Cath Lab Spotlight

The Mount Sinai Medical Center

Samin K. Sharma, MD, FSCAI, Director, Cardiac Catheterization Laboratory & Intervention, Zena and Michael A. Wiener Professor of Medicine, Co-Director, Cardiovascular Institute, Beth Oliver, RN, MS, Senior Director of Nursing, Mount Sinai Medical Center, New York, New York
Samin K. Sharma, MD, FSCAI, Director, Cardiac Catheterization Laboratory & Intervention, Zena and Michael A. Wiener Professor of Medicine, Co-Director, Cardiovascular Institute, Beth Oliver, RN, MS, Senior Director of Nursing, Mount Sinai Medical Center, New York, New York
Tell us about your cath lab. There are a total of 6 cath rooms in our cath lab, with one room dedicated to pediatric cardiology. We have 2 separate electrophysiology (EP) rooms, and a total of 10 intake beds and 10 post procedure beds in the cath lab facility. Also, in our facility, there is a separate large room for patient registration and another area (with 10 beds) for patient preparation prior to procedure on the same floor as the cath lab location. Our cath lab consists of over 130 employees. We have a clinical nurse manager, a satellite cath lab program manager, and an operations manager. We have 5 full-time cardiac interventionalists, 10 voluntary cardiac interventionalists, 13 nurse practitioners (NPs), 45 registered nurses (RNs), 11 patient care associates, 16 cardiac cath specialists [2 of which are certified cardiovascular technologists (CVTs)], 3 cardiac liaisons (people who meet and greet patients and families), 8 interventional fellows, 4 radiologic technologists, and 3 materials coordinators. Our staff varies in seniority. We have staff who have been here for 20 years, 10 years, and some who have been here a year or less. As our cath lab volume has grown, we have added additional nurses, NPs, and techs over the years. Our average daily number of procedures is about 60 cases, which also includes EP, pediatrics, and cardiac biopsy. Per week, we do about 360 cases. Who manages your cath lab? Our cath lab is managed by a collaborative team. Dr. Samin Sharma is the director of the cath lab. Dr. Annapoorna Kini is the associate director of the cath lab. They work with the nursing leadership team, which consists of the clinical nurse manager and senior nursing director, to establish evidence-based practice. Our cath lab inventory is managed by our operations manager. Our cath lab process is based on established protocols with involvement from each team member. Can you describe the systems used to organize staff and communicate necessary information? Our communication plan is done both formally and informally. All staff have an email account. In addition, every Tuesday, a staff meeting is conducted. We have 3 staff meetings every Tuesday to accommodate the 3 different shifts – 7am, 9am, and 12 noon. During that time, an inservice is provided on any new practice, device, or new protocols. The meeting is about 60-90 minutes long. Once a month, cardiac cases are reviewed. At 6:50am every day, the 7am team gathers at the board to look at the day’s cases. During this time, protocols or practice changes are also reviewed. Do you have cross-training? Who scrubs, who circulates and who monitors? Half of our nursing staff is cross-trained to EP, pediatric and cardiac cath procedures. Our interventional fellows and nurse practitioners scrub into the procedural cases. There is always one nurse and one CVT in each room. The nurse circulates and administers medication. The CVT preps the patient, as well monitors the hemodynamics. They are responsible for entering the data into the report-generating system. 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? The radiology tech, cath lab attending or interventional fellow can all operate the x-ray equipment. Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab? We always have 3 radiology technologists on daily. The shifts are 6:30am – 3pm, 9am – 5pm and 2pm – 10:30pm. The RTs are responsible for checking all the equipment. They are not required to be present in the room during a procedure. During a case, the attending and fellow are always present. How does your cath lab handle radiation protection for physicians and staff? On a monthly basis, a radiologic technologist takes badges to measure the radiation level. A report is generated monthly and distributed. If a reading comes back “high” for a nurse or tech, they are taken out of the cath lab and are assigned to other areas within the cath lab until the level goes down. What percentage of your patients is female? Sixty-one percent (61%) of our patients are males and 39% are females. What percentage of your diagnostic cath patients go on to have an interventional procedure and what percentage of your diagnostic caths are normal? Approximately 70% of our diagnostic caths go on to have an interventional procedure. About 18% of diagnostic caths for non-valvular disease are normal, or have non-obstructive disease. What are some of the new equipment, devices, and products introduced at your lab lately? We are constantly trying new equipment, such as the fractional flow reserve (FFR) pressure wire (Volcano Corporation, San Diego, CA) for borderline lesions, and infrared spectroscopy (LipiScan Coronary Imaging System, InfraReDx, Burlington, MA) for yellow plaque detection. Do physicians utilize transradial access? Several of our interventionalists use the transradial approach. About 9% of our cath PCI procedures are done transradially. How does your lab handle hemostasis? A vascular closure device is used in over 85% of interventions; in the remaining patients, manual pressure is applied due to unfavorable femoral anatomy. Our arterial sheaths are pulled by cardiology fellows, interventional fellows or NPs. What is your lab’s hematoma management policy? We monitor and apply manual compression to resolve any hematoma. The size is marked to monitor for any increase in size; if not resolved by manual compression, we use a FemoStop (St. Jude Medical, Minnetonka, MN) or sandbag. This is done by the NP or cardiac intervention fellow. If the hematoma is still not resolved, we consult a vascular surgeon. Serial hematocrit (HCt) are checked to determine the need for blood transfusion (usually when HCt is How is inventory managed? Our inventory is managed by 3 full-time materials coordinators. Two work day shift (7am – 5pm), and we recently added an additional person to manage evenings (2pm – 10pm). We have Mobile Aspects (Pittsburgh, PA) as our inventory management system. Overall, our purchasing of new equipment and supplies is handled by our operations manager. How is coding and coding education handled in your lab? We have 2 full-time medical record coders in our cath lab. One works on all the inpatient cases and the other works on all the outpatient cases. We have seen a major benefit within the cath lab in capturing lost revenue. Is your lab involved in clinical research? Yes. Our cath lab has 1 research manager, and 5 cath and 2 peripheral research coordinators. We have a very large database and are involved in several device trials such as the Lipiscan study, Mount Sinai Biobank study (compiling and reviewing genetic information obtained from blood samples along with health information), SPIRIT trial (Xience V stent, Abbott Vascular, Redwood City, CA), PARIS (Patterns of non-adherence to dual anti-platelet regimen in stented patients) trial and PROTECT II [A prospective, multi-center, randomized controlled trial of the Impella Recover LP 2.5 system versus intra aortic balloon pump (IABP) in patients undergoing non-emergent high risk PCI]. Have you had any cath lab-related complications in the past year requiring emergency cardiac surgery? In 2009, of 5,800 total interventions, including 5,078 PCIs, none required emergency cardiac surgery, so our urgent emergency cardiac surgery was 0%. Where is your cath lab located in relation to the operating room (OR) and emergency department (ED)? The cath lab is located on the fifth floor of the Gugenheim Pavillion, with our operating rooms on the third floor and ED on the ground floor of the same building. 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 door-to-balloon time is 67 minutes. Our ER calls the cardiac interventionalist who activates the cardiac cath lab team by phone, not beeper. One of our cath attendings has developed a detailed sheet for documentation to streamline time and prevent any confusion with documentation. Over the years, we have done well in achieving DTB times of 85% of our STEMI cases. How does your lab handle call time for staff members? Is there a particular mix of credentials needed for each call team? Cath lab staff on call is cross-trained to do all types of cases. At least one year of experience is needed before being placed on the on-call roster. Within what time period are call team members expected to arrive to the lab after being paged? A cath lab on-call team member is expected to arrive 20 minutes after being paged. An interventional fellow is always on site. An interventional attending cardiologist is expected to arrive in less than 30 minutes. We have also made two on-call rooms in-house available for cath lab staff. Do you have flex time or multiple shifts? Yes, we have both available. What other modalities do you use to verify stenosis? Two modalities (in addition to angiography) that we use for lesion assessment are intravascular ultrasound (IVUS) and fractional flow reserve (FFR). Each cath lab room is equipped with IVUS machines (4 from Boston Scientific Corporation, Natick, MA, and 2 from Volcano Corporation). Volcano’s pressure wire is available in two rooms, and we have one extra mobile unit. What measures has your cath lab implemented in order to cut or contain costs? We are constantly reviewing prices by using benchmarking tools to ensure best possible pricing. We have our stents on consignment. We continue to bulk buy implantable cardiac defibrillators (ICDs) and pacemakers, receiving 6 to 8% savings. We are also participating in the “Go Green Campaign.” The cath lab recycles all boxes and cans. Finally, due to increased volume, we added a third shift (12 noon – 12 midnight) to the cath lab in order to decrease 2-3 hours of OT per RN at night. What type of quality control/quality assurance measures are practiced in your cath lab? We are a member of the New York State Percutaneous Coronary Interventions Reporting System, which benchmarks all cardiac cath labs in the state of New York for volume and complication rate. A state form is completed on all cardiac interventional procedures. The form is completed by the fellow or attending for that case. The form is then reviewed by our quality assurance nurse for completeness. The first of the month, we hold a monthly cardiac cath lab QA meeting where we review vascular complications, blood transfusions, and procedure-induced myocardial infarctions (MIs). This committee reports to the Mount Sinai Heart Principal Investigator (PI) meeting. Has your cath lab recently expanded in size and patient volume, or will it be in the near future? Our cath lab has grown exponentially over the past 4 years. We are continually preparing for growth and have planned for a 5% growth for 2010 (see Figure 1). How does your cath lab compete for patients? Has your institution formed an alliance with others in the area? We have strong relationships with private attendings in the community, as well as the boroughs of New York, i.e. Queens, Brooklyn, and Staten Island. In addition, we have formed partnerships with Lutheran Medical Center, North General Hospital, and St. John’s Riverside Hospital. Our high quality patient care and patient satisfaction has provided a major role in increasing our referrals to the cath lab. Our cath lab has initiated and established numerous outreach programs so that a community physician has a direct link with us in terms of referring the patient, and in return, gets the best treatment and guaranteed follow up. Does your lab have a clinical leader? Yes, with nurse in charge, nurse manager and nursing director. Also, senior nurses are considered experts and serve as the preceptors for the new hires. How are new employees oriented and trained at your facility? Registration is required for all cardiac/vascular techs as well as RNs. Our nurses are given a preceptor for 12 weeks. They attend didactic classes led by our education specialist. All nurses are given an orientation binder that has the orientation lined out week by week with goals and objectives. The orientee meets every 2 weeks with the preceptor and educator team to see how they are progressing. Our CVTs are precepted by another CVT. They also meet with the CVT preceptor and education specialist. We are in the process of formalizing a competency program for our techs. Our cath lab currently employs 15 nurses with less than 1 year of cath lab experience. We have received most of our staff via transfers from within our institution, mostly from telemetry units. What type of continuing education opportunities are provided to staff members? Because our RN staff is unionized (NYSNA), they are entitled to 5 conference days per year. Our department of nursing education has many continuing education opportunities such as advanced cardiac life support (ACLS), basic cardiac life support (BCLS), pediatric advanced life support (PALS), evidence-based practice, critical care courses, etc. In addition, each June, we host a nurse/technologist symposium where attendees come from all over the country to learn about the latest in interventional cardiology. Four of the cath lab staff members (2 nurses, 1 NP and 1 CVT) are sponsored each year to attend the annual American College of Cardiology meeting. How is staff competency evaluated? Staff competency is categorized by RN and CVT. RN competencies include: - All 8 point-of-care instruments - Sedation/analgesia - CLABS (Central line-associated bloodstream infections - EKG recognition - Impella (Abiomed, Danvers, MA) - IABP (intra-aortic balloon pump) - Radiation safety - Patient identification/time out - Medication CVT competencies include: - IABP - Impella - Radiation safety - Patient identification/time out In addition, BCLS competency is done every 2 years. Does your lab utilize alternative therapies (such as guided imagery, etc.)? Yes, in selected cases. We tried guided imagery a few years ago, but stopped because of poor feedback from the patients. How do you handle vendor visits to your lab? All vendors must be registered with security to gain access to Mount Sinai Hospital. In order to get clearance, vendors must submit a photo with all training documentation for the company, vaccines, and CV. Vendors must schedule an appointment with our secretaries in order to come into the cath lab. Has your lab has undergone a Joint Commission inspection in the past three years? Yes, we have had a Joint Commission inspection in the past three years. We advise all cath labs to pay attention to time out. How do you see your cardiac catheterization laboratory changing over the next few years? More and more procedures will be done on an all-ambulatory basis. We are also planning to add new satellite cath labs in the peripheral areas. What do you consider unique or innovative about your cath lab and staff? Teamwork and protocol-driven care are unique ingredients of our cath lab. The stamina and work ethic of our cath lab staff is amazing and unbeatable. Also, the cath lab staff stays beyond their shift time to complete all cases. No case is postponed for the next day just for being late at night. Is there a problem or challenge your lab has faced? One problem that we encountered was performing well in DTB time in STEMI. It was a challenge and asking cath lab staff to report to the lab in twenty minutes when called solved the problem. Another challenge we faced was lack of recovery space. With the shift to outpatient ambulatory PCIs, about 30% of our current PCI volume is outpatient. Through teamwork with our interventional inpatient unit, we created a 4-bed ambulatory space that can accommodate this additional volume. To minimize sick calls, we reward those cath lab staff having perfect attendance. 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”? Since we are located in a metropolitan city, our patient population is culturally diverse, which is also true for our cath lab staff. Patients of different backgrounds find corresponding staff working here and feel more at ease. Our hospital serves some of the most economically challenged zip codes in the country. Questions from the Society of Invasive Cardiovascular Professionals (SICP): Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? Yes, if staff members take the registry exam for the registered cardiovascular invasive specialist, they will receive a $10,000 bonus, which is added to their annual base salary. We encourage them to do so. Are your clinical and/or managerial team members involved with any professional organizations that support the invasive cardiology service line? Yes, our clinical/managerial team members are involved in the following organizations: Society of Invasive Cardiovascular Professionals (SICP), Association of Critical Care Nurses (AACN), and American College of Cardiology Care Associates (ACC-CA). The majority of our nurses are CCRN-certified. Dr. Samin Sharma can be contacted at