St. Mary’s Hospital is a 440-bed tertiary community hospital located in Madison, Wisconsin, offering a full range of inpatient and outpatient treatment and diagnostic services in primary care and nearly all specialties. It opened its doors in September 1912.
The St. Mary’s campus includes an outpatient surgery center and an employee child-care center. St. Mary’s also operates an off-site Adult Day Health Center, is part-owner of a home health care organization, and is affiliated with the St. Mary’s Care Center (skilled nursing facility) on Madison’s southwest side.
St. Mary’s and its affiliated physician group, Dean Clinic, together own and manage more than 20 primary care clinics, which includes approximately 100 physicians. They also jointly own and operate the Surgery and Care Center in Madison, the Surgery Center in Janesville, and Davis Duehr Surgery Center in Madison.
Since 1972 St. Mary’s also has been affiliated with the University of Wisconsin School of Medicine’s three-year family practice residency program.
St. Mary’s Hospital is a part of St. Louis-based SSM Health Care, the first healthcare organization to be awarded the Malcolm Baldrige National Quality Award. It is sponsored by the Franciscan Sisters of Mary.
Tell us about your cath lab.
Currently, St. Mary’s has three cath lab suites, two electrophysiology (EP) suites and a hybrid suite. Our team of physicians and staff perform over 3,000 cases per year with American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR) outcomes in the top quartile.
Our team members have been with St. Mary’s from several weeks to over 30 years. We currently have 21 clinical staff: 11 registered nurses and 10 technologists comprised of both radiologic and cardiovascular technologists. In addition, the department is overseen by a manager with support from a clinical nurse specialist, material management staff, a cardiac emergency coordinator, and two secretaries.
What procedures are performed in your cath lab?
Left and right heart catheterizations, coronary interventions, peripheral studies and interventions, patent foramen ovale closure, valvuloplasty, temporary pacemaker placement, intra-aortic balloon pump insertion, endovascular aneurysm repair (EVAR), and initiation of therapeutic hypothermia. We average 60 cases per week.
Tell us more about your hybrid lab.
Our hybrid suite is operational. Edwards Lifesciences activated us as a TAVR site in February 2013. Other procedures that take place in the hybrid suite include EVARs, mini sternotomy aortic valve replacements (AVRs), hybrid coronary revascularization and hybrid peripheral vascular interventions. Our hybrid team is comprised of staff from the cath lab and the cardiac surgery OR.
Does your cath lab perform primary angioplasty without surgical backup on site?
No. We have a cardiovascular surgery team available 24/7 for percutaneous coronary intervention (PCI) backup and other cardiac surgical emergencies.
What percentage of your diagnostic caths is normal?
Our running four-quarter CathPCI registry data shows a 44% non-obstructed coronary rate for the time period.
Do any of your physicians regularly gain access via the radial artery?
Who manages your cath lab?
An invasive cardiac services manager oversees the cath lab, EP lab, and cardiac procedure unit. The manager reports to the director of cardiac services.
Do you have cross-training?
Yes, all staff cross-train as job description and roles allow. Registered nurses (RNs) function in the RN role, and in the circulator, scrub, and monitor roles. Cardiovascular technologists function in the circulator, scrub, and monitor roles.
Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab?
No. Under Wisconsin law, physicians are responsible for managing fluoro, but must meet organizational criteria.
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?
Any personnel may position the II, pan the table, or change angles, but only a physician or radiologic technologist may step on the fluoro pedal.
How does your cath lab handle radiation protection for the physicians and staff?
We have a radiation safety officer who reviews/manages exposure data on a quarterly basis. All new staff members complete a radiation safety module in orientation and meet with the radiation safety officer.
What are some of the new equipment, devices and products introduced at your lab lately?
We have Cardiohelp (Maquet) now available. End tidal CO2 and wireless fractional flow reserve (FFR) are now available with our GE MacLab upgrade to version 6.9.
How does your lab communicate information to its staff and physicians to stay organized and on top of change?
How is coding and coding education handled in your lab?
We have a dedicated coding/charge capture expert that we share with radiology.
Who pulls the sheaths post procedure?
Any staff member who has completed the sheath/line pull competency may pull a sheath. Depending upon the procedure and the physician, diagnostic sheaths are pulled on the cart in the lab. (If the patient has a large body habitus, the patient is unstable, or the scrub person has concerns for hemostasis, the sheath can be pulled on the table). Interventional sheaths are pulled on the nursing floor at the time ordered by the physician. Registered nurses must go through the same initial class and maintain annual competency also. Radial sheaths are pulled in the lab by the physician (at this time) and a Terumo TR Band is applied.
What kind of training is mandated before someone can pull sheaths?
Staff must attend an in-person class on sheath pulls. They must then demonstrate competency on five supervised line pulls. Annual competency is demonstrated by a line pull observed by our super-user.
Where patients are prepped and recovered (post sheath removal)?
Scheduled patients are currently admitted through our Surgical Procedure Center (SPC). Prepping is currently occurring in the cath lab. Patients are considered recovered from procedural sedation in our institution when the patient reaches an Aldrete score of 8 or above for two consecutive assessment checks with no single score of 0, or returns to pre-procedure Aldrete score. After recovery from procedural sedation, the patient is either returned to the SPC or to an in-patient room. Patients can also be held in the cardiac procedure area for short time periods while awaiting room assignment.
How does your lab handle hemostasis?
We treat a high percentage of patients with manual closure (62%). Manual closure is managed by the cardiac cath lab staff, telemetry staff, or discharge area staff.
How is inventory managed at your cath lab?
We have a dedicated material management full-time employee for the cath lab and EP labs.
How do you handle the purchasing of equipment and supplies?
Through the cardiac services director, in concert with physicians and staff. Capital purchases are presented to a hospital-wide operational council for approval. Capital purchases over 25K go through an annual approval process.
Has your cath lab recently expanded in size and patient volume?
We have added a hybrid suite to support our increasing EVAR volume, as well as our initiation of TAVRs. We continue to do about 3,000 procedures annually.
Is your lab involved in clinical research?
No, not at the present time.
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 median D2B is 46 minutes. St. Mary’s Hospital has an accredited Chest Pain Center and a dedicated ST-elevation myocardial infarction (STEMI) coordinator. To keep our D2B times low, we have assigned cath lab/emergency department (ED) roles and responsibilities for STEMI care, run STEMI drills, and have incorporated pre-hospital activations with ED physician assistance (paramedics interpret the EKG, while all other levels transmit an EKG). We also have STEMI boxes with appropriate supplies and standardized protocols. We incorporate real-time feedback with shared ED/cath lab metrics. ED and cath lab staff members have created a collaborative workgroup to continually improve the D2B process.
Are you registered with the American Heart Association’s Mission: Lifeline or the American College of Cardiology’s D2B Alliance?
Yes. We partner with Mission: Lifeline.
Who transports the STEMI patient to the cath lab during regular and off hours?
ED transports during on and off hours. Pre-hospital providers are escorted by the ED and security.
What do you do when the call team is already busy doing a procedure and a STEMI comes into the ED?
ED initiates STEMI protocol and the cath lab identifies a patient who can be safely removed from the table.
What measures has your cath lab implemented in order to cut or contain costs?
We have a supply review on a quarterly basis with physicians. We have engaged a consulting firm to assist us with efficiency opportunities.
What quality control/assurance measures are practiced in your cath lab?
We monitor radiation safety, STEMI performance, and procedural sedation.
Are you recording fluoroscopy times/dosages?
Yes, as part of our procedure log on each patient. We review the logs with our radiation safety officer on a monthly basis to look for exposure reduction.
Who documents medication administration during the case?
Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR)?
Yes. We participate in the ACC-NCDR registry. Our hospital-based quality department manages the data collection and submission.
How does your cath lab compete for patients? Has your institution formed an alliance with others in the area?
We have an 18-county outreach program led by our cardiologists and STEMI coordinator, and participate in a regional STEMI protocol with other local PCI centers in the 18-county geographic area. We collaborate with regional paramedic-level EMS services to facilitate field-activated STEMIs with ground and air transport.
How are new employees oriented and trained in your facility?
New employees are given a two-day general house-wide orientation. Also included in general house-wide orientation is attendance at the “Always Safe” class. Registered nurses who are new to the organization also go through a two-week RN orientation.
Orientation in the cath lab begins with a learning style needs assessment and clinical skill assessment. From there, the orientation is personalized to the individual using pathways developed around each of the roles in the cath lab: RN, scrub, circulator, and monitor. Weekly/bi-weekly meetings with the manager and the clinical nurse specialist are conducted to ensure the orientation is meeting the needs of the employee. Every effort is made to minimize the number of preceptors. In addition, opportunities for other didactic classes, such as basic EKG, are available as needed, based upon the learning needs/skills assessment.
What continuing education opportunities are provided to staff members?
We provide multiple avenues: CME credits are obtained through the weekly multi-disciplinary cath lab conference, vascular conference, nursing grand rounds, and physician grand rounds. In addition, funds are budgeted to send staff to local and/or national conferences.
How do you handle vendor visits to your lab?
All vendors must be scheduled through the director, manager, or clinical nurse specialist. Vendors sign in through the materials management department.
How is staff competency evaluated?
Competency is evaluated in three domains: knowledge, technical skills and interpersonal communication.
Does your lab have a clinical ladder?
No, not at the present time. Our registered nurses are participating in the development of a peer review process within the nursing organization.
How does your lab handle call time for staff members? Is there a particular mix of credentials needed for each call team?
Currently, we have a four-person call team, with a split of two RNs and two techs.
Within what time period are call team members expected to arrive to the lab after being paged?
Staff has 30 minutes from the time of page to arrival in the cath lab.
Do you have flex-time or multiple shifts?
We currently have overlapping hours for day shift, with evening/night cases covered by the call team.
Has your lab recently undergone a national accreditation agency inspection?
We recently had a Joint Commission visit in the spring of 2012. The focus was on procedure time out, and post procedure physician documentation of procedure and complications, as well as documentation of history and physicals. St. Mary’s received accreditation by the Society of Cardiovascular Patient Care as a Chest Pain Center in April 2012.
Where is your cath lab located in relation to the operating room (OR) and emergency department (ED)?
We are on separate floors linked by dedicated elevators.
What trends have you seen in your procedures and/or patient population?
We have seen stable volumes in cardiac coronary procedures, with increases in peripheral and balloon aortic valvulopasty (BAV) procedures. A transradial program was initiated in the summer of 2012, with increasing conversion from the femoral to radial approach.
What is unique or innovative about your cath lab staff and staff?
It has been a pleasure to watch our staff becoming a “hybrid” team with our cardiac surgery colleagues.
Is there a problem or challenge your lab has faced?
We have multiple projects going on all at once, from our hybrid suite to an upgrade of our monitoring system and procedure log, to our conversion to a new cardiovascular PACs system.
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)?
No, but we encourage our staff to become certified and work to hire new staff with RCIS certification.
Does staff receive an incentive bonus or raise upon passing the exam?
Upon passing the exam, staff is eligible to participate in the Reimbursement of Advanced Achievement Certification Fees Program. This program reimburses the employee for the examination fee and recertification fees. (This does not cover certifications that are required for the job position.)
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. Various staff members have joined the Society of Cardiovascular Patient Care, American Association of Critical Care Nurses, and Emergency Nurses Association.
Craig Sommers can be contacted at Craig_Sommers@ssmhc.com.