Cath Lab Spotlight

Provena St. Mary's Hospital Catheterization Lab

Bernie Hinrich, RN, CCRN Kankakee, Ilinois
Bernie Hinrich, RN, CCRN Kankakee, Ilinois
What type of procedures are performed at your facility? > We do coronary angiograms, angioplasties and stenting, intravascular ultrasound (IVUS) and Pressure Wire® (Radi Medical Systems, Wilmington, MA), intra-aortic balloon pump (IABP) insertions, temporary and permanent pacemaker insertion, automatic implantable cardioverter-defibrillators (AICDs) and bi-ventricular pacemakers, electrophysiology studies and ablations, cardioversions, arteriovenous (AV) fistulograms and fistula angioplasties, difficult peripherally inserted central catheters (PICC lines), carotid stenting, peripheral and renal angiograms and angioplasties/atherectomies/stents. We average 25 cases per week. We average 6“7 peripheral angioplasties per month. Does your cath lab perform primary angioplasty with surgical backup? All of our coronary angioplasties are done with surgical backup. Surgical backup is provided by a neighboring hospital. The cardiologist and surgeon discuss each case prior to angioplasty. What procedures do you perform on an outpatient basis? All of the above procedures can be done as outpatient, with the exception of interventions and device implants, which require an overnight stay. What percentage of your patients are female? Forty-seven percent. What percentage of your diagnostic cath patients go on to have an interventional procedure? Approximately 35%. Who manages your cath lab? I currently manage the lab on a day-to-day basis. Our director of imaging and cardiology services, Tony Hardesty, is actively involved in the budgeting and administrative side of management. Our medical director is Dr. Mario Massullo, DO, FACOI, FACC, FSCAI. Do you have cross-training? Who scrubs, who circulates and who monitors? The RTs scrub and run the x-ray equipment (panning, positioning and fluoroscopy). RNs assess and manage the patient’s care, and give all medications. RNs and RTs both monitor. Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab? Yes. How did your lab begin doing peripheral interventions? Peripheral interventions began in our lab eight years ago when cardiologists who had prior privileging were introduced to our area. We had a rather unique situation, as we began diagnostic catheterizations in a mobile cath lab (Calumet Coach Company, Calumet City, IL) which we shared with our neighboring hospital. As the patient volume grew and each hospital developed in-house labs, we chose to install a 14 image intensifier (II) (Siemens Medical Solutions, Malvern, PA) to accommodate both peripheral and cardiac cases. Our new second lab also has a larger II (GE Healthcare, Waukesha, WI). Approximately one-half of our inventory related to peripheral work is on consignment from two major vendors (Cordis Corp., Miami Lakes, FL and Guidant Corp., Santa Clara, CA). They keep us current with the various lengths, sizes, and new generations of balloons and stents. Staff was educated on- and off-site with in-servicing and by mentoring with experienced staff. The majority of peripheral work is done by cardiologists, although we have several interventional radiologists who utilize our lab. Does your lab have a clinical ladder? Our lab does not currently have a clinical ladder. What are some of the new equipment, devices and products introduced at your lab lately? We recently started using the Tri-Active distal protection device (Kensey Nash, Exton, PA) for SVG angioplasties, and have begun using the new Benephit infusion system (FlowMedica, Inc., Fremont, CA) for renal compromised patients. We have recently been using more of the FoxHollow SilverHawk (Redwood City, CA) atherectomy device for peripheral procedures. How is coding and coding education handled in your lab? We attend coding updates and seminars as they are offered. We have active communication with our coders and the health information management (HIM) department. Our organization utilizes Code Correct (Yakima, WA). How does your lab handle hemostasis? We use manual compression, Perclose® (Abbott Vascular Devices, Redwood City, CA), Angio-Seal (St. Jude Medical, Minnetonka, MN) and VasoSeal® (Datascope Corp., Mahwah, NJ) to achieve hemostasis. We have some physicians who use 4 Fr sheaths and catheters. For these patients, we utilize manual pressure. The other patients receive closure devices. The cath lab staff is responsible for hemostasis unless the patient recovers in one of our ICUs post-intervention. Does your lab have a hematoma management policy? Hematomas are managed according to their severity by the cath lab or ICU staff. All hematomas are tracked by our quality management team. How is inventory managed at your cath lab? Inventory is managed by the entire cath lab staff. Each member plays an active role in making sure the lab is well-stocked. The manager generally orders supplies and equipment. Has your cath lab recently expanded in size and patient volume, or will it be doing so in the near future? In January of 2005, we expanded to 2 labs to accommodate the increase in patient volume. This allows the physicians more flexibility for scheduling and allows patient procedures to be done in a more timely fashion. Is your lab involved in clinical research? Not currently. Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? We have had one this past year where the patient was taken to surgery on an urgent basis. The patient is doing well. What other modalities do you use to verify stenosis? We utilize IVUS and Pressure Wire to verify stenosis. The reimbursement for these two procedures is adequate. What measures has your cath lab implemented in order to cut or contain costs? Our staff is extremely flexible with scheduling. All are willing to flex up when needed and to take time off during slow periods. This helps us maintain a high productivity rate. We are part of the Provena Health system, which consistently works with vendors and companies to achieve the best pricing on supplies. What type of quality control/quality assurance measures are practiced in your cath lab? Any time we introduce a new product we intend to use consistently, we run QA for 6 months to 1 year. We track all complications as identified by the American College of Cardiology (ACC) guidelines. We also track fluoroscopy time, contrast usage, door-to-perfusion time for acute myocardial infarction (MI) patients (average 103 minutes), physician delay time, and normal angiograms following non-invasive testing (15%). Our medical director, Dr. Mario Massullo, is very helpful in assessing and assuring that the quality of care is above standard. How are new employees oriented and trained at your facility? New employees are assigned to a mentor. We have an orientation checklist and multiple competencies that must be completed for each new employee. RNs must have critical care experience. All RTs must be registered. What type of continuing education opportunities are provided to staff members? We have an education fund which we use to finance off-site educational opportunities for a variety of topics of interest. We utilize on-site education for new products and procedures. How do you handle vendor visits to your lab? Vendor visits are scheduled through the manager. Vendor badges are necessary for those spending time in the lab. How is staff competency evaluated? For any new product or procedure, competency is initially assessed by the company representative. We annually have staff re-competency for procedures and equipment. Does your lab utilize any alternative therapies (such as guided imagery, etc.)? We offer moderate sedation to all of our patients. We currently do not have any alternative therapies. How does your lab handle call time for staff members? Each 3 person call team has at least 1 RN and 1 RT. Average call days are 10 per month, including every third weekend. Any procedures which extend past 4 pm are handled by the call team. We have staggered start and stop times for staff relating to patient volumes. Our average overtime per pay period is 6“10 hours, which includes callback pay for acute MIs and for emergency cases. What trends do you see emerging in the practice of invasive cardiology? With government money being released more readily for stem cell research, I can see the results of this playing a role in future cardiac care. Non-invasive diagnostics have been receiving much more attention (MRIs and CT scanners). Magnetic catheters to navigate the coronary arteries and robotics for precise deployment of stents may soon play a role in invasive cardiology. Has your lab has undergone a JCAHO inspection in the past three years? We had an inspection in June 2005. Our lab did very well. All standards were in compliance. Our inspection was unannounced and we have attempted to continue using the mentality of always being prepared. Where is your cath lab located in relation to the OR department, ER, and radiology departments? The cath lab, OR, ER and radiology departments are all on the first floor in close proximity to one another. Please tell readers what you consider unique or innovative about your cath lab and staff. Our staff is always looking for ways to provide the best service to our patients. This includes keeping things light during the procedure. When we moved into our new area, we named our rooms instead of calling them cath lab 1 or 2. We now have a Flamingo Room and an Aloha Room, and each have been appropriately decorated. We provide the patient with their favorite music as requested for their procedure. Our staff and physicians have a wonderful, mutually respectful relationship. Is there a problem or challenge your lab has faced? Our recent expansion in January 2005 included a patient prep area, which was new for us. We had staff members volunteer to accept this challenge and organize a very smooth transition from an outpatient prep area to an in-lab site. The expansion also included a second lab. The entire staff was very creative and supportive of the new challenges. We had weekly staff meetings and a communication board to keep everyone posted of what was or was not working well. 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 area is basically known as a rural area. Many of our patients and staff were born and raised in this area and have families which have been here for decades. We care for many patients with whom we are acquainted. This helps to foster a family atmosphere. 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 raise upon passing the exam? The registry exam is not required but we have an RT who has achieved CV registration status. Several of our staff members are currently exploring RCIS credentialing. In the past, incentives have been given upon achieving additional credentialing. 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 of our RTs belong to the ASRT. Several of our nurses belong to AACN. The cath lab manager is a member of the SICP. Bernice Hinrich can be contacted at