Cath Lab Spotlight

Orlando Regional Medical Center

Sandra Tart, RT(R), BAOM, Orlando, Florida
Sandra Tart, RT(R), BAOM, Orlando, Florida
Tell us about your cath lab. Orlando Regional Medical Center (ORMC) is the only Level I Trauma Center in central Florida. It is the flagship hospital for Orlando Health, an eight-hospital organization. ORMC recently received full accreditation from the Society of Chest Pain Centers’ Accreditation Review Committee. We are the first Level I Trauma Center in Florida to receive this designation. The first cardiac catheterization was performed at ORMC in the mid-1960’s by Dr. Clarence Gilbert. We currently have six state-of-the-art cardiac cath labs. Four of our labs are dedicated to cardiac procedures and two labs are designed to accommodate both cardiac and peripheral procedures. The hospital also has a new endovascular suite utilized by the vascular surgeons. We have a very experienced clinical team comprised of nineteen registered nurses (RNs), ten radiologic technologists [RT(R)s], fourteen registered cardiovascular invasive specialists (RCISs), and one cardiovascular technologist (CVT). We also are fortunate to have a team of three clerical support staff. Over seventy cardiologists and six vascular surgeons are credentialed in the cath lab. Recently, our hospital was honored to host Dr. Morton Kern for an educational seminar. Dr. Kern shared his unique perspective of the cardiac catheterization environment and gave a presentation on fractional flow reserve (FFR) technology. What procedures are performed at your cath lab? We perform diagnostic and interventional cardiac procedures, as well as diagnostic and interventional peripheral procedures. The vascular surgeons also perform perm caths, arterio-venous (AV) fistula placements, and an assortment of complex procedures. Both cardiologists and vascular surgeons utilize the two labs that can accommodate peripheral procedures (interventional radiologists have their own suites in radiology). All staff disciplines are cross-trained to work in the peripheral labs; although there is usually a radiology tech in the procedure to facilitate filming. We average approximately 6,000 cardiac and peripheral procedures annually in the cath lab. Does your cath lab perform primary angioplasty with surgical backup on site? Yes. Our excellent surgical program provides surgical back-up to the interventional cardiologists 24/7. Our hospital is very fortunate to have many cardiovascular surgeons on the medical staff. ORMC has a renowned open heart program and recently received approval to start a heart transplant program. What procedures do you perform on an outpatient basis? Most of our procedures are offered on an outpatient basis. If the patient has an intervention, the cardiologist may choose to keep them overnight. Outpatients are prepped and discharged from our pre/post cath department. Patients that are being kept overnight are cared for by our dedicated cardiac intervention unit. What percentage of your diagnostic cath patients go on to have an interventional procedure? Due to the number of smaller community hospitals in the area that perform diagnostic caths, the majority of our cases are interventional. On average, less than 20% of our cases are diagnostic only. What is your female patient percentage? In 2008, 42% of our patients in the cardiac cath lab were female. As an organization, Orlando Health is dedicated to supporting and educating female patients, staff, and community. During February, the organization celebrates the American Heart Association’s “Go Red for Women.” Who manages your cath lab? Our cath lab management team is comprised of a business manager, an RT(R), an RCIS, and an RN. Do you have cross-training? Who scrubs, who circulates and who monitors? At ORMC, only nurses may administer medications. This necessitates that a nurse is always the circulator. The techs scrub and monitor, and several of our nurses have made the choice to cross-train in the scrub and monitor positions. Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab? We do not require an RT(R) to be in the room for all fluoroscopic procedures, but there are certain peripheral procedures that require the presence of an RT(R). 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? Some of our physicians choose to do their own panning, but any of our techs [RT(R), RCIS, RRT, or PN] may pan for the physician, position the II, and change the angles. ORMC is fortunate to have many team members that have been in the cath lab for years, and these individuals are often able to give the physicians the benefit of their vast experience and knowledge during difficult cases. How does your cath lab handle radiation protection for the physicians and staff that are in the lab day after day? The department monitors its radiation levels monthly. In addition, the organization has a corporate radiation safety department monitoring and educating team members and physicians. Annual radiation safety education is required for all staff members. What are some of the new equipment, devices and products recently introduced at your lab? Due to the size of our facility and the high procedure volume, vendors vie to introduce new products at ORMC. Currently, we are trialing the EKOS ultrasound-accelerated infusion catheter (Bothell, WA) and starting a study for the Medtronic Endeavor Resolute stent (Minneapolis, MN). We are working with Boston Scientific to introduce a new integrated IVUS system (Natick, MA) and we are upgrading to the new AngioJet system (Medrad, Inc., Warrendale, PA). Can you describe the system(s) you utilize? ORMC uses the Siemen’s Axiom Artis (Malvern, PA) in all of our cath labs. For hemodynamics, we use Horizon Cardiology (McKesson, San Francisco, CA). We are currently investigating the possibility of upgrading to version 12.0. In addition, the organization is in the process of planning the implementation of a new cardiovascular information system (CVIS) to refine the processes for all our cardiovascular patients. How is coding and coding education handled in your lab? Our coding department receives a copy of every patient’s hemodynamics report and the associated charges. If there are any discrepancies, one of the coding department personnel will contact the cath lab tech who monitored the case for a clarification. How does your lab handle hemostasis? We are fortunate to have a pre/post cath recovery unit that attains hemostasis on most of our diagnostic patients. We also have a post intervention unit for all patients staying overnight. In addition, several of our cardiac and vascular nursing units have trained personnel that can pull sheaths. When a physician wishes to utilize a closure device, we can offer AngioSeal (St. Jude Medical, Minnetonka, MN), Perclose (Abbott Vascular, Redwood City, CA), Mynx (AccessClosure, Inc., Mountain View, CA), StarClose (Abbott Vascular), and Boomerang (Cardiva Medical, Inc., Sunnyvale, CA). Only our physicians may deploy a closure device. We also have FemoStop (Radi Medical Systems, Wilmington, MA) for those situations where we are having difficulty attaining hemostasis. What is your lab’s hematoma management policy? ORMC endeavors to maintain a very low complication rate. Whenever there is a hematoma, it is recorded and tracked. Our QA coordinator watches for any trends in physicians, staff, or procedures. Re-training is utilized whenever necessary. How is inventory managed at your cath lab? The hospital has a cardiology supply chain department that manages the inventory for the cath lab, electrophysiology lab, and interventional radiology. As part of our future CVIS, we hope to automate our inventory system. Cardiology supply chain personnel work closely with materials management to obtain the best equipment available. Has your cath lab recently expanded in size and patient volume, or will it be in the near future? Our facility renovated several years ago and added a sixth lab. There are no plans in the immediate future to further expand our department. Is your lab involved in clinical research? We have several physicians currently involved in clinical trials. The organization and its physicians are always striving to stay on the cutting edge of technology. One of our cardiologists is involved in the ROX COPD study. This study, sponsored by ROX Medical (San Clemente, CA) is investigating the Rox Anastomotic Coupler System (ACS), inserted through an AV fistula (iliac vein and artery) to allow oxygenated blood to flow back to the pulmonary system. Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? ORMC is a Level I Trauma center, so we see some of the sickest patients in the community. Many of the outlying hospitals transfer their critical patients to our organization. Due to our willingness to treat these types of patients, we do occasionally have a complication that will require transfer to surgery. 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? While mandated DTB time is 90 minutes, ORMC strives to be below those guidelines. For fiscal year 2007, our average DTB time was 83 minutes. In 2008, it went down to 79 minutes and in 2009, it dropped to an average of 64 minutes. We anticipate continued improvement. We provide ST-elevation myocardial infarction (STEMI) services for several of the community’s outlying hospitals and those transfers will sometimes skew our DTB numbers. We are actively working with those hospitals to improve their STEMI processes. In an effort to reduce our DTB time, the organization implemented a 24/7 team in the cath lab. During the latter half of 2008, the cath lab hired and began training many new team members to fill these slots. Currently, we are fully staffed 24/7. During our recent Chest Pain Center survey, this practice was praised by the surveyors. There is always a call team on backup to cover any additional emergent cases. The cath lab works closely with the cardiologists, the patient care coordinator (PCC) and the emergency department (ED) to refine the STEMI process and further reduce our times. Another component of the process is the relationship developed with our local EMS teams. Often, the STEMI patient can be identified in the field, which reduces lag time when they arrive in the ED. ORMC continues to work to identify any areas where the DTB can be reduced and thus improve patient outcomes. Personnel from the emergency room and EMS rotate through the cath lab as observers in order to create a stronger relationship between the various departments. What measures has your cath lab implemented in order to cut or contain costs? While always a cost-conscious organization, the current economic times have forced ORMC to re-double its cost containment efforts. Whenever possible, high-dollar interventional equipment is on consignment. Staff and physicians are encouraged to reduce inventory waste. Equipment is always being reviewed to reduce duplications. Any new equipment requests go through the Medical Economic Outcomes Committee to ensure the benefits justify the cost. Finally, the staff flexes their time on slower days. What type of quality control/quality assurance measures are practiced in your cath lab? We have a dedicated quality assurance coordinator that monitors our DTB time, but also performs audits on various other areas. Sometimes these audits are organization-wide and sometimes they are specific to the cath lab. In addition, we have a dedicated unit base educator who works to ensure all team members stay current in their clinical and procedural knowledge. This helps the department provide an outstanding level of quality care. How does your cath lab compete for patients? Has your institution formed an alliance with others in the area? Our organization has several satellite hospitals which feed us patients. There are other organizations in the area, but ORMC believes the skills, knowledge, and reputation of our team lead the referring physicians and cardiologists to send their patients to us. How are new employees oriented and trained at your facility? Our unit educator has developed an outstanding orientation program. Each new team member is partnered with an experienced preceptor who oversees the orientation. The orientation encompasses every aspect of the cath lab. Team members are not released until the department educator, preceptor and management team all agree they are ready to perform solo. Due to our expanding coverage hours, we have many new employees. The new members are offset by the many employees we have who have been with the department for ten or more years. Only a few of our new team members came to us with cath lab experience. Several others transferred in from other areas in the hospital. We have hired new RRTs, RNs, RT(R)s, and RCISs. What continuing education opportunities are provided to staff members? The cath lab team is offered a wonderful variety of education opportunities. Vendors are encouraged to provide formal continuing education unit (CEU) opportunities on their lab days. These vendors often offer free CEUs on their websites. In addition, the hospital often provides CEU opportunities that are not specific to the cath lab. Team members recently had the opportunity to attend a free, day-long seminar called HEARTBEAT 2009. This seminar was spearheaded by the cath lab educator. Several cardiologists donated their time to advance the knowledge base of the cath lab team. This program was open to staff throughout the organization and attendees received multiple CEUS, depending on the licensure. How do you handle vendor visits to your lab? Vendors are only allowed in the lab to provide in-service training or clinical support. They are restricted to a specific area and may not actually enter the labs unless a physician has specifically requested their clinical support. All vendors must report to materials management to receive their temporary pass and unless they have been placed on the vendor calendar, they will not be issued a badge. The vendors are used to our stringent guidelines and for the most part, are compliant. How is staff competency evaluated? Annual competencies are required organization-wide. In addition, cath lab-specific competencies are added when necessary. Team members have bi-annual coaching plans in order to give and receive feedback on their daily performance. Does your lab have a clinical ladder? The organization has clinical ladders for both the nurses and the techs. The clinical ladder for the techs was implemented recently to offer our techs a change to grow professionally. How does your lab handle call time? Our call teams are generally comprised of two nurses and two techs. ORMC pays a flat hourly rate for call. If there is not an in-house team available, call team members are required to arrive within thirty minutes. There is not always a cardiologist in-house, but they are held to the same thirty minute time-frame. With the implementation of the 24/7 team, the patient is usually ready in the lab when the cardiologist arrives. Does your cath lab do electives on weekends and or holidays? We currently provide elective services for inpatients on the weekends with the in-house team, but generally we only provide emergent services during the holidays. In addition, we offer outpatient slots on the weekends for those patients that cannot schedule their procedures during the week. Holidays are handled with a call team. Has your lab has undergone a Joint Commission inspection in the past three years? The hospital went through the Joint Commission survey this past summer. My strongest recommendation for cath labs preparing for a survey is to avoid the “gearing up” quagmire. Many organizations rush to refine their procedures and policies right before a survey. If you maintain a high level of standards year-round, then there is no need to fear a survey. ORMC’s administration encourages its team members to be “ever ready”. We could successfully undergo a survey any day or time. Where is your cath lab located in relation to the OR and ED? The 5B wing, where the cath lab is located, is shaped like a horseshoe. The cath lab sits in the center of Open Heart, CCU, ICU, and CVRR. The ER is located on the first floor. They have access to the cath through a dedicated elevator that can be controlled by security during a STEMI. How do you see your cardiac catheterization laboratory changing over the next decade? As more community hospitals start performing elective interventions, we see our facility becoming more dedicated to critical cases. ORMC will continue to offer state-of-the-art interventions for all patients. Please tell the readers what you consider unique or innovative about your cath lab and its staff. The sheer volume of procedures performed at our facility is different than most facilities. Our staff is one of the things that makes us unique. As a team, our cath lab staff has over five hundred years experience. We have several employees that have been on staff for over twenty years. This experience, combined with our Level I Trauma Center and accredited Chest Pain Center with PCI designation, makes us a truly unique facility. 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”? Orlando is one of the tourism capitals of the world. We see patients from every country and culture. In addition, this area is home to citizens from diverse cultural backgrounds. Having so many different cultures is one area creates unique challenges. ORMC works to meet the needs of every group, no matter how small. We are proud to be say that we have the only board-certified Muslim chaplain in the state of Florida on staff at ORMC. Ashiq Kermalli is one of only five board-certified Muslim chaplains in the United States. Central Florida is also home to many senior citizens. We have many ‘snowbird’ residents, who live in this area only during the winter months. This practice means the average age of our patient is higher than seen in many demographics. ORMC is dedicated to meeting the diverse physical, emotional, and spiritual needs of all our patients and team members. The cath lab culture reflects this organizational policy. The Society of Invasive Cardiovascular Professionals (SICP) has added two questions to our spotlight: 1. Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? Do staff receive an incentive bonus or raises upon passing the exam? New CVT graduates are required to take and pass the RCIS examination. When the clinical ladder for the invasive specialists is implemented, team members will be rewarded for attaining RCIS certification. 2. 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? All clinical members are encouraged to participate in the various professional societies. It is not required. Sandra Tart can be contacted at