Cath Lab Spotlight

Cath Lab Spotlight: Dr. Benjamin and Marian Schuster Heart Center, Kettering Medical Center

Nathaniel Wynn, MBA, BSN, RN, Cory Robbins, BSN, RN, CEN, Deanna Del Valle, BSN, RN, CCRN, Kettering, Ohio

Nathaniel Wynn, MBA, BSN, RN, Cory Robbins, BSN, RN, CEN, Deanna Del Valle, BSN, RN, CCRN, Kettering, Ohio

Tell us about your facility and cath lab.

Kettering Medical Center (KMC) is a 387-bed facility nestled amongst the rolling hills of Kettering, Ohio. It is the main hospital campus for Kettering Health Network (KHN), a faith-based organization whose mission is to serve the members of the community. Located in southwest Ohio just outside of Dayton, Kettering is home to approximately 60,000 residents. KHN is a nonprofit network of eight Dayton- and Cincinnati-area hospitals, Kettering College, and 120 outpatient facilities.

The Dr. Benjamin and Marian Schuster Heart Hospital was constructed and opened in October 2010, expanding the hospital with 90 patient rooms. This facility is home to a large cardiovascular imaging center with transthoracic and transesophageal echocardiography, vascular imaging, nuclear studies including cardiac computed tomography (CT) and cardiac positron-emission tomography (PET), a pre- and post-procedural area with 20 private patient rooms adjacent to our catheterization lab, and a dedicated telemetry unit.

The Heart and Vascular service line ensures that we provide premier cardiovascular care.

What is the size of your catheterization lab facility and number of staff members?

Our lab is an expansive 8,250 square feet, allowing for ample space in the control rooms, catheterization labs, and storage facilities. The catheterization lab includes three catheterization labs, two electrophysiology (EP) labs, and a hybrid operating room/catheterization room.

The staff includes registered nurses (RN) (19) with bachelor of science degrees and a few with certifications, radiology technologists (RT) (19) with cardiovascular interventional radiographers (CI) and registered cardiovascular invasive specialist (RCIS) credentials, and providers who have MD, DO, PA, and NP qualifications. We also have general (6) and interventional (1) cardiovascular disease fellows. We have several staff members with more than 15 years of experience, as well as a few with less than two years under their belt.

What procedures are performed in your catheterization lab?

The bulk of our procedures include diagnostic coronary and peripheral angiograms, percutaneous coronary interventions (PCI), peripheral interventions, EP studies, device implantations, radiofrequency ablations, and cryoablations. The lab has expanded its scope to tackle complex higher-risk (and indicated) patients (CHIP) cases such as chronic total occlusion (CTO) procedures and ventricular assist device (VAD) and extracorporeal membrane oxygenation (ECMO)-assisted PCI, as well as added a structural heart program and complex lead extractions.

Can you share your center’s experience with transcatheter aortic valve replacement (TAVR)?

KMC currently leads the Dayton area in TAVR procedures, having completed our 400th procedure since the program’s inception in 2016. Other hybrid procedures we currently perform include pacemaker lead extractions, Watchman left atrial appendage closure devices (Boston Scientific), and atrial septal defect (ASD) and patent foramen ovale (PFO) closures.

Do any of your physicians regularly gain access via the radial artery? If you are performing peripheral vascular procedures, do any operators utilize pedal artery access when appropriate?

Our method of choice for access is the radial artery and we opt for left radial access for patients with prior bypass surgery. We also perform peripheral vascular procedures with a small number of physicians using pedal access.

Who manages your cath lab?

Our medical director for the catheterization lab is Raja Nazir, MD, FACC, FSCAI. The catheterization lab is directed by Nathaniel Wynn, MBA, BSN, RN, and managed by Corin Robbins, BSN, RN, CEN. Day-to-day functions are supervised by three clinical coordinators: Sandy Sendlebach, RN, Emir Steward, BSN, RN, and Nathan Leonard, RT(R)(CI), RCIS.

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

Our teams are set up with four staff members per room, with RNs who circulate and monitor, and RTs who scrub and monitor. Typically, we schedule two RNs and two RTs in one room.

Which personnel can operate the x-ray equipment in your catheterization lab?

Our RTs operate the x-ray table. They position the image intensifier, pan the table, and change angles. The cardiologists and the fellows operate the fluoroscopy pedal.

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

All staff are required to wear radiation badges and rings. Radiation doses are monitored and reported monthly. The modes of protection include ensuring lead viability with yearly scans, providing staff with protective aprons and eyewear, and outfitting the room and table with appropriate shields. Pregnant women undergo increased training with our radiation safety officer and their fetus is further monitored.

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

We have recently acquired a fiber-optic balloon pump and the Rhythmia mapping system (Boston Scientific). Our hybrid room, which was opened in July 2018, brought all the structural heart procedures and lead extractions from the operating room (OR) to the lab.

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

To stay current with the latest innovations, our physicians have robust continuing medical education (CME) involvement — attending and presenting at national and international conferences, including American College of Cardiology (ACC) Scientific Sessions, Heart Rhythm Society (HRS), Transcatheter Cardiovascular Therapeutics (TCT), and Society of Cardiovascular Angiography and Interventions (SCAI) Annual Scientific Session. Communication and training from equipment representatives are frequently held on site. Dedicated educational material and specialized training is offered to RNs and RTs when new equipment is introduced.

How is coding and coding education handled in your lab?

We have a primary coder, Amanda Klintworth, RT, who attends ZHealth Publishing coding seminars, and trains lab coders across the network, in other facilities.

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

The catheterization lab is connected to a 20-bed short-stay cardiac unit. The unit is staffed by RNs that are specially trained to manage all access sites. Additionally, all RNs and RTs are trained to manage sheath sites safely.

The catheterization lab staff built and developed HealthStream modules required for all staff that pull sheaths. The HealthStream modules are connected to a live course that presents scenarios with complications and hands-on teaching. This course is required for all new personnel in the catheterization lab, the pre- and post-procedural unit, cardiac care unit (CCU), cardiothoracic care unit (CTCU), and post-anesthesia care unit (PACU) staff within six months of hire.

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

Acute myocardial infarction and critical patients are recovered in the CCU and CTCU. Patients with general anesthesia are recovered in PACU. The catheterization lab staff are available to assist PACU and the intensive care units (ICU) in the event of a complication. We utilize closure devices when appropriate, primarily the Perclose ProGlide (Abbott Vascular), Angio-Seal (Terumo), and occasionally, the Mynx (Cardinal Health). Our radial access site closure is with the Terumo radial compression band. We have joined the ACC Reduce the Bleed Campaign to reduce our femoral access complications.

How is inventory managed at your catheterization lab?

James Minier is our dedicated full-time inventory specialist, and manages the existing inventory and purchasing.

Has your catheterization lab recently expanded in size and patient volume?

The overall volume has remained approximately stable, though we significantly increased our ability to care for more complex and higher acuity patients. Surgically declined patients for VAD-assisted multivessel PCI, CTOs, and structural heart patients with multiple co-morbidities are in our lab on a daily basis.

Is your lab involved in clinical research?

We were recently accepted by the National Cardiogenic Shock Initiative and have a research team dedicated to following the patients who are eligible.

Can you share your lab’s door-to-balloon (D2B) times?

We have a monthly tracking sheet to report D2B times and our current average is 48 minutes. We identify outliers with a continual review in order to focus on opportunities to improve.

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

Patients presenting to the KMC emergency department (ED) are transported to the catheterization lab by ED staff. Patients transferred from outlying facilities are transported by the emergency medical services (EMS) personnel directly to the lab.

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

During regular hours, scheduled outpatient procedures are delayed, and the STEMI patients have full priority. On rare occasions, when more than one cardiac alert is occurs, additional staff members are called to come in on a volunteer basis.

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

Understanding equipment costs can be challenging; thus, we developed processes to simplify it. Equipment was categorized into price groupings — red signifying high cost items, yellow for intermediate cost, and green for lower cost. The physicians and staff were educated and made aware of the cost savings of using specific equipment. This gave us leverage with vendors to reduce the cost of equipment to match the lower range. We were also offered bulk purchases to lower costs based on the results of this project.

What quality control measures are practiced in your catheterization lab?

We run two morbidity and mortality meetings — one for interventional cardiologists and cardiothoracic surgeons, and another for electrophysiology complications. It is protected time and allows for honest peer review of cases to ensure quality metrics are met in all cases.

As noted above, we have joined the ACC Reduce the Bleed Campaign to improve our femoral access complications.

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

During an angiographic procedure, we measure contrast dose usage with the ACIST CVi device: measuring the dye given and subtracting an estimated waste. The manifold is used for lengthy cases such as CTOs.

Are you tracking the incidence of contrast-induced acute kidney injury in patients? If so, can you explain?

We track contrast-induced acute kidney injury (CI-AKI) through the ACC’s National Cardiovascular Data Registry (NCDR). Based on the ACC’s recommendations, KMC has incorporated a fluid management order set within our post-procedure order sets, to reduce the incidence of AKI.

How are you recording fluoroscopy times/dosages?

We input total fluoroscopy time and dosage into the Merge Cardio documentation system (Merge Healthcare), which is incorporated into the Electronic Privacy Information Center (EPIC) medical records. Radiation dosage is monitored and any case that has exposure of more than 5 Gray (Gy) is reported to the radiation safety officer for follow up investigation. The cardiologist in the case is responsible for notifying the patient of the high dosage use, providing education about signs and symptoms of damage, and arranging for clinical follow-up.

Who documents medication administration during the case?

All medications are documented by the circulating RN. Each procedure is staffed by two technologists and at least one RN.

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

Our physicians utilize the Merge Cardio system for their procedural dictation. All of our invasive cardiologists type or dictate (using Dragon Speech Recognition) their findings immediately after each case. They use the templates in Merge and will utilize Epic notes to relay any additional information.

How are you populating the registry data records?

We have an extraction team that manually performs chart reviews. This team extracts pertinent data and enters it into our Dexter system, which sends the data to ACC. We receive and review quarterly outcome reports from the NCDR.

How does your catheterization lab compete for patients? Has your institution formed an alliance with others in the area?

KMC is part of KHN, which is one of two health systems in the Dayton, Ohio region. Within KHN, there are five facilities that house catheterization labs, two of which also contain EP labs. These five labs are all staffed by a team of 48 cardiologists, six vascular surgeons, and five cardiothoracic surgeons who are employed by the Kettering Physicians Network (KPN). Most of our patients are referred to our KPN providers from the many physician relationships established across a wide network. We have developed partnerships with the Dayton Veterans Affairs Medical Center, The Ohio State University, University of Cincinnati Medical Center, and the Wright-Patterson Air Force Base Hospital.

How are new employees oriented and trained at your facility?

All new employees are placed in a formalized orientation process that typically lasts four to six months. This process includes on-the-job training, online modular learning, competencies, live classes, and an extensive checklist to track all required skills. This process is managed by our full-time educator and professional development specialist, Deanna Del Valle, BSN, RN, CCRN.

What continuing education opportunities are provided to staff members?

Physicians, the professional development specialist, and vendors coordinate continuing education opportunities. Didactic courses focusing on camera views, intracardiac and hemodynamic tracings, and catheter selection are undertaken by the cardiologists. Vendors assist in setting up simulation lab courses for catheter management and pig heart dissection.

How do you handle vendor visits to your lab?

All vendors are required to check-in with our Vendormate system and wear a badge while on campus. Currently, we have a moratorium on pharmaceutical vendors and are only allowing device representatives into the lab. Staff members are encouraged to meet with the vendors when it involves training on a device the lab already utilizes. Sometimes, we require the staff to train with the representatives for in-servicing, in which case we track participation with HealthStream transcripts.

How is staff competency evaluated?

Staff undergo hands-on education with ventricular assist devices and covered stents every quarter, and must have their performances evaluated by educators and vendors. There are competencies that must be met via the HealthStream online modules.

Does your lab have a clinical ladder?

KMC catheterization lab staff have two clinical ladders available to them. Our RNs can participate in KHN’s nursing development program, which is a four-tiered plan that offers progressively higher financial rewards to RNs who complete program objectives. The RTs at KHN can participate in a ladder specific to cath lab techs. Similar to the nursing ladder, this is a tiered program with rewards for completion of objectives of increasing difficulty. We are the only system that offers a clinical ladder specifically for our catheterization and EP RTs.

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?

We do not require our team members to take the RCIS exam. We do however, heavily encourage it and will pay for the exam as well as the preparatory classes. While we do not offer a direct incentive to those who pass the exam, any RT who has their RCIS receives a significant amount of points toward their RT clinical ladder.

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

Our current lab is only eight years old and has a fairly efficient layout. However, we are limited by the position of our unit in relation to the CCU and the OR, as we are located on the opposite side of the hospital to these units.

What do you like about your physical space?

Our catheterization lab is directly connected to the pre- and post-procedural (Same Day) cardiac unit, where the majority of our patients are prepared for and recovered from procedures. This has greatly reduced transportation time and provides us plenty of team members to call upon in case of emergencies. We also have a hybrid OR within our lab, hence we have an OR staff and a CT surgeon available.

The spacious lab overlooks the hospital’s sky walk, allowing for a central view of our campus. We are especially proud of the Environmental Services crew at KMC, who do an exceptional job of ensuring a safe, clean, and beautiful work area.

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

We are committed to run a four-person call team that consists of 2 RNs and 2 RTs, and are ardent in maintaining this mix. If the team is working through most of the night, we shift our team assignments around in the post call day to allow these individuals to go home early.

How does your lab schedule team members for call?

We have a full-time staff RT who creates the call schedule as part of her responsibilities, for which she earns points on the RT clinical ladder. She evenly divides the call amongst the RTs and RNs. We aim to stay six weeks ahead on the staffing schedule. Currently, we have an even number of RNs and RTs, and each member of the team is required to take call one weekday per week, and one weekend per month.

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

All employees are required to respond to alert pages within 30 minutes.

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

Our current hours of operation in the catheterization lab are 7:00 am to 5:30 pm. To meet the demands of our patients and physicians in this time period, we hire RTs and RNs into 8-hour, 9-hour, and 10-hour shifts.

When there is downtime, team members can work on training and education, or “overstaff” and head home. Overstaffing can be mandatory or voluntary. If the team members overstaff, they can choose to spend their paid time off (PTO) to supplement their hours or save the PTO.

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

Our lab personnel enjoy several perks, including evening-based incentive pay, flexibility in scheduling, as well as the clinical ladders.

Has your lab recently undergone a national accrediting agency inspection?

We have not recently had a national agency inspection; however, in December 2018, we successfully completed a survey from the Ohio Department of Health. Our advice for surveys would be for catheterization labs to ensure their meeting minutes are accurate and up to date. Any procedure that does not meet our quality standard, or has experienced a major morbidity or a mortality, is peer reviewed in our monthly morbidity and mortality conferences. We maintain extensive records of these meeting for our records and keep them organized for ease of use.

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

The biggest notable trend is the increased acuity of our patients and the increased complexity of our procedures.

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

The catheterization lab staff enjoy working in a team-based environment that values their work and time. We appreciate the demands of the profession and ensure a nurturing environment for those willing to learn and grow in their field. We maintain high morale and ensure each individual has opportunities to excel.

Most importantly, our catheterization lab, EP lab, and pre- and post-procedural staff work remarkably well together. For example, when a code is called, it is “all hands on deck” with incredible responsiveness from staff and physicians.

Recent changes in management have also been very well supported by staff. This year, the number of RNs and RTs completing the professional ladder and completing projects to improve knowledge and skill throughout the lab has reached an all-time high.

Is there a problem or challenge your lab has faced?

Given the complexity of the cases we currently undertake, we have aimed to better manage the chaos of codes. We run mock code scenarios and evaluate each participant to ensure their readiness to face difficult situations.

What’s special about your city or general regional area in comparison to the rest of the U.S.?  How does it affect your “catheterization lab culture”?

KMC is a faith-based organization, putting value in patient care and relationships. Patients are often surprised when we offer to pray with them prior to a procedure — a solemn vow that binds us in their care. This is especially important to our staff as we have personal connections with our patients.

As a community hospital in a small town in the Midwest, we have been blessed to help thousands of patients and their families. We take this charge seriously and have emboldened our physicians and staff to grow, learn, and develop new techniques. We are ahead of the national and regional quality metrics data and strive to improve further. Our lab has been extremely supportive of each other, and we have a lively and fun work environment while maintaining standards of professionalism and patient care.

A question from the American College of Cardiology’s National Cardiovascular Data Registry:

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

The NCDR outcome reports were the primary drivers for creating the quality improvement initiatives to improve CI-AKI in our network and to join the Reduce the Risk of Bleed campaign. We hope to see significant improvements arise from the changes that have already been instituted. 

The authors can be contacted via Cory Robbins, BSN, RN, CEN, at corin.robbins@ketteringhealth.org.