Cath Lab Spotlight

WakeMed Health and Hospitals

Gwen Anderson, RT(R) (CV), RCIS, BSBA, Education Resource Team Leader Invasive, Cardiology/ Electrophysiology; Kim Bradshaw, RT(R)(CT), Supervisor Invasive Cardiology/Electrophysiology; Paula Cole, Strategic Sourcing Contract Specialist; Rhonda Davis, RN, BSN Education Resource Team Leader Invasive Cardiology/Electrophysiology; Sheila DeBastiani, RT(R), Supervisor Invasive Cardiology/Electrophysiology; Jojo Ponsones, RN, BSN, Cardiovascular Specialist III; Kim Wooten, RN, BS, RCIS, Supervisor Invasive Cardiology/ Electrophysiology, Raleigh, North Carolina
Gwen Anderson, RT(R) (CV), RCIS, BSBA, Education Resource Team Leader Invasive, Cardiology/ Electrophysiology; Kim Bradshaw, RT(R)(CT), Supervisor Invasive Cardiology/Electrophysiology; Paula Cole, Strategic Sourcing Contract Specialist; Rhonda Davis, RN, BSN Education Resource Team Leader Invasive Cardiology/Electrophysiology; Sheila DeBastiani, RT(R), Supervisor Invasive Cardiology/Electrophysiology; Jojo Ponsones, RN, BSN, Cardiovascular Specialist III; Kim Wooten, RN, BS, RCIS, Supervisor Invasive Cardiology/ Electrophysiology, Raleigh, North Carolina
WakeMed is an 804-bed private, not-for-profit health care system based in Raleigh, North Carolina. It operates two acute care hospitals (WakeMed Raleigh Campus and WakeMed Cary Hospital), two healthplexes (WakeMed North and WakeMed Apex), two skilled nursing facilities, a home health agency, three dedicated outpatient facilities, four collaborative outpatient rehabilitation programs located inside area YMCAs, and WakeMed Faculty Physicians, a multi-specialty physician practice. It is a leader in both Wake County and the state in developing innovative services to meet the needs of its community and the region. WakeMed is one of the state’s largest providers of comprehensive cardiothoracic and vascular services. The hub of cardiac services at WakeMed Raleigh Campus is the WakeMed Heart Center. This facility, which is physically connected to the main hospital, first opened in 1998 and underwent expansion and renovation in 2005. The layout of the Heart Center allows patients to register, see their cardiologist in his or her office, and have non-invasive cardiovascular tests and invasive cardiac catheterization procedures performed, all under one roof. If an overnight stay is required prior to or following a specific procedure or test, patients and their families have the option of spending the night in the full-service hotel located on the top floor of the Heart Center. Other services unique to WakeMed that bring added value to the communities we serve include: • Primary stroke center with The Joint Commission Stroke Accreditation. • Wake County’s only Level I Trauma Center as designated by the North Carolina Office of Emergency Medical Services. • Seventeen mobile critical care ambulances and one air ambulance offering ground and air transport for adults and children. • Chest Pain Center accredited by The Society of Chest Pain Centers. • The Heart Center Conference Center, which is a 5,000-square foot facility with meeting rooms for conferences and symposia, and state-of-the-art capabilities for streaming video directly from the cardiac catheterizations labs and operating rooms to the conference center. WakeMed physicians frequently present findings from research, as well as host experts in cardiovascular disease treatment and management for local physicians and health care professionals. • Construction in progress for new patient tower with additional beds for cardiac care and a Children’s Hospital. • On-site 24/7 cath lab staff to expedite all emergent procedures. What is the size of your cath lab facility and number of staff members? The invasive cardiology department at WakeMed Health and Hospitals consists of eight cardiac catheterization procedure rooms (three of which are functional for both coronary and peripheral procedures) and two electrophysiology rooms. Construction is currently in progress within the department to add an additional multi-purpose room for coronary, peripheral and electrophysiology procedures. We have eighty-seven cardiovascular specialists (CVS), five secretaries, one scheduler and nine cath lab assistants/patient service assistants. The cardiovascular specialist title encompasses multiple modalities. These modalities consist of 30 registered nurses (RN), 24 radiologic technologists [RT(R)], 16 emergency medical technicians-paramedics (EMT-P), three registered respiratory therapists (RRT) and 14 registered cardiovascular invasive specialists (RCIS). Nine of departmental staff members are credentialed in multiple disciplines. What type of procedures are performed at your facility? The invasive cardiology department performs left heart and right heart catheterizations from multiple access sites (femoral, brachial and trans-radial), percutaneous coronary interventional (PCI) procedures (including intravascular ultrasound, pressure wire, embolic protection devices, mechanical and manual thrombectomy systems, intra-aortic balloon pumps) and patent foramen ovale closures. The department also performs multiple peripheral vascular procedures, including renal angiography and intervention, iliac and lower extremity angiography and intervention, and carotid/intracerebral angiography and intervention. This procedure base covers the fastest-growing volume of procedures performed within our department. Electrophysiology procedures [implantation of pacemakers and internal cardiac defibrillators (ICD)] are also occasionally done within the invasive cardiology procedure rooms, but are most commonly performed in our two electrophysiology rooms. The invasive cardiology department performs an average of 273 procedures a week. This average consists of 197 coronary diagnostic/interventional procedures, 30 peripheral vascular procedures, three cardiac computed tomography procedures and 43 electrophysiology procedures. Does your cath lab perform primary angioplasty with surgical backup on site? Yes. Our department performs primary PCI procedures without a dedicated surgical back-up team on standby. The operating room and surgeons, however, are available for support if emergent situations arise, and they are located on the same floor as the cath lab. What percentage of your diagnostic cath patients go on to have an interventional procedure? At present, about 33% of our patient volume progress from diagnostic procedures to interventional procedures. Who manages your cath lab? The management team consists of a division vice president (Betsy Gaskins-McClaine, RN, BSN, MSN-C), a department manager (Jeannie Moore, RN, BSN, CCRN, NE-BC), four supervisors [Kim Bradshaw, RT(R), CT, Sheila DeBastiani, RT(R), Diana Flynn, RN and Kim Wooten, RN, BS, RCIS], two education resource team leaders, three patient flow coordinator team leaders, one coding specialist team leader and 19 procedure room team leaders. Do you have cross-training? Who scrubs, who circulates and who monitors? The department staff is completely cross-trained. All of our cardiovascular specialists, regardless of credentials and training background, are trained to function in all three cath lab roles (monitor, scrub and circulate). 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? In our department, the physicians and the CVS in the scrub role operate the x-ray equipment. During an average procedure, the CVS will position the image intensifier, pan the table during image production and change tube angles. In our lab, the physician controls the fluoro pedal for procedures. How does your cath lab handle radiation protection for the physicians and staff that are in the lab day after day? Radiation protection is an important part of our day-to-day operations and our department has implemented several radiation safety measures. All staff and physicians are monitored utilizing two radiation badges (one under their lead apron at waist level and one on the outside of their lead apron at collar level). These badges are exchanged monthly and readings are available to staff. In addition to two monitoring badges, all staff and physicians are provided with personal lead aprons and lead glasses. Radiation badge audits are performed monthly by a departmental radiation safety committee on staff and physicians to verify that monitoring devices and protective equipment are being utilized appropriately. Within the peripheral vascular rooms, additional lead shielding has also been added to both sides of the procedure table to include table shielding and hanging lead shields. This provides additional protection for staff regardless of access site. Our peripheral cardiologists are also currently involved with a blinded study that is measuring radiation reduction during peripheral studies utilizing the Radpad radiation shield (Medi-inn Ltd., Cameron, Ontario, Canada). Do interventional radiologists and cardiologists perform procedures in the same area? The peripheral procedures that are performed within our department are performed by cardiologists and one neurosurgeon. Interventional radiologists do not work in our department. What are some of the new equipment, devices and products introduced at your lab lately? Currently, our department performs procedures utilizing the Diamondback (CSI) atherectomy system (Cardiovascular Systems Inc., St. Paul, MN) and Spectranetics Laser (Colorado Springs, CO) for lower extremity interventions. We are also in the process of introducing an interventional stroke program that will utilize the Penumbra aspiration system (Penumbra, Inc., Alameda, CA) and the Merci Retrieval system (Concentric Medical, Mountain View, CA). Our department installed integrated intravascular ultrasound (IVUS) systems [Boston Scientific’s iLAB (Natick, MA) and the Volcano System (Volcano Corporation, San Diego, CA)] in six of our eight procedure rooms. Our department also utilizes the PressureWire system (Radi Medical Systems, Inc., Wilmington, MA) to assist with lesion severity diagnosis. Can you describe the system(s) you utilize and how they work in cath lab daily life? Our department utilizes the GE DMS scheduling system (Waukesha, WI) for our procedures. This is integrated with the hospital information system. The GE Mac-Labs are used for procedure documentation, American College of Cardiology (ACC) data, charges and inventory management, and are interfaced with Heartlab (Agfa HealthCare, Westerly, RI) to populate the ACC database. IVUS and Philips X-ray equipment (Bothell, WA) are interfaced as well to automatically populate patient demographics. How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies? All inventory is hospital-owned and not accepted on consignment. Inventory is stocked through a bar code system, which replenishes inventory (generates a purchase order) based on par levels set once the item is scanned/used during a procedure. Products are selected through a department/hospital product review committee, which consists of physicians, clinicians and a strategic sourcing contract specialist. Products are given first priority when the vendors are included on our group purchasing organization (GPO) Novation contract. The strategic sourcing contract specialist (Paula Cole) is responsible for purchasing equipment and supplies. Has your cath lab recently expanded in size and patient volume, or will it be in the near future? Our patient volume has remained consistent over the past two years. We have experienced growth with our peripheral vascular procedures. Construction is currently in progress for an additional multi-functional procedure room. Is your lab involved in clinical research? WakeMed Heart Center is the site of numerous research studies involving cardiac-related devices, equipment, techniques, and pharmaceuticals. WakeMed Raleigh Campus has an Institutional Review Board (IRB) that complies with the FDA regulations for investigations involving human subjects. Two physician practices based at the WakeMed Raleigh Campus, Wake Heart & Vascular Associates and Raleigh Cardiology Associates, are involved in primary research for a number of projects. Examples of IRB-approved studies include, but are not limited to, the following: • Randomized Controlled Trials to Evaluate the Safety and Efficacy of the Zomaxx Drug Eluting Coronary Stent, as Compared to the Taxus Express 2 Paclitaxel-Eluting Stent in de novo Coronary Artery Lesions (Abbott Vascular); • Symbiot III: A Prospective Randomized Trial Evaluating the Symbiot Covered Stent System in Saphenous Vein Grafts (Boston Scientific); • FLAME: The FilterWire EX System Used in the Treatment of an Acute Myocardial Infarction for Embolic Protection (Boston Scientific); • A trial looking at the Spider distal embolic protection device (ev3 Inc.); • SAPPHIRE, a carotid stent trial (Cordis Corporation); • CAPTURE 2, a carotid stent trial (Abbott Vascular); • SPIRIT III and SPIRIT IV, Xience drug-eluting stent trials (Abbott Vascular). Currently, over 50 active research projects involving cardiovascular services are being conducted at WakeMed Raleigh Campus. Physicians on the WakeMed medical staff are on the forefront of medical research. This commitment to cutting-edge technology benefits patients of WakeMed Heart Center. 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? WakeMed initiated a Code STEMI (ST-elevation myocardial infarction) process in March 2006 to facilitate improvement of door-to-balloon (DTB) times. The process involves early identification through the Wake County Emergency Medical Services (EMS) system. The paramedics in the field are trained to recognize criteria for ST elevation. The electrocardiograms (EKG) are transmitted from the field to the emergency department (ED) for confirmation by a physician. Once confirmed, the ED physician can activate the internal Code STEMI response. The response team consists of a Cardiac Care Unit (CCU) Rapid Response nurse, the clinical administrator, the PA/NP for the cardiology practice on call, and cath lab staff. The Code STEMI response team assists the ED staff with facilitating and expediting transport of the patient to the cath lab. Before the initiation of the Code STEMI response process, our average DTB time was 120 minutes. Since the implementation of the response team, our DTB has lowered to 78 minutes. In January 2008, the invasive cardiology department implemented 24/7 cath lab staffing. This staffing is made up of a full-time, four-member team and was developed to further improve the Code STEMI response time. During the last six months (April 2008 to October 2008), the DTB time has shown an average of 55 minutes in 100% of Code STEMI patients. As a back-up to the 24/7 staffing, our department maintains an on-call team to respond if multiple emergent procedures occur. The on-call team for our department has a 30-minute response time for arrival to the cath lab when called to duty. How are new employees oriented and trained at your facility? The orientation process for new employees usually takes from three to six months. Each employee is given an orientation manual (that provides didactic explanations of procedures, equipment, anatomy and medications) and is assigned to a preceptor who has worked in the lab for a minimum of two years for hands-on experience. The orientee is trained in each of the three roles (monitor, scrub and circulate). Each role takes six weeks to two months for complete training. Each employee must complete several checklists and have the approval of their preceptor, educator and management prior to completion of a role. For new employees who have cath lab experience, the same process is utilized. However, the orientation time frame is usually cut in half. New orientees are assigned an educator to facilitate the learning process and evaluate their progress. This educator works one-on-one with the new employee on a bi-weekly basis, performing procedures and reviewing equipment/anatomy or any questions the orientee may have. Performance evaluations are completed at the stages of 30 days, 60 days and 90 days to assess the progress and needs of the new employee. Our educators also have access to a simulation lab that can be utilized in the teaching of new staff and students on coronary and carotid procedures. Every employee must be credentialed as an RN, EMT-P, RRT, RCIS or RT in order to work in the lab. Our staff is also required to have Basic Life Support (BLS) on hire, Advanced Cardiac Life Support (ACLS) within three months of employment and obtain the NIH Stroke Scale certification (NIHSS). What type of continuing education opportunities are provided to staff members? WakeMed’s professional development of staff is supported by our mission, values and strategic goals through continuing education opportunities. Opportunities include tuition reimbursement, an on-site RN-to-BSN program, an on-site BSN-to-MSN program, Masters in Health Administration and Masters in Business Administration programs, WakeMed’s Leadership Academy and WakeMed Foundation grants and scholarships for skills development. Within our department, we provide monthly in-services on medications, equipment and anatomy that assist with obtaining continuing education for our staff. Our staff also have annual blitz check-offs that include staff and vendor education on frequently and in-frequently utilized devices. Programs are also offered from our Area Health Education Center (AHEC) organization that include but are not limited to RCIS review seminars, cardiac symposiums and stroke symposiums. Bi-monthly peripheral vascular case reviews are held among surgeons, cardiologists and staff to facilitate understanding of treatment options available to patients. How do you handle vendor visits to your lab? All appointments and visits are handled through the strategic sourcing contract specialist (Paula Cole) and all vendors must be Status Blue Compliant. Vendors are not allowed on the hospital premises without an appointment and must wear their Status Blue Badge at all times while on the premises. Vendors are not allowed in procedure rooms unless invited by a physician. They must wear hospital-issued scrubs when in procedure rooms. How is staff competency evaluated? Our department holds an annual educational blitz that exposes staff to equipment and emergency procedure protocols. All staff are also required to complete a yearly department medication exam and right heart competency exam. Our department also has the advantage of being a high-volume lab, allowing our staff to gain exposure to various procedure types in order to maintain their competency level. Does your lab have a clinical ladder? Our facility does have a progression ladder program available to staff after one year of employment (six months if prior cath lab experience) within the department. Staff are required to fulfill a standard set of requirements that include technical skill check-offs/experience, education of other staff/peers, community involvement and leadership components. A cardiovascular specialist that progresses from a CVS I to a CVS II receives a 5%-of-base salary increase. Staff that continue and progress to a CVS III receive a 10%-of-base salary increase. Staff that obtains the RCIS certification receives credit when progressing to the CVS III level. Our department also offers a progression ladder process for our team leaders as well, with the requirements containing more leadership expectations. How does your lab handle call time for staff members? Staff members are assigned to a call team. Each call team consists of four team members. An RN and RT(R) are assigned to each call team. Each team also has at least one member with peripheral vascular experience. The staff takes call one night every other week and every eighth weekend. Within what time period are call team members expected to arrive to the lab after being paged? The department on-call team has a 30-minute response time. We routinely do not have an attending cardiologist on-site. However, PA/NPs affiliated with the physician practices are on-site 24 hours a day. Do you have flex time or multiple shifts? Currently our department consists of multiple shifts for 24-hour coverage. We have staff that work 8-hour shifts, 10-hour shifts and 12-hour shifts. There is also staff that are scheduled to work night and weekend shifts. Does your cath lab do electives on weekends and or holidays? A 24/7 operation allows our department to perform elective and emergent procedures at any time on weekends and holidays. If additional staff is needed, there is an on-call team that is available. Where is your cath lab located in relation to the operating room (OR) and emergency department (ED)? The OR and the cath lab are both located on the second floor of the hospital. These departments are separated only by the critical care units and critical care family waiting room. Our ED is located on the first floor of the hospital, directly below the critical care units. How do you see your cardiac catheterization laboratory changing over the next decade? Integration of multiple modalities has been key to the growth of our cardiovascular program. Peripheral vascular intervention is a rapidly growing market. We anticipate progressing as a regional stroke center utilizing mechanical intervention. Planning for future expansion and renovation projects will be geared toward multi-purpose procedure rooms for flexibility to perform heart caths, electrophysiology and peripheral vascular procedures. This flexibility will require staff cross-training into various modalities. What do you consider unique or innovative about your cath lab and its staff? There are several items that we consider that make our lab unique and innovative. • NIH Stroke Scale Certified. Our department prides itself on the fact that 100% of our staff is NIH Stroke Scale Certified. As our department moves into the field of stroke intervention, we feel we need to have the knowledge to best support and treat our patients. • Fully Cross-trained Staff. Our department is also unique because our staff (both RN and non-RN) is fully cross-trained. This means each staff member can contribute to a procedure or emergency in every way possible to take exceptional care of our patient’s well-being. • Computed Tomography Coronary Angiography (CTA) Program. Our department includes a 64-channel Brilliance CT scanner for coronary CTA. The scanner is located in our Heart Center and is separate from radiology. Two of our employees are registered CT technologists. We are also cross-training our radiologic technology staff to perform the CTAs. One of our cardiologists specialized in cardiac CTA interpretation at The Cleveland Clinic. Since mid-August of 2007, we have performed 195 CTAs. • 24/7 Staffing. We pride our department on being able to provide our patients with full-time, 24-hour staffing coverage. We employ a four-staff member team during off hours (nights and weekends) to allow for quick emergency coverage and availability for elective procedure completion beyond regular lab hours. This coverage has reduced the amount of staff call back and has reduced the Code STEMI DTB times. • Stroke and Carotid Interventional Program. Our department has been performing carotid interventions since October 2003 and is currently one of the few national cath labs developing interventional stroke programs. The Society of Invasive Cardiovascular Professionals (SICP) has added a question 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? Currently, our staff members are not required to take the RCIS exam. However, we do encourage our staff to obtain the certification. The RCIS is recognized in our progression ladder process for advancing to a CVS III. The authors can be contacted at: