Washington cath labs

Spotlight: PeaceHealth Southwest Medical Center

Mic Bradshaw, RN, MSN, MHA, CCRN, RCIS, Vancouver, Washington
Mic Bradshaw, RN, MSN, MHA, CCRN, RCIS, Vancouver, Washington

Mic Bradshaw can be contacted at kmbradshaw@swmedicalcenter.org

The cath labs at PeaceHealth Southwest Medical Center will be celebrating 30 years of operation in July of this year.

Tell us about your cath lab. 

Peace Health Southwest Washington is a 450-bed, not-for-profit institution. We have 5 cath labs: 1 dedicated to electrophysiology (EP), 1 dedicated to interventional radiology and neurology, 2 primary cardiac rooms, and 1 suite designed for peripheral vascular procedures. We currently employ 11 radiologic technologists (RTs, 2 of whom also have registered cardiovascular invasive specialist [RCIS] certification), 9 registered nurses (RNs), and one EP specialist. We have a full-time scheduling person, a dedicated environmental services person, and an inventory specialist who round out our talented team. We provide services for 18 cardiologists, including 4 cardiovascular interventionalists and 4 electrophysiologists. We also perform procedures with our 3 vascular surgeons, 3 interventional radiologists, and 2 neurosurgeons, who perform cerebral and spinal diagnostics and interventions. Our talented team of dedicated caregivers has a cumulative 350+ years of cardiovascular lab experience. 

The cath labs at PeaceHealth Southwest Medical Center will be celebrating 30 years of operation in July of this year.

Tell us about your cath lab.

Peace Health Southwest Washington is a 450-bed, not-for-profit institution. We have 5 cath labs: 1 dedicated to electrophysiology (EP), 1 dedicated to interventional radiology and neurology, 2 primary cardiac rooms, and 1 suite designed for peripheral vascular procedures. We currently employ 11 radiologic technologists (RTs, 2 of whom also have registered cardiovascular invasive specialist [RCIS] certification), 9 registered nurses (RNs), and one EP specialist. We have a full-time scheduling person, a dedicated environmental services person, and an inventory specialist who round out our talented team. We provide services for 18 cardiologists, including 4 cardiovascular interventionalists and 4 electrophysiologists. We also perform procedures with our 3 vascular surgeons, 3 interventional radiologists, and 2 neurosurgeons, who perform cerebral and spinal diagnostics and interventions. Our talented team of dedicated caregivers has a cumulative 350+ years of cardiovascular lab experience.  

What procedures are performed in your cath lab?   

The cardiac rooms perform all standard diagnostic and interventional procedures. We have intra-aortic balloon pump (IABP) and Impella capability (Abiomed, Inc.) and have recently started performing advanced techniques for patients with chronic total occlusion of their coronary arteries. 

The interventional radiology/neurology room is a bi-plane suite where we perform various venous and arterial studies including Transjugular intrahepatic portosystemic shunt (TIPS) procedures, carotid stenting, TheraSphere y90 insertion (BTG International), kypho/vertebroplasty, uterine fibroid and other embolization procedures, and intracerebral coiling for aneurysm care. We are also a stroke center and perform our interventional cerebral cases in this room. Our interventional radiologists perform yttrium-90 (y-90) TheraSphere brachytherapy, abdominal aortic aneurysm (AAA) endografts, thrombolysis, stroke care, and other percutaneous diagnostic and interventional procedures in addition to various venous line insertions, tube placements, and drainage catheters. 

The peripheral vascular room is where we perform our non-cardiac angiography and also our thoracic and abdominal stent graft insertions. 

The electrophysiology room is where we perform basic EP studies/radiofrequency ablation studies, and also atrial fibrillation and ventricular tachycardia ablations. We use cryoablation as well as radiofrequency techniques for our ablation procedures. We offer a complete device program, including pacemakers, implantable cardiac defibrillators (ICDs), and bi-ventricular devices, and PeaceHealth Southwest Medical Center was the first hospital in the Portland metro area to implant subcutaneous defibrillators. 

We perform approximately 425 procedures each month. 

Is your cath lab performing transcatheter aortic valve replacement (TAVR)? 

We do not currently perform TAVR, but do have a bi-plane room utilized for specialty cases involving a combination of operating room and cath lab staff located within our department. This room is used to perform thoracic and abdominal stent grafting procedures, as well as peripheral cases that involve a percutaneous and surgical approach. We have plans for a new single-plane, ceiling-mounted, hybrid room. Our current projections have that room fully operational by November 2014.

Does your cath lab perform primary angioplasty with surgical backup on site? 

PeaceHealth Southwest Medical Center has a cardiothoracic surgical team available during business hours and on call 24/7 during off hours.

What percentage of your diagnostic caths are normal? 

10.9% of our diagnostic cardiac procedures are deemed normal.

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

We have 6 physicians who utilize the radial approach. Currently, approximately 17% of our cases are done via the radial artery and 9% of our interventions are done radially. Access via the radial artery is not standard practice for our ST-elevation myocardial infarction (STEMI) patients at this time.

Who manages your cath lab? 

We have an RN who directs the lab operations and a team leader who manages day-to-day workflow. The director of heart & vascular services oversees this area from an administrative perspective. 

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

Many of our radiologic technologists have certification required to administer medications (except sedation) and the RNs can perform all facets of medication administration needed in the cath lab setting, except deep sedation and the administration of propofol, based on Washington State guidelines. RNs participate in monitoring and circulating, while RTs perform scrubbing, x-ray, and monitoring roles. 

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

Each caregiver and the physicians are provided a custom lead apron and thyroid shield fitted to the individual. Each room is equipped with lead shielding both below and above the working area to protect our staff. Our staff has access to their monthly dosimeter readings and receives updates if their exposure is above standard limits. We also notify the performing provider of each Gy delivered during the case to promote awareness and patient and staff safety. 

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

We utilize the Impella device (Abiomed) and have recently upgraded to modules capable of utilizing new catheter technology. We use the EkoSonic Endovascular System (EKOS Corp.) for peripheral intervention requiring thrombolytic administration. The NRG RF Transseptal Needle (Baylis Medical) has reduced our transseptal puncture times dramatically. We perform TheraSphere y-90 administrations to select oncology patients. We have been performing cryoablations for four years and we are the first site in the Portland metro area to implant the new subcutaneous implantable cardioverter-defibrillator (S-ICD) (Boston Scientific). Our embolic stroke patients benefit from our use of the Solitaire FR Revascularization device (Covidien). 

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

We are led by a governance council comprised of hospital administration and physicians. Sub-councils exist that handle supply decisions and electrophysiology needs, and there is an acute coronary syndrome committee that provides guidance for this subset of patients. Physician leaders communicate with their peers at monthly section meetings and cath conference. Every other Friday morning is blocked out for one hour and is dedicated to staff in-services or meetings. The cath lab staff wears pagers and Vocera devices for ease of communication during the day. Our EP staff also utilizes hands-free headsets to communicate during procedures. 

How is coding and coding education handled in your lab? 

We employ a coder who handles our billing.

Who pulls the sheaths post procedure, both post intervention and diagnostic? 

The majority of our sheaths are pulled by our specialized CardioVascular Observation (CVO) staff. The CVO is a cardiovascular prep and recovery area with 16 beds, employing 10 RNs, 2 certified nursing assistants (CNAs), 2 monitor techs/unit secretaries (MT/USs), and 1 licensed practical nurse (LPN). Acute and/or critically ill patients will have their sheaths discontinued by the CardioVascular Intensive Care Unit (CVICU). 

Where are patients prepped and recovered (post sheath removal)? 

The majority of our patients are prepped and recovered in our CVO unit. Manual pressure, FemoStop (St. Jude Medical), Angio-Seal (St. Jude Medical), Perclose (Abbott Vascular), and Starclose (Abbott Vascular) are used, depending on patient condition and body habitus. Cath lab staff and physicians deploy closure devices and bi-annual competencies are in place to ensure a heightened skill level. We use the TR Band system (Terumo) for our radial access patients. Our emergent or unstable percutaneous coronary intervention (PCI) patients are taken directly to the critical care unit.

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

We are transitioning to an automated approach that uses information we scan into our hemodynamic system and sends that data onto the materials department for purchasing and billing for our supply charges. We have a dedicated materials specialist who handles day-to-day ordering and an RT dedicating time to assuring the clinical product line is loaded with current technology at competitive pricing.

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

We plan to expand the technology and services related to development of a hybrid suite this fall. Our overall patient volume has remained stable over the previous year with a slight increase in EP, pacemaker, and ICD visits.

Is your lab involved in clinical research?

We have been involved in the SAPPHIRE trial for carotid stenting, the subcutaneous ICD implant registry, and a post ICD implant patient/partner study through the University of Washington. 

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?  

For the first quarter of 2014, we reported an average 60-minute DTB time. We have an acute coronary syndrome (ACS) committee that analyzes data and identifies trends that may provide an opportunity for improvement. This committee also incorporates physicians and leaders from outside institutions to ensure the safest care possible for the patients in our service area. 

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

Cath lab staff transports STEMI patients to the cath lab during regular hours and after hours. We have the paramedics bring patients directly to the cath lab, depending on availability of staff and physicians.

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

An assessment of estimated completion time of the current case is taken into account along with the STEMI patient’s stability. If it is deemed that the wait would compromise the STEMI patient’s safety, thrombolytics would be used and/or the patient would be transferred to a facility that could provide acute PCI care. 

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

We have a dedicated supply chain sub-committee that consists of an interventional cardiologist, cath lab manager, materials director, cath lab clinical specialist, heart and vascular director and executive director. This team has worked to partner with vendors who offer discounted pricing for various levels of commitment across our 5 specialties. Our current contract resulted in substantial savings across the spectrum of our product lines. 

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

We monitor charts monthly for time-outs, patient identification, appropriate chart documentation, in-hospital outcomes, and door-to-balloon times, to name a few. We monitor National Patient Safety Goals, such as time-outs, hand hygiene, medication labeling, and 2 patient identifiers. At a system level, we monitor appropriate use criteria for PCI, acute kidney injury (AKI), and radiation safety parameters. Our hospital performance improvement department monitors our core measures and any major complications, such as hematomas requiring transfusion, deaths, strokes, etc. 

Are you recording fluoroscopy times/dosages? 

We record fluoro times in our MacLab system (GE) and also document air kerma (AK) times in mGy, and report findings of >15 Gy to our risk department. Patients that receive over 5 Gy receive an informational letter and a follow-up phone call at 30 days. We make a concerted effort in the EP lab to decrease fluoro doses to staff and patients. We use intravascular ultrasound to assist with guidance for atrial fibrillation ablations, further decreasing fluoro times. Our new hybrid room will have a dose reduction package intended to reduce fluoro doses by as much as 80%.

Who documents medication administration during the case? 

The RN or RT recording the case enters medications given.

Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) or any other outside data collection registry? 

Yes, we submit data to the ACC-NCDR and participate in Washington State’s Clinical Outcomes Assessment Program (COAP). We also participate in the Society of Thoracic Surgeons (STS) national database for cardiovascular surgery and the NCDR-ICD registry. 

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

In our area, we are in a unique situation since we are the only facility in southern Washington offering emergency cardiac services 24 hours per day, seven days per week, 52 weeks per year. We have an agreement with the other hospital in our county to accept their patients that need a higher level of service than they provide. We also have developed a relationship with our sister hospital, 40 minutes north, to accept their STEMI, stroke, and any other patients needing an increased level of care that may be more than they can provide. Our partnership with community hospitals within our region has helped grow our stroke and STEMI programs. 

How are new employees oriented and trained at your facility? 

New employees are paired with trained preceptors and a plan of training is outlined. This is a fluid process, dependent on the new caregiver’s previous experience and challenge areas. 

What continuing education opportunities are provided to staff members? 

We schedule vendor inservices on select Friday mornings to allow for our staff to obtain CEUs, and learn about new technologies and equipment. 

How do you handle vendor visits to your lab? 

Vendors are asked to make an appointment with our inventory specialist. They are allowed in limited areas of the lab and only allowed in the procedure rooms if requested by a physician. They may come once per month, by appointment only, and are expected to check in through RepTrax.

How is staff competency evaluated? 

Competencies for high-risk/low-use items are in place in addition to hospital competencies. These range from web inservices and written tests to return demonstration.

How does your lab handle call time for staff members? 

Our team leader completes the call schedule for the department. Each team member is on call approximately every 4-5 weekends and usually 1 day during the week.

Is there a particular mix of credentials needed for each call team? 

Each call team must have at least one RN and one RT. The other two people can be either entity. 

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

Caregivers are expected to be in the lab within 30 minutes of being paged.

Do you have flextime or multiple shifts? 

Our caregivers work 10-hour shifts, from 0700 to 1730.

Has your lab recently undergone a national accrediting agency inspection? 

We passed our DNV inspection last year. The focus for our area was time-out completion.

Where is your cath lab located in relation to the operating room (OR) and emergency department (ED)? 

The five cath labs and two cardiovascular operating rooms (CVOR) surround a center core within the department. We are located within 150 feet from the ED. 

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

We have seen a trend toward younger, more acutely ill patients. This ranges from our cerebrovascular accident (CVA) care to our STEMI population. Our electrophysiology lab has been seeing more complex ablation cases and our ability to manage acute stroke patients is on the cutting edge of technology. 

What is unique or innovative about your cath lab and staff? 

Our cath labs are state of the art, housed in a tower that is 6 years old. Our staff brings an abundance of experience with low turnover. Our staff and physicians are a very close-knit group, attending social gatherings together outside of the work area. The level of cross-trained individuals adds to the flexibility of the group. 

Is there a problem or challenge your lab has faced? 

Training new staff to all of the intricacies and varied procedures performed in the department and ensuring competency is a long and arduous process. Additionally, developing a smooth and efficient process for transferring acute patients to our facility added some challenges. A multidisciplinary committee has been effective in facilitating improvement through identification of trends. 

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 essentially a suburb of the Portland metropolitan area and patients in our area are generally averse to crossing the river boundary between the states for their care. We provide the only interventional cardiovascular labs in the county and the only one in southwest Washington that operates 24/7. One of the metrics demonstrated from our COAP data revealed that 13.8% of our institution’s PCI patients come to us as STEMIs. 

A question from the Society of Invasive Cardiovascular Professionals (SICP):

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? 

It is not a requirement at this time. 

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?  

The outcome reports are forwarded to the physicians, the quality assurance department, and are used in our departmental quality meetings. These reports are used to assist in changing practice toward evidence-based medicine; for example, an increase in the prescribing of beta-blockers and ACE inhibitors based on best-practice scenarios.