Spotlight: Houston Heart Institute

Tell us about your facility and cath lab.

Houston Heart Institute (HHI) is a 17,000-square-foot facility with four procedural rooms and 12 recovery bays. We have one dedicated cardiac room, one combo room where we do cardiac, peripheral and device procedures, and we also have an electrophysiology (EP) lab. We have 12 registered nurses (RNs), two registered cardiovascular invasive specialist (RCIS) technologists, and three radiologic technologists (RTs) trained to scrub. We have one cardiovascular (CV) technologist whose specialty is post cath groin management. Approximately 70 percent of the current staff has been with us since the inception of the program in 2010. 

What procedures are performed in your cath lab?

The following are procedures that will be routinely performed in the cardiac cath cab, within C-PORT trial (Cardiovascular Patient Outcomes Research Team) guidelines where applicable:     

• Left heart cath: 30-45/week
• Right heart cath: 2-3/week
• Electrical cardioversion
• Transesophageal echocardiogram (TEE)
• Angioplasty
• Percutaneous coronary intervention (PCI): average 8-10/week
• Abdominal aortography with or without runoff
• Permanent pacemaker
• Temporary pacemaker
• Intra-aortic balloon pump (IABP)
• Pericardiocentesis
• Thrombectomy
• Peripheral transluminal angioplasty with and without stent placement
• Intravascular ultrasound (IVUS)
• Fractional flow reserve (FFR)
• Loop recorder
• Renal angiography selective (unilateral or bilateral)
• External pacing
• Fluoroscopy 

You mentioned C-PORT guidelines. Does your cath lab perform primary angioplasty without surgical backup on site? 

HHI does perform primary angioplasty without surgical backup. Our tertiary partner is located 20 minutes north and we have a transfer agreement with them to accept our patients. We also own our Emergency Medical Services (EMS) service and have protocols in place to expedite transfers from HHI to our tertiary partner very quickly. Since we operate under C-PORT guidelines, we report our outcomes to the American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR). Within the registry, hospitals in the 90th percentile have a mean time of transfer from emergency department (ED) arrival at the transferring facility to ED arrival at the receiving facility of 48 minutes, which is very good. The mean time of transfer for HHI is 29 minutes. Our staff takes their work very seriously and we are very proud of that metric.

Can you tell us more about the start of your interventional program in 2010?

Prior to 2010, HHI was a one-lab, diagnostic-only cath lab with non-invasive cardiology and a cardiac rehab department. We deployed our first stent on October 12, 2010. Since that time, we expanded by building two new state-of-the-art cath labs outfitted with Siemens Artis Q and Artis zee x-ray equipment. We also converted our old cath lab to an EP lab. Our echo department achieved IAC (Intersocietal Accreditation Commission) accreditation in 2015 and is the only echo department in a 50-mile radius to have such accreditation. We also recently submitted our application for ACE (Accreditation for Cardiovascular Excellence) accreditation for PCI. We would be only the third cath lab in Georgia to have this accreditation.

Our cath volume has grown; however, we feel — like most areas nationwide — that growth in heart caths will be flat or decreasing over the next few years. Our greatest area of growth has been in devices. Our peripheral volume is also growing, and we are working hard to build that program, because it reflects a huge need in our area. Also, our EP program is new, so we are still in the early building stages of that service line. We have come a long way in a short time.  

Who manages your cath lab? 

Scott Cole, RN, is our manager for Invasive Cardiology. Brandy Hill, RN, is the assistant nurse manager.    

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

We encourage our nurses to train to scrub, and currently one RN is actively being trained to do so. Naturally, it will be accomplished over time. We have RCIS and RT staff that scrub. The nurses circulate. All RCISs, RTs, and RNs may monitor. 

What percentage of your diagnostic caths is normal?

We have struggled at times with this metric. On our last ACC report, we had a 62 percent “clear cath” rate. We have gone from 17 percent or so to 62 percent since we started in 2010. We now have in place several measures to lower this percentage, including more accurate documentation. We expect to improve, and be more consistent and in line with what is expected.

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

We have four physicians that perform radial approaches. Radial access has been slow to take hold here, but all our physicians recognize the advantages of going radial. 

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

All staff, technologists and RNs, takes an occupational radiation exposure learning session and competency test annually. All staff and physicians wear lead aprons, thyroid shields, and eye protection. All staff wears dosimetry badges and reviews their readings monthly.

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

After a recent expansion, we have Siemens Artis Q and Artis Zee x-ray equipment. We purchased two integrated Volcano systems for FFR and IVUS fairly recently. We have started using the Medtronic percutaneous loop recorder, and we also recently purchased a vein finder device to aid in intravenous starts on patients with hard-to-find veins.

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

We utilize our vendors to a great extent for doing lunch and learns, as well as occasional after-work dinner meetings to discuss new technology and products. We occasionally have a staff member research a new product and do a presentation for staff. 

How is coding and coding education handled in your lab? 

Coding is performed in our coding department within medical records.

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

All of our clinical staff is trained to pull sheaths AND manage groins. We believe pulling a sheath is standard practice for all our clinical staff, but managing a challenging groin takes much more skill. We have a post cath groin management team of two people that rounds on all our patients and rotates call 24/7. They also make post discharge calls to our patients to see if there have been any issues or concerns from the patient since discharge. The staff making up this team can be a RN, RCIS, RT, or our CV technologist. It has been a tremendous resource for the floor and intensive care unit nurses, and demonstrates the dedication our people have to delivery of very high quality care for our patients. We have a very vigorous training program undergone by all new clinical staff, consisting of printed literature and instruction on all aspects of groin management. We ultimately require 10 independent successful pulls to be checked off in orientation and then 5 yearly on competencies. 

Where are patients prepped and recovered post sheath removal? 

Our patients are prepped in our 12-bay recovery area. We have two types of vascular closure devices and one access device available, but primarily use Angio-Seal (St. Jude Medical). Manual pull and closure device patients both go back to cath recovery. Angio-Seal patients are recovered for a minimum of 30 minutes and transferred to our cardiovascular floor or to ICU. Manual pull patients have their sheath pulled in cath recovery by either our CV technologist or other clinical staff that have been trained in groin management. After transfer, all our patients are rounded on twice a day by our CV technologist or another staff member trained in groin management. Of course, if the floor nurse has any concerns over the groin, we encourage them to call for help — the post cath groin team is available as a resource to them 24/7. As a safety measure, we make post discharge follow-up calls to check on the groin. We recognize the critical nature of this component of care and the post cath groin management team is an example of how dedicated our staff is to patient safety.   

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

We use the SpaceTrax inventory management system (Stanley Healthcare) in interventional radiology and in HHI. Through the use of this system, staff can see what items are common to both areas and manage inventory par levels accordingly. We were able to achieve a 38 percent decrease in supply cost per procedure in the first 18 months of use. Supplies are ordered by Katie Graham, RT. Katie does a great job of utilizing SpaceTrax to its fullest extent. She has been very successful in establishing appropriate par levels and in getting our needed supplies here quickly.   

Is your lab involved in clinical research?

Not at this time.

Can you share information about your lab’s door-to-balloon (D2B) times and structure of your ST-elevation myocardial infarction (STEMI) program?  

Door-to-balloon time is a critical metric with regard to positive outcomes for the patient. Working with Francis Peed, RN, Director of Critical Care and ED, and David Borghelli, Director of EMS, we developed a process that begins in the field with EMS. Our medics receive excellent training in ECG interpretation and will obtain an electrocardiogram (ECG) on site. If the ECG indicates a STEMI or if it is questionable, they transmit it to the ED physician, who can direct them to the cath lab, bypassing the ED. At the same time the ED physician makes that call, the ECG is sent by secure e-mail to the cardiologist on call, who will verify the need to go to the cath lab or wave them off. For patients that arrive by patient office visit (POV), our criteria for an ECG in less than 10 minutes are: 30 years old or older, and pain above the umbilicus. The national standard is 15 minutes; however, we felt we could do it in 10 or less, and we consistently achieve this goal. We monitor this closely, and meet monthly with EMS and ED leadership to review these times, which are presented on a spreadsheet. Many factors dictate D2B times. STEMIs can present in a number of ways that might not be identified quickly. But by being as diligent as is humanly possible on the front end, we eliminate as many of those variables as we can. Our EMS and ED staff has done a tremendous job of getting these patients to the cath lab as quickly as possible. Our median time for immediate PCI for STEMI patients, as reported on our last ACC report, was 62 minutes. Ideally, we would like to drop this number down to 50 minutes within the next year.     

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

For regular hours and off hours, we require two members of the STEMI call team to transport these patients. One must be an RN. 

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

Appropriate triage is the first step. In the case of an STEMI being intra-procedural and a second STEMI presenting, the teamwork between the ED nurses, house supervisor, and the rapid response nurse is employed. The ED physician will discuss further treatment in addition to the ED protocols in place with the interventional cardiologist.

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

The SpaceTrax inventory control system has been a big help in managing inventory, which reduces cost. Our hospital joined SCSS, a large purchasing group, and that has also helped us reduce cost.                                 

What quality assurance (QA) measures are practiced in your cath lab?

We have several QA measures in place within HHI. We have 100 percent physician review of all STEMI cases. We have monthly meetings to review every STEMI case for procedural hiccups — a measure that has proven to be very effective. We have quarterly cath conferences that are open to everyone in the hospital and offer CMEs for the physicians that attend. We also have monthly morbidity and mortality conferences with the physicians. 

Are you recording fluoroscopy times/dosages? 

Fluoroscopy times/dosages are recorded using our recording systems and entered in the procedure report. 

Who documents medication administration during the case? 

The monitoring technologist enters all meds given during the case and the RN signs off on the report at the end of the case. We also have a Pyxis medication-dispensing machine (Becton, Dickinson and Company) in our procedure rooms.

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

Our hospital is working with Duke University to establish a FastSTEMI program. We have partnered with the three other facilities in our area that offer PCI to accomplish this. We are fortunate to be the only healthcare system within our community. Our objective is to get patients in our area to the nearest PCI center as quickly as possible and to establish protocols for treating STEMI patients in the ED in rural hospitals until patients can be transported to a PCI center.

How are new employees oriented and trained at your facility?

New employees are placed with one of our two preceptors. Their preceptor or team leader provides intense training on all the equipment and will ultimately check them off on a competency worksheet. Orientation and training includes medication administration, circulator role, recorder role, primary recovery room nurse, and post cath groin management. It is a progressive approach to training where the new employee is primarily exposed to one area for a certain amount of time or until they demonstrate competency, and then they move to the next area. Midway through what is typically a three-month training period, new employees go on “buddy call” with their assigned team. This approach allows us to transition new staff members from their previous experience into the unique world of cath lab patient care. 

How do you handle vendor visits to your lab? 

Vendors can be a huge asset to our staff in terms of training and education, and we deeply appreciate what they do. We have to manage their access to the lab, however, to prevent too many from being here at once. Vendor access is managed by Brandy Hill, RN, assistant nurse manager for invasive cardiology. Brandy will typically allow one vendor a day to sign in through Vendormate in our supply chain department. They are allowed in the cath lab at the request of the physician that is working at the time, but are not given free access to the lab. Otherwise, vendors are asked to set up in one of the break rooms. Device representatives have been issued hospital badges.

How is staff competency evaluated?  

Standard nursing competencies are done by our hospital education department yearly, but competencies specific to the cath lab are done yearly by the cath lab manager and assistant nurse manager by demonstration.

How does your lab handle call time for staff members?

HHI has five call teams of four people. There are three RNs and a technologist per team. Obviously with five teams, each team will have one day of call a week and on a rotation, the Friday team covers Friday, Saturday, and Sunday.

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

All members of the STEMI team, including the physicians, are required to be on site within 30 minutes.

Do you have flextime or multiple shifts? 

We do not currently have multiple shifts, but we do have the ability to flex on the occasion that the call team gets caught up all night or if the late stay team works more than 12 hours, which happens frequently.

Has your lab recently undergone a national accrediting agency inspection?

We are extremely proud to report that we have been granted provisional accreditation by ACE. This is something that we worked very hard at and it was a very rigorous process, but very well worth it!  It is very challenging, but it is our belief that to do your best, you must constantly challenge everything you do, as well as each other. It is not enough to know that you have a great program and staff ­— you have to demonstrate that fact to the world. We think we have a world-class program and staff here at HHI, but we recognize that we have struggles just like every other program. We don’t want to hide from the areas in which we are weak — we want to identify them and work together to find a solution. We sought ACE accreditation because we feel their organization will challenge us to be the best, support us on our journey, and help us in areas where we need it most. We welcome their feedback and appreciate their investment in our continuous learning. Their standards are very high and it is a very rigorous process to achieve accreditation from them. We feel it provides legitimacy to our program and validation to our belief in the quality of our program and people. It certainly demonstrates to our community our level of dedication to high quality care for our patients and families. We highly recommend accreditation for anyone thinking about pursuing it.    

As a part of the ACE accreditation process, we undertook an evaluation of structured reporting software. We are now going through the approval process internally to purchase the software we chose (ProVation MD, ProVation Medical).  

Where is your cath lab located in relation to the emergency department (ED)?

From the door nearest to the cath lab, it is 69 steps and two automatic double doors to the emergency department. 

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

We have seen a trend toward younger people in their early to mid-30’s having STEMIs.

What is unique about your cath lab and staff?

It is unique to have a staff of men and women as eager and willing to provide the best care to our patients and also to provide the best service possible to our physicians. I have never worked with a group as dedicated and determined as this one. If a physician requests an earlier than usual start time, it is accommodated without question, every time. Regardless of the time, we do not put restriction on numbers of cases or start times — staff will come back 24/7 for any reason. I have seen this staff identify patients at high risk for re-bleed and spend the entire night to assure the safety of the patient. It is not uncommon for us to get a request over the weekend for a permanent pacemaker. We cannot utilize the STEMI team in this case, but frequently the call team will call everyone else on all the call teams to ask if they can come in to do the procedure. While we cannot guarantee we will be successful in finding staff to agree to return after hours when not on call, there is not an instance I am aware of that the need wasn’t met. These are things that are certainly not mandated (it would be very difficult, if not impossible, to mandate that), but this team takes it on themselves to go the extra mile. I could cite many examples of this level of dedication. This is something that can’t be taught and this staff consistently steps up to a higher level.  

Is there a challenge your lab has faced? 

The biggest challenge we encountered was getting past the old culture of only having a diagnostic cath lab and the reluctance of people to accept that change. Another challenge was getting past the fact that we do not offer surgical backup. Both are legitimate concerns and people have a right to their opinion, but both of these were monstrous obstacles for us to face. Our approach was to simply recognize and understand these concerns and to not try to minimize them. Our solution was a two-step program: education and performance. Much of our early efforts revolved around educating everyone in the hospital and the public on why it is safe to perform this procedure without surgical backup. We were able to speak at community events and with civic organizations, and educate people about our new processes, as well as share some of our successes. We used the C-PORT findings as well as follow-up studies from C-PORT to our advantage, and that is about all we could do early on, but we knew we had the facts on our side. Our message was simply that we understand completely why people were apprehensive, but C-PORT proved the safety of the procedure and our people will not let you down. All it took was time. The staff proved themselves many times over to be more than equal to the task. There will always be the naysayers, but at this point, I think it is safe to say we won the battle decisively by the outstanding work done in the ED, HHI, and post nursing care. 

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”?

We are fortunate in our region to have two other outstanding hospitals with great cardiovascular programs. The unique thing for us at HHI is that south of our hospital is a vast, rural geographical area with a large population, but it is almost two hours to the next PCI facility. This makes us a very valuable resource for all of those people, because now they have faster and easier access to this life-saving procedure. 

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?

This report is a very valuable tool. We use it extensively to help identify trends that might indicate that our processes are not being followed. We review each report with leadership and the medical director of the PCI program. We review our report one standard at the time, identify areas that need improvement, and develop an action plan to resolve the issue. Our quality department is very helpful in investigating any issues and recommending changes. 

The Society of Invasive Cardiovascular Professionals (SICP) has added two questions to our spotlight:

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

We do encourage our staff to obtain the RCIS credential. Some of our staff are currently preparing to take the registry 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 are members of VHA Georgia (now known as Vizient MidSouth) and that association has been invaluable to us. It is a great way to network with others in the area and exchange ideas.

Ray Jones, RN, Associate Director of Cardiovascular Services, can be contacted at lrjones@hhc.org.