What is the size of your cath lab facility and number of staff members? Saint Vincent Healthcare, employing approximately 2,300 employees, is a 300-bed faith-based facility, one of twelve hospitals in the Sisters of Charity of Leavenworth Health System. Our cath lab has three cardiac suites, one interventional radiology suite, and one bi-plane neuro-interventional suite. We have ten registered nurses (RNs), ten radiologic technologists (RTs), an RN manager, and three support personnel. We provide services for two cardiovascular interventionalists, six cardiologists, five interventional radiologists, and one neurosurgeon, who does cerebral diagnostics and interventions. What procedures are performed at your facility? Diagnostic angiograms: We do heart caths, renal angiograms, aortograms, runoffs, carotid angiograms, cerebral angiograms, fistulograms, and upper extremities angiograms. Interventional procedures: We do coronary angioplasty, coronary stent placement (bare metal and drug-eluting), peripheral atherectomy [SilverHawk (ev3, Inc., Plymouth, Minn.) and laser (Spectranetics Corp., Colorado Springs, Co.], peripheral angioplasty and stenting, cerebral angioplasty, cerebral stenting, cerebral coiling, intravascular ultrasound (IVUS), Rotablator (Boston Scientific, Natick, Mass.), pressure wire, AngioJet (Medrad, Inc., Warrendale, Pa.), cutting balloon (Boston Scientific), FilterWire (Boston Scientific), Merci retrieval device (Concentric Medical, Inc., Mountain View, Ca.), thrombolysis, peripheral embolization, and intra-aortic balloon pump (IABP). Device implants: We do pacemaker insertion, implantable cardioverter defibrillator (ICD) insertion, bivenricular pacemaker insertion, loop recorder insertion, abdominal aortic aneurysm (AAA) stent graft placement, thoracic stent graft placement, vena cava filters, nephrostomy tube placement, and nephro/ureteral stent placement. Line placement and evaluation: We do peripherally inserted central catheters (PICCs), Groshong catheters, temporary dialysis catheters, tunneled dialysis catheters, infusaports, and pain pump trials. Back procedures: We do discograms, nerve root blocks, vertebroplasty, kyphoplasty, facet fusions. Miscellaneous: We do cardioversions, transesophageal echocardiograms (TEEs), TIPS procedures, pericardiocentesis, use the Arctic Sun cooling device (Medivance, Inc., Louisville, Co.), trigeminal nerve ganglioplasty, uterine fibroid embolization, fallopian tube balloon procedure, and diagnostic studies for donor patients. Our RNs place all PICC lines for our facility and provide coverage for treadmills, stress echos, and computed tomography (CT)-guided biopsies. Heart procedure volume: 40 per week Interventional radiology procedure volume: 15 per week Neuro procedure volume: 5 per week Implant procedure volume: 10 per week PICC procedure volume: 15 per week Other procedure volume: 5 per week (Total procedures/week: 90) Does your cath lab perform primary angioplasty without surgical backup on site? Yes, we have a CV surgeon and OR staff available 24/7. What percentage of your patients is female? Thirty-eight percent of our patients are female. What percentage of your diagnostic cath patients go on to have an interventional procedure? Thirty-five percent of our diagnostic patients also have an intervention. Who manages your cath lab? Theresa Ketterling, RN, BSN, manages the cath lab, and we have three clinical supervisors: 1 RN and 2 RTs. Do you have cross-training? Who scrubs, who circulates and who monitors? We provide cross-training. RTs scrub all cardiac angiogram procedures, and RNs and RTs rotate through scrubbing interventional radiology and neuro bi-plane cases. RNs circulate all cases. All RTs and RNs are trained to monitor. Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab? No, as long as the physician is present and he/she obtains the images. In the interventional radiology procedures, an RT is required to do the filming of the procedure. 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? MDs and RTs can perform all of the above. RNs are cross-trained to position and pan. How does your cath lab handle radiation protection for the physicians and staff? All staff is required to wear lead in any procedure room. We are each provided with our own personal wrap lead and thyroid shield. We have ceiling-mounted lead shields as well as lead shields hanging from the table in front of the operator and the scrub assist. We have radiology safety officers: one RT in the lab and one organizational officer. They monitor radiation usage and exposure, and provide feedback and education to the cath lab staff, as well as other departments who use portable c-arms. What are some of the new equipment, devices and products introduced at your lab lately? New equipment and devices include the Toshiba 320-slice Aquilion 1 CT (Tustin, Ca.), Penumbra device for stroke interventions (Penumbra, Inc., Alameda, Ca.), Mynx closure device (Access Closure, Mountain View, Ca.), the Volcano IVUS/pressure wire (Volcano Corp., San Diego, Ca.), and the HoverTech mattress patient transfer system (HoverTech, Bethlehem, Pa.) for all procedures. This transfer system is awesome! It is saving the backs of all our staff members. Can you describe the system(s) you utilize? We have the Siemens Axiom Artis x3 (Siemens Medical Solutions, Malvern, Pa.) in the cardiac cath labs and an old Siemens Multistar TOP in the angiography room. We use a Philips Allura Xper Fd Series (Bothell, Wa.) in the bi-plane room. For hemodynamic monitoring, we utilize the GE MacLab IT (Waukesha, Wisc.) in all 5 rooms. We have Fuji PACS (Stamford, Conn.) for our angiography and bi-plane rooms. We have the Fuji ProSolv PACS for our cardiac studies. All of our data is captured by an interface between the MacLab and our Apollo server (Lumedx, Oakland, Ca.). How is coding and coding education handled in your lab? We have a full-time coder in our lab that is also a cath lab RT. She reads all dictation and double-checks all charges against that dictation. She provides feedback and education to the physicians and cath staff. Do any of your physicians utilize transradial access? No. How does your lab handle hemostasis? We use closure devices [primarily Starclose (Abbott Vascular, Redwood City, Ca.) or Angio-Seal (St. Jude Medical, Minnetonka, Minn.), but we also use the Mynx on occasion) on 95% of all arterial punctures. Handheld pressure is used for any other patients. All of our sheaths are pulled and closed immediately after the procedure, unless circumstances dictate otherwise. Patients with interventions go to the telemetry unit. If it is an acute myocardial infarction patient, they generally go to the ICU. The staff on these units is responsible for monitoring the patient’s groin for hemostasis. The cath lab staff provides back up if a patient bleeds unexpectedly, and they also educate floor nurses about hematomas and how to deal with them. What is your lab’s hematoma management policy? The cath lab staff is called for any groin bleeds that happen after the patient leaves the cath department. We go to the floor and manage any hemostasis issues. We document all failed vascular closure devices and hematomas. We use that data for quality improvement and further staff development/education. How is inventory managed at your cath lab? We have a dedicated inventory control person (supply chain coordinator) who is employed by materials management, but resides permanently in the cath lab. Our inventory system is Optiflex, a division of Omnicell (Mountain View, Ca.). Our group purchasing organization (GPO) is Broadlane (Dallas, Texas) and we have input into that process via a value analysis team (VAT). Decisions are made by input from staff and physicians. Stocking is done by cath lab staff and the supply chain coordinator. The staff is responsible for making sure the rooms are stocked appropriately. They also check expiration dates and rotate supplies. The supply chain coordinator oversees a process where all supplies get counted on either a weekly, monthly or quarterly basis. At year’s end, a full inventory is completed by the department. Has your cath lab recently expanded in size and patient volume? We have not recently expanded, but we are actively doing vascular outreach. We have also started doing hybrid procedures with a cardiovascular surgeon in our bi-plane room. Is your lab involved in clinical research? Yes. We participate in the SAPPHIRE study as well as the Endologics Powerlink 34 mm Bifurcated Trial for large AAAs. Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? Yes, we had one patient require emergent cardiac surgery. Can you share your lab’s average door-to-balloon (D2B) times and some of the ways employees at your facility have worked together to keep D2B times under the mandated 90 minutes? Our average D2B time for 2009 was 58 minutes. We have a STEMI activation team and coordinator that review each STEMI and provide follow-up education. Our call center activates the STEMI team per request of the emergency department (ED) physicians. Electrocardiograms (ECGs) are performed in the field by our ambulance crew and faxed to the ED prior to their arrival so the team can be activated before the patient hits the door to the hospital. What measures has your cath lab implemented in order to cut or contain costs? We utilize just-in-time ordering and have decreased our par levels considerably. We monitor outdated inventory and proactively trade out supplies with the product representatives prior to actual expiration date. We consign all possible supplies. We stage procedures in order to give us time to order specialized product for the procedure. This allows us not to have to keep unusual supplies on the shelves. What quality control/quality assurance measures are practiced in your cath lab? We monitor radiation exposure to the patient and report it per physician/month. We monitor antibiotic administration to implant patients — type of antibiotic and time administered. We track and report D2B times by month and report a rolling 12 months as well. We distribute physician report cards that include D2B times, radiation usage per case to include mGy, complication rates, volumes and CMS core measures. Cath lab staff abstract data for all peripheral and heart cases, submit the data to national databases, as well as use it internally for quality improvement. How does your cath lab compete for patients? Has your institution formed an alliance with others in the area? We are one of 2 similarly sized hospitals in Billings, Montana, population approximately 120,000. Both institutions have cath lab facilities. The hospitals are 3 blocks from each other physically, but have very different philosophies as it relates to doing business. Our competitor is a combined clinic/hospital with all employed physicians. St. Vincent Healthcare has traditionally been a stand-alone hospital, utilized by independent physicians. Over the past 10 years, we have begun to employ primary care practices and even a few specialty clinics. However, the majority of physician who utilize our services are independent practitioners. We have done joint ventures with our competitor with areas like MRI and cancer treatment. We willingly share supplies, if needed, and occasionally socialize, but otherwise are quite separate. The Clinic physicians seldom come to St. Vincent and the independents do not often go to the Clinic. We draw patients from a tri-state area and compete by advertising and physician outreach clinics in towns as far as 6 hours away. Other methods are physician CME outreach, referring physician education conferences, and alliances with outlying hospitals and clinics. We have the only helicopter service in Billings, and are only one of four in Montana. How are new employees oriented and trained at your facility? • New team members are assigned a mentor and receive an education binder with information and competencies to be completed. Orientation is 8 to 12 months. All staff participate in the education of new employees. • Our newest team member has been in the lab 2 years. • In Montana, we seldom get applicants with cath lab experience. Most RNs have ICU and/or other critical care experience. Most RTs come straight from radiology and are “on-the-job” trained. We have had the pleasure of two RTs with some diagnostic cath experience. Otherwise, all have been trained in our lab. • RNs and RTs must have their state and national licensure. We ask our supervisors to also be certified as a registered cardiovascular invasive professional (RCIS). Everyone is BLS and ACLS certified. • Currently our RNs are in the process of becoming PICC ultrasound certified. What continuing education opportunities are provided to staff members? We have weekly staff meetings where education is provided by guest speakers, by invitation. Vendors provide education and CEUs with new products and other subjects by request. Staff can request out-of-town education opportunities and will be granted tuition and travel dollars when available. We recently hosted an RCIS review course that attracted cath staff from a 6-state area. We also attend multiple education offerings put on by the hospital education department. These are either a full day or a weekend conference that offers CEUs. How do you handle vendor visits to your lab? Vendors must pre-schedule their visit through the cath lab vendor liaison. When they arrive at the hospital, they sign in with the facility access coordinator and receive a vendor badge. They must wear company- and hospital-issued badges. We allow one vendor in the department at a time. They are usually scheduled for a half-day or a full day. Depending on the physician, they can sit in the monitor room during the procedure. How is staff competency evaluated? Staff competency is evaluated on a hospital level and a department level. There is a house-wide skills day that is required of all RNs. RTs participate in some of the stations. In the department, we have monthly competency demonstration and check off for infrequently used devices (i.e., Rotablator) and required skills. Our BLS and ACLS certification must remain current or we are not allowed to work in the lab. Our annual evaluation includes peer and physician evaluation feedback. Does your lab have a clinical ladder? Not currently. Does your lab utilize any alternative therapies (such as guided imagery, etc.)? We are a faith-based ministry providing spiritual care with the support of our spiritual care department, on call 24/7. We provide background radio music per patient preference. How does your lab handle call time? Our call team is comprised of three people, with a fourth person on backup call. Backup call is defined as two emergencies presenting at the same time. Our group of 4 call people is two RTs and two RNs. A call team could be 2 RNs and 1 RT, or 2 RTs and 1 RN. It just depends on the day. We are on call one night every week and about every fifth weekend. We rotate holidays, working one or two a year. Within what time period are call team members expected to arrive to the lab after being paged? We have a 15-minute response expectation for the cath lab crew. Our actual policy states a 30-minute response time. Do you have flextime or multiple shifts? We have staff on either ten-hour or eight-hour shifts and we do self-scheduling. Some people come in at 0730, some at 0800, and the call people come in at 0930. Has your lab has undergone a Joint Commission inspection in the past three years? We just completed our survey and were recognized as in the top 10% of the nation for quality performance. We benefited by having strong leadership, who were knowledgeable of the standards and developed systems to support these standards. We had frequent mock surveys to prepare us. What is unique or innovative about your cath lab and its staff? We recently were awarded Best in the Nation for heart attack care in a recent edition of Inside the Joint Commission. This data comes from CMS and rates over 4,000 hospitals throughout the nation. We are ranked better than average for readmission rate for hospital heart attack care. We are a combination lab, providing cardiac and interventional radiology care, including peripheral and neuro. We have a very low staff and physician turnover rate. Our newest team member has been with us 26 months. In 2004, we added a second cardiology practice and increased our staff by about 50%. Our average length of employment in the cath lab is 10.3 years. Is there a problem or challenge your lab has faced? We do aortic endovascular stent grafts in a collaborative effort with the OR. We had to work with anesthesia and OR staff to define roles and ensure safe practice. We discussed each case and communicated before, during and after, having a continuous improvement process. 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”? Many of the patients we serve are over 150 miles away from acute care facilities and require air transport to our facility. We do many rescue and salvage interventions. 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? No, but we do have some RCIS-certified members. There is a work in progress for including it as part of a clinical ladder. Our certification and recertification costs are paid for. 2. Are team members involved with any professional organizations that support the invasive cardiology service line? Several staff are members of the SICP and AACN (American Association of Critical-Care Nurses).
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