New Jersey Cath Lab

Spotlight: Cardiac Catheterization Lab at Gagnon Cardiovascular Institute, Morristown Medical Center

Robin Weiner Renteria, Director, Invasive Cardiology Service, and Cath Lab Staff, Morristown, New Jersey
Robin Weiner Renteria, Director, Invasive Cardiology Service, and Cath Lab Staff, Morristown, New Jersey

Tell us about your cath lab.

The cardiac catheterization lab at Morristown Medical Center has 51 staff members and consists of five rooms. The mix of credentials in the cath lab includes nurses, cardiovascular technologists, radiologic technologists and administrators. The amount of time staff members have been “in residence” ranges from just recently to 25 years, with a majority being here for at least seven years.

What procedures are performed in your lab?  

The procedures performed at the Morristown Medical Center cath lab include diagnostic catheterization, elective and high-risk angioplasty, and ST-elevation myocardial infarction (STEMI) intervention.

The cath lab also features structural heart procedures, including transcatheter aortic valve replacement (TAVR), atrial septal defect (ASD) and patent foramen ovale (PFO) closures, lower extremity angiogram and angioplasty, carotid angiogram and angioplasty, and some device implantation in coordination with our electrophysiology labs. About 110 procedures are performed each week.

Can you share your TAVR experience? 

The cath lab at Morristown Medical Center has performed a tremendous amount of transcatheter aortic valve replacements, with more than 120 using both the CoreValve (Medtronic) and Sapien (Edwards Lifesciences) valves. Staff surgeons, interventionalists and research coordinators hold a TAVR conference every week. During these conferences, all patients are discussed, and determinations are made whether to go forward with the procedure, what valve to use, and the date of the procedure. As TAVR programs grow and become more integrated, holding similar TAVR conferences is an efficient way to breed success.

What percentage of your diagnostic caths is normal?

About 25 percent of diagnostic caths at Morristown Medical Center are normal, based on numbers from the CathPCI Registry.

Do any of your physicians regularly gain access via the radial artery?

Yes, about 25 percent of procedures involve our physicians gaining access via the radial artery.

Who manages your cath lab? 

The cath lab at Morristown Medical Center is managed by Robin Weiner Renteria, who also manages the hospital’s electrophysiology (EP) lab, as well as the other cath labs in the Atlantic Health System.

Do you have cross-training? Who scrubs, who circulates and who monitors? 

Yes, about 40 percent of staff is cross-trained on circulating, scrubbing and monitoring roles. Generally, technologists monitor, nurses circulate and both scrub. We would like everybody to be trained to be able to perform all three functions. The cath lab is about to begin hiring new staff; once that is done, the staff will be retrained so that everybody is cross-trained in all three functions.

Which personnel can operate the x-ray equipment [position the image intensifier (II), pan the table, change angles, step on the fluoro pedal] in your cath lab? 

Only the physician or a radiologic technologist (RT) can operate the X-ray equipment, including positioning the II, panning the table, changing angles and stepping on the fluoro pedal.

How does your cath lab handle radiation protection for the physicians and staff?

The cath lab’s lead RT serves as the radiation safety liaison and manages exposure on a monthly basis. Additionally, all staff members have annual competencies in radiation safety and receive a new dosimeter that tracks radiation exposure to wear every month.

What are some of the new equipment, devices and products recently introduced at your lab? 

The cath lab at Morristown Medical Center recently installed optical coherence tomography (OCT), a new signal acquisition and processing method for assessing the severity of a coronary or arterial lesion.

How does your lab communicate information to staff and physicians to stay organized and on top of change?

Cath lab administration holds a monthly staff meeting, one in the morning and one in the afternoon, to accommodate everybody’s schedule. The lab maintains a dedicated physician liaison, who communicates with all physicians via email on a routine basis, and a dedicated unit educator, who is responsible for educating all nurses and techs on new policies and procedures.

How is coding and coding education handled in your lab? 

The cath lab recently hired a dedicated financial coordinator in charge of all coding and charge capture. Previously, coding and coding education had been handled by cardiovascular technologists. 

Who pulls the sheaths post procedure, both post intervention and diagnostic? What kind of training is mandated before someone can pull?

Most of the time, the sheaths are pulled by the cardiovascular technologists, although nurses are also able to do so. Technologists pull the sheaths when they are directed to do so by the physician. If the patient is no longer in the unit, the lab sends a tech to the floor to pull the sheath. Training is conducted on the unit, pairing new staff with senior staff during orientation. Staff members are required to watch sheath pulls, participate alongside the senior staff, then be observed while pulling sheaths on their own. Sheath pulling competencies are reviewed and updated annually.

Where are patients prepped and recovered (post sheath removal)? How does your lab handle hemostasis?

Patients are mostly prepped and recovered in the cardiac access unit. Patients staying in extended observation status can recover there overnight as well. If a patient needs to stay in an inpatient unit post-procedure, they are taken to the telemetry floor. Regarding hemostasis, the majority of diagnostic patients are managed with manual pressure, which is held by cardiac cath lab staff. The majority of interventional patients receive a vascular closure device.

How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies?

The cath lab at Morristown Medical Center has a dedicated inventory coordinator for the cath and EP labs who works with all vendors and handles purchasing. The cath lab manager handles all price negotiations, large purchases, and bulk orders.

Has your cath lab recently expanded in size and patient volume, or will it be in the near future?

Yes, the cath lab’s patient volume has increased by 11 percent in the last year and is expected to increase by another 10 to 11 percent in the coming year. The increase is largely due to effective physician recruitment. The lab currently performs about 5,800 procedures annually.

Is your lab involved in clinical research?

Yes, the cath lab is involved in a number of research trials, including trials involving the CoreValve, renal denervation, bioresorbable stents, the Abbott Vascular MitraClip and a number of drug trials.

How does your lab maintain its door-to-balloon (D2B) times under the mandated 90 minutes?

  The lab’s median D2B time is 67 minutes. To keep D2B times under the mandated 90 minutes, cath lab administration meets monthly with the emergency department and Atlantic Ambulance to review cases and look for improvements. The lab performs STEMI drills, and staff members share next-day case feedback on whether the procedure was successfully done in less than 90 minutes. The cath lab is also registered with the American Heart Association’s Mission: Lifeline.

Who transports the STEMI patient to the cath lab during regular and off hours?

The emergency department transports STEMI patients to the cath lab during regular and off hours.

What do you do when the call team is already busy doing a procedure and a STEMI comes into the ED?

When the call team is already busy doing a procedure, they reach out to an administrative person to call in a second call team. The administrative person is on call each evening and weekend, and will call staff who live nearby in order to assemble a second team to come in and care for the patient.

Can you share some of what you like about the layout of your cath lab and where it is located within the hospital?

There is definitely a lot to like about the layout of the cath lab at Morristown Medical Center. First, the rooms are large, making it easier for necessary staff to move freely during procedures. Perhaps the most advantageous aspect of the layout is that the rooms are located very close to the ED (down the hall) and OR (across the hall), which helps to streamline our efforts with those departments and further ensure the quality of our patient care. One aspect of our cath lab layout that we would love to address in the future is additional space for more recovery beds.

What measures has your cath lab implemented in order to cut or contain costs?

The cath lab is currently undertaking a project to streamline inventory for less specialized items. Administrators work closely with vendor partners to do strategic bulk purchases or coordinate other arrangements to bring net effective prices down. Administrators estimate the cost per case for the lab as a whole and analyze those costs quarterly. We also track and report the individual cost per case for our busiest physicians.

What quality control/quality assurance measures are practiced in your cath lab?

All cath lab staff is trained and encouraged to report safety concerns and any near misses, as well as come up with ideas to continue to improve quality. We have a quarterly review of any quality issues to track performance and help us improve. We also perform analyses of patient safety issues as specific issues come up.

Are you recording fluoroscopy times/dosages? 

Yes, we record total fluoroscopy time and measure total radiation exposure in milligrays.

Who documents medication administration during the case?

The staff person monitoring the case documents the medication administration during the case, including the time given and the name of the staff member administering the medication.

In addition to the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) do you use any other outside data collection registry?

In addition to the NCDR, we also report data to several other ACC registries and to the New Jersey Department of Health. Within the Gagnon Cardiovascular Institute at Atlantic Health System, there is a cardiac data department. We work closely with that department on all externally reported data.

How does your cath lab compete for patients? Has your institution formed an alliance with others in the area?

Being in northern New Jersey and so close to both New York and Philadelphia, we work in a highly competitive area and our physicians often have privileges at more than one hospital. Therefore, we focus on three key factors: making our cath lab the safest location, making sure it is the easiest place for our physicians to work and ensuring that patients have a good experience.   The Morristown Cath Lab works closely with the cath labs at the other three hospitals within the Atlantic Health System: Overlook Medical Center, Newton Medical Center and Chilton Hospital. We get referrals from the other cath labs within the system and receive all of their high-risk patients. In addition, Atlantic Health System recently partnered with other health systems in New Jersey and Pennsylvania to form AllSpireHealth Partners, which will focus on quality, affordability and access to health care for the patients in our area.

How are new employees oriented and trained at your facility? 

All new employees receive standard institutional orientation, which differs based on their specific clinical roles and their skill sets. Once they are in the cath lab, we put them through a clinical skills assessment. We assign preceptors to individuals based on who we think will make the best partnerships and what we think will give a staff member his or her best chance of a successful orientation, based on teaching and learning styles. Orientations last eight to 14 weeks. A unit educator meets with the orientee and preceptor biweekly to make sure they are making the best opportunity of orientation time and to make sure the relationship is going well.

What continuing education opportunities are provided to staff members?

The cath lab offers a wide variety of continuing education opportunities to staff members. We hold cardiac grand rounds every Friday, which staff members are encouraged to attend and result in continuing education unit (CEU) credits. We work with our vendor partners on bringing in new equipment and incorporating new techniques. We also support sending staff to local and national conferences.

How do you handle vendor visits to your lab? 

All vendor visits are scheduled through our inventory coordinator. If a vendor representative is slated to be present in the procedure room, the patient must consent to his or her presence prior to the visit. Where vendors can go during their visits depends on the purpose of their visits. If it is for a general visit, we ask them to stay in a conference room. If they are there for education purposes, we reserve them a space in the cath lab suite. All vendor representatives get visitor badges, and we don’t schedule more than one or two on any given day.

How is staff competency evaluated? 

We evaluate clinical competency on an ongoing basis. Staff members are given routine feedback with regard to areas that need improvement and areas in which they are excelling. Staff members are evaluated annually on overall performance, clinical knowledge, communication skills and technical skills.

Does your lab have a clinical ladder? 

Yes, the cath lab’s Professional Advancement Clinical Tracks book allows staff to annually document their own involvement within the lab, as well as educational and advancement activities with themselves and their peers. From there, staff is rewarded with bonuses based on points achieved in the program.

How does your lab handle on-call? 

We currently keep three people on call: one nurse, one technologist and one that could be either a nurse or a technologist. Everybody is required to work a certain number of weeknights and weekends within the year. Every staff member is required to work one holiday period each year.

Within what time period are call team members expected to arrive to the lab after being paged? 

After being paged, team members are expected to arrive to the lab within 30 minutes.

Do you have flextime or multiple shifts? 

The cath lab maintains multiple shifts: an early morning shift, a second team that arrives at noon to cover late evening cases, and a small contingent of flex shifts that might come in an hour or two earlier or later.

Has your lab recently undergone a national accrediting agency inspection?

We are entering our re-survey period for The Joint Commission (TJC). The lab staff works together to ensure we are compliant with all TJC standards every day. We work very hard to focus on ensuring all of our documentation is clearly recorded, complete and accurate. This includes proper documentation prior to the procedure, including a history and physical, and the procedural consent form.

What trends have you seen in your procedures and/or patient population? 

We have seen an increase in structural heart procedures and an increase in peripheral vascular procedures. We are seeing a higher percentage of patients being transferred here from other facilities than we have seen in the past. We have also witnessed a rapid increase in the percentage of procedures performed through radial access.

What is unique about your cath lab and staff?

What makes the staff of the cath lab at Morristown Medical Center’s Gagnon Cardiovascular Institute so innovative is that we really have a very collaborative team. Nurses, technologists and the administrative team work very closely together. We maintain an excellent relationship with our surgical colleagues, and patient care decisions are often made collaboratively with our surgical team.

Is there a problem or challenge your lab has faced? 

While we have been fortunate enough to undergo rapid growth in patient volume, we have had to work hard to accommodate that volume while slowly growing our staff. It takes a significant amount of time to get new positions approved and hired, and then get new staff members trained. Meanwhile, existing staff has gotten busier, which leads to exhaustion. To address the situation, we decided to completely rethink how we staff our procedural areas. We created a whole new staffing model that helped us look at how many staff members we need in the lab each day and accounted for staff vacations, sick leave and conference time. We used those numbers to calculate the total number of FTEs required to maintain the lab. Based on that, we were able to get new nursing positions approved. We used those new positions to create the second shift, which gives our daytime staff a little bit of a reprieve and ensures they can go home at the end of their shifts. We have integrated more cross-training of existing staff. And we remind leadership to routinely recognize and show staff members how much they are appreciated.

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”?

We are located very close to New York City, which can sometimes make it difficult to recruit and retain staff. We serve a very wide geographical area – all over New Jersey and parts of New York and Pennsylvania. We have patients coming in from up to an hour away for elective procedures.

Two questions from the Society of Invasive Cardiovascular Professionals (SICP):

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?

All new staff is required to pass the registry exam for Registered Cardiovascular Invasive Specialists (RCIS). We encourage – but have not yet required – all current staff to take the exam. More than 90 percent of our tech staff has passed the exam, and all staff members receive raises for passing the exam and maintaining their certification.

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?

Yes, clinical leadership is involved in various organizations, including SICP, the American Association of Clinical Care Nurses and the American College of Cardiology.
The authors can be contacted via Robin Weiner Renteria at Robin.WeinerRenteria@atlantichealth.org.

A Question From The American College of Cardiology's National Cardiovascular Data Registry

How do you use the NCDR Outcome Reports to drive QI initiatives at your facility?

We review the NCDR Outcome Reports quarterly. They help us determine what to focus on as we develop our initiatives. We have developed initiatives to make sure all patients discharged with a statin or given a cholesterol-lowering drug are documented. And we were able to bring our median fluoroscopy times down as a result of the reports.