Tell us about your cath lab.
The cath lab at Saratoga Hospital, recently renamed the Cardiovascular and Interventional Suite (CVIS), opened in 2001 as a single diagnostic cardiac cath lab providing diagnostic catheterization, peripheral angiograms and interventions, and permanent pacemaker implants. Patients requiring coronary intervention, coronary bypass, or valvular surgery were transferred 45 minutes south to Albany Medical Center. Over the years, we have expanded our services to offer percutaneous coronary intervention (PCI), performing our first PCI in December 2014. We began offering community-wide ST-elevation myocardial infarction (STEMI) coverage in March 2017. The CVIS has also been expanded to include interventional radiology procedures.
Our administration made the decision to become a cardiac center and began planning towards a cardiovascular service line strategy. Administrative director Jeffrey Winacott, MBA, RN, was recruited to bring cardiology, noninvasive cardiology and invasive cardiology together, under the service line umbrella. Jeff is also a former cath lab and cardiology nurse. Saratoga Hospital has been fortunate to experience a significant growth in our cardiac services, and we continue to grow and expand our offerings to the community.
In 2017, Saratoga Hospital joined Columbia Memorial Health as an affiliate of Albany Med. We are now a part of the largest locally governed health system in the region. One significant benefit of our affiliation with Albany Med is a higher degree of coordinated and collaborative patient care with the center’s cardiac specialists.
Our physical space has just been expanded and renovated from 7000 square feet to 9800 square feet and includes 2 procedure rooms with a 16-bed recovery area. This expansion has increased our bed count from 8 usable bays to 16 New York State Department of Health-compliant bays, along with 2 separate nursing stations offering direct visibility of all patients for monitoring purposes. Our waiting room has doubled in size, with a more inviting and comfortable space for families.
Our staff consists of 9 registered nurses (RNs), including one RN clinical coordinator and 7 staff members who hold radiologic technologist (RT), respiratory therapist (RT), and/or registered cardiovascular invasive specialist (RCIS) credentials. We have a great mix of experience overall, ranging from 25 years in the cath lab to 1 year; our technologists have varied cath lab experience, ranging from 10 years to 1 year in the cath lab. Seven nurses hold bachelor’s degrees, one is currently enrolled in a bachelor’s degree program, and one RN is enrolled in a family nurse practitioner (FNP)master’s degree program.
What procedures are performed in your cath lab?
Cardiac procedures: Right and left heart catheterization, percutaneous coronary intervention, temporary and permanent pacemaker insertion with generator changes and lead revisions as needed, loop recorder insertion and removals, pericardiocentesis, cardioversions, implantable cardioverter defibrillators (ICDs), therapeutic hypothermia with the Thermogard (ZOLL), and transesophageal echocardiograms.
Peripheral procedures: Upper and lower extremity angiography and intervention.
Interventional radiology: Mediport insertion and removal, biliary drainage catheter insertion, embolization (gastrointestinal [GI] bleed, uterine, etc.), fistulagrams and interventions, inferior vena cava (IVC) filter placement and retrieval, nephrostomy tube insertions, percutaneous endoscopic gastrostomy (PEG) tube, gastrostomy (G) tube and gastrostomyjejunostomy (GJ) tube insertion, PleurX catheter (BD) insertion, temporary and tunneled hemodialysis catheters, thoracentesis, upper and lower extremity venogram and thrombectomy, transjugular intrahepatic portosystemic shunt (TIPS), balloon-occluded retrograde transvenous obliteration (BRTO), Y90 radioembolization.
Does your cath lab perform PCI without surgical backup on site?
Yes, we started offering this service in late 2014 and perform an average of 260 PCIs annually.
What is the percentage of normal diagnostic caths?
Twenty-three percent (23%) of diagnostic catheterizations are normal.
Do any of your physicians regularly gain access via the radial artery?
The majority of our cases utilize a radial artery access approach.
If you are performing peripheral vascular procedures, do any of the operators utilize pedal artery access?
Yes, our interventional radiologists and vascular surgeons both utilize pedal access when appropriate for below-the-knee procedures.
Who manages your cath lab?
Our clinical nurse manager, Jennifer Brandon, BS, RN-BC, CCRN-CMC, RCIS, has experience in the technical arena, having experience as a cardiovascular specialist as well, and currently holds her RCIS credential. She is also enrolled in a FNP program. We also have a clinical care coordinator, Peter Pope, RN. Peter has years of experience in the RN and scrub roles.
Do you have cross-training? Who scrubs, monitors and circulates?
We are currently in the process of cross-training many of our staff members to perform multiple roles in the CVIS. Scrubbing in is performed mostly by the technologists, but we have several nurses who have scrub experience and participate in the scrub rotation as needed. The RNs circulate all cases in order to medicate and monitor patients undergoing procedures. Both the technologists and nursing staff perform hemodynamic monitoring.
Are there licensure laws in your state for fluoroscopy?
New York state law limits dispensation of radiation to licensed independent practitioners and licensed radiologic technologists.
Which personnel can operate x-ray equipment (position the detector, pan the table, change angles, step on the fluoro pedal) in your cath lab?
The physician and radiologic technologists can both position the detector and step on the fluoro pedal. The physician must pan and change angles.
How does your cath lab handle radiation protection for the physicians and staff?
Staff and physicians are monitored using Landauer radiation badges. The department radiation safety liaison as well as the radiation safety committee monitor radiation reports. Any doses that are higher than expected are investigated and reported to the radiation safety committee. All staff is required to follow standard radiation safety practices (ALARA) as well as utilize all radiation personal protective equipment, including rolling shields, table shielding, lead glasses, and aprons. The imaging equipment allows us to monitor dosage using dose maps as well as incorporating dose area product (DAP) values in our procedural reporting. We also have a patient exposure policy to alert the physicians performing extended procedures to higher patient radiation exposures and thresholds in order to begin monitoring patients for effects of prolonged exposure to limited areas.
What are some of the new equipment, devices and products recently introduced at your lab?
With our department’s recently added interventional radiology procedures, several new pieces of equipment and products have been introduced into our lab. New products in our cardiovascular product line include the intravascular ultrasound (IVUS) HD (Boston Scientific), the Sapphire 1.0 mm balloon (CSI) and the wireless fractional flow reserve (FFR) link (Boston Scientific). New products in our peripheral/interventional radiology product lines include Penumbra embolization products, Lutonix balloons (BD) for arteriovenous fistula use, and Mediports with smaller profiles for increased patient comfort.
How does your lab communicate information to the staff and physicians to stay organized and on top of change?
Information is communicated through regularly occurring staff meetings, email, and educational boards and flyers in general staff areas. Our management team has an open-door policy and invites staff to come in and ask questions or discuss their concerns at any time. As changes are happening, our clinical nurse manager makes herself available to the staff and provides updates through the use of team “huddles” and verbal one-on-one communications to ensure staff are educated and prepared for any changes to daily events.
How is coding and coding education handled in your lab?
Our front office coordinator handles all changes regarding coding and coding education for our staff. We have billing sheets that our clinical staff complete following each procedure and these sheets are forwarded to our front office for processing.
Who pulls the sheaths post procedure, both post intervention and diagnostic?
Sheaths are pulled at the end of the procedure by the person in the scrub role before the patient is taken off the table, since most of our cases are performed via the radial approach. When we have a femoral case, we use MynxGrip (Cordis, a Cardinal Health Company) or Angio-Seal (Terumo). Only staff who have demonstrated competency in manual holds with an experienced RCIS are permitted to pull and hold manual pressure when that need arises.
Where are patients prepped and recovered post sheath removal?
Patients are prepped and recovered in our recovery area. We currently have 16 patient bays and maintain a 4:1 RN-to-patient ratio. In the event of a critical patient, assignments are adjusted to accommodate the 1:1 ratio.
How is inventory managed at your cath lab?
Inventory is managed through a manual system of entering item codes into the materials management system after the items are used on a patient. A report is printed for items used on each patient and the system is depleted using that report. Our supply chain personnel then runs orders for the day to replenish the supplies consumed. Our inventory is a mix of bought and consigned product in order to maintain an appropriate mix of products necessary for a multidisciplinary lab. We have a dedicated cardiovascular materials management coordinator who manages the inventory, supports the director with data, and is the vendor liaison.
Can you share your lab’s average D2B times and some of the ways your employees at your facility work together to keep door-to-balloon times under 90 minutes?
We have an average door-to-balloon time of 55 minutes for 2018. We participate in the American Heart Association (AHA)’s Get With the Guidelines-Coronary Artery Disease (GWTG-CAD), Misson:Lifeline, and the American College of Cardiology’s National Cardiovascular Data Registry (NCDR)’s CathPCI registry.
We have a multidisciplinary STEMI team including physicians, registered nurses, cath lab technologist, emergency room technologist, the hospital operator, registrar, and security. We utilize a broadcast alert for a code STEMI via the Vocera badge system. When the code STEMI is called, the entire team is activated at one time. The operator takes the call from the emergency department (ED) to call a code STEMI, pages the team and broadcasts the alert. Cath lab staff report directly to the lab to prepare medications and equipment. The intensive care unit (ICU) RNs report to the ED to provide specialized care and transport the patient. Security clears the path from the ED to the cath lab, the registrar reports to the ED to “quick reg” the patient, and the ED staff assess, care for and place orders into the electronic medical record. Our STEMI committee is multidisciplinary, and meets regularly to discuss any possible areas of improvement, review data, and to celebrate accomplishments collaboratively. We received the AHA Silver Plus Receiving Center Award for 2018 and the Gold Receiving Quality Achievement Award in 2019.
Who transports STEMI patients to the cath lab during regular hours and off hours?
When a code STEMI is called, a nurse from the ICU responds. They bring the patient to the cath lab, circulate with the cath lab nurses, and then transport the patient to the ICU and take that patient as their next assigned patient. This process was implemented for continuity of care and also proves to be helpful in freeing the cath lab call team at the end of the case.
What measures has your cath lab implemented in order to cut or contain costs?
Cost containment is accomplished by evaluating new products with a multidisciplinary value analysis committee. New products are brought to the committee by the CVIS team and evaluated based upon a variety of criteria, including need, cost, usage, and reimbursement. We utilize a variety of techniques to contain costs on products, including bulk purchases and negotiating rebates based on usage. Our hospital participates in a multi-hospital group purchasing organization, recently implemented to drive down costs across all three organizations based on a compliance percentage.
What quality control measures are practiced in your cath lab?
Our department is involved in quality control measures for our point-of-care testing devices, as well as quarterly radiation testing for our procedure room imaging equipment. We also maintain quality control for radiation personal protection equipment biannually. We maintain New York State laboratory standards for point-of-care testing for the i-Stat (Abbott) and Avoximeter (Instrumentation Laboratory Worldwide). The refrigerators for equipment and medications are monitored via AeroScout (Stanley Healthcare) for temperature. Our procedure rooms are remotely monitored for both temperature and humidity.
How do you determine contrast dose delivered to the patient during an angiographic procedure?
The ACIST CVi injection system (ACIST Medical Systems) monitors the contrast administered during each case. It is recorded in the procedure log that is part of the medical record.
Are you tracking the incidence of contrast-induced acute kidney injury (AKI) in patients?
We are utilizing the NCDR CathPCI collection tool to track contrast- induced AKI.
How are you recording fluoroscopy time and dosages?
Fluoro times are monitored and a report is generated by the Innova system (GE Healthcare) for each case. This report imports to the Mac-Lab report and is sent with the images to the PACS system.
What is the process that occurs if a patient receives higher than normal amounts of radiation exposure?
We have a protocol to notify the physician of increasing amounts of radiation dose to the patient. Once a threshold has been reached, a protocol is in place where the patient is followed and monitored for any sequelae that may be a direct result of their radiation dose. Patients are educated as to what to look for and are discharged home with proper education following their procedure. The cases are discussed at regular radiation safety committee meetings.
Who documents medication administration during the case?
Medications are documented during the procedure in the hemodynamic monitoring system. We employ a read-back and verify methodology to ensure all medications given by the nurses and physicians are recorded correctly. The record is reviewed and signed off on at the end of the case by the nurse and physician.
Are your physicians dictating cath procedure reports or do they use a structured reporting tool?
Some of our physicians dictate and others use structured reporting tools. Due to the various types of cases that we perform, not all physicians report their procedures out in the same manner.
Do you use any other outside data collection registry?
In addition to Mission:Lifeline, GWTG-CAD, and the NCDR CathPCI registry, we report to the New York State Percutaneous Coronary Interventions Reporting System (PCIRS).
How are you populating the registry data records?
A registered nurse with cardiac catheterization and critical care experience extracts the data and populates the registries. We are in the process of upgrading our in-lab documentation to assist in data extraction.
How does your cath lab compete for patients?
Our affiliation with Albany Med, our region’s only academic medical center, allows us to collaborate for higher level of care needs. This access to coordinated cardiac specialty and subspecialty care for our patients provides a distinct advantage over the five hospitals in our market that perform PCI/STEMI care. We also benefit from our affiliate providers, including Dr. Alfred Loka, who is an electrophysiologist at Albany Med and sees patients here at Saratoga Hospital. He performs EP services, primarily ICD and bi-ventricular device implants; higher specialized procedures are performed at Albany Med.
How are new employees oriented and trained at your facility?
New employees are assigned to an experienced staff member within the same scope of practice. They function in a “shadow” capacity until they are comfortable with the flow of the department and then work with their preceptor until they feel comfortable and can demonstrate competency. Nurses take the Basic Knowledge Assessment Tool (BKAT) exam to assess their knowledge of critical care. All nurses are required to complete the Essentials of Critical Care Orientation (ECCO) program administered by the American Association of Cardiovascular Nurses (AACN) unless they score high enough on the BKAT exam to demonstrate adequate experience. Technologists train in the same fashion, working side-by-side with a preceptor until they can demonstrate competency. The cath lab medical director and procedural physicians also give input on the staff member’s progress, ultimately providing a final signoff.
What continuing education opportunities are provided for staff?
Saratoga Hospital has purchased the Wes Todd’s Cardiovascular Review program and each staff member completes each of the modules while on orientation. Inservices are provided by clinical specialists from various companies and conference attendance is encouraged.
How do you handle vendor visits to your lab?
Vendors all must be cleared and carry VeriRep credentials (Vendormate) that are verified in the purchasing department for each visit. They may check in with security to obtain a badge with prox reader access and when they reach the department, must sign in at the registration desk. Vendors may only go to the lab when they have a scheduled lab day or they are providing assistance to the performing physician.
How is staff competency evaluated?
Staff demonstrate competency on an annual basis through direct demonstration and educational modules, and quarterly skills days.
Does your lab have a clinical ladder?
A clinical skill level compensation scale was implemented last year to compensate staff as they take on more responsibility and cross train.
Do you require your staff to take the registry exam for the RCIS?
All staff are encouraged to take the RCIS exam once they meet the qualifications to do so. Saratoga Hospital offers an annual bonus for maintaining the RCIS certification.
Is there a particular mix of credentials needed for each call team?
The call team consists of 2 nurses and 2 technologists (RNs who have cross-trained to function in the technologist role may fill one of the tech spots). Staff are permitted to come in late after a long night of call so they may get some rest and/or they are given the option to go home early.
How does your lab schedule team members for call?
Staff work together to create the schedule 12 weeks in advance so they can plan for time with family. The schedule is created in an Excel worksheet. Staff are requested to enter requests for “no call” days and days off, and then the remainder of the schedule is filled in to meet the needs of the department.
Within what time period are call team members expected to arrive to the lab after being paged?
The call team is required to respond to the initial blast page by calling the hospital operator within 5 minutes; at the 5-minute mark, the operator calls them to make sure they are on their way. There is an expected arrival time of 30 minutes or less to comply with D2B guidelines.
Do you have flextime or multiple shifts? How do you handle slow periods?
Slow periods are handled on a case-by-case basis. If the ED is over capacity, we take inpatient holds, generally chest pain/rule out MI, into the recovery area. These patients are taken care of by the staff who are not on call. The call team is reserved for cardiac and other emergencies.
Do staff members have any additional perks?
Staff has flexible scheduling, financial incentives for agreeing to additional call, and significant exposure to new and upcoming procedures as offered by our interventional radiology physicians.
Has your lab recently undergone national accrediting agency inspection?
We are in the process of becoming accredited by the Intersocietal Accreditation Commission (IAC).
What trends have you seen in procedures or patient populations?
Radial access has become the primary method of access for most cardiac cases, as well as some of our peripheral cases. Patients we see in our department are well informed and seem to be pleased when radial access is an option.
What is unique or innovative about your cath lab and staff?
Our cath lab staff are competent in cardiac and interventional radiology procedures, and pacemaker/ICD implantation, allowing us to meet the needs of the community on a variety of levels, without patients having to travel.
Is there a problem or challenge your lab has faced?
We faced a major challenge meeting the growing needs of our community. Through the ongoing support of our hospital leadership, we were able to expand our service line in order to meet the needs of our community.
What is 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?
We are in Saratoga Springs, New York, which is famous for horse racing. During the summer, we have a huge influx of patients from all over the country who come visit the track; we are also very close to the Adirondack Mountains, which are famous for hiking, kayaking, skiing, and various outdoor activities.
How do you use your NCDR Outcome Reports to drive quality improvement initiatives?
We are new to the NCDR registry and submitted our first quarter in early 2019. The real-time reporting option through the NCDR has made it possible to easily identify and correct potential issues. We use the NCDR data reports for process improvement and data analytics.
Jeff Winacott, MBA, RN, can be contacted at email@example.com.