Cath Lab Spotlight

Cath Lab Spotlight: Chesapeake Regional Medical Center

Sherwood A. Moore Sr., MBA, RCIS,

Cardiovascular Services Director,

Chesapeake Regional Healthcare,

Chesapeake, Virginia

Sherwood A. Moore Sr., MBA, RCIS,

Cardiovascular Services Director,

Chesapeake Regional Healthcare,

Chesapeake, Virginia

Tell us about your cath lab. Is it part of a cardiovascular service line?

Yes, Chesapeake Regional Medical Center is part of a cardiovascular service line that has received many accreditations, awards, and honors (Table 1). We have two large procedure labs, staffed with registered cardiovascular invasive specialists (RCISs) and registered nurses (RNs). Our invasive team consists of 3.0 full-time employee (FTE) cardiovascular RNs and 5.0 FTE RCIS members. The average tenure of our staff is 15 years, with a few over 19 years. Adjacent to the procedure area is a 10-bed holding area staffed with a 1.0 FTE posting secretary, 4.0 RNs, and 0.2 emergency medical technician (EMT). In 2019, Chesapeake Regional Medical Center implemented two CorPath GRX robotic systems (Corindus Vascular Robotics) in the cath labs. The robotic systems were added to reduce overall radiation exposure and enhance the current delivery of devices during interventional procedures.

What procedures are performed in your cath lab?

Chesapeake Regional Medical Center performs an average of 3800 procedures annually, including diagnostic minimally invasive cardiac and interventional procedures that can include use of intravascular ultrasound (IVUS) and instant wave-free ratio (iFR). We also perform peripheral vascular interventions. Electrophysiology (EP) implant procedures include permanent pacemaker, implantable cardioverter defibrillator, biventricular pacemaker/defibrillator, and loop recorders, and we also do EP studies and ablations. We do not perform structural heart interventions.

Does your cath lab perform primary angioplasty without surgical backup on site?

Yes. We began performing primary angioplasty without surgical backup in 2005. We have surgical backup agreements with two different health systems and an ambulance agreement to be on site during elective intervention cases.

What is your percentage of normal diagnostic caths?

Our percentage of normal diagnostic caths is roughly 60%.

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

Yes, we are a 99% radial access program.

If you are performing peripheral vascular procedures, do any operators utilize pedal artery access when appropriate?

We do perform peripheral vascular procedures and operators will utilize the pedal artery for access when appropriate.

Who manages your cath lab?

Our service is managed by an administrative team that includes Dustin Harley, RN Clinical Manager, Denise Rowe, RCIS, Technical Lead, Eric Palacioz, EP RN, Jamie Hayman, Quality Assurance (QA) RN, Denise Zelms, Administrative Assistant, and Sherwood A. Moore Sr., MBA, RCIS, Cardiovascular Services Director.

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

All staff are cross-trained. We have used cross-training since the program was initiated. We are fortunate to have one of the first nationally accredited cardiovascular programs in our region, the Sentara College of Health Sciences. Our RCIS staff are trained to independently function in all positions involved in diagnostic and interventional procedures. An RCIS engages in training our RNs who have critical care backgrounds.

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?

Physician and scrub (RCIS or RN) per Virginia State guidelines.

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

The team’s protective attire includes the latest in lead aprons, leaded glasses, thyroid collars, and shielding. Radiation protection is monitored with the use of personal radiation protection devices and this data is submitted to an outside vendor. The reports are reviewed and discussed transparently at our quarterly Radiation Safety Committee meeting. The committee consists of a radiation safety officer, physicist, radiology administration member, cardiac administration member, executive sponsor, and administrative assistant.

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

Immediate updates are provided within our organization via daily morning huddles. At the huddle, we discuss safety barriers and pertinent workflow/throughput. We have quality boards throughout each department where our staff and visitors can see our quality progress. For a more in-depth communication, we have monthly staff meetings where an agenda is provided and minutes are recorded.

How is coding and coding education handled in your lab?

We use hard coding via our GE Healthcare data management server (DMS) for C-codes and Current Procedural Terminology (CPT) codes. Procedures and devices are selected by the monitor staff member. Those selected items are interfaced to GE’s DMS and soon to be Centricity Cardio Workflow (CCW). Our procedures for the day are batched and reviewed by the team. Once released, the charges are reviewed collaboratively by a billing specialist, coder, and auditor.

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

Our patients are prepped and recovered within the cardiovascular holding area.

Who pulls the sheaths post procedure, both post intervention and diagnostic?

We are primarily a radial access program and utilize the TR Band (Terumo) and D-Stat (Teleflex) for hemostasis. Sheaths are removed at the end of the procedure within the lab. Any invasive or holding care team member can pull sheaths. All received training within their 90-day onboarding to the service line. Each member had to remove a minimum of 10 sheaths successfully prior to being approved to pull independently. Each staff member has an annual skill review prior to their performance review.

How is inventory managed at your cath lab?

Our inventory is managed by our GE DMS interface to our Mac-Labs (GE Healthcare). Each item’s description, item optical character reader (OCR), cost, and par is stored in this mechanism. Once a device such as a catheter, balloon, wire, or stent is used, if it has reached a below-par level, it is reordered. Additionally, we can override the auto feature when undergoing high usage of items. We charge for procedures and manage the inventory through our GE DMS to Mac-Lab interface. This mechanism is extremely efficient and accurate.

Has your cath lab recently expanded in size and patient volume or will it be in the near future?

Both cath labs are aged and are in the process of being replaced with the latest in radiation reduction cardiac imaging. Our labs will be interfaced with pertinent PACs imaging from other services. Our providers will not have to leave the cath lab tableside to view any stored image.

Is your lab involved in clinical research?

We have participated in clinical trials and currently have a trial under review by our Institutional Review Board (IRB).

Can you share your lab’s door-to-balloon (D2B) and ST-elevation myocardial infarction (STEMI) treatment efforts?

Our facility has been 100% compliant for two and a half years, recording times below the mandated 90 minutes. Many years ago, we became the region’s leader with regards to early activation by becoming the first accredited Chest Pain Center (CPC). The CPC processes eventually became second nature, from first responders to the emergency department (ED), to cath, and to the floor. Over time, all care providers have become fluent with our chest pain workflow. We have maintained one of the oldest existing hospital committees and our data review/agenda was foundational to the region’s overall STEMI processes. Our CPC committee meets regularly on a monthly basis to discuss chronological data, events, challenges, outcomes, and new processes. Our latest process enhancement included the implementation of Pulsara as our single activation tool for the activation of STEMI and stroke care.

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

At our facility, the assigned cath team transports the STEMI patient to the lab. This will include a cardiovascular nurse and RCIS. Our team is then assisted by an ED care partner and/or nurse if needed. A cardiologist or emergency care physician monitors the transport.

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

If both labs are occupied when EMS or the ED calls a STEMI, the cathing physician and ED physician evaluate the remaining time necessary to complete the procedures that are within the labs. If those times are outside of our protocol for mechanical intervention, we will use our thrombolytic protocol.

What measures have been implemented to contain costs?

We strictly abide by our group purchasing organization (GPO)’s guidance and outside of GPO purchasing, have placed costly items on consignment agreements to keep from purchasing in bulk or purchasing items where technologies tend to change rapidly. As mentioned, we monitor our par levels daily by utilizing GE’s DMS inventory mechanism. Additionally, on a monthly basis, staff checks all inventory for expiration dates and rotates where necessary.

What quality control measures are practiced in your cath lab?

With regards to quality of care, we use our ACC data as quality controls and work to improve on our trends. For example, with access site injury, we reviewed our heparin protocols and made sure they were within current evidence-based standards. As with most labs, we routinely test and monitor all point-of-care devices and remain with College of American Pathologists (CAP) guidelines.

How do you determine contrast dose delivered to the patient during an angiographic procedure?

Our facility adopted automated contrast delivery as our primary means of delivering contrast dose. We have used the ACIST CVi contrast delivery systems for well over a decade. There is no guess or question — it allows us to provide accurate dose data.

Are you tracking the incidence of contrast-induced acute kidney injury in patients?

We track acute kidney injury data and provide these data for internal committee review on a quarterly basis.

How are you recording fluoroscopy times/dosages?

We track both fluoroscopy dosages in mGy and dose area product (DAP) in mGycm2.  These are measures offered on all Philips systems.

What is the process that occurs if a patient receives a higher than normal amount of radiation exposure?

If a patient receives a higher than normal dose of radiation, they are told immediately following the procedure. The physician discusses the signs and symptoms that may occur. Additionally, the patient is provided with printed educational material regarding the exposure. If the patient was an inpatient, during handoff, the care nurse would provide reinforcement of the physician discussion and materials received.

Who documents medication administration during the case?

The circulator and monitoring team member collaboratively record all medication administration. This information is recorded immediately in the procedural documentation and is signed by the operating physician immediately after the procedure is complete.

Are your physicians dictating their cath procedure reports, or do they use a structured reporting tool?

A portion of our physicians are using a template designed in Epic and the remainder are using dictation. We are currently in discussions to move to a 100% structured report tool.

Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) or any other outside data collection registry?

We are a participant in four data registries provided by the ACC and one data registry provided by the AHA. Each of those registries provides metrics that are reviewed and used for quality improvement or service enhancement.

How are you populating the registry data records?

We have data harvesters and a QA nurse that obtains the data, and checks for accuracy and proofs of documentation prior submission to registries.

How are new employees oriented and trained at your facility?

At our facility, all staff are onboarded within 90 days. We determine during that time period if that new staff member is a correct fit and have the necessary tools for the service. After being educated on the organization’s policies and expectations, the new staff member is released to the designated department. For the cath lab, the new hire is assigned an ambassador who will provide an all-encompassing review beginning with radiation safety, policies and procedures, and ending with the majority of time spent exposing the new hire to all positions within the cath lab, i.e. scrub, float and monitor.

What continuing education opportunities are provided to staff members?

The organization budgets for off-site continuing education in the form of degree assistance. If anyone desires to obtain a degree above an associate in the health sciences, Chesapeake Regional aids them in obtaining a degree. For those who seek further advances in their specialty, funds are budgeted for off-site seminars inclusive of moderate compensation of hotel and airfare.

Are your clinical and/or managerial team members involved with any professional organizations that support the invasive cardiology service line, such as the Alliance for Cardiovascular Professionals (ACVP) or regional organizations?

Most of our technologists and our cardiovascular services director are members of ACVP.

How do you handle vendor visits to your lab?

Vendor visits are by appointment only. Representatives are allowed in the cath lab only if a physician is using their product and desires a specialist’s opinion or technical advice about the product.

How is staff competency evaluated?

Competency of the team is monitored daily by our clinical manager and technical lead whose concern is safety and accuracy. We provide competency review semi-annually that is a summation of challenges necessitating improvement.

Does your lab have a clinical ladder?

No, we do not have a clinical ladder.

Do you require your clinical staff members to take the registry exam for the Registered Cardiovascular Invasive Specialist (RCIS) credential?

Our technologists must hold a RCIS registry or be registry-eligible if they have recently graduated from an accredited program.

Does your lab have any physical (layout) bottlenecks or limitations?

We are currently landlocked, meaning there is no room left to expand. Our concerns are being addressed and hopefully in the very near future this major challenge will be resolved.

Is there a particular mix of credentials needed for each call team?

We encourage our call teams to consist of one nurse and two technologists. If there are dual STEMIs, we may have a different ratio, but safety is paramount. Call staff is allowed to leave early and/or start later after a night of being called in, but not for being on call.

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

We require a 30-minute arrival to the lab after being notified of a STEMI. This is part of our flow mechanism for providing STEMI services at our facility and for our region. We track this data among many data points provided for review during the monthly Chest Pain Committee session.

Do you have flextime or multiple shifts? How do you handle slow periods?

We flex our staff during slow periods, but it is usually voluntary that staff request time off.

Do staff members have any particular perks that you might like to share?

Our staff receives incremental incentives for taking call and for signing up for very lengthy/difficult procedures. We also budget for conferences, but those conferences must enhance our current service or offer information that would benefit our program with new procedures.

Has your lab recently undergone a national accrediting agency inspection?

We recently underwent review and re-accreditation with Healthcare Facilities Accreditation Program (HFAP), an authorized Centers for Medicare and Medicaid Services surveyor. My advice would be to prepare for ligature and malignant hyperthermia (MH) education. We were prepared, as our organization did have a mock survey, and by doing so, we had no challenges with re-accreditation.

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

In our region, we are seeing a definite increase in heart attacks for those 30 to 40 years old. We are seeing an increase in multivessel disease and are sending more from that age group to surgery for bypass.

What is unique or innovative about your cath lab and staff?

Our cardiovascular team has always adopted a “can-do” mindset. They are quick to adapt and incorporate procedures into their daily care workflows. Many years prior, one of our medical directors said, “We are here to serve” and that became our program’s soul. Our team wants to learn, works to be safe, and strives to advance.

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”?

We are blessed to have a fairly stable economy. We are currently buffered by the shipping industry, space industry, and armed forces. That stated, with regards to cardiovascular services, we have a community that is fluid, growing, and supportive of its health systems, which is very positive for any cath lab.

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

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

Our NCDR data reports are reviewed quarterly by the Chest Pain Committee. The quarterly metrics for identified challenges are set as improvement goals for the most current quarter. Using the described methods, we have improved not only our service quality and outcomes, but also those of the region as a whole.