Cath Lab Spotlight

Memorial Hospital

Jennifer Brunworth, RN, BSN, Nurse Manager Mike Brabenec, RT(R), Data Specialist, Belleville, Illinois
Jennifer Brunworth, RN, BSN, Nurse Manager Mike Brabenec, RT(R), Data Specialist, Belleville, Illinois
We have 18 staff members, comprised of: • 1 nurse manager • 1 staff educator • 1 data specialist • 7 RNs [4 full-time (FT), 3 part-time] • 5 RTs (4 FT, 1 PRN) • 3 tech aides (TA) Our tech aides receive on-the-job training. They are able to scrub, record and run the x-ray equipment as needed, functioning much like our RT(R) staff members, but with some limitations. RN experience ranges from 1 year to 16 years. RT(R) experience ranges from 10 years all the way up to 36 years. Our TA experience ranges from 1 year to 11 years.

What procedures are performed in your cath lab?

We perform left and right heart catheterizations, percutaneous coronary interventions, pacemaker and implantable cardioverter-defibrillator (ICD) insertions, temporary pacemaker placement, EP studies, radiofrequency ablations, loop recorder implants, peripheral diagnostic studies, peripheral interventions, dialysis catheter placement, filter placements, transesophageal echos (TEE), cardioversions, computed tomography (CT) coronary angiography and tilt table tests. Our procedure volume is as follows: • Diagnostic and interventional cardiac procedures: 25.5 diag/ week, 3.8 int/week • Diagnostic and interventional peripheral procedures: 7 diag/ week, 3 int/week • EP/ablations: 1.1 EP/week; 0.6 abl/week • Pacer/ICD/loop recorder implants and changes: 3.9/week • TEE/cardioversions: 3.7/week • Tilt table tests: 1/week Peripheral interventions are done in the cath lab by vascular surgeons. During these cases we have the same case mix as our other procedures. We have 1 circulating RN, an RT and a recorder (TA, RN or RT).

Does your cath lab perform primary angioplasty with surgical backup on site?

We do have on-site surgical back up. When necessary, our cardiac surgeons are consulted and can frequently come to the cath lab for an initial meeting and evaluation of the patient. The surgeons and their support staff schedule the surgery.

What procedures do you perform on an outpatient basis?

Diagnostic caths, diagnostic peripheral studies, tilt table tests, cardioversions, TEE, EP studies, ICD/ pacer generator changes, dialysis catheter placement and CT angiography are performed on an outpatient basis.

Do any of your physicians regularly gain access via the radial artery?

Not at this time. However, our physicians are interested in performing radial access cases. We are currently examining the equipment and training needs to successfully perform radial access cases.

What percentage of your patients is female?

48.2% of our patients are female.

What percentage of your diagnostic cath patients go on to have an interventional procedure?

We perform interventions on approximately 14% of our cath patients.

Who manages your cath lab?

Jennifer Brunworth, RN, BSN, is our nurse manager. She coordinates all clinical aspects of the cardiac cath lab and manages the staff. Jenn has worked at Memorial Hospital since 2006. Prior to accepting the nurse manger position, she was a staff RN in the cardiac cath lab. Kathryn Cramer, MBA, is the manager of the cardiovascular division as a whole. Kathy manages the non-clinical aspects of the cath lab and other cardiovascular departments. Kathy and Jenn coordinate all of their efforts to ensure the cath lab runs efficiently and effectively. Ruth Holmes, RN, BSN, RVT, is the vice president of Division I. She is always directly involved with the cath lab as well as the many other departments that she heads.

How does your lab communicate information to staff and physicians to stay organized and on top of change?

Communication with all physicians, staff and co-workers is clearly an integral part of any successful cath lab environment. We have a monthly cath conference, during which we communicate new information, reiterate important information, provide inservices and more. We also have regular staff meetings as well as email communications. Physicians and other department staff are frequently invited to our cath conferences to present information or to learn about our procedures and processes. And, of course, we never fail to utilize the tried and true word-of-mouth method of communication!

Do you have cross-training? Who scrubs, who circulates and who monitors?

Our team is cross-trained in many areas. Our RNs, RTs and tech aides are able to monitor our hemodynamic recording system. Our tech aides are also able to scrub. Our RNs do not scrub at this time. Our RNs administer moderate sedation and monitor patients, as well as circulate.

Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab?

No, an RT is not required to be present for all fluoroscopic cases. However, an RT would always be available upon request.

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?

Our x-ray equipment is operated by our physicians and radiologic technologists, as well as our TAs, with some limitations.

How does your cath lab handle radiation protection for the physicians and staff that are in the lab day after day?

All staff, technologists and physicians are provided with lead aprons and dosimeter badges. Our procedure tables are equipped with groin shields and face shields are suspended above the tables. We also provide rolling shields for staff to use for extra protection if necessary.

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

Some of the new equipment we have begun using includes the Volcano intravascular ultrasound system (Volcano Corp., San Diego, CA), and Bard EP equipment & mapping system (Lowell, MA). We have added the Medtronic Attain StarFix lead wire (Minneapolis, MN). We also became the first hospital in our area to use the Angio-Seal Evolution (St. Jude Medical, Minnetonka, MN) closure devices.

Can you describe the system(s) you utilize and how they work in cath lab daily life?

We use the Witt/Philips system (Melbourne, FL) for documenting all procedural information. We will actually be upgrading this system to allow the physicians to produce complete procedure report and diagrams electronically. We use Philips Xcelera (Bothell, WA) for digital image storage. This system enables physicians to view films throughout the hospital and in their offices. Xcelera is also used during our cases to calculate arterial stenosis and ejection fractions.

How is coding handled in your lab?

Our tech aides complete our charges, working in conjunction with physicians, staff and our billing department. Coders review each patient charge, using physician documentation to ensure proper charging. Managers review codes, and the charge master annually and as needed, to ensure that we are charging appropriately.

How does your lab handle hemostasis?

We use a closure device, the Angio-Seal Evolution, on approximately 50% of our patients. When we cannot use a closure device, the circulating RN and the RT pull the sheath and obtain hemostasis. We also employ the use of the D-Stat Dry pad (Vascular Solutions, Inc., Minneapolis, MN), FemoStop (St. Jude Medical), and c-clamps.

What is your lab’s hematoma management policy?

Hematomas that develop in the cath lab are managed immediately by our trained staff and documented in our procedure log. Cath lab staff also manages hematomas that occur on the telemetry unit if requested. Our clinical educator provides continuing education and competency assessment of all cath lab staff, as well as staff on our telemetry units. The cath lab staff also make rounds each morning on any patients who are still in-house. We document the condition of the groin, noting bruising, oozing, and/or hematomas. We track all complications and use that data to identify training needs to ensure patient safety.

How is inventory managed ?

We currently use Meditech (Westwood, MA) to monitor our inventory. We have set minimum par levels for all products and supplies. Our RTs do a fantastic job tracking our inventory and ordering supplies as needed. It can be a thankless job, but we absolutely applaud their attention to detail and hard work!

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

Our patient volumes are increasing. As of the end of the 3rd quarter 2009, our patient volume had increased by almost 30%. We are certainly proud of our success and we are committed to continuing our growth. We completely remodeled and relocated our lab in 2006. We moved from a smaller area into a new, expansive area with 4 procedure rooms, 8 prep/recovery bays, a large storeroom, meeting space, patient/family waiting room and a consultation room. Our new area offers physicians a private reading/viewing area that allows them to access their films and dictate their reports.

Is your lab involved in clinical research?

Not at this time.

Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery?

No, as of the end of 3rd quarter 2009, we have not had any complications requiring emergent cardiac surgery.

Where is your cath lab located in relation to the operating room (OR) and emergency department (ED)?

The cath lab, ED and OR are all on the same level, and are connected by a common hallway.

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?

This is a great success story for us and one of which we are particularly proud. Reducing our D2B times has been a major initiative for Memorial Hospital in the past few years. Our cath lab and emergency departments have been working diligently together to form a cohesive team to manage ST-elevation myocardial infarction (STEMI) patients. Both departments have made significant changes to ensure the best possible outcome. We are particularly proud that for the past two consecutive quarters, we have exceeded our 90-minute D2B goal on 100% of our CMS STEMI cases! We are thrilled with our successes, but certainly realize that there is even more to do. We have put a tremendous amount of work into refining our STEMI processes. Our average D2B time in 2009 was 68 minutes (Figure 1). In 2006, our average D2B time was 106 minutes, so our efforts are indeed making a difference. In 2009, 97% of our CMS STEMIs met or exceeded the 90-minute D2B goal. The national average is 98%! The dedication of everyone involved, including EMS, ED and cath lab staff, is incredible. The most important step that we took to improve our STEMI process was to create a team environment. We overcame an embedded “us and them” mentality. We gave everyone the tools to understand the vital role they play in the process, from the registration clerk all the way up the line. Each person who is involved with these patients is critical to our success. We want everyone to know about our successes and our missed opportunities. In order to do that, we send out a post-STEMI communication, detailing each piece of the process. Times are all documented and angiographic images are printed to show everyone the difference that we made. These are distributed to, EMS, ED staff, physicians and our entire STEMI committee. When people can see the difference that their efforts make to a patient, it encourages them to strive even harder to achieve our common goal.

What other modalities do you use to verify stenosis?

We use intravascular ultrasound and fractional flow reserve (Volcano) to provide stenosis verification.

What measures has your cath lab implemented in order to cut or contain costs?

We recently began using Meditech to track our inventory and control costs. We also underwent a major transition to a 2-vendor system for cardiac cath and rhythm management devices. We will apply the same strategy in our EP and peripheral vascular labs as well.

What type of quality control/quality assurance measures are practiced in your cath lab?

We report statistics through the American College of Cardiology (ACC) National Cardiovascular Database Registry (NCDR) ICD and Cath PCI registries. In 2010, we began reporting to the NCDR ACTION registry as well. Our staff is diligent about quality control within our department, ensuring that all point-of-care devices, refrigerators and other machines are checked daily (or as required). Many members of our staff perform additional quality assurance projects. For example, we track post procedure complications and we perform documentation audits to verify complete documentation and compliance.

How does your cath lab compete for patients?

We compete by providing exceptional service, without exception, to all of our customers. Our outpatient customer satisfaction scores are reported by Press Ganey and are strictly monitored. We are always striving to improve our processes and procedures to make our customers’ experience second to none. We have also developed a marketing tool for our patients and referring physicians. The brochure provides all of the necessary information to make scheduling and preparing for any cardiovascular procedure simple. In addition, we present quarterly informational programs for referring physicians and medical staff.

How are new employees oriented and trained at your facility?

New cath lab team members are partnered with a preceptor for an average of 12 weeks. Our clinical educators determine an orientation plan with the new employee based on previous experience, and they continually monitor and re-assess progress. We currently have 1 RN, previously an ICU nurse, with less than 1 year of experience in the cath lab setting. RNs and our radiologic technologists are all licensed by the state of Illinois.

What type of continuing education opportunities are provided to staff members?

We provide frequent inservices, presented by our clinical educators or educators from other departments, and outside vendors. We provide opportunities for our staff to attend formal CEU programs when offered in our area. We also have monthly cath conferences presented by the cath lab staff, educators, physicians, and others. These conferences have a wide variety of relevant topics to keep our staff members informed.

How do you handle vendor visits to your lab?

Vendors are required to make an appointment to visit the cath lab for any type of meeting or presentation. All vendors must check in with our materials management office to receive a vendor badge before going anywhere in the hospital. Pharmaceutical representatives are required to check in with the pharmacy department before visiting the cath lab.

How is staff competency evaluated?

Our staff educator, Ramona Stein, RN, BSN, performs annual competency evaluations and individualized training programs for cath lab staff. Staff members are required to attend regular “cath conferences” which cover relevant topics and they are also required to remain up-to-date with mandatory online education.

Does your lab have a clinical ladder?

No, we do not currently have a clinical ladder. However, our RNs can participate in the Nurse Professional Development Program. Our RTs can participate in the Ancillary Staff Professional Development Program. Both programs offer monetary rewards for achievement and participation in categories pertinent to their professional goals.

How does your lab handle call time for staff members?

Call teams are comprised of 4 staff members. Two RNs are required in addition to a minimum of 1 RT scrub person and another staff member to record (RT, TA or RN).

Within what time period are call team members expected to arrive to the lab after being paged?

As part of our commitment to meeting our 90-minute D2B time, we recently changed our expected response time to 25 minutes. We do not have a cardiologist on site 24/7. Cardiologists are expected to arrive in 30 minutes.

Do you have flex time or multiple shifts?

We currently have 8-hour and 9-hour shifts.

Does your cath lab do electives on weekends and or holidays?

Typically, we do not schedule elective cases on weekends or holidays. However, we would always accommodate an elective procedure for an in-patient if it would impact length of stay (LOS).

Has your lab has undergone an outside inspection from an accrediting body (such as the Joint Commission) in the past three years?

We are accredited by the Healthcare Facilities Accreditation Program (HFAP). We recently went through a mock inspection and we passed with flying colors. We are anticipating our HFAP survey in 2010. In preparation for our mock survey, we obtained the HFAP standards and identified all of the items that applied to the cath lab. We then divided those up among the director, manager and our clinical educator. Each person was charged with ensuring that we were meeting those standards. We collected all pertinent policies and samples, and placed them in one binder for the surveyor. Our clinical educator put an incredible amount of time and effort into this project, and it showed. The surveyor used our model as an example for other departments . In 2008, we achieved our accreditation from the Society of Chest Pain Centers. In 2008, we were awarded Magnet status. We are incredibly proud of our recent accomplishments!

How do you see your cardiac catheterization laboratory changing over the next decade?

We foresee many changes in the next decade. Cardiology and vascular services are dynamic areas, and we are prepared to adapt accordingly. We hope to add percutaneous valve replacement procedures to our current list of services in the near future. We are dedicated to offering a comprehensive suite of service to our community residents and our physicians. In the very near future, we will begin to provide one-stop care for our patients. Up through 2009, our outpatients were prepped and recovered (post sheath removal) in the outpatient surgery department. In an effort to provide excellent service and continuity of care, we are preparing to shift all prep and recovery opportunities to the cath lab. We have begun prepping our own patients early this year and are evaluating the appropriate time to transition recovery duties.

What do you consider unique or innovative about your cath lab and staff?

We do daily rounds on any patients who are still admitted to the hospital the day following their procedure. During this visit, we ask the patient and/or their family questions about their experience in the cath lab. We then use that feedback to fine-tune our methods of patient care. We also take this opportunity to visualize the percutaneous entry site and check for bruising, bleeding or evidence of hematoma. This information is then tracked for our physicians. Our clinical educator is made aware of any areas of concern so that she can customize staff development plans. Our staff members are assigned to a patient from prep all the way through their recovery. Patients are frequently anxious about their upcoming procedures and/or the results of their procedure. Therefore, eliminating multiple hand-offs provides our patients with an additional level of comfort and confidence.

Is there a problem or challenge your lab has faced?

Like many other labs around the country, we are faced with slow periods that require us to send staff members to other areas to work or home (take low census). Productivity is a critical piece of our bottom line. When the need arises for low census, we typically have volunteers! Down time between cases allows for quality improvement/quality assurance projects to be completed by our staff members.

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”?

We are located in southwestern Illinois, across the Mississippi river from St. Louis, Missouri, so we have a unique mix of rural and urban areas within reach. We have several large, nationally-known medical facilities nearby which drive us to constantly improve our patients’ experiences and provide exceptional care. We want our customers to know that we are always going to go above and beyond in their care and treatment to thank them for their loyalty. Questions from the Society of Invasive Cardiovascular Professionals (SICP):

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?

We do not require staff to obtain an RCIS certification. However, we encourage our staff to obtain the certification. We currently have 2 staff members planning to take the exam in 2010. A one-time bonus is provided through our Nurse Professional Development Program.

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?

Jenn Brunworth, RN, Kathryn Cramer, and Ramona Stein, RN, recently became members of the SICP. We are also active members of the Advisory Board Company and the Cardiovascular Roundtable. Jennifer Brunworth, RN, Nurse Manager, can be contacted at Mike Brabenec RT(R), Data Specialist, can be contacted at