Cath Lab Spotlight

Spotlight: Parkland Health & Hospital System

Laura Ragland, RT(R)(CI), Sha’ni Mays, RN, Adam Leslie, RN, Catalina Corona, RN, Amy Callahan, RN, Donna Alvarado, RN, Laurie Beall, RN, Dallas, Texas

Laura Ragland, RT(R)(CI), Sha’ni Mays, RN, Adam Leslie, RN, Catalina Corona, RN, Amy Callahan, RN, Donna Alvarado, RN, Laurie Beall, RN, Dallas, Texas

What’s special about your city or general regional area in comparison to the rest of the U.S.?

The Dallas area is currently experiencing unprecedented population growth. In 2017, the Dallas/Fort Worth (DFW) area was the fastest growing (~160,000 new residents) metropolitan area in the United States, according to the United States Census Bureau. DFW airport is a major travel hub and makes getting around the world easier than most cities. These facts contribute to the outstanding diversity our facility enjoys from our patients, physicians, and staff.

Tell us about your cath lab. Is it part of a cardiovascular service line?

The cath lab is part of Parkland Memorial Hospital’s surgical services line. This division also includes OR, anesthesia, sterile processing and supplies, GI lab, radiology nursing, OR prep/recovery, shared prep/recovery, and surgical inpatient units. Our lab currently employs 11 RNs, five radiologic technologists, and two department assistants. Our clinical staff experience levels range from 2 years to 20+ in cath labs. The Parkland Cath Lab has two GE Innova cath rooms, one dedicated Siemens Artis Zee EP lab, and one shell room available for future expansion.

Can you tell us about the institution supporting your cath lab?

Parkland Health & Hospital System first opened its doors in 1894. The system averages more than 60,000 hospital discharges and 1 million outpatient visits annually. Premier services include the Level I Rees-Jones Trauma Center, the only burn center in North Texas verified by the American Burn Association and a Level III Neonatal Intensive Care Unit. The system also includes 30 community-based clinics, and numerous outreach and education programs. Parkland is the primary teaching hospital for The University of Texas Southwestern Medical Center. In August 2015, Parkland opened its new state-of-the-art facility. The 2.8-million-square-foot campus includes an acute care hospital licensed for 870 beds, outpatient center, logistics building, and central utility plant.

What procedures are performed in your cath lab?

Our diagnostic and interventional cardiac catheterization services include right and left heart procedures, percutaneous coronary interventions, congenital diagnostic studies, acute coronary revascularization, complex chronic total occlusion (CTO) revascularization, peripheral diagnostic and interventional procedures, atrial septal defect (ASD)/patent foramen ovale (PFO) closures, ventricular septal defect (VSD) closures, patent ductus arteriosus (PDA) closures, aortic coarctation repair, coil embolization, balloon aortic valvuloplasty, perivalvular leak repairs, alcohol septal ablations, endomyocardial biopsies, and pericardiocentesis procedures.

We do not perform transcatheter aortic valve replacement (TAVR), but we can provide “bridging” balloon valvuloplasty to aortic stenosis patients prior to being transferred to our partner, William P. Clements Jr. University Hospital (CUH) of Dallas.

Our electrophysiology (EP) services include diagnostic EP studies, 3D virtual mapping services, intracardiac echocardiography, radiofrequency catheter ablations, cryoballoon ablations, permanent pacemaker placement, single chamber, dual chamber, and biventricular ICD placement, Micra (Medtronic) transcatheter pacemaker implantation, transesophageal echocardiography, cardioversions, and minimally invasive implantable loop recorder placement.

We typically perform 40-50 cases a week, but due to the large patient population we serve, that number can fluctuate greatly.

Does your cath lab perform primary angioplasty without surgical backup on site?

Yes, but we work closely with the CUH cardiothoracic surgeons and refer patients for surgical consultation prior to attempting complex interventions.

Do your physicians regularly gain access via the radial artery?

All of our attending physicians are highly competent in radial access procedures. Because Parkland is a teaching facility for general and interventional cardiology fellows, radial access is stressed as a preferred method in reducing bleeding risk and increasing patient comfort.

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

Yes, our physicians will gain ultrasound guided pedal access when the need arises.

Who manages your cath lab?

We have an assistant nurse manager and a nurse manager whose offices are adjacent to our front desk. They are very hands-on in our day-to-day functions. The daily board-running duties fall to a rotating charge nurse selected from our full-time nursing staff.

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

The nurses circulate and the radiologic technologists scrub. Everybody in the lab is trained to monitor all cases. Our nurses are also trained in proper sterile technique so they can help in preparing the patient for the procedure when the technologist is busy. We are also very proud of the fact that all of our technologists and most of our nurses are cross-trained in the EP lab.

Are there licensure laws in your state for fluoroscopy?

Under RULE §194.17 of the Texas Administrative Code, fluoroscopy is considered a “Dangerous or Hazardous Procedure” and can only be performed by a practitioner, medical radiologic technologist (MRT), or limited medical radiologic technologist (LMRT) with a certificate issued in the cardiovascular category. Because of this, at Parkland only board-certified physicians and radiologic technologists can manipulate the x-ray equipment.

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

All physicians and staff wear lead aprons provided by the facility. They may choose to wear their own aprons provided those aprons meet Parkland’s radiation safety policy standards. All lead aprons are inspected annually by the radiology department. All cath lab team members and physicians are issued one whole body and one thyroid dosimeter that are measured and replaced monthly. Those dosimeter reports are delivered directly via internal email. All the fluoroscopy suites are equipped with adjustable tableside lead aprons and floating lead shields on booms. Our EP lab is also equipped with a Zero-Gravity suspended radiation protection system (CFI Medical) if the physicians prefer not to wear lead.

Can you share some of the new devices and systems recently introduced at your lab?

In the last year, our EP lab rolled out the use of the MediGuide navigation system (Abbott) and the Advisor HD Grid Mapping Catheter, Sensor Enabled (Abbott). We also recently changed our hemodynamic monitoring system to Horizon Cardiology 14.0 (Change Healthcare). In May 2019, we launched the Watchman (Boston Scientific) left atrial appendage closure program.

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

We participate in monthly staff meetings, monthly staff/physician meetings, and weekly staff huddles. Internal email communications are also vital to sharing important information. Our staff members participate in facility-wide committees such as unit-based council, peer review committees, and other practice-related groups.

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

All cath lab nurses, technologists, and department assistants are competent in pulling both venous and arterial femoral sheaths and removing TR Bands (Terumo). Staff is checked off after five supervised sheath pulls. The physicians pull radial sheaths and apply TR Bands. Venous interior jugular sheaths are removed in the procedure room by the physician or technologist.

All of our elective patients are prepped and recovered in our shared prep/recovery area on the same floor. This area also services the GI lab and interventional radiology. Only cath lab staff and physicians acquire hemostasis as described above, and only physicians are allowed to deploy femoral closure devices. We use Angio-Seal (Terumo), Perclose (Abbott Vascular), and MynxGrip (Cardinal Health).

How is inventory managed at your cath lab?

We have a dedicated inventory control specialist assigned to the cath lab from the sterile supply department that orders supplies, stocks rooms, and monitors expiration dates. Additionally, all cath lab staff is responsible for keeping the procedure rooms adequately stocked for the next procedure.

Is your lab involved in clinical research?

Our lab has participated in many clinical trials in the past. We are currently participating in the ACCESS trial, for patients resuscitated after cardiac arrest due to ventricular fibrillation outside of the hospital, but who have no evidence of a heart attack on electrocardiogram.

Who transports the ST-elevation myocardial infarction (STEMI) patient to the cath lab during regular and off hours?

During the day, the emergency department (ED) or floor staff will assist in transporting STEMI patients to the cath lab. After hours, we are very fortunate to have a Rapid Assessment Team (RAT) that has been trained to not only deliver the patient to the cath lab, but to also set up the x-ray exam and hemodynamic system while the call team is en route.

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

The RAT team will assist in prepping and setting up the patient in the other cath lab while the call team finishes their first case pending the interventional cardiologist’s approval.

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

We only use single patient use contrast bottles and the circulating nurse visually monitors how much is being given throughout the procedure. At the end of the case, the amount used is documented in the EMR and hemodynamic reporting system.

How are you recording fluoroscopy times/dosages?

The total fluoroscopy time, dose, and dose area product are recorded in the EMR and hemodynamic system. A photo file of these measurements is also saved in the PACS exam for future reference.

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

We use our internal patient safety reporting system to escalate the case for review and provide additional education to the patient.

Who documents medication administration during the case?

The circulating nurse documents all procedural medications into the EMR, then the staff member assigned to monitor copies them into the hemodynamic report.

Are your physicians dictating their cath procedure reports, or do they use a structured reporting tool?

Our physicians build their cath reports in the McKesson Cardiology system. The signed reports then transfer over to the patient’s chart in the Epic EMR.

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

We participate in the ACC-NCDR CathPCI and ICD registries. The CathPCI registry is populated from McKesson into the Cedaron Medical CardiacCare application and then completed by designated cath lab staff members. The ICD registry is input directly into the ACC online data collection tool by another designated cath lab staff member.

How does your cath lab compete for patients?

The greater Dallas area has many facilities equipped with cath labs, but Parkland is the safety net hospital serving Dallas County and therefore, we are the preferred service provider for the under-insured population in the area. All TAVR and cardiovascular surgery candidates are referred to UT Southwestern Medical Center only a few blocks away.

What continuing education opportunities are provided to staff members?

We have regularly scheduled in-services provided in the department by staff and vendors. Our break room also has a bulletin board where management and facility educators post information on CEU and enrichment courses available to all staff. Parkland also has an online education system available to all employees for both mandatory and optional education opportunities.

How do you handle vendor visits to your lab?

Clinical support representatives are here on a case-by-case basis when invited by the physician, but sales representatives must schedule their visit with management. All representatives must check in with the Symplr database on the first floor, check out scrubs from the charge, and wear special colored surgical hats to designate their status.

What do you like about your physical workspace?

We are very fortunate to have larger than average procedure rooms. The department is also laid out in a linear fashion with shared hallways that allow for ease of movement between procedure rooms, and efficient loading and transport of patients. Each lab has its own leaded glass control room and multiple slave monitors to ensure uninterrupted patient monitoring. Each suite also has a boom equipped with power outlets and gas for anesthesia cases.

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

We have three-person call teams consisting of one technologist and two nurses.

How does your lab schedule team members for call?

Staff members sign up for their preferred call holidays and everyone takes their fair share. The technologists then make the weekend call schedule one year in advance. The nurses sign up for weekend call on a monthly basis. Our lead technologist then makes the monthly call schedule for all remaining shifts by allowing staff to sign up in a rotating order that changes every month. (The first person to pick his or her days this month moves to the last spot next month, etc.) This schedule is then forwarded to the manager for final approval and published a month in advance.

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

Thirty minutes.

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

Staff has the option to work either five 8-hour shifts or four 10-hour shifts as long as there is adequate coverage. All cath lab staff members have special duties and/or projects assigned to them to be performed during downtime (data collection, patient phone calls, PACS maintenance, etc.) Additionally, all team members are responsible for keeping the department stocked and clean. Once all duties are performed, non-call team staff may go home early with manager approval.

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

We have an employee of the month nominated by staff and announced at the monthly staff meeting. He or she receives a small gift. Also, any staff member who receives 6 kudos from another employee or patient will get a $5 gift card to the coffee shop. We also participate in bimonthly birthday potlucks and a yearly staff holiday party.

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

We have a really deep bench as far as experience goes. All of our staff can perform any case on the schedule. We haven’t needed to fill a position with a travel nurse or technologist for about a year and a half because of our high retention rate. As mentioned above, we are unique in that almost all of our cath lab staff works in the EP lab as well. Everyone is willing to help out and change room assignments as needed, according to caseload. It is not uncommon for EP staff that is done for the day to come relieve people assigned to the cath rooms for lunch and vice versa. During emergencies, our lab really shines as everyone jumps in to help whenever possible. It is a testament to the exceptional teamwork that exists in our department. 

The authors can be contacted via Laura Ragland, RT(R)(CI), at laura.ragland@phhs.org.

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