Transcatheter aortic valve replacement

University of Wisconsin Heart and Vascular Care Procedure Center at UW Health

Chris Griffin, RN, BSN-Nurse Manager, Karna Boquet, RN, BSN-Nursing Supervisor, Brenda Larson, RN, BSN-Chest Pain Coordinator, Amy Hawkinson, RN, BSN-Products and Inventory Coordinator, Stacey Saari, RN-Data Coordinator, Jill Lindwall, RN, BSN-Coordinator, Laura Brown, RN, BSN, Maggie Morrison, RN, BSN, Sarah Benedict, RN, BSN, Becky Atkins, RN, BSN, Michelle Boers, RN, BSN, Cara Miller, CVT, RT(R), Jennifer DeKeyser, CVT, RCIS, and Kara Hembrook, BS, RT(R), Madison, Wisconsin
Chris Griffin, RN, BSN-Nurse Manager, Karna Boquet, RN, BSN-Nursing Supervisor, Brenda Larson, RN, BSN-Chest Pain Coordinator, Amy Hawkinson, RN, BSN-Products and Inventory Coordinator, Stacey Saari, RN-Data Coordinator, Jill Lindwall, RN, BSN-Coordinator, Laura Brown, RN, BSN, Maggie Morrison, RN, BSN, Sarah Benedict, RN, BSN, Becky Atkins, RN, BSN, Michelle Boers, RN, BSN, Cara Miller, CVT, RT(R), Jennifer DeKeyser, CVT, RCIS, and Kara Hembrook, BS, RT(R), Madison, Wisconsin

Tell us about the cath labs at UW Health.

The University of Wisconsin Heart and Vascular Procedure Center currently has five procedure rooms, including two coronary labs (one single plane and one bi-plane), one peripheral vascular (PV) lab, one bi-plane electrophysiology (EP) lab, and one multi-procedure lab. We are currently under construction, building a PV hybrid lab, and following its completion, our current PV lab will be remodeled to be our second EP lab. By July of 2013, we will have six procedure labs in our department. We are also constructing a pediatric hybrid lab in the adjacent American Family Children’s Hospital, scheduled to open in December 2013. Our department also includes a 15-bed pre/post care area.

Our staff consists of 14 Bachelor of Science in Nursing (BSN)-prepared registered nurses (RNs), both full and part time. Several of our nurses are pursuing advanced practice degrees. Our RNs staff adult and pediatric procedures and the prep/recovery area on a rotational basis. The cath lab is staffed with eight full-time cardiovascular technologists: two are cardiovascular invasive specialists (CVIS) and six are registered radiology technologists [RT(R)], including two who have a Bachelor of Science degree in radiology. Registered cardiovascular invasive specialist (RCIS) certification is a requirement for our two senior techs and is encouraged for the remainder of our cardiovascular technologists (CVTs).

Our EP staff includes four BSN-prepared RNs and one senior CVT, a registered cardiovascular electrophysiology specialist (RCES). We are currently recruiting for a second senior EP tech.  The EP department is supported by two nurse coordinators and two physician assistants. 

Our additional support staff includes two schedulers, one full-time central supply inventory specialist, and one full-time RN Inventory and Products Coordinator.

The cath department is supported by a data coordinator who manages data abstraction and submission to several national registries, as well as our Chest Pain and Level I Heart Attack coordinator, who works with our emergency department (ED), regional EDs, and paramedics to streamline our ST-elevation myocardial infarction (STEMI) process.

Two additional nurse coordinators and two nurse practitioners coordinate patient care for our outpatient cardiac procedures. 

RN and CVT longevity ranges from 20 years to newly hired, with the majority of our staff having more than four years experience. 

What procedures are performed in your cath lab?  

Our cath lab performs diagnostic and interventional cardiac catheterization procedures on both adult and pediatric populations, including:

  • Transfemoral and transapical aortic valve replacement; 
  • Balloon valvuloplasty;
  • Atrial septal defect (ASD)/ventricular septal defect (VSD)/patent foramen ovale (PFO)/patent ductus arteriosus (PDA) closures;
  • Ventricular-assist device placement;
  • Intra-aortic balloon pump placement;
  • Pericardiocentesis; 
  • Thrombectomy;
  • Coronary and peripheral brachytherapy; 
  • Laser atherectomy;
  • Fractional flow reserve (FFR), intravascular ultrasound (IVUS), and optical coherence tomography (OCT);
  • Right ventricular biopsies.
  • We also perform EP procedures on adult and pediatric populations, including temporary and permanent pacemaker insertions, loop recorder insertions, implantable cardioverter-defibrillator insertions, laser lead extractions, diagnostic EP studies and complex ablations including atrial fibrillation ablations using cryoballoon and 3-D mapping. We also perform cardioversions in our prep/recovery area. 

Diagnostic and interventional peripheral vascular procedures include limb salvage procedures, thrombolysis, peripheral vascular laser artherectomy, carotid angioplasty and stenting, abdominal angiography and coiling and interior vena cava filter placement/retrieval. 

We perform interventional nephrology procedures such as diagnostic and interventional fistulagrams, temporary and tunneled hemodialysis catheter insertion, and peritoneal dialysis catheter placements and infusaport placements.

We will soon be using the Melody pulmonic valve (Medtronic) in our pediatric population, and will perform the LARIAT procedure (SentreHEART, Inc.) for appropriately selected atrial fibrillation patients.

Weekly, we perform approximately 86 procedures: 40 cardiac, 16 electrophysiology, 10 peripheral vascular, and 20 nephrology. We provide 24/7 emergency call for adult and pediatric emergencies.  

Can you share your transcatheter aortic valve replacement (TAVR) experience? 

We began our TAVR program in January 2012. As of this writing, we have performed 25 transfemoral and three transapical procedures (we began the transapical approach for TAVR in November 2012). The program has been very successful, without any in-hospital mortalities. Our TAVR team is highly collaborative and multi-disciplinary, including specialists from interventional cardiology, cardiothoracic and vascular surgery, echocardiology, anesthesia and radiology. The program is supported by one full-time TAVR RN coordinator, Nicole Wolter. Our physicians work closely with our regional partners in screening potential patients and for patient follow-up. 

The TAVR cases are currently being performed in the hybrid operating room (OR) (Siemens Zeego). Upon completion of our hybrid lab (Philips FlexMove) in April 2013, the TAVR procedures will be performed in our department. We began with a core staff from our cath lab, surgery, and radiology for these procedures. Moving forward, all staff in the cath lab will be trained to staff TAVR cases. In the fall of 2013, we will host the first Wisconsin TAVR Symposium. 

Where is your cath lab located in relation to the OR and ED? 

The Heart and Vascular Procedure Center is adjacent to the OR on the third floor, with cardiothoracic and peripheral vascular surgeons on call 24/7 providing full surgical back up. We also serve as an emergency back up site for an affiliate hospital without surgical back up. 

The ED is located on the second floor, with approximately a 5-minute walk to the cath lab.

Do any of your physicians regularly gain access via the radial artery?

All of our cardiac procedural physicians are competent in radial artery access. For some, it is their preferred method. Others use radial access based on anatomy and difficulty related to femoral access. Radial access is the preferred method for some physicians during STEMI cases as well. Dr. Peter Mason conducts a quarterly, hands-on, Terumo transradial course for visiting physicians and staff.

Who manages your cath lab?

Christine Griffin, RN, BSN, is the invasive cardiology manager. She is responsible for administrative leadership, and manages the capital and operational budgets for the departments. Karna Boquet, RN, BSN, is the invasive cardiology supervisor. She is responsible for staffing and daily operations, coordinating the procedural workflow and efficiency. We have three senior CVTs, two cath and one EP, who assist with daily operations, billing, and staff training. Dr. Giorgio Gimelli is the medical director for the cardiovascular lab and Dr. Michael Field is the medical director for the EP lab.  

Do you have cross-training? Who scrubs, who circulates and who monitors? 

We are an academic medical hospital and have an accredited interventional cardiology fellowship program, so we routinely have an interventional fellow as well as a diagnostic fellow in the cath lab to scrub with the attending physician. CVTs and nurses are cross-trained for the scrub role. The nurse is the primary circulator, and administers moderate sedation and other medications. The CVT monitors hemodynamics and documents the procedural log for the case. An additional staff member, either RN or CVT, functions as a second circulator for complex or critical cases.

Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab?

No, an RT does not have to be present for procedures in our cardiovascular lab.

Which personnel can operate the x-ray equipment [position the image intensifier (II), pan the table, change angles, step on the fluoro pedal] in your cath lab? 

Physicians and trained staff can operate the x-ray equipment. Attending physicians, as well as diagnostic and interventional fellows, operate the fluoro pedal, pan the table, and position the II during cases.  

How does your cath lab handle radiation protection for the physicians and staff?

Our staff receives radiation badges on a monthly basis and monitors their radiation exposure online. Our medical physicist monitors the lead aprons annually. Our nursing staff rotates between the prep/recovery area and the procedure labs, which helps minimize exposure. Hemodynamic monitoring of cases is done by the CVTs from a separate lead-shielded control room. 

What are some of the new equipment, devices and products recently introduced at your lab? 

We hired a new pediatric interventionalist, Dr. Luke Lamers, in July 2012, and are currently growing our diagnostic and interventional pediatric procedure volume, soon to include the Melody (pulmonic) valve procedure. We currently utilize the Volcano s5/s5i Imaging System for FFR and IVUS, and have added the St. Jude Medical’s ILUMIEN system with OCT and wireless FFR in our cardiovascular lab. The Lariat procedure, closure of the left atrial appendage, will also begin in 2013. Our EP lab added the new cryoablation balloon for afib ablations in August 2012.

How does your lab communicate information to staff and physicians to stay organized and on top of change?  

We use e-mail for daily communications. We have monthly staff meetings and an active unit council that meets monthly. We also utilize bulletin boards and whiteboards in our break room and central lab area for announcements and other staff communications.  

How is coding and coding education handled in your lab? 

Our cath lab manager, product and inventory coordinator, senior CVTs and other selected, trained staff are all responsible for ensuring we have appropriate supply and billing codes for all procedures performed in the department. Our cardiology coders are available to answer staff and physician coding questions, and provide annual training to review the billing document.

The senior technologists review and reconcile each patient encounter to make sure all supply charges are captured on a daily basis. A dedicated hospital and physician coding specialist reviews each procedure billing form and the associated medical documentation prior to submitting the final patient procedure bill. 

Who pulls the sheaths post procedure? 

All nurses and CVTs are trained to pull sheaths. During orientation to the lab, each staff member is required to pull three sheaths using manual pressure and three sheaths using a FemoStop (St. Jude Medical) under the direct supervision and guidance of an experienced individual to ensure competency. In addition, every staff member is required to complete an annual competency showing a successful sheath pull with hemostasis. Fellows also pull sheaths, and are utilized for back up, or to pull if the nurse or tech has any questions or concerns with the removal or hemostasis. We have an approved protocol that defines the appropriate amount of time required for holding pressure, depending on sheath size and insertion site. This protocol also defines timing for pulling sheaths post intervention, depending on the anticoagulation received.

Where are patients prepped and recovered (post sheath removal)? 

We have a 15-bed prep and recovery area where all outpatients and inpatients (excluding intensive care unit patients) are prepped prior to their procedure. Patients also recover in this area post sheath removal. Inpatients remain in our recovery area until sheaths are removed, and for one hour post arterial sheath removal, to ensure hemostasis before returning to their unit. Outpatients recover in and are discharged from our prep and recovery unit. Nurses care for each of these patients pre and post procedure.  

Hemostasis is achieved in a variety of ways. Vascular closure devices are often used. In cases where a closure device is not used, manual pressure is applied by the physician, nurse, or tech, and in few cases, FemoStop holds are performed. If a hematoma occurs post sheath removal, manual pressure is applied until hemostasis is achieved. If needed, a FemoStop is placed to further achieve hemostasis. The TR Band (Terumo) is used for radial artery hemostasis and is placed post procedure before the patient is transferred from the procedure table to the recovery area.

How is inventory managed at your cath lab? 

QSight (OMSolutions), a web-based automated inventory management system, is currently used in the Heart and Vascular Procedures Center for inventory management. The system was implemented in April 2011 to keep an accurate account of equipment and expiration dates, as well as to track products used during each patient procedure and borrowed equipment. The majority of our inventory is maintained through QSight. In collaboration with the physicians, the department manager, supervisor, inventory coordinator, central supply inventory control specialist and purchasing specialist meet weekly to review new purchasing contracts, inventory management strategies, and discuss contract negotiations for the department’s capital and operational equipment and supply needs.

Can you share your lab’s average door-to-balloon (D2B) times and some of the ways employees at your facility have worked together to keep D2B times under the mandated 90 minutes?  

Our current median door-to-balloon time for UW ED cases is 41 minutes (this includes both field-activated and non field-activated cases). We are registered with the American Heart Association’s Mission: Lifeline.

Brenda Larson, RN, BSN, our Chest Pain and Level I Heart Attack coordinator, has worked exclusively with local and regional emergency medical services (EMS), EDs and cardiology staff to devise a field activation protocol that allows direct transport to the lab from the field, reducing our overall D2B time. The ED staff is trained to prep the patient for the procedure. The ED has a STEMI order set that includes all the primary medications, including aspirin, nitroglycerin, heparin, and clopidogrel.  

Our Med Flight and ED staffs are actively involved in the STEMI process, and take pride in their effort to minimize our overall D2B times. Every STEMI case is reviewed and processes are constantly evaluated for efficiency. 

Who transports the STEMI patient to the cath lab during regular and off hours? 

The sending unit, whether the ED or an inpatient unit, always transports the STEMI patient to the cath lab during both regular hours and off hours. If EMS is activated and the cath lab staff is ready, EMS will transport the patient directly to the lab, accompanied by an ED staff member.

What do you do when the call team is already busy doing a procedure and a STEMI comes into the ED?

During regular working hours when we have a second STEMI activation, the supervisor triages the second patient to the appropriate procedure room. If necessary, a patient will be taken off the procedure table if there are no other rooms available. After hours, if a second STEMI case presents while the call team is busy with another STEMI case, we use one of the two RNs on the call team to set up a second room and call for the patient. The CCU and critical care float staff may also be utilized to assist in the care of the patients. The ED may need to hold the patient in the ED longer than usual until the on-call staff is ready to bring the patient to the lab. If there is sufficient notification of the arrival of the second STEMI, the call team will phone other cath lab staff to see if anyone is available to come in to assist.

What measures has your cath lab implemented in order to cut or contain costs?

We conduct a weekly materials management meeting, including physicians and a purchasing specialist, to review new product requests. We consistently review our contracts, ensuring we have the most competitive pricing available. In addition, we work with the physicians in all procedural specialties to standardize equipment and supplies, which reduces our overall inventory. Our QSight inventory management system enables us to practice “just-in-time” ordering, which keeps our par levels low. It also generates multiple inventory reports and assists us in identifying products nearing expiration.  

What quality control/quality assurance measures are practiced in your cath lab?  

A monthly cardiology quality conference is attended by cardiologists and cardiology fellows, and is open to any staff member in the cardiology department. Cases involving complications are reviewed and discussed. In addition, there is a process in place where anyone can request a case be submitted for review of any patient care concern.

Are you recording fluoroscopy times and dosages? 

Currently, we document fluoroscopy times and dosages in our hemodynamic monitoring system, along with printing an examination report from our radiology system and filing it with our medical physicist. Cardiology physicians also dictate fluoro times into their reports. Additionally, a separate form is completed and submitted for follow-up if dose area product (DAP) levels exceed 400 for a single plane procedure and 800 for a bi-plane procedure. In these cases, the patient is provided with a patient education handout regarding the exposure. Our procedure nurse practitioners follow up with these patients to evaluate for high radiation exposure symptoms.  

Who documents medication administration during the case?

The nurse and CVT both document medications during the case. Currently, the nurse documents medications on a paper flow sheet that remains with the patient upon transfer to the next area of care. The CVT documents on the hemodynamic chronological log. Both modalities are scanned into the electronic medical record. The cath lab is not using EPIC or an electronic medical record for procedure documentation, but will be working on an electronic documentation process within EPIC in 2013.

How are new employees oriented and trained at your facility? 

New employees go through a hospital-wide orientation before they start working in the cath lab.  The orientation process in the cath lab lasts from three to six months, depending on the previous experience of the applicant. New hires are oriented to our prep and recovery area for one to two weeks before they begin their orientation in the cath lab. The newly hired staff member is partnered with a preceptor who has several years of experience in the cath lab.

What continuing education opportunities are provided to staff members?

Staff is encouraged to obtain higher learning opportunities, taking advantage of UW Hospital’s outstanding tuition reimbursement program. The Heart and Vascular Procedure Center holds a monthly educational series that provides CEUs through the Nursing Education Department. The series is coordinated in collaboration with physicians, who provide education related to current and new trends pertaining to heart and vascular procedures. Nurses and techs are required to maintain annual competencies on procedural equipment utilized in the lab. There are weekly cath and EP fellow conferences that are open to all cath lab staff.   

 

How do you handle vendor visits to your lab? 

We are a closed lab and require vendors to schedule meetings with physicians outside of the lab.  We have a vendor liaison office where all vendors are required to register on an annual basis. They receive a vendor identification badge that must be visible at all times. The vendors are required to schedule appointments with the inventory coordinator or manager as needed.

How is staff competency evaluated? 

Staff is assigned as superusers on the variety of equipment that is used in procedures. Superusers are responsible for updating the competency and signing off co-workers who must demonstrate proficiency. Our facility requires that all staff monitoring heart rhythms complete an annual telemetry competency. RNs and CVTs are all required to maintain advanced cardiac life support (ACLS) certification.

Does your lab have a clinical ladder? 

Beginning January 2013, the UWHC Nursing Department launched the Clinical Advancement program for direct care RNs. This program will establish a culture for the development and promotion of the professional nurse from advanced beginner to expert. RNs will receive an annual bonus of $1,500-$2,500 depending on their level of advancement.

 

How does your lab handle call time for staff members? 

Staff members are on call, on average, one night a week from 5 pm-6:30 am. Weekend call is from 5 pm Friday night through 6:30 am Monday. Our emergency on-call staff team consists of two RNs, one CVT, one cardiology or interventional fellow, and one interventional cardiologist.   

Within what time period are call team members expected to arrive to the lab after being paged? 

The call team is required to be at the hospital and ready to receive the patient no later than 30 minutes after being paged.  

Do you have flextime or multiple shifts? 

We have multiple shifts throughout the day. The first RN arrives at 6 am to open our prep and recovery area. All other staff arrives from between 6:30 to 9:30 am during the week. Staff has the flexibility to work 8- and/or 10-hour shifts. Also, staff has the opportunity to earn compensation (comp) time at time and one half, versus being paid overtime at time and a half, when working in overtime status. Staff can accrue up to 40 hours of comp time that can be used for approved time off.

Has your lab recently undergone a national accrediting agency inspection? 

We received Joint Commission accreditation in December 2011 and will resubmit for Magnet Recognition in 2013.  

What trends have you seen in your procedures and/or patient population? 

Our Heart and Vascular Procedure Center has experienced accelerated growth and expansion in interventional treatments due to advancing technology. In the early 1980s, the Center consisted of one cardiovascular and one EP lab. Today, the lab has grown to include two cardiovascular labs, one EP lab with a second EP lab opening in July, one multi-procedure lab, one hybrid vascular lab scheduled to open in April 2013, and a hybrid pediatric lab (Cath, EP and IR) under construction and due to open in December 2013.  

Since 2000, UW’s Heart and Vascular Procedure Center has expanded the varieties of procedures performed in the cardiovascular and EP labs. Peripheral vascular procedures, heart failure/transplant follow-up procedures, ASD/PFO/PDA closures, interventional nephrology procedures, and TAVR procedures performed in the cardiovascular lab have all been added. Practice in the EP lab has grown as well, as the Center added 3D mapping, afib ablations and laser lead extraction procedures. Similarly, the number of procedures performed daily has grown. In 2002, the Heart and Vascular Procedure Center performed a total of 3,968 peripheral and cardiovascular procedures and 560 EP procedures. During the fiscal year 2011, the Center increased to a total of 4,680 procedures (including cardiovascular, peripheral and interventional nephrology), observing nearly 25 percent growth, and performed 1,163 EP procedures, resulting in nearly 50 percent growth.

 

What is unique about your cath lab and staff?

We are currently constructing a hybrid lab in collaboration with the OR, which will be used as our peripheral vascular procedure room and to perform specialty procedures such as laser lead extractions, TAVR procedures or any other high risk procedure. Our staff is proud to be part of a team that embraces advancements in the cardiology field, and welcomes learning and being involved in new procedures.

Is there a problem or challenge your lab has faced? 

Due to the layout of the hospital, space constraints are a consistent challenge, as we have limited area for storage space or outward expansion. One way we improved efficiency was by building a prep and recovery area located adjacent to the procedure labs, which enables physicians to easily see patients before and after procedures. This has resulted in improved patient and family satisfaction, as well as more efficient procedure turnover times. The area is staffed by cath lab RNs, which is unique and provides continuity of care, because all nurses are familiar with the roles played in each step of the process, from patient prep through recovery and discharge.

The growth in procedural volume results in a constant evaluation of how we staff cases. This ongoing challenge has been met with a conservative increase of full-time employees and a strong focus on flexibility and teamwork. Our staff takes pride in being able to handle anything that happens in the course of the day.

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”? 

Madison is the capital of Wisconsin and the county seat of Dane County. Madison is the second largest city in Wisconsin, after Milwaukee, and the 81st largest in the United States. Badgers athletics, as part of the Big Ten conference,  has a strong presence in our community. Because we are affiliated with the University of Wisconsin, our hospital participates in the education of students in several health care/medical specialties. The Heart and Vascular Procedure Center provides a clinical observation experience for students in many specialties, including nursing, pharmacy, cardiac rehabilitation and physical therapy.

The Society of Invasive Cardiovascular Professionals (SICP) ASKS:

1. Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? Does staff receive an incentive bonus or raise upon passing the exam?

The RCIS certification is a requirement for our senior technologists. We do encourage all staff to take the RCIS exam. Currently, there is no additional compensation offered upon passing the exam.

2. Are your clinical and/or managerial team members involved with any professional organizations that support the invasive cardiology service line, such as the SICP, ACVP, or regional organizations?

Not at this time. 

The authors can be contacted via Amy Hawkinson, RN, BSN, at ahawkinson@uwhealth.org.

Questions from the American College of Cardiology’s National Cardiovascular Data Registry (ACC-NCDR): 

Do you use the ACC-NCDR or any other outside data collection registry?

Yes, we participate in the CathPCI, ACTION-GWTG, ICD, CARE, TAVR, and IMPACT national registries.

 

How do you use the NCDR Outcome Reports to drive quality improvement (QI) initiatives at your facility?

Outcome reports are reviewed quarterly and quality initiatives have been instituted both within our cath lab and hospital-wide. Examples of QI projects include compliance/completeness of stress test and medication documentation (CathPCI), in-house STEMI improvement (CathPCI), increased compliance (hospital-wide) of ordering appropriate medications and cardiac rehab on discharge for acute MI patients (ACTION), improved door-to-echocardiogram times in the ED (ACTION), improvement of documentation for antibiotic timing (ICD), and staff training/certification for the NIH Stroke Scale (NIHSS) (CARE). TAVR procedures and our participation in the IMPACT Registry are new within the past year; however, quarterly reports will be reviewed and initiatives will be established accordingly.

University of Wisconsin Hospital and Clinics (UWHC) and American Family Children’s Hospital are part of UW Health, recognized as one of the most progressive and prominent health care systems in the country. UW Hospital is a 566-bed academic medical center with 85 outpatient clinics. In 2012, UW Hospital and Clinics was named the number one hospital in Wisconsin by U.S. News & World Report  — and was among the nation’s top 50 hospitals in seven medical specialties. UW Hospital and Clinics received Magnet hospital designation by the American Nurses Credentialing Center in 2009.  UWHC was one of five hospitals in Wisconsin to receive the NCDR ACTION Registry-GWTG Platinum Performance Achievement Award for 2012.