Cath Lab Spotlight

The Marlin Miller, Jr., Regional Heart Center at The Reading Hospital

Jo Ann Bretz, Director Cardiac and Vascular Services, Reading, Pennsylvania
Jo Ann Bretz, Director Cardiac and Vascular Services, Reading, Pennsylvania
What is the size of your cath lab facility and number of staff members? We have six invasive suites: 3 cardiac catheterization, diagnostic/interventional 1 multi-purpose 1 electrophysiology (EP) lab 1 peripheral angiography lab All labs are single-plane. A 24-bed prep & recovery unit is immediately adjacent to the labs. Eight of the 24 beds are staffed on all three shifts from Monday to Saturday noon. The labs are scheduled Monday through Friday from 0700 to 1700. The remaining hours are covered by an on call team. The staff consists of approximately 31 FTEs, with credentials that include RCIS, Certified Cardiac Vascular RN, LPN, RT(R), Tech I and patient care assistants (PCA), as well as office support. Seniority runs from six months to 30 years; the average length of service is approximately ten years. What types of procedures are performed at your facility? On average, we complete 100 adult procedures per week; approximately 10% of which are peripheral. Procedures include angioplasty, stenting, rotoblation, directional atherectomy, AngioJet® (Possis Medical, Inc., Minneapolis, MN), intravascular ultrasound, right ventricular biopsy, carotid stenting, aortic stent grafting, peripheral angioplasty and stenting, bi-ventricular pacing, implantable cardioverter defibrillators (ICDs), EP studies, radiofrequency (RF) and cryoablations, tilt table studies, and cardioversions. Does your cath lab perform primary angioplasty with surgical backup? Our lab performs primary interventional procedures. We are fortunate to also have surgical backup. What procedures to you perform on an outpatient basis? We perform adult diagnostic procedures, EP studies, and device change-outs on an outpatient basis. What percentage of your patients is female? Approximately 47% is female. What percentage of your patients go on to have an interventional procedure? Forty-two percent of our procedures are interventional. Who manages your cath lab? Invasive and non-invasive cardiac vascular services are managed by the nurse director, partnered with physician directors and a leadership team. Members of the leadership team include two nurse managers, two cardiac coordinators, the inventory coordinator, non-invasive vascular coordinator, cardiac ultrasound coordinator, cardiac rehab coordinator, exercise testing manager, and clerical coordinator. In addition, the following multi-disciplinary teams meet: cardiac clinical services meets monthly, the outcomes team meets approximately every six weeks and marketing meets quarterly. Do you have cross-training? Who scrubs, who circulates, who monitors? All technologists and nurses are cross-trained. RNs administer all IV medications. Technologists do not administer medications. All technologists and nurses run the fluoroscopic equipment under the direction of the physician. Troubleshooting and quality management of the x-ray systems is done by the radiology technologists. Physicians primarily operate the x-ray equipment, while lab personnel inject contrast. Does an RT have to be present in the room for all fluoroscopic procedures in the cath lab? The fluoroscopic equipment is run at the direction of the physician. However, there are RT(R)s in the labs. What disciplines are involved in your peripheral procedures? Vascular surgeons and cardiologists perform peripheral cases in a dedicated Siemens peripheral lab (Malvern, PA). This lab was newly installed in October 2005. A core team was trained specifically to perform peripheral vascular procedures. Everyone on the team had several years of cardiac catheterization experience, and continues to rotate to the catheterization lab and participate in the on-call system for cardiac emergencies. We are currently not on-call for peripheral cases. Does your lab have a clinical ladder? The hospital has a career advancement program in place for RNs. Pay-for-performance is being rolled out to other positions over the next few years. The staff participates on department and hospital teams, and provides input for best practices. Can you describe the system(s) you utilize and how they work in cath lab daily life? We have been filmless since 2000. Three cardiac cath cabs are GE Innova (Waukesha, WI), our EP lab and multipurpose lab are GE Advantx, and the peripheral lab is a Siemens Axiom Artis. Our images are newly incorporated into PACS. Images are available throughout the lab and the OR. Our hemodynamic monitoring system is a GE Prucka MAC System. The system is networked throughout the labs. A nurse is assigned to triage and coordinates patient flow, add-ons and emergencies with the functioning labs. How is coding and coding education handled? Secretaries input charge data into the hospital information system. The charge information is acquired after each cath procedure and is the responsibility of the monitor person to provide. Collaborative efforts are in place with the compliance officer, medical records and quality management departments to keep up-to-date on coding needs. Quality checks are done weekly to ensure appropriateness of accurate billing. Cath lab senior leaders provide information one-on-one and at staff meetings. How does your lab handle hemostasis? Manual pressure is used in approximately 48% of patients. Physicians place closure devices. We utilize StarClose (Abbott Vascular Devices, Redwood City, CA), Angio-Seal (St. Jude Medical, Minnetonka, MN) and Perclose® (Abbott Vascular Devices). Nurses and physicians also utilize the FemoStop® (Radi Medical Systems, Wilmington, MA). All cath staff are able to pull sheaths. Patients are observed in triage or returned to the prep and recovery unit for potential discharge or admission to an inpatient unit. Does your lab have a hematoma management policy? Our lab follows the American College of Cardiology guidelines for hematoma management. Any site indication of potential hematoma is marked and measured. We do have a groin management and hematoma process improvement tracking system in place. How is inventory managed at your cath lab? Patient care assistants (PCAs) maintain inventory par levels and check expiration dates in all labs. The inventory coordinator works closely with materials management using the Lawson System (St. Paul, MN) to track utilization of products. Back orders are communicated to the leadership team. Consignment product needs are adjusted through the inventory coordinator. Has your cath lab recently expanded in size? In July 2005, all cardiac invasive and non-invasive services were centralized on one dedicated floor in a brand new building. Prior to the relocation, labs and other heart services were spread out in various hospital areas. An additional lab was added for peripheral angiography and an existing lab was upgraded to be used for EP overflow. The three Innova Labs and one Advantx (EP) lab are brand-new. Is your lab involved in clinical research? Current interventional clinical research includes: CONCERTO (Medtronic, Clinical Investigation of the Medtronic Concerto Cardiac Resynchronization Therapy [CRT] and Implantable Cardioverter Defibrillator [ICD] Therapies [CRT+ICD Device]); BLOCK HF (Medtronic, Biventricular Versus Right Ventricular Pacing in Heart Failure Patients With Atrioventricular Block); REVERSE (National Heart, Lung, and Blood Institute, REsynchronization reVErses Remodeling in Systolic Left Ventricular Dysfunction) MENDMI (Guidant, Prevention of Myocardial Enlargement and Dilatation Post-Myocardial Infarction). We also have clinical research programs in cardiac pharmacology, electrophysiology, and heart failure. Have you had any cath lab-related complications in the past year regarding emergent cardiac surgery? Our emergency CABG rate for failed intervention is approximately 0.01%. What are some of the new equipment, devices or products introduced at your lab lately? We completed our first carotid stent procedure on February 22, using Guidant’s Acculink Carotid Stent System (Santa Clara, CA). Also, we have recently reviewed the intra-renal infusion catheters from FlowMedica, Inc. (the Benephit Infusion Systems, Fremont, CA). What measures has your cath lab implemented in order to cut or contain costs? Cardiologists, healthcare administrators, and materials management personnel share information and plan strategies for contracting with interventional and rhythm management manufacturers. Accessory items are bundled for best pricing and most balloons/stents are consigned. We are currently exploring the use of disposable trays. What type of quality control/quality assurance measures are practiced in your lab? We monitor room utilization, finish times, moderate sedation, final time out, patient occurrences such as contrast allergy and documentation compliance. Patient satisfaction is measured through Press Ganey Surveys. In 2006, we implemented a new process where the emergency department physicians activate the call team at the same time the cardiologist is called for acute ST-elevation myocardial infarction (STEMI). Our average time from field to intervention is 120 minutes; our goal is 90 minutes or less, which we hope to achieve by obtaining EKGs pre-hospital. We participate in the American College of Cardiology (ACC-NCDR®) and Society of Thoracic Surgeons (STS) Registry. What other modalities do you use to verify stenosis? We use angiography and IVUS. How does your cath lab compete for patients? Has your institution formed an alliance with others in the area? We are one of two hospitals in the Reading area. Approximately 50% of our admissions are referrals and approximately 50% come through the emergency department. How are employees oriented and trained at your facility? New employees who come from experience or accredited Allied Health Programs are oriented and trained by a preceptor. Average training time is six months to achieve minimum standards in all invasive disciplines. All employees are required to be certified in Basic Life Support and Advanced Life Support, which is offered in-house by certified personnel. Critical care staff development provides an added educational link through hemodynamic, pulmonary, and renal programs. What type of continuing education opportunities are provided to staff members? Staff members have the opportunity to obtain educational contact hours at various times in the department through product- or disease-related inservices, or through hospital-provided programs. Vendors participate in providing inservice programs. The staff is encouraged to attend conferences on a rotational basis. How do you handle vendor visits to your lab? Sales or clinical persons need appointments to be in our lab. We require evidence of education on the Bloodborne Pathogen Standard and vaccinations prior to the person being able to enter a lab. HIPAA guidelines are strongly adhered to and the patient makes the final decision whether or not there is comfort with a visitor during the case. This is included with our documentation on the medical record chart. How is staff competency evaluated? The education team is active in providing competency reviews. Invasive staff have one year, coordinated with annual evaluations, to complete competencies. High risk, low volume procedures are inserviced approximately every six months. Evaluations require comments on technical ability, service culture initiative, motivation, team player behaviors and creative ideas. Several persons are validators. Does your lab utilize any alternative therapies (such as guided imagery)? Music is available in all procedure rooms and patients may request favorite tunes. Warm blankets from a blanket warmer are provided in the labs. Alternative therapies, such as TV, computers, and music are available at each bedside to patients pre- and post-procedure. How does your lab handle call time for staff members? Three staff members are on-call 24/7; at least one must be an RN. Call rotates daily until Friday, and Friday’s team remains on-call throughout the weekend. Call schedules are provided for the calendar year and are created by an invasive team. Staff assigned to the labs (room ownership) finish last cases of the day if all rooms are functioning. Call team members will relieve the last functioning room. What trends do you see emerging in the practice of invasive cardiology? We see computerized tomographic angiography (CTA) on the horizon as offering the opportunity to an additional population of patients for diagnosis of coronary disease. In addition, shorter length of stay and more evidence-based practices will contribute to further directions in invasive cardiology. Since the introduction of drug-eluting stents, percutaneous coronary intervention procedures have increased significantly in volume and complexity, with multi-vessel, multi-lesion procedures and left main stenting now commonplace. Has your lab undergone a Joint Commission inspection in the past three years? We are awaiting inspection at this time (March). We have an ongoing hospital mock survey team to maintain our proficiency for unannounced JCAHO inspections. Where are your labs located in relation to the OR, emergency and radiology departments? The invasive labs are on the first floor. The OR is on the fourth floor. Radiology is immediately adjacent to cardiology services, on the first floor in the next building. The emergency department is two floors below. There are dedicated elevators for patient transport. Please tell the readers what you consider unique or innovative about your cath lab and staff. Staff is cross-trained to work in all roles. Rotation is provided to all labs. The staff is required to be proficient in all elements of adult cardiac and peripheral disease management. Several staff rotate to prep and recovery, cardiac rehab, and exercise testing. We affiliate with several schools for intern programs through the cath lab and non-invasive procedure areas. Is there a problem or challenge your lab has faced? The challenge has been collaborating with the rest of the hospital for interventional beds when the hospital is full. We have partnered with staff to be creative and innovative to accommodate our patients during those busy times. What is special about your city or general area in comparison to the rest of the U.S.? How does it affect your cath lab culture? Reading is located approximately one hour from Philadelphia and two and a half hours from New York. Berks County is listed as one of the fastest-growing counties in Pennsylvania. Beach and casino activity are a short distance away at Atlantic City and skiing opportunities are within an hour and a half at the Poconos. Our patients are from varying ethnic backgrounds and our staff reflects a similar mix. We provide culturally sensitive, patient-focused care. Questions from the Society of Invasive Cardiovascular Professionals (SICP): Do you require your clinical staff members to take the registry exam for the Registered Cardiovascular Invasive Specialist (RCIS)? Does staff receive an incentive bonus or raise for passing the exam? We encourage staff to sit for registry. Nurses have a career advancement program with the voluntary opportunity to move within a clinical ladder. We are a strong RN lab. Some nurses have the RCIS and some have the ANCC Cardiac Vascular Nurse Certification. The staff is reimbursed for sitting for the exam. Are your clinical and/or managerial team members involved with any professional organizations that support the invasive cardiology service line, such as SICP, ACVP, or regional organizations? Yes, the American College of Cardiovascular Administrators (ACCA), American College of Cardiology (ACC), SICP, Alliance of Cardiovascular Professionals (ACVP), and American Nurses Association (ANA). Jo Ann Bretz can be contacted at