The authors can be contacted via Swame Kue, CVT, at xkue@lifespan.org.

Tell us about your hospital and cath lab.

The Miriam Hospital has a total of four labs. Two are primarily for coronaries, one is a coronary/peripheral lab, and one is a peripheral/electrophysiology lab. We have a total of 37 staff members, consisting of registered nurses (RNs), cardiovascular technologists (CVTs), registered cardiovascular invasive specialists (RCISs), nurse practitioners, physician assistants, an environmental services staff member and our wonderful secretaries. There are approximately 20 diagnostic cardiologists and seven interventional proceduralists. All interventional cardiologists are board certified. Staff member tenures in the cath lab range from 2-30 years. 

What procedures are performed in your cath lab? 

We perform cardiac catheterizations, percutaneous coronary interventions (PCIs), chronic total occlusions, intra-aortic balloon pump insertions (IABPs), left ventricular assist devices (LVADs), coronary/peripheral laser atherectomy, aortic valvuloplasties, atrial septal defect (ASD) and patent foramen ovale

(PFO) closure, pericardiocentesis, myocardial biopsies, intravascular ultrasound (IVUS), fractional flow reserve (FFR), rotational atherectomies, thrombectomy, intracardiac echo, cardioversions, transesophageal echocardiogram (TEE), and TEE with cardioversions. With regards to peripherals, we perform carotid stenting, peripheral vascular stenting, endovascular aortic repair (EVAR), EKOS ultrasound-accelerated infusion, infusion for thrombolysis, orbital atherectomy, renal and visceral interventions, and inferior vena cava (IVC) filter placement. 

In the electrophysiology (EP) lab, we perform pacemaker insertions, cardiac defibrillator placement, subcutaneous implantable cardioverter-defibrillator (ICD), biventricular pacemaker/ICD implantation, loop recorders (injectable), and revisions.

Our volume, by procedure includes:

• Diagnostic caths: 45/week
• Percutaneous coronary interventions: 25/week
• Peripheral interventions: 10/week
• Pacemakers: 8/week
• PFO/ASD closures: 2/month

Does your lab have a hybrid room?

We have one hybrid room for peripheral vascular and EP procedures. We do perform EVAR in our hybrid room with the assist of a vascular surgeon and anesthesia. Patients are normally discharged the next day. There is no cardiac surgery on site, so transcatheter aortic valve replacements are performed at another hospital in our system. 

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

Yes, we are the largest volume cath lab in the northeast without surgery on site. High-risk interventions such as left main stenting or multi-vessel PCIs are done with the assist of an Impella device (Abiomed) or an IABP. We have had no emergent coronary artery bypass graft surgeries transferred from our facility since the cardiothoracic program was relocated 3 years ago. 

What percentage of your diagnostic caths is normal?

Approximately 10% of our diagnostic catheterizations have non-obstructive coronary artery disease.

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

Yes, currently 45% of our total cases are performed via the radial artery. Most of our interventional cardiologists prefer radial access. The Allen’s test is performed on every patient prior to the procedure to ensure adequate blood flow. We also perform right heart catheterizations via the brachial, basilic or medial cubital vein with ultrasound-guided access. 

Do you have cross-training? 

Cross training is encouraged in our lab. We are a teaching institution and have cardiology fellows from Brown University/Warren Alpert Medical School who perform a rotation of their fellowship in the cath lab. They assist in the procedures. In addition, we have mid-levels comprised of nurse practitioners and physician assistants that assist. Also, cardiovascular technologists can also assist the proceduralists. There are two RNs that circulate and one cardiovascular technologist that monitors during every cardiac catheterization procedure. During our EP procedures, there are two RNs who circulate and monitor. A cardiovascular technologist or an RCIS will assist the physician. 

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 physician and his assistant, whether a cardiology fellow, physician assistant, nurse practitioner, or cardiovascular technologist, perform all the functions listed. The physician is the primary operator. 

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

Physicians and staff are required to have training in radiation safety every two years. All staff members are fitted for lead aprons and thyroid collars, and are required to wear radiation badges. Radiation badges are measured monthly for exposure dosage. Lead aprons are checked annually for imperfections, holes, or breaks. Each lead apron is numbered and dated, and removed from use if compromised. A lead apron log is kept by the lead technologist. We will be using the X-Trak apron tracking system (AADCO Medical) in the near future. 

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

We have two Philips FD20 labs that are utilized mostly for peripheral procedures.

We have an array of products for coronary interventions such as the Impella CP (Abiomed), intra-aortic balloon pump (Maquet), AngioJet (Medrad), laser atherectomy (Spectranetics), IVUS and fractional flow reserve (both Volcano Corp.), and the CrossBoss catheter (Boston Scientific). We have started using the Diamondback 360˚ coronary atherectomy device (CSI). 

Our peripheral vascular devices are comprised of laser atherectomy, Crosser (Bard PV), ultrasound-accelerated thrombolysis (EKOS Corp.), Stealth 360˚ orbital atherectomy (CSI), Turbohawk (eV3), Frontrunner (Cordis), Outback catheter (Cordis), Wildcat/Kittycat catheter (Avinger), Truepath (Boston Scientific), Pioneer Plus (Volcano) and Trellis (Covidien). The Zilver PTX (Cook) drug-eluting peripheral stent is the newest product in the lab. The Lutonix drug-coated balloon (Bard PV) will be on our shelf in the near future.

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

We have a staff communication board located in the break room. Any new equipment or departmental concerns are posted. Weekly staff meetings and email are also effective sources of communication. 

How is coding and coding education handled in your lab? 

Our cardiovascular technologists are trained and responsible for billing the correct charges for coronary and peripheral procedures. During EP procedures, our staff nurses document the correct charges. The final coding is handled by our cath lab manager and secretaries. Every billing slip is checked for the correct codes and supply charges. Special in-services and training are offered through Lifespan and the Miriam Hospital to stay aware of CPT changes and the upcoming ICD-10 changes.

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

Diagnostic femoral sheaths and (transradial) TR Bands (Terumo) are removed by our procedural care unit (PCU) staff. Our nurse practitioners and physician assistants pull all interventional sheaths during regular hours. We have a sheath team on the evening shift that pulls all the interventional sheaths. Training is done by our lead nurse practitioner or our experienced sheath pullers. Training is completed when staff members feel comfortable removing all types of sheaths, whether it is a femoral sheath (antegrade, retrograde) or brachial sheath, or removal of a TR Band from a radial patient. Completion of the competency checklist is necessary and the final approval by the lead nurse practitioner is mandatory before a sheath puller becomes independent.

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

Patients are initially examined during pre admission testing in our procedural care unit (PCU) a few days before the procedure by our mid level team of nurse practitioners and physician assistants. The PCU has the responsibility of prepping and recovering our patients on the day of their procedure. Sheaths are removed by our mid levels, as well as trained PCU nurses and cath lab technologists. 

With regard to closure devices, femoral artery angiograms are performed prior to choosing a closure device. Closure devices are done by the physicians. Any radial access cases with a TR Band are closely monitored and the TR Band is removed by the PCU RNs. When appropriate, Perclose (Abbott) and Angio-Seal (St. Jude Medical) are our preferred closure devices for femoral access. However, most of our physicians prefer manual compression.

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

We have a technical coordinator that does all the coronary equipment ordering and supplies for the lab. We assign two cardiovascular technologists to manage the entire peripheral inventory. Balloons and stents are on consignment. A par is set for catheters and wires. With every case, supplies are automatically subtracted from inventory when used. When the par drops to a predetermined number, it is flagged and the technologist is able to quickly scan all inventories for flagged items. This keeps the par at a cost-effective but safe level. Larger ticket items (i.e., Impella) are ordered as they are used. Monthly quality assurance is conducted on every piece of equipment by all staff members to check expiration dates.

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

Our peripheral vascular procedures have had a steady increase in volume. In order to facilitate procedural volume flow, there is a plan for a dedicated EP lab in the near future. We also recently acquired the cardioversions and TEE/cardioversions from the post anesthesia care unit (PACU), in order to keep all cardiovascular procedures in the same area. The stress lab, nuclear imaging, echo, pre/post procedure area, and cath/EP lab are all located on the same hallway.

Is your lab involved in clinical research?

Yes, we have a research department that is currently participating in twenty ongoing clinical trials. Some of the trials that we are involved in include:

• The PFO ACCESS Registry (Amplatzer PFO Occluder by St. Jude Medical);
• PILOT-SECRET (Coracto Rapamycin-Eluting coronary stent delivery system by Alvimedica); 
• ABSORB III (Absorb bioresorbable vascular scaffold, Abbott Vascular); 
• CANTOS (reducing inflammation in previous heart attack patients with canakinumab, Novartis);
• ISCHEMIA (cardiac cath with optimal medical therapy vs optimal medical therapy alone for stable coronary artery disease);
• THEMIS (ticagrelor vs placebo in patients with type 2 diabetes mellitus, AstraZeneca);
• TAILOR PCI (using genetic information to determine the best antiplatelet therapy for patients who undergo coronary angioplasty, Mayo Clinic);
• AVERT (very early mobility training after stroke, National Stroke Research Institute, Australia);
• LATITUDE-TIMI 60 (anti-inflammatory medication losmapimod vs placebo in ACS, GlaxoSmithKline);
• PARACHUTE IV (Parachute device in ischemic heart failure, CardioKinetix, Inc.)
• SCAFFOLD (Gore carotid stent, W.L. Gore & Associates);
• REMEDIAL II (Renal Guard vs sodium bicarbonate infusion plus N-acetylcysteine to prevent to prevent contrast-induced acute kidney injury, Clinica Mediterranea);
• LUTONIX BTK (Lutonix below-the-knee drug-coated balloon, C.R. Bard);
• LUTONIX ISR (Lutonix drug-coated balloon for coronary in-stent restenosis, C.R. Bard); 
• DANCE (Bullfrog Micro-Infusion Catheter to deliver dexamethasone to the adventitia after endovascular therapy, Mercator MedSystems);
• VIABAHN (Viabahn endoprosthesis with heparin bioactive surface, W.L. Gore & Associates).

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

Our D2B time numbers are below the 90-minute mark. Some of the initiatives we have recently started include having the emergency department (ED) doctors page the call team in when they suspect an acute myocardial infarction. After paging the team, the ED physician has a conversation with the interventionalist on call to discuss the patient. By this time, the staff is already en route to the hospital. We have also started a process where the Emergency Medical Service (EMS) teams call into the ED with ST-elevation myocardial infarctions (STEMIs), while the patient is in transport to the hospital. When this occurs during the day, the cath lab physician and RN will meet EMS and the patient at the ED door, assess the patient, and bring the patient directly to the cath lab if necessary, thus eliminating the ED admission.

We participate in the American College of Cardiology’s National Cardiovascular Data Registry (ACC-NCDR) – PCI Registry and are looking into Mission:Lifeline with the American Heart Association.

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

Two cath lab staff members go to the ED to pick up the patient. If intubated, a respiratory therapist will accompany them to ambulate and assist with poles/pumps, etc. This occurs whether it is on or off hours.

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

The call team will be paged for STEMIs, ischemic lower extremities that require EKOS insertion, acute pulmonary embolism that requires EKOS with thrombolytic infusion therapy, aortic valvuloplasties, IABP, or temporary pacer insertion. The team will either finish up the case as effectively and efficiently as they can, and move on to the STEMI case, or have the nursing supervisor call in a back-up call team to do the STEMI. There are always RN and technologist staff members that have stated they are available on a moment’s notice to come in and back up the call team.

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

Keeping tighter control on our inventory has been key in saving costs. We were involved in a Yellow Belt project with Lean Six Sigma, and we organized, sorted, and straightened all our supplies and equipment to streamline the numbers and the footsteps needed to obtain the supplies for a case. This year, we were fortunate to be part of a Six Sigma Green Belt project. Our project leader, Leisa, has compiled volumes of flow statistics based on times of cases, availability of physicians, block times used and unused, overtime hours paid per day of week, and times of cases ending on days of week. This project has gone on for 6 months and we are eagerly awaiting the results. As of now, the cath lab is open 7am to 7pm Monday through Friday, but we are trying to better facilitate our volume flow.

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

We hold monthly QA meetings for peripheral, EP, and coronary procedures. Weekly cath conferences are where cases are discussed and therapies recommended. Bi-monthly D2B and ACC-NCDR meetings are held to go over the latest data, and study shifts or trends. 

Are you recording fluoroscopy times/dosages? 

Yes, we document fluoroscopy time, total air kerma (AK) and total dose area product (DAP) for every patient. A DAP of 500mGy or AK of 1000mGy is reported to the radiation safety officer. Patients who have received a high radiation dose are given an extended fluoroscopy form with instruction to report any skin irritation. A follow-up phone call is made to ensure the patient has not had any problems.

Who documents medication administration during the case?

We have the Mac-Lab/CardioLab (GE Healthcare) for our recording system. All our RNs, CVTs, and RCISs are responsible for medication documentation. A medication log is generated at the end of each case. Each medication includes the name of ordering physician and the nurses who administer the medication, time, dosage, and pain assessment with q 5-minute vital signs and pain reassessment. 

How long have you been enrolled in the ACC-NCDR?

We have been enrolled for approximately 6 years. We also participate in the ICD registry and participate in the Vascular Quality Initiative (VQI) registry. The VQI registry collects data from carotid artery stenting, endovascular repair (EVAR), and peripheral vascular interventional procedures. 

How does your cath lab compete for patients? 

The physicians that bring their patients to the Miriam Hospital have been doing so for many years. There really is not a “competition” between hospitals, as the physicians realize the high quality of care that is being given to their patients. Also, we are very accommodating with regards to add-ons and time constraints the physicians might have with office hours, etc. We have been known to add on non-emergent patients as late as 4pm in order to facilitate the needs of a patient and/or physician. 

How are new employees oriented and trained at your facility? 

New staff is paired with more experienced staff. A preceptor is assigned to the new staff member, and they train for approximately 16 to 24 weeks. Each new staff receives an orientation packet that breaks down goals and expectations on a weekly basis. If more training is needed, the orientation period can be extended.

What continuing education opportunities are provided to staff members?

Inservices are provided to staff by company representatives. There is also education about seminars, tuition assistance, and support for any and all opportunities for growth.

How do you handle vendor visits to your lab? 

All vendors are required to sign in with Reptrax and must wear an identification badge. Arrangements are made with the cath lab manager, technical coordinator, or the cardiovascular technologists. Vendors are not allowed in the room, except if there is new equipment or product where they have to be present in order to proctor the cardiologist. 

How is staff competency evaluated? 

Hospital and cath lab competencies are evaluated annually via written tests. RNs participate in peer feedback, whereby they receive positive and negative suggestions from their colleagues, thus opening the door for self-growth.

How does your lab handle call time for staff members? 

All staff members are required to be on call. There are a total of six call teams. Our call teams consist of the interventional cardiologist, interventional cardiology fellow, two RNs, and one cardiovascular technologist. Teams are on call once per week from 5:30pm to 7:00am. Holiday calls are distributed fairly.

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 for call cases. 

Do you have flextime or multiple shifts? 

Lab hours are 7am-7:30pm, with 12-, 10-, and 8-hour shifts. Staff arrives at 7am, 9am, or 11am. 

Has your lab recently undergone a national accrediting agency inspection? 

The Joint Commission visited in June 2014. Patient safety, environment of care issues, and cleaning competencies seem to be high points of concern this year. 

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

We are located on the first floor adjacent to the emergency department, literally across the hallway. The OR is located on the second floor, approximately 3 minutes walking time.

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

Diagnostic procedure volumes are dipping, perhaps due to the ACC appropriate use criteria parameters, whereas cardiac interventional procedures are remaining even. STEMI volumes have dropped, perhaps due to drug-eluting stents or better medically managed patients. EP volumes and peripheral volumes are both on the increase.

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

Cross training. We have RNs who can “tech”, and techs that are able to circulate in the rooms and scrub on the cases. RNs and techs are involved in inventory as well as the purchasing of supplies. Another key factor is the role played by our mid level providers, who perform preadmission testing, scrub in the cases, write orders, and discharge the patients that evening or the next day. They truly facilitate patient flow and bring continuity of care to a new level. Our scheduling secretary, who is not involved in patient procedures, best describes the cath lab staff: “I’m proud to say I work with such great professionals. There is no other place I would have my family, friends, acquaintances than this lab if ever needed.”

Is there a problem or challenge your lab has faced? 

A few years ago, the cardiothoracic surgical program was relocated to our sister hospital, Rhode Island Hospital, located on the other side of the city of Providence. Although our services have not changed within the cath lab itself, it was a loss nonetheless.

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”?

Patients have a preference with regards to their hospitals. If their parents went to a hospital, then that is where they want to go as well. That is why it is so very important to provide the highest quality of care at every aspect of their stay. Patient satisfaction can be attained or lost with one encounter. 

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?

The outcomes are scrutinized by the director and by Quality, trying to find the common thread if the outcomes are low, and changing the processes to support positive results.

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?

There are eight cardiovascular technologists in the lab. Two have just recently passed the RCIS exam. The RCIS certification is not required, but the process is supported by management, and reimbursement is obtained for successful outcomes. There are no raises or bonuses upon passing the exam.