Cath Lab Spotlight

St. Rose Hospital

Shannon E. Wilson, CVT
Shannon E. Wilson, CVT
What is the size of your cath lab facility and number of staff members? St. Rose has a single-suite combo lab with a new Philips Integris Allura Flat Detector (Philips Medical Systems, Bothell, WA). We find it to be phenomenal in its capacity to achieve top-notch imaging. It possesses user-friendly auxiliary components, and is highly versatile for not only cardiac procedures, but also for peripheral studies. The equipment is designed so that the user need to not be exposed to cumbersome repositioning of a patient mid-procedure. Alternately, for special procedure overflow, our staff will, on occasion, utilize a radiography or an OR suite. Eight healthcare members currently staff our lab. Each case usually consists of 2 RNs and 2 RTs (or CVTs), or a combination. Our designated supervisor is an RT. Three of our regular staff are per diem. We perform an average of 4 cases per day or 20 cases per week. What types of procedures are performed at your facility? Not long ago, diagnostic caths accounted for the bulk of our procedures. However, our cath lab is also involved in peripheral work, including cerebral angiograms, carotids, arteriograms, arteriovenous (AV) fistulograms, PTAs, vertebroplasties, etc. Our lab also implants permanent pacemakers, automatic implantable cardioverter/defibrillator devices (AICDs) and loop recorders. Does your cath lab perform primary angioplasty without surgical backup? Currently, practitioners at St. Rose Hospital perform percutaneous coronary intervention (PCI) without surgical back-up. If surgery became evident during PCI, St. Rose has an ambulance on standby specifically for cardiac transfer. Although St. Rose is a relatively small community institution, the staff possesses an intra aortic balloon pump (IABP) and all equipment necessary to provide a safe transfer to a facility with a cardiothoracic surgery suite. What percentage of your patients are female? Until recently, we have not classified procedures based on gender. However, this statistic is now being recorded. Unofficially, female patients account for at least 40% of our total volume. What percentage of your diagnostic cath lab patients go on to have an interventional procedure? At this point, St. Rose has not been engaged in ad hoc procedures. Although a small percentage would account for diagnostic peripheral procedures going onto interventional procedures. Who manages your cath lab? St. Rose is grateful to have Gary Heist, RT, Cath Supervisor, at the helm, as well as John Helleson, who manages the Cardiology Department, Pulmonary/Respiratory, and the Cath Lab. Do you have cross-training? Who scrubs, who circulates, and who monitors? Originally, all staff members were cross-trained. Nurses were the sole individuals to administer medications, as per California law. Likewise, nurses were trained to both scrub and monitor. Our nurses, at one point, felt that scrubbing was out of their scope of practice, and requested that they not scrub. Routinely at present, nurses circulate and monitor. Techs scrub and monitor. But certainly this is not written in stone. Does your lab have a clinical ladder? We do have a clinical ladder which is currently being revised. What are some of the new equipment, devices, and products introduced at your lab lately? At St. Rose, a formal committee exists which examines new products and devices. The Angio-Seal device (St. Jude Medical, Minnetonka, MN), VasoSeal® (Datascope Corporation, Mahwah, NJ) and Perclose® ProGlide (Abbott Vascular Devices, Redwood City, CA) products were recently approved. As mentioned, our lab is not only involved in cardiology but also radiology. Through Cardinal Health, we have begun doing vertebroplasty procedures. Also, Drs. Kwan-Sian Chen, Ash Jain, and others are considering performing carotid stenting. Dr. Maiman, our staff radiologist, utilizes a compact ultrasonic device called SonoSite (SonoSite, Inc., Bothell, WA). He strongly recommends that cardiologists utilize this device to gain access in both arteriopunctures and venopunctures, i.e., the subclavian vein (pacemaker access). How do your cath lab systems function in daily life? For nearly three years, our cath lab has been filmless. Yes, not too long ago, our cath lab contained an old Jameson film processor which still functioned amazingly well. However, our current cineless system features the Heartlab archiving product (Heartlab, Inc., Westerly, RI). Not only is our cath lab successfully engaged in utilizing this digital system, but our non-invasive lab also stores their 2-D and Doppler echocardiographic studies on it as well. Producing copies for transfer patients, requesting physicians, families, etc., is a breeze. Does your lab have a hematoma management policy? Yes, indeed, St. Rose is very JCAHO-minded. Not only is a hematoma recorded and documented, as with most facilities, but we also have a staff member follow up with the patient within a certain time frame. Moreover, upon discharge, the team further investigates and documents the hematoma. All information is of course confidential and logged in our hematoma management binder. Fortunately, St. Rose Hospital has experienced very few hematomas. How is inventory managed at your cath lab? St. Rose is very team-oriented. Everyone is responsible for inventory management, under the effective oversight of Lead RT, Kim Conti. She works closely with our Purchasing Division. Naturally, authorization of the Cath Supervisor and Cardiopulmonary Manager is required. In the near future, bar coding will be the standard at St. Rose Hospital. Has your lab recently expanded in size and patient volume, or will it be in the near future? Our cath lab is expected to dramatically increase in patient volume due to our new cardiac intervention program. In the past, our affiliate center, Washington Hospital, usually received our cardiac intervention referrals. With the advent of primary PCI without surgical backup, our patients receive the same high-quality care without the physical transfer. Is your cath lab involved in clinical research? Although our lab representatives have often been approached to participate in various projects, we seldom initiate the process. However, our new Cath Lab Director, Aditya Jain, may promote our lab to participate more in clinical research. Have you had any cath lab- related complications in the past year requiring emergent cardiac surgery? Especially with the advent of a non-surgical standby PCI program, strict measures have been adopted to insure adherence to specific policies and procedures. Education is a top priority. Despite several acute myocardial infarction (MI) scenarios, this institution is proud to answer with a resounding no! What measures has your cath lab implemented in order to cut or contain costs? Many measures have been taken to reduce or contain costs within the cath lab budget. Much careful thought has gone into any new product purchases. Like most labs, we always try to purchase via consignment, bargain for the lowest cost with premium service, etc. If all else fails, I usually try to write our state governor! What type of quality control/quality assurance measures are practiced in your cath lab? St. Rose, along with associates Cardiac Consultants, worked hard to develop data collection protocols to include emergency PCI pertinent to the National Regional MI database. For example, our tracking worksheet includes such information as pre and post stenosis per lesion, TIMI flow, and site complications. Moreover, areas such as performance improvement (as it relates to QC/QI) focus on such goals as improved documentation, chart audits, and menu revisions. How does your cath lab compete for patients? St. Rose is located in the East Bay of Northern California. In this area, the population is served by many cardiologists who likewise practice in this region. Marketing and public relation’s Pam Russo and associates promotes the fine services of St. Rose. Additionally, our newly renovated laboratory serves as a demonstration site for northern California. The community respects St. Rose, which is regarded as one of the top hospitals in the East Bay, and we do not have to aggressively seek out our patients. How are new employees oriented and trained at your facility? St. Rose is a classic hospital that truly welcomes its new employees. This hospital still has a deep sense of religious conviction and it is common to see nuns on the premises. The Education and Training facility, overseen by Mary Wheaton, RN, is thorough and ensures that each department demonstrates competency in its respective field. Naturally, the physicians and representatives are tremendous resources as well. Our lab also utilizes educational services provided by consultants, and Vangie Ford, Educator and Gary Heist, Cath Supervisor, have also implemented a cardiovascular orientation. All our staff members must possess BCLS and ACLS licensure. RCIS credentialing is preferred. How do you handle vendor visits to your lab? A vendor must first communicate with the cath lab supervisor to arrange a potential meeting. Upon arrival, the vendor must go through security via the Purchasing Department and possess a temporary identification card. Each vendor has a limited visit. If a vendor is attending a particular case, then an observer form must be filled out to allow his or her presence during the procedure. Does your lab utilize any alternative therapies? No. How is coding and coding education handled in your lab? Medical Records Department personnel, including Carolyn Dwyer, Nancy Poot, and Renee Lecca, assure quality performance in the area of coding. Weekly, a Cath Lab/Medical Records Conference is held to insure proper coding in light of complex peripheral cases. 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? At one period in our history, all cath lab personnel were able to operate fluoroscopy. However despite obvious competency and experience, the Radiologic Health Division of the State of California limits only specific personnel such as MDs and radiology technologists the authority to fluoro and angle equipment. Personally, I feel that this limitation is unfair. CCI permits individuals of all persuasions to bear the name and responsibility of the RCIS title. Furthermore, anyone is able with the appropriate amount of credit hours to challenge the various nursing titles. If chiropractors and dental assistants can gain the Radiologic Health Division’s blessing, why not recognize the talents of CVTs and others who have undergone formal training with emphasis on radiologic safety/principles and hands-on experience by experts? Does an RT (Radiographic Technologist) have to be present in the room for all procedures in your cath lab? RTs need not be in the room. How does your lab handle hemostasis? In the past, manual compression remained the norm. However, nowadays, at least 75“85% of procedures are closed via vascular closure devices. Our lab tends to favor Angio-Seal. Perclose and sometimes VasoSeal are also utilized. ICU uses FemoStop® (RADI Medical Systems, Inc., Reading, MA) for post-PCI patients. Has your lab undergone a JCAHO inspection in the last three years? St. Rose underwent a JCAHO inspection in 2004 and successfully accomplished full accreditation. We did hear about one San Francisco Bay Area institution (unaffiliated with St. Rose) which received a demerit based on an observation of a CVT engaging in a sheath removal. This act was deemed beyond the scope of practice. How is staff competency evaluated? Staff competency is evaluated on a yearly basis. Although some staff members are very diverse in their knowledge of cath technology, a clinical educator whose background is not cath lab arranges competencies for both RN and non-RN staff. Annually, our staff participates in a competency day. What type of continuing education opportunities are provided to staff members? As frequently as possible, St. Rose sends its cath lab staff to many national and local symposiums. Mr. Mahoney, our CEO, and our Cardiopulmonary Manager Mr. Hellesen have always encouraged staff to attend conferences to improve their knowledge, with the end result of a higher level of care for our patients. Also, each cath lab member is privileged to present annually on interesting cardiovascular topics pertinent to both ICU and cath lab staff. How does your lab handle call time for staff members? Currently, all staff members participate in call. A percentage of staff members only take call. Similarly to most labs, call coverage typically ends at the end of the regular shift. This coverage continues to the following morning. Until recently, St. Rose offered a flat rate payment for on-call, but with the onset of our new interventional program, call time is now 1/2 pay. Recent efforts by Administrative Vice President Brian Daylor and Cardiopulmonary Manager John Hellesen, has resulted in more competitive call pay at St. Rose. Some Bay Area labs are very protective about adding new individuals to their call roster. St. Rose operates differently, with a fair distribution of call for staff. A possible two-tiered shift may be in the works to compensate for an increase in volume. What trends do you see emerging in the practice of invasive cardiology? Emerging trends in the practice of invasive cardiology include the use of various protective devices. More and easier to use hemostatic devices have also appeared. Other devices are available other than strict angiographic methods of measurement of stenosis. I certainly believe that cardiologists will become more involved in peripheral studies and interventions. With the advent of MRA and other advances in non-invasive technology, diagnostic caths may become fewer and fewer. Where is your cath lab located in relation to the OR department, ER and radiology department? Our cath lab is centrally located near both the OR and ER, and the radiology department. In actuality, we are located in the radiology department. Furthermore, our ICU is a short distance away. Please tell readers what you consider unique or innovative about your cath lab and its staff. Having worked in several cath labs over the years, I must say that the St. Rose Hospital Cath Lab is truly unique. All the physicians are approachable and helpful, and the cath lab team is down-to-earth, without any sort of facade. The cath lab team reacts and bonds together amazingly well. We are also ethnically diverse and represent the likes of our community. The physicians are also ethnically diverse, more so than other Bay area cath labs. Our staff is free to express their opinions. Our managers allow some flexibility for those who have children. What’s special about your city or general regional area in comparison to the rest of the U.S.? The East Bay community remains a diverse population, one of especially hard-working individuals. The East Bay area is a still relatively affordable region compared to its neighbor, San Francisco. Other hospitals ship their patients out of the East Bay region to San Francisco for catheterization. Many East Bay families have expressed their dissatisfaction with this treatment. The East Bay also has a humble attitude to it. Some families are well-to-do, but don’t flaunt it. In my opinion, the East Bay people are very down-to-earth. I am proud to be of service in this community. Is there a problem or challenge your lab has faced? Although we are very settled with our Philips Allura lab, things were not always so easy. For nearly one year, while awaiting lab restructuring, we labored temporarily in the Pulmonary Lab’s extra procedure room. (In California, mobile labs are illegal.) Cases were executed in one of the many operating suites. (Incidentally, many thanks are still due to Rozanne O’Keefe, RN and the entire OR staff.) In a sense, our staff was mobile. Following each procedure, all equipment had to be returned to our temporary office in Pulmonary. Included in this exodus was an extra heavy X-ray table, portable digital C-arm with monitors, and much more. Setting up and breaking down our equipment was taxing. Yet the experience was an interesting one. We gained valuable insight, experience, and greater teamwork. Shannon Wilson can be contacted at: A special thank you to the Witchita Order of Nuns, especially Sister Rose Helen Burger, Sister Antoinette Yelek, and Sister Mary Alice Girrens. Thank you for starting and supporting the hospital and community for so many years.