Tell us about your facility and cath lab.
Penn Medicine Chester County Hospital is a 244-bed, non-profit hospital located in West Chester, Pennsylvania. Our invasive cardiovascular department consists of 3 invasive suites and a 6-bay pre and post holding area. We have 18 employees (full-time, part-time and per diem), including 10 registered nurses (RNs), 5 registered cardiovascular invasive specialists (RCISs)/registered radiologic technologists [RT(R)s], 1 unit secretary, 1 patient care technician level III and 1 patient care technician I. We have an extremely low turnover rate. A number of employees have been with the hospital for many years, with 6 employees >5 years, 5 employees >10 years, 5 employees for >20 years and 1 employee >30 years.
What procedures are performed in your cath lab?
We perform diagnostic and interventional cardiac cath procedures, diagnostic and interventional peripheral vascular procedures, electrophysiology (EP) studies and ablations, and EP implant procedures. Also, any cardiovascular testing procedures that require hemodynamic monitoring and nursing care are performed in our cath lab holding area. Each week we perform an average of 35-45 invasive procedures and 10 cardiovascular tests.
What percentage of your diagnostic caths is normal?
Our diagnostic normal rate runs about 35-40%.
Do any of your physicians regularly gain access via the radial artery?
We have 4 interventional cardiologists who all routinely use the radial artery for access. We are currently in the second year of our radial program, and continue to increase our volume of radial versus femoral artery for access. Over the last year, we performed approximately 70% of our diagnostic procedures using the radial artery, and 60% of our interventions. We typically use the brachial vein for right heart procedures, alleviating the need to use the femoral access site.
What are some of the new equipment, devices and products recently introduced at your lab?
With a recent update to our moderate sedation policy, CO2 monitoring has been established throughout the cath and EP labs, including for testing procedures. We are currently using the Quattro catheter (Zoll Medical) for all cardiac arrest patients who meet the criteria for therapeutic hypothermia.
Who manages your cath lab?
We have a collaborative approach to the management of the invasive labs. The director of cardiology oversees invasive cardiology, non-invasive cardiology, cardiac rehab and the neuro-diagnostic lab. The assistant director of the invasive labs is responsible for the daily operations of the cardiac cath, electrophysiology, and peripheral vascular labs. The nurse manager and clinical educator are responsible for the RN staff in invasive cardiology and cardiac rehab, and also handle education for all of cardiology. The clinical manager for invasive cardiology is responsible for all of the technical devices and equipment in the department.
Who scrubs, who circulates and who monitors?
Only an RN circulates, and only an RCIS or RT(R) scrubs. All staff is cross-trained to monitor. What makes our staff unique is that we not only cross-train through the different rolls in a cardiac procedure, but we also cross-train through the different specialties. We do not have a designated EP or peripheral vascular team. Everyone works in cardiac cath procedures and then is trained in either electrophysiology or peripheral vascular. Some staff is trained in all three areas.
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?
RT(R)s, RCISs, and physicians can operate all functions of the x-ray equipment in the labs.
How does your cath lab handle radiation protection for the physicians and staff?
Physicians and staff are individually assigned and fitted for lead aprons and thyroid shields. Protective eyeglasses are available and strongly recommended for all staff. Each employee has two radiation badges and monthly dosage reports are reviewed by a nuclear physicist. We provide an annual in-service with our nuclear physicist on radiation safety practices, and offer online radiation education opportunities. Our lead aprons are visually inspected and tagged annually.
How does your lab communicate information to staff and physicians to stay organized and on top of change?
We recognize that it is important to distribute information in many ways. All staff members and physicians have a hospital email address, so it makes it easy for us to quickly distribute information to a large group of people. Staff and physicians also have access to the hospital intranet for up-to-date information on hospital communication. We hold a monthly staff meeting and a monthly medication safety meeting. The department has a multidisciplinary unit council, which represents our department with any inter-departmental changes or challenges, and for any hospital-wide initiatives. Many of our staff belongs to a hospital committee, so we created an electronic folder in which cath lab staff can view the stored meeting minutes, and they can also save minutes to this file from meetings they have attended. We still keep a traditional communication book, where all updates, handouts, reports, e-mails, and minutes are filed in paper form. Staff is asked to read their email at least once a week and read the communication book monthly.
How is coding and coding education handled in your lab?
Cath lab staff charge for each case using the charge master sheet. Each item has a code associated with the procedure. Procedure codes are updated by our cardiovascular revenue cycle manager in accordance to Medicare changes on an annual basis. The interventional cardiologists and cardiovascular nurse practitioners receive guidance on documentation through our case management department and from clinical documentation specialists.
Who pulls the sheaths post procedure, both post intervention and diagnostic?
The technologists pull most of the sheaths while the patient is in the cath lab, but if the sheath remains in place, the RNs in the cath lab or post interventional unit will pull them. Initial training requires a preceptorship with a cath lab technologist, and an annual review is required to maintain competency. Currently, only the physicians and technologists remove radial sheaths.
Where are patients prepped and recovered (post sheath removal)?
Patients are received, prepped and recovered in our 6-bay cath lab holding area. Outpatients check in at our cardiovascular center, which is our centralized patient registration and scheduling center for all cardiovascular procedures. What is unique about our lab is our one-stop philosophy of focused care. Patients are prepped, treated and recovered in the same area, which delivers personalized care; as a result, our patients have given us very high patient satisfaction scores. Recovery for most patients is in our holding area. The sheath is removed in the cath lab post case or in the holding area, depending on patient volume. Manual pressure is used for most diagnostic cases and radial cases utilize an inflatable wristband. Interventional patients who have a bed on our post-interventional unit are moved directly to their bed post case with their sheath in place or the physician will deploy a hemostatic closure device when appropriate.
How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies?
We have a dedicated inventory specialist who works in conjunction with the materials management department. They utilize an electronic inventory control system and order supplies on a “just-in-time” basis.
Has your cath lab recently expanded in size and patient volume, or will it be in the near future?
The interventional labs are used for cardiac catheterization, EP device implants and ablations, and peripheral vascular cases. We have one lab dedicated to cardiac catheterization, one lab that shares time for cardiac catheterization and EP device implants, and one lab that shares time for peripheral vascular cases and EP ablations. The volumes for all three of these services have leveled off over the last couple years, with a slight growth in the peripheral vascular volume. We are maximizing the use of our three labs with potential for growth and expansion in the future. We are now one of four hospitals under Penn Medicine, which is world-renowned for its clinical and research excellence. Our hospital is building a new patient tower that expands bed capacity adding 72 single patient beds. Since becoming part of the Penn Medicine Heart and Vascular Center, and the building of the new tower, the hospital is well positioned to expand interventional lab services.
Is your lab involved in clinical research?
Yes, we have participated in several clinical trials in collaboration with our cardiologists. Our staff also participates in nursing research. Recent projects have been “Project RED” (Re-Engineered Discharge) and hands-only CPR training for family members of patients who are at high risk for sudden cardiac death.
Can you share your lab’s average door-to-balloon (D2B) times?
Our average D2B time for calendar year 2012 was 64 minutes. Keeping the times less than 90 minutes has been a real team effort. Our cath lab data coordinator and our medical director meet with paramedics and the emergency department (ED) frequently to review cases and to look at ways to improve the process. During off-hours ST-elevation myocardial infarctions (STEMIs), our hospital-based paramedics carry a pager and start to prepare the procedure room while the on-call team makes their way to the hospital. Once two of the three team members have arrived, they call the ED to have the patient transported to the lab. Following the procedure, a real-time summary is distributed by email to the paramedics, ED, cath lab, physicians, and various departments within the hospital. It lists a breakdown of the time the patient spent in each area, what we did well, and where we could make improvements. Penn Medicine Chester County Hospital is registered with the American Heart Association’s Mission: Lifeline, and the American College of Cardiology’s (ACC’s) D2B Alliance. We are also a Certified Chest Pain Center, and recently achieved Accreditation for Cardiovascular Excellence (ACE).
Who transports the STEMI patient to the cath lab during regular and off hours?
During regular and off hours, the ED transports the patient to the cardiac cath lab. During regular hours, the cardiovascular nurse practitioners respond to the STEMI page, and assist with the transport.
What do you do when the call team is already busy doing a procedure and a STEMI comes into the ED?
It would depend on where the team is in the procedure and what type of procedure is being performed. If the patient on the table is non-emergent, they stop the procedure and tend to the STEMI patient. If we have two STEMIs simultaneously, the interventionalist makes the decision of whether or not to transfer one of the patients to another facility. We do not delay treatment.
What measures has your cath lab implemented in order to cut or contain costs?
As a hospital, we have leveraged our relationship with VHA (Voluntary Hospitals of America) on a cost reduction process that led to us to receiving the VHA award for supply chain management excellence in 2011. In the invasive cardiology area, over 1.3 million dollars was achieved in savings, with over 850,000 realized in implantable devices. The cath lab RN staff worked with pharmacy on cost reduction in medications utilized in the lab. As part of a hospital-wide initiative, contrast use was evaluated and standardized using only a low-osmolar agent. With the exception of acute renal failure cases, iso-osmolar agents are no longer available for use.
Cath lab staff is also involved in inventory control and cost reduction. Inventory is checked and ordered on a daily basis. Utilizing a just-in-time inventory model is the most efficient way to hold inventory cost to a minimum in the cath lab. Our inventory specialist also routinely investigates ways to reduce expenses.
We have a real-time peer review process that checks for accuracy in the procedure report after each case. At this time, the technologists reconcile the inventory used to the charge sheet, which has significantly reduced errors in charging.
Cath lab staff is cross-trained in all three areas of invasive services: cath, EP and peripheral vascular procedures, leading to a more efficient staffing model. In addition cath lab nurses also work in the holding area, prepping and recovering patients. RNs are also responsible for cardiac testing, transesophageal echocardiograms, cardioversions and tilt table testing. Due to the cross-training of staff, the full-time employee (FTE) cost of running the lab is reduced, contributing to our model of being a low-cost provider.
Tell us about the quality control (QC)/quality assurance (QA) measures practiced in your lab.
Many QC/QA measures are performed by staff during down time. We have a peer-to-peer review process for procedural documentation, making sure the procedure report meets specific criteria. Staff reviews the physician reports for completeness. The physicians perform a peer-to-peer review for images and documentation. We look at procedural fluoro times and contrast volumes for each physician on a monthly basis. The quality manager applies appropriate use criteria to all interventional procedures, and any procedures that fall outside guidelines are reviewed at the interventional section meeting. We report our diagnostic and interventional procedures to the ACC-National Cardiovascular Data Registry (NCDR), our implantable cardioverter defibrillators (ICDs) to the ICD Registry, and our myocardial infarction data to the ACTION Registry.
Are you recording fluoroscopy times/dosages?
We record our fluoro time in seconds and our patient dose in milligrays. As part of our ongoing quality assurance process, this data is reported to the ACC-NCDR, allowing us to monitor and benchmark ourselves nationally and against like-size facilities.
Who documents medication administration during the case?
Both the circulating RN and the monitor person document medications, utilizing the electronic barcode scanning system and documentation in the procedure report. This important safety initiative ensures that potentially unsafe drug interactions are avoided, as well as adds an additional screening tool for drug allergies. A recent collaborative practice improvement initiative between interventional radiology, information technology (IT) and the cath lab resulted in the development of an auto stop occurring for metformin medications in any patients that receive contrast. An alert is then sent to the physician.
How does your cath lab compete for patients? Has your institution formed an alliance with others in the area?
Our lab competes for patients through our high quality and low cost initiatives. The cardiology department has received accreditation in the areas of echocardiology, our cardiac nuclear stress lab and cardio-pulmonary rehabilitation. Recently, the cardiac cath lab became the eleventh hospital in the nation and the only hospital in our region to be awarded Accreditation for Cardiovascular Excellence (ACE). We were also the area’s first Certified Chest Pain Center and we hold a number of community outreach programs to educate the community on the risk of cardiovascular disease. Penn Medicine Chester County Hospital recently became the fourth hospital in the University of Pennsylvania Health System.
How are new employees oriented and trained at your facility?
It is our good fortune to have very little turnover; however, when staff is hired, they first complete the general hospital orientation. A preceptor is matched to the new employee for the 60- to 90-day orientation to the cath lab. Job- and role-specific competencies have been developed to validate current and acquired knowledge as the orientee proceeds through the experience. On a regular basis, the orientee, preceptor, and manager sit down to review the goals achieved. An orientation binder is supplied with recommended articles, forms, and checklists to guide the orientation process. We actively mentor students from regional cardiovascular technology programs as well as student nurses, students from allied health programs, and high school students considering a healthcare career.
What continuing education opportunities are provided to staff members?
Among the educational opportunities for our staff are monthly case reviews with all staff, physicians, and nurse practitioners, and a guest lecture series that has visiting experts in interventional cardiology present on new techniques and/or management strategies for cardiovascular disease. Any member of the team may apply to attend an off-site educational meeting. Conferences attended in the recent past include the Heart Rhythm Society Scientific Session, ACC-NCDR annual meeting, and Cardiovascular Research and Technologies Conference. If a staff member attends any off-site program, they return and give a presentation to the team on an area of interest from the conference. We have also sponsored in-house education prep classes for achieving certifications such as RCIS and critical care nursing (CCRN).
How do you handle vendor visits to your lab?
We have implemented a comprehensive vendor policy. Representatives must meet with the leadership team to review expectations and be cleared by Vendormate prior to their visit. Representatives can schedule 1-2 days per month in the lab and only one representative is allowed per day. Vendor representatives are not permitted in the procedure room during patient preparation or in the staff break room during lunch hours.
How is staff competency evaluated?
We hold an annual program for required competencies, such as radiation safety, as well as proficiency and competency reviews for point-of-care testing, sterile technique, and OR consciousness, to name a few. Our unit council recently reviewed our annual competencies, and made suggestions on additions and changes to keep us current with best practices. Before new techniques and/or equipment is introduced to the labs, we ensure that staff has received education and hands-on training if needed.
Does your lab have a clinical ladder?
We established a clinical ladder for RNs hospital-wide in 2010. Currently, we have three RNs who have achieved clinical level 2 and one RN who has achieved clinical level 3. We are currently looking at a clinical ladder for all allied health professionals.
How does your lab handle call time for staff members?
Each full-time staff member takes call one night per week (Monday-Thursday), and every fourth weekend (Friday-Sunday). We try to keep it consistent, so everyone knows their call schedule for the entire year. There is one RN and one RCIS/RT(R) in every case, and the third person could be an RN, RCIS, or RT(R).
Within what time period are call team members expected to arrive to the lab after being paged?
All three call team members must be on site within 30 minutes.
Do you have flextime or multiple shifts?
We have a variety of 8-, 9-, and 10-hour shifts for staff working 3, 4, and 5 days per week. We have a fixed call schedule and a fixed monthly staff schedule, which occasionally gets flexed depending on the case volume.
Can you tell us more about the process of achieving Accreditation of Cardiovascular Excellence (ACE)?
We have just acquired ACE accreditation in cardiac cath. We would recommend this for labs that perform percutaneous coronary intervention. The process is helpful in reviewing appropriate use criteria and meeting national guidelines. Some labs have been in the news for inappropriate stenting, which has been an item of concern. ACE accreditation validates that we are following the guidelines and have a high-quality review process in place. The best recommendation we can give for hospitals that may want to go through this process is to review the guidelines ahead of time, making sure that you meet all the areas that are identified in the criteria. ACE allows you to download the application and criteria prior to actual submission for accreditation. The other key factor is to identify a physician champion in your lab that will help streamline the process for physician review and quality of case image acquisition. Our physician champion was very engaged in the process and assisted in promoting the quality initiatives in the cath lab.
What trends have you seen in your procedures and/or patient population?
We have seen an increase in radial access procedures. We have increased from approximately 45% of our cases using the radial artery last year, to approximately 70% in 2013 thus far. We have seen a decrease in our cath intervention numbers.
We have also seen an age reduction in our STEMI patients; we are averaging ages in the 40 to 60 range, which is a change from 60 to 80.
Is there a problem or challenge your lab has faced?
Over the past several years, we have been challenged with implementing a hospital-wide electronic health record (Soarian, Siemens Healthcare). Most recently, we have been working to create interfaces with Soarian and the Centricity reporting system (GE Healthcare) used in the cath lab.
In addition, this past fall, the nurses have achieved implementation of a barcode scanning system for documenting medication administration. While difficult to implement in a cath lab setting, it has added a tremendous level of safety for our patients.
Collaboration between our anesthesia department, cardiovascular management team, the interventionalists and cath lab staff was established to review the American Society of Anesthesiology (ASA) guidelines and evaluate our current practices. We now have 6 Zoll monitor/defibrillators with EtCO2 monitoring capability for the cath lab. Staff participated in revising the hospital moderate sedation policy, done in accordance with the most recent guidelines. Training that included the pathophysiology of and the role of EtCO2 monitoring was held for the cath lab and all other areas that perform moderate sedation.
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”?
Over the last 20 years, the number of cardiac cath labs in Philadelphia’s suburban region has increased. Within a 15-mile radius of our hospital, there are three other hospitals with interventional labs. For the most part, our patients have a choice as to where they have their procedure performed. In order to set ourselves apart, we are committed to deliver an extraordinary experience for our patients and their families, and be a national model for quality.
1. 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?
At this time, there is no incentive bonus or raise upon passing the RCIS exam. Technologists are required to be either RCIS or RT(R). All clinical staff is encouraged to take the RCIS exam and application fees are reimbursed to the employee upon passing.
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?
The management team has a wide array of expertise and training, and many of us are members of a professional organization. These include the SICP, the Heart Rhythm Society (FHRS), and Cardiovascular Credentialing International (CCI). Locally, we are members of the southeastern Pennsylvania division of Mission: Lifeline, the Regional CV Registry Data Managers Group (ACC-NCDR), the Cardiovascular Roundtable for the Advisory Board Company, Society for Cardiovascular Patient Care (SCPC), and Accreditation for Cardiovascular Excellence (ACE).
The authors may be contacted via Kimberly White, BSBA, RCIS – Assistant Director of Invasive Services, at email@example.com.