Spotlight: Saint Agnes Medical Center

Mike Colgate, RCIS, MPH, Lead Cardiovascular Technologist, can be contacted at mike.colgate@samc.com. Katherine McCardell, RN, Heart and Vascular Services Director, can be contacted at katherine.mccardell@samc.com.

Tell us about your cath lab.

Saint Agnes Medical Center is a 436-bed acute care hospital with a comprehensive heart and vascular service line. We are a ST-elevation myocardial infarction (STEMI) receiving center, with a combined cath lab/interventional radiology (IR) department. Housed within the department are three dedicated Philips cardiac cath suites and two IR suites. The cath lab and IR employ separate staffing, utilizing teams of registered nurses (RNs), registered cardiovascular invasive specialists (RCISs) and registered radiologic technologists (CVRTs). The cath lab operates with 9 RNs, 5 RCISs, 4 CVRTs, and 4 supporting staff members who each have between 5 and 25 years of experience.

What procedures are performed in your cath lab? 

The following procedures are performed in our cardiac cath lab: diagnostic and interventional angiography, cardiac rhythm management (CRM), electrophysiology studies (EPS)/ablations, 

peripheral revascularization, abdominal aortic aneurysm (AAA) repair, and structural heart procedures. We serve 40 cardiologists that include diagnosticians, interventionalists, and electrophysiologists. Approximately 80 to 90 procedures are performed each week.

If your cath lab is performing transcatheter aortic valve replacement (TAVR), can you share your experience? 

In April 2014, Saint Agnes became the first area hospital to offer the TAVR procedure, and has since performed 28 cases utilizing the Philips Allura FD20. Multiple disciplines from both the cardiac cath lab and cardiovascular operating room (CVOR) are involved in the procedure. The synergy created by this collaboration is the driving force of our success. 

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

Our cath lab operates with informal surgical back up. Formal back up is available upon request for high-risk percutaneous coronary intervention (PCI).

What percentage of your diagnostic caths are normal?

Approximately 10 percent of our diagnostic caths are normal.

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

Approximately 35 to 40 percent of our interventional cardiologists utilize radial access for diagnostic and interventional procedures.

Who manages your cath lab? 

Practice coordinators George Nan, RN, and Bryan Weiss, RN, along with RCIS lead Mike Colgate, manage the cath lab’s daily operations. These positions are governed by a nurse manager under the supervision of the Heart & Vascular Services Director, Katherine McCardell, RN, and Cardiac Cath Lab Medical Director, Rimvydas Plenys, MD. 

Who scrubs, who circulates and who monitors? 

The scrub role is shared by all 3 disciplines. The circulating role, however, is only assigned to RNs. The monitor role is shared by both RCIS and CVRT staff.Are there licensure laws in your state for fluoroscopy?  

Yes. The staff operates under the direct supervision of the performing physician who holds a fluoroscopy license in the state of California. In addition, all CVRTs are licensed by the state of California for the use of fluoroscopy. Performing physicians and licensed CVRTs are the only individuals authorized to position the tube, pan the table, change angles and step on the fluoro pedal.

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

We have a designated CVRT who is given the role of radiation safety officer. He/she reports to the radiology department. All physicians and staff utilize lead aprons, lead glasses, and dosimetry badges. These badges are reviewed and renewed on a monthly basis.

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

Our three cardiac suites recently underwent comprehensive upgrades. We utilize Philips Healthcare Systems: 2 Allura FD 10s and 1 Allura FD 20. All three suites feature FlexVision to integrate multiple IS modalities onto the 56-inch flat-panel display monitor. Stentboost, along with the latest software and hardware release, allow staff to easily navigate from suites. We have also incorporated Volcano’s CORE and St. Jude Medical’s ILUMIEN systems for intravascular ultrasound (IVUS), fractional flow reserve (FFR), and optical coherence tomography (OCT) at tableside.

We use St. Jude Medical’s WorkMate for recording of all EP studies/ablations. All 3-D mapping and ablation procedures are navigated by Biosense Webster Carto 3 and St. Jude Medical’s NavX Velocity.

Our TAVR program employs both Edwards Sapien and Medtronic Core Valve for optimum patient outcomes.    

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

Our lab has monthly staff meetings, as well as daily morning huddles. In addition, our cath lab leadership team attends the monthly cardiology meetings to discuss operational and policy issues.

How is coding and coding education handled in your lab? 

All coding is performed by a dedicated clinical revenue specialist, Cynthia Martinez. Coding education is administered through corporate and vendor webinars.

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

Routinely, femoral sheaths are pulled in our post-procedure recovery area by RNs. At the physician’s request, clinical cath lab staff may be called upon to pull sheaths in the procedure room or in the post-procedure recovery area. All radial sheaths are pulled in the procedure room immediately after procedure, utilizing the Terumo TR Band.

All staff must be validated for sheath pulls. This requires five successful sheath pulls.

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

All patients are prepped and recovered in our 35-bed Cardiovascular Recovery Area (CVRA). This area is staffed by RNs, a licensed vocational nurse (LVN), and clinical assistants, who perform all preop prep and postop sheath pulls and recovery care.

Hemostasis is achieved by both manual compression and vascular closure devices. We utilize Abbott Vascular’s Starclose and Proglide, St. Jude Medical’s Angio-Seal and FemoStop, and AccessClosure’s MynxGrip. Vascular Solutions’ D-Stat Dry Patch can be used with manual compression.

How is inventory managed at your cath lab? 

The cath lab utilizes Omnicell for inventory management and patient equipment charges.  The RCIS lead and the supply chain system administrator work in conjunction to purchase equipment and manage inventory par levels.

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

The cath lab recently underwent a two-and-a-half year renovation of all procedural rooms. Construction began July 2015 on a fourth suite, which will be a hybrid suite specializing in TAVR, peripheral, and EP procedures.

The Saint Agnes cath lab is on track to increase our volume by 10 percent. Our success is a direct result of our commitment to offer a service-oriented, high-quality experience, for our patients and physicians. Our workflow, as it pertains to throughput of pre- and post-areas, electronic medical record (EMR) and information systems (IS) interfaces, aids us in achieving this goal, which ultimately has an impact on growing our volume.

Is your lab involved in clinical research?

Not at this time. However, we are actively looking to participate in future trials.

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?  

Based on data from the last 12 months, we are currently averaging D2B times of 59 minutes — well below the national standard of 90 minutes. The STEMI team is comprised of four clinical staff members and has a required 20-minute response time. All suites are fully equipped to emergently perform acute myocardial infarction (AMI) procedures. The hospital maintains an integrative AMI committee comprised of the emergency department (ED), quality department, cath lab, cardiovascular (CV) diagnostics, and clinical cardiology, in conjunction with administration. This committee meets monthly for case review, enhancement of protocols for early activation, and to streamline patient throughput. There is same-day review of STEMI cases with delayed door-to-electrocardiogram (EKG) times. Emergency medical services (EMS) maintains protocols to active the STEMI team from the field in order to decrease door-to-balloon times. 

We are not currently registered with the American Heart Association’s Mission: Lifeline or the American College of Cardiology’s D2B Alliance.

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

All STEMI patients are transported to the cath lab by two clinical cath lab staff members.

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

In the event a STEMI comes to the ED when the call staff is in the middle of a non-emergent procedure, communication takes place between both physicians. An arterial line is secured and the patient is transported to CVRA for observation.

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

We have implemented a Unit Based Council comprised of cath lab and CVRA staff. This Council meets monthly to evaluate workflow, patient throughput, and policy and procedures in order to streamline and reduce duplication of efforts. Our Value Analysis Team (VAT) meets monthly to review all equipment and product trends to promote standardization of equipment and reduce costs.

What quality control/quality assurance measures are practiced in your cath lab?

The cath lab quality assurance and control measures include, but are not limited to, the following: universal protocol or “time out,” radiation safety and reduction, appropriate and consistent hand hygiene, correct sponge accountability, accurate “point of care” testing, and minimizing contrast utilization.

Are you recording fluoroscopy times/dosages? 

Fluoroscopy times/dosages are manually entered into the Philips Xper procedural log.  We are currently evaluating the use of Philips’ Modality Performed Procedure Step (MPPS) to electronically transmit all numeric fluoroscopy data.

Who documents medication administration during the case?

The RN circulator records and documents all medication administration and conscious sedation.

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

Physicians are currently dictating their cath reports. However, structured reporting is currently being evaluated for efficacy and workflow.

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

Yes. We currently participate in the CathPCI and Implantable Cardioverter Defibrillator (ICD) Registries.  

How does your cath lab compete for patients? 

In April 2015, Saint Agnes Medical Center and Dignity Health signed a definitive agreement that will expand health care resources for patients and physicians from Stockton to Bakersfield.  

How are new employees oriented and trained at your facility? 

New employees are placed on a 6-month probationary period. They are assigned a preceptor who is responsible for their orientation and training. Weekly evaluations are conducted to monitor progress. Physician and peer input is solicited to determine whether or not the individual is retained or the probation period extended. 

What continuing education opportunities are provided to staff members?

Continuing education opportunities are provided by approved American Society of Radiologic Technologists (ASRT)/Board of Registered Nursing (BRN) vendor in-services and webinars, the Heart & Vascular clinical educator, and hospital-based educational conferences.

How do you handle vendor visits to your lab?

The hospital utilizes RepTrax for the management of outside vendors and representatives who visit the cath lab. All must wear a RepTrax identification badge and adhere to policies and guidelines that direct their role in the cath lab. Vendors/representatives must obtain prior approval to obtain access to the cath lab. There are guidelines to ensure competing vendors are not present on the same day. At the request of a physician, vendors/representatives are allowed in the procedure rooms to assist with procedures.

How is staff competency evaluated? 

Annual comprehensive evaluations are conducted for merit-based compensation and retention. The evaluations are conducted with a physician and peer. Computer-based competencies are performed to maintain hospital policies and procedures.  

Does your lab have a clinical ladder? 

All clinical disciplines have merit-driven ladders based on licensure/registry, years of experience, and hospital committee and project involvement.  

How does your lab handle call time for staff members? 

Staff members average 8-10 call shifts per month, including weekends. Call teams require four staff members that include two RNs and two RCISs or CVRTs for all cardiac cases. The cath lab maintains a required 20-minute response time from activation

Do you have flextime or multiple shifts? 

Flextime and multiple shifts are not a common practice. All clinical staff members work 12-hour shifts.

Has your lab recently undergone a national accrediting agency inspection? 

The hospital underwent successful Joint Commission accreditation in July 2014. We recommend paying careful attention to the following: ensure pre-procedure history and physicals (H&Ps) are complete and accurate, and ensure proper charting in EMR as it relates to plan of care and medication administration.

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

The three cath lab suites and four cardiothoracic (CT) operating rooms are adjacent and are located two floors above the emergency department. 

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

Utilization of radial access has increased for both diagnostic and interventional procedures. TAVRs and high-risk PCIs with mechanical support (Impella, Abiomed) have modestly increased in volumes. In addition, EP/afib ablation procedures continue to grow at a steady pace. Unfortunately, co-morbid conditions and varied advanced diseases are seen in a majority of patient populations.

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

The cardiac cath lab maintains a dynamic partnership with numerous vendors, which integrates forward thinking and state-of-the-art technology to benefit our patients and physicians.

The staff has invested a tremendous amount of time evaluating workflow and case navigation from start to finish. The goal has always been to reduce time and expedite physician throughput by streamlining workflow.

Is there a problem or challenge your lab has faced? How was it addressed?

Case turnover time has markedly improved with metric-based solutions. Utilizing Philips Xper Information Management System and charting, we have improved patient case flow, increased efficiency, and exceeded physician satisfaction. These metric-based solutions have decreased our average case turnover time to less than 10 minutes.

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”?

The city of Fresno is located in the heart of California, in the fertile San Joaquin Valley — what many describe as the agricultural capital of the world. Unique to Fresno is its cultural diversity, representing more than 80 different nationalities. With such diversity comes language and cultural differences that Saint Agnes must be careful to address in its delivery of care. To that end, we offer audio and visual interpreter services to assist in integrating the patient and family in the cardiovascular plan of care. In addition to audio and video interpreter services, educational materials are also printed in multiple languages.

Read more about Saint Agnes Medical Center and their technological and systems expertise! 

Don’t miss Cath Lab Digest’s April 2015 interview:

“Saint Agnes Medical Center Improves Cardiovascular Workflow with the Philips Xper Flex Cardio with Xper IM”, online at: https://www.cathlabdigest.com

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

1. 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?

All CVTs are required to hold and maintain the credential of RCIS. RTs are required to obtain the credential of RCIS, CI (Cardiac-Interventional Radiography) or VI (Vascular-Interventional Radiography) within two years of hire to the cath lab. RNs are strongly encouraged to obtain the credential of CCRN. A monetary incentive is attached to all advanced registries/credentials recognized by the hospital.

2. Are your clinical and/or managerial team members involved with any professional organizations that support the invasive cardiology service line?

RNs are strongly encouraged to obtain the CCRN (critical care registered nurse) or Cardiac-Vascular Nursing credential. Nationally recognized credentials assist in advancement of clinical nurse ladders. In addition, RNs, RCISs and CVRTs are also encouraged to become members of the American College of Cardiology’s clinical team by becoming an Associate of the American College of Cardiology (AACC).

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?

Saint Agnes Medical Center does utilize the NCDR Outcome reports to identify areas of improvement. As an example, past reports showed D2B times were averaging 90 minutes. Despite the fact that Saint Agnes was meeting this national benchmark, it identified an opportunity to improve its processes to achieve D2B times less than 90 minutes. So an AMI collaborative team was formed, comprised of the ED, cardiology, cardiac cath lab, quality improvement department, CVDS (Cardiovascular Diagnostic Services), and Heart & Vascular administration in order to identify and implement changes. As a result, we succeeded in reducing our D2B times and have averaged 59 minutes for the past 12 months.