Cath Lab Spotlight

The Mayo Clinic

Stephen Pieper, RN, BSN
Stephen Pieper, RN, BSN
What is the size of your cath lab facility and number of staff members? Our cath lab facility consists of two separate entities on the Mayo Medical Center campus. We have five adult procedure rooms, one pediatric procedure room and one EECP room at Saint Mary's Hospital. The Gonda Cath Lab facility consists of two adult procedure rooms that primarily support our outpatient practice. Each particular site operates its daily practice independently; however, there is also an intra-campus shuttle that runs every 7 minutes for easy personal interaction between St. Mary's Hospital, Mayo Clinic and the Gonda building. We began performing cardiac catheterization procedures at the Gonda facility on September 15, 2003. The building is located less than 1 mile from Saint Mary’s, but adjacent to the Rochester Methodist Hospital, to which it is connected by tunnels and skyways. The outpatients that proceed to percutaneous coronary intervention after their diagnostic procedure stay at Rochester Methodist overnight. The cardiac cath lab is staffed by a variety of individuals with the following criteria: 16 interventional cardiologists 7 diagnostic cardiologists 4 pediatric cardiologists 28 RNs 17 CVTs 4 RTs 2 CVISs 10 RCISs 9 secretaries 14 data collection and clinical research individuals The length of our staff members being in residence widely varies, from less than 1 year to 34 years. These numbers, however, only represent the cardiac catheterization practice. Electrophysiology/ pacemaker is a separate lab within the cardiovascular division. We are two separate labs that provide the framework for the cardiac lab as a whole, and we share space on the 4th floor of Saint Mary’s in the Mary Brigh Building. Each lab has its own procedure rooms due to the unique technologies and particular equipment needed; however, we share a prep and recovery area for all the cardiac lab patients. What type of procedures are performed at your facility? Last year, we performed 7,109 diagnostic cardiac catheterization procedures and over 1,700 interventional procedures. Our basic interventions can range from the elective percutaneous transluminal coronary angioplasty (PTCA) to the emergent PTCA and/or stent. In addition, we also perform many other types of diagnostic and interventional procedures: right and left heart catheterizations, right ventricle biopsies, atrial septal defect/patent foramen ovale closures, septal ablations, constriction/restriction drug studies, coronary spasm studies, mitral and aortic valvuloplasties, rotational and directional atherectomy, pulmonary artery angioplasty and stenting, IABP insertion, and intravascular ultrasound, as well as diagnostic/interventional congenital catheterizations. We do an average of 140 diagnostic angiogram cases per week, with an average of 30% proceeding to intervention. We have recently begun performing peripheral interventions within the department. Does your cath lab perform primary angioplasty with surgical backup? We perform all elective percutaneous interventions with surgical backup at Saint Mary's Hospital. There is a cardiac surgeon, as well as the surgical team, on-call and available 24 hours a day to support our interventional practice. What procedures do you perform on an outpatient basis? We perform diagnostic angiograms and left/right heart catheterizations. Right ventricle biopsies and the majority of our ASD/PFO closures are also done on an outpatient basis. What percentage of your patients are female? About 35% of our patients are female. What percentage of your diagnostic cath patients go on to have an interventional procedure? About 30% of our diagnostic cases receive interventional procedures. Who manages your cath lab? Our cath lab is managed by Mr. Doug Parks, Administrator, Division of Cardiovascular Diseases, and Mr. Jim Ryan, Operations Manager. The lab is medically directed by Dr. Charanjit S. Rihal and other co-directors who support clinical practice, education and research: Dr. John F. Bresnahan, Operations; Dr. Amir Lerman, Research, and Dr. Robert Simari, Education. There are also two supervisors for the allied health staff: Sarah Fink, RCIS/CVT Supervisor and Travis Paul, RN Supervisor. There are three other supervisors for materials, research and technical support: Alan Mirehouse, LaVon Hammes and Steve Winter. Do you have cross-training? Who scrubs, who circulates and who monitors? The cath lab at the Mayo Medical Center does support a high degree of cross-training within the staff. The staff that scrub include RCISs, CVTs, CVT/RTs and cardiology fellow MDs. Circulators include RCISs, CVTs and CVT/RTs. The individuals who monitor are trained camera operators and CVTs, but we are currently in the process of cross-training the RCIS and RT staff. The RNs perform conscious sedation and assist with circulating duties. Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab? Our four RTs are present within the cath lab and readily available to assist when needed, but they do not need to be present in the rooms for all fluoroscopic procedures. Which personnel can operate the x-ray equipment in your cath lab? Under the direction of the consultant MD, the cardiology fellows, CVTs, RTs and RCISs may operate the x-ray equipment when assisting. Does your lab have a clinical ladder? We do not presently have a clinical ladder. What are some of the new equipment, devices and products introduced at your lab lately? We have had many new devices and products introduced into our lab recently. They include the latest drug-eluting stents (Boston Scientific’s Taxus® and Cordis Corporation’s Cypher®), the Amplatz® PFO/ASD closure device, distal protection devices (Boston Scientific’s FilterWire® and Medtronic/AVE’s PercuSurge®), vascular access closure devices (such as St. Jude Medical’s Angio-Seal and Abbott Vascular Devices’ Perclose®) and numerous ongoing investigational devices (for example, Watchman® which is manufactured by Atritech, Inc). Is your cath lab filmless? Yes, we have been filmless since 1999. We have equipment from Philips and General Electric, which interfaces with the Heartlab Encompass System for immediate viewing throughout the Mayo Medical Center Campus. We have 25 viewing stations, with 7 of those being dedicated to the cath lab. The other stations are situated throughout the campus, including the many cardiac floors, the coronary care unit, the echo lab, and the cardiology clinic settings. There are also two regional cath lab satellite facilities that are connected to our lab via a T3 direct landline to surrounding communities for assistance. How is coding and coding education handled in your lab? There are two staff members who do the billing for procedure and supplies, and two surgical coders who work closely with us. If new orders are being introduced or changed, our revenue analyst gives us the information. On the other hand, if we are notified by the company of a change in coding, we would relay the information to the billing department and our revenue analyst. If we add an item, we add in the cost code associated with that particular item. How does your lab handle hemostasis? We deploy vascular access closure devices (at present, Angio-Seal or Perclose) in approximately 10% of our cases. In regards to the other 90%, sheaths are pulled in our recovery area by the available staff technical, nursing or cardiology fellow MDs. Individual discretion is used as to whether a c-clamp or manual pressure is applied to achieve hemostasis. Outpatients are then transferred back to their rooms, where they complete an average of 1-2 hours of bed rest post-sheath removal. Once the patient meets the discharge criteria and dismissal instructions are provided, they are dismissed from the hospital and the Cath Lab Outpatient Service. Patients requiring interventions are transferred to our CV Interventional floor or the Coronary Care Unit if necessary. These particular individuals will have their sheaths removed by the staff once a desired activated clotting time is achieved. Does your lab have a hematoma management policy? We follow the American College of Cardiology (ACC) criteria for hematoma management. How is inventory managed at your cath lab? We have two material management individuals who work with our supplies. Most of the everyday supplies are kept in the Mayo Inventory Center (MIC) and are PAR stocked in the lab. The MIC staff scans the barcodes on the items on a handheld computer and resupplies our stock on an as needed basis. The interventional supplies are ordered on a biweekly basis, which is monitored by the Materials Management staff. Other supplies are ordered as needed by electronic ordering through the Purchasing Department. This is all completed through the Lawson System, which is an internal ordering system. We also are trialing an automatic reordering system, the SIMS (Supply Inventory Management System) at the Gonda Outpatient Lab. Has your cath lab recently expanded in size and patient volume? Our cath lab has recently expanded in both size and volume. As mentioned, our outpatient practice has expanded to the Gonda building, where we have an additional two rooms to perform diagnostic and interventional percutaneous procedures. We also have had an average of 3% growth in patient volume annually. Is your lab involved in clinical research? Our lab is currently involved with many different ongoing trials. For example: PROXIMAL Trial. Prospective, Multicenter, Randomized Study To Evaluate The Safety And Efficacy Of The PROXIS Embolic Protection Device During Percutaneous Intervention In Saphenous Vein Grafts Shock 2. A Randomized, Double-blind, Placebo-controlled, Dose-ranging Study of Nitric Oxide Synthase Inhibition with N(g)-Monomethyl-L-Arginine (L-NMMA) in Patients with Cardiogenic Shock Complicating Acute Myocardial Infarction: Preliminary Evaluation of Safety, Efficacy, and Biological Activity ARCTIC SUN. Feasibility Study of Inducing Mild Hypothermia in Acute Myocardial Infarction using Non-invasive Cooling with the Medivance Arctic Sun System WATCHMAN. The primary objective of this pilot study is to demonstrate the safety of the Watchman left atrial appendage (LAA) device in patients with non-valvular atrial fibrillation who require treatment for potential thrombus formation and are eligible for warfarin therapy. The device is permanently implanted in the patient to prevent the embolization of thrombi that may form in the LAA, therefore, preventing the occurrence of ischemic stroke and thromboembolism. Bypass Angioplasty Revascularization Study 2 Diabetes (BARI 2D). Evaluating the treatment efficacy in 2,600 patients with Type II diabetes mellitus and documented stable CAD, in the setting of uniform glycemic control and intensive management of all risk factors including dyslipidemia, hypertension, smoking and obesity. Subjects will randomize to elective revascularization of choice (surgical or catheter-based) combined with aggressive medical therapy or a strategy of aggressive medical therapy alone. Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? We have had cath lab-related complications requiring emergency surgery, but these occurrences are very rare. Due to our high patient volume and acuity, these phenomena do occur. What measures has your cath lab implemented in order to cut or contain costs? We have many different avenues that we currently follow in order to cut and contain costs. We went to filmless electronic imaging in August of 1999, and the majority of the information obtained during the angiogram is electronic. We continue to negotiate with x-ray equipment and supply vendors to obtain the lowest possible price. The Mayo Clinic is responsible for contracting with these vendors in regard to both diagnostic and interventional cath lab supplies, and not only for the Rochester, Minnesota locations, but for our Jacksonville, Florida and Scottsdale, Arizona locations as well. We also have an equipment engineering service readily available in-house. What type of quality control/quality assurance measures are practiced in your cath lab? Quality control is performed on all of our equipment daily. The staff performs daily QC on the ACT, OSM3®, I-Stat®, defibrillator and anesthesia machines. We have regularly scheduled maintenance on all of the lab’s x-ray equipment. We recently started participating in the American College of Cardiology’s Cath Kit pilot, which is an evaluation and monitoring program to assess whether the members of the cardiac catheterization laboratory team have increased their knowledge of continuous quality improvement (CQI). It also offers a methodology to increase improvement. We are currently using this kit to organize and individualize current CQI projects in our lab. Examples of ongoing projects include efficiency within the department and early ambulation with outpatients undergoing closure devices. How does your cath lab compete for patients? Our cardiac catheterization laboratory is a tertiary referral center and patients are referred to the Mayo Clinic from around the state, the country and the world. Mayo also has cath labs at our sites in Jacksonville, Fla. and Scottsdale, Ariz. locations, as well as the surrounding Rochester area. These are all part of the Mayo Health Systems. How are new employees oriented and trained at your facility? We have a formal hospital-wide orientation process, which every new employee attends. Orientation is then departmentally-based. Each person in the cath lab is assigned a primary preceptor and their training is individualized and based on prior experience. RNs and RTs are required to be licensed in the lab. CVTs are required to take the RCIS exam if they were hired after 2002 and the CVIS individuals are required to take the exam within two years of their start date. Every employee must have current BLS training and all the RNs must have ACLS training. What type of continuing education opportunities are provided to staff members? We have various in-services offered by qualified staff members and vendors regularly. Many of the interventional fellows have been willing to provide their knowledge on such things as atrial fibrillation, vascular complications and 12-lead ECG interpretations. If appropriate, the allied health staff that attend these particular sessions are offered CEUs and/or CMEs. The cath lab staff is also offered the opportunity to attend local and national conferences when staffing permits. How do you handle vendor visits to your lab? Our major vendors have a one-day-per-month visit in the lab. They are assigned to the vendor room for an allotted time frame. Physicians and allied health staff are welcome to visit with them throughout the day. The vendors must sign a confidentiality agreement, set up a one-on-one visit with a particular physician, sign in for the day and wear a name tag while on campus. If a physician is using their product, they are allowed to be present in the control area. Otherwise, we prefer them to stay in the allocated vendor room. How is staff competency evaluated? Staff competency is evaluated on an ongoing basis. There are annual online competencies that must be completed, along with a 360-degree appraisal from both a peer and the supervisor. There are also Point-of-Care classes that staff must attend to be accredited to run various equipment located in the lab. Does your lab utilize any alternative therapies (such as guided imagery, etc.)? We utilize Enhanced External Counter Pulsation (EECP) therapy in the lab. There are an average of four patients undergoing treatment daily for a 7-week duration. We have numerous studies currently underway that may lead to future alternative treatments. How does your lab handle call time for staff members? There are always four allied health staff members, two cardiology fellows and one consulting physician who are on-call for the lab. The staff who work in the lab start at 7:30 am, with hours of operation until 5 pm. Individual on-call time starts at 5 pm Monday through Thursday, with weekend coverage beginning at 5 pm on Friday. The technical staff work staggered shifts that start throughout the morning, while the nurses have a variety of clinical areas staffed each day. At this time, our physicians do not schedule cases on the weekend. We only provide emergency coverage. What trends do you see emerging in the practice of invasive cardiology? We are considering purchase of a Stereotaxis machine in the lab that will help with guidance in difficult interventional cases. We are also exploring in the area of interventional percutaneous valvular cases to help treat mitral regurgitation and other valvular problems. There is also the potential expansion of gene therapy for the treatment of severe multivessel coronary artery disease. Has your lab has undergone a JCAHO inspection in the past three years? Our cardiac cath lab underwent JCAHO accreditation 20 months ago and successfully passed. We are currently preparing for the next visit. Where is your cath lab located in relation to the OR department, ER, and radiology departments? The lab at Saint Mary’s is located on the fourth floor in the Mary Brigh Building. The Emergency Room is located on the main floor, OR is located on the first floor of the same building, and the CCU and the interventional unit are both located just down the hallway. Please tell the readers what you consider unique or innovative about your cath lab and its staff. The cath lab facility at the Mayo Medical Center and the entire staff are very well diversified. We perform a wide variety of procedures both at Saint Mary’s Hospital and at the Gonda facility. We have an extremely large staff with an enormous range of experience. There are an average of 125 individuals who may be in the lab at any given time, providing care, reassurance, and treatment to any particular patient visiting the lab. Is there a problem or challenge your lab has faced? Due to the high patient volume and our two different cath lab locations (Saint Mary’s and Gonda), the most pressing challenge is cost containment. We have noticed duplication of both supplies and equipment at each location. In addition, we are constantly doing more cases at both facilities, requiring need of additional FTEs for our department. We are happy to report that our administration was extremely supportive and recently allotted us another 2.75 nursing FTEs to help meet our demand. What's special about your city or general regional area in comparison to the rest of the U.S.? Rochester, Minnesota is a very special city and home to the world-famous Mayo Clinic. We have hotel shuttles all around the city that transport patients to their designated appointments on the Mayo campus. We also have a skyway/subway system that allows the patients to travel from one building to the other on-campus without going outside in inclement weather. The city of Rochester has been voted the #1 city in which to live in Money Magazine numerous times over the last several years. Not only is the cardiac cath lab well-diversified, but the entire city reflects a variety of ethnicities, religions, and cultural differences. This makes the cath lab a wonderful place to work, and the city of Rochester a wonderful place in which to reside. Author Stephen Pieper can be contacted at Pieper.Stephen@mayo.edu The author wishes to thank the following individuals for their help in writing this article: Charanjit S. Rihal, MD John F. Bresnahan, MD Travis Paul, RN, Supervisor Sarah Fink, RCIS/CVT, Supervisor Pamela Johnson, RCIS Allan Mirehouse, Materials Manager Janet Yngsdal, Quality Assurance Specialist Mike Godfrey, RN, Education Coordinator Lee Meyer, CVIS Program Director Bonnie Foster, CVT Gene Severson, RN
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