Cath Lab Spotlight

Cath Lab Spotlight: UnityPoint Health – Trinity Heart Center

Jessica Tapia-Mier, BSN, RN, Manager Invasive Cardiology; Kathy Pulley, BS, Director, Cardiovascular Service Line; Rock Island, Illinois

Jessica Tapia-Mier, BSN, RN, Manager Invasive Cardiology; Kathy Pulley, BS, Director, Cardiovascular Service Line; Rock Island, Illinois

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

UnityPoint Health – Trinity Heart Center offers a comprehensive cardiovascular service line that involves the collaboration between our team of cardiologists, cardiac surgeons, nurses and radiologic technologists. UnityPoint Health – Trinity Heart Center harnesses the latest advances in medicine and technology, treating complicated cardiac conditions with minimally invasive surgeries, open-heart procedures, and innovative therapies that help patients live longer, healthier lives. We are also proud to be one of only 52 cardiology programs in the United States to offer our patients the opportunity to participate in Pritikin Intensive Cardiac Rehab.

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

We have over 55 team members in our pre/post area and cath lab, including PRN team members. We have five cath labs: four in Rock Island, Illinois, and one in Bettendorf, Iowa. We also have a pre and post Cardiac Treatment Unit (CTU) in our Rock Island facility with 22 beds and a 5-bed unit in Bettendorf.

What is the mix of credentials at your lab, and how long have staff members been “in residence”?

We have a mix of registered nurses (RNs) and radiologic technologists, (RT[R]s), with varying years of experience. Our most senior person has recently celebrated her 44th year with us.

What procedures are performed in your cath lab?

We perform diagnostic heart caths and interventions, peripheral caths and interventions, implantable cardioverter defibrillators (ICDs), pacemakers (including His bundle pacing and Micra [Medtronic]), ablations (pulmonary vein isolation [PVI], supraventricular tachycardia [SVT], ventricular tachycardia [VT], premature ventricular contraction [PVC]), endovascular aneurysm repair (EVAR), transcatheter aortic valve replacement (TAVR), left atrial appendage (LAA) closure (Watchman [Boston Scientific]), patent foramen ovale (PFO) closures, peripherally inserted central catheter (PICC) insertions, CardioMEMS (Abbott), loop recorders, mechanical and laser lead extractions, sleep apnea phrenic nerve stimulators, and interventional radiology procedures.

On average, 80 procedures are performed in our cath labs each week. In addition, we perform approximately 20 transesophageal echocardiograms (TEEs), cardioversions, and tilt table procedures in the pre and post area on a weekly basis.

Can you share your experience with structural heart interventions?

Our first TAVR case was performed in February 2016 and as of mid-August 2020, we have performed 226 cases. Admission takes place the morning of the procedure to our Cardiac Treatment Unit (CTU). The TAVR case is performed in our state-of-the-art hybrid OR suite in the cath lab with balloon aortic valvuloplasty (BAV) not routinely done unless necessary.

We have a dedicated TAVR team, including a valve clinic coordinator, RNs, and RT(R)s. We have three dedicated RT(R)s who rotate scrubbing and preparing the valve for implantation. An open-heart team presents for all cases to assist with patient and anesthesia setup and room turnover. Setup depends on whether patient is a bailout or a no bailout (for bailout, the open-heart table is opened and bypass pump prepared; for no-bailout cases, the open-heart team is still present and on standby). For anesthesia, we mostly use monitored anesthesia care (MAC). Our patients recover in our CTU for five hours on average with specialized cardiac nursing care, avoiding a stay in the ICU. They are then transferred to our cardiac stepdown unit to stay overnight and are discharged by early afternoon the next day. Patients typically go home on an aspirin and clopidogrel regimen for at least six months. A follow-up visit is scheduled prior to discharge for one week with their primary cardiologist. Follow-up 30 days and one year post includes transthoracic echo and a visit with the procedural cardiologist. Our most recent published Society for Thoracic Surgeons (STS)/American College of Cardiology (ACC) Transcatheter Valve Therapy (TVT) registry data for mortality and stroke risk ranked us above the 75th percentile in both metrics.

How has COVID-19 affected your cath lab and facility?

COVID-19 has had an impact on all workflows ranging from patient scheduling to discharge. We now routinely screen all elective cases for COVID-19 and have implemented procedural changes with donning and doffing personal protective equipment (PPE). Our hospital guidelines require that all patients are masked when medically able. Additionally, we have reorganized supplies and established a dedicated COVID lab. All STEMI cases get a rapid COVID-19 test and are treated as positive until test results return, usually within an hour.

Any helpful tips regarding your process of donning and doffing PPE?

Extra team members are deployed to observe, monitor and assist to ensure proper PPE procedures are being followed by staff and physicians.

How are you improving communication while wearing PPE?

Our team’s ability to be proactive and pay close attention to all details during procedures has greatly benefitted our communication during the pandemic. Utilizing the Vocera Communication System has assisted with communication to one another and simply speaking in a louder tone to overcome barriers in communication that PPE might create has also helped.

Can you describe how you are testing patients and clinical staff for COVID-19?

We are doing everything we can to provide safe care for every patient in the safest possible environment. All patients admitted to our hospital are tested for COVID-19. This testing includes planned admissions and transfers of all ages who have not been tested for COVID-19 in the prior 72 hours. Patients undergoing elective procedures are tested 72 hours prior to their surgery and are asked to self-isolate until their procedure. Patients admitted to the hospital, including those for emergency procedures and labor and delivery, are screened using rapid tests.

UnityPoint Health – Trinity continues to prioritize the safety and health of our patients and team members in light of this pandemic. As such, we screen each physician and team member for fever and signs and symptoms of COVID-19 at the beginning of their shift. Staff experiencing any symptoms are sent home and tested for COVID-19.

How has the pandemic affected your patient population?

We are seeing that patients are waiting longer to get care in the hospital and as a result, our patients’ acuity has increased.

Who manages your cath lab?

Jessica Tapia-Mier, BSN, RN.

Do you have cross-training?

Yes, all staff are trained to be competent in all roles. All staff are cross-trained to scrub and monitor; RNs circulate/administer meds and RT(R)s administer fluoroscopy.

Are there licensure laws in your state for fluoroscopy?

Yes. We are unique in that our organization follows licensure laws for two different states. Both Illinois and Iowa require licensure for RTs through the American Registry of Radiologic Technologists (ARRT) initially before state licensure.

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?

Only RT(R)s, radiologists, or cardiologists.

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

Radiation safety is overseen by the radiologic technologists. We provide annual education to all staff members and work collaboratively with our radiology department.  All staff take an Image Wisely pledge annually. Staff and physicians are notified if they have received high dosage levels for the month according to badges. All team members have their own individual lead aprons, and we routinely use disposable scatter radiation pads, portable lead shields, and maintain distance — this is easy to do with our large procedure rooms!

Can you describe the extent and use of radial access at your lab?

Approximately 35 percent of cases are performed radially. Our cardiologists have very low complication rates from bleeding issues and over 55 percent of our patients go home the same day post percutaneous coronary intervention (PCI).

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

Yes, several operators use pedal artery access.

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

Some of the new devices include Watchman, the remedē System (a device for patients with central sleep apnea) (Respicardia), Micra pacemakers and subcutaneous ICDs. New equipment includes the Auryon Laser (AngioDynamics), coronary laser, the Viewmate ZS3 Intracardiac Ultrasound Console (Abbott), hand-controlled Rotablator (Boston Scientific). We also recently upgraded our intravascular ultrasound (IVUS) system to IntraSight (Philips) and all labs have this integrated into the room.

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

We have regular monthly meetings with the cardiologists, administration and cardiology management team. In addition, we have monthly staff meetings and monthly education meetings, as well as routine huddles. We also have communication posted to our quality and kudos boards located in the pre and post area.

How is coding and coding education handled in your lab?

We have a dedicated RN with expertise in charge/capture and revenue cycle. From physician and staff documentation, she assigns the appropriate Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), and billing codes, which are then entered into patient’s account in Epic. Cath lab staff are educated annually during a skills day regarding their role in being able to code accurately. Staff are also provided feedback and updates during the year if new procedures or processes are added.

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

We provide 24/7 sheath pulling with a dedicated sheath pull team. This team pulls all sheaths regardless of the patient’s location in hospital, including the ICU. For training, we initially do a hands-on simulation class, track to make sure the team member has done an adequate volume, and then offer hands-on education. Groin management is a required annual education/competency for all cardiovascular team members.

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

In our pre/post treatment area, the Cardiac Treatment Unit. Most inpatients also recover in the CTU, our pre and post unit, until the sheath is removed.

How is inventory managed at your cath lab?

Our Cardiovascular Services Logistics and Product Line Lead oversees all supplies for the lab. We work closely with UnityPoint Health’s Value Analysis Team (VAT) and contracting teams to ensure compliance with all corporate contracts. Being part of a large system like UnityPoint Health allows us to leverage best market pricing and build stronger vendor partnerships. Our inventory of owned and consigned items is cycle counted once every quarter. Items are scanned into our Sensis system (Siemens Healthineers) as each item is used in the procedure rooms, then is decremented from our warehouse system. Based on set reorder points, daily auto purchase orders go out to the vendors to replenish the inventory. We also have a warehouse on site that houses all our commodity items. This warehouse fills our par cart using par levels and handheld scanners that interface with the system.    

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

We had a major Heart Center addition to our campus in 2015, giving us four extremely large (each is 900 square feet), state-of-the-art cath labs in Rock Island, Illinois. In June 2019, we relocated our Bettendorf Cath Lab to a larger space and reoutfitted with brand new equipment.

Is your lab involved in clinical research?

Yes. Our lab has been heavily involved in clinical research in collaboration with the Midwest Cardiovascular Research Foundation, under the Research Directorship of Nicolas W. Shammas, MD, MS, and with a specific focus on peripheral arterial disease. Several projects have been conducted in the lab. Current research includes the application of the Auryon laser in treating infrainguinal arterial disease. In this project, the focus is on defining the impact of the Auryon laser on deeper layers of the artery, bailout stenting, and the presence of distal embolization. In this prospective cohort of consecutive patients, we are using a quantitative vascular analysis (QVA) and IVUS core labs for dissection analysis. The National Heart, Lung, and Blood Institute (NHLBI) and iDissection classifications are being used for angiographic and IVUS classification of dissections, respectively. Over the past few years, our lab was involved in research related to Shockwave Intravascular Lithotripsy (IVL) (Shockwave Medical), (both registry and randomized trials), the Tack Endovascular System (Intact Vascular) (TOBA II and TOBA II BTK), FLEX Vessel Prep (VP) (VentureMed Group), (FLEX iDissection study), Jetstream atherectomy (Boston Scientific) (JET ISR, JET Ranger), and others.

Can you share your lab’s median door-to-balloon (D2B) times and some of the ways employees at your facility have worked together?

Our median D2B time is 63 minutes. We have worked with our emergency medical services (EMS) coordinators and emergency department (ED) to implement STEMI protocols.

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

Two cath lab team members go to the ED to pick up the patient, one being the circulating nurse. Cath lab staff always goes to the patient.

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

The back-up team is called in.

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

We monitor productivity daily and flex staff off when necessary. We also consistently review cost/case by case type, as well as supply utilization. In 2019, another innovative strategy involved the creation of a Post Cardiac Care Unit (PCCU) for our outpatients who need an overnight stay. These patients are monitored by our Cardiac Treatment Unit RNs and are discharged early the next day. The PCCU has allowed us to increase capacity on the stepdown unit, as well as decrease length of stay. The patients appreciate not having to go the inpatient unit, as well as being able to go home first thing in the morning.

What quality control measures are practiced in your cath lab?

We utilize data from the National Cardiovascular Data Registry (NCDR) registries and use national benchmarks to identify areas of opportunity. We regularly provide cardiologists with blind results of performance and then provide the detail to each individual cardiologist.

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

We use the ACIST CVi Contrast Delivery System (ACIST Medical) that records volume and then is documented in the procedural log. When utilizing the manifold, we verbalize the amount of used contrast to be documented.

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

Yes, by using data provided from registries.

How are you recording fluoroscopy times/dosages?

We document total minutes, total dosage and dose area product (DAP) in our procedural log. This information is also recorded in our CardioPACS (Lumedx) system.

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

At 60 minutes or more than 500 mGy, the RT(R) in the room completes a form and submits it to cath lab manager. This form is then sent to the cardiologist’s office, triggering an appointment for follow-up to see the patient in 4-6 weeks to assess the skin.

Who documents medication administration during the case?

The circulating nurse.

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

Our physicians utilize Dragon (Nuance Communications).

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

Yes, we use the NCDR’s CathPCI, Chest Pain MI, and Left Atrial Appendage Occlusion (LAAO) Registries, the STS/ACC TVT Registry, and AFib IQVIA for the STS Adult Cardiac Surgery Database (ACSD).

How are you populating the registry data records?

For Chest Pain MI, LAAO, AFib, and STS/ACC TVT registry data, we enter directly into NCDR’s data collection tools. For CathPCI, we are using a third-party vendor that coordinates with software used in the cath lab that is uploaded to NCDR’s site. We have two full-time abstractors and one part-time abstractor.

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

We have a large referral network of our own UnityPoint Health and independent primary care physicians. We have built strong relationships and developed a collaborative approach to care that is mutually beneficial to our patients, as well as our providers. We pride ourselves on our high-quality care and responsiveness to patient needs. Our division’s mission is to improve the hearts of our community so they can live happier and healthier lives. We have made a commitment to provide our community with knowledge they can use to improve their health. One initiative we have developed is an education series titled, “Heart to Heart,” where we provide the members of our community the opportunity to hear our cardiologists speak on a variety of heart health topics, followed by question and answer sessions. Since the fall of 2018, we have offered over 10 in-person forums, with average attendance of over 100 people at each session. We are currently developing a plan to offer these same sessions virtually.

How are new employees oriented and trained at your facility?

The cardiology division has a dedicated clinical educator to help onboard new team members to our area. We have a structured orientation process that has been specifically developed to help our new cath lab staff be successful. The orientation is structured for three separate areas of focus. New nurses spend four weeks circulating, four weeks scrubbing, and four weeks monitoring and spending time in the electrophysiology (EP) lab. Radiologic technologists spend their orientation time learning the scrubbing and monitoring role, as well as spending time in the EP lab. Meetings are held on a weekly basis with each new orientee and their preceptor to discuss how they are doing, and develop and review their progress on their personalized education plan.

What continuing education opportunities are provided to staff members?

In addition to an annual hands-on skills lab, team members are provided monthly education opportunities on site. CEU offerings are provided as available and staff are offered attendance at specialized conferences for EP, stroke, etc.

Are your clinical and/or managerial team members involved with any professional organizations that support the invasive cardiology service line?

Various staff and clinicals are members of the Association of periOperative Registered Nurses (AORN), Society for Cardiovascular Angiography and Interventions (SCAI), and the ACC.

How do you handle vendor visits to your lab?

We have a closed lab. Sales representatives are only permitted in the lab on occasions when they are providing product support during procedures or education sessions on products or equipment. All representatives who enter our facility are screened at the front doors and required to sign into SEC3URE Ethos (formerly known as Reptrax) (IntelliCentrics). The SEC3URE Ethos system has policies that representatives must agree to and it tracks all their medical requirements, such as TB, flu vaccines, etc., and the reason for their visit. If all requirements are met, a badge will print out of the system. This badge must always be worn while the vendor is on site and is only valid for that specific visit. In the event representatives need to scan their consignment product, a separate visit must be scheduled with our logistics team.

How is staff competency evaluated?

Staff is expected to be able to pass an annual cardiac rhythm competency. All nurses are required to be sedation certified. All of our pre and post nurses are National Institutes of Health Stroke Scale (NIHSS) certified. We have an environment of continuous learning, and staff are constantly learning new procedures and skills. After each education session, staff complete a competency test administered by the cardiology educator. We also have a “Machine of the Month” where a superuser is identified, and along with the lead and educator, will go through competencies for equipment that may not be used on a regular basis.

Does your lab have a clinical ladder?

Yes, we have a clinical ladder for RNs.

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

No. Staff who have registered cardiac electrophysiology specialist (RCES) certification are offered a 10 percent increase in base pay.

What do you like about the physical space in which you work?

We have very large rooms, all set up the same for standardized workflow and supply management. Our Bettendorf lab even has a beach scene that welcomes the patient and provides a calming environment!

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

Each call team is comprised of four staff members, with a mix of at least two RNs and one RT(R). Staff are permitted to leave early or start later after a night of on-call if the schedule allows.

How does your lab schedule team members for call?

We schedule differently for weekdays compared to weekends. During the week, we have one team dedicated to each campus. On weekends, we have a primary team who responds to both campuses. If the primary team is working and another emergency occurs, then the back-up team is utilized.

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

After being paged, team members are expected to arrive within 30 minutes to either campus location. Sheath pull call response time is one hour.

Do you have flextime or multiple shifts?

Yes, we have 10- and 12-hour shifts. During slow periods, we will flex staff off.

Has your lab recently undergone a national accrediting agency inspection?

Yes, we underwent a Joint Commission inspection in 2019. Hang your lead up! Also, make sure the IFU is followed for contrast and that ACIST syringes are single patient use. Another recommendation is to make sure patients have appropriate sedation-related instructions on discharge.

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

We have seen younger people needing cardiac care.

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

We are fortunate to have blocked anesthesia time for our cardiologists and have a good relationship with our anesthesia department. This has helped with scheduling higher risk patients for receiving procedural sedation. We also have an anesthesia technician on staff every weekday to assist with anesthesia needs and machinery.

What’s special about your city or general regional area in comparison to the rest of the U.S.?

UnityPoint Health – Trinity is multi-state, divided by a river. People generally want to be treated in their home state. We are often dealing with construction issues and bridge traffic concerns.

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?

In addition to discussing the data with the cardiologists during our monthly meetings, we are also able to compare our site to other affiliates within our system, as well as other hospitals across the nation. We evaluate and review the data on a regular basis to identify opportunities for improvement in the cath lab, inpatient units, pre/post treatment area, or with physicians. 

Jessica Tapia-Mier, BSN, RN, Manager Invasive Cardiology, can be contacted at jessica.tapia@unitypoint.org.

Kathy Pulley, BS, Director, Cardiovascular Service Line, can be contacted at kathy.pulley@unitypoint.org