Cath Lab Spotlight

St. Anthony’s Hospital

Jim O’Malley, BS, RCIS, RRT Manager, Cardiology St. Petersburg, Florida
Jim O’Malley, BS, RCIS, RRT Manager, Cardiology St. Petersburg, Florida
What is the size of your cath lab facility and number of staff members? St. Anthony’s Hospital has three cath labs. Two inpatient cath labs offer a six-bed holding and recovery area. One lab is used primarily for peripheral interventions and the other for cardiac procedures. A third cath lab, located in an attached medical office building, is dedicated to outpatients. The outpatient cath lab has six individual admission-recovery rooms, offering patient comfort features in each room that include step-down areas, reclining chairs, flat-screen TVs and if time allows, a served lunch. Staffing is optimal with four full-time and three per-diem (prn) registered nurses (RNs), two prn licensed practical nurses (LPNs), and five full-time and three prn cardiovascular technologists. Experience ranges from 3 to 25 years, and includes a manager with 23 years of cath lab experience. What type of procedures are performed at your facility? We perform: • ST-elevation myocardial infarction (STEMI) percutaneous coronary intervention (PCI); • Elective PCI; • Right and left diagnostic heart catheterizations; • Permanent pacemaker exchange and insertion; • Implantable cardioverter defibrillators (ICDs); • Pericardiocentesis; • Temporary pacemaker insertion; • AngioJet (Possis Medical, Inc., Minneapolis, MN); • Intra-aortic balloon pump (IABP) insertion and timing; • Trans-esophageal echocardiograms (TEEs) and cardioversions are performed in the holding-recovery area; • Peripheral interventions, including carotid angiography and carotid stenting; • De-clotting and interventions of arterio-venous (AV) grafts. We perform approximately 1200 procedures per year. Does your cath lab perform primary angioplasty with surgical backup on site? We do not have surgical backup on site. What procedures do you perform on an outpatient basis? Right and left heart diagnostic catheterizations are the primary outpatient procedures. The outpatient lab has a GE 3100 Innova (GE Medical, Waukesha, WI) which allows peripheral angiography and peripheral procedures to be performed. There is a temporary pacemaker and IABP also available. What percentage of your patients is female? Forty-six percent of our patients are female. Who manages your cath lab? Jim O’Malley, BS, RCIS, RRT. Do you have cross-training? Who scrubs, who circulates and who monitors? All team members are cross-trained to scrub, circulate record, admit and recover. RNs administer medications. Anesthesia is called upon for pacemaker and ICD insertion. Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab? The presence of an RT is not required for fluoroscopic procedures. 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? All team members can position the table, pan the table and change the angles. Radiology technologists and physicians can operate the fluoro. Physicians must provide proof of competency prior to using the fluoro. If your lab performs peripheral interventions, what disciplines are involved? Peripheral procedures are performed by RNs, certified respiratory care technicians (CRTTs), registered respiratory therapists (RRTs), RT(R)s and registered cardiovascular invasive specialists (RCISs). Both cardiologists and vascular surgeons perform peripheral interventions. What are some of the new equipment, devices and products introduced at your lab lately? • SilverHawk atherectomy catheters (ev3, Inc., Plymouth, MN) • High-pressure balloons (C. R. Bard, Inc., Murray Hill, NJ) • 150 mm stents (ev3, Inc.) • Covered stents • Ekos ultrasound drug delivery system (Bothell, WA) • Cryo PolarCath (Boston Scientific, Natick, MA) • Trellis-8 peripheral infusion system (Bacchus Vascular Inc., Santa Clara, CA) The MacLab (GE Medical) has been upgraded. A picture archiving and communication systems (PACS) Cardiomedix/CDP system (Evanston, IL) has been installed. Can you describe the system(s) you utilize and how they work in cath lab daily life? Our MacLab is used for hemodynamic monitoring, procedure note recording and provides the templates for the American College of Cardiology (ACC) databases. St. Anthony’s Hospital participates in the PCI, carotid, peripheral and ICD databases. In the recovery/holding area, each bed has a MacLab patient monitoring PC. This allows a report to be generated that covers from the time the patient was admitted to discharge. The PACS system displays the cath lab studies in the cath lab and the operating rooms. Both systems are connected to an off-site data center with the servers. How is coding and coding education handled in your lab? Our coding system consists of the recorder providing a list of procedures and equipment to our system analyst. The system analyst codes the procedures and equipment, and provides the information to a clinician. The clinician reviews and compares the transcribed report performed by the physician, the procedure notes and the coded information. Necessary changes are directed to the system analyst. Challenged dictated reports are discussed between the manger and the physician. Coding education has been an on-the-job training process with help from the medical records and charge master teams. How does your lab handle hemostasis? Hemostasis education and competency evaluation is required of all team members. All team members perform hemostasis technique using the D-Stat Dry hemostasis patch (Vascular Solutions, Minneapolis, MN), manual pressure or C-clamp. FemoStop (Radi Medical Systems, Wilmington, MA) is also used. Critical care RNs perform hemostasis for patients moved to the intensive care units. Hemostasis is obtained in the procedure room, the holding-recovery area and the intensive care units. What is your lab’s hematoma management policy? Hematomas and re-bleeds are reported to the manager. The manager records team members involved in the case. The data is entered into St. Anthony’s quality improvement tool, called The Team MAP. Reoccurring hemotomas and re-bleeds by the same team members result in retraining and competency assessment. How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies? There are two team members that handle the inventory management and purchasing of equipment and supplies. The Lawson system (St. Paul, MN) is used by our facility for ordering supplies. Has your cath lab recently expanded in size and patient volume, or will it be doing so in the near future? No expansion is planned at this time. Our cath lab was built in 2004 and volume continues to increase. We do have a room that could be converted to an electrophysiology lab in the future. Is your lab involved in clinical research? St. Anthony’s Hospital cardiology department is not involved in clinical research at this time. Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? Yes, we had a dissection of the circumflex artery. St. Anthony’s Hospital currently has been approved by the Investigational Review Board (IRB) for covered coronary stent usage. 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? Our average EKG-to-balloon time is less than 90 minutes. Recently, a time flow sheet was introduced that breaks down the process into time goals. These times are reviewed at a monthly STEMI committee meeting. There is an action plan formulated to address the outliers, such as EKG not performed within ten minutes. We also implemented the process of transporting the patient to the cath lab. Now, the unit nurse and the emergency department nurse bring the patient to either the cath lab holding area or the cath lab, and stay with the patient until the entire cath lab team is present and the room is set up. What other modalities do you use to verify stenosis? Physician subjective evaluation provides stenosis percentage. Occasionally, the GE coronary analysis program is used. What measures has your cath lab implemented in order to cut or contain costs? One of the great benefits to belonging to a healthcare system is the increased buying power. BayCare Health System has consignment agreements with all our vendors. The team is cost containment-minded. Team members do not open any product until they are sure it will be utilized. What type of quality control/quality assurance measures are practiced in your cath lab? All of our equipment has a maintenance agreement with the manufacturer. Regular preventive maintenance is scheduled and daily quality controls for the ACT machines and co-oximeters are performed. Radiation badges are worn. How does your cath lab compete for patients? Has your institution formed an alliance with others in the area? St. Anthony’s Hospital is part of the BayCare Health System and we use our other facilities for benchmarking best practice. Our cardiologists are on staff of several local hospitals and it is primarily through them that we coordinate care. How are new employees oriented and trained at your facility? New team members attend a general hospital orientation program. The department uses an orientation checklist that is completed by the clinical coordinator or a designated preceptor. All procedures performed in the lab have a performance objective. Each objective is performed by the new team member and evaluated by the clinical coordinator or the preceptor. Licensure is not required. Team members’ experience ranges from 3-25 years. Cath lab team members must have two years of related allied health care experience or be a graduate of an accredited invasive program. RNs must have two years of critical care experience. What type of continuing education opportunities are provided to staff members? St. Anthony’s Hospital offers continuing education opportunities. Yearly review and evaluations of high-risk or low-frequency procedures are conducted and team members are recertified. Attending local seminars is reimbursable. How do you handle vendor visits to your lab? The manager schedules vendors in the lab. Badges are required. How is staff competency evaluated? Performance objectives are used to prove competency. Does your lab have a clinical ladder? Yes, we have: • Tech I • Tech II • Tech III • Clinical coordinator • Manager How does your lab handle call time for staff members? The call schedule is a 24/7 format. There are an equal number of days on call given to each team member. The only requirement is that an RN be on the call team. Within what time period are call team members expected to arrive to the lab after being paged? Team members must arrive within 30 minutes. The cardiologist also is expected to be in the lab within 30 minutes. Do you have flex time or multiple shifts? Most team members work 10-hour shifts; however, flex time is available. Does your cath lab do electives on weekends and or holidays? St. Anthony’s Hospital does not perform electives on the weekend or holidays. Has your lab has undergone a Joint Commission inspection in the past three years? We were visited by The Joint Commission in 2004 and passed without any recommendations. The charting procedure was commended. We do hospital-wide mock Joint Commission inspections. The manager performs surprise department Joint Commission inspections based upon a “Manager Day Checklist.” Results are shared with the staff. Where is your cath lab located in relation to the operating room (OR) and emergency room (ER)? The OR is on the second floor directly below the cath lab. The ER is on the first floor. Transport time from ER to the lab is at most, three minutes. How do you see your cardiac catheterization laboratory changing over the next decade? St. Anthony’s Hospital predicts an increase in acute admissions and less elective procedures performed. What do you consider unique or innovative about your cath lab and its staff? We are promoters of a Quality Culture of Leadership, Education & Training, Reward and Recognition, and Communication. These four components work together to create a work environment that is needed to encourage and support Quality. Team member involvement on these task forces provides leadership with front-line opinions and a better understanding of the needs that exist to successfully develop a Quality Culture for the purpose of achieving our mission. 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”? The cath lab is located in the Tampa Bay area, which consists of Tampa, Clearwater and St. Petersburg, FL. This area has major league sports: the Lightening Hockey team, Tampa Bay Bucs football, and the Rays baseball team. Busch Gardens is located in Tampa. We have a symphony orchestra and major plays are presented in the Tampa Bay Performing Arts centers. Country-western, rock and roll, and hip-hop live music make the area a must-stop. There are many freshwater lakes and the Gulf of Mexico available for water activities such as water skiing, diving, fishing and swimming. The weather cannot be beat. In November (at the writing of this article), the daytime temperature is 74ºF and nighttime is 54ºF. 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)? Do staff receive an incentive bonus or raise upon passing the exam? Tech IIIs and managers are required to take the RCIS. There is a one-time bonus for team members that obtain the RCIS credential. 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? The cath lab manager belongs to the SICP. Author Jim O’Malley can be contacted at jim.o’