Tell us about your cath lab. Is it part of a cardiovascular service line?
Yes, the cath lab at Saint Vincent Hospital provides both diagnostic and interventional services for cardiac patients, as well as emergency ST-elevation myocardial infarction (STEMI) care. We do approximately 65 to 75 cases per week. We treat vascular patients, including more complex procedures such as endovascular aneurysm repair and carotid stenting. We have a comprehensive electrophysiology (EP) program with two suites available for device, permanent pacemaker (PPM) and implantable cardioverter-
defibrillator (ICD) implantation, and all complex EP cases, including cryoablation and radiofrequency ablations.
Our lab also has a successful structural and valvular heart program caring for patients in need of transcatheter aortic valve replacement (TAVR), MitraClip (Abbott Vascular), patent foramen ovale (PFO) closure, and left atrial appendage occlusion (LAAO) with a device used to reduce the risk for stroke in our patients with atrial fibrillation.
What is the size of your cath lab facility and number of staff members?
We have a four-room cardiovascular interventional lab that is open 5 days a week for 12 hours, with after-hour and weekend emergency care coverage. There is presently a staff of 18 registered nurses (RNs), 5 radiologic technologists (RTs), physician assistants (PAs), nurse practitioners (NPs), and cardiology fellows. Most of the staff is quite tenured; some hold over 30 years of experience.
Can you share more about your lab’s experience performing structural heart interventions?
We started performing TAVR in 2014. Since then, we have completed a total of 458 cases. In 2016, we included MitraClip procedures into our structural heart interventions and have completed a total of 65 cases thus far. The Watchman device (Boston Scientific) for LAAO was added in 2017, and to date, we have performed 27 procedures. Our program has progressed successfully over the years. We are offering moderate sedation versus general anesthesia to 90% of our patients. These patients are recovered for only a short time in the post-anesthesia care unit (PACU) and then are transferred directly to a cardiac telemetry floor, bypassing the intensive care unit (ICU) altogether.
Do your physicians regularly gain access via the radial artery?
All of our physicians prefer to gain radial access and do so if anatomy allows. Our current rate is approximately 80%.
If you are performing peripheral vascular procedures, do any operators utilize pedal artery access when appropriate?
We are currently performing peripheral vascular procedures, we do not utilize pedal artery access.
Who manages your cath lab?
The lab is overseen by a nurse manager responsible for the day-to-day operations, along with the director of cardiac and vascular services, and the senior director for heart and vascular.
Do you have cross-trained staff? Who scrubs, who circulates and who monitors?
Our cross-trained staff consists of RNs and RTs who are all able to participate in any case, regardless of the discipline. RNs are responsible for circulating and monitoring, and are certified in moderate sedation. RTs provide scrub assistance and are responsible for all radiologic and technical tasks.
Are there licensure laws in your state for fluoroscopy?
Yes, all are licensed and credentialed as required by state law. Our hospital staff includes the radiation safety officer and a radiation safety specialist that track and ensure up-to-date credentials.
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?
The radiologic technologists, under the direct supervision of a credentialed physician, and credentialed physicians are the only personnel allowed to perform any and all of these actions.
How does your cath lab handle radiation protection for the physicians and staff?
Our lab supplies lead aprons, thyroid protection, and lead glasses as required. Our protective aprons and equipment are checked first immediately after purchase and arrival, as needed if there is a concern, and yearly to ensure integrity and safety of the staff. All staff is badged and tracked by the radiation safety officer.
What are some of the new equipment, devices and products recently introduced at your lab?
Some of the new devices include a cerebral protection device utilized during TAVR, a small leadless pacemaker, and a wire converter that allows subsequent delivery of compatible catheters, sheaths, and devices. We also are now using a new device for mechanical clot aspiration and removal.
How does your lab communicate information to staff and physicians to stay organized and on top of change?
Our lab is fortunate to have engaged medical directors, both in cardiology and electrophysiology. Our medical directors routinely inquire and seek out new information and technology in line with current changes and advancements in order to better serve our patients. In the lab, we have daily huddles and monthly staff meetings, along with monthly cardiology performance improvement, peer review, and leadership meetings.
How is coding and coding education handled in your lab?
The director for cardiac and vascular services is responsible for keeping coding requirements and changes up to date and ensuring accuracy. The staff is responsible for recording procedures, which are all linked to specific CPT codes that are later sent to charging personnel and the billing department.
Who pulls sheaths post procedure, both post intervention and diagnostic?
The sheaths can be pulled by nursing, the fellow staff, or the physician responsible for the case. Training is completed during an extensive orientation and kept current with yearly competencies.
Where are patients prepped and recovered (post sheath removal)?
Outpatients brought in for procedures are admitted and prepped in a same-day admitting department. Post procedure-admitted patients remain in the lab recovery area and patients to be discharged return to the same-day area for recovery. We use a combination of both manual and vascular closure devices, depending on the case. All patients are cared for by registered nurses both pre and post procedure.
How is inventory managed at your cath lab?
Our lab has a materials manager responsible for the day-to-day charges, and reordering of equipment and supplies. He has shared reporting to the director of cardiac and vascular services and the director of materials management. All new equipment and supplies are vetted through a monthly value analysis committee for approval. This committee evaluates costs and clinical needs.
Has your cath lab recently expanded in size and patient volume?
While we have not physically expanded, we recently upgraded one of the rooms to serve as our second comprehensive EP suite. Prior to the upgrade, we were only able to accommodate patients requiring advanced EP studies and treatment in one room. This project was completed based on planned growth in the EP specialty. In addition, at the beginning of December 2019, a hybrid OR was completed. We are able to perform all procedures presently done in the cath lab in this hybrid room as well, leaving more opportunity for growth.
Is your lab involved in clinical research?
Not at this time.
Can you share information about your lab’s door-to-balloon (D2B) times?
We consistently exceed the national benchmark of 90 minutes with median D2B times of under 60 minutes, hitting 49 minutes in one quarter. The lab works closely with the emergency department for quick activation of the team, and we have put processes in place for rapid registration and transport of the patient. We review cases monthly in a multidisciplinary D2B times meeting. Any outliers are identified and discussed, and we are always looking for improvement opportunities.
Who transports the STEMI patient to the cath lab during regular and off hours?
Once notified of an incoming STEMI, the cath lab team reports to the emergency department (ED) to transport the patient to the lab. On off hours, the emergency department team transports the patient to the lab while cath lab staff is preparing the room.
Is there a particular mix of credentials needed for each call team?
The call team consists of an interventional cardiologist, interventional cardiology fellow, 3 RNs, or 2 RNs and 1 RT. The team is expected to arrive no later than 30 minutes for the page activation. On days post call, the team always has an option to rest if needed. Most, however, choose not to. We have an extremely dedicated team.
How does your lab schedule team members for call?
The lab team members do self-scheduling, including their call schedule. They are responsible for a full weekend starting at 6:30pm on Friday through Monday morning at 6:30am. Their weekend responsibility is every 7 weeks. During the week, all are required to work one night a week.
What do you do when the call team is already busy doing a procedure and a STEMI comes into the ED?
The patients in the lab are evaluated by the team and the resource nurse to quickly identify a patient who can be safely removed from the table. The patient is moved to the recovery area. Once clear, the room is cleaned and prepped to accommodate the emergency.
How do you handle slow periods?
We flex staff for lower volume days. Reducing staff goes in the order of volunteers, per diem, and then flex staff above budgeted hours.
What measures has your cath lab implemented in order to cut or contain costs?
In monthly value analysis meetings, we discuss cost saving opportunities with members from the materials team. When savings are identified, such as, for example, competitive pricing on cath packs, the clinical impact is discussed and vetted, and clinical trials are conducted. Labor costs are also monitored and we try to adjust to meet actual volume.
What quality control measures are practiced in your cath lab?
Followed by cardiology performance improvement team members, we monitor, audit and evaluate compliance with procedural sedation, radial access percentage, D2B times, and heart failure and acute MI readmissions. In the lab itself, we also have put processes in place to prevent skin injury, falls, and catheter-associated urinary tract infections (CAUTIs).
How do you determine contrast dose delivered to the patient during an angiographic procedure?
Contrast dose is determined following a standardized risk assessment for kidney injury. Any patient requiring new hemodialysis is recorded.
How are you recording fluoroscopy times/dosages?
The fluoroscopy times and doses are recorded and saved through our electronic documentation system. This information becomes part of the physician’s procedural report.
What is the process that occurs if a patient receives a higher than normal amount of radiation exposure?
Following the radiation safety policy, all cases are reviewed by the radiation safety officer. The patient’s primary care physician is notified and follows up with the patient.
Who documents medication administration during the case?
The nursing staff documents administration of medication.
Are your physicians dictating their cath procedure reports or do they use a structured reporting tool?
The physicians use both. The case times and details are documented live through an electronic documentation system, followed by dictation following the procedure.
Do you participate in the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR)?
Yes. Data is abstracted by a quality RN specializing in cardiology and is entered by a data entry specialist.
How are new employees oriented and trained at your facility?
New hires begin with a general hospital orientation. Staff RN and RT orientation is accomplished with assigned preceptors in the clinical area for several months, focusing separately on cardiac and vascular cases and patients, and then EP. For emergency STEMI call, RNs and RTs are placed on “buddy” call with their preceptors until they are proficient.
What continuing education opportunities are provided to staff members?
Yearly competency reviews are held that cover all aspects of care in the lab. Staff are routinely offered programs and inservices through various companies in order to review procedures and equipment as needed. All staff have the opportunity to use granted education time to attend conferences.
How is staff competency evaluated?
Staff competency is evaluated through yearly competency reviews, standardized required testing, and online learning modules. Staff receives an annual performance evaluation and is required to be advanced cardiovascular life support (ACLS)-certified.
How do you handle vendor visits to your lab?
All vendors are tracked through Reptrax (IntelliCentrics). Representatives must report daily in order to be provided badges and access to enter the cath lab. We request vendors make appointments to see the manager or director. If not in for specific procedures, vendor lab time is booked and managed by the materials manager.
Do you require your clinical staff members to take the registry exam for the registered cardiovascular invasive specialist (RCIS) credential?
Not at this time.
What do you like about the physical space in which you work?
Our procedural rooms are up to date with the latest equipment and are all decent-sized rooms. With room expansion and upgrade, storage is challenging, but otherwise the physical layout works well for the flow.
Has your lab recently undergone a national accrediting agency inspection?
Last year, we had a visit from Joint Commission. It went very well. The staff is knowledgeable and documents well. If you practice consistently, routinely audit, and give feedback to your staff, they will never be unprepared.
What trends have you seen in your procedures and/or patient population?
We are seeing EP procedural growth for patients requiring ablations.
Is there a challenge your lab has faced?
Accommodating the demand for EP access was challenging last year. We were fortunate to receive approval and build a new comprehensive EP suite.
What is unique about your cath lab and staff?
Staff is unique in that they are cross-trained in all areas. All staff are competent in caring for patients in need of cardiac, vascular, electrophysiology, and structural procedures. When visited, whether by new nurses or physicians, the feedback is always positive. Staff knowledge and expertise stands out, they are proud of their abilities, and they work well together as a team.
A question from the American College of Cardiology’s National Cardiovascular Data Registry:
How do you use the NCDR Outcome Reports to drive quality improvement initiatives at your facility?
We review outcomes and any outliers in monthly performance improvement meetings to drive any needed change. We also use this data in a peer review process.
Bethanne Mazzola, RN, BSN, MBA, can be contacted at firstname.lastname@example.org.