Cath Lab Spotlight

Saint Francis Heart Hospital

Jason L. Davis, RN, Cath Lab Team Leader, Richard Slagle, MD, Hospital Chief of Staff, Richard Lowry, MD Tulsa, Oklahoma
Jason L. Davis, RN, Cath Lab Team Leader, Richard Slagle, MD, Hospital Chief of Staff, Richard Lowry, MD Tulsa, Oklahoma
We have 18 full-time clinical staff, consisting of RNs, RT(R)s, and CVTs. The staff that are employed here all have significant amounts of interventional radiology, cath lab, and cardiology experience. The average experience for our staff is over five years in the lab. What type of procedures are performed at your facility? We perform everything from diagnostic heart caths to complex interventional cases. We have the AngioJet® (Possis Medical, Inc., Minneapolis, MN) and X-Sizer® thrombectomy system (ev3 Inc., Plymouth, MN). We use intra-aortic balloon pumps on many of our ST-elevation myocardial infarction (STEMI) and surgery patients. We have had quite a great deal of growth in carotid angiography. We are looking to add carotid stenting at our facility in the future. We perform a fair number of peripheral interventions. The SilverHawk atherectomy catheter (FoxHollow Technologies, Menlo Park, CA) is one that we are using quite often for our peripheral work. Also, we perform abdominal aortic aneurysm (AAA) stent grafting. Electrophysiology procedures are also included in our cath lab program. We perform permanent pacemaker, defibrillator, and bi-ventricular device implantations, as well as electrophysiology studies and basic ablations. Has your cath lab recently expanded in size and patient volume, or will it be in the near future? Our lab opened in April of 2004, so we are still ramping up this phase of our business. We are averaging 300 cath and peripheral procedures per month. Additionally, we average 30 device implants per month. We do have space to expand by another lab as our cath lab reaches capacity. Does your cath lab perform primary angioplasty with surgical backup? We have surgical services in-house. They are on call and available within 30 minutes. What procedures do you perform on an outpatient basis? We have a lab solely dedicated to outpatient procedures. We perform diagnostic heart caths, diagnostic peripheral studies, and basic peripheral interventions as outpatients. We also perform our pacemaker and defibrillator generator changes as outpatients. What percentage of your patients are female? Forty percent of the patients we see are female. What percentage of your diagnostic cath patients go on to have an interventional procedure? Approximately 30% of our diagnostic cases undergo interventional work. Who manages your cath lab? Jason Davis, RN, manages the cath lab. He came to us with an extensive cardiac background. The cath lab reports to the clinical services branch of the hospital. The physicians are actively involved in the day-to-day workings of the lab and all major decisions are routed through the proper committees. Do you have cross-training? Who scrubs, who circulates and who monitors? We do have cross-training in our lab. All CVTs and RTs are expected to be able to scrub and monitor. The nurses are required to learn one other role in the cath lab within one year of hire. Only nurses can circulate in the lab. Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab? RTs do not have to be present for fluoro to be used. 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? The scrub tech can position the II, pan the table, and step on the fluoro pedal. This is all done under physician supervision. What disciplines (physician and non-physician) are involved in peripheral interventions? Only interventional cardiologists currently perform these in our facility. All core cath lab staff are expected to work in peripheral cases as well. How did you begin performing peripheral procedures? Several of the interventional cardiologists had peripheral training in their programs of study. Those physicians then trained some of our other interventional cardiologists in peripheral work. What specific equipment was instituted and/or dedicated towards peripheral cases above and beyond what is used for coronary cases? We have a specific lab designed for peripheral work. It has a GE Innova 4100 x-ray system (Waukesha, WI) that has the large field of view and bolus-chasing DSA. The lab is also set up to be used as an operating suite for the endograft procedures we also perform. This room has its own sub sterile room, full surgical lighting, and all necessary anesthesia equipment available. The GE Innova system is configured to be flexible in positioning and allows easy access to the patient and for anesthesia if needed. How is inventory management handled for the peripheral equipment? Our peripheral inventory is managed by one of our experienced peripheral technologists. She does a great job keeping the supply organized and current. We have several large rolling carts on which we keep our balloons and stents, according to size. We use GE’s Centricity Data Management System (DMS) to handle our inventory organization. We have worked to limit the number of vendors used in that lab in order to better utilize space and gain better pricing. What training was instituted so staff could be competent and skilled? Several of the technologists and nurses we hired had extensive peripheral vascular experience. They have become very good resources for training the other staff. It is important to have the staff keep current with in-services from the device companies and reading journals with the latest studies from both the cardiovascular and peripheral world. We schedule one to two CE-approved programs per month for our staff. Did your facility need to make any changes to the imaging equipment to accommodate peripheral procedures? Only one of our labs has DSA (Digital Subtraction Angiography) capabilities. All four of the other labs can be used for peripheral work, provided the physician does not want to use DSA. We had to load a special program on our GE LC2350 x-ray systems to improve image quality by decreasing burnout on peripheral cases. Do you average any overtime per pay period? We are a busy lab and do average our fair share of overtime. The goal at this facility is to get the patient into the lab as soon possible to prevent any potentially life-threatening complications. We average approximately four hours of overtime per pay period. Does your lab have a clinical ladder? We do not currently have a clinical ladder, though we are looking to implement one in the future that is based on national certifications such as the Registered Cardiovascular Invasive Specialist (RCIS) or Radiologic Technologist - Cardiovascular [RT(R)(CV)]. What are some of the new equipment, devices and products introduced at your lab lately? We have started using the X-Sizer catheter system as a manual thrombectomy device. We have achieved nice results with this device. It can be used for both cardiac and peripheral work. Additionally, we have started with the power pulse system for use with our AngioJet, using Retavase (PDL BioPharma, Inc., Fremont, CA) to assist in opening some stubbornly blocked vessels. We have also added the Rotablator (Boston Scientific, Maple Grove, MN) and Galaxy2 Intravascular Ultrasound (IVUS) devices (Boston Scientific) recently. Can you describe the systems you utilize and how they work in cath lab daily life? This is an area in which our hospital really shines. We are an all-digital environment. Everything is completed electronically and there is no paper chart. Everything consents, lab work, ECGs, etc., is automatically populated in the chart. We use the GE MacLab hemodynamic system to document during the case. As we complete the case, all the information is exported to GE’s Data Management System (DMS). The DMS system completes the report of the procedure, replacing the physician’s need for a dictated report. DMS also submits the charges and reports to the billing and coding departments. All images from the procedure are immediately available in the charting system, which is of great value for patient education. Physicians and staff can show the patient exactly what was found during the procedure. What other modalities do you use to verify stenosis? Are you using physiology for lesion assessment? We have recently obtained the Boston Scientific Galaxy2 IVUS system to help verify stenosis. Physicians and staff have taken quickly to this technology, though we have used this on less than 5% of our interventional cases. We are not currently using physiological assessments to verify stenosis though we may be going this route in the future. How is coding and coding education handled in your lab? How is coding communication handled with the billing dept.? The procedure receives the appropriate codes in DMS as they are entered into the MacLab by the monitor tech. The codes are confirmed in DMS and then are placed on the patient’s bill. The business office and Health Information Management (HIM) departments attend to the coding after the procedures are entered in the cath lab. How does your lab handle hemostasis? We utilize a mixture of hemostasis methods at this facility. If manual pressure is ordered, either the daypatient or inpatient unit performs it when the patient returns from the lab. Cath Lab personnel handle all closure devices. We do not have a specific recovery unit. We use the D-Stat Dry patch from Vascular Solutions (Minneapolis, MN) for a majority of our patients. We had previously used a closure device for over 50% of our patients. We performed a month-long evaluation of patients receiving catheterizations at our institution, containing both diagnostic and interventional studies that included anticoagulation. We involved all staff in pulling lines and the cathing physicians in the evaluation. We compared Angio-Seal (St. Jude Medical, Minnetonka, MN), SyvekPatch (Marine Polymer Technologies, Inc., Danvers, MA), Chitoseal (Abbott Vascular Devices, Redwood City, CA), Perclose (Abbott Vascular Devices, Redwood City, CA), and Vascular Solutions’ D-Stat Dry Patch. The evaluation showed an overall decrease in hematoma rates of 1% with major groin complications (pseudoaneurysms and retroperitoneal bleeds) also dropping significantly. We selected the D-Stat Dry patch as our hemostatic method of choice. Through this process, we have also saved the hospital over $20,000.00 per month. (Editor’s note: This evaluation is currently being written up for submission to Cath Lab Digest). Does your lab have a hematoma management policy? We do have a hematoma management policy. All hematomas are reported to both the performance improvement department and the cath lab. The circumstances of each case are then investigated by the cath lab to try to determine any potential causes. How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies? Inventory is managed with our GE DMS system. We have a technologist that works with the coronary product inventory, one with the peripheral inventory, and one who is responsible for the electrophysiology inventory. We have a product workgroup at this hospital that evaluates any new products brought to the hospital that affect more than one department. For cath lab-only devices and products, we have several of our key physician partners evaluate the device and then come to a joint decision with management whether to purchase the device or product. Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? We have had one emergency where the left main was dissected while trying to pass a stent into the circumflex artery. The patient was sent to emergent bypass surgery and suffered no long-term effects. What measures has your cath lab implemented in order to cut or contain costs? We have evaluated the inventory on hand and have limited equipment and supplies to items routinely used. As mentioned, we did a comprehensive evaluation of arterial closure methods and found that by using the D-Stat hemostatic bandage, we saved several thousand dollars, with an actual decrease in hemostasis complications. What type of quality control/quality assurance measures are practiced in your cath lab? The cath lab tracks all problems with the groin site and follows up to see if there was anything that could have been done to prevent the complication. We also have implemented some performance improvement (PI) recommendations for our device implants to insure that we remain free of infections in our department. How does your cath lab compete for patients? Has your institution formed an alliance with others in the area? We are partially owned by the Saint Francis Health System, a large regional healthcare system, but have no connections with that facility other than the fact that our physicians practice at both facilities. We have cultivated a strong connection with many of the outlying facilities and do receive many of our cases from them. A majority of our STEMI patients are transferred to our facility. We market our facility by letting the community know that we are the hospital that specializes in cardiac care. Our outstanding performance in our treatment of STEMI patients has also been a useful marketing tool. How are new employees oriented and trained at your facility? All new employees attend a weeklong hospital orientation. Not only do they learn the policies and procedures of the hospital, but also they receive the computer training they need to work in our digital environment. Nurses are required to have RN licensure and experience in cardiac nursing. RTs are required to have ARRT licensure and cath lab or interventional radiology experience. CVTs do not have specific licensure but must have an extensive cardiac background. New staff are then assigned an experienced preceptor that handles the day-to-day cath lab orientation. What type of continuing education opportunities are provided to staff members? Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) are required of all staff members working in the cath lab. This is provided by our facility. Recently, our facility received the ability to give American Association of Critical Care Nurses Continuing Education credits for all of our critical care classes. Additionally, we have staff attend continuing education training inservices put on by vendors in the area. How do you handle vendor visits to your lab? Vendors must schedule a time to visit the lab. We do not allow representatives in the procedure areas unless actively involved with a case. Vendors must check in with the hospital front desk before being brought back to the cath lab. Routinely, representatives are expected to wait in the break room and catch staff and physicians between cases. Does your cath lab do electives on weekends and or holidays? We do not routinely perform elective cases on weekends or holidays. In the past, if a physician wanted to perform an elective case over the weekend, he or she would call the cath lab staff on call to schedule a time that worked with everyone’s schedule. How is staff competency evaluated? New staff members are placed with a personal preceptor upon starting in the cath lab. We have developed a competency form that must be completed before the new members can perform cases on their own. Annual skills fairs are held to ensure that staff remains competent. How does your lab handle call time for staff members? Cath lab staff are expected to take call. Call averages to approximately one day per week and one weekend out of six. There has to be one RN and two technologists on call. For the technologists, it can be any two technologists (an RT does not necessarily have to be on call). We do not have multiple shifts. We do have the call team flex and come in an hour and a half later. We have an assigned crew every day that stays and helps finish up the late cases for the day. What trends do you see emerging at your facility in the practice of invasive cardiology? With this new hospital, we have seen the treatment of STEMI patients improve greatly. We have streamlined the process in getting those patients to the lab as soon as possible. In our unannounced STEMI patients arriving at our hospital, our door-to-balloon time is 79 minutes. Where our hospital really shines is with our known STEMI patients. The arrival-to-balloon time with these patients is 29 minutes. I have personally seen cases where the door-to-balloon time is just over 10 minutes. As a result, we have had limited incidents of cardiogenic shock with our STEMI patients. By focusing on primary percutaneous coronary intervention (PCI), our mortality with STEMI patients has been outstanding. The latest numbers show a mortality of 2.8%, a marked decrease over the national average of 5.6%. Has your lab has undergone a JCAHO inspection in the past three years? We did undergo our first JCAHO inspection last year and received no deficiencies or recommendations. Where is your cath lab located in relation to the OR department, ER, and radiology departments? Being a newly designed and built hospital, we had a large amount of input in the design. The OR department and laboratory are across the hall from the cath lab. The ER and radiology are on the same floor as the cath lab and only a few steps past the OR. This is important when moving the critical patients from one area to another to decrease wait time. Please tell the readers what you consider unique or innovative about your cath lab and its staff. Our greatest innovation is our prompt treatment of cardiac patients. The hospital was designed from the ground up to treat those patients as quickly and safely as possible. Our prompt treatment of STEMI patients has shown a significant decrease in mortality in our STEMI patients. The treatment at Saint Francis, from admission to discharge, has shown all involved with the patient care that we are going about this the right way. Is there a problem or challenge your lab has faced? The nursing shortage has hit us very hard as of late. It has been difficult to find qualified applicants and retain the staff that we have. We have instituted sign-on and retention bonuses, but as in other areas, those are no longer attracting the candidates they once did. We have resorted to a hiring agency and traveling nurses to fill some of the openings in staffing. 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? While Tulsa is a large city, it still retains its small-town charm. We have numerous connections to the rural communities that surround the area. We have used these towns in our business development to ramp up our numbers while carving out our niche in the Tulsa market. 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)? Does staff receive an incentive bonus or raise upon passing the exam? We currently do not require any staff to have their RCIS registry. We are looking at implementing a clinical ladder for staff that does achieve this registry. There would be a financial incentive to those staff that have their RCIS. 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? Several of the clinical staff and the cath lab manager are members of the SICP. We are still ramping up the membership drive in the cath lab. Jason Davis can be contacted at