Tell us about your facility and cath lab.
Ochsner/LSU Health System (OLSU) is a partnership between Ochsner Health and LSU Medical School. There are 3 campuses that comprise the Ochsner LSU Health System. Two campuses in Shreveport, Louisiana (OLSU Medical Center at Kings Highway and St. Mary’s Medical Center at Margaret Street) and one hospital in Monroe, Louisiana (Conway OLSU Medical Center). OLSU is an academic and teaching facility that includes a Level 1 trauma center and multi-discipline fellowship programs that include cardiology. We are currently running 4 lab suites among the facilities with plans to expand services in the future.
Our cath lab is a part of the newly created Heart and Vascular Institute service line under the leadership of Franklin Espanto, AVP, Heart & Vascular Institute (HVI) of Shreveport/Monroe Academic Medical Centers. This service line consists of interventional cardiology, non-invasive cardiology, electrophysiology (EP), echocardiography, and the HVI clinic.
What is the size of your cath lab facility and number of staff members?
Our department consists of a pre/post area for all interventional cardiology and EP inpatients and outpatients. In the cath lab, we are staffed by 4 registered nurses (RNs) and 2 radiologic technologists. Our RNs all came to the cath lab from the medical and surgical intensive care unit (ICU). Our cath lab is open 24/7 and the call team (which consists of 2 RNs and 1 tech) is available after hours and on the weekend. Our pre-post staff is made up of 4 RNs that provide coverage 7 am to 7 pm. The EP lab is comprised of 2 RNs and 2 radiologic technologists. The cath and EP staff have plans to test for the registered cardiovascular invasive specialist (RCIS) certification later in 2021. Our goal is to have all RCIS-certified employees in the cath and EP labs. This will be a tremendous accomplishment for our department. We are excited about the challenge! We meet every other week for our “Cath Academy”, led by our AVP, Heart & Vascular Institute. Franklin has an extensive cardiology background, and has been the catalyst for broadening our knowledge base and challenging us to strive to be a Center of Excellence!
What procedures are performed in your cath lab?
We perform approximately 40 cardiology procedures a week. A few of the procedures we perform are listed below:
- Diagnostic left and right heart catheterizations
- Percutaneous transluminal coronary angioplasty (PTCA), stent deployments
- Chronic total occlusions (CTOs)
- Intravascular ultrasound (IVUS)
- Fractional flow reserve (FFR)/instantaneous wave-free ratio (iFR)
- Rotational atherectomy
- Intra-aortic balloon pump (IABP) insertion
- Impella (Abiomed) insertion
- Laser atherectomy
- Peripheral angiography and PTA
- Balloon aortic valvuloplasty (BAV)
- MitraClip (Abbott Vascular)
- Watchman (Boston Scientific)
- Atrial septal defect (ASD)/ventricular septal defect (VSD)/patent foramen ovale (PFO) closure
- Temp pacers
If you are not performing transcatheter aortic valve replacement (TAVR), is your lab planning to do so in the future?
We have plans for performing TAVR in a new hybrid lab in the near future. Our two structural cardiologists on staff, who have an extensive history of performing structural procedures, are currently doing TAVRs at a nearby hospital. There are plans in the next six months to complete a new cardiac hybrid lab suite, as well as additional cath and EP labs. Once our new hybrid lab is complete, TAVRs will become a part of our routine procedures at OLSU.
How has COVID-19 affected your cath lab?
As you can imagine, it has been a challenge. During the early months of pandemic, we were unable to schedule any elective procedures. Because of the dramatic decrease in patient volume, those employees with enough paid time off were allowed to take vacation days as needed or they worked in other units at the hospital to maintain their hours. The cath lab call team remained in-house during those early months of the pandemic. However, as the state of Louisiana opened up, starting in May 2020 and continuing through the present, our outpatient volume has increased. What we have seen over the last few months is a conscious effort by our hospital to be more open and return to full operations, while still maintaining and following the guidelines we have been given to promote a safe working environment for patients and employees.
Can you describe the use of personal protective equipment (PPE)?
All patients, whether an inpatient or outpatient, are masked. The cath lab staff (including physicians) treats all patients as though they are COVID-positive. Varying degrees of PPE are worn by the staff depending on their role and degree of involvement in the procedure. We use digital Bluetooth headsets that are worn by all staff during the procedure, which helps greatly with communication.
Can you describe if/when patients are being tested for COVID-19?
All outpatients are tested within 3 days of their procedure. Inpatients are tested upon arrival and every 8 days if still admitted. All emergent cases (ST-elevation myocardial infarctions [STEMIs]/non-STEMIs) are tested in the emergency department (ED) upon arrival.
Can you describe the extent and use of radial access at your lab?
The use of radial access in our lab is around 80%. We have used left radial/ulnar access for those with left internal mammary artery (LIMA) grafts. We love radial access for peripheral angiograms. Our patients also love the radial approach, for obvious reasons. They want to sit up afterwards, they can eat and drink, and they have the capability for early ambulation.
If you are performing peripheral vascular procedures, do any operators utilize pedal artery access when appropriate?
We have not utilized that access for peripheral cases. We do regularly utilize radial access for peripheral angiograms.
Who manages your cath lab?
The cardiac catheterization laboratory is managed by nurse supervisor Paul Davison, RN.
Do you have cross-training? Who scrubs, who circulates and who monitors?
We do not have cross-training at this time. We have a cardiovascular technologist (CVT) who scrubs and drives the table. The other technologist is in the control booth during cases. Our nurses rotate duties during the cases. Typically, one nurse is documenting the case in our electronic medical record (EMR) and sedating the patient. The other nurse is monitoring and assessing the patient, and the other nurse is circulating.
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?
Our cardiologists and licensed radiologic technologists are allowed to operate the fluoro based on state regulations. Other licensed medical personnel in the lab that have been credentialed on the Azurion Flex System (Philips) can position the image intensifier (II), pan the table, and move the table for patient placement and removal from the table.
How does your cath lab handle radiation protection for the physicians and staff?
Our lab is equipped with a great deal of radiation protection. In addition to the room itself, all staff, fellows, and faculty physicians are measured for personal lead protection. Many choose arm, head, and eye protection as well. All cath lab personnel are issued a radiation dosimeter badge to be worn and sent in every month for evaluation. We have a radiation safety team that meets monthly to review protocol and staff radiation exposure levels.
What are some of the new equipment, devices and products recently introduced at your lab?
We have a brand-new Philips Azurion with FlexArm and ClarityIQ in our remodeled lab. We have the latest Philips Flex Cardio software. We also have integrated SyncVision precision guidance system and Philips Volcano systems that have been incredible additions to our lab. Finally, we have the capability for live camera and video to local and distant locations. As an academic center, this have been an invaluable addition for educational offerings.
How does your lab communicate information to staff and physicians to stay organized and on top of change?
We have bi-monthly staff meetings for cath and EP lab personnel. We also have weekly cardiology service team meetings, as well as an HVI monthly report-out meeting with all the service leaders and physicians (cardiologists and surgeons).
How is coding and coding education handled in your lab?
We perform daily charge reconciliations. Our coding department is always at hand to assist and guide our coding process.
Who pulls the sheaths post procedure, both post intervention and diagnostic procedures?
All sheaths are pulled by the nurses from our pre/post area, RNs from the lab, or the fellows assigned to the lab during that month. Radial sheaths are pulled in the lab by the fellow and a TR Band (Terumo) is then placed. An RN new to the cath lab or pre/post is trained and signed off on sheath removal after being observed pulling 10 sheaths under watchful eye of a sheath removal-credentialed RN (arterial and venous) before being allowed to pull a sheath on their own.
Where are patients prepped and recovered (post sheath removal)?
Our patients are prepped and recovered in our own pre/post area, which has 8 beds for our cath and EP patients. Some of patients return to their ICU beds with sheaths, and in that case, the cath fellow or interventional fellow will pull those sheaths. There was a time when most of our femoral cases were manual pulls. However, with the popularity of radial and frequency of patient requests for radial access, femoral sheath pulls have decreased dramatically. The physicians make a more concerted effort to utilize closure devices when warranted (no peripheral arterial disease, good stick, etc.).
How is inventory managed at your cath lab?
One of the newest members of our department is Dylan Clark, our materials manager. Dylan has been a huge addition to our service line. He sees to it that our entire service line has the products and materials they need daily. It is a tremendous comfort to know that we can let Dylan know about a particular need and he will take it from there. As materials management coordinator, Dylan handles all of the purchasing for our cath lab, but inventory management is a full team effort that includes our nurses and radiologic technologists. We monitor inventory levels to ensure all products stay stocked and above par levels.
We are in the process of establishing an active monitoring, auto-depletion inventory system that will communicate with both our Lawson ordering system (Lawson Products) and our Epic charting system. The system will allow for items to deplete from inventory as used by nursing staff and limit the chances of human error. By analyzing 3-, 6-, and 12-month supply usage sorted by physician and procedure, we are building “Physician Preference Cards” that will allow us to forecast supply usage and take a proactive approach to inventory management, instead of the traditional reactive approach.
Is your lab involved in clinical research?
Yes. Our most recent research work involves an assessment of the VIVO (View into Ventricular Onset) system (Catheter Precision, Inc.) for the non-invasive estimation of left ventricular diastolic pressures as an aid in the diagnosis of heart failure. Participation in this trial began in December 2020.
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?
We have recently implemented a new STEMI algorithm and pager system. We are also looking to begin using Pulsara in the near future. Our recent pagers were numeric so when paged, we had to call into the switchboard individually. With the current pagers, “one call, pages all”, notifying all STEMI members. This has significantly reduced our D2B times and we can proudly say that we are right on goal. When possible to be activated pre-hospital by EMS, it gives us even more of a head start to get the patient to the lab as soon as possible. We also have monthly STEMI team meeting including EMS, ED, and cardiology leadership to further streamline our STEMI workflows.
Who transports the STEMI patient to the cath lab during regular and off hours?
The algorithm dictates the ED staff transports the STEMI patient to the cath lab as soon as the cardiac cath lab staff notifies that the lab is ready. There are also times when cath lab transports the patient.
What happens when the call team is already busy doing a procedure and a STEMI comes into the ED?
If the cath lab procedure has not progressed to the point of a wire being placed across a lesion, then the cath lab team will halt the progress of this patient, secure the arterial sheath (radial or femoral), remove the patient from the procedure table, and transport the patient to the post-op area for monitoring. The cath lab team cleans the procedure room and prepares for the STEMI patient to be delivered by the ED staff. After the STEMI patient procedure has been completed, the staff will clean the lab and set up to complete the previous patient’s procedure.
If the cath lab patient’s procedure has progressed to the point of a wire being placed across a lesion, then the one of the following options will be chosen:
- If the current procedure can be completed in a timely manner, it will be finished and the patient transported to the post-op recovery area asap. The room will be cleaned and ED called to transport the STEMI patient to the lab. The procedure room will be set up for the STEMI patient’s arrival.
- If the EP lab doesn’t have a patient on the procedure table, then the cath team will call the backup interventional cardiologist to come to the lab and cath the STEMI patient in the EP lab. The back-up interventional cardiologist must stop any work they are currently doing in the hospital or clinic, and immediately assume care of the STEMI patient coming to the EP lab. The ED staff will deliver the patient to the EP lab.
- If both the cath lab and EP lab are occupied and not available in a timely manner, then it is incumbent upon the interventional cardiologist staff and ED attending to make a decision on administering thrombolytics or transferring the patient to another local STEMI center for cath.
What measures has your cath lab implemented in order to cut or contain costs?
The addition of a materials manager has made a huge difference in our ability to cut or contain costs. Primarily, we have implemented lean inventory with JIT (just-in-time) replenishment to minimize capital tied up in inventory on the shelf. We also have completely reworked our Cath Pack to better match the routine items used in each case. We utilize a first-in, first-out (FIFO) stocking and pulling system, which allows us to minimize product expiration.
What quality control measures are practiced in your cath lab?
Additional quality measures have been put in place since arrival of new leadership. We have implemented new practices to capture procedural complications and system process breakdowns. One practice includes our cardiovascular service line complications outcome committee that meets monthly and is overseen by cardiology services and the hospital quality department. We have a standard process to report and review variances. We are improving our National Cardiovascular Data Registry (NCDR) data participation and use the data to further develop our service line.
How do you determine contrast dose delivered to the patient during an angiographic procedure?
We identify key information that is needed for a procedure. One of our focuses is acute kidney injury (AKI) prevention. We document the patient’s creatinine and glomerular filtration rate (GFR), and calculate the maximum amount of contrast that the patient can be given. These data are then included in the time-out process before the start of every procedure. The cardiologists are reminded of the patient’s renal function during the timeout process. The technologist then informs the operators of contrast use and limits during the procedure. We use the data from the NCDR to further track our progress.
How are you recording fluoroscopy times/dosages?
We record fluoro and dosage time in the EMR after every procedure is completed.
What is the process that occurs if a patient receives a higher than normal amount of radiation exposure?
The patient and radiation safety officer are notified. The patient is informed about signs to look for at home and is instructed to call with any issues. The patient is followed up in the clinic one week post procedure and one month post procedure, and as needed after that.
Who documents medication administration during the case?
The RN, who is the documenter, is responsible for all medication documentation.
Are your physicians dictating their cath procedure reports, or do they use a structured reporting tool?
Our physicians use a standard reporting tool in Epic Cupid.
How are you populating the registry data records?
Although our cardiac recording system and EMR has capability to collect registry data, we have not utilized this option, but instead have been collecting data manually. We are switching to a third party shortly, called Q-Centrix.
How does your cath lab compete for patients?
As an academic center in the region, we are a transfer receiving center for the area for patients from other facilities in the area.
How are new employees oriented and trained at your facility?
New employees undergo a standard onboarding process guided by hospital human resources. They attend an orientation session, are trained in the use of our EMR, tour in the facility, and are introduced to the staff and leaders in the hospital. They also have to complete online learning courses before they are fully introduced to the workplace. The new staff member will complete a 6-month training and orientation phase, and must be signed off on all department competencies before talking call in the cath and EP lab.
What continuing education opportunities are provided to staff members?
Ochsner has an online education program called OLN (Ochsner Learning Network). We also send staff to attend national conferences, and have routine inservices in the cath and EP lab.
How do you handle vendor visits to your lab?
Vendors are only allowed to visit our labs on an “as needed” basis (such as checking consignment inventory or offering clinical support during a case). They are required to check in via our Reptrax system (IntelliCentrics) and must wear a badge during their time on campus. Vendors are only allowed in the lab during procedures if they are providing clinical support on items not used on a routine basis by cath lab staff.
How is staff competency evaluated?
Staff competency is evaluated daily during the mandatory 6-week orientation period and is ongoing throughout staff time in the lab. As stated earlier, we try our best to hire nurses with critical care experience. It is not a dealbreaker, but it is our preference. It is our opinion that these nurses possess the critical thinking skills and disposition to be tremendous assets in the cath lab. When that nurse takes his or her first night of call, we want to be confident that they will be up to the task in all those areas that matter most!
Does your lab have a clinical ladder?
Ochsner Health System does have a clinical ladder offered to all employees at this time, but a revised ladder is in the works for the near future.
Can you share more about your lab’s efforts to have staff obtain the RCIS credential?
We currently do not have staff members who are RCIS. However, all staff members of the cath and EP lab have been preparing for the RCIS and registered cardiac electrophysiology specialist (RCES), and are preparing to take the exam in 2021. If we are successful in this challenge, every staff member in both labs will be RCIS and/or RCES certified. We are aware of very few RCIS individuals in the state of Louisiana today. It would be a tremendous accomplishment if we had 9 from one facility!
Does your lab have any physical (layout) bottlenecks or limitations? How do you work around the resulting challenges?
Although we have a newly remodeled lab, they were unable to make it larger in size. It can be a little tight when we have a structural case like a MitraClip that includes anesthesia, transesophageal echocardiogram (TEE), and increased personnel. Because we only have 1 lab currently, heavy case load days are challenging because we must follow ourselves in our room. This spotlights our turnover time. We just wish the room was bigger. Our lab is set up opposite from the EP lab, so when we do devices in our lab, it is a little backwards from what EP team members are accustomed to. This will be remedied when our hybrid/second cath lab is complete.
Is there a particular mix of credentials needed for each call team?
Our call team consists of 2 RNs and 1 CVT, and we usually take a week of call at a time. Sometimes we deviate from that if there are time-off requests that upset the week-on/week-off rotation. We determine the upcoming schedule on 15th of every month. We check the vacation book to see if anyone has requested time off and if so, put those days on the schedule and fill in with the others as needed. Right now, we have 3 nurses taking 21 days of call a month until we get someone hired and trained up.
Within what time period are call team members expected to arrive to the lab after being paged?
The call team is expected to arrive within 30 minutes.
Do you have flextime or multiple shifts? How do you handle slow periods?
We currently do not have multiple shifts. Our volume does not yet warrant multiple shifts, but we have a long-range plan if that does occur. We do have 2 shifts in our pre/post area, which has coverage from 6 am to 7 pm.
Do staff members experience any perks that you might like to share?
Our environment is staff friendly. We have lunches catered in several times a week. Conferences are provided to our staff on a regular basis. Call pay was just doubled for the cath and EP call teams.
Has your lab recently undergone a national accrediting agency inspection?
We are preparing for an inspection in early 2021.
What trends have you seen in your procedures and/or patient population?
The early months of the pandemic affected procedures in 2021 dramatically. We finally noticed our volume increase over the last 6 months.
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”?
Our academic medical center is located in the northern Louisiana region. We treat patients from over a 200-mile radius over a 3-state area. We are the only Level 1 Trauma center and only academic medical center in our region.
The authors can be contacted via Curtis L. Elkins, BSN, RN, at firstname.lastname@example.org