Cath Lab Spotlight

Spotlight: South Texas Health System Heart

Scott Fylling, RCIS, FACVP, Director, Cardiac Catheterization Laboratory, McAllen, Texas

Scott Fylling, RCIS, FACVP, Director, Cardiac Catheterization Laboratory, McAllen, Texas

Tell us about your cath lab and facility.

South Texas Health System Heart (STHS Heart) is part of South Texas Health System, the largest healthcare system in the Rio Grande Valley. South Texas Health System is a subsidiary of Universal Health Services. As stated in the name of the facility, STHS Heart is primarily dedicated to cardiac care. We are the area’s only freestanding cardiac hospital and the only one in the region with a dedicated heart emergency room. Hard work and determination have allowed us to be the recipient of five stars by Healthgrades in multiple service lines over the last five years, including being named to the Healthgrades America’s 100 Best Hospitals for Cardiac Care list for five years in a row.

What is the size of your cath lab facility and the number of staff members?

The facility has three all-purpose labs and one hybrid lab that can safely perform various studies, from cerebral to complex below-the-knee interventions. The staff consists of multiple professional disciplines that include registered nursing (RN), radiologic technologist (RT), registered cardiovascular invasive specialist (RCIS), and certified nursing assistant (CNA). Most members of the department have at least five years of experience, with many having more than 10 years of experience.

What procedures are performed in your cath lab?

We perform approximately 175 procedures monthly, with continued growth in all areas.

Patient procedures completed weekly include the following:

  • Diagnostic cardiac and peripheral;
  • Interventional cardiac and peripheral;
  • Electrophysiology (EP) diagnostic and therapeutic;
  • Intravascular ultrasound (IVUS), fractional flow reserve (FFR), and instantaneous wave-free ratio (iFR) procedures;
  • Impella (Abiomed), intra-aortic balloon pump;
  • Pacemakers, implantable cardioverter- defibrillator (ICD), bi-ventricular ICD;
  • Transcatheter aortic valve replacement (TAVR).

Can you share your lab’s experience with structural heart intervention?

Despite the severe impact of the COVID-19 pandemic on healthcare over the past year, STHS Heart has been able to successfully launch multiple programs. One of the new programs implemented during this time was TAVR. We are incredibly proud of this accomplishment during these trying times.

We began our TAVR program using the Sapien 3 transcatheter heart valve (Edwards Lifesciences), with impressive results that have been remarkable for our patients and organization. We are continuing efforts to expand options for our cardiac patients and working with implanting physicians to train them on new technologies available, including Medtronic’s Evolut Pro+ transcatheter aortic valve. Our institution’s Objective and Key Result (OKR), a framework for goal setting, aims to expand our service to cover additional patients in need, including use of the MitraClip (Abbott Vascular) for mitral valve repair, and patent formen ovale (PFO), atrial septal defect (ASD), ventricular septal defect (VSD), and left atrial appendage (LAA) closures.   

How has COVID-19 affected your cath lab and facility?

STHS Heart had to be very proactive when the COVID-19 pandemic broke out in Texas. We took one of our four cath labs and designated it solely for patients who had tested positive or who were suspected as COVID-19 positive. All staff, including the physician, were required to dress in full personal protective equipment (PPE). No one was allowed to leave the room during procedures being performed on this patient population. To accomplish this safely, an additional staff member was assigned to get supplies needed for the procedures and pass them through the door, never entering the procedure room.   

Do you wear PPE with all ST-elevation myocardial infarction (STEMI) cases?

Yes, we do wear PPE for all STEMI or person under investigation (PUI) cases, before the polymerase chain reaction (PCR) results.

Any helpful tips regarding the process of donning and doffing PPE?

As always, practice, practice, practice, and always make sure that you do not cross-contaminate when doffing.

How are you improving communication while wearing PPE?

It may sound simple, but developing hand signals with the team and speaking louder seems to work well while wearing PPE.

When are patients masked?

Patients are masked immediately either in the field or the emergency department (ED).

Can you describe the COVID-19 testing process for patients?

We test all patients for COVID-19 and are fortunate to have a lab within the facility to analyze the PCR onsite. This routinely gives us the ability to have the patient’s results before transporting them to a monitored unit post procedure. For those outpatients needing pre-admission testing, results are completed within 60 minutes.

What metrics monitored regarding hospital employees?

We believe the guidelines set forth by the Centers for Disease Control (CDC) are essential, and we encourage all staff, patients, and community members to adhere to these guidelines. The metrics we continue to monitor at STHS Heart are as follows:

  • The number of employees currently self-quarantined due to travel (domestic, international, cruise);    
  • SELF-quarantine due to a family member/co-habitant with COVID-19 or other outside exposures;    
  • SELF-quarantine due to a possible workplace exposure without a directive from Infection Prevention (IP) or Department of Health (DOH);    
  • Quarantine either by IP or DOH due to possible exposure to a COVID-19 PATIENT at the facility;    
  • Quarantine either by IP or DOH due to possible exposure to COVID-19 positive EMPLOYEE(s) at the facility;   
  • Out due to POSITIVE TEST COVID-19 illness due to possible exposure AT WORK;    
  • Out due to a POSITIVE TEST COVID-19 illness NOT related to work.   

Can you describe the extent and use of radial access at your lab?

Our physicians who are trained in radial access use this approach 95% of the time.

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

Yes, we use pedal artery access. We are lucky enough to have one of the most skilled peripheral cardiologists I have ever witnessed in my 30-plus years as a leader. He truly believes in limb salvage and has the wire skills to match.

Who manages your cath lab?

The department has multiple trained charge personnel that rotate their daily responsibilities. This group of empowered healthcare professionals handle the day-to-day operations, including add-on procedures, breaks/lunches, equipment, and supply issues.

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

Yes, we have cross-training and expect to have it completed within the next six months. We have RTs/registered cardiovascular invasive specialists (RCISs) that scrub and monitor, while RNs monitor and circulate.

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

We badge all staff who enter the cath labs when the physician could be either stepping on the fluoro or cine pedal. The team must also complete and pass a yearly competency review to ensure all members have a basic understanding of the potential risks that come with working in these rooms.

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

All four procedure rooms are Siemens Artis Q rooms (Siemens Healthineers) and are updated with the latest software. Our home office just approved a capital purchase for an update to our GE Mac-Lab systems with one combo lab. This unit will allow us to have the ability to perform EP procedures in two of the four rooms.

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

Communication is done daily in the morning huddle, which is led by the department director. We also have a communication log that we keep in the employee breakroom for staff to review.

How is coding and coding education handled in your lab?

Charge entry and reconciliation are completed daily by the department director. Daily team discussions take place during the morning huddle on questions that revolve around changes or errors. The coding department sends a weekly cardiology coding update to explain coding procedures. Recently our home office had a coding expert present an online video conference covering cath, EP, peripheral, and interventional radiology coding. Post presentation, we were given the PowerPoint presentation for future reference.

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

The sheath is removed, and pressure is applied by any trained member of the cardiac cath department. In terms of training, all staff must successfully pull and maintain pressure long enough to achieve hemostasis to the artery or vein used during the procedure. The new team member is required to complete five successfully before being receiving a sign-off by a proctor.

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

We have a 10-bay pre/post area within the cardiac cath lab department. Hemostasis post-procedure is achieved in multiple ways, including manual pressure, intravascular devices, extravascular devices, or suture devices when using a large-bore entry device.

How is inventory managed at your cath lab?

Stock is monitored by the team using the product, along with our inventory control coordinator. Daily inventory usage reports and communication from department leadership guide our inventory control coordinator when ordering replacement products.    

Has your cath lab recently expanded in size and patient volume?

STHS Heart has grown our volume during the last nine months. We have opened two new service lines: electrophysiology and a structural heart program. Both programs continue to grow and service patient needs within the Rio Grande Valley.

Can you share your lab’s door-to-balloon (D2B) times and some of the ways employees at your facility have worked together to lower D2B times?

The average for the 2020 D2B time was 63 minutes. Strategies to help reduce times focus on early identification, LifeNet (Stryker) (installed in order to minimize field-to-balloon times) in collaboration with local EMS, remote electrocardiogram (ECG) overreading capabilities for the cardiologist, and the establishment of ECG classes for EMS staff.

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

The focus here is the team, so the answer is simple. We all transport or assist as needed. No one algorithm dictates what is best for the patient at any given time. If the emergency department is busy, we go for the patient. If the cardiac cath lab is too busy, they bring the patient.

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

We treat the patients in as timely a fashion as possible. If needed and only as a last resort, we give thrombolytics. This question has many potential variables that would need to be considered for timely patient care of the second STEMI, including the time remaining on the previous STEMI and whether a second cardiologist is available.

How are you recording fluoroscopy times/dosages?

Fluoroscopy dose is recorded in milligray (mGy) along with the time and becomes a permanent part of the patient’s medical record.

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

We use the following when evaluating patients who receive a high amount of radiation during a case:

Fluoroscopically Guided Interventional (FGI) Procedure Reference Levels (RL)

Reference Levels for Equipment Monitoring mGy or mRad

RL1 – 2000 mGy or 200,000mRad

RL2 – 3000 mGy or 300,000mRad

RL3 – 5000 mGy or 500,000mRad

Reference Levels for Equipment Monitoring Fluoro Time:

RL1 – 20 minutes

RL2 – 30 minutes

RL3 – 50 minutes

Patients undergoing interventional FGI imaging procedures with the potential to exceed established reference levels will be required to sign an informed consent.

XVII. RL Exceeded Follow-up

a. Presentation at RSC of a summary of procedures that exceeded PRLs (Procedure Reference Levels),

b. Review of protocols and meetings with the staff to address practices that continue to exceed reference levels.

c. Follow-up action:

RL1 = Notify physician during the procedure that the Air Kerma has reached

RL2 = Notify physician during the procedure that the Air Kerma has reached

And Complete and submit an RL2 form

RL3 = Notify physician during the procedure that the Air Kerma has reached

And Complete and give the patient a copy of the form “Fluoro Skin Dose – Patient Notification” (as part of the patient’s post-procedure instructions/follow-up and

Send a copy of the procedure information to the physicist for a Peak Skin Dose estimate and follow physicist’s recommendations for patient follow-up.

Who documents medication administration during the case?

Documentation of medication records is a two-step process. During the procedure, the medication administered is part of the permanent record and then is recorded within the hemodynamic recording system’s procedural documents. The hemodynamic system prints out a list of all medication ordered and given during the procedure. This sheet is signed, dated, and timed by the physician and the qualified healthcare professional administering the medication.

What measures have your cath lab implemented to cut or contain costs?

We use a new product and equipment request form, and then have a value analysis committee review the document before bringing a product in for trial or replacement.

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

We use structured reporting within the electronic medical records system.

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

We focus on acute kidney injury, making sure that labs document serum creatinine levels, age, gender, and race in order to calculate the value of glomerular filtration rate (GFR). We calculate the maximum contrast dose for all patients.

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

Our Chest Pain Center participates in the NCDR’s EP Device Implant registry (formerly the ICD registry), Chest Pain-MI, and the ACC Accreditation Conformance Database (ACD).

How are you populating the registry data records?

The Chest Pain Center Department mines documentation from the EMR and then manually inputs the required data.

How are new employees oriented and trained at your facility?

New employees undergo a standard onboarding that requires multiple days, depending on your hired position. Orientation consists of the facility tour, introduction to leadership throughout the organization, benefits, and job-specific requirements.

What continuing education opportunities are provided to staff members?

We use HealthStream to assign and monitor annual requirements based on the area of practice and conditions set forth by the staff member’s license or certification. We also have inservices on new technology or service lines such as structural heart or EP.

Are your clinical and/or managerial team members involved with any professional organizations that support the invasive cardiology service line, such as the Alliance for Cardiovascular Professionals (ACVP)?

Yes, the department director has been a longtime member of professional societies and recently achieved fellowship standing from the ACVP.

How do you handle vendor visits to your lab?

The facility uses SEC3URE Ethos (IntelliCentrics) (formerly RepTrax) to monitor vendor visitation within the organization. Open visitation is an area that needs to be closely monitored within the department and as we continue to see a decrease in COVID-positive patients within the facility. Badges are mandated when visiting the cardiac cath lab area.

How is staff competency evaluated?

Yearly competency and peer review are the most professional way to evaluate each employee. New devices or services would require training by each employee before assisting with patient care.   

Does your lab have a clinical ladder?

No, but presently a clinical ladder is under development.

Do you require your clinical staff members to take the Registered Cardiovascular Invasive Specialist (RCIS) registry exam?

At STHS Heart, it is not a requirement for other healthcare professionals to take the RCIS or the registered cardiac electrophysiology specialist (RCES). However, we do have employees who have successfully passed the national boards for these registries.

Does your lab have any physical (layout) bottlenecks or limitations? How do you work around the resulting challenges?

Our three procedure labs surround a central storage area, which frees up space in the labs. Our hybrid room is in the surgery department, approximately 150 feet away. To mitigate any potential bottlenecks or limitations, we purchased supply cabinets to ensure our supplies for our typically hybrid room procedures (aortic abdominal aneurysms, structural heart, and EP) are always available.

What do you like about your physical workspace?

A centralized supply room is a huge plus to any health system. It allows the organization to decrease the number of owned and consigned products.

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

Each call team has at least one RN and one RT. The remaining two members could be RCIS, RCES, RN, or RT.

Are staff permitted to leave early or start later after a night of on-call?

Safety of the patient and safety of the staff are paramount. Therefore, the department director has the autonomy to allow staff to leave early or start late as they see fit.

How does your lab schedule team members for call?

We believe in empowerment, allowing the staff to work these types of issues out between themselves. We only assist with ideas on making the system work for the majority. An example would be the runner call for the PUI/COVID STEMI procedures done after hours. Each staff member was assigned a position in this rotation, and each month the process started with the next person in line. Allowing everyone to start first and everyone to be last at some point during the cycle.

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

All staff are required to arrive onsite within 30 minutes of the emergency page.

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

On days when the lab is running at high capacity, the facility will provide lunch for the team.

Has your lab recently undergone a national accrediting agency inspection? Do you have any recommendations or advice?

We are presently in the timeframe for our Joint Commission review and re-certification for Chest Pain/Percutaneous Coronary Intervention (PCI) accreditation.

What trends have you seen in your procedures and/or patient population?

Our volumes have increased over the first three months of 2021. The increase is due to the new services being offered and the decrease in COVID-positive patients in the Rio Grande Valley area.

Is there a problem or challenge your lab has faced?

A challenge that we face at the hospital is having limited staff while continually growing exponentially. Our leadership acknowledges this challenge and fully supports additional staff hiring to service our patient and physician needs. A significant factor for our administration is ensuring a work-life balance for the team while ensuring that the quality of our patient care is not hindered.

What’s unique about your city or general regional area in comparison to the rest of the U.S.?  How does it affect your “cath lab culture”?

The Rio Grande Valley is located at the southernmost point of Texas, at the meeting point of Mexico and United States. Diabetes, hyperlipidemia, and hypertension are highly prevalent in the Rio Grande Valley population. A large portion of the population is non-English speaking; therefore, the cath lab is obligated to have diverse staff to be able to communicate with all patients. 

Scott Fylling, RCIS, FACVP, Director, Cardiac Catheterization Laboratory, can be contacted at Scott.Fylling@uhsrgv.com