Tell us about your cath lab.
Blessing Hospital is a 307-bed acute care hospital in Quincy, Illinois, a small city located along the eastern banks of the Mississippi River. Blessing is the largest healthcare provider in a 100-mile radius with an overall catchment area of approximately 203,000, serving 19 counties in western Illinois, northeast Missouri, and southeast Iowa. The hospital is part of Blessing Health System, which also consists of a critical access hospital in Pittsfield, Illinois, Illini Community Hospital; 2 multispecialty physician groups, Blessing Physician Services based in Quincy and Hannibal Clinic, based in Hannibal, Missouri; and Blessing-Riemann College of Nursing and Health Sciences.
The cardiac cath lab is part of the Heart and Vascular service line supporting the cardiovascular physician group of Blessing Physician Services, currently with 8 cardiologists and 4 nurse practitioners; the cardiovascular group of Quincy Medical Group, currently with 2 cardiologists and 2 nurse practitioners; and the cardiothoracic surgical team, which consists of a surgeon and 2 nurse practitioners. The cardiac catheterization lab is utilized by the entirety of the service line. The first percutaneous coronary intervention (PCI) and open-heart surgery procedure was performed at Blessing in 2004, with consistent growth occurring ever since.
Can you tell us more about your Heart and Vascular service line?
Blessing Hospital has 3 cath labs and one hybrid operating room (OR) available for cardiac/peripheral procedures. The dedicated coronary labs are Philips-based, one of which was outfitted in early 2020 with the Azurion flat plate system that includes a peripheral package. A dedicated electrophysiology (EP) lab with coronary capabilities is also Philips, and a hybrid OR suite uses the Siemens Healthineers Artis zeego system. A typical cardiac case is staffed by 2 certified radiologic technologists (RT[R]s), one of whom scrubs into the procedure and operates the table and one of whom remains in the control room and records the case, including equipment and medications, and one circulating RN. Everyone is cross-trained to each of the roles within their scope of practice.
We currently employ 9 full-time RNs and 7 RTs at this time. Staff retention has been excellent and it has not been necessary to augment with temporary staff. Staffing has staggered start times to ensure adequate coverage for the day, with staff working 8-, 9-, and 10-hour shifts. We allow self-scheduling for on-call shifts with the requirement of at least one RN and one RT per call shift; the third person can be either a RN or RT.
What procedures are performed in your cath lab?
In our facility, we perform diagnostic and interventional coronary procedures, peripheral procedures including lower/upper extremity intervention, renal intervention, acute pulmonary embolism intervention, patent foramen ovale (PFO)/atrial septal defect (ASD) closure, CardioMEMS (Abbott), and carotid diagnostic and stenting procedures. Our EP program performs both radiofrequency ablation and cryoablation of atrial fibrillation, device implantation including the Micra leadless pacemaker (Medtronic) and His-bundle pacing, supraventricular tachycardia (SVT) ablation, ventricular tachycardia (VT) ablation, and lead extractions. From a coronary interventional perspective, we routinely perform rotational, laser, and orbital atherectomy in appropriately selected cases. There is available percutaneous ventricular assist device (PVAD) support with Impella 2.5 and CP (Abiomed), along with extracorporeal membrane oxygenation (ECMO) services provided by the cardiovascular surgical team with the Cardiohelp System (Getinge). The average number of total cases performed in our cath labs weekly is over 100, with the percentage of normal coronaries currently at 33%. There is a robust primary PCI ST-elevation myocardial infarction (STEMI) program that receives patients from 19 counties, with 24/7 surgical backup. Most of our operators are radial-first operators, with the percentage of cardiac cases performed radially currently at 72% and STEMI cases currently at 71%. Common reasons that femoral access is used is to allow for larger bore access for atherectomy devices, employment of support devices, or in graft cases.
If your cath lab is performing structural heart interventions, can you share your experience?
Blessing came online with transcatheter aortic valve replacement (TAVR) in December of 2019. The TAVR team consists of 2 interventional cardiologists, our cardiac surgeon, and a valve clinic coordinator that is nurse practitioner-trained. TAVR is performed in the hybrid OR with a percutaneous-only approach used in the vast majority of the cases. We are primarily using the Medtronic Evolut system, with the secondary device being Lotus (Boston Scientific) at this time. We are in the exploratory phase for the Watchman device (Boston Scientific) and plan to launch the Watchman procedure in late 2020.
If you are performing peripheral vascular procedures, do any operators utilize pedal artery access when appropriate?
We operate primarily as a contralateral access/antegrade-first lab for claudication and critical limb ischemia (CLI) cases, with the capability to proceed to retrograde approach from pedal access when appropriate, using a 4 French (Fr) microsheath and .018-inch equipment. When employed, retrograde crossing success has been high overall.
Who manages your cath lab?
Reginald Suhling BA-HCM, RT(R)(CI), RCIS, AACC is currently the cath lab manager. He has spent 10 years overall in our cath lab, 5 years in the capacity of RT, and 5 years as the cardiac cath lab manager.
How does your cath lab handle radiation protection for the physicians and staff?
We have monthly optically stimulated luminescence (OSL) badge checks reviewed by the radiation safety officer. If someone demonstrates high readings, s/he is educated on radiation precautions, and is assigned to fewer cases and/or utilized in a recording role. This is a rare occurrence overall, however. We do annual lead checks with replacement as appropriate. Lead curtains are used on both sides of the table for left arm cases and peripherals. The new Azurion lab has several dose-reduction features that have been proven effective in providing less radiation as compared to older models.
What are some of the new equipment, devices and products recently introduced at your lab?
As noted above, TAVR was launched in 2019 and was a coordinated multidisciplinary effort between cardiology, cardiac surgery, cath lab/OR staff, radiology, marketing, and administration. Micra and His-bundle pacemaker capability came online in 2019, carotid stenting in 2018, and coronary atherectomy in 2017. Cryoablation of atrial fibrillation and CardioMEMS came online in 2016. EKOS therapy (Boston Scientific) for acute pulmonary embolism was started in 2013.
Who pulls the sheaths post procedure, both post intervention and diagnostic?
Radial cases have a Vasc Band device (Teleflex) applied. In appropriate cases, femoral sheaths are addressed with a closure device, including Angio-Seal (Terumo), ProGlide (Abbott), and Mynx (Cardinal Health). Sheath management in non-closed groins is a joint effort between cath lab staff and cardiovascular ICU (CVICU) staff. All cases are assigned a bleeding risk score prior to the procedure and is part of the “time-out” process to assist in anticoagulation decisions. All groin cases are triaged for recovery in CVICU. During daytime hours, patients with sheaths are transferred to the CVICU, and sheaths pulled at the appropriate time by cath lab staff. Overnight, groins are managed by the CVICU staff, who are directly trained by the cath lab manager and CVICU management. Typically, at least 20 minutes of pressure is mandated. With a fair amount of CVICU staffing turnover, in 2019, we implemented the “MASH” approach to urgently address formation of hematoma. Groins in which a sheath has been manually pulled is applied a MASH sticker, reminding nursing staff that in the event of symptomatic hematoma: perform Manual pressure, administer Atropine, administer Saline, and position bed Head down, before calling the physician.
Can you share a look at your lab’s door-to-balloon (D2B) times and some of the ways employees at your facility have worked together to lower this time?
Our rolling door-to-balloon (D2B) time is 54 minutes, with >90% of cases achieving D2B time <90 minutes. Several initiatives have been put into place to ensure rapid throughput in the emergency department (ED), including transmission of electrocardiograms (EKG) from the field, enabling EMS staff to activate the STEMI pager, and ED bypass in clear-cut STEMI cases. After physician assessment, patients are brought to the cath lab by ED staff while cath lab staff prepares the room. As we receive STEMI cases from several surrounding hospitals, the default treatment in these cases is “drip-and-ship”, ie, administration of full-dose lytics, with invasive management on arrival.
We have an interdisciplinary STEMI committee meeting monthly to discuss each STEMI activation. The committee is comprised of the cath lab leadership and staff, EMS representatives, ED leadership and staff, a heart and vascular center data analyst, and the administrative director of the heart and vascular center. There is a drilldown of each case including demographics, mode of arrival, time to activation, and review of any barriers causing delay. Follow-up documentation that includes D2B time and improvement opportunities is sent to all referring facilities, EMS, ED, and the cath lab. D2B times are also posted in the cath lab and ED for staff review. For a broader overview, our facility also has a “Heart First” chest pain committee meeting quarterly that is comprised of representatives of the same departments noted above, as well as air evac, noninvasive cardiology, and cardiac unit managers. Overviews of D2B, ED dwell times, transport times, door-in, door-out (DIDO) times, EMS accuracy in interpretation of STEMI EKGs, and community education are discussed, as well as educational opportunities for staff and Blessing affiliates, as well as opportunities to identify areas of process improvement.
What measures has your cath lab implemented in order to cut or contain costs?
Same-day discharge has been encouraged over the last several years for both radial PCI and EP procedures. Based on standard cited cost-per-case savings, Blessing saved approximately $800,000 in fiscal year 2019 using same-day discharge of PCI and EP patients. We have significantly reduced the use of bivalirudin in radial cases, which eliminates the majority of anticoagulation costs. Block scheduling of physician procedures and monitoring of “on-time” starts has been implemented in order to prevent overtime utilization of cath lab staff. We are currently reviewing cost-per-case per physician and correlating cost with quality.
What are strategies used to reduce/eliminate contrast-related kidney injury?
All patients are assessed for contrast limits based on patient data and renal function using estimated glomerular filtration rate (eGFR). Contrast limits are verbally reported during the “time-out” prior to each case. Hypo-osmolar contrast (iodixanol) is used in cases where GFR is calculated <60. Contrast delivered is monitored via the ACIST CVi contrast delivery system (ACIST Medical). Road mapping is used extensively in peripheral cases and can also be performed with the Azurion software in coronary cases.
Are your physicians dictating their cath procedure reports, or do they use a structured reporting tool?
Cath reports are generated by Dragon software (Nuance), which is institution-wide. While certain components of the report are mandated, physicians are allowed to generate their own boilerplate format. While this took a while to implement after several years of utilizing transcription, it offers the benefits of immediate availability of reports and ultimately a minimal change to dictation time.
Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) or any other outside data collection registry?
Yes, we participate in the ACC-NCDR for CathPCI, Implantable Cardioverter Defibrillator (ICD), Society of Thoracic Surgeons (STS)/ACC Transcatheter Valve Therapy (TVT) registry for TAVR procedures, and the STS Adult Cardiac Surgery Database. We are an accredited Chest Pain Center through the ACC and publicly report our data on the ACC CardioSmart Find Your Heart a Home search tool. We are currently recognized as a Blue Distinction Center for Cardiac Care due to our commitment to quality care, resulting in better overall outcome for the cardiac patient.
How are you populating the registry data records? Who is inputting the data, and is any of it accomplished through in-lab systems?
Data abstraction for each registry is a mainly a manual process accomplished by our Heart & Vascular Data Analyst, Nicole Stanford RT(R)(MR), RCIS. Demographics, Cath/PCI procedure times, procedure contrast and fluoro times, and certain pre-procedure risk factors do flow over automatically via the Xper Information Management system (XIMS [Philips]) hemodynamic system.
How are new employees oriented and trained at your facility?
We have a standard orientation process and competency checkoffs for all staff members. New trainees are assigned a designated, experienced preceptor and we utilize device clinical representatives to assist with providing education on specialized devices/equipment as well. The assigned preceptor is expected to provide most of the education for the new employee, but we try to treat orientation as a group effort. Vendor education is required at least yearly on all equipment, with competency assessment as appropriate.
How do you handle vendor visits to your lab?
Blessing Hospital has a policy and guidelines for vendors. Vendors are encouraged to make an appointment with the cath lab manager and are welcomed into the actual lab if they are supporting a case. If they are not specifically supporting a procedure and/or are providing education for the staff, vendors are met outside of the lab by the cath lab manager. All vendors check in using the Reptrax platform on arrival to the facility.
What do you like about the physical space you work in?
The cath and EP labs are centrally located around the holding area, and are one floor directly above the ED and one floor directly below the CVICU, with a large connecting elevator that allows for efficient patient flow. Each cath lab suite has a “back door” to the surgical hallway leading to the CVOR suites, which allows easy access for emergency situations. The cath lab holding area was updated in 2013 to a radial lounge setup with comfortable upright seating, large windows, and individual stalls with personal televisions. Patients arrive at and leave from the same space in same-day discharge scenarios, which they appreciate. Blessing has been proactive when updating the unit to keep a natural, less “institutional” theme (neutral colors, wood-grain floors, etc) that flows from the radial lounge area into the cath lab itself. Patients frequently comment on the pleasant look of the space and we hope this helps alleviate anxiety.
Do staff members have any little or big particular perks that you might like to share?
The Blessing Health System offers tuition forgiveness for bedside RNs and radiologic technologists (up to $10,000 for full time and up to $5,000 for part time) and has the Vizient/AACN Nurse Residency Program (NRP), which is the gold standard for nurse residency programs. Blessing Hospital also offers educational assistance programs, on-site childcare, and access to a state-of-the-art wellness center and worksite wellness program, along with the normal benefits of health, dental, vision, etc. All staff have the opportunity to participate in clinical ladders.
Are staff permitted to leave early or start later after a night of on-call ?
Every effort is made to alter shifts to accommodate after-hour call-ins if the schedule allows. Staffing is based on departmental need, so if cases are completed, many people leave early, or on slower days, we flex staff unless needed in another department.
How does your lab schedule team members for call?
The call schedule is separated by weekday call and weekend call. Weekend call is a pre-scheduled rotation to help staff members plan ahead, though staff are flexible in switching and in picking up assignments as needed. Weekday call is Monday-Thursday and staff pick their call days on a rotation. If a person picks first for 6 weeks of call they go last next time and this rotates for each schedule. Staff consistently switch call to cover each other on weekdays as well. Staff are expected to arrive to the lab for urgent cases within 30 minutes.
What trends have you seen in your procedures and/or patient population?
With expansion of some of the procedures and technology available, there seems to be a trend towards older patients with more comorbidities, and certainly more involved/longer-duration cases. Many of these patients may have previously been referred to university settings or managed palliatively. Certainly some of the procedures are more demanding, and we are looking at ways to potentially increase the number of staff members assigned; for instance in valvuloplasty, carotid cases, atherectomy, etc.
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”?
Quincy is situated on something of a “land island”, without a comparable facility close by, but also draws from a sizable catchment area. As a result, all disciplines on the cath lab staff are exposed to a variety of cases and have developed a nice breadth of expertise. It has been a good option for those native to Quincy (which applies to most of the staff) to be involved in a comprehensive interventional lab without having to leave home.
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?
NCDR outcomes and drilldowns are shared at quarterly Physician Collaborative committee meetings that are comprised of physician groups that admit, perform, and discharge PCI patients, along with anesthesiologists, ED physicians, hospitalists, senior suite leadership, and cardiovascular surgeons. These outcomes are also shared and presented to a multidisciplinary committee comprised of department leaders in lab, radiology, respiratory, surgery, cardiology, nursing units, and observation units. Round-robin discussions are held pertaining to any obstacles or process flows that need improvement.
One example of a NCDR outcome that drove a quality initiative adapted at our facility is how we decreased median time for in-house STEMI-to-balloon from 119 minutes to 31 minutes. This was a collaborative effort from many ancillary departments. Another example is how we improved our discharge process to refer 100% of patients for cardiac rehab post PCI procedure.
The authors can be contacted via Dr. Jeffrey Cook at firstname.lastname@example.org.