Cath Lab Spotlight

Pikeville Medical Center Cardiac Cath Lab

Muhammad Ahmad, MD, FACC, FSCAI

Cheryl Hickman, RN, RN, BSN, MS, NE-BS

CCMSCP CJCP, Senior Vice President/Chief Regulatory Officer, Deanna Porter, RN, BSN,

AVP Patient Services, Lorri Burgess, RN, Director,

Johnny Webb, RT(R), Assistant Director,

Pikeville, Kentucky

Muhammad Ahmad, MD, FACC, FSCAI

Cheryl Hickman, RN, RN, BSN, MS, NE-BS

CCMSCP CJCP, Senior Vice President/Chief Regulatory Officer, Deanna Porter, RN, BSN,

AVP Patient Services, Lorri Burgess, RN, Director,

Johnny Webb, RT(R), Assistant Director,

Pikeville, Kentucky

Tell us about your hospital and cath lab.

Pikeville Medical Center is located in Pikeville, Kentucky. Nestled in the beautiful mountains of Appalachia, Pikeville Medical Center services a large rural area, including bordering states of West Virginia and Virginia. We began with a mobile catheterization lab in 1992 as a part of the cardiovascular service line. After years of dedicated hard work and determination to provide quality cardiovascular care to our patients, we have opened a brand new, state-of-the-art heart and vascular suite. It consists of three catheterization labs: one Azurion 12 cardiac suite (Philips) and two FlexMove Hybrid (Philips), and 20 cardiac and vascular suites with 7 pre-op bays. The cardiac cath lab employs 28 staff members, including 11 registered nurses (RNs), 11 special procedure technologists, one cath lab technologist, a director, assistant director, chest pain coordinator (an advanced practice registered nurse [APRN]), and materials management coordinator.

We have a very dedicated, professionally trained catheterization lab staff with experience ranging from 2 to 23 years.

What procedures are performed in your cath lab?

Pikeville Medical Center Cardiac Cath Lab performs various cardiac, vascular, and electrophysiology (EP) procedures. We perform all kinds of diagnostic and interventional procedures for all the subspecialties. These include, but are not limited to transcatheter aortic valve replacement (TAVR), Watchman (Boston Scientific), acute myocardial infarctions, diagnostic catheterizations, peripheral interventions, cardiogenic shock requiring Impella (Abiomed) insertions, endovascular aortic aneurysm repair, permanent pacemaker (PPM) or implantable cardioverter-defibrillator (ICD) placement, and laser lead extractions. We perform approximately 35-40 diagnostic procedures a week with 8-10 interventions. Vascular procedures are about 5-7 a week with one-third being interventions. We also perform 10-12 EP studies each week.

Does your cath lab have onsite surgical backup?

Yes, since our early vision was to become the tertiary hospital for the region, we have always had surgical backup available. When we started our program in 1992, we realized that to provide the best and safest care to our patients, we needed an onsite surgical program. That decision was based on a complex patient population and the fact that the referring facility was more than 100 miles away.

Can you tell us more about your TAVR program?

Our new cath lab equipment gives us the capability to perform hybrid procedures. Our valve clinic opened in August 2018 and our staff has undergone extensive training for our TAVR program.

What is your percentage of normal diagnostic caths?

Our rate of normal diagnostic caths is in line with national average, ranging from 30 to 40%.

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

Eighty to 85% of our diagnostic and interventional cases are done from the radial approach. Radial artery access is the primary approach in all cases, except with known bypass patients. We use the left radial approach for coronary artery bypass graft (CABG) patients, but some physicians will choose femoral access in these patients. Pikeville Medical Center has a Radial Access Recovery Suite with radial recovery chairs instead of beds. The patients love the comfort and faster recovery time with the radial approach. We first started using radial access in 2011, after physicians and staff attended a radial course. We are one of the top radial access centers in Kentucky, performing the highest number of radial cases in the state.

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

Yes, our vascular surgeon will often use a pedal artery approach via ultrasound for infrapopliteal cases.

Who manages your cath lab?

The cath lab is being managed by Deanna Porter, RN, BSN, AVP of Patient Services, Lorri Burgess, RN, Director of the Heart and Vascular Institute, and Johnny Webb, RT(R), Assistant Director of the Cardiac Cath Lab.

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

We strongly believe in cross-training. All our staff are able to assist each other at any position when needed. The team includes a physician, registered nurse, special procedure technologist, and monitor personnel. Team members can include more than one nurse or technologist at any given time.

Which personnel can operate the x-ray equipment (position the image intensifier [II], pan the table, change angles, step on the fluoro pedal) in your cath lab?

Along with our physician, the scrub special procedures technologist, an RT(R), can pan the table, position the image intensifier, change angles, and step on the fluoro pedal.

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

We have two ways to handle radiation protection for the physician and the staff. Each staff member is provided with mandatory dosimeter badges to wear that are examined monthly. The reports are provided to each operator, especially if they are over the limit. We also have real-time dose badges with the new Philips system that provide our staff continuous monitoring of their live radiation dosing.

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

Along with the purchase and installation of 3 new Philips Azurion cath labs, two 20-inch FlexMoves (a ceiling-mounted option for the x-ray system), and one 12-inch diagnostic cardiology lab, we also purchased Philips instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR), intravascular ultrasound (IVUS), and SyncVision technology. We have started CardioMems implantation (Abbott) for heart failure patients and are currently working with Edward Lifesciences on our structural heart disease program.

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

We have staff meetings monthly to communicate issues, new procedures, and new changes in our organization. Our hospital recently implemented Workplace on Facebook to keep staff informed of updates. We also have tracking boards in our break rooms that are used to inform the staff of all issues that need to be addressed.

How is coding and coding education handled in your lab?

Charge sheets are collected daily by secretary Kirstin Wells. These are reviewed and reconciled with materials management coordinator Thomas Coleman before being sent to our offsite coder, who then charges for the procedure and supplies used.

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

Almost all the sheaths are removed by trained cath lab staff before the patient leaves the cath lab. We also use closure devices for femoral cases. With the high number of radial cases, removing sheaths has not been an issue across the facility. If (rarely) we have to send a patient to the cardiac telemetry floor or intensive care unit (ICU), the nurses are trained to remove the sheaths. The nurse must have removed three sheaths successfully under the supervision of a senior trained nurse.

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

We have a pre- and post-recovery cardiac unit for our daily outpatient caths. Most of the sheaths are removed in the cath lab, but hemostasis is monitored further by the nurses in the post-recovery cardiac unit. The ultimate responsibility is with the physician, who is always available for any complications or questions from the concerned nurse.

How is inventory managed at your cath lab?

We use a PAR system (PAR Excellence), which is an automated scan and re-order system for chargeable items maintained by our materials management coordinator (MMC), Thomas Coleman. All special order items are ordered by MMC with approval from director or manager.

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

In addition to having added three new cath labs, we also have plans to add three new EP labs by the end of 2019. We have hired five new cardiologists in the last three months due to the increased burden of cardiovascular disease in our local population. We have become a tertiary referral care center for the region, and hope to continue our expansion to provide world-class care for our patients.

Is your lab involved in clinical research?

We have previously been involved in clinical research with participation in the ELIXA trial (Evaluation of LIXisenatide in Acute coronary syndrome). We are in the process of developing a research department for the entire hospital and hope to start research soon.

Can you share your lab’s average door-to-balloon (D2B) times?

Our average D2B time is 56 minutes. We have streamlined our process by bringing ST-elevation myocardial infarction (STEMI) patients directly to the cath lab via the use of emergency department (ED) staff, emergency medical services (EMS) staff, and inpatient nurses. Our new cath labs are located directly across the hall from the ED. Over the years, we have trained all staff to expedite the transfer of patients to the cath lab. We have provided all EMS with electrocardiogram (EKG) and fax machines, and the ability to engage the cath lab from the field, which has cut down our D2B times tremendously. We have also educated transfer facilities on ways to cut down on transfer time, which can be a big problem due to our location. The field patient, brought in by EMS, comes directly to the cath lab, bypassing the ED. All the labs for these patients are performed by the ED’s i-STAT (Abbott) in the cath lab. We provide regular training to hospital staff for immediate alerts and on how to transfer the patient for in-house STEMI. We are also registered with the American Heart Association: Lifeline and hold Chest Pain Center accreditation.

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

All the STEMI patients from the ED are transported to the cath lab by ED staff. This reduces our D2B time by about 10 minutes. All transfers and STEMIs from the field are brought directly to the cath lab, bypassing the ED. During off hours, field STEMIs come to the ED first. In-house STEMIs are transported from the floor by a registered nurse and one cath lab staff member.

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

We have two call teams (primary and backup) available at all times during off hours. If the primary team is busy doing a procedure and a STEMI comes into the ED, the backup team is called.

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

We are constantly looking at vendor pricing and negotiating in order to receive the best prices. Our organization has used ECRI to compare pricing in our purchasing department. We have purchased the ACIST CVi contrast delivery system to reduce contrast use. Our high use of radial access has also allowed us to reduce nursing costs for monitoring patients.

What quality control measures are practiced in your cath lab?

Our Heart-to-Heart committee meeting, which involves performance improvement and all cardiovascular service lines, takes place on a quarterly basis. Core measures and all adverse outcomes are reviewed by the committee.

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

We use the ACIST CVi for all contrast delivery. The device accurately measures the amount of contrast being delivered to the patient.

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

We are very diligent about monitoring acute kidney injuries. The staff calculates the maximum contrast delivery per patient based on their glomerular filtration rate (GFR). High risk patients undergo mandatory labs after 72 hours and are followed by the performing physician.

How are you recording fluoroscopy times/dosages?

Our Philips equipment records the dose automatically and it is saved in our electronic medical records system after each case.

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

Our Philips equipment records all doses and the angles at which the dose was given. If we reach our threshold point of 9000 mGy, the RN on the floor is notified to do checks the following morning and the physician’s office is notified so they can do checks during follow-up visits. We notify the patient and the physician to do the regular check-up in the office at least every three months. The patient is also educated on symptoms to look for and immediately report to the physician’s office. We will send the reports to the state physicist to analyze the given skin dose.

Who documents medication administration during the case?

We use the Mac-Lab hemodynamic patient monitoring system (GE Healthcare) for case documentation, administered medications, and supplies. The scheduled monitor personnel for the case documents all medications given by physician or circulating RN on behalf of the physician. The physician and circulating RN sign off on that document after the procedure verification.

Are your physicians dictating their cath procedure reports?

Our physicians use a dictating system they can access by any landline or mobile phone, and we have provided them with dedicated dictaphones. All physicians will complete a heart diagram with all information readily accessible for anyone to review.

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

Yes, we do use the ACC-NCDR. We use Chest Pain-MI registry (formerly ACTION) to collect data.

How are you populating the registry data records?

We have an APRN who is our chest pain coordinator. She collects all of our data and reports quarterly at our internal Heart-to-Heart meeting. 

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

Over the years we have developed friendly relationships with all the local hospitals and have become a tertiary referral center. We are the largest and most experienced facility in the region, and have been fortunate enough to have alliances with multiple surrounding facilities, some as far as 90 road miles away. Our friendly relationships have helped us to develop a setup that does not compete, but works to provide quality care to the patients in our region. We receive patients from all local hospitals for interventions, cardiac catheterizations, and higher levels of care.

How are new employees oriented and trained at your facility?

Our organization has a structured orientation and training program for new employees. The program involves 5 days of in-house hospital orientation, followed by 12 weeks of training in the cath lab with a preceptor. We also have a buddy call system for the new staff members with their preceptor for about 6 months in order to make sure the new staff member is completely comfortable. The manager and director monitor progress, and get regular feedback from the other staff members and physicians.

What continuing education opportunities are provided to staff members?

Our facility offers the majority of continuing education hours in-house and free of charge. The physicians also take regular quarterly teaching sessions to keep staff updated on new developments. For the new products and medications, vendors will do in-house training for employees.

How do you handle vendor visits to your lab?

We use the Vendormate system (GHX) for all vendors that visit our organization. When coming into the cath lab area, vendors/representatives schedule with our secretary, Kirstin Wells, prior to the visit. We only allow two visits per month per physician for a case, unless otherwise requested.

How is staff competency evaluated?

We have an annual competency used by management to evaluate employees yearly. The hospital also provides annual safety check-off stations each year for employees.

Does your lab have a clinical ladder?

We do not have a structured clinical program ladder in our lab, but we do provide management opportunities to our staff by allowing them to run the day-to-day operation of the cath lab on a weekly basis. That helps provide adequate coverage when one of the senior management is on vacation.

Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? Does staff receive an incentive bonus or raise upon passing the exam?

Staff is not required to be RCIS certified, but we do encourage them to obtain the RCIS credential. We do not offer a bonus or raise at this time for certification, but it is something we would like to offer in the future.

What do you like about your physical space?

In designing our new cath labs, we made sure the transfer of our patients was as smooth as possible. Our new labs are located directly across from the ED, near the main elevator that accesses the helipad and transfers to other locations in the hospital, such as the OR. Our smooth transfers have helped decrease D2B times. The monitor booths, inside our cath labs, have decreased the outside noise during the cases. The rooms are very spacious for complex cases (TAVR, MitraClip [Abbott Vascular], etc.) and are equipped with OR lights and anesthesia booms. The layout of the new cath labs helps procedures to run very smoothly.

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

Each primary and backup team consists of 3 staff members; one RN, one RT(R), and the third can be an RN, RT(R), or cath lab technologist. If the call team is out late, they have the option to come in late the next day or leave early when cases are finished. It is our policy to provide staff with adequate recuperating time if they have been working long hours.

How does your lab schedule team members for call?

Staff members are given an opportunity each month to provide a list of requested days off before the call schedule is created. The majority will take 7 to 8 days of call each month with one weekend of call on average. Scheduling covers both primary and backup call.

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

Call team members have a 30-minute response time to arrive once they are paged.

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

The cath labs are open from 7am to 7pm, 5 days a week. We have a mixed number of 10- and 12-hour shifts. During slow periods, the manager will navigate the schedule to allow time off for those in need and will also use that opportunity to schedule the mandatory in-services with our specialty equipment that are otherwise difficult to attend. Staff will also utilize the slow time to complete online education.

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

Our facility parking is free to both our patients and the staff. We are currently expanding our Heart & Vascular Institute. This nearly $32 million project will provide free rooms for overnight call staff if they live outside the 30-minute call window. Staff receive additional pay according to their professional and educational growth. The second back-up team also gets paid to carry a pager.

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

Our cath lab is very unique in the sense that we started in a small hospital with one mobile lab and now have expanded into 6 cath labs. Our department started by performing diagnostic procedures in a single lab and over the years, began performing all kinds of cardiac, vascular, and EP procedures. As our abilities to perform complex procedures developed, we started treating higher acuity patients and those with more complex disease. Our staff learned hands-on to deal with all procedures not only in cardiology, but in electrophysiology, vascular, and interventional radiology. We are very proud of our staff. We believe our cath lab staff is second to none when it comes to learning new procedures to help our patients in any way we can.

Is there a problem or challenge your lab has faced?

Like many other cath labs, we have faced problems and challenges related to periods of rapid growth. When we were upgrading our cath labs, we were only left with one in-house cath lab, so we leased a mobile cath lab to make sure our patients received the best care. Another occasion of growth and its resulting challenges came when we recruited a vascular surgeon, interventional radiologist, and electrophysiology specialist, who all started nearly at the same time. We only had two labs in use at the time, to be shared with the cardiologists. Our staff worked diligently to accommodate everyone until the specialty labs were built. We were then able to hire more staff and worked to give current staff adequate rest to prevent burnout.

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 city was recognized as one of the “100 best small towns in the U.S.” when the coal industry was booming. We are located in the Appalachian Mountains of eastern Kentucky. The area was well known for coal mining, which has been on decline for the last few decades. We have used this change as an opportunity to develop our small town into a “hub” for all the other small cities around us. Pikeville Medical Center grew into a referral tertiary center for the region and is one of the largest employers in Pikeville. The entire Appalachian belt has a high prevalence of heart disease, so our patients have a high rate of premature coronary artery disease and other complex vascular problems. Our cath lab staff are able to handle all kind of emergencies with a great deal of professionalism and experience.   

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 review data before and after receiving reports from the NCDR. If any deficiencies are noted, we will address them with all concerned team members, which could include transferring facilities, EMS, EKG techs, and transferring physicians. The director of the cath lab meets with the staff on a regular basis to review the implementation of quality initiatives. We will also use the reviews to train staff in order to overcome any deficiencies in our efforts to deliver world-class care. 

Dr. Muhammad Ahmad can be contacted at md.mahmad@gmail.com.

Assistant Director Johnny Webb, RT(R), can be contacted at johnny.webb@pikevillehospital.org.

Secretary Kirstin Wells can be contacted at kirstin.wells@pikevillehospital.org.