be completed within the next year and will serve as a dedicated EP/Surgical suite. We have twenty-four staff members, including twelve RNs, eight RT(R)s, one transporter, three office staff and six cardiologists. The average length of tenure is six years. Four of the five original staff members who helped open the cath lab in 1986 are still working in the cath lab. Our turnover rate remains very low at 0.2%. What types of procedures are performed at your facility? We perform both diagnostic and interventional procedures at Lynchburg General Hospital. Our cardiologists are credentialed to perform diagnostic left and right heart catheterizations, coronary interventions, valve assessment, bypass angiography, and peripheral angiography and intervention. Our peripheral work includes carotid angiography and stenting, EP studies/ablations, pacemakers, ICDs and bi-ventricular devices. We complete over 4100 procedures annually, with an average monthly volume of 340 cases. We began our peripheral program in 2001 and average 50 cases per month. Our EP/device insertion program averages 40 cases per month. Does your cath lab perform primary angioplasty without surgical backup? When a high-risk intervention patient is scheduled, cardiac surgery is notified for standby. Otherwise, we perform primary angioplasty without formal backup. The cardiac surgery team and surgeon are on call after hours and are available within 30 minutes for emergencies. What procedures do you perform on an outpatient basis? Elective diagnostic coronary catheterizations, peripheral diagnostic and selected interventions, EP/ablations, pacemakers and loop recorder implants may be done on an outpatient basis. What percentage of your patients is female? From May of 2003 to May of 2004, 41% of our patient population was female. What percentage of your diagnostic cath patients go on to have an interventional procedure? From May of 2003 to May of 2004, an estimated 36% of our diagnostic cath patients went to interventional procedures. Who manages your cath lab? Our Cath Lab Manager is Mary Floyd, RN, RCIS, CCRN. Mary is one of the original team members and has been the only manager of the cath lab in 18 years. Our medical director is Dr. Daniel Carey, who recently took over the position from Dr. Thomas Nygaard, the cath lab founder. Do you have cross-training? Who scrubs, who circulates and who monitors? We have limited cross training within our department. The radiology technologists scrub all heart caths and peripheral procedures. Several technologists scrub device insertions; however, the nurses are the primary scrubbers in the device implantation cases. Both nurses and radiologic technologists record or monitor the patients. A nurse performs the circulating duties in all cases. Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab? Yes, an RT(R) has to be present for all fluoroscopic 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? The scrub technologist performs the position of the II, the panning of the table and changing the angles. The performing physician operates the fluoro pedal. Does your lab have a clinical ladder? Our hospital has a clinical ladder in place for the nursing staff. However, we do not currently have a RT(R) clinical ladder. Our Professional Practice Council is currently addressing this issue and is trying to establish a clinical ladder for the RT(R)s. What are some of the new equipment, devices and products introduced at your lab lately? Most of the new equipment that we have had introduced into our lab has been related to peripheral procedures. For peripheral cases, the new devices we are using are the SilverHawk (FoxHollow Technologies, Inc., Redwood City, CA), a linear plaque excision device, the PolarCath cryoplasty balloon device (Boston Scientific Corporation, Maple Grove, MN) and the FrontRunner catheter (LuMend, Inc., Redwood City, CA) that facilitates a lumen through a chronically occluded vessel. The new devices we are using in coronary cases are the MiniRail balloon catheter (Guidant Corporation, Santa Clara, CA) and the distal protection device the Filterwire EX (Boston Scientific). Can you describe the cath lab system you utilize? We became filmless in 1999 with the introduction of the Archium archiving system (Camtronics Medical Systems, Hartland, WI). In 2003, we updated our digital film system to the Vericis archiving system (Camtronics). We still house a number of cine films that occurred before 1994 that are part of our patient records. How is coding and coding education handled in your lab? We rely on the cath lab physicians to complete a charge sheet specifying the performed procedures and codes. A duplicate copy of this charge sheet goes to the physician's office for professional billing purposes. The cath lab administrative secretary enters the cath lab charges into the hospital billing system. This process ensures consistency between the professional and provider billing codes. The clinical coding department reviews all charges. If there are any discrepancies between the codes selected and the cath lab report, the unit manager is contacted and asked to review both documents for clarification. There are separate forms for interventional and diagnostic caths, device implants and electrophysiology procedures, and peripheral procedures. All peripheral charges are reviewed before entering into the system because of the complex nature of these charges. The clinical staff, using the Witt hemodynamic system (Witt Biomedical, Melbourne, FL), does procedure designation. This information interfaces and populates data fields in our cath report and database (Lumedx, Oakland, CA). How does your lab handle hemostasis? The majority of the time, hemostasis is handled in the room post procedure. We use a combination of manual compression and a ChitoSeal patch (Abbott Vascular Devices, Redwood City) on our diagnostic patients who have not received any anticoagulants. The Perclose® suture device (Abbott Vascular Devices, Redwood City, CA) is used on all intervention patients and patients that have received anticoagulation therapy. If either of these closure devices fails to obtain hemostasis, we will hold extended manual pressure or use the FemoStop® compression device (Radi Medical Systems, Wilmington, MA). Does your lab have a hematoma management policy? No, we do not have a policy devoted to hematomas. We do have policies regarding sheath management and sheath removals that also address the treatment of a hematoma in the event one should occur. How is your inventory managed at your cath lab? One person oversees the maintenance of our inventory supplies. This job duty averages between 20 to 25 hours a week. Part of our inventory is set up in our Witt Series IV inventory module that documents, charges and maintains par levels of inventory for reordering. The majority of our high-cost items are on consignment and are reordered and paid for after each use. Consignment items are also documented and charged through the Witt inventory module system. The par level and consignment items are checked and ordered throughout each day. Other non-billable inventory handled specifically by our department is maintained by a manual system. At present, inventory needing reorder has to be transferred to a different computer program controlled by our Purchasing Department to facilitate the ordering process. Hopefully, by the end of the year, Purchasing will have an ordering system in place that will note our par levels and consignment orders automatically, eliminating the majority of the manual data transfer. Items in our lab that are used hospital-wide are maintained by our Central Storeroom. Capital equipment purchases are handled by departmental administration. Has your cath lab recently expanded in size and patient volume, or will it be in the near future? We opened our third room in April 2003. This is a combination cardiac and peripheral room with an Acist Contrast Management System (Eden Prairie, MN). When we began performing peripheral procedures, we had only cardiac rooms and saw the need for a peripheral room right away. We have plans to replace our two original rooms with flat panel technology in the near future. Currently, we use one of our cardiac rooms to perform our electrophysiology studies and device insertions. Not only does this tie up one of our cath rooms, but also the EP equipment setup becomes very involved. Fortunately, we will be opening our fourth room in the very near future and this will be a dedicated EP room. We have had an increase in patient volume, especially since the onset of peripherals in our department over two years ago. We also had a dedicated EP physician join our cardiology group, which has helped our EP volume grow as well. Is your lab involved in clinical research? Our cardiologists employ a full-time nurse practitioner that is responsible for coordinating all clinical trials. We have been involved in numerous clinical trials, and are frequently invited to participate due to our success with high enrollments. Trials we have participated in include: PREVENT IV (Treatment of coronary vein grafts with CGT003 in patients undergoing CABG), IMPACT II (Randomised placebo-controlled trial of effect of eptifibatide on complications of percutaneous coronary intervention), COMMA (compliment inhibition in myocardial infarction treated with percutaneous transluminal coronary angioplasty [evaluation of IV dosing regimens of h5G1.1-scFv]), SYNERGY (superior yield of the new strategy of enoxaparin, revascularization, and glycoprotein IIb/IIIa inhibitors), and TRAP (a trial looking at the TRAP Vascular Filtration Device by Microvena Corp., White Bear Lake, MN). Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? Over the last year we had a 0.0007% incidence of complications requiring emergent cardiac surgery. What measures has your cath lab implemented in order to cut or contain costs? Staff are encouraged to avoid overtime, but that's not always possible. They are held accountable to the unit manager and to the RN in charge. We make productivity comparisons with other cath labs through Solucient Action data. Most staff work variable shifts: either 7¬-3:30, 8-4:30, 8:30-5, 9-5:30 or 10-hour shifts that are 7-5:30. The 10-hour shifts allow for late in the day coverage. Inventory costs have always been a closely controlled factor in our lab. We have always tried to keep our par levels set to a minimum. This eliminates excessive inventory build up on our shelves for long periods of time. Also, consignments of our most costly items help us contain dollars spent on items until the products are used. Periodically, we buy pacemakers, AICDs and leads in bulk at a major cost savings. We also actively search for better prices as new products come on the market and become available. What type of quality control/quality assurance measures are practiced in your cath lab? We participate in the ACC-NCDR database, CHF Optimize and NRMI data registries, and we submit an in-house complication report quarterly. Two of our most recent quality assurance measures have been the patient identifier and pain scale with a 0-10 patient response. To comply with JCAHO™s patient identifier requirements, we identify patients pre-procedure and again immediately before the physician begins the procedure. Patients are asked to state their names and birthdates while the nurse compares the information given with the information found on the armband. How does your cath lab compete for patients? Our hospital has entered into an agreement with Halifax Regional Hospital, in Halifax Virginia. This agreement helped implement a diagnostic cath lab program at Halifax Regional. We are providing advice on the physical plant and will assist training the staff, when hired. The interventional and surgical referrals have increased for us since entering into this agreement. Our facility serves the very large county area that surrounds Lynchburg in addition to Lynchburg city. Our cardiac director maintains a strong focus on community involvement in an effort to continue to enlarge our referral patterns. How are new employees oriented and trained at your facility? Staff members are comprised of registered nurses and registered radiologic technologists. The nursing preceptor and chief radiologic technologist work together with senior staff to orient new employees. We offer new employees classroom time and in-services on all procedures that are performed in our lab. New staff members also get hands-on training with an experienced staff member. Our orientation process generally lasts 3 to 6 months, depending upon the new staff member's prior experience. We require that our radiologic technologists and nurses be registered by the State of Virginia. The nurses are required to take a critical care course. What type of continuing education opportunities are provided to staff members? Our lab has recently formed an Education Council under a shared governance structure that meets monthly and discusses the education needs for our department. The council organizes department-specific education, purchases books for our lab library and sends staff on a rotational basis to conferences. Our lab is associated with several different medical equipment companies. We utilize their clinical specialists who provide in-services on new products and procedures. Monthly, we offer Chest Pain and Vascular Conferences for staff to attend. How do you handle vendor visits to your lab? We have recently implemented a policy of no longer allowing drug representatives to visit the cath lab. Product representatives are allowed to visit every 3-4 weeks if they have a new product. In that case, they are given the appropriate amount of time needed to introduce the new product. The product representatives are not required to check in at the purchasing department. How is staff competency evaluated? Each staff member has equipment and procedure competencies that they are required to review. Satisfactory performance and completion of all competencies must be documented. Our manager evaluates the competency forms at the end of the year in conjunction with our evaluations. Does your lab utilize any alternative therapies (such as guided imagery, etc.)? No, our lab does not utilize alternative therapies. How does your lab handle call time for staff members? Our call team is made up of 2 nurses and 1 radiologic technologist. The nurses take call every third to fourth weekend and one day during the week. The radiologic technologists take call every third weekend and 1 to 2 days during the week. What trends do you see emerging in the practice of invasive cardiology? Dr. Daniel Carey, our Cath Lab Medical Director, sees two emerging trends. First, vascular medicine is becoming progressively more recognized as part of the core duties of practicing cardiologists in clinical, invasive and non-invasive testing. In the cardiac cath lab, we are evaluating patients with a wide variety of vascular disorders in addition to coronary and vavular heart disease. This means the cath lab needs to be more broadly equipped, be ready for longer and more complex procedures, and staff members need to possess broader skill sets. Second, drug-eluting stents are creating larger procedure volumes. These increased volumes are creating great budgetary challenges because reimbursement has not been able to keep up with the new medical advancements. There are an increasing number of patients with multi-vessel disease being successfully treated with drug-eluting stents. Before the advent of drug-eluting stents, these patients would have gone on to bypass surgery. Has your lab undergone a JCAHO inspection in the past three years? JCAHO performed a site visit at our cath lab in May of 2003. Patient safety and pre-procedure H&Ps were very important issues. They were very impressed with our quality-focused acute myocardial infarction (AMI) initiative. Where is your cath lab located in relation to the OR department, ER, and radiology departments? Our cath lab is located directly across the hallway from the OR Suite. The emergency room and radiology departments are next door to each other and are located on the opposite side of the hospital from the cardiac cath lab and OR. However, there is a main hallway that runs between these areas to aide in transportation of patients to the cardiac suite and OR. Radiology, the emergency room, the OR and the cardiac cath lab are all located on the first floor of our facility. Please tell the readers what you consider unique or innovative about your cath lab and its staff. Numerous studies have documented increased mortality associated with delays in balloon angioplasty and/or stent deployment for patients presenting with acute myocardial infarctions. A collaborative team effort between the emergency department and the cardiac cath lab was formed and implemented in 1999. This streamlined treatment plan was developed for acute myocardial infarction patients. Most recently, Centra Health's cardiac program was recognized for extraordinary performance in the treatment of heart patients by raising the bar on treatment protocols for patients with emergent heart problems. We have achieved the 90-minute gold standard 75% of the time, compared to the national benchmark of 37%. In addition, our median emergency room door-to-device activation time is currently 64 minutes, compared to a national median of 103 minutes. This recent data set from NRMI ranks our center as one of the best in the country and places us in the 100th percentile for like-size hospitals. Our hospital cardiology program was awarded the VHA Leadership Award for Clinical Effectiveness in 2004. Centra Health was chosen out of a pool of 1,400 hospitals. Eight leadership awards were presented with one for single hospitals and one for health systems in each of four categories: clinical effectiveness, operational performance, supply chain management, and community health. The acceptable gold standard of 30 minutes from cath lab door to balloon angioplasty and/or stent deployment is rarely met, even by high-volume centers. As part of our institution's quality initiatives, the cath lab sought to improve our baseline average time of 40 minutes in 1999 to less than the Virginia Hospital Association's Gold Standard time of 30 minutes. As a multi-disciplinary group of nurses, technologists and physicians from both the ED and cath lab, we analyzed current practices and identified sources of delay. As most recently reported, from May 2003-April 2004 we have achieved a median time of 14 minutes. In this same timeframe, our cath lab door to device time has been Is there a problem or challenge your lab has faced? All labs have challenges, but the biggest challenge for us is keeping up with technology, as it is always changing. This requires the staff to be prepared to work with new equipment and perform new procedures daily. Due to the fact that our lab is expanding at such a rapid pace, staffing has been an issue. It was necessary to increase our staff; however, finding staff requires more time than we would like. Our philosophy is that the right fit is important and finding the right people takes time. What's special about your city or general regional area in comparison to the rest of the U.S.? Centra Health™s Lynchburg General Cardiac Cath Lab is located in Lynchburg, Virginia, in the heart of central Virginia. Our geographical location is idyllic due to the fact that both the majestic Blue Ridge Mountains and the beautiful Virginia Beach Eastern shore are located only hours away. We are also lucky enough to enjoy all four seasons and experience relatively mild winters averaging 22 inches of snow. Overall, Lynchburg ranks very high in the national polls. Money Magazine ranked Lynchburg as the second best city in the south to live in, within the small cities category. Lynchburg has a relatively low cost of living; gasoline prices, for instance, are about a dime below the state average and nearly 20 cents below the national average. In Readers Digest, parents around the country ranked Lynchburg among the top 50 places to live in the United States. Lynchburg topped other Virginia cities in areas concerning crime rates, excellent public schools, good health care and strong economic growth. Due to the low cost of living and the generally mild climate, Lynchburg is regarded as a great retirement location. As Lynchburg™s older population has increased, we have seen an increase in our already large work volume. The authors can be contacted at Kim.Carwile@centrahealth.com