Cath Lab Spotlight

Cath Lab Spotlight: St. Francis Hospital – The Heart Center

Eileen Hague, BSN, RN, CV-BC, Alicia Johnson, MSN, RN, CV-BC, Donna Mohr, BSN, RN, CV-BC, Angela Bush, BSN, RN, CV-BC, Steven Kalish, CVT, Jeronimo Rodriquez, BS, Respiratory Care, CVT Manager, Janet Cacioppo, MSN, RN, CV-BC, CNE, and Dana Shapiro, BSN, RN, CV-BC, Nurse Manager, Roslyn, New York

Eileen Hague, BSN, RN, CV-BC, Alicia Johnson, MSN, RN, CV-BC, Donna Mohr, BSN, RN, CV-BC, Angela Bush, BSN, RN, CV-BC, Steven Kalish, CVT, Jeronimo Rodriquez, BS, Respiratory Care, CVT Manager, Janet Cacioppo, MSN, RN, CV-BC, CNE, and Dana Shapiro, BSN, RN, CV-BC, Nurse Manager, Roslyn, New York

Tell us about your facility and cath lab.

The Cardiac Catheterization Laboratory (CCL) at Saint Francis Hospital (SFH) – The Heart Center is one of many departments providing high-quality cardiovascular care. The hospital has been rated as one of the top 50 hospitals in Cardiology and Cardiac Surgery by U.S. News & World Report for the past 11 years. Our cath lab performs the entire spectrum of diagnostic and interventional coronary and peripheral angiograms/angioplasties, as well as structural procedures, such as MitraClip (Abbott Vascular), transcatheter aortic valve replacement (TAVR), and Lariat (SentreHEART). We perform patent foramen ovale (PFO) and atrial septal defect (ASD) closures for the adult and pediatric population. Our cath lab implants the CardioMEMS (Abbott) pulmonary artery sensory device in the pulmonary artery to optimize the care of heart failure patients. A neuro-interventional program was started to treat embolic stroke with mechanical thrombectomy.

This program is expanding in 2019 to treat hemorrhagic stroke symptoms. Our lab is equipped to open chronic total occlusions of the coronary arteries. Chairman of Cardiology Dr. Richard Shlofmitz is a leader of precision angioplasty using optical coherence tomography (OCT) to optimize stent placement. Our physicians use the latest technologies to assist them in achieving the best results for our patients. We have a research department that is involved with variety of research trials to help improve the technology used in our cath lab. Our unit strives for the best cardiac care with the best outcomes.

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

Our CCL contains six procedure rooms, three of which are peripheral capable and two of which are TAVR capable. We have a six-bed holding room that provides immediate pre and post procedure care to cath lab patients requiring increased monitoring and/or acute care. Our sister unit, the Ambulatory Cath Unit (ACU), prepares ambulatory and admitted cath lab patients, and continues post procedure patient care through discharge home.

To assure appropriate staffing, our cath lab has a total of 81.7 full-time employees (FTEs), of which 75.7 FTEs are direct caregivers. Our nurse manager began her SFH cath lab career in 1986 as a clinical nurse and has over 15 years of tenure at the administrative level. The direct caregivers include:

  • 3.0 FTE assistant nurse managers;
  • 1.0 FTE cardiovascular technologist manager;
  • 41.1 FTE clinical nurses;
  • 15.4 FTE cardiovascular technologists;
  • 8.6 FTE scrub technologists;
  • 4.6 patient care associates;
  • 2.0 FTE cath lab assistants.

The CCL staffing plan includes 1.0 FTE material inventory management nurse, 2.0 FTE inventory secretaries, and 2.0 FTE unit secretaries. There are 31 interventional cardiologists on staff and three neuro interventional physicians on staff. Our staff have worked in the CCL over periods ranging from 30+ years to less than a year of experience.

What procedures are performed in your cath lab?

Procedures include left and right heart catheterizations, percutaneous coronary interventions (PCIs) (including highly complex PCIs and CTOs), ASD/PFO closures, peripheral and cerebral angiograms/interventions, CardioMEMS placement, septal alcohol ablation, left atrial appendage closure, and mitral valve repair. The CCL is integral to the TAVR team working with the operating room (OR) staff in this hybrid procedure. Approximately 220 procedures are performed each week in our cath lab.

Can you share more about your experience with TAVR?

Our catheterization lab has been working with our OR staff for eight years in performing TAVR. The OR is located next to our cath lab, with six open heart surgeons. We presently have two hybrid operating rooms to accommodate our TAVR cases. We continuously collaborate with our OR staff for improved patient outcomes. Several meetings have occurred to achieve common goals and keep communications open. Monthly meetings are still occurring, with a strong focus on efficiencies and lean methodology. We have presently dedicated two days a week to perform TAVR procedures. Our TAVR program has become so successful that we are presently performing 12-16 cases per week.

What is your percentage of normal diagnostic caths?

Our percentage of normal diagnostic caths is 18%.     

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

Yes, several of our physicians regularly gain access via the radial artery.

Who manages your cath lab?

The Cardiac Cath Lab management team is led by Dana Shapiro, BSN, RN, CV-BC, Nurse Manager. She is in charge of the Ambulatory Cath Unit (ACU) and the Cardiac Cath Lab (CCL). The management team is comprised of three assistant nurse managers: Karline Rocha, BSN, RN CV-BC, for the ACU, and Mary Rogan, BSN, RN, CV-BC, and Alan Florence, BSN, RN, for the CCL. Jeronimo Rodriguez, BS, is the CVT Manager and Janet Cacioppo, MSN, RN, CV-BC, is the Clinical Nurse Educator. All work collaboratively as a team to make things run efficiently and effectively.

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

Yes. Our cath lab initiated cross-training over 25 years ago when we had less staff to facilitate the flow of our unit and cross-training continues today. Only registered nurses circulate cases. Registered nurses are cross-trained to scrub and record cases. Cardiovascular technologists are cross-trained to scrub and record cases. Registered nurses, cardiovascular technologists, and scrub technologists all monitor our patients. Registered nurses, cardiovascular technologists, and scrub technologists need electrocardiogram (EKG) proficiency, hemostasis proficiency, and Association of periOperative Registered Nurses (AORN) sterile technique proficiency to scrub cases.

Are there licensure laws in your state for fluoroscopy?

Yes. Our hospital follows the guidelines regarding fluoroscopy from the State of New York Department of Health.

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?

Manipulation of all x-ray equipment is only done by the physician in the room.

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

Radiation protection is monitored through the use of personal radiation badges that are submitted and read monthly. We also hold quarterly radiation safety meetings, overseen by the radiation safety officer and the head of our radiology department, where all issues pertaining to radiation safety are reviewed. We use protection devices including shields from the ceiling, lead aprons, vests, thyroid collars, and leaded goggles. Our leaded aprons and thyroid collars are checked twice a year for integrity and upgraded as needed. All staff must complete annual radiation safety education.

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

Our physicians are using the newest technology, including OCT, intravascular ultrasound (IVUS),  physiologic measurements of ischemia with instantaneous wave-free ratio (iFR) or fractional flow reserve (FFR), and rotational and orbital atherectomy to assist with their stent placement in calcified coronary arteries. Highly complex PCI is assisted with partial circulatory support (Impella) or use of an intra-aortic balloon pump. Our lab stays current with the usage of the newest generation of stents as well.

The SFH CCL has a strong interventional neuro program for treatment of patients suffering from embolic stroke. The neuro interventionalist is readily available to make a quick assessment of these patients based on the patient’s presentation, NIH Stroke Scale, and symptom onset. When a large vessel occlusion is seen on computed tomography angiography (CTA) of the brain, the neuro interventional physician will activate the CCL team to perform cerebral thrombectomy with the use of an aspiration catheter or stent retriever, or a combination of both.

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

Staff members are updated with monthly staff meetings, read and sign papers, and daily group huddles to keep everyone informed and keep lines of communication open. Interventional cardiologists meet biweekly to discuss cases and outcomes. The staff is educated by our clinical nurse educator regarding all new equipment. Staff members complete education modules monthly and attend conferences.

How is coding and coding education handled in your lab?

Coding is handled through a collaboration between our inventory team, our charge capture specialist, and our CVT manager/system administrator. Each play a different role in obtaining coding and implementing codes into our Philips Xper system. Billing is transmitted daily for the preceding workday and a charge reconciliation process occurs daily against billing detail.

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

Any cath lab staff providing direct patient care who is trained in sheath removal post intervention and/or diagnostic procedures can pull arterial and venous sheaths. These staff members are provided with hands-on training and must perform a minimum of 10 successful sheath removals before being deemed competent.

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

The majority of outpatients are prepped in our 24-bed ACU immediately prior to being sent to the CCL. Occasionally, outpatients are admitted and prepped in our CCL holding room. Inpatients are prepped in our CCL holding room area. Patients can recover in the CCL holding room until they meet the appropriate Aldrete score and then continue through discharge in the ACU. The physician decides whether the sheath is to be removed manually or by using a vascular closure device, which is deployed by the physician only. All trained CCL and ACU staff are responsible for maintaining hemostasis.

How is inventory managed at your cath lab?

Our inventory team includes the clinical material management nurse and the inventory secretaries. They work with the nurse manager and the supply chain to request and procure equipment and supplies.

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

Four out of six of our cath lab procedure rooms have recently undergone renovation, but not increased in size. One single-plane cath lab will undergo construction to install a biplane fluoroscopic unit in early 2019. Our patient volume has demonstrated a steady increase.

Can you tell us about your lab’s clinical research?

The research department has a large presence in the CCL. The physicians participate in several trials, both sponsor-driven and investigator-initiated. Various trials include managing antiplatelet medication post PCI, imaging tools such as OCT and IVUS, and the use of FFR and iFR. Our robust TAVR program is a result of taking part in the TAVR trials. We are actively enrolling patients in the ECLIPSE trial (orbital atherectomy), CREST 2 registry for carotid patients, and the TAVR and mitral valve trials (COAPT).

Can you share your lab’s door-to-balloon (D2B) times and the ways employees at your facility have worked together to keep D2B times under the mandated 90 minutes?

Our facility averages a monthly D2B time well under the 90-minute benchmark set by the American College of Cardiology (ACC). In 2017, the annualized D2B time was 67 minutes for all cases. During work hours, there is rarely a delay in D2B times. A cath lab nurse and an additional cath lab team member will transport the patient to the cath lab. During the cath lab off hours, if an acute myocardial infarction (MI) occurs in the emergency department (ED), a ST-elevation MI (STEMI) Rapid Response Team (RRT) will be called overhead. Upon direction from the ED physician, the ED charge nurse is advised to activate the CCL team. In addition, the ED charge nurse notifies the nursing supervisor of the emergency and that the CCL team has been called in. A critical care nurse reports directly to the ED to assist with the care of the acute MI patient. While waiting for the CCL on-call team to arrive, the STEMI RRT team, consisting of an ED nurse and a critical care nurse, work together to get the patient ready to be transported to the CCL. Once one of the nurses from the CCL team arrives, a phone call to the ED charge nurse alerts the STEMI RRT team to transport the patient to the cath lab. The ED nurse gives hand-off to the cath lab nurse, then returns to the ED. Until the entire CCL team arrives, the critical care nurse remains in the CCL for continued monitoring of the patient and assistance in placing the patient on the procedure table.

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

A backup call team is called as a second call team. The nursing supervisor has been provided a list of the staff likely to be close to the hospital and who will often respond to the call for additional resources.

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

In order to contain cath lab costs, our staff members do not open the packages of high-cost items until it is definitively confirmed that those products will be used. Our cath lab conducts frequent analysis of supply utilization, with adjustments of par levels accordingly. Stock is rotated on a daily basis by the inventory personnel to reduce waste and inefficiency associated with product expirations. No short-dated items are accepted upon inspection of deliveries. We also adjust our staffing levels when we can predict when our volumes will decrease or when our high-volume physicians take vacations. The CCL has strong, collaborative relationships, including working with the cardiothoracic OR team to assist with cost containment so that no supplies are wasted or over-ordered for hybrid procedures such as TAVR.

What quality control measures are practiced in your cath lab?

Our cath lab strives to consistently provide safe care to our patients. All staff have completed an error prevention class to continue to raise awareness on safe practice and improve on the care we provide on a daily basis. We perform daily and weekly quality control, as well as proficiency testing on the two analytes we run in the CCL (activated clotting time [ACT] and platelet assay). We also perform correlation studies on both, in conjunction with the computed tomography (CT) lab and our main lab.

How are you recording fluoroscopy times/dosages?

Total fluoroscopy time is recorded in minutes to the nearest tenth of a minute. We record fluoroscopy times/dosages as air kerma in mGy units. We also record dose area product (DAP) in mGy cm2 units in our Philips system, cGy cm2 units in our Toshiba system, and µGym2 units in our Siemens system. We utilize Philips and Toshiba in the cath lab, and Siemens in our hybrid operating room. Times and dosages are both sent to our main Agfa server for permanent storage.

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 amount of radiation exposure, the patient is given education regarding the extended amount of fluoroscopy they received, and the signs and symptoms they should be aware of that could occur. This education is given in person. A printed sheet is given to the patient and the education is also included in the patient’s discharge instructions. The higher amount of radiation exposure is also communicated during nursing transfer handoff. Once the patient has been discharged, a follow-up phone call is made to check on the patient once they are home.

Who documents medication administration during the case?

The circulating nurse routinely documents medication administration. All medications given are reviewed at the end of the case, signed by the registered nurse, and given in the handoff report.

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

The physicians use the Philips Xper system to document their cath reports. This report is then electronically sent to the patient’s electronic medical record.

Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR)?

Yes, we participate in reporting data to the ACC-NCDR. Data collection starts from the moment the patient arrives to SFH, with clarifying elements in the patient’s EMR. This information is translated to detailed Xper data screens by the CCL recorder. Xper has been tagged with ACC-required fields so that the physician-specific items can be documented. The CCL works closely with two mid-level practitioners who review all PCI patient records. These practitioners identify further opportunities to complete the physician’s report to the greatest level of detail, prior to sending information to the NCDR.

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

Our hospital is part of Catholic Health Services of Long Island. Our cath lab receives patients from our sister hospitals, along with patients transferred from other local hospitals in the Nassau-Suffolk region. Our hospital also has advertisements on the radio and TV commercials to inform the public regarding our latest innovative technologies.

How are new employees oriented and trained at your facility?

All employees receive a general hospital orientation offered by the human resources department. Depending on the employee’s role in the cath lab, the employee receives an individualized, structured orientation to the cath lab. Our new RNs must have critical care experience and are trained to the cath lab over 18 weeks by an RN preceptor. The RNs are trained to circulate and scrub all cath lab cases. The cardiovascular technologists (CVTs) are trained by a senior CVT over 8 weeks. The scrub techs receive 8 weeks of training as well, either from a senior scrub technologist, senior RN, or CVT. Our RNs are cross-trained to perform the recorder role and the CVTs are cross-trained to the scrub role. All cath lab staff are given training regarding sterile technique, radiation safety, and achieving hemostasis.

What continuing education opportunities are provided to staff members?

Staff members have many continuing education opportunities. Education is provided via computer-based educational modules, as well as through access to online training sessions. There are seminars throughout the year given by the hospital and physicians. Our CCL/ACU nurses provide education to the SFH nursing staff in collaboration with our cath lab medical director at our annual Cath Lab Symposium. Topics are selected that are current and pertinent to cardiovascular procedures and to nursing practice associated with the care of the patient undergoing a wide array of cath procedures. The nursing presenters research their topic and discuss evidence-based nursing practice either preceding or following a discussion given by an interventional cardiologist about the procedure and/or technology.

Our hospital generates a great deal of cardiovascular research. The Chairman of Cardiology, Dr. Richard Shlofmitz, feels strongly that the success of this research depends heavily on the great work and expertise of the CCL staff. To further staff knowledge and to inspire staff to incorporate this knowledge into their practice, nurses and cardiovascular technologists are encouraged to attend national and international conferences. The total cost of our staff attendance at acclaimed conferences such as Transcatheter Cardiovascular Therapeutics (TCT) is sponsored by philanthropic contributions to the Cath Lab Nurse/Tech Research and Education Fund. The CCL staff also participates in and attends our annual OPCI (Optimizing Percutaneous Coronary Intervention) conference with the goal of providing education to interventionalists and CCL staff in imaging modalities.

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

While we prefer to hire candidates who have obtained the RCIS credential, it is currently not required. We do, however, encourage all of our employees to register and sit for the exam, and supply study materials when possible. We are looking to implement some form of compensation to provide further incentive.

How is staff competency evaluated?

Staff performance is reviewed twice yearly to discuss progress, goals, and the needs of the unit. The RNs participate in a peer review annually to highlight areas of strength and improvements that can be made to their practice. Staff members must complete several training modules that include a post test. The requirement for most tests is to pass with a grade of 90% or better. Staff are directly observed for certain competencies, such as maintaining hemostasis, drawing blood, and performing 12-lead electrocardiograms (EKGs).

Does your lab have a clinical ladder?

The RNs have the opportunity to participate in a clinical ladder. St. Francis Hospital strives to have the best nursing care. We are always encouraged to better ourselves to increase our knowledge base for better patient care. The RN clinical ladder is composed of four levels. It is based upon years of experience and includes many options for participation in order to expand nursing experience. Financial incentives are given to those RNs who maintain 3 & 4 clinical levels. All “CN 4” nurses must obtain and maintain a professional nursing certification in their specialty area.

How do you handle vendor visits to your lab?

Our inventory specialist oversees the schedule for vendor visitation to the lab, and ensures that representatives have valid visitation passes on applicable days. All vendors are required to be scheduled, sign-in with the inventory clerical staff, and to have obtained medical clearance via the Employee Health Services screening process. All vendors are required to obtain a daily or monthly vendor pass prior to entering the hospital. The educational needs of the staff for new technologies are coordinated with the vendor through the cath lab clinical nurse educator.

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

The physical layout of our cath lab has very minor limitations. Our recovery area contains six beds and at times can get filled to capacity. The cath lab staff will then recover the patient in the procedure room until space becomes available. Supplies are consolidated into the supply room and on procedure carts to increase efficiencies and reduce waste.

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

All call team members are expected to arrive to the hospital within 30 minutes of being paged.

How does your lab handle call time for staff?

Our staff members utilize self-scheduling, so most of the time, our staff can initiate their on-call time to best meet the needs of our unit and their home life. The on-call team consists of two RNs and one CVT for cardiac cases. If a neuro case is called, an additional RN is on call to assist with the case. Staff members mostly schedule themselves to be off the day after they are on call. If staff members are expected to be at work the day after their on-call shift, if staffing permits, staff members may leave early or start their shift later.

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

Our cath lab staffing consists of both flextime and multiple shifts. The majority of our staff members work 12-hour shifts. We handle our slow time by encouraging cath lab staff to educate staff on our clinical units regarding post-cath patient care, the importance of dual antiplatelet therapy, complications that could arise post cath, and how to improve patient outcomes. Staff members may use their benefit time or elect to take unpaid time during slow periods as well.

Has your lab recently undergone a national accrediting agency inspection?

Our hospital and cath lab recently underwent an inspection by The Joint Commission. Our advice would be to follow policy at all times and continue performance improvement efforts.

Where is your cath lab located in relation to the OR and ED?

Our cath lab and operating room are located across the hall from one another. A badge access door divides the two units. The emergency room is located on the first floor of the hospital and the cath lab is on the third floor. During acute myocardial infarctions, security secures an elevator to assist in transferring the patient to the cath lab as quickly as possible.

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

Over the last few years, we have experienced an expansion in specialized procedures, namely TAVR, Lariat, mitral valve repair, and in our neuro program. We have also increased our participation in numerous trials utilizing cutting-edge technology (FFR/iFR/OCT). Our cath lab has seen an increase in the usage of intravascular imaging. Many of our physicians use OCT or IVUS to assist in the course of treatment of the target vessel. Our patient population has a high number of comorbidities. Our cath lab has seen an increase in the number of CTO, septal alcohol ablation, TAVR, and MitraClip procedures due to the needs of our current patient population.   

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

A unique quality we possess is that our cath lab is nurse driven. Our cath lab staff members work as a team and are consistently seeking opportunities to educate themselves regarding the new technologies that become available to our lab. We are always striving to improve the care we provide to our patients and strive for excellence in our practice. Our cath lab was awarded the American Association of Critical Care Nurses (AACN) Beacon Award for Excellence in August 2016, and looks forward to receiving the award again in 2019.

Is there a problem or challenge your lab has faced?

Our lab recently faced challenges when new physicians joined our hospital and the number of procedures in the cath lab increased as a result. New RNs were hired to safely support this period of rapid growth in our patient workload.

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 on the outskirts of New York City and our patient demographic represents the broad spectrum of socioeconomic groups and payer mix. However, we have a significant percentage of well-educated patients with very high expectations. We are also the only state-recognized designated heart center. As such, demands on us to provide the highest level of cardiac care are substantial. Our goal is to provide the best service to all, using evidence-based medicine while continuing to provide personalized care. Our staff also relies heavily on Press Ganey reports for patient feedback. This allows us to provide outstanding care for our patients at all levels.

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?

These reports are reviewed with our performance improvement team. If we are deficient in any of the performance indices, we make efforts to educate our staff and institute adjustments in our practice in order to maintain our performance at the highest level. 

The authors can be contacted via Dana Shapiro, BSN, RN, CV-BC, Nurse Manager, Cardiac Cath Lab, at dana.shapiro@chsli.org.