Oakwood Hospital & Medical Center (OHMC) in Dearborn has served southeast Michigan for more than 50 years. This 623-bed full-service teaching hospital offers state-of-the-art emergency medicine, general medicine and surgery. OHMC provides excellent acute care, with more open-heart surgeries than any other hospital in metro Detroit. This campus is also the hub for Oakwood’s centers of excellence in Heart & Vascular, Orthopedics and Neurosciences, Women’s Health and The Center for Cancer Care. The facility is accredited by The Joint Commission.
Tell us about your cath lab.
In the heart catheterization lab, there are four labs with approximately 700 square feet per lab. OMHC has two dedicated cardiac labs and two combo cardiac/peripheral labs. We have approximately 55 staff members, 45 clinicians, and 10 ancillary staff, including administrators, secretaries, patient representatives, and a supply coordinator. We have staff that have been “in residence” for over 25 years. There are approximately 40 physicians with privileges in our lab.
What procedures are performed in your cath lab?
We perform diagnostic cardiac caths and interventions, diagnostic peripheral procedures and interventions, patent foramen ovale (PFO) closures, and valvuloplasty; insert permanent pacemakers, bi-bentricular pacemakers, implantable cardioverter-defibrillators (ICDs), and left ventricular assist devices (Impella, Abiomed); and utilize imaging technologies such as intravascular ultrasound (IVUS) and opical coherence tomography (OCT). We perform approximately 125 procedures per week.
What percentage of your patients is female?
Of the nearly 8000 procedures performed in the last year, 42% were in female patients.
What percentage of your diagnostic caths is normal?
Thirty-five percent of our procedures are followed by intervention and 16% of our procedures have non-significant disease with lesions of 50% or less. Our normalcy rate is below the national average.
Do any of your physicians regularly gain access via the radial artery?
Yes, many of our physicians are gaining access through the radial artery; however, the majority of our procedures are done via the femoral approach.
What other modalities besides angiography are used to verify stenosis?
We are a fractional flow reserve (FFR)-, OCT-, and IVUS-equipped lab, so there is not only an angiographic assessment of the vessel, but we can also visualize with IVUS/OCT and incorporate FFR physiologic measurements if needed.
Who manages your cath lab?
Steve Le Moine is the director of cardiology services, Michelle Moul, RN, BSN, is the clinical nurse manager, and Mary Jo Usher-Plank is the assistant clinical manager.
Do you have cross-training? Who scrubs, who circulates and who monitors?
We do have some cross-training; however, the majority of the staff is not cross-trained. Registered nurses (RNs) circulate all cases. Our registered cardiovascular invasive specialists (RCISs), cardiovascular technologists (CVTs) and RNs monitor cases, and registered radiologic technologists [RT(R)s], RNs, RCISs and CVTs scrub cases.
Does an RT(R) have to be present in the room for all fluoroscopic procedures in your cath lab?
We do have registered radiological technologists as staff members, but an RT(R) is not required to be present during cases. The entire cath lab staff, including physicians, is required to be competent in radiation safety, undergoing annual training.
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?
Every member of the team that scrubs with the physician has been trained to pan, change angles and to control the fluoro pedal if asked. Training is done by the physician and an experienced scrub technologist until both feel that the new scrub is appropriately qualified. We have a check-off list of criteria that must be completed.
How does your cath lab handle radiation protection for the physicians and staff?
Lead aprons, protective eyewear, and shielding are utilized by staff and physicians for each case. There is a mandatory annual radiation training for all staff members and physicians. All staff wear dosimeter badges that are monitored on a monthly basis. Radiation reports are posted on the unit in the ‘mandatory read’ file. Excess exposure is reported directly to the staff member or physician in the form of a letter from the outside monitoring company.
What are some of the new equipment, devices and products introduced at your lab lately?
As everyone in this field is aware, products and devices are always changing. To help, we have instituted a Products Committee. Prior to committing to the purchase of a new device, a trial is performed to judge the device’s efficacy and value. Members of the committee include staff and administration, with some help from our physicians. The most recent trial was for our optical coherence tomography (OCT) unit.
How does your lab communicate necessary information to staff?
Monthly staff meetings are conducted by the manager with input from administration and our medical director. A monthly cardiac section meeting is held and facilitated by the medical director. The hospital has initiated a Huddle Program where hospital, department and personal news is disseminated every day and during every shift. The department has a newsletter with contributions from staff and administration. Our ‘mandatory read’ file is utilized to ensure that all staff is receiving the same information related to changing policies and procedures.
How is coding and coding education handled in your lab?
The staff members that monitor have been trained to enter the cath lab charges that are hard-coded with the CPT (Current Procedure Terminology) procedure. We have two dedicated staff members that review the charges for accuracy and work closely with the coding compliance department. The ICD 9 coding is done by the HIM (Health Information Management) department.
Where are patients prepped and recovered (post sheath removal)?
We have two holding areas, a six-bed pre-op and a sixteen-bay post holding area. There are nine RNs and two business office assistants staffing this area. We employ a variety of closure devices such as the Mynx (AccessClosure), Angio-Seal (St. Jude Medical), TR Band (Terumo) and Perclose (Abbott Vascular). We also use manual pressure. Our clinical staff is required to pass an initial competency for sheath removal as well as a yearly competency. Patients who have diagnostic caths are discharged from our post area and patients who receive an intervention are monitored until groin management is complete and a ready bed is available.
What is your lab’s hematoma management policy?
How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies?
A few years ago, our cath lab acquired an inventory management system, SpaceTRAX (Stanley Healthcare Solutions), managed by an inventory manager and other members of the staff. Par levels have been set and the system will flag any items that need to be ordered. Random cycle counts are done to ensure the accuracy of the system.
Has your cath lab recently expanded in size and patient volume, or will it be in the near future?
The cath lab has attained some new physicians and is always looking for ways to expand, although there are no immediate plans for expansion at this time.
Do you have a hybrid cath lab, or are you planning to build one?
A few years ago, a hybrid lab was built in the operating room for vascular surgery and is maintained by our interventional radiology department. We have used the hybrid lab for a few peripheral procedures where a vascular surgeon has performed a cut down so the cardiologist could insert the catheter.
Is your lab involved in clinical research?
Yes, we have a cardiac clinical research department that is active in many clinical trials. Currently we are actively enrolling in seven trials and doing follow-up in five. Some of the trials include:
- SOLID: The stabilization of plaques using darapladib-thrombolysis in myocardial infarction 52 trial (SOLID-TIMI 52);
- TOPCAT: Aldosterone antagonist therapy for adults with heart failure and preserved systolic function;
- PROMISE: Prospective multicenter imaging study for evaluation of chest pain;
- IMPROVE-IT: Examining outcomes in subjects with acute coronary syndrome: Vytorin (Ezetimibe/Simvastatin) vs simvastatin;
- TAO: Effect of otamixaban vs unfractionated heparin + eptifibatide in patients with unstable angina/non ST elevation myocardial infarction undergoing early invasive strategy;
- XIENCE: Xience V everolimus-eluting coronary stent system USA post-approval study (Xience V USA long term follow-up cohort).
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?
Currently, our year-to-date D2B time is 58 minutes and our percent of cases less than 90 minutes is 100%. One of the initiatives put in place to work on our D2B time was a one-call activation of the physician and staff. We also have our first responding cath team member go directly to the emergency room (ER) and help transport the patient to the lab. Well-defined electrocardiogram (EKG) criteria, the ER physician initiating the activation, and the ability to send an EKG to the cardiologist via smart phone technology have all been instrumental in helping us reach our goal. We are also registered with the American Heart Association’s Mission: Lifeline.
What measures has your cath lab implemented in order to cut or contain costs?
With the benefit of an inventory system, we try to maintain a lower on-hand inventory count and only order as par levels indicate. The system also provides tracking of near-expired items for immediate use or return to the vendor. We have also tried to consign as many higher-priced items as possible. A goal of the Products Committee is to closely examine the need for new products and to eliminate duplication of products. If a new product is brought in to replace another product, we will not use the new product until the old product is consumed.
What quality control/quality assurance measures are practiced in your cath lab?
At the physician level, there are numerous committees set up to assure quality and excellence. At the administrative level, quality and safety are constantly evaluated and analyzed. At the department level, in-service training, chart reviews, unit council, and department audits related to safety and quality are ongoing.
Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) or any other outside data collection registry?
We are currently using the ACC-NCDR, along with the Blue Cross Blue Shield Michigan Consortium (BMC2).
How are new employees oriented and trained at your facility?
New employees work one-on-one with a preceptor. A series of skills and experiences are outlined for mastery and exposure. Experience would include lab time along with holding area time. Some training is provided via computer testing that is mandated by the hospital. Orientation time is generally two to three months, depending on the level of experience of the new employee. We presently have only two staff members with less than a year of experience: an RN who comes to us from the ER with a few years of critical care and an RCIS who graduated from her program in March 2011. She worked with us as a trainee for about six months before she graduated.
What continuing education opportunities are provided to staff members?
We have a cardiothoracic conference every week where cases studies are discussed. The audience is a mixture of physicians and staff.
How do you handle vendor visits to your lab?
We do not have lab days for vendors. We only have vendors in the lab when a physician requests they be available for a case. Other vendors who want to check on product or share new products must schedule an appointment. All vendors must sign in with Vendormate and wear a badge. Once in the department, they must sign in at the front desk and wear a white hat when in the rooms.
How is staff competency evaluated?
Yearly education is provided via computer presentations and post-tests. We also a have yearly groin management, arterial access, i-STAT (Abbott), oximeter and ACT (activated clotting time) competencies. We have a unit educator who provides in-services related to clinical care.
Does your lab have a clinical ladder?
Not a true clinical ladder. Presently, we have an opportunity for our CVTs to take their registry exam and then be placed into a RCIS job code that comes with a financial reward.
How does your lab handle call time for staff members? Is there a particular mix of credentials needed for each call team?
Each call team consists of four members: two RNs, a monitoring person (usually a CVT or an RCIS) and a scrub [usually an RT(R) or RCIS]. Call starts at 5:30 pm or the end of the individual’s shift, and goes to 6:00 am the next morning.
Within what time period are call team members expected to arrive to the lab after being paged?
Everyone, staff and physicians, is expected to respond and be present in the lab within 30 minutes. We do not have attending cardiologists who are on site 24/7.
Do you have flextime or multiple shifts?
We have a variety of shifts, including 8-, 10-, and 12-hour shifts.
Has your lab recently undergone a national accrediting agency inspection?
This past year, we had a Joint Commission inspection and passed with flying colors. Advice we would give would be to make sure you have a good time-out for each procedure. Also, make sure that any medications on the tables are labeled completely and correctly. We have been doing both of these things for years, but it seems that there was a great deal of emphasis on these two factors during our recent survey.
Where is your cath lab located in relation to the operating room (OR) and emergency department (ED)?
We are across the hospital from the operating room and above the ER.
What trends have you seen in your procedures and/patient population?
Our population appears to be getting younger. At one time, it would have been rare to see 30- and 40-year-olds having elective and emergency procedures, but now it is fairly common.
What is unique or innovative about your cath lab and staff?
Our staff and physicians come from a variety of disciplines and cultures, and have varied education and experiences. We have grown as a team not in spite of our diversity, but because of it. There is a great deal of respect for what each team member brings to the table. That respect has allowed us to grow and achieve good outcomes for our patients.
Is there a problem or challenge your lab has faced?
Improving our D2B time has been a challenge that we have met very successfully. Collaborating with area fire departments and the emergency room, we were able to bring our D2B time from 70% compliance up to 100%. Realizing that no one entity was going to be able to achieve any success alone, we built a team and it was then that we were able to meet our goals.
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?”
Our hospital is situated in Dearborn, Michigan, which has one of the largest Arab populations in the country. Developing our lab staff to be educated and sensitive to this population has made us a stronger team and improved our “cath lab culture.”
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?
Obtaining the RCIS is not mandatory at this time; however, we have instituted a monetary incentive for those CVTs who meet criteria and obtain their 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.
The authors can be contacted via Michelle Moul RN-Clinical Manager, at Moulm@oakwood.org