Cath Lab Stories

North Oaks Heart Health Services

Carolyn Himel, RN, BSN, Patrick Slaven, RT(R)(CV)ARRT, Hammond, Louisiana
Carolyn Himel, RN, BSN, Patrick Slaven, RT(R)(CV)ARRT, Hammond, Louisiana

Tell us about your cath labs.

North Oaks Medical Center has two cardiac cath labs and a four-bay pre-procedure/post-procedure holding area. Currently, we have six radiologic technologists (RTs) and six registered nurses (RNs), with experience ranging from 1 to 26 years. Twelve cardiologists belong to the North Oaks Medical Staff. Two of our long-term cardiologists have 18 years and 24 years of experience, respectively.

What procedures are performed in your cath lab?

We perform left and right heart catheterizations, coronary, peripheral, carotid and cerebral angiography, percutaneous transluminal coronary angioplasty (PTCA), coronary (bare metal and drug-eluting) stenting as well as peripheral and carotid stenting, intravascular ultrasound (IVUS), fractional flow reserve (FFR), intra-aortic balloon pump (IABP), Impella (Abiomed), temporary and permanent pacemaker insertions and replacements, implantable cardioverter defibrillator (AICD) insertions and replacements, loop recorder insertions and removal, Rotoblator (Boston Scientific), PTA, transesophageal echocardiography (TEE), cardioversion, embolizations, coronary and peripheral thrombectomy, peripheral thrombolysis, peripheral atherectomy and pericardiocentesis.

In addition, our cath lab RTs assist our cardiothoracic surgeon with abdominal aortic aneurysm endograft insertion.

We average 50 to 60 procedures per week. 

If you are not performing transcatheter aortic valve replacement (TAVR) or any other hybrid procedure, is your lab planning a hybrid room in the future?

We do not perform TAVR at this time. With the recent addition of 14 new operating suites to our hospital, it is a procedure under investigation.

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

Our facility has had surgical backup for 21 years (since 1992).

How many of your diagnostic caths are normal?

Approximately 30% of our diagnostic caths are normal.

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

Radial access has gained popularity recently with some of our newer cardiologists.

Who manages your cath lab? 

Cath Lab Coordinator Carolyn Himel, RN, BSN, oversees daily operations in the lab. Charge Tech Patrick Slaven, RT(R)(CV)ARRT, ensures the daily schedule runs smoothly and inventory is up to par. Cardiologists William Kopfler, MD, Jherie Ducombs, MD, and James Parker, MD, serve as medical directors. Christi Marceaux, RN, serves as Assistant Vice President/Heart Health Services.

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

Yes. RTs scrub. RTs or RNs circulate and monitor. We have one RN cross-trained to scrub, circulate and monitor. All cath lab RNs are cross-trained to circulate and monitor.

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

Yes. Per the Louisiana Society of Radiologic Technologists Executive Director:  Only a physician or a licensed radiologic technologist is allowed to expose humans to ionizing radiation. This is governed by LRS 37:3200-3219. So the answer is yes, unless the physician performs fluoroscopy.

Which personnel can operate the x-ray equipment [position the image intensifier (II), pan the table, change angles, step on the fluoro pedal] in your cath lab? 

An RT can position the II, pan the table, change angles, and step on the fluoro pedal. Based on personal preference, the physician also may position the II, pan the table and perform fluoroscopy. RNs who scrub during procedures are allowed to position the II and pan the table. The physician or RT will perform fluoroscopy.

How does your cath lab handle radiation protection for the physicians and staff?

Every physician and cath lab staff member has two radiation film badges — one placed at neck level and the other at waist level. The physician also has radiation film rings. We receive a monthly radiation dosimetry report that is reviewed by the radiation safety office and the cath lab coordinator. The report is kept within the lab for staff and physicians to view. A cath lab staff member serves as the radiation safety liaison, attending all radiation safety meetings and reporting back to the staff. We utilize RadPads (Worldwide Innovations & Technologies, Inc.) for procedures that have a high risk for radiation exposure.

How does your lab communicate information to staff and physicians?

We use direct communication, monthly team meetings and email. An interdisciplinary Heart Health Leadership Team meeting is held bimonthly to review outcomes data and quality measures, identify trends, and evaluate new services and products. Heart Health Services staff, physicians and leaders of the various hospital departments we interact with are also in attendance (i.e., the emergency department and critical care services). 

We contact physicians by phone or text to inform them about procedures.

How is coding and coding education handled in your lab? 

We have a charge tech to enter charges and codes. Each case is reviewed to validate correct billing. Coding changes are communicated via formal staff education.

Who pulls the sheaths post procedure, both post intervention and diagnostic? What kind of training is mandated before someone can pull?

Both RNs and RTs pull sheaths post-procedure. New employees must complete an orientation process and prove competency before they are allowed to pull sheaths without direct supervision. This process requires the employee to pull 10 sheaths without complications with direct supervision by a mentor. Sheath pull also is covered in annual competency labs.

Where are patients prepped and recovered (post sheath removal)? 

Post-procedure patients return to our holding area. Hemostasis is achieved by manual pressure or vascular closure devices, if access or patient anatomy allows. Closure devices include Angio-Seal (St. Jude Medical), Perclose (Abbot Vascular) and Mynx (AccessClosure).

When using manual pressure to pull sheaths, we require that both an RT and RN are present. The RT pulls the sheath, and the RN monitors the patient.

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

Recently introduced technology includes the Impella left ventricular assist device, the EkoSonic Infusion System (EKOS Corp.) for thrombolysis of peripheral and pulmonary arteries, and the TruePath CTO device (Boston Scientific) to cross chronic total occlusions in the lower extremities.

How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies?

A charge tech oversees inventory and ensures par levels are maintained. Our health system utilizes a multidisciplinary value analysis team, spearheaded by our material services department, to ensure patient safety and care standards when considering the purchase of new equipment and new supplies.

Has your cath lab recently expanded in size and patient volume?

We were fortunate to expand our cath lab as part of a 10,000-square-foot expansion of our Heart Health Center in 2005. We continue to evaluate opportunities to grow our services.

Is your lab involved in clinical research?

We presently are not involved in clinical research. However, we are in the process of investigating the feasibility of such.

Can you share your lab’s average door-to-balloon (D2B) times and some of the ways employees at your facility have worked together to keep D2B times under the mandated 90 minutes?

Our average door-to-balloon time is 67 minutes. Our emergency department (ED) and cath lab have processes/protocols in place for when a ST-elevation myocardial infarction (STEMI) presents. EMS (Acadian Ambulance Service) works with the ED by notifying the ED of a STEMI in route. The EKG is transmitted to the ED physician. All STEMI cases are reviewed by the cath lab coordinator. We have implemented a STAT STEMI team that meets to discuss processes and ways to improve. This team consists of the ED director and coordinator, ED medical director, cath lab coordinator, AVP/Heart Health Services, and Performance Management. All staff and physicians involved in the care of a STEMI patient receive an email informing them of D2B times and letting them know how much their teamwork is appreciated. Also, the cath lab and ED have a whiteboard in the staff break room that lists monthly percutaneous coronary intervention times. All acute MI data is presented quarterly to our health system’s Quality Council group.

We are not registered with Mission: Lifeline or the D2B Alliance at this time.

Who transports the STEMI patient to the cath lab during regular and off hours?

A cath lab RT and cath lab RN will transport the STEMI patient to the cath lab during both regular hours and off hours. 

What do you do when the call team is already busy doing a procedure and a STEMI comes into the ED?

We have an action plan that calls for the utilization of intensive care unit (ICU) nurses in the event the cath lab call team is in an after-hours procedure. The hospital nursing supervisor coordinates the process and stays in constant communication with the cath lab team in procedure to gauge their progress. The hospital nursing supervisor will call out a second cath lab call team if the procedure in progress will not be completed in time to meet the D2B mandate for STEMI.

Is there a particular mix of credentials needed for each call team? 

We have a three-member call team, consisting of 2 RTs and 1 RN.

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

Team members must arrive at the cath lab within 30 minutes after notification.

Do you have flextime or multiple shifts? 

Hours of operation are Monday-Friday from 7:00 am-3:30 pm. We offer staff the choice of two weekday start time options—7 am or 8 am. Our call team covers all after-hours cases and also works weekends from 7 am-7 pm.

How do you schedule on call for staff?

A call schedule is made for the month and is issued to the staff two weeks prior to the start of the month. Call weekends fall in a rotation. For the cath lab techs, this is every third weekend, and for the cath lab RN, it is every fifth weekend.

Where is your cath lab located in relation to the surgical and emergency departments? 

On January 7, 2013, North Oaks Medical Center opened 14 new intra-operative operating suites as part of a $95 million expansion. The hospital addition is 232,000 square feet, and is focused on more privacy, advanced surgical services technology and expert staff. Our cath lab is located on the hospital’s second floor, adjacent to the new operating suites. The emergency department is positioned below the cath lab and operating suites on the first floor. A dedicated trauma elevator from the ED expedites care for emergent surgical and cardiac catheterization patients.

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

We have found benefit from bulk orders on high-volume supplies, consignment on high-price inventory, a creative staffing model, including implementation of a day off for each staff member during the week prior to their on-call weekend, and cross-training staff.

Has your lab recently undergone a national accrediting agency inspection? 

Not at this time.

What quality control measures are practiced in your cath lab?

The Cardiac Cath lab adheres to quality controls and quality assurance measures established by the American College of Cardiology, including metrics for appropriate maintenance of equipment, chart documentation and clinical outcomes (expected and adverse).

Are you recording fluoroscopy times/dosages? 

Fluoroscopy time is recorded for every procedure. The procedure RN documents fluoroscopy time in the cath lab nurse’s notes and the RT enters time into the Witt/Philips system. Fluoroscopy time is also dictated in the post-procedural report by the performing clinician.

Who documents medication administration during the case?

The cath lab RN.

Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) or any other outside data collection registry?

Yes, we participate in the NCDR-ICD registry, NCDR-Care registry and the Society of Thoracic Surgeons (STS) database.

How are new employees oriented and trained at your facility? 

New employees complete our general health system orientation program and a 90-day cath lab-specific orientation program. The new employee is precepted by a consistent senior staff member throughout the entire orientation process. The new employee is issued an orientation checklist that must be completed under the guidance of their preceptor by the end of the 90-day orientation period. For the first several weeks, the new employee focuses on the daily processes/procedures of the cath lab, followed by “buddy call” with their preceptor for the remainder of the orientation period.

What continuing education opportunities are provided to staff members?

North Oaks is committed to fostering a continuous learning environment to better equip present and future staff to meet the growing Northshore region’s current and future health care needs. North Oaks staffs a full-service education department that is approved as a provider of continuing education for the American Society of Radiologic Technologists, Clinical Laboratory Science, Louisiana State Nurses Association, and Social Work. Last year, classroom-based instruction offered by the department had a participation count of 10,000. More than 52,000 computer-based continuing education opportunities were completed. In addition, North Oaks contracts with HealthNet Systems, a satellite education resource, through which more than 1,300 courses were completed. Employees also have access to individual education sessions as needed.

An e-learning environment is utilized for annual training events. During an employee’s annual performance evaluation, areas in need of development are identified and addressed. A learning needs assessment also is conducted annually for employees. Results of the learning needs assessment and departmental requests assist in planning future educational offerings. An on-site staff education center with three designated employee training centers and a reference library are all available to cath lab staff. A 2,505-square-foot interactive training auditorium also is used for medical education, and is capable of simulating the patient environment to enhance the learning experience. Staff is also educated alongside our physicians on all new supplies/equipment and services prior to use.

Since 1967, North Oaks has operated its own School of Radiologic Technology, which is accredited by the Joint Review Committee on Education in Radiologic Technology (JRCERT). The School offers a comprehensive 24-month program that provides classroom and clinical instruction to prepare students for careers in the field of diagnostic imaging. Upon graduation, students are eligible to take the American Registry of Radiologic Technologists (AART) National Certification examination and apply for Louisiana state licensure. Since inception, graduates of the North Oaks School of Radiologic Technology have achieved a 100% passage rate on the national certification examination.

How is staff competency evaluated? 

We conduct annual hospital-wide and cath lab-specific competency labs every October. We review current processes, low-volume procedures, and high-risk procedures.

Does your lab have a clinical ladder? 

North Oaks is in the process of implementing a shared governance model to include a council on professional development and clinical ladders. 

How do you handle vendor visits to your lab? 

All vendors must register in RepTrax. Once the vendor checks in with the RepTrax system, a name badge is generated. The vendor must wear the name badge at all times during their visit. The vendors schedule meetings with the Cath Lab Coordinator. All vendors are required to stay in the cath lab break room. Only at physician request are vendors allowed in the cath lab.

What trends have you seen in your procedures and/or patient population? 

We are seeing an alarming uptick in the number of young adults presenting with coronary artery disease. 

What is unique or innovative about your cath lab and staff?

We have the pleasure and privilege of working alongside highly specialized physicians who truly value our input. 

Is there a problem or challenge your lab has faced? 

A challenge that North Oaks Health System is currently embracing is the implementation of electronic health record technology with industry leader Epic. Our physician group completed implementation in October and November 2012. North Oaks Medical Center and North Oaks Rehabilitation Hospital are scheduled to complete implementation in March/April 2013. The cath lab team continues to share our co-workers, medical staff and leadership’s commitment to training and preparation to ensure the transition goes as smoothly as possible. 

What is 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?”

Our hospital is located in Hammond, Louisiana, which is known as the “Crossroads of the South,” due to its proximity to the intersection of I-12 and I-55. Our region also has a population with a high incidence of heart disease, with heart disease being the number one cause of death in our home parish (county) of Tangipahoa. These factors contribute to our emergency department’s status as the third busiest emergency department in the state of Louisiana and a high volume of emergent cath lab patients. In response, our cath lab team has developed a culture of readiness and a commitment to outreach to educate our population on controllable risk factors and healthy lifestyle choices.

QUESTIONS FROM THE SOCIETY OF INVASIVE CARDIOVASCULAR PROFESSIONALS:

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, staff is not required to take the RCIS registry exam. We do have RTs who have taken advanced registry exams through the ARRT, passing the Cardiovascular Interventional (CV) registry and Cardiac Interventional (CI) registry. 

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.  

Cath Lab Coordinator Carolyn Himel can be contacted at himelc@northoaks.org. Charge Tech Patrick Slaven can be contacted at slavenp@northoaks.org.