Tell us about your hospital and cath lab.
Mercy Hospital (formerly St. John’s Regional Health Center) of Springfield, Missouri is a large regional health care provider, level one trauma center and referral institution for a large catchment area. Our hospital has achieved national recognition for outstanding patient care, with industry leading results for very low rates of chronic heart failure readmission and the highest ratings for patient safety (First in Missouri and 6th nationally). Our cath lab services a region extending from southwest to central Missouri, northwest Arkansas and into eastern Kansas. Our 800-bed hospital has 4 cardiac catheterization labs, 2 electrophysiology (EP) labs, 2 coronary/peripheral/cerebral labs and a hybrid lab. We have been a regional leader in coronary intervention since the late 1970’s, and we have a dynamic group of 9 skilled interventional cardiologists, 2 electrophysiologists, and a dedicated heart failure/pulmonary hypertension specialist, with a combined 200 years of experience. Our members have come from well-known programs across the country such as Johns Hopkins, Yale, Texas Heart Institute, Mayo Clinic, Washington University, University of Southern California, and Stanford.
We have 60 staff, including ancillary staff. Credentials include critical care registered nurse (CCRN), progressive care certified nurse (PCCN), advanced cardiac life support (ACLS), and registered cardiovascular invasive specialist (RCIS). We have staff that has been in residence for 26 years with the average staff person >10 years.
We are consistently either first or second in our region in cath lab volume, and uniquely, we achieve this without house staff. We are also unique in that as a community hospital, we participate in many national and international research studies. We are in the process of designing a state-of-the-art heart institute that will house our entire program in a facility of 200,000 ft.
What procedures are performed in your cath lab?
Procedures performed at our facility include coronary angiography, right heart studies, heart biopsy, pericardiocentesis, intra-aortic balloon pump (IABP), Impella left ventricular assist device (Abiomed), temporary and permanent pacer placement, implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy (CRT) insertions, loop recorders, percutaneous transluminal coronary angioplasty (PTCA), AngioJet thrombectomy (Medrad), laser, rotoblator (Boston Scientific), stents (bare metal and drug-eluting), intravascular ultrasound (IVUS), fractional flow reserve (FFR), peripheral angiography (diagnostic and interventional), carotid angiography (diagnostic and interventional), PFO/ASD closures, electrophysiology studies, ablations, cryoablations, tilt table testing, transesophageal echo (TEE), cardioversions, and in this past year, transcatheter aortic valve replacement (TAVR).
We see approximately 5,500-6,000 patients annually.
Can you share more about your experience with TAVR?
We have completed 17 TAVR procedures. It allows us to continue to be a leader in provision of new technology to our community. Many patients feel better within 12-24 hours! It has been a great collaborative initiative with our cardiovascular surgeons, cardiologists and supporting staff in both environments. We have a hybrid room adjacent to the standard OR suites.
Does your cath lab perform primary angioplasty with surgical back up on site?
Yes, we have 24/7 surgical back up for our cath lab.
What percentage of your diagnostic caths is normal?
Less than 20% of our diagnostic caths are normal.
Do any of your physicians regularly gain access via the radial artery?
We do perform radial access coronary catheterizations on a regular basis. Our planned heart institute will have a same-day radial access recovery suite.
Who manages your cath lab?
Our lab is managed by Lisa Hutchison, RN, BSN.
Tell us about your particular cath lab layout.
The current layout of the cath lab was by default — our program has outgrown the original space allocated. Expansion has required creative thinking by our engineers and biomedical staff. The layout simulates an “S,” which does not lend to centralization. We also took the opportunity to have a shared control room, which we have found to be a little noisy. We do appreciate the generous size of most of our procedure rooms, however. Fortunately, we are designing a new heart institute, which will allow us to take into consideration patient and work flow.
Do you have cross-training? Who scrubs, who circulates and who monitors?
We cross train a select group of RNs to scrub. RNs also monitor and circulate, and the licensed radiology technologist scrubs and provides technical support for the cardiologist. The physician or the tech positions, pans the table, and fluoros during the exam.
Does an RT have to be present in the room for all fluoroscopic procedures in your cath lab?
No, we sometimes have three RNs in the procedure room. However, for all emergencies we have an RT and we always have radiology techs available to help a cross-trained RN in our lab.
How does your cath lab handle radiation protection for physicians and staff?
We have an annual competency training dedicated to radiation safety for physician and staff. Our radiation safety officer has implemented processes for physicians to acquire credentialing and/or education in “Minimizing risk from fluoroscopic x-rays.” Additional protection measures include the use of the RadPad (Worldwide Innovations & Technologies, Inc.) for extensive, lengthy procedures. We also use standard above and below table shields for all cases.
What are some of the new equipment, devices and products recently introduced at your lab?
TAVR (as we discuss above) and cryoablation. We are also using our scanning as a Unique Device Identifier (UDI), a new initiative for the cardiac cath lab. This is a very significant to our process in accountability to implanted devices. Being a part of the Mercy Health system has assisted in this initiative with resource support.
How does your lab communicate information to staff and physicians to stay organized and on top of change?
We text our physicians to let them know a case is ready and we have a dedicated point person to verbally communicate the daily schedule. Pagers are becoming obsolete, but are used as a backup. We also have created a SharePoint website (Microsoft) to post resources and updates.
How is coding and coding education handled in your lab?
We have a credentialed coder within the cath lab that reviews every case and verifies correct billing. We also have a hospital facility coder that provides oversight.
Who pulls the sheaths post procedure, both post intervention and diagnostic?
RNs, RTs and CVTs pull sheaths post procedure. We have a formal didactic and “hands on” demonstration and education for this procedure. We also monitor bleeds post procedure to identify any opportunities for improvement.
Where patients are prepped and recovered (post sheath removal)?
Outpatients are prepped and recovered in the adjacent Same Day Admit area. Inpatients are prepped in the holding room. If the patient receives an intervention, they are recovered in our Cath Lab Recovery Unit.
We utilize mostly Starclose (Abbott Vascular), Perclose (Abbott Vascular) and Mynx (AccessClosure) closure devices. Approximately 45% of our cases reach hemostasis via manual compression.
How is inventory managed at your cath lab? Who handles the purchasing of the equipment and supplies?
We have one coordinator that provides oversight to inventory and she works closely with the coder to reconcile utilization and charges. We started scanning in late 1990’s and in 2004, implemented a process that incorporates inventory, patient charge and clinical documentation with one scan. Most recently, we have integrated the OptiFlex software system (Omnicell) for supply items.
Has your cath lab recently expanded in size and patient volume?
We have seen our most recent growth in the areas of electrophysiology, peripheral procedures and TAVR.
Is your lab involved in clinical research?
We keep four full-time coordinators busy. Our research participation has included investigational medications, investigational EP devices, interventional cardiology, and cardiothoracic studies. Some of the studies we have participated in include:
- AMEthyst trial: an 800-patient, U.S.-based multicenter, randomized trial to evaluate the safety and efficacy of the Medtronic Interceptor PLUS Coronary Filter System as an adjunct to percutaneous interventions on saphenous vein bypass grafts (SVGs).
- EMERALD trial: Enhanced Myocardial Efficacy and Removal by Aspiration of Liberated Debris (Medtronic GuardWire temporary occlusion–aspiration system).
- TRA-2P TIMI 50: A phase III trial to assess the effects of SCH 530348 in preventing heart attack and stroke in patients with atherosclerosis (Schering-Plough).
- SOLID-TIMI 52: Testing whether darapladib in addition to standard therapy can safely lower the chances of having a cardiovascular event when treatment is started within 30 days after an acute coronary syndrome in high risk patients. Darapladib has been shown to decrease plaque inflammation and necrotic core.
- Dual antiplatelet therapy studies: XIENCE, CYPRESS, and HCRI-DAPT
- SIRS: Steroids in cardiac surgery
- PainFree SST: A prospective, multicenter clinical trial with two consecutive phases; “Phase I (Protecta Clinical Study)” followed by “Phase II (PainFree SST Clinical Study)”. Collectively, Phase I and Phase II will provide data to support market release of the Medtronic Protecta devices and evaluate the SmartShock technology features in reducing inappropriate shock.
- Analyze ST: ST Monitoring to Detect ACS (Acute Coronary Syndrome) Events in ICD Patients (St. Jude Medical’s Fortify® ST implantable cardioverter defibrillator system).
- CHOICE: The aim of the study is to see if biventricular pacemakers offer any advantage over conventional pacemakers in patients with heart failure who require pacemakers. The investigators’ hypothesis is that biventricular pacing is preferable to conventional pacing in these heart failure patients (St. Jude Medical).
- TRACER: Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome (Merck).
- ROCKET AF: A major clinical trial showing that rivaroxaban (Xarelto, Bayer/Johnson & Johnson) is noninferior to dose-adjusted warfarin for the prevention of stroke or major embolism in patients with atrial fibrillation.
- VIRGO trial: Variation In Recovery: Role of Gender on Outcomes of Young AMI Patients
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?
We have a very active, multidisciplinary ST-elevation myocardial infarction (STEMI) committee that meets monthly. We review all STEMI cases and processes, and have utilized Six Sigma strategies in improvement. We are members of the American College of Cardiology’s D2B Alliance. We also have played central role in the planning for the Missouri statewide initiative, Time Critical Diagnosis. Our facility plans to apply for STEMI Level 1 Recognition. Our current average D2B time is 61 minutes, and steadily dropping. Data from the previous quarter showed an average time of 45 minutes.
How does your lab handle call time for staff members? Is there a particular mix of credentials needed for each call team?
Call time is a rotational team assignment. The team consists of two ACLS-certified RNs and a radiology tech.
With what time period are call team members expected to arrive to the lab after being paged?
The call team is expected to receive the emergency patient into the cath lab within 30 minutes of receiving a page. Our average time is around 20 minutes.
Who transports the STEMI patient to the cath lab during regular hours and off hours?
Emergency Medical Services (EMS) and/or emergency department staff transport the STEMI patients to the cath lab.
What do you do when the call team is already busy doing a procedure and a STEMI comes into the emergency department?
During regular working hours (0603- 1900), we have an emergency team available; during off hours, if the first call team is busy with an emergency, we call in a second team.
What measures has your cath lab implemented in order to cut or contain costs?
Our initiatives in cost containment primarily center on inventory management/utilization and cross training. We have become more efficient and concise with our inventory scanning system. We review supplies carried and track cost per case, and share this information with physicians and staff. We accept bids from equipment vendors for volume or market share percentage discounts.
Cath lab RNs are cross-trained to the Same Day admit area and Cath Lab Recovery. This cross training allows us to utilize staff where they are most needed throughout the day. It also increases the continuum of care as the cath lab patient proceeds through the procedure and is prepared for discharge.
What quality control/quality assurance measures are practiced in your cath lab?
Our facility participates in ACC registries and utilizes those results to identify opportunities for improvement, as well as Core Measures initiatives. Some of the standard clinical monitors include any bleeding complications, glomerular filtration rate and contrast utilization per case. We also currently document fluoro time, mGy, and cGy/cm2 for each case. Fluoroscopy times are calculated by our radiology equipment. Physicians are kept informed of fluoro time during the procedure and routinely move the image intensifier (II) every 4-5 minutes. Outcomes are monitored daily and mortality/morbidity conferences are held monthly.
Who documents medication administration during the case?
The RNs document medications used during the procedure in our hospital electronic medical record (EMR).
Along with the ACC National Cardiovascular Data Registry (NCDR), do you use any other outside data collection registry?
Yes. ACC and Society of Thoracic Surgeons (STS) registry data is presented at our Cardiovascular Consortium, which is a division committee. This committee consists of cardiologists, cardiovascular surgeons, nurse practitioners, nursing, and administration. We develop action items as it relates to each discipline.
How does your cath lab compete for patients? Has your institution formed an alliance with others in the area?
We have multiple satellite facilities and outreach clinics to maintain and expand our patient base. There are competitive local institutions, but we do work with many in alliance. One recent example is a standardized protocol for STEMI treatment for regional facilities. We meet regularly with these facilities and EMS providers to support community collaborative care. This initiative has improved patient care for our community by decreasing confusion for EMS and regional facilities.
How are new employees oriented and trained at your facility?
There is a formal didactic orientation program. The new staff member is assigned a preceptor and these two work side by side until the new employee has completed their skills training.
What continuing education opportunities are provided to staff members?
Continuing education is completed primarily online. We also have periodic education forums during staff meetings and also through vendors. The system offers stipends to help with achievement of advanced degrees and certifications which include CCRN and PCCN.
How do you handle vendor visits to your lab?
Vendors must apply and utilize VendorMate. Vendors typically work out of a conference room within the cath lab. We have 3-5 vendors visit per week.
How is staff competency evaluated?
Along with hospital-based competency, cath lab staff has specific technology skills that require validation of competence. This is achieved via demonstration, didactics and paper programs. Completion of these established skills is reviewed annually.
Does your lab have a clinical ladder?
We are currently in the process of a clinical ladder development. We have implemented Shared Governance and are utilizing this program to assist in the pursuit of facility Magnet status.
Do you have flextime or multiple shifts?
We have incorporated a tiered staffing model beginning with one room at 0630, building to 8 available rooms, and then transitioning down to one room at the end of the day. This is accomplished with 4-, 8-, 10-, and 12-hour shifts.
Has your lab recently undergone a national accrediting agency inspection?
We have had a recent Joint Commission inspection and our physicians and staff did very well! We stressed understanding the National Patient Safety Goals and how they each apply to the cath lab environment. We have recently been recognized as a national leader in patient safety.
Where is your cath lab located in relationship to OR and to ER?
Our cath lab is located 3 floors above the ER, with private elevator access. The cath lab is directly above the OR; however, in the new heart institute, we will be adjacent to this department.
What trends have you seen in your procedures and/or patient population?
Trends in the cath lab have focused around Appropriate Use Criteria. We are seeing more patients with end stage disease and many have been turned down by cardiothoracic surgery for bypass. Our use of the Impella device is gradually increasing.
What is unique or innovative about your cath lab staff?
We have a very dedicated cath lab staff with low turnover. Many of our staff members have worked together for 20 years or more. We have cross-trained staff across disciplines.
Is there a problem or challenge your lab has faced?
Dealing with EMR (Epic) implementation was a challenge that impacted workflow and efficiency for a period of time. Thankfully, we are through this period. Our physicians have tried a few reporting tools, but the search goes on. Cost containment is a constant challenge, and we track cost per case and provide feedback.
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 program size is of recognized urban status and yet we reach a very large rural community of patients. We may be treating an executive in one lab and have someone in an adjacent lab from rural Missouri that hasn’t “been to town” in years. We see a steady influx of people visiting or moving to our area because of the low cost of living and multiple recreational activities available.
The Society of Invasive Cardiovascular Professionals (SICP) has added two questions to our spotlight:
Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)?
We do not require this registry at this time, but we do have staff that has acquired it. We do provide opportunity to attain it.
Is your clinical and/or managerial team involved with any professional organizations that support the invasive cardiology service line, such as the SICP, ACVP, or regional organizations?
We have affiliation with our regional ACC and the American Association of Critical-Care Nurses (AACN).
Lisa Hutchison can be contacted at Lisa.Hutchison@Mercy.Net.
Dr. Donald Myears can be contacted at Donald.Myears@Mercy.Net.