Staffing Model Dictators

By Kenneth A. Gorski, RN, RCIS, RCSA, FSICP, The Cleveland Clinic, Cleveland, Ohio

I recently received an e-mail regarding staffing levels in catheterization laboratories. I’ve edited the message a bit, so “names have been changed to protect the innocent.”

Oh Wise One: I have been a Cath Lab Manager for XX years. Over the past XX years, we have been inundated with consultants from various organizations, all claiming to be experts on optimizing staffing ratios for hospital nursing units, ORs, and the Cath/EP Labs. The latest and greatest staffing level given to me by a group of experts would cut my staff in more than half (from 15 to 7 clinical staff. The experts came up with this staffing ratio based on ~ 40 patients/10 hour day, in 3 procedure rooms. We have all lost good people to these numbers that may or may not be realistic. There has to be a number that is correct for both the hospital and the personnel. I would like to speak with someone who will work with me toward finding out the real staffing number. I realize the number would not be absolute for everyone since we have different mixes of diagnostic only labs, interventional labs, and labs that may or may not perform EP studies and/or peripheral vascular procedures. Sincerely, Stressed-Out CVL Manager After downing another Starbucks Venti Pike with a shot of hazelnut syrup (which I mooched off the vendor of the day), I sat down behind my desktop and tried to think of what information I could share to best help this colleague out.

Dear Stressed,

This is your lucky day. Being co-chair of the Professional Standards Committee, I wrote the Cath and EP Lab Staffing Position Statement from the Society of Invasive Cardiovascular Professionals (SICP) which can be found at [update - link no longer valid].

The meat of the statement is: "There are three primary roles of the cardiovascular invasive specialist: hemodynamic monitoring/documenting, circulating, and scrubbing. Minimal optimal staffing for diagnostic and interventional cardiovascular procedures allows for staff to assume these individual roles. For diagnostic or interventional procedures staffed by only one physician, at least three non-physician personnel should be present. When there is more than one physician scrubbed for the procedure, a minimum of two non-physician personnel are recommended for monitoring/documentation and circulating for the procedure. For unstable patients, or complex interventional procedures involving multiple technologies, additional staffing may be needed. On-call staffing for emergency cardiovascular procedures should meet the same minimal staffing levels". This is your first weapon of war.

Your second weapon can be state nursing standards. In Ohio, there is a position statement from the Board of Nursing that reads: "The Registered Nurse’s role in the care of patients receiving intravenous moderate sedation for medical and/or surgical procedures: The registered nurse responsible for monitoring the patient during the procedure should not engage in other activities that would divert the nurse’s attention from the patient."

I will assume your hospital is a private practice institution. Let’s try and figure out how to divide 7 into 3: if your scrub assistant is one of the 7 nurses/techs, that leaves you with just 1 nurse or tech per room to attend to the patient, monitor, and retrieve equipment. Would the 7th employee be the charge nurse, or someone running room to room to relieve for bathroom breaks? What about lunches? If your work at a non-teaching hospital (without a cardiology fellowship program), how can you staff three procedure rooms with 7 staff? If your staff physician routinely works with a PA or another physician, two non-physician personnel (i.e., an RN and an RCIS or RT) are necessary for monitoring/documenting and circulating for the procedure. A facility with three rooms performing 30-40 patient procedures a day on average is (very) busy. It is one thing when you have multiple call-ins, such as with a weather emergency day, and you are in a bind trying to complete procedures; it is completely different when you are using this as your routine, daily staffing ratio. If you do not have a cardiologist fellowship program and the cardiologist requires one of your team to be the scrub assistant, the staffing model your "consultant" is proposing is unsafe patient care. I would not work in a lab utilizing this model, nor would I want myself or a family member being taken care of in this facility. I hope you find this information helpful.

Sincerely, The Wise and Wonderful Wizard of Cath