Spotlight: Harris Health System Ben Taub Hospital – Cath Lab

Tell us about your cath lab.

Ben Taub Hospital is the flagship hospital for Harris Health System and is located in the heart of the Texas Medical Center. Harris Health is a safety net dedicated to providing high quality, cost-effective, compassionate healthcare to all residents of Harris County. Ben Taub Hospital is a 487-bed academic facility staffed by physician partners from Baylor College of Medicine. Services that support cardiovascular care include an eight-bed coronary care unit (CCU), twelve-bed post cardiac cath unit, two cardiovascular operating rooms, and a 30-bed post-anesthesia care unit (PACU). 

How many rooms are in your cath lab?

The cath lab consists of two rooms with a layout that is ideal for patient flow, and for utilizing the two labs as a swing lab between different procedures and doctors.

What is the mix of credentials at your lab, and how long have staff members been “in residence?” 

Staff members include six full-time registered nurses (RNs), one cardiovascular technologist (CVT), one registered cardiovascular invasive specialist (RCIS), one radiologic technologist (RT), and a procedure scheduler. The experience of staff ranges from 2 to 11 years.

What procedures are performed in your cath lab?  

We perform a variety of procedures, including: 

• Coronary angiography
• Percutaneous coronary intervention (PCI)
• PCI of chronic total occlusions (CTOs)
• Stenting
• Coronary thrombectomy
• Left heart catheterization
• Right heart catheterization 
• Myocardial biopsy 
• Aortic valvulosplasty
• Alcohol septal ablation
• Foreign body retrieval
• Intracardiac ultrasound
• Atrial septal defect (ASD), patent foramen ovale (PFO) and patent ductus arteriosus (PDA) closure devices
• Peripheral angiography with interventions (lower extremities, renals, subclavian)
• Right and left ventricular angiography
• Intra-aortic balloon pump (IABP) 
• Implantable cardioverter-defibrillator (ICD) insertion
• Permanent and temporary pacemaker placement 
• Bi-ventricular implantable cardiac defibrillator & pacemaker placement 
• Electrophysiology studies (EPS) and radiofrequency ablation
• Cardioversion 
• Fractional flow reserve (FFR)

Approximately how many procedures are performed each week?

The cath lab is staffed 24 hours daily for cardiac emergencies. An average of 40 diagnostic procedures and 16 PCIs are performed each week. Three of the procedures are typically for primary PCI related to ST-segment elevation myocardial infarctions (STEMI). In 2014, our lab performed 1675 diagnostic catheterizations, 850 PCIs, and 300 EP/cardiac rhythm management (CRM) procedures. 

Is your cath lab performing transcatheter aortic valve replacement (TAVR)? 

Transcatheter aortic valve replacement is not planned for the near future at our facility.  

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

No, the cath lab has an operating room (OR) for surgical backup within the hospital.

What percentage of your diagnostic caths is normal?

On average, 40% of diagnostic caths are found to be non-obstructive disease. 

Do any of your physicians regularly gain access via the radial artery?

Between the two full-time interventional cardiologists, about 50% of the cardiac cath cases are radial approach.

Who manages your cath lab?

The Ben Taub cath lab is managed by an interprofessional collaborative team consisting of the physician medical director, Nasser Lakkis, MD, Cath Lab Nursing Director Ana Davis, MSN, RN, CCRN, FNP-C, and a charge nurse.

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

Emails, texting, meetings, and morning huddle are the major methods of communicating information. Staff meetings are held on a regular basis; physicians have monthly meetings to update faculty and staff members. The cath lab nurses have a very strong shared governance council or Community of Practice (CoP) that meets monthly, and is where nursing practice and or any other issues are discussed. 

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

All the nurses and cardiovascular technologists can scrub, circulate, and monitor. Medications and documentation are done only by the nurses. The radiologic technologist can scrub and circulate, and is responsible for operating the imaging equipment.

Are there licensure laws in your state for fluoroscopy?

Texas law provides guidelines on who can operate radiation-emitting equipment. The physicians are certified through the radiation safety officer. The radiologic technologists are the only ones allowed to use fluoroscopy without the presence of a doctor. Cardiovascular technologists can use fluoroscopy with a physician present. 

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? 

All cath lab staff has been trained in appropriate use of x-ray equipment, radiation protection and safety. The x-ray equipment can be operated by the staff with the presence of a physician or radiology technologist, but stepping on the fluoroscopy pedal is only done by the physician or fellow.

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

Radiation safety training is undergone yearly by all physicians and staff. The staff also has quarterly checks of their lead aprons and radiation badges. Individual, personalized lead aprons are provided to all staff members and there are additional shields in each cath lab to reduce the amount of scattered radiation.

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

The cath lab recently installed the new Philips Xper Hemodynamic System and St. Jude Medical 3D Mapping. Another big change is the utilization of the Transradial (TR) Band (Terumo) this past year. 

Who pulls the sheaths post procedure?

The fellows or faculty physicians pull the sheaths immediately after the procedure in the cath lab for both diagnostic and interventional cases. Attending physicians train the fellows on closure devices and monitor their closure technique until they feel the fellow physician can utilize closure devices independently.    

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

The patients are prepped in the cath lab holding area and if discharged, they are recovered in the PACU. If patients are admitted, they go straight to the admitting unit, CCU, or post cardiac cath unit. Patients receive closure devices if applicable in groin cases, and if radial access is obtained, then TR Bands are placed. Groin closure options include Angio-Seal (St. Jude Medical), Mynx (Cardinal Health), and manual pressure. Manual pressure is done by the primary fellow who was involved in the procedure. The receiving nurses in the recovery units are responsible for managing TR Bands until removed per protocol.

How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies?

Inventory is managed by our cardiovascular invasive specialist, who utilizes a Pyxis (CareFusion) for general supplies and high-dollar items. Larger purchases or new equipment must go through the system’s Medical Capital Committee, which conducts a value analysis. 

How is coding and coding education handled in your lab?

The monitoring RN selects and records in Xper for each procedure performed during each case. Xper extracts all charges entered by the staff, which also includes the supplies used during the procedure. The main procedure is ordered by the physician in the electronic medical record (EMR) via Epic, which is linked to the report. Once the procedure report is archived, it generates the charges in the patient’s accounts. The charges are reviewed by the office manager for accuracy in collaboration with the coding department. 

Has your cath lab recently expanded in size and patient volume, or will it be in the near future?

The cath lab volume has been stable during past two years, and there is no anticipated expansion in size or volume in the near future.

Is your lab involved in clinical research?

Not at this time.

Can you share your lab’s average door-to-balloon (D2B) times and some of the ways employees at your facility have worked together to keep D2B times under the mandated 90 minutes?  

Ben Taub has exemplary D2B times, despite having mostly walk-in patients in the emergency center (EC). The EC is one of two level-one trauma centers in the city and is considered one of the busiest in the Houston area. Through collaboration between the EC, cardiology, and Houston Fire Department Emergency Medical Services, our D2B times have consistently been below 60 minutes. We are also 100% compliant in meeting the 90-minute D2B time over the last several years. Also, 80% of STEMI patients transferred to our facility in 2015 have a door-to-device time of <120 minutes. Ben Taub has been awarded the American Heart Association Mission Lifeline: STEMI Receiving Center Gold Plus Award and the NCDR-Action Registry Platinum Performance Achievement Award in both 2015 and 2016. 

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

The transfer of patients from EC to the cath lab is the result of collaboration between the EC nursing staff and cath lab fellows, while the cath lab staff prepares the cath lab for the patient’s arrival. 

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

The CCU nursing staff will assist in getting the patient ready and the cath lab staff will take over once the other case is finished. This practice and collaboration has shed minutes from our door-to-balloon time and improved quality of care. 

What measures has your cath lab implemented in order to cut or contain costs?

We have negotiated pricing on drug-eluting stents, ICDs, and cardiac resynchronization therapy (CRT) implants. We have limited the number of vendors used for all supplies and we review the cost of CRT implants on a monthly basis. Additionally, every new product used in the cath lab is reviewed by the value analysis committee. 

What quality control measures are practiced in your cath lab? 

Quality control is ensured through a quarterly review of all procedures by the cardiology quality review committee. All cases with adverse outcomes are reviewed immediately. All STEMI cases are concurrently reviewed by the chest pain coordinator, who shares a STEMI log with all the stakeholders on critical time elements. Additionally, these data logs are discussed during the chest pain steering committee.  

Are you recording fluoroscopy times/dosages? 

Fluoroscopy time and total radiation dose (mGy) is recorded from the Innova image system (GE Healthcare) into the Xper monitoring system for each case. 

Who documents medication administration during the case?

The circulating nurse documents all the medications in the EMR and the recording nurse will keep real-time recording of the administration in the hemodynamic system. The medication record is reconciled by both nurses during or after the case.

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

The physicians use ProSolv reporting software that has built-in templates for complete documentation of the procedure. ProSolv reports are interfaced to the EMR (Epic) system.

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

Currently, Cedaron is installed, in order to interface with the new Philips Xper hemodynamic recording system and transfer the cath lab data to the NCDR-ACTION registry. We also participate in the NCDR-ICD registry to meet the

CMS requirement and we include all ICD patients, regardless of payer or indication.  

How does your cath lab compete for patients? Has your institution formed an alliance with others in the area?

Ben Taub is the only facility that provides invasive cardiology services within Harris Health System. Harris Health System is a large healthcare system that includes over 20 ambulatory clinics and a sister hospital that refers outpatient, inpatient, urgent, and emergent cases.  

How do you handle vendor visits to your lab? 

All vendors check in using our electronic vendor sign-in. The computer will print them a badge that lists the area and the person that they will be visiting for that day. They are allowed in the cath lab to visualize procedures.  

How are new employees oriented and trained at your facility?

The cath lab only hires nurses with a minimum of two years of critical care experience. Each new RN hired to work in the cath lab will receive the Performance-Based Development System (PBDS) exam. The exam is used as a tool to determine the nurse’s assessment and critical thinking skills. Based on each new RN’s PBDS clinical assessment summary, a plan of action is created to formulate a competency-based orientation plan. Each nurse will receive a competency-based orientation form to complete prior to orientation. The newly hired RN will use a daily documentation form to engage in critical thinking exercises.  

Each employee is given a competency-based performance tool to document their self-assessment needs. The competency-based performance tool self-assessment, PBDS clinical assessment summary, job description, and plan of action will be employed by the preceptor to the guide the nurse’s practice and assess for clinical competency. The preceptor provides 1:1 feedback daily during the unit-based orientation process. The nursing director, clinical resource nurse, preceptor, and new RN meet to review the new RN’s progress. They work collaboratively to revise the action plan when needed and outline specific desired outcomes to assist the new RN in meeting the required objective within a precise timeline. 

What continuing education opportunities are provided to staff members?

Staff members are informed of and encouraged to attend the numerous local or national conferences to continue their education by nursing leadership. The hospital has partnered with vendors to provide educational opportunities on new and upcoming equipment. The cardiology service has a bi-annual nursing educational symposium that focuses on any trends or updates in cardiology.

How is staff competency evaluated?

There is a comprehensive process in place to assess staff competency within the cardiovascular work environment. After completion of the orientation-based competency assessment, each staff receives an annual evaluation to assess competency via exams, staff feedback, and day-to-day performance observation. Prior to the annual evaluation process, there is a continuous evaluation of staff competency based on daily assignments, monthly meetings with nursing director, and impromptu meetings when needed. 

Competency evaluation is a continuous assessment. Staff competency evaluation is an inclusive assessment that involves a written exam, staff self-assessment, and preceptor assessment (for new RNs). 

Does your lab have a clinical ladder?

There is a hospital-wide nurse clinical ladder for clinicians. The clinical advancement programs are recognized within the nursing profession as an indication of a highly developed professional environment. The American Association of Critical Care Nurses (AACN) cited clinical advancement programs as one of the eight hallmarks of a professional environment. The Harris Health System Nursing Practice and Professional Model (NPPM) includes a Clinical Advancement Program (CAP) component that differentiates practice levels based upon education, credentials, and demonstrated clinical ability. 

How does your lab handle call time for staff members? Is there a particular mix of credentials needed for each call team?

Call time is evenly distributed among nursing and technologist staff. With every STEMI on call, there is at least one nurse who meets annual credentials to manage temporary pacemaker, IABP, advanced cardiovascular life support (ACLS), and moderate sedation monitoring.

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

The call team is expected to arrive within 30 minutes; however, the CCU teams are next to the cath lab and also get paged when the cath lab gets activated. The CCU nurse will open the cath lab, receive the patient, and start the case until the cath lab staff members arrive. They assist with bed management and other activities as needed. This is a collaborative effort to ensure patients receive timely, safe care.

Do you have flextime or multiple shifts?

All shifts are staggered, with first nurse starting at 0600 and the last nurse finished at 1800. We have 12-hour day shift coverage and 12-hour on-call coverage, Monday through Friday, and 24-hour on-call weekends and holidays.

Has your lab recently undergone a national accrediting agency inspection? 

Yes, yearly national accreditation by the Det Norske Veritas (DNV) is required. We recommend having the hospital’s infection control and safety officers involved in surveying relevant areas, with advice supplied regarding anything that does not meet specific safety standards. 

Additionally, two years ago, Ben Taub received Chest Pain Accreditation from the Society of Chest Pain Centers. Having a strong collaborative relationship with all departments involved in the accreditation process is paramount to a successful accreditation visit.

Where is your cath lab located in relation to the operating room (OR) and EC? 

The cath lab is on the sixth floor and the OR is on the fourth floor. The EC has straight access to the cath lab and OR through a set of emergency elevators. 

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

A major trend we have seen recently is the percutaneous treatment of patients with complex lesions. Our patient population is becoming more ethnically diverse as the Houston area grows, and therefore, the evolution of disease processes varies in terms of presentation. Shifting to radial approach procedures has increased patient comfort and lessened ambulation time.  

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

Collaboration with the CCU has helped in expediting STEMI care during cath lab off hours. The cath lab is unique in that all patients are set up for success during the patient’s pre-procedure cardiology clinic appointment for elective cases and while in the hospital for inpatients. All cath lab outpatients are scheduled through the cardiology clinic, which is across the hallway from the cath lab. The proximity and access to all the services provides an environment that is conducive to continuity and increases access to cardiology care. In addition, the electronic health record at Ben Taub is shared with the clinic and all information is available for all providers. The patients’ entire medical record is seen as “one” in the Epic electronic health record, which makes it easy for follow-up for all patients post cardiac catheterization. We believe Ben Taub Hospital has one of the strongest cardiology programs in the nation, with the outcomes to show it, and this is possible due to the commitment and team spirit of the staff. There is a collaborative team approach with common goals among the staff, helping to get things done quickly and effectively. 

Is there a problem or challenge your lab has faced? 

One challenge we have faced is a long transfer time between hospitals. The sister hospital to Ben Taub does not have a cath lab. A systematic process was put into place that was developed in order to decrease transfer time of cardiac patients requiring specialized care in a timely fashion. 

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?”

Houston houses the world’s largest medical center and is populated by diverse cultures. Ben Taub Hospital is in the Texas Medical Center and patients come from all over the world to be treated here. Ben Taub is the only safety net hospital with PCI capabilities, so there is a large collaboration with EMS and the Houston Fire Department to provide timely care. The hospital sits a couple of miles from downtown Houston and about 2 miles from the NRG stadium, home to the Houston Texans. The staff in the cath lab is diverse in culture and age; they come from a variety of places throughout the world. 

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??
The NCDR Outcome Reports are shared with all stakeholders via the hospital quality review committee, which evaluates any opportunity in areas that may need improvement. Based upon the outcome results, initiatives are developed to focus on and improve patient care and processes.   

Two questions from the Society of Invasive Cardiovascular Professionals (SICP):

Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? Does staff receive an incentive bonus or raise upon passing the exam?

Only the invasive cardiovascular technologists are required to take the exam for the RCIS credential. Nurses are encouraged to take the RCIS exam.

Are your clinical and/or managerial team members involved with any professional organizations that support the invasive cardiology service line, such as the SICP, ACVP, or regional organizations?

We have several nurses and technologists that are involved in the SICP and Alliance for Cardiovascular Professionals (ACVP). 

The authors can be contacted via Jaromir Bobek, CVT, RCIS, at jaromir.bobek@harrishealth.org.