Note: Certain photos in this article were taken prior to the COVID-19 pandemic.
Tell us about your facility and cath lab.
Ochsner Medical Center – Kenner, Louisiana is a 110-bed facility with two cardiac catheterization laboratories (cath lab), a pre-operation department and a post-operation department. As part of the John Ochsner Heart and Vascular Institute, the staff is a diverse group of individuals with international experience and a common goal: to save lives. The team is composed of interventional cardiologists, cardiovascular technologists, and registered nurses (RNs) who possess more than 40 years of combined experience. The team performs approximately 40 procedures a week, including extensive interventions for peripheral artery disease.
How has the pandemic affected your cath lab and facility?
During the COVID-19 pandemic, our team at Ochsner Medical Center – Kenner changed the staffing plan to meet the demands of our patients. We had staff on-call while other staff redeployed to the intensive care unit (ICU) to care for critically ill patients. Our priority has always been our patients. This pandemic has unified our teams and changed our culture. We are no longer defined by our department, but our purpose.
What do you expect will happen with COVID and your local population?
Louisiana remains in phase two, with COVID cases increasing. Louisiana has a high-risk population with most already having a disease or medical condition, so we are anticipating an increase in cases.
Does your cath lab perform primary angioplasty without surgical backup on site?
Yes, we do, but we have an ambulance on standby for those cases.
Can you describe the use of radial access at your lab?
We are at 80% radial access.
Who manages your cath lab?
We have a cath lab RN director who manages the cardiology clinic as well as the labs. All staff are oriented to all areas to understand the patient experience and the multiple roles of the physicians. This has removed silos, and helped communication and coordination of care. Cath staff shadow in the clinic and medical assistants shadow in the cath lab. It has helped build teamwork, improved clinical knowledge, and helped us develop a holistic approach to the patient experience.
Who scrubs, who circulates and who monitors?
All staff are cross-trained to monitor and circulate. Only the cath technologists scrub with the physicians. A registered nurse (RN) gives and documents all medications during the case.
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?
Cath lab technologists position and pan the table. Physicians step on the fluoro pedal.
How does your cath lab handle radiation protection for the physicians and staff?
All staff have lead aprons and lead glasses. We have a lead skirt on the table and a shield to protect staff. We also drape the patients with Radpads (Worldwide Innovations & Technologies, Inc.). Each staff member has a dosimeter.
Tell us about some of the new equipment, devices, and products recently introduced at your lab.
The use of CO2 has been very beneficial to our patients with renal disease. Any patient with a creatinine clearance <60 ml/min gets a combination of CO2, extravascular ultrasound (EVUS), and intravascular ultrasound (IVUS).
How does your lab communicate information to staff and physicians to stay organized and on top of change?
We have daily team huddles, group messaging, and group email.
How is coding and coding education handled in your lab?
We have coding team with a physician educator.
Who pulls the sheaths post procedure, both post intervention and diagnostic?
Our cath techs and RNs pull sheaths, and must be checked off annually for this skill.
Where are patients prepped and recovered (post sheath removal)?
Patients are prepped and recovered in the pre/post area. The RNs in this area are also encouraged to cross-train into the intra phase of care once they have mastered these phases of care. We utilize closure devices.
How is inventory managed at your cath lab, and who handles the purchasing of equipment and supplies?
These tasks are accomplished by our technologists and our dedicated supply chain coordinator.
Has your cath lab recently expanded in size and patient volume?
Yes, we recently added a second lab. We are expecting to increase our volume to 1,800 cases per year.
Is your lab involved in clinical research?
Yes, we are involved with the PROMISE II trial (Percutaneous Deep Vein Arterialization for the Treatment of Late-Stage Chronic Limb-Threatening Ischemia), BEST-CLI (Best Surgical Therapy in Patients With Critical Limb Ischemia), and several registries.
Can you share your lab’s door-to-balloon (D2B) times and some of the ways employees at your facility have worked on this issue?
We average 57 minutes. Taking ownership of the care is important. Each person in the team knows their role as well as that of their team member. They support and over communicate. Each ST-elevation myocardial infarction (STEMI) case is reviewed with the team. Strong skills and opportunities are identified and addressed. We also have a tracking board with the fastest times posted.
Who transports the STEMI patient to the cath lab during regular and off hours?
The emergency department (ED) staff.
What do you do when the call team is already busy doing a procedure and a STEMI comes into the ED?
After hours, the patient will be medically managed, but during operational hours, we have the staffing to run two cath labs.
What measures has your cath lab implemented in order to cut or contain costs?
Preference cards, bulk purchases, and consignment agreements.
What quality control measures are practiced in your cath lab?
Blood glucose, activated clotting time (ACT), and daily checks of our radiology system prior to use.
How do you determine contrast dose delivered to the patient during an angiographic procedure?
In advance of the procedure, we use the formula 5 × weight (kg)/cr to determine the max contrast load. During the procedure, the tech announces at each interval our contrast usage. We also utilize only 50 cc bottles of contrast.
Are you tracking the incidence of contrast-induced acute kidney injury in patients?
Yes. We participate in the American College of Cardiology’s National Cardiovascular Data Registry (NCDR) and receive a daily report from our cardiology performance improvement (PI) coordinator.
How are you recording fluoroscopy times/dosages?
In Cupid (EPIC) and measured in Gy.
What is the process that occurs if a patient receives a higher than normal amount of radiation exposure?
We have a radiation dose tracking system that shows you exactly how much radiation exposure each patient is getting and exactly what part of the body is being exposed. Our interventional equipment is from Canon Medical Systems and facilitates improved dose management by leveraging low dose modes that maintain high image quality. Their dose tracking system (DTS) provides real-time displays of estimated patient skin dose. Being able to visualize the radiation dose in color on a realistic patient graphic enables dose management and helps minimize radiation exposure to our patients. Any patients who are exposed for extended periods of time are assessed by our nurses post procedure for any signs of radiation burn or injury. Reports are sent to a radiation committee.
How are you populating NCDR data records?
We have an independent auditor who tracks all data from our labs.
Are your physicians dictating their cath procedure reports, or do they use a structured reporting tool?
We use Cupid as a structured reporting tool.
How does your cath lab compete for patients? Has your institution formed an alliance with others in the area?
We are the only STEMI/after-hours lab in the River Region (Kenner is part of this geographical area along the Mississippi River). We work closely with other hospitals in the area, including 4 parishes: Jefferson, St. John Baptist, St. James, and St. Charles, that are not able to accommodate emergent or after-hour cases.
How are new employees oriented and trained at your facility?
For new intra-lab employees, we have a 2-month orientation process, depending on previous experience, knowledge base, and skill set. After a month of orientation, they can begin taking “buddy call” with their preceptor in order to train for STEMIs and other emergent procedures. For our new pre/post cath lab staff, we have a 6-8 week orientation process, also depending on previous experience. Every new employee is given a primary preceptor. A new hire packet is made with all necessary check-off and educational materials. The new employee and their primary preceptor meet weekly to assess progress and make new goals for the coming week. Huddles are done weekly with preceptor and preceptee leader.
What continuing education opportunities are provided to staff members?
The Ochsner system offers educational opportunities through our online learning network. A few times throughout the year, we also set up continuing educational opportunities with device representatives for our unit-specific equipment/procedures. This allows our staff to stay up to date on the new technology coming out in our specific field. The registered nurses can participate in a clinical ladder program. Ochsner offers a 3-level clinical ladder to nurses that is addressed annually. In addition, our staff does have the opportunity to go to conferences throughout the year. Advanced approval is required and the content must be specific to our unit/patient population.
How do you handle vendor visits to your lab?
All vendors must complete the Reptrax attestation and have a picture badge before coming to the lab. They must make an appointment in advance and are limited to certain days a week. We also have a no-gift policy in place for all vendors.
How is staff competency evaluated?
Our staff have yearly checkoffs during our hospital-wide annual skills fair in March. We also have yearly unit-specific checkoffs done during each employee’s yearly evaluation period.
Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)?
Although taking the RCIS examination is not required by our lab, it is encouraged. Staff receive a one-time bonus upon successful completion of the examination.
Does your lab have any physical (layout) bottlenecks or limitations?
Thankfully, both of our labs and our pre/post area have been newly renovated. The staff had plenty of input in the layout and design of the new spaces to guarantee the easiest possible workflow.
What do you like about your lab’s physical space?
We have 2 newly renovated labs and a new pre/post area as well. Our pre/post area is cardiac-specific, and was designed to be able to accommodate our specific procedures and patients. We have an extra-large “procedural” bay in our pre/post cath lab that accommodates transesophageal echocardiograms (TEE)/cardioversions and endovascular sclerotherapy procedures. In the intra-cath lab area, we have connecting monitor rooms and we also have windows to look outside. During our recent renovations, our department acquired some New Orleans-specific art that adds a personal touch to our area.
Is there a particular mix of credentials needed for each call team?
We normally have 1 RN and 2 RTs on each call team. We do have some RNs who are able to monitor and circulate cases, and are able to assist with some extra call in order to make a 2 RN and 1 RT call team. Staff are permitted to start later after an early morning “call out” when needed.
How does your lab schedule for call?
Our lab does self-scheduling for call. We use seniority to decide who gets to sign up first. Our team is always very accommodating with each other when it comes to filling out the call schedule.
Within what time period are call team members expected to arrive to the lab after being paged?
We have a 30-minute callback time.
Do you have flextime or multiple shifts? How do you handle slow periods?
We do not have multiple shifts. During slow periods, we cross-train our staff to work on our sister units, pain management and interventional radiology. We also utilize the time to do mock codes, sedation audits, and online learning through our Ochsner Learning Network.
Has your lab recently undergone a national accrediting agency inspection?
Our lab had our Joint Commission Survey done in 2019 and was successful. Even though we passed, we still have staff performing tracers monthly to ensure the standard is maintained.
What trends have you seen in your procedures and/or patient population?
We have had an increase in our peripheral cases over the last few years. We are able to offer zero contrast technique with CO2 angiography, IVUS, and EVUS. This allows patients with kidney injuries/impaired renal function to have the appropriate imaging and revascularization without harming their kidneys any further from contrast exposure. We have also seen an increase in the amount of critical limb ischemia (CLI) cases. This is something our team feels very passionate about. We aim to “Stop the Chop” and save people from limb amputations.
What is unique or innovative about your cath lab and staff?
Our lab carries the fastest door-to-balloon time in our region. We also have the lowest acute kidney injuries (AKI) in our region. We attribute this partly to our Poseidon protocol, which adequately hydrates our patients to flush the kidneys before and after contrast dye exposure. The staff at our facility practice open communication and transparency. The entire cath lab team supports, encourages, and motivates each other. They hold each other accountable and have the courage to have a difficult conversation. They see a challenge as an opportunity to learn something new.
Is there a challenge your lab has faced?
We have undergone multiple different phases of renovations over the past 2 years. We converted from a 1-lab unit to a 2-lab unit. We completely designed a new pre/post cath lab area. We were able to work with our sister unit and use the interventional radiology suite at times when emergency cases had to be done without taking our patient off the table in the lab. We found creative ways to work around the construction. Our team came together and always found a way to provide excellent patient 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”?
New Orleans and the surrounding areas are a melting pot of different people and different cultures from around the globe. We are known for our hospitality and friendliness. We are also known for our amazing food, which tends to be high in sodium and high in fat. Obesity is a problem in many of our patients. The majority of our patients need extensive education on diet modification and healthy eating.
A question from the American College of Cardiology’s National Cardiovascular Data Registry:
How do you use the NCDR Outcome Reports to drive QI initiatives at your facility?
We have quarterly meeting where we dissect the data and find ways to get better every day with the delivery of care.