Cath Lab Spotlight

Cath Lab Spotlight: Wheeling Hospital

Triston Smith, MD, FSCAI, Chairman, Department of Cardiovascular Medicine; Clinical Director, Structural Heart and CHIP Interventions, Heart and Vascular Center, Wheeling, West Virginia

Triston Smith, MD, FSCAI, Chairman, Department of Cardiovascular Medicine; Clinical Director, Structural Heart and CHIP Interventions, Heart and Vascular Center, Wheeling, West Virginia

Tell us about your cath lab. 

The cardiac cath lab is an integral part of our cardiovascular service line at Wheeling Hospital. Serving as one of the pillars of the service line, the cath lab has been in constant service to the community since 1978. We were the first facility in the region to offer balloon angioplasty for primary percutaneous coronary intervention (PCI) in 1994 and are the only Mission:Lifeline Gold Plus STEMI Receiving Center with Primary PCI and Resuscitation in the region. In 2008, we expanded to offer electrophysiology services in our facility, and continue this full line of diagnostic and therapeutic services today. 

Our growing structural heart program started in the fall of 2017 and continues to offer the latest treatments to our region without the need to travel to larger cities. We perform transcatheter aortic valve replacement (TAVR), Watchman (Boston Scientific), MitraClip (Abbott Vascular), and patent foramen ovale (PFO) and atrial septal defect (ASD) closures, as well as aortic and mitral paravalvular leak closures. Our lab also has an excellent CHIP (Complex High-Risk Indicated Procedure/Patients) program with use of Impella and Rpella (both Abiomed), and orbital atherectomy. We perform an average of 100 exams per week. We perform all cardiac cath, electrophysiology, structural heart, and some peripheral cases in our department.   

What is the size of your cath lab? 

Our cath lab is comprised of three procedure rooms and a 9-bed pre/post care unit. We are staffed with registered radiologic technologists (RT[R]s), registered nurses (RNs), nurse aides (NAs), and support staff. The cath lab is staffed with an even mix of RTs and RNs, while the pre/post unit is staffed with RNs and NAs. We have staff with varying experience, from orientation to 30-plus years in cardiovascular patient care. 

Can you describe more of your experience performing TAVR? 

Our department has been performing TAVR since September 2017. The entire process is well orchestrated by our cardiac service coordinator in concert with the vendor and with administrative support. We are able to have a very safe and successful program in the community hospital setting to provide this life-saving treatment to our local communities. Almost all of our cases have been performed percutaneously without the need for cut down. Although we are a community hospital, we have successfully performed alternate access cases via the percutaneous transaxillary and transcaval approaches. Transcaval access is our preferred alternative access site. We were the first in our region to do TAVRs via this route. Very early in our experience, we transitioned to a minimalist approach using transthoracic echocardiography (TTE) and conscious sedation. Over 95% of our patients are discharged within 24 hours. This is proof that such procedures can be performed safely in a community setting based on the strengths of the local heart team that adheres to proper checks and balances.     

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

Our physicians use the radial artery as their primary point of access for >90% of all cardiac cath cases. Exceptions are planned complex PCI necessitating the use of Impella, bifurcating and trifurcation interventions, or ST-elevation myocardial infarction (STEMI) with cardiogenic shock. 

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

To date, we have not used pedal access in the cath lab. However, below-knee intervention is now a focus of ours, so we foresee pedal access occurring within the coming months. 

Who manages your cath lab?  

The department is managed by a nurse manager.  

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

The staff in our cath lab cross-train for most tasks. All staff are required to learn to monitor and circulate. Only RTs scrub and only RNs administer medications/sedation, as per state guidelines. Medication administration is documented by the monitor or circulating staff during procedures. 

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 physician staff and licensed radiologic technologists may operate the imaging system while it is powered on. This includes administering fluoroscopy and moving the c-arm or table while a patient is on the table. The State of West Virginia requires that fluoroscopic operators have either a medical license from the Board of Medicine or a license from the Board of Radiologic Technology in order to operate any part of the imaging system. 

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

All staff are issued film badges and instructed how to properly wear them on orientation. Monthly film badge reports are reviewed by our radiation physicists. Staff are notified if they exceed hospital dose levels and these individuals are followed at monthly radiation committee meetings. All physicians and staff receive annual radiation safety education.  

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

Our department was renovated in early 2017. All imaging and support equipment were replaced at that time. We have both intravascular ultrasound (IVUS) (Philips) and optical coherence tomography (OCT) (Abbott Vascular) platforms for intravascular imaging with co-registration capabilities. We also have the ability to perform instantaneous wave-free ratio (iFR) with co-registration and wireless resting full-cycle ratio (RFR). We are implanting the latest generation drug-eluting stents and using Impella for left ventricular support on complex PCI cases. Our electrophysiology specialists are implanting the latest cardiac rhythm management (CRM) devices, including subcutaneous implantable cardioverter defibrillators (S-ICDs) and leadless pacemakers, as well as using 3D mapping technology to diagnose and treat arrhythmias. Our structural heart team utilizes the most up-to-date Epiq echo machines with TrueVue imaging (Philips). We have the capability of performing fusion imaging fluoro, echo, and computed tomography (CT) overlays (TrueFusion, Siemens Healthineers).   

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

Patients are prepared and recovered in our cath lab pre/post unit unless the patient requires post-anesthesia care unit (PACU) or critical care disposition. 

Who pulls the sheaths post procedure?  

Most cases are performed radially. However, in the event that the femoral route is used, a closure device is usually deployed at the end of the procedure. The vast majority of cases are closed with hemostasis bands or vascular closure devices. These patients would receive closure in the cath lab and be recovered in the pre/post unit. Any patients that require manual hemostasis would be pulled and held in the lab or pre/post unit, based on sheath size, sheath location, and use of anticoagulants and coagulation time results. Should a sheath need to be removed outside of the cath lab, pre/post RNs are responsible to remove the sheath and maintain hemostasis in their unit. All new RN and RT staff receive didactic and hands-on training during initial orientation. Arterial and venous hemostasis is also an annual competency for RN and RT staff. 

How is inventory managed at your cath lab?  

Inventory is managed by a materials management assistant. Daily inventory counts and manual inventory use is entered into the hospital inventory management system for reorder. Any new inventory items are reviewed by the hospital product analysis team and/or purchasing department prior to use in the facility. 

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

The cardiology physicians have a monthly department meeting as well as a structural heart section meeting. Staff attend monthly staff meetings and staff huddles to ensure communication. We utilize hospital email as well. 

How is coding and coding education handled in your lab?  

Our billing/coding coordinator is responsible for proper charge capture and coding functions. The coordinator reviews cases and applies proper procedural codes, as well as initiates and reconciles all cath lab charges. Annual and ongoing code changes are communicated by our revenue cycle team. 

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

Our department’s volumes have remained relatively stable with the expansion and growth associated with the introduction of our structural heart program.   

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

Our average D2B time is 63 minutes. We have an interdisciplinary team that includes cardiology, the emergency department (ED) staff and leadership, the cath lab staff and leadership, quality management/performance improvement, cardiac rehab, senior administrative staff, marketing staff, EMS representation, etc. If we have a case that deviates from normal, a timeline is completed and presented to this multidisciplinary team, as well as the individual departments involved, in order to see where time could have been saved. We are a Mission:Lifeline accredited facility and our quality management representative, Tish Holden, is also the regional team leader for Mission:Lifeline. Wheeling Hospital is an accredited Chest Pain Center, with recent reaccreditation in November 2019. 

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

STAT Page or ED staff transport STEMI patients to the department during regular hours. Cath lab staff transport STEMI patients to their receiving location in order to provide a face-to-face handoff to the receiving RN(s).   

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

In the event the STEMI team is not available, and should the delay in care be deemed to put the patient’s wellbeing at risk, adequate assessment of the patient’s condition and comorbidities is performed, and thrombolytic therapy is considered. 

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

Our call team consists of two radiologic technologists and two registered nurses. Staff is able to flex down if it does not impact patient flow. 

How does your lab schedule team members for call? 

Call is assigned on the staff schedule. Management works around staff member personal needs when possible. With current staffing levels, staff cover about 1 weekend per month and between 3 to 5 weeknights per month. The call team is required to arrive to the department in less than 30 minutes after being paged. 

Do you have flextime or multiple shifts? 

We do not currently have multiple shifts, but are looking to extend a later shift in the near future. 

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

Cath lab staff monitors daily schedules and flexes down when possible in order to reduce full-time employee (FTE) costs. The department works in conjunction with the purchasing department to reduce and contain supply expenses. We constantly encourage feedback from all stakeholders regarding steps and equipment that they deem are unnecessary and could be safely eliminated. One measure we implemented was to stop opening a full set of open heart surgical equipment when performing TAVRs. In our experience of close to 200 cases, we have not had to do a sternotomy, so we thought that was unnecessary and it was eliminated.   

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

All power injections are recorded in the hemodynamic system as well as total volume of contrast injected by hand at the end of each case.  

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

We do not track this on a local level. However, we do rely on the quarterly reports from the National Cardiovascular Data Registry (NCDR) CathPCI Registry to inform our decisions regarding policies for contrast use, etc.  

How are you recording fluoroscopy times/dosages?  

Radiation dose summary reports are automatically created for each exam completed and automatically sent to PACS for archive.   

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

Patients receiving an excess of 5Gy are documented in the patient record. The physician is required to complete an educational document for the patient and follow-up with the patient in clinic to assess for any complications.   

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

The majority of physicians are dictating reports; however, a few are getting done with a structured report tool from GE Healthcare. We are implementing the Philips IntelliSpace software across all cardiovascular imaging modalities and structured reporting will be encouraged once the installation is completed.  

You mentioned participation in the NCDR’s CathPCI registry. Do you use any other outside data collection registries? 

We also report to the NCDR Chest Pain MI registry, the Get With The Guidelines - Coronary Artery Disease (GWTG-CAD) registry, and the SCPC registry. 

How are you populating the registry data records?  

The data is abstracted and input by a nurse with critical care and management experience. If there is any confusion about how to answer a specific question, we can refer back to the physician involved in the case. We have considered using in-lab systems, but the data would have to be validated, so we opted not to do this.  

How does your cath lab compete for patients? 

Wheeling Hospital has been the region’s “Heart Hospital” for many years. We offer the latest diagnostic and interventional procedures to our region, and are the only STEMI receiving center within a 25-mile radius. Our tradition of excellence, community outreach, and advertising make us very competitive.   

How are new employees oriented and trained at your facility?  

All new cath lab employees attend general hospital orientation, as well as nursing and EMR orientations, arrhythmia classes, and BLS/ACLS training.  

Staff then completes department-specific training/competency with existing staff.      

What continuing education opportunities are provided to staff members?  

Staff attending approved educational events are reimbursed for any tuition and travel. We encourage attendance to our local state American College of Cardiology (ACC) annual scientific conference. The cardiovascular department hosts a yearly scientific conference. The cath labs are closed to elective cases that day so that all can attend. 

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

The Director of Cardiac Imaging is a member of the Society for Cardiovascular Angiography and Interventions (SCAI). 

How do you handle vendor visits to your lab?  

Vendors must schedule an appointment and participate in our vendor credentialing process. All vendors must sign in, print and wear a badge, and then sign out when visiting campus for any reason.   

How is staff competency evaluated?  

Ongoing and annual didactic education is evaluated for all staff. Low volume, high acuity devices are reviewed multiple times annually by vendor staff to assist in staff competency. The nurse manager is responsible to document annual competency for all team members. 

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

This is not a requirement, but all advanced registry exams (American Registry of Radiologic Technologists [ARRT], RCIS, critical care registered nursing [CCRN], etc.) are encouraged and test fees are reimbursed on successfully passing an exam. 

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

Our current pre/post unit is located three floors away from the cath lab, which results in longer than expected transportation and turnaround times. We have pre/post staff deliver and pick up patients in place of lab staff transporting, which allows for shortened lab turnaround times. Future construction slated for the near future will locate the pre/post unit adjacent to the lab.  

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

The labs are large and very well organized. Most supplies and equipment are readily available or close by. 

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

Staff park on site at no charge. We encourage staff to leave early and spend time with family and friends whenever volume allows, knowing that they commit a great deal of time to their patients. We try to allow as much flexibility with staff schedules and work with the team to the best of our ability to make sure everyone gets to manage their personal life.   

Has your lab recently undergone a national accrediting agency inspection? 

We recently received our recertification as a Chest Pain Center from the ACC and are currently undergoing the process to be a TAVR-certified center. We believe that going through the process of certification validates the excellent work that is being done. Having policies and processes in place ensures that all team members are following best practices and leads to better patient outcomes. 

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

Commensurate with the types of cases we have been doing, we are seeing a trend towards sicker and older patients in the structural heart and CHIP space. We believe that this is because a higher level of complex care is now being performed at a local level. The vast majority of these patients would not travel long distances to receive care due to health, financial, and/or social reasons. However, since care for those complex conditions are now being offered locally, the elderly and sicker populations who stand to benefit most from these interventions can readily access our services and take advantage of them. 

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

We are fortunate to be a cardiology program and cath lab in a community hospital with a large academic hospital mentality. We are very outcomes oriented, and every decision is made with the patient’s safety and procedure outcomes in mind. We believe that knowledge and skill paired with appropriate policies and leadership are all transferrable assets that, if put to use in a community setting with the proper infrastructure, can create outcomes rivaling larger urban institutions. We have a group of staff and physicians dedicated to offering a wide range of cardiovascular services to the community in a local setting, allowing these patients to be treated, recover, and heal close to home.  

Is there a problem or challenge your lab has faced? 

The department was short on staff for an extended period of time. Contracted staff were used to cover for a period of time, but eventually, permanent staff were hired. Our administration made staffing a priority and we placed a high level of focus on active recruiting. We were very fortunate to find talented individuals to fill the vacancies. All of the new staff have oriented quickly and show a high degree of aptitude for cardiac care. 

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”? 

Wheeling is a small community with many smaller towns in close proximity. Most local families would rather stay local to receive care than travel to a larger and unfamiliar city. With this in mind, we make every effort to offer the latest technologies and the highest quality possible, so people can be diagnosed and treated where they are most comfortable — at home. Our department reflects this same mentality. The cath lab is our second home and the staff function like a family unit, always aware of each other’s needs and lending a hand wherever we can. 

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 initially used the reports to ascertain our baseline, and now we trend and make changes to our processes according to what our outcomes show. We also run physician-specific reports to show physicians how they are trending. We have used reports to show our referral facilities how they are doing in moving STEMI patients out of their EDs and transferring to us for PCI. We have worked with our local EMS and have provided them with their first medical contact to balloon (FMC2B) times so they can improve their on-scene times. We have noted that patients that have prehospital EKGs performed have better FMC2B and D2B times. As a result, we have worked with EMS to get the capabilities to be able to do prehospital EKGs and transmit that EKG to us prior to patient arrival, allowing us to activate the cath lab pre arrival. 

Triston Smith, MD, FSCAI, can be contacted at tbsmith@wheelinghospital.org.