Cath Lab Spotlight

Cath Lab Spotlight: Rapid City Hospital Cardiac Catheterization Lab

Cassie Brandsted, RN, Cath/EP Lab Manager, Todd Sorenson, RCSA, Cath/EP Lab Supervisor, Rapid City, South Dakota

Cassie Brandsted, RN, Cath/EP Lab Manager, Todd Sorenson, RCSA, Cath/EP Lab Supervisor, Rapid City, South Dakota

Tell us about your facility and cath lab.

Rapid City Hospital is located in the center of the Black Hills in Rapid City, South Dakota. We are associated with Regional Health Heart and Vascular Institute. Our outlying area expands over 300 miles and our outreach program encompasses 5 states, including South Dakota, North Dakota, Wyoming, Montana, and Nebraska.

We have 2 cardiac cath labs, 1 hybrid room that is utilized by diagnostic and interventional cardiologists and cardiovascular surgeons, 1 electrophysiology (EP) lab with a bi-plane, 1 EP device lab, and a 7-bed pre/post area. Cath lab staffing consists of 2 clinical resource nurses, 10 registered nurses (RNs), 3 registered cardiovascular specialist assistants (RCSAs), 3 registered cardiovascular invasive specialists (RCISs), and one registered radiologic technologist (RT[R][VI]). EP lab staffing consists of one clinical resource nurse, 3 RNs, one RT(R)/RCIS, and 2 RT(R)s. Staff experience ranges from 29 years to a nurse that recently started 8 months ago. We also have many nurses and technologists that have been here 10+ years.

This experience has allowed us to develop a great working relationship with our physicians, and has helped to create an amazing work family.

What procedures are performed in your cath lab?

Rapid City Hospital (RCH) Cardiac Cath Lab performs a variety of cardiac, peripheral, and structural heart procedures, including diagnostic and interventional coronary angiograms, complex coronary percutaneous coronary interventions and chronic total occlusions (CTOs), diagnostic and interventional peripheral angiograms (upper/lower extremity, abdominal), limb salvage cases, patent foramen ovale (PFO) closures, transcatheter aortic valve replacement (TAVR), Watchman (Boston Scientific), left ventricular assist device (LVAD) insertions (Impella [Abiomed], Cardiohelp [Maquet], TandemHeart [Cardiac Assist]), right ventricular assist device (RVAD) insertions, intra-aortic balloon pump (IABP) insertions, carotid angiograms/stenting, cerebral/vertebral angiograms, temporary pacemaker insertions, coronary/peripheral atherectomy/thrombectomy/thrombolysis, endovascular aneurysm repair (EVAR), embolizations, inferior vena cava (IVC) filter insertions and removals, intravascular ultrasound, fractionated flow reserve/instant wave-free ratio, visceral stenting, venograms, IVC stenting and thrombolysis, and pulmonary angiograms and interventions. In the near future, we are looking to start performing venous ablations and laser atherectomy. Our cath labs perform on average 10 to 15 cases a day or approximately 75 cases per week.

Can you share more about your TAVR experience?

We have been performing TAVR procedures since January 2014. These procedures are performed in our hybrid cath lab with involvement from the cath lab and OR team.  TAVRs are scheduled 2 days a month, with the future goal of expanding to perform at least 10 TAVRs a month. We have recently added a structural heart coordinator to assist in the efficiencies of the TAVR process. In the beginning, TAVRs involved general anesthesia, but today, the majority are performed under monitored anesthetic care. A transesophageal echocardiogram used to be performed with all cases, but today, we primarily utilize transthoracic echocardiography. A temporary pacemaker continues to be inserted during the procedure, but the pacemaker is removed prior to completion of the case, unless it is needed. In the future, we hope to start MitraClip (Abbott Vascular) procedures.

What is your percentage of normal diagnostic caths?

Annually, 30% of the diagnostic caths performed are non-obstructive or less than 50%, per the American College of Cardiology’s National Cardiovascular Data Registry (ACC-NCDR).

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

All of our physicians are trained for radial access. RCSAs obtain the majority of radial accesses. Our radial access percentage is greater than 90% for all coronary procedures.

Do any operators utilize pedal artery access when appropriate in peripheral vascular procedures?

Two of our interventional cardiologists, Dr. Joseph Tuma and Dr. Bhaskar Purushottam, obtain pedal access for CTOs or advanced below-the-knee disease. Ultrasound is utilized in the majority of pedal access cases.

Who manages your cath lab?

Cassie Brandsted, RN, is manager of the cath/EP labs and Todd Sorenson, RCSA, is supervisor of the cath/EP labs.

Who scrubs, who circulates and who monitors?

We run a three-person team, including a nurse that circulates, nurse or technologist that monitors, and a technologist (RT[R], RCIS, and/or RCSA) that scrubs. We do not cross-train the nurses to scrub.   

Are there licensure laws in your state for fluoroscopy?

As of January 2019, Joint Commission standard requires annual fluoroscopy testing for anyone operating fluoroscopy equipment. South Dakota does not have specific licensure laws.

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?

The scrub personnel or the physician are allowed to operate the x-ray equipment.  During a procedure, the physician runs the fluoroscopy, while the scrub personnel have the ability to position the II, pan the table, and change the angles.

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

All the cath lab staff has completed the appropriate radiation safety training and is required to wear lead aprons. In addition to the lead aprons, all staff is required to wear dosimetry badges that are analyzed quarterly. We have added lead barriers in the rooms to reduce scattered radiation.

What new equipment, devices, or products have been recently introduced at your lab?

We have recently started using Boston Scientific’s newest atherectomy device, Jetstream, and are involved in the JET-RANGER trial. The peripheral Rotablator (Boston Scientific) is also fairly new to us. Our lab has used the peripheral Penumbra for a while and recently introduced the coronary Penumbra system. Our utilization of the Impella has also increased. Our facility inserted the first Impella RP in the Dakotas — an achievement occurring before Mayo Clinic.

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

The cath lab management team meets with cath lab medical director Dr. Bhaskar Purushottam at least monthly to discuss changes and/or issues. We also hold monthly staff meetings to keep staff informed of changes, new products, and provide an opportunity for staff to voice concerns, which has helped increase staff engagement.

How is coding and coding education handled in your lab?

We have a revenue integrity department that manages coding and reviews all charges after posting.

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

At this time, cath lab staff, pre/post staff, intensive care unit (ICU), and stepdown staff are trained in sheath removal. We have recently updated our sheath removal policy to require one observation and 10 monitored sheath removals, as well as quarterly education from physicians. In moving forward, we will be developing a sheath pull team for all sheath removals.

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

All outpatients are prepped and recovered in our cardiac prep unit. Inpatients are currently prepped in the inpatient rooms and we are planning to expand the cardiac prep unit to accommodate those patients. Currently, the cardiac prep unit consists of 7 pre/post rooms. Inpatients are recovered on the cardiac intermediate unit (admission floor). All intensive care unit patients are prepped and recovered in the ICU or post-anesthesia care unit (PACU). Patients are allowed to go to the cardiac prep unit, cardiac intermediate unit, critical care areas, or remain in the cath lab for sheath removal. We are currently refining this process to include a sheath removal team that will cover all areas 24/7. We currently utilize the Perclose ProGlide (Abbott Vascular) and Angio-Seal (Terumo) closure systems. If closure systems are unable to be used, manual pressure is performed. For anticoagulated patients, an activated clotting time (ACT) level of <170 seconds is required prior to sheath removal. The TR Band (Terumo) is used for radial compression. The radial sheath is removed immediately, regardless of anticoagulation.

How is inventory managed at your cath lab?

During procedures, supplies and implants are scanned into the Epic system by staff members. We have a dedicated materials management person managing inventory, which includes consignment, specials orders, cycle counts, and bi-annual physical inventory counts. Cath lab management also reviews all cases the following day for correct supplies and procedure documentation.

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

We have not added any additional labs, but our volumes have increased in the last two years and we continue to grow.

Is your lab involved in clinical research?

Over a span of many years, our cath lab has been involved in multiple research trials:

  • Gore SCAFFOLD: Carotid stent clinical study for the treatment of carotid artery stenosis in patients at increased risk for adverse events from carotid endarterectomy.
  • PRINCIPLE-TIMI 44: Prasugrel vs clopidogrel for inhibition of platelet activation and aggregation in elective PCI.
  • DURABILITY Post Approval Study (PAS): Primary stenting using EverFlex stent (Medtronic) in the treatment of superficial femoral artery and proximal popliteal lesions.
  • CREATE PAS: Carotid revascularization with ev3 arterial technology.
  • TRA-PCI: Vorapaxar in 1030 patients undergoing non-urgent PCI or coronary angiography with planned PCI.
  • SuperNOVA: Innova stent system (Boston Scientific) long-term (12-month) safety rates and vessel patency when treating femoropopliteal lesions.
  • CHAMPION PHOENIX: Comparing cangrelor to clopidogrel standard therapy in subjects who require PCI.
  • INNOVATE-PCI: A Phase II safety and efficacy study of PRT060128 (elinogrel), a novel intravenous and oral P2Y12 inhibitor in non-urgent PCI.
  • CONFIDENCE: Microvention-Terumo carotid stent trial to evaluate the safety and efficacy of the Roadsaver stent used in conjunction with the Nanoparasol embolic protection system.
  • LEADERS FREE II: Evaluating the non-inferiority of the BioFreedom drug-coated stent (Biosensors) vs the Gazelle bare-metal stent (Biosensors) arm of the LEADERS FREE study in high bleeding risk patients.
  • REDUCE: Gore PFO trial.
  • JET-RANGER: Randomized study evaluating the use of Jetstream atherectomy (Boston Scientific) followed by drug-coated balloon in comparison to the use of plain old balloon angioplasty followed by drug-coated balloon alone in the treatment of complex lesions in femoropopliteal arteries.

Can you share how you have worked to keep your door-to-balloon (D2B) times low?

Data from our most recent CathPCI outcomes report shows that our median D2B time is 64 minutes. RCH has had a robust D2B program for the past 15 years. This includes the tracking of all acute myocardial infarction (MI) patients with both the ACC-NCDR CathPCI and Chest Pain MI (formerly ACTION) registries. Registry data is used to provide concurrent and monthly feedback to referring facilities, EMS, emergency department (ED) staff, cath lab staff, floor nursing staff, management, and cardiology providers. Opportunities for improvement of D2B times are discussed at our monthly section meetings, where all ST-elevation MI cases are reviewed via an internally developed dashboard. We have been affiliated with the American Heart Association’s Mission:Lifeline for a number of years and have received the Platinum award from Mission:Lifeline 6 years in a row.

Who transports the STEMI patient to the cath lab?

All STEMI patients are transferred to the cath lab by at least one RN and one other staff member. On rare occasions, patients are a direct admit to the cath lab. When this occurs, EMS will meet the RN in the lab.   

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

If the call team is not available and will not be available in a short time period, thrombolytics are administered.

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

We work with the Premier buying group to decrease costs and limit vendors. We also have our own materials management staff member who closely monitors supplies. To reduce overtime, we implemented the second shift for the call team. We are currently working with the Medtronic ProCV team to improve the efficiencies and utilization of the cath labs.

What quality control measures are practiced in your cath lab?

We participate in the Chest Pain MI, CathPCI, ICD, TVT, PVI, and LAAO registries, and these drive the quality of our lab. These data are presented to the cardiology practitioners and management monthly at the section meeting, as well as at the cardiology quality meeting. The data are also used in the cardiology morbidity & mortality (M&M) meeting, as well as the PCI appropriate use committee meeting. We have implemented many practices based on the data from our quality registries, including developing a 90% radial access program when groin bleeding complications in our coronary angiography patients were found to be above the national benchmark; implementing a renal protection protocol in the lab when the ACC started reporting acute kidney injury rates in the CathPCI Registry and we became aware that our rates were higher than our peers within the registry; and standardizing groin sheath management practices among the various nursing units when we noticed the rate of groin bleeding in our peripheral vascular intervention (PVI) patients was higher than we desired.

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

We have developed a formula for ideal and maximum contrast allowable for a procedure. The limits are discussed during the time out, and staff is in contact with the physician frequently throughout the procedure if contrast limits are approaching ideal or maximum doses. The formula is as follows:

Weight (in kg):_____

Creatinine: _____     Age:_____

Creatinine Clearance

Male = (140 – age)(body wt in kg)

    72(serum creatinine)

Female = (140 – age)(body wt in kg(0.85)

        72(serum creatinine)

Estimated Creatinine Clearance =

_______________________________

2 x_____________________________

(Creatinine Clearance) =____ml

(Ideal contrast load)

3 x_____________________________

(Creatinine Clearance) =____ml

(Upper contrast load)

Contrast used:____________________

The protocol to reduce AKI rates was implemented approximately four years ago as a project done in partnership with nephrology. We calculate an appropriate contrast dose on each case performed in the lab. We also track whether or not each case falls below, meets, or exceeds the recommended amount of contrast allowed. A pre- and post-hydration protocol was also part of the AKI project. We receive an AKI report each quarter and share this information with our physicians and management. We are able to drill down and see each individual physician’s rates of AKI and adherence to recommended contrast load, and we periodically provide them with feedback regarding their individual rates.

How are you recording fluoroscopy times and dosages?

Both of these values are recorded in the procedural log and physician dictation, as well as with the procedural images.

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

Per policy, if a patient receives higher than normal dose of radiation, the physician is required to have a conversation with the patient and family regarding potential side effects. This conversation must occur face-to-face. Follow-up occurs in the clinic setting.

Who documents medication administration during the case?

Either a nurse or technologist can document medication administration; this task is completed by the monitor personnel.

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

A few of our physicians utilize structured reporting, but currently the majority dictates their reports.

Which data registries are in use at your lab?

We currently participate in 7 ACC-NCDR registries: CathPCI, Chest Pain MI, TVT, PVI, LAAO, ICD, and Pinnacle. We also participate in the Society for Thoracic Surgeons (STS) Adult Cardiac Surgery registry. Our quality team is comprised of four staff that input the data and manage the abstraction, submission, interpretation, presentation, and process improvement of the quality data. We have interoperability between several of the registries and some of the data is auto-populated by the hemodynamics system in the cath lab, though some of the auto-population was recently interrupted during the transition to a new, system-wide electronic medical record.

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

The cardiology program in general provides care to the entire western half of the state. The other competing cath labs in South Dakota are about 300-350 miles to the east. The cardiology program does, however, do outreach clinics to 2 other neighboring states to the south and west, which yields referrals to the program as a whole, as well as the cath lab. The closest competing cath lab is about 130 miles to the west, has just opened within the last several years, and is a much smaller volume program than the one at RCH. We do have a good relationship with this outside lab and they refer their more complex cases to our program.

How are new employees oriented and trained at your facility?

Generally, orientation takes four months, but the process is personalized depending on experience. Two preceptors are assigned to each new staff member. Weekly to bi-monthly conferences occur among the new employee, preceptors, and management to discuss progress. A 90-day evaluation is also completed. All new staff members are required to complete an orientation checklist. Buddy call is also incorporated into the orientation prior to completion.

What continuing education opportunities are provided to staff members?

Each year, two staff members are approved to attend a cardiac conference. Otherwise, vendors frequently complete education with the staff. The facility holds an annual cardiac symposium that is also available to staff.

How do you handle vendor visits to your lab?

Vendors are allowed to schedule time in the lab once every 6 weeks. However, if a physician is performing a procedure and requests a vendor, that vendor is allowed to schedule additional time. All vendors are required to check in through RepTrax and must wear hospital-provided attire. Vendors are allowed in the labs, but are not allowed to handle product.

How is staff competency evaluated?

Each staff member is required to complete three competencies a year. These competencies are to be completed by using a variety of verification methods. Management or clinical resource nurses are allowed to sign off staff members.

Does your lab have a clinical ladder?

We do not have a clinical ladder specifically; however, the technologists can complete additional training and become a registered cardiovascular specialist assistant (RCSA). Nurses also have the opportunity to become a clinical resource nurse. Both technologists and nurses can advance by becoming a daily charge person.

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

The technologists are either required to be RCIS or American Registry of Radiologic Technologists (ARRT) certified. The facility is currently reviewing incentive bonuses for additional training and certifications. However, technologists that complete additional training for the RCSA certification receive a raise and an increased pay grade.

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

Currently, RCH is expanding and building a new ED, cardiology clinic, and inpatient areas. Due to this construction, patients are directed to many different areas throughout the facility. At present, the cardiology waiting room and consult rooms are not in close proximity to the cath lab. Our pre/post area is also limited in space. When census is high, patients are held in the cath lab due to limited rooms. Communication and teamwork are key elements in these situations.

What do you appreciate about your physical space?

The two cardiac cath labs have a shared control room, which aids in great teamwork. Our hybrid cath lab is very large and has a state-of-the-art design. This room is excellent for the multiple modalities involved in structural heart cases or endografts. All rooms are equipped with storage and are also nearby to storage areas. All rooms are in the same area in order to keep the team working in close proximity.

Can you share how on call is handled at your lab?

Our call team consists of two RNs and one technologist. If the schedule allows, the call team is allowed to leave early the next day. If the staff is working throughout the night, as long as there is communication and enough staff for morning cases, the call team is permitted to come in later.

How does your lab schedule team members for call?

The schedule is built off of the weekend schedule. Currently, nurses are scheduled every 4th to 5th weekend, and technologists are scheduled every 6th weekend. The weekends are filled in, and typically, the weekend call team will be off the Thursday prior to the weekend and the Tuesday after the weekend. Once these times are scheduled, the rest of the team is filled into the slots. Nurses are typically on call one to two nights per week, and the technologists are on call one night per week. Staff are also scheduled one holiday each year.

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

We have a 20-minute callback time.

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

Our prime hours are from 0700-1630. Staff arrives at 0600, with the exception of the call team. The call team is scheduled from 0730-1800. During slow periods, staff is allowed to leave, as long as there is enough staff for two rooms. Otherwise, stocking, cleaning, education, and next day’s case prep occurs.

How do you work to raise team morale?

Every month, we have a “Birthday Potluck.” Staff members that have a birthday one month pick a potluck theme and are excluded from having to bring a potluck item. Each year, we budget for two staff members to attend an annual national conference. We have a daily “leave early” option that any staff member is allowed to request if the schedule allows. Staff understands that leaving early is not guaranteed. We also offer frequent education. On occasion, we have a “Boss’s Breakfast,” a made-to-order breakfast from managerial staff. We try to get together as a team for charity work, annual Heart Ball, American Heart Association (AHA) Heart Walk, etc.

Has your lab recently undergone a national accrediting agency inspection?

Joint Commission visits our area annually. Time outs are always a hot topic.

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

Our monthly STEMI population has increased. Our chronic limb ischemia population is at 60%, which is greater than three times the national average. We have also increased our utilization of the Impella for high risk PCI cases.

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

We are a very close-knit team; we enjoy each other’s company and consider each other family. We perform a vast array of procedures, ranging from coronary angiograms to peripheral and carotid angiograms with interventions, to TAVRs. All staff is trained to perform all procedures. Our technologists that are RCSA-credentialed gain arterial/venous access for the majority of the cases. We perform greater than 90% of coronary angiograms via radial access.

Is there a problem or challenge your lab has faced?

Staffing is always a challenge. Due to the lack of competition and our location in South Dakota, we face challenges of recruiting staff. Our recruitment team is looking at innovative ideas to aid in obtaining new staff. We have also struggled with the utilization and efficiencies in the labs, and the Medtronic ProCV Lean Six Sigma team is helping us to improve our processes.

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”?

As our medical director of the cath lab, who originally came to us from New York, would state, “We have sick patients in this area.” The multiple comorbidities of our population result in very ill patients. We treat many cardiogenic shock patients and our 2017 mortality rate for these patients was 35%, which is much lower than the national average. We are located in the Heart of the Black Hills, and are near Mount Rushmore, Crazy Horse Memorial, and Custer State Park. Every summer, the Black Hills host the annual Sturgis Motorcycle Rally. During this time, our local population increases from 75,000 people to nearly 750,000 people. We are a very touristy area during the summer months, which, in turn, can lead to an influx of patients and staff overtime.

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

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

We use the multiple NCDR registries to drive quality by using the information we gain from the registries to provide feedback to the referring facilities, EMS, ED, cath lab, floor nursing, administration, and providers within the cardiovascular program. After we analyze the registry data, we also change patient care protocols and treatment patterns as needed, to improve patient care and outcomes by applying best practice guidelines and evidence-based medicine. The data is shown to the providers and program leadership monthly at our cardiovascular section, QA/QI, M&M, and appropriate use meetings.  

Cassie Brandsted, RN, Cath/EP Lab Manager, can be contacted at cbrandsted@regionalhealth.org.

Todd Sorenson, RCSA, Cath/EP Lab Supervisor, can be contacted at tsorenson@regionalhealth.org.