Saint Anthony Memorial Health Centers

Linda Rempala, RN, Cardiology Manager, Michigan City, Indiana
Linda Rempala, RN, Cardiology Manager, Michigan City, Indiana
Tell us about your cath lab.    Saint Anthony Memorial has two state-of-the-art cath labs, with one lab also functioning as an electrophysiology (EP) lab. In 2006, a new, state-of-the-art, dual-function lab was constructed (cath and EP). A second dual-function lab was added in January 2008. Cath lab procedures have been performed since 1989 in the cath lab at Saint Anthony Memorial.    Our current staff and physician mix consists of: • 5 radiologic technologists (RTs) • 6 registered nurses (RNs) • 5 board-certified cardiologists • 2 board-certified interventional cardiologists • 2 board-certified vascular surgeons • 3 board-certified electrophysiologists • 1 board-certified interventional radiologist What procedures are performed in your cath lab?    The two labs allow for a wide array of procedures, including: • Bilateral diagnostic catheterizations • Emergent primary angioplasty and stenting • Elective primary angioplasty • Intra-aortic balloon pump insertions • Coronary thrombectomy and graft • Intravascular ultrasound (IVUS) • Temporary pacer wire insertion • Pericardiocentesis • Peripheral artery angiograms and stenting • Peripheral and coronary atherectomy • Ablation of hepatic and gastrointestinal bleeds • Drain placement • Tunnel catheter placement • Fistulagrams and declots • Renal and mesenteric stenting • Thrombolysis • Carotid and cerebral angiography • Transjugular intrahepatic portosystemic shunts (TIPS) • Uterine fibroid embolization (UFE) • Radio-frequency ablation (RFA) • Vertebroplasty • Vena cava filter insertions • Full-service electrophysiology procedures • Permanent and temporary pacemaker implants • Biventricular\automatic implantable cardioverter defibrillator (AICD) • Cardioversion    Peripheral interventional procedures are performed by two board- certified vascular surgeons, an interventional radiologist and an interventional cardiologist, who work together in a healthy, collaborative approach. Does your lab perform primary angioplasty with surgical backup on site?    Yes, primary emergent angioplasty and elective angioplasty have been performed in our facility with on-site surgical backup since April 2007. Our coronary artery bypass graft (CABG) program officially started at that time, which allowed us to add elective angioplasties and to enhance our primary angioplasty program, formerly run without surgical backup on site. What procedures do you perform on an outpatient basis?    All procedures scheduled in the cath lab are considered outpatient, with the exception of complex EP studies, acute myocardial infarction (primary angioplasty), and selective SilverHawk plaque excision (ev3, Inc., Plymouth, MN) patients. Who manages your cath lab?    The cath labs are managed in a multi-disciplinary approach to peripheral and cardiac interventions by co-directors William Espar, MD (cardiology) and Virginia Newman, MD (vascular surgery). They work in conjunction with the cath lab nursing leadership team, which consists of Linda Rempala, Cardiology Manager, and Tom Swedenberg, Cardiology Supervisor. Penny Ballestero, Cardiovascular (CV) Coordinator, and Stacie Bailey, Peripheral Vascular (PV) Coordinator, manage inventory, and review supply opportunities with the medical directors and manager. The cath lab reporting structure includes: • Trish Weber, RN, VP Clinical Operations/CNO • Pam Goddard, RN, Director Perioperative and CV Services. Who scrubs, who circulates and who monitors?    Radiologic technologists scrub and are trained to deploy closure devices and suture sheets. RNs circulate cases. All modalities rotate monitoring, and all modalities are trained to pull sheaths and manage hemostasis. Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab?    According to Indiana state law, yes, a radiologic technologist must be present in the room for all fluoroscopic procedures. Which personnel can operate the x-ray equipment in your cath lab?    The radiologic technologist man- ages and operates all x-ray equipment, including positioning the table, tilting the angle, and managing the fluoro table. How does your cath lab handle radiation protection for the physicians and staff that are in the lab day after day?    Radiologic protection is managed by the radiation safety officer who oversees badge counts and leaded apron distribution. A radiation safety committee meets monthly to address any radiological issues. Some safety initiatives include: • Monthly badge distribution • Collar and waist bands • Thyroid collars • Leaded aprons • Maternity and pregnancy aprons • Leaded goggles What new equipment, devices and products have recently been introduced in your lab?    Procedures rotate between two cardiac/peripheral GE Innova 3100 dual-purpose rooms (GE Healthcare, Waukesha, WI). The first GE Innova 3100 lab was installed in February 2006, and then duplicated in a January 2008 installation, with additional holding rooms.    We initiated our EP program in April 2008, utilizing EP MedSystems, Inc. (West Berlin, NJ) and the Maestro system (Boston Scientific Corp., Natick, MA) for the dual-purpose EP lab. A portable table can be used in either lab.    Portable AngioJet (MEDRAD Interventional/Possis, Pittsburgh, PA) and IVUS (Boston Scientific) are avail- able for use in both labs.    Three types of drug-eluting stents are available on consignment: Promus (Boston Scientific), Taxus (Boston Scientific), and Endeavor (Medtronic, Minneapolis, MN).    We utilize a ceiling-mounted Skytron lighting system (Grand Rapids, MI).    Our pre-and post-holding area was upgraded and remodeled to include flat-screen TVs that allow the patient and family to review their study with the physician.    The Heartlab picture archiving and communication system (PACS) (Agfa, Westerly, RI) provides easily accessible images to patients and physicians. The Heartlab system can send and retrieve images from other hospitals within the Sisters of St. Francis Health Services system. How does your lab manage hemostasis?    Staff uses both manual and vascular closure devices. Physicians are certified to deploy multiple closure devices. The radiologic technologists are certified to deploy Angio-Seal (St. Jude Medical, Minnetonka, MN). An annual competency is completed by all staff on hemostasis and pulling sheaths. Superusers have been cross-trained for staffing our specialty areas. How is inventory managed?    The cath lab physician staff, with the support of the co-medical directors, have taken ownership of fiscal responsibility and achieved the goal of reducing owned inventory by 35% and increasing consigned inventory by 30%, while simultaneously increasing procedure volumes by 66% over the past year. The vision of providing one model of health delivery was initiated by transferring cath lab supply inventory from materials management to the cath lab budget.    The Omnicell System (Mountain View, CA) is utilized for all supplies and medications, and is maintained by coordinators Penny Ballestero and Stacie Bailey. The Omnicell is stocked daily. All inventory par levels are reviewed monthly for over-or under-utilization and possible adjustment. All product rotation, expiration and control is managed by the CV and PV coordinators.    New item requests are completed by the requesting physician, which are then formally submitted and reviewed by the cath lab medical directors on a monthly basis. This procedure must be followed in order to add a product to inventory.    Capital equipment is ordered out of the regional budget and approved annually. Has your cath lab recently expanded in size and patient volume?    The cath lab has expanded in both size and volume since opening the second dual-purpose lab in 2008, almost doubling the amount of cases seen per week. This is due to a variety of factors, including: • Recruitment of two board- certified vascular surgeons • Recruitment of two additional board-certified cardiologists • Development of the EP service line • Initiation of the CABG program Is your lab involved in clinical research?    Not directly, but Saint Anthony Memorial recently opened a facility dedicated to clinical research. 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?    All STEMI cases are reviewed at a monthly cardiology meeting to maintain 90-minute door-to-balloon (D2B) times. Current D2B times were at 100% for the last quarter. We have developed a multi-disciplinary team (including a Six Sigma Green Belt Team), involving the cath lab, cardiology, emergency department (ED) physicians and staff, and administration. This team meets quarterly to evaluate processes and implement change. Every STEMI case is evaluated within 48 hours. Key team members review the highlights and evaluate opportunities for improvement. How does your lab handle call time for staff members?    Call time is shared among staff equally. The team consists of four staff members. All coronary call-in consists of at least one RT, two RNs and one monitoring staff (RN, RT or cardiac tech).    The entire team is paged on a group pager (along with the interventional car- diologist) by the ED upon recognition of a STEMI. This may happen as early as in-transit per EMS.    Staff takes nine to fourteen call shifts a month. All cath lab staff are expected to arrive within 30 minutes of being paged. We are fortunate to have staff that live in the community and frequently arrive within 10 minutes.    There is an emergency drug kit on standby at all times, and an emergency scrub tray kit readily available to decrease time pulling all needed supplies.    The on-call interventional cardiologist is expected to respond within 30 minutes. What other modalities do you use to identify stenosis?    We utilize imaging, IVUS, frac- tional flow wire (Volcano Corp., San Diego, CA), and CO2 capnography. What measures has your cath lab imple- mented in order to cut or contain costs?    We evaluate expiring products at least 6 months prior to the expiration date. Low utilization equipment is assessed of to see if elimination is possible. We assess evidence-based technology with the intent to remain abreast of progress. Duplication of equipment is minimized. We maintain a continuous dialog with industry to negotiate better pricing. How do you manage staff and overtime?    A staggered second shift was provided to help eliminate overtime. Staff are cross-trained with cardiac services to assist with call, and to float in high-volume situations. A regional cardiology buying group evaluates product lines and commits to a contract for better pricing. OmniCell was implemented to help eliminate lost charges and lower product volumes. Patient admission status is evaluated to ensure that patients are handled on an outpatient basis as indicated. What quality control measures are in place?    Saint Anthony Memorial reports to the American College of Cardiovascular Data Registry for Cath PCI and ICDs. Cath lab physicians meet quarterly to review D2B times and implement cath lab changes in procedure. How are new employees oriented and trained at your facility?    Employees have a preceptor orientation that lasts three months, with monthly evaluations. Preceptorship can be extended an additional three months to ensure that all skills necessary to work autonomously are achieved. All scrub personnel that operate the GE Innova are ARRT-registered.    All staff must have basic life support (BLS) along with basic EKG and hemodynamic monitoring training (IABP).    All RNs are advanced cardiac life support (ACLS)-certified, and we use our sister hospitals to cross-train for skill enhancement.    A learning forum is planned to review unique cases that present learning opportunities. How is staff competency evaluated?    Staff competency is evaluated on an annual basis. Mandatory, hospital-specific competencies are provided through computer education and safety fairs. Department-specific competencies are offered throughout the year. Does your lab have a clinical ladder?    No, but specialty certifications are offered additional incentive pay. Do you have flex time or multiple shifts?    Saint Anthony Memorial utilizes flexible shifts and call staff is scheduled for the 8am–4:30pm shift to accommodate cases later in the day.    We currently do not perform electives on weekends or holidays, but do provide call for emergent cases at those times. How do you handle vendor visits to your lab?    All vendors are required to check in to materials management, and are seen by appointment only. The Sisters of St. Francis Health Services participate with contracted buying groups to purchase some supplies. When was your most recent accreditation?    Saint Anthony Memorial was last successfully accredited in March of 2008 by Healthcare Facilities Accreditation Program (HFAP). HFAP was especially interested in the terminology of consent forms, and the completion of “time out” and its documentation. What is unique and innovative about your cath lab and staff?    Before the initiation of the CABG program, Saint Anthony Memorial was one of the few hospitals to perform rescue PCI without surgical backup.    Dual capability of the labs allows us to perform both cardiac and peripheral interventions in each lab. We also have a portable EP Med System so EP studies can be performed in either lab.    We have EMS 12-lead capability so that cath lab staff and the cardiologist can be called in while the patient is still in the field, enhancing our D2B times.    We have engaged our physicians into taking leadership for fiscal responsibility for management of the cath lab.    Our cath lab offers a collaborative interdisciplinary approach to interventional care to include four specialties: interventional cardiology, electrophysiology, interventional radiology and vascular surgery.    Our cross-trained cardiac and cath lab staff encourages flexing to meet patient demand and eliminates low-censusing of staff. This enhances continuity of care related to the patient experience, and provides a sense of security for the physician.    Cath lab management rounds on patients to ensure the highest quality of care.    Press Ganey patient satisfaction scores for the first quarter of 2010 showed our cath lab to have the highest percentile rank of 99%, compared to the ranked peers.    The philosophy of the cath lab centers around a strong work ethic, collaboration, innovation, and fiscal responsibility. Linda Rempala can be contacted at