Cath Lab Spotlight

The Robert F. Schaper Heart Center at Tomball Regional Hospital

Debbie Rockoff, RN, BSN, RCIS, FSICP; Debbie Bhai, RN, BSN, RCIS; Dennis Semmler, Executive VP/Assistant Administrator; Dr. Daljit Muttiana, MD, FACC, FSCAI, Medical Director of CV Imaging; Lynne Jones, RN, RCIS, FSICP, President, SICP, Director of CV Imaging
Debbie Rockoff, RN, BSN, RCIS, FSICP; Debbie Bhai, RN, BSN, RCIS; Dennis Semmler, Executive VP/Assistant Administrator; Dr. Daljit Muttiana, MD, FACC, FSCAI, Medical Director of CV Imaging; Lynne Jones, RN, RCIS, FSICP, President, SICP, Director of CV Imaging
In addition, Tomball Regional Hospital is an accredited chest pain center. Chest pain patients that come through the Emergency Department are monitored in the Observation Unit. The cardiovascular cath lab team consists of MDs, who are board-certified, RNs, LVN, RT(R)s, MA and CVT students. We have staff members in residence from the conception of the cardiac cath lab in 1989 to new staff members who have been here less than a year. Tomball Regional Hospital (TRH) is an award-winning 326-bed facility with more than 1500 employees. TRH opened in 1976 as a small community hospital and has grown into a strong regional medical center. Other services include: a 24-hour ER department, an air ambulance service, open heart surgery, orthopedic surgery, outpatient surgery center, a senior services facility, cancer center, wound care center, rehabilitation center, obstetrics, and sports medicine center. The heart center, opened in November 2004, was named after the hospital’s 29-year veteran CEO, Robert Schaper, who passed away in August 2005. He commented, Building Tomball Regional Hospital from scratch and watching it flourish has been my proudest career accomplishment. Our goal with the new Heart Center is to bring the talent of our interdisciplinary team to treat heart disease at all stages and all under one roof. What type of procedures are performed at your facility? In 2005, 12,996 procedures were performed; including our move to the new heart center in November. The new year has enabled us to perform more procedures because of a faster turnaround time utilizing our pre/post area. In the cath labs, we perform: Diagnostic left and right heart caths Percutaneous coronary intervention (PCI)/stenting Carotid stenting Intravascular ultrasound (IVUS) AngioJet® (Possis Medical, Minneapolis, MN) Rotoblator (Boston Scientific, Maple Grove, MN) Intra-aortic balloon pump (IABP) therapy Temporary and permanent pacemakers, biventricular pacemakers, and loop recorder insertion/removal Automatic implantable cardioverter defibrillator (AICD) implantation Peripheral angiography Peripheral interventions including Silverhawk (Foxhollow Technologies, Inc., Redwood City, CA), PolarCath (Boston Scientific), percutaneous transluminal angioplasty (PTA)/stent of renal, iliac and superficial femoral artery (SFA), inferior vena cava (IVC) filters, and drug infusion thrombolysis for peripheral total occlusions. Radiology procedures include: cerebral/carotid angiography, nephrostomy catheter/stent placement, cardiovascular (CV) infusion lines, vertebroplasty, and microembolization. At this time, we do have both cardiologists and radiologists working in our labs. But, since our department has experienced such an increase in volumes, the radiology department is in the process of taking over the radiology cases using the special procedures room located in their area and their own dedicated staff. In the pre/post area: Pre-procedure teaching, admission/discharge of patients Trans-esophageal echocardiograms (TEEs) Tilt table Cardioversions Does your cath lab perform primary angioplasty with surgical backup? We do have a surgical program, although both scheduled and primary angioplasty are performed without formal surgical backup. A cardiothoracic surgeon and CV surgical team are available 24 hours a day, 7 days a week. What procedures do you perform on an outpatient basis? Diagnostic heart caths, uncomplicated PTAs, pacemaker generator exchanges and most radiology procedures are performed on a same-day outpatient basis. Our PCIs with stent placement are twenty-three hour observation, unless their condition or treatment plan requires inpatient. What percentage of your patients are female? In the last year, forty-five percent of our patients have been female. What percentage of your diagnostic cath patients go on to have an interventional procedure? Approximately fifty percent. Who manages your cath lab? The CV Imaging department reports to Dennis Semmler, Executive VP, Assistant Administrator. Lynne Jones, RN, RCIS, FSCIP is the Director of Cardiovascular Imaging. Kathy Whitfield, RT(R) is the Technical Coordinator, Donna Schneider, RT(R) is Assistant Director. Alicia Kayga, RN is the charge nurse for the pre/post area. Dr. Daljit Muttiana, MD, FACC, FSCAI serves as the Medical Director of CV Imaging. Do you have cross training? Who scrubs, who circulates and who monitors? Staff members are cross-trained in accordance with the scope of practice for their licensure/credentials in the state of Texas. For example, RNs scrub, circulate and monitor. RTs scrub and operate the x-ray equipment. We are in the process of expanding our cross-training. Since expanding our department, we have many new employees, all at different levels. We have just completed an interventional preceptor program. The preceptor provided hands-on training and theory to ensure that all staff are competent in performing interventional scrubbing skills. All staff members provide patient care and teaching. Does a RT need to be present in the room for all the fluoroscopic procedures in your cath lab? They are present. 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? RTs perform all the above with the x-ray equipment. Physicians step on the fluoro pedal. Does your lab have a clinical ladder? YES. Our clinical ladder designates four levels. Cardiovascular Invasive Specialist I is entry level to CVIS IV, which requires advanced certification. All staff, regardless of licensure, participate in the same ladder. The clinical ladder is based on advancing skills and educational goals. As part of our ladder, cath lab staff presents in-services to other hospital departments. This has resulted in a much better understanding of what we do in the lab. A very good example of how well the ladder has worked was the implementation of a new process, our balloon pump to go. The cath lab used to be called out to insert IABPs. Debbie Rockoff, RN, RCIS came up with the idea of a balloon pump to-go box. She put together all of the supplies needed to insert an IABP at the bedside, in-serviced the SICU and CCU nursing staff, and acted as a resource in the beginning. As a result, the cath lab is no longer called out to insert IABPs and the physicians feel comfortable performing this procedure at the bedside. There is no longer a delay in treatment for these critically ill patients, which can only serve to improve outcomes. For further questions about our clinical ladder and how it was implemented, contact Lynne Jones at What are some of the new equipment, devices and products introduced at your lab lately? Since the opening of the heart center in November 2004, we are working with all-new equipment. The center is equipped with the GE Innova 2000 flat panel detector (Waukesha, WI), Philips Integris system (Bothell, WA), and GE Mac-Lab IT hemodynamic monitoring system. Mac-Lab bedside workstations with Dash 4000 monitors which are interfaced with the cath lab procedure room are used in the prep/recovery area. All patient documentation is electronic. We also worked with the Director of Pharmacy, John Butler, to incorporate an anesthesia Pyxis system (Cardinal Health, San Diego, CA) in each lab for control and distribution of medications. This year has brought us new peripheral procedures performed by the cardiologists: Silverhawk plaque excision, carotid stenting, and AICD implantation. Can you describe the introduction of carotid stenting at your lab? Equipment training was provided by our Guidant representative. Our department educator researched and set up a neurological assessment training program for the prep/recovery nurses, cath lab staff, and CCU-SICU nursing staff. The process starts with the prep/recovery nurse and the cath lab circulating nurse performing the pre-procedure neurological exam together, assessing the 12 cranial nerves. Neuro checks are performed every 5 minutes during the procedure by the circulator and usually no sedation is given. After the procedure, the circulator and receiving nurse perform a post procedure neurological exam again together. We feel performing the exam together ensures accurate knowledge of the neurological status of the patient by all nursing staff. We currently have four cardiologists trained to perform carotid stenting. We do not coordinate the procedures with the surgeons. Since starting our program in August 2005, we have performed 49 procedures with excellent results. Can you describe the system(s) you utilize and how they work in cath lab daily life? Patients come in before their procedure for pre-op teaching and pre-procedure labs, EKG and chest x-ray. On the day of the procedure, the patient is admitted/prepped in the pre-area. Mac-Lab allows us to continue the patient record in the cath rooms. We rotate room assignments on a weekly basis to ensure working cohesiveness and a team approach. After the procedure, the patient is taken to the post-area for recovery/discharge utilizing the flow of the patient documentation on the Mac-Lab. The turnaround time for our cath lab rooms is expedited because we are a self-contained area. How is coding and coding education handled in you lab? How is coding communication handled with the billing dept? Coding and coding education is done by our technical coordinator, Kathy Whitfield, RT(R). She has instituted the coding of procedures and supplies in the Mac-Lab IT. In turn, the coding is communicated through the Meditech hospital computer system (Westwood, MA) to the billing office. How does your lab handle hemostasis? We use both closure devices and manual pressure. We use Perclose (Abbott Vascular Devices, Redwood City, CA), Angio-Seal (St. Jude Medical, Minnetonka, MN) and D-Stat Dry hemostatic bandage (Vascular Solutions, Minneapolis, MN). Our patients are recovered in our pre/post area. CCU/SICU patients are returned to the designated unit for recovery. Does your lab have a hematoma management policy? Our pre/post area tracks the outpatients by telephone the day after the procedure. Our physicians inform us of vascular complications which are researched through a multidisciplinary approach. When a hematoma complication requires surgical intervention or blood transfusion, our quality assurance department will track the patient and inform us of the outcome. How is your inventory managed at your cath lab? We have designated staff members, Yvonne Stuart, RT(R), RCIS and Cary Darling, RT(R), RCIS who are responsible for maintaining inventory along with other duties. Items have a par level on the GE Mac-Lab system and prompt a reorder. The requisition is printed and our purchasing department completes the reorder. Our hospital is a member of the VHA buying group. The director of CV Imaging monitors physician practice patterns and negotiates supply and equipment contracts with administration approval. We also have a central supply department for further inventory. Has your cath lab expanded in size and patient volume, or will it be in the near future? We have tripled our size and staff and increased our volume by 38% since 2003. We expect to keep growing and are planning to add another cath lab and expand our pre/recovery area. Is your lab involved in clinical research? TRH participates in the CRUSADE registry, which measures more than 600 hospitals nationwide on their responsiveness, diagnosis and treatment of chest pain upon a patient’s arrival at a hospital emergency department. Our hospital consistently performs in the top 10% of CRUSADE-participating hospitals. As a result, Tomball Regional Hospital was the first in the nation to be awarded the Gold Seal of Approval from JCAHO for treatment of acute coronary syndrome (ACS). The Gold Seal of Approval recognizes hospitals for outstanding disease-specific outcomes. We are the first in the state of Texas to be awarded The Gold Seal of Approval for the treatment of heart failure. We are also preparing to participate in the CAPTURE 2 Registry (Carotid ACCULINK/ACCUNET Post Approval Trial To Uncover Rare Events, Guidant Corporation). Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? In a lab such as ours with a high volume of interventions, complications may occur. Due to the availability of the CV surgery team, patients experiencing an emergency surgery have had good outcomes. What other modalities do you use to verify stenosis? Stenosis is usually visually verified by the cardiologist. Intravascular ultrasound (Boston Scientific) is used for lesion assessment. Also, the imaging equipment is capable of performing quantitative measurements. What measures has your cath lab implemented in order to cut or contain costs? Our technical coordinator informs us of updated coding and reimbursement changes as they occur. The hospital is contracted with Novation (Irving, TX) for our product purchases and we take advantage of bulk purchases when appropriate. We have standardized our pacemaker and coronary diagnostic and interventional inventory, which has resulted in a significant savings. We are currently working on standardizing our peripheral product inventory. Standardization is an excellent way to increase inventory selection and contain costs. Our physicians have supported this change. Our staff works implemented 10-hour shifts and overtime costs have been reduced significantly. Recently, the staff was inserviced on how to interpret the monthly operating report for our department. Our director informed us that it is our report card! We are taking ownership for our department and will continuously monitor this report and develop ways to impact our financial performance. What type of quality control/quality assurance measures are practiced in your cath lab? We do ACT proficiency annually and quality control on the equipment in the rooms daily. Continuous quality assurance measures are reported on a quarterly basis. Indicators are chosen by looking at processes that impact patient outcomes, financial performance, and regulatory compliance. How does your cath lab compete for patients? Has your institution formed an alliance with others in the area? Until recently, our cath lab was the only interventional lab in the immediate area. Two new programs have started recently, but we have not seen a decrease in our volume, even though some of our cardiologists are on staff at those hospitals. Our administrative team is committed to our hospital being the regional referral center for cardiac care. We will be proactive in the continued development of our heart center and strive to offer the best service to our physicians and patients. How are new employees oriented and trained at your facility? What licensure is required for all professionals who work in your lab? New employees have one full day of hospital orientation and RNs have three days of hospital orientation. Cath lab employees follow the clinical ladder, which includes a hospital preceptor course. The new employees are assigned a preceptor for a 90-day orientation period. When the guidelines have been met, the new employee follows the clinical ladder and is able to take call. Nurses are licensed by the state of Texas. Radiology techs must be registered with the American Registry of Radiologic Technologists (ARRT). All cath lab employees are basic life support (BLS)- and advanced cardiac life support (ACLS)-certified. Some staff members have recently passed the Registered Cardiovascular Invasive Specialist (RCIS) examination. What type of continuing education opportunities are provided to staff members? Our hospital education department provides a BLS/ACLS recertification course, IABP course, 12-lead EKG interpretation, the RN licensure CEU requirements, satellite education through GE TIP-TV, and continuing education through the hospital website. Our staff regularly attends Society of Invasive Cardiovascular Professional (SICP) chapter meetings, which award CEUs. Attendances at educational conferences are granted with administration approval. How do you handle vendor visits to your lab? The vendor schedules an appointment for a cath lab visit with our assistant director. The vendor must check in with purchasing and receive a visitor’s badge. They stay in our education conference room to inservice the physicians and staff. The vendor only goes into the cath lab rooms by the invitation of the physician. How is staff competency evaluated? We have an orientation program, including a preceptor with new staff members and then an annual evaluation from the assistant director and director thereafter. Does your lab utilize any alternative therapies? Not at this time. How does your lab handle call time for staff members? Cath lab staff work 10-hour shifts, 4 days a week, on a rotating schedule which allows for a 4-day weekend every fifth week. On-call rotation is approximately 8-10 days per month. Three staff members are on call each day. We have one RN and one RT(R), and the third can be either a RN or RT(R). Does your cath lab do electives on weekends and or holidays? We do not perform electives on weekends or holidays. What trends do you see emerging in the practice of invasive cardiology? Invasive cardiology will be enhanced by the emerging technology of computed tomographic angiography (CTA) and magnetic resonance angiography (MRA). Hospitals will need to determine credentialing requirements for physicians interpreting those studies. Has your lab has undergone a JCAHO inspection in the past three years? Yes. We experienced the new tracer methodology review. Our hospital did exceptionally well and received accreditation for another three years. The recent survey was our last announced survey, so we will be ready at all times for a visit. Our laboratory survey was completed in July, and we had no recommendations. Where is your cath lab located in relation to the OR department, ER, and radiology departments? Our cath lab is located just down the hallway from OR, ER, and the radiology department, allowing for easy access to the lab. What is considered unique or innovative about your cath lab and its staff? We have developed into a self-contained CV Imaging department. We schedule and register patients through the hospital Meditech information system. Pre-teaching is usually done before the procedure. On the scheduled day of the procedure, the patient arrives and is already familiar with staff/surroundings in our pre-holding area. The patient assessment is performed on the GE Mac-Lab system, which is linked to the procedure room’s computer. This flow of information allows us to spend more time teaching the patients and their family to alleviate anxiety, and for us to be influential patient advocates. Most patients, post procedure, are appreciative of the staff’s cohesiveness and professionalism. Due to our patient-focused approach, patient satisfaction scores are excellent. Is there a problem or challenge your lab has faced? How was it addressed? The transition from two outdated cath labs without a prep and recovery area to the heart center posed a growth challenge. All staff participate in trouble-shooting problems as they arise. The solutions are communicated with the entire staff to facilitate communication and enhance patient care. The physicians’ challenge was to convert to a paperless system. Completion of medical records has improved. We have found that now the physicians are more likely to complete their dictation. 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? Tomball is located in North Harris County. It is a very popular area for increased growth. Economic developers project 18-20 percent of all new homes built in the area will be built in the Northwest. To support this population growth comes new shopping, recreational activities, restaurants and subdivisions, plus we have easy access to the fourth largest city in the nation, Houston. Our hospital was started in 1948 by members of the community, each giving $100.00 to fund the building of the 18-bed facility. Dr. Norman Graham came to Tomball as a young physician in 1951 and actually owned the hospital at one time. After serving in the army, he returned to Tomball and is still an integral part of our hospital. Another way we are unique is that until his death, our hospital has had only one CEO, Mr. Robert F. Schaper, for whom who our heart center is named. He led the growth of the hospital and when the latest construction is finished, we will have 550 beds. Our new President/CEO, Lynn LeBouef, has been at the hospital for over 28 years, serving as Vice President of Cardiopulmonary Services before moving into administration as Executive Vice President and then Chief Operating Officer. She notes, I am ready to take Tomball Hospital to the next level. We are on the verge of phenomenal growth. The area is experiencing tremendous development, and we will be here to deliver state-of-the-art health care to the community we serve. Two more of our senior administrators have also been here over 29 years. Tomball is considered an edge city to Houston and we combine a small-town atmosphere with the cutting edge of cardiovascular advancements. 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)? Do staff receive an incentive bonus or raise upon passing the exam? To become a CVIS IV in our clinical ladder, you are required to have the RCIS. The incentive is, of course, a higher pay scale that is very generous as well as the personal pride that comes with successfully completing the registry. Are your clinical and/or managerial team member involved with any professional organizations that support the invasive cardiology service line, such as the SICP, ACVP, or regional organizations? We are proud to say that 95% of our staff are members of the SICP and the Gulf Coast chapter of the SICP. Our Director, Lynne Jones, RN, RCIS, FSICP, is president of the SICP. We would like to see a grassroots effort for SICP chapters nationwide, with legislator involvement to promote recognition of cath lab professionals. The authors can be contacted via Lynne Jones at