WakeMed Health and Hospitals Invasive Cardiology

Tell us about your facility and cath lab.

WakeMed is a 919-bed, private, not-for-profit health care system based in Raleigh, North Carolina. It operates two acute care hospitals (WakeMed Raleigh Campus and WakeMed Cary Hospital), a women’s hospital (WakeMed North Family Health & Women’s Hospital), a physical rehabilitation hospital, three healthplexes (WakeMed Apex, WakeMed Brier Creek and WakeMed Garner), a home health agency, two outpatient facilities, four collaborative outpatient rehabilitation programs located inside area YMCAs, and WakeMed Physician Practices, a multi-specialty physician practice. WakeMed is a leader in both Wake County and North Carolina in developing innovative services to meet the needs of the community and region. 

WakeMed is one of the state’s largest providers of comprehensive cardiothoracic and vascular services. The hub of cardiac services at WakeMed Raleigh Campus is the WakeMed Heart Center. This facility, physically connected to the main hospital, first opened in 1998 and underwent expansion and renovation in 2005. The layout of the Heart Center allows patients to register, see their cardiologist in their offices, and have non-invasive cardiovascular tests and invasive cardiac, peripheral and neuro procedures performed all under one roof. If an overnight stay is required prior to or following a specific procedure or test, patients and their families have the option of spending the night in the full-service hotel located on the top floor of the Heart Center.

Other services unique to WakeMed that bring added value to the communities we serve include: 

• Wake County’s only Level I Trauma Center as designated by the North Carolina Office of Emergency Medical Services;
• Chest Pain Centers accreditation by The Society of Cardiovascular Patient Care;
• Primary Stroke Centers certified by The Joint Commission;
• The Heart Center Conference Center, a 5,000-square foot facility with meeting rooms for conferences and symposia, with state-of-the-art capabilities for streaming video directly from the cardiac catheterizations labs and operating rooms to the conference center.  WakeMed physicians frequently present findings from research, as well as host experts in cardiovascular disease treatment and management for local physicians and health care professionals;
• On-site 24/7 invasive cardiology staff to expedite all emergent procedures in the cath lab.

Who manages your cath lab?

The Invasive Cardiology management team consists of a department manager (Kim Wooten RN, BSN, RCIS), three cath lab supervisors (Kristy Whitley, BSN, RN, RCIS, Mike Turner, RT[R], RCIS, and Hollie Boswell, MHA, RCIS), and one electrophysiology (EP) supervisor (Jeannine Volles, BSN, RN, RCIS).

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

The Invasive Cardiology Department at WakeMed Health and Hospitals consists of 11 procedure rooms, which include cardiac catheterization labs, a hybrid room, and EP procedure rooms. Five of the coronary procedure rooms are equipped to perform complex peripheral vascular and neurovascular procedures. The hybrid room is also used for structural heart and complex endovascular procedures. Our newest procedure room is equipped to perform coronary, peripheral vascular, and complex EP procedures such as complex ablations.  

The staff within our department consists of 59 cardiovascular specialists (CVS), three secretaries, one scheduler, and two cath lab assistants. The cardiovascular specialist or CVS title encompasses multiple modalities, consisting of 25 registered nurses (RNs), 20 radiologic technologists (RT[R]s), 8 emergency medical technicians-paramedics (EMT-Ps), 3 registered respiratory therapists (RRT) and 3 registered cardiovascular invasive specialists (RCISs), although all 59 of our CVS staff are RCIS certified in addition to any credentials they may hold.

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

Our cardiovascular specialists, which include nurses, radiology technologists, paramedics, and respiratory therapists, are cross-trained to function in all three roles (monitor, scrub and circulate). They have all achieved the RCIS credential, in addition to their primary credentials.

What procedures are performed at your facility? 

Our facility performs coronary, peripheral vascular, and neurovascular diagnostic and interventional procedures. Our coronary procedures include left heart and right heart catheterizations from multiple access sites (femoral, brachial and transradial). Percutaneous coronary interventional (PCI) procedures include intravascular ultrasound, fractional flow reserve (FFR), embolic protection devices, mechanical and manual thrombectomy procedures, and insertion of intra-aortic balloon pumps and Impella (Abiomed) ventricular assist devices.  We also perform complex chronic total occlusion interventions using both the antegrade and retrograde techniques.

Peripheral vascular procedures performed include atherectomy (Jetstream [Boston Scientific], Diamondback [CSI], TurboHawk [Medtronic]), drug-coated balloons, EkoSonic (EKOS Corporation), stenting and mechanical thrombectomy (AngioJet [Boston Scientific]). We are also using the tibiopedal arterial minimally invasive retrograde revascularization (TAMI technique) for critical limb ischemia (CLI). 

Our neurovascular procedures include carotid/intracerebral angiography and interventions.  Interventions performed include stroke, aneurysm coiling, arteriovenous malformation (AVM) and arteriovenous fistula (AVF) embolizations and stenting (Pipeline [Medtronic]).

Electrophysiology procedures are also occasionally done within the invasive cardiology procedure rooms, but are most commonly performed in our EP procedure rooms. 

We perform transcatheter aortic valve replacement (TAVR) procedures, MitraClip (Abbott Vascular) procedures, endovascular aneurysm repair (EVAR) and thoracic endovascular aneurysm repair (TEVAR) in our hybrid procedure room.

Can you share more about your TAVR experience?

Our TAVR program began in March 2013. We perform all our cases in our hybrid procedure room in our invasive cardiology department. We have performed a total of 93 cases over the past two years.  

Do interventional radiologists and cardiologists perform procedures in the same area?

The peripheral procedures that are performed within our department are performed by interventional cardiologists, vascular surgeons and one neurosurgeon. We do not have interventional radiologists that work in our department.

Can you share your lab’s average door-to-balloon (D2B) times?

Our D2B times are consistently less than 50 minutes for 100% of Code STEMI (ST-elevation myocardial infarction) patients. We average less than 90 minutes for first medical contact to balloon/device time. We were awarded the Mission Lifeline Silver Award in 2015 for consistently following the American Heart Association’s treatment guidelines for four consecutive quarters, meeting performance standards and measures for STEMI care.

WakeMed initiated a Code STEMI process in March 2006 to facilitate improving the door-to-balloon (D2B) times. The process involves early identification through the Wake County Emergency Medical Services (EMS) system. The paramedics in the field are trained to recognize criteria for ST elevation. They utilize Bluetooth technology to transmit electrocardiograms (EKGs) directly to the emergency room and the cath lab prior to arrival with the patient for confirmation. Once confirmed, the emergency department (ED) physician can activate the internal Code STEMI response. 

The response team consists of a cardiac care unit (CCU) rapid response nurse, the clinical administrator, the physician assistant/nurse practitioner (PA/NP) for the cardiology practice on call, and the in-house cath lab staff. The Code STEMI response team assists the ED staff in facilitating and expediting transport of the patient to the cath lab.

Before the initiation of the Code STEMI response process, our average D2B time was 120 minutes. In January 2008, the invasive cardiology department implemented 24/7 cath lab staffing. This staffing is made up of a full-time, 4-member team and was developed to further improve the Code STEMI response time.  

As a backup to the 24/7 staffing, our department maintains an on-call team to respond if multiple emergent procedures occur. The on-call team for our department has a 30-minute response time for arrival to the cath lab when called to duty.

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

The Code STEMI response team (critical care RN, respiratory therapist, house clinician, NP/PA) in collaboration with members of the cath lab team will transport the patient to the cath lab during both regular and after-hours operations.  

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

The department on-call team has a 30-minute response time. We do not routinely have an attending cardiologist on-site; however, PA/NPs affiliated with the physician practices are on-site 24 hours a day. 

How does your cath lab handle radiation protection for the physicians and staff that are in the lab day after day?

Radiation protection is an important part of our day-to-day operations and our department has implemented several radiation safety measures. All staff and physicians are monitored utilizing radiation badges. These badges are exchanged monthly and readings are available to staff. In addition to monitoring badges, all staff and physicians are provided with personal lead aprons and lead glasses. Radiation badge audits are performed monthly on staff and physicians by a departmental radiation safety committee to verify that monitoring devices and protective equipment are being utilized appropriately.

Within the peripheral vascular rooms, additional lead shielding has also been added to both sides of the procedure table to include table shielding and hanging lead shields. This provides additional protection for staff regardless of access site.  

Can you describe the system(s) you utilize and how they work in cath lab daily life?

Our hospital system switched to EPIC for our electronic medical records (EMR) last year. Our department uses the cardiology module of EPIC, known as CUPID. We use CUPID for scheduling and documentation of our procedures. However, we still use the GE Mac-Labs system for hemodynamic monitoring. We use Lawson (Lawson Software) for our inventory system, which interfaces with the CUPID EMR system. 

Who documents medication administration during the case?

For every case, we have an assigned documenter. The role of the documenter is to monitor vitals and record all procedure and medication events. Using CUPID, the documenter is able to record the physician order, dosage, route, indication and medication administrator in the procedural event log.

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

Inventory is managed through our Lawson system using a bar code system for scanning inventory into the procedure log, which replenishes inventory (generates a purchase order) based on par levels set once the item is scanned/used during a procedure. Products are selected through a department/hospital product review committee, which consists of physicians, clinicians, and a strategic sourcing contract specialist. The strategic sourcing contract specialist works with department management to purchasing equipment and supplies, and negotiates pricing contracts. 

How do you handle vendor visits to your lab? 

All appointments and visits are handled through the strategic sourcing contract specialist and all vendors must be compliant with all immunizations, mandatory education, and HIPAA (Health Insurance Portability and Accountability Act). These requirements are managed through our Reptrax vendor credentialing system. Vendors are not allowed on the hospital premises without an appointment and must wear their Reptrax badge at all times while on the premises. Vendors are not allowed in procedure rooms unless invited in by a physician and must wear hospital-issued scrubs. 

How are new employees oriented and trained at your facility? 

The orientation process for new employees usually takes up from 3 to 6 months. Each employee is given an orientation manual (that provides didactic explanations of procedures, equipment, anatomy and medications) and is assigned with a preceptor who has worked in the lab for a minimum of two years for hands-on experience. The orientee is trained in each of the three roles (monitor, scrub and circulate). Each role, on average, takes 4 to 6 weeks for complete training.  Each employee must complete competency checklists, and have the approval of their preceptor, educator and management prior to completion of a role. For employees entering with cath lab experience, the same process is utilized; however, the orientation time frame is usually shorter.  Performance assessments are completed at the stages of 30 days, 60 days, and 90 days to assess the progress and needs of the new employee. 

Our educators also have access to a simulation lab that can be utilized in the teaching of new staff and students on coronary and carotid procedures.

Every employee must be credentialed as an RN, EMT-P, RRT, RCIS, or RT in order to work in the lab. Our staff is also required to have basic life support (BLS) on hire, advanced cardiac life support (ACLS) within 3 months of employment, and obtain the National Institutes of Health Stroke Scale certification (NIHSS). The registered cardiovascular invasive specialist credential (RCIS) is required within 2 years.

What continuing education opportunities are provided to staff members?

WakeMed’s professional development of staff is supported through various continuing education opportunities. Opportunities include:  tuition reimbursement, an on-site RN to BSN program, an on-site BSN to MSN program, Masters in Health Administration and Masters in Business Administration programs, WakeMed’s Leadership Academy, and WakeMed Foundation grants and scholarships for skills development.  

Within our department, we provide monthly in-services on medications, equipment and anatomy that assist with obtaining continuing education for our staff. Our staff also has annual blitz check-offs that include staff and vendor education on frequently and infrequently utilized devices. 

Programs are also offered from our Area Health Education Center (AHEC) organization that include but are not limited to: RCIS review seminars, cardiac symposiums, and stroke symposiums.  

As part of our department’s employee evaluation, every CVS is required to obtain a minimum of 15 continuing education units (CEUs) annually. 

Does your lab have a clinical ladder? 

Our facility does have a professional development program that is available to staff after one year of employment (6 months if prior cath lab experience) within the department. Staff is required to fulfill a standard set of requirements that include technical skill check-offs/experience, education of other staff/peers, community involvement, and leadership components. There are three levels of progression: CVS I, CVS II, and CVS III. 

Our department also offers a professional development program for our team leaders as well, with requirements containing more leadership expectations.

How does your lab handle call time for staff members? 

Our call team consists of 4 staff members, all of whom are cross-trained and RCIS-credentialed to staff every role needed. This team is utilized for situations in which there are multiple emergencies. Our in-house team is the primary response team for emergencies after hours.

Do you have flextime or multiple shifts? 

With 24/7 operations, our department can perform elective and emergent procedures at any time, including weekends and holidays. If additional staff is needed, there is an on-call team that is available. Currently our department consists of multiple shifts for 24-hour coverage. We have staff that work 8-hour shifts, 10-hour shifts, and 12-hour shifts. There is also staff that is scheduled to work night shifts and weekend shifts. 

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

The OR and the cath lab are both located on the second floor of the hospital. These departments are separated only by the critical care units and critical care family waiting room. Our ED is located on the first floor of the hospital directly below the critical care units.

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

The current trend in our department is an increase in complex procedures. We are performing an increased number of hybrid procedures, as well as complex peripheral vascular and EP procedures.  

How do you see your cardiac catheterization laboratory changing over the next decade? 

Integration of multiple modalities has been key to the growth of our cardiovascular program. Peripheral vascular intervention is a rapidly growing market as we progress towards more CLI and hybrid procedures. We anticipate progressing as a regional stroke center utilizing mechanical intervention. Planning for future expansion and renovation projects will be geared toward additional multi-purpose procedure rooms for flexibility to perform heart caths, EP and peripheral vascular procedures.  

What do you consider unique and/or innovative about your cath lab and staff?

Several items make our lab unique and innovative:

• Fully cross-trained staff: What this means for our patients and staff is that each staff member can contribute to a procedure or emergency in every way possible to take exceptional care of our patients’ well-being.  
• 24/7 staffing: We are proud that our department can provide patients with full-time, 24-hour staffing coverage. We employ a 4-member team during off hours (nights and weekends) to allow for quick emergency coverage and availability for elective procedure completion beyond regular lab hours. This coverage has reduced the amount of staff callback and has reduced the Code STEMI D2B times.
• Stroke and carotid interventional program: Our department has performed carotid interventions since October 2003 and is currently one of the few cath labs developing interventional stroke programs in the nation.   
• NIH Stroke Scale certified: Our department prides itself in the fact that 100% of our staff is NIH Stroke Scale certified. As our department moves into the field of stroke intervention, it was felt that our staff needed to have the knowledge to best support and treat our patients. 

WakeMed Awards & Accolades:

• Magnet Designated facility by the American Nurses Credentialing Center
• Blue Distinction Center+ for Cardiac Care by Blue Cross and Blue Shield of North Carolina
• American College of Cardiology’s NCDR ACTION Registry–GWTG Platinum Performance Achievement Award for 2015
• American Heart Association’s Mission: Lifeline® Receiving Center – SILVER Plus Level Recognition Award
• 2015 Get With the Guidelines Heart Failure Gold-Plus Quality Achievement Award
• WakeMed Raleigh Campus was rated “High Performing in Heart Bypass Surgery and Heart Failure” and WakeMed Cary Hospital was rated “High Performing for Heart Failure” by U.S. News & World Report

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?

We use the NCDR Outcome Reports in both our physician quality committee as well as our department QI committee.

A question 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?

We take pride that the majority of our staff is recognized as RCIS certified. We require new staff to obtain the RCIS credential within 2 years of hire. WakeMed makes every effort to help each employee achieve this through RCIS exam review and exam reimbursements. The RCIS is recognized in our progression ladder process for advancing to a CVS III.