Cath Lab Spotlight: Banner Thunderbird Medical Center

Tell us about your cath lab.

Banner Thunderbird Medical Center cath lab has 3 cardiac catheterization labs, 1 electrophysiology (EP) lab, a shared bi-plane room and a shell for future expansion. Our 26 staff members consist of both registered nurses (RNs) and radiologic technologists (RTs). Full-time staff includes 11 RNs and 10 RTs (36 hours/week). In addition, there are 5 per diem staff that are utilized when needed to help to insure adequate staffing, one scheduler, and one inventory coordinator. Our staff’s experience in the cath lab ranges from 6 months to 20 + years, with our turnover rate for 2013 being 15%.

What procedures are performed in your cath lab?

The average number of procedures performed each week is 60. Procedures include diagnostic cardiac catheterizations and coronary interventions, including angioplasty, atherectomy, and stenting; diagnostic and interventional peripheral procedures, including angioplasty, atherectomy, and stenting, including carotid stenting; and diagnostic and interventional electrophysiology procedures including ablations of atrial and ventricular arrhythmias, atrial fibrillation, pacemakers, internal cardiac defibrillators, patent foramen ovale and atrial septal defect closures.

Fractional flow reserve, intravascular and intracardiac ultrasound, intra-aortic balloon pumps, and left ventricular assist devices such as the Impella (Abiomed) are additional tools used in our labs.  

Does your cath lab perform primary angioplasty with surgical backup on site? 

Yes, we perform primary angioplasty 24/7. Our cardiac surgeons are on-call and available for our patients at all times. Patients that are considered “high risk” are prescheduled with the OR and cardiac surgeons. 

What percent of your diagnostic caths are normal?

We fall within the national benchmark of between 20 to 39%.

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

Yes, we have providers that prefer to use the radial artery for arterial access. 

Who manages your cath lab? 

We currently have 1 EP RT supervisor, 1 senior RN manager, and a director of cardiovascular services. The RT manager oversees the day-to-day operations, while the senior RN manager is involved with developing and/or changing current processes at the facility and system level. We also have a medical director who assists us with future direction and physician issues.  

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

We are unique in our region in that both our RTs and RNs scrub procedures. The RNs circulate and monitor, and the RTs run the x-ray equipment during the cases (in Arizona, only RTs can operate x-ray generating equipment). We are in the process of cross-training the RTs to monitor as well. 

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

Staff and physicians must wear lead aprons and thyroid collars. Lead glasses are available for those who choose to utilize them. All staff, vendors, and physicians are required to wear radiation badges and the x-ray equipment is not turned on until all persons have on protection and their badge. All staff is required to do a radiation safety module annually.  Lead is checked on an annual basis for any cracks or holes. The cath lab has representation on the hospital radiation safety committee.

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

We began supporting our high-risk cases with left ventricular assist devices such as the Impella. We have also implemented end tidal carbon dioxide (ETCO2) monitoring for all sedated patients this past year. The cath lab is consistently bringing in new products, which are evaluated by our products standard committee. In addition, 3D-ATG software packages (Philips) have been added to our labs as well. 

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

We have monthly cardiology department meetings as well as monthly heart and vascular committee meetings. The meetings are attended by physicians, hospital leaders, educators, and staff, and discuss updates, pending issues, new trends, and case studies.  Information from these meetings is passed down to staff through staff meetings held monthly and through huddles that are held twice weekly. Emails and bulletin boards are also used to communicate any updates or changes.

How is coding and coding education handled in your lab? 

At the end of each day, a trained, designated staff member will review each case, as well as supplies used, for accuracy. These charge sheets are then scanned to our coder. She compares the items used and procedures indicated to the physician-dictated report. Any discrepancies are addressed so that all aspects match and accurate coding can be completed.  

Coding education is offered a few times a year by different companies. Management and coders are encouraged to go to the education in order to stay up on the latest coding changes and updates. We are also a part of a large health care system. Corporate administrators stay on top of changes in coding and share updates with those doing the coding at the facility level.  

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

Both RTs and RNs pull sheaths. They are trained during orientation and undergo a sheath pulling class. Staff is then signed off via competency checklists by trained staff. Annual competencies for sheath removal are required of all trained staff. There is a groin management committee with representatives from the cath lab and the units that care for post procedure patients. All complications are reviewed with feedback and education provided when indicated.  

Where are patients prepped and recovered post sheath removal? 

Both manual closure and vascular closure devices are used in our lab, and most sheaths are removed in the cath lab. Patients are transferred to designated units post procedure with staff that are trained to monitor the care of these patients and their post procedure sites. There is specifically-trained staff on these units to pull sheaths in the event that a sheath must stay in for a period after the procedure. Outpatients are prepped in the specific outpatient unit that performs all necessary pre procedure lab testing, EKGs, prepping, and teaching of these patients. Inpatients are prepped and educated in the units where they reside.   

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

Inventory decisions are made at a system level. A product standards committee reviews supplies and makes the decisions for all labs in the system. Each facility has knowledgeable people that participate on this team. Recommendations from physicians are brought to this team for discussion. At our facility, we have an inventory clerk, who orders supplies daily, and monitors par levels and expiration dates. Banner Thunderbird Medical Center utilizes SpaceTRAX (Stanley Healthcare) as our inventory management system, as well as doing bi-annual manual inventory counts.   

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

Banner Thunderbird Medical Center’s cath lab expanded in size approximately 3 years ago. Previously, the lab consisted of 2 cath labs and 1 EP lab. After our expansion, there are now 3 cath labs, 1 EP lab, a shared biplane lab/second EP lab (for overflow), and a shelled space for further growth.  

Is your lab involved in clinical research?

Most of the clinical research is performed primarily at our partner facility, Banner Good Samaritan Medical Center.

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?  

We have a team with a long history of representation from cath lab physicians and staff, the emergency department, and management that meets regularly to review all D2B data. The team has been very effective in enhancing cooperation between the emergency department and the cath lab, and dramatically improving our D2B times. In 2013, we met 99% compliance of less than 90 minutes with D2B times. Our 2013 D2B time averaged 68 minutes. Physicians and the staff receive immediate feedback on cases. Each case is reviewed within 24 hours of the procedure.    

Who transports the ST-elevation myocardial infarction (STEMI) patient to the cath lab during regular and off hours?

The emergency room staff generally transports all STEMI patients, but the cath lab staff often goes to assist. This shared cooperation has been effective in improving our D2B times.

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

We have a specific written workflow process for handling this situation. The emergency room doctor, nurse and house supervisor assist in this process.  

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

Our lab is currently encouraging the use of fractional flow reserve to better determine the true flow-limiting lesions. We also reprocess many different EP catheters, allowing us to recycle the catheters additional times, and recycle precious metals. Bulk purchasing is another way we save cost, along with contract negotiations. We include our physicians in the decision-making process on products to help their understanding of our need to practice cost-conscious decision-making.  

The RT on each case is required to print out the inventory list for each case, and review and sign it to provide accountability. In addition, specific staff is assigned to check all charges for a specific day to ensure that all equipment has been charged for what was used during a procedure.  

Are you recording fluoroscopy times/dosages? 

Yes, we record fluoroscopy times/dosages on every case. We notify the physician at 15-minute intervals. We monitor and track fluoroscopy times, and report data to our radiation safety committee on a monthly basis.

Who documents medication administration during the case?

The RN caring for the patient documents all medication administration during the case.

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

We track D2B times and fluoroscopy times over 30 minutes, perform radiation badge and lead audits, chart audits for regulatory compliance as well as Joint Commission requirements, and perform medical necessity audits. We also track and audit our patient satisfaction scores with pre and post follow-up patient visits.

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

At present, we do not submit any data.

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

Banner Health markets cardiology services for all of its facilities with heart programs, which includes 7 in the Phoenix area. We also offer risk screening and community lecture series to increase awareness of our programs.   

How are new employees oriented and trained at your facility? 

Our orientation is customized to the individual employee, depending on their previous experience. Each employee is assigned a preceptor that works with the new employee for their entire orientation. Orientation has been standardized at our system level. Cardiovascular educators and the RN managers monitor the progress of each new employee. Competencies are completed and signed off by the assigned preceptor, educator, and RN manager. Orientation is generally completed in 3 months.

What continuing education opportunities are provided to staff?

We utilize our vendors a great deal to provide in-servicing on equipment, current trends, and updates. Our physicians provide education through cardiac cath conferences offered throughout the year.   

How do you handle vendor visits to your lab? 

Vendors are allowed to provide educational in-services in our lounge area on a scheduled basis. They are only allowed into the labs when they have a new product, in order to help support the physicians and staff in learning. They are required to complete a vendor contract that is monitored at the corporate level. They must check in on every visit with materials management to make certain all necessary paperwork has been completed. They are required to wear a radiation badge when supporting physicians during the procedure. 

How is staff competency evaluated? 

Staff receives a performance review annually. A competency-based tool outlines specific criteria for individual staff members to complete on an annual basis. Staff can meet these competencies by performance of procedures, use of equipment, and/or self-learning packets/videos, with completion of a post test. Once a quarter, we provide a “Skills Day” for staff to attend from all Banner cath lab facilities, and vendors provide a review of low-use, high-risk equipment and procedures. Additional education is added as necessary. In addition, all staff is required to attend annual “Mandatory Days” that include medical center-specific education such as infection control. Banner has a very robust on-line education program and multiple modules are required to be completed on an annual basis. Advanced cardiac life support (ACLS) is required of all RNs and RTs in our labs.  

Does your lab have a clinical ladder? 

We do not use a clinical ladder process, but we have instituted a Clinical Expert Recognition program for our nurses. It requires certification in their area of expertise or a master’s degree. A monetary reward is present upon completion.

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

We require 2 RNs and 2 RTs for our call team. Each staff member carries a pager and a group page is initiated by the operator. Those on the call team must respond and arrive to the hospital within 30 minutes. This team is available during all hours that the labs are closed: nights, weekends, and holidays.  

Do you have flextime or multiple shifts? 

We have only 12 shifts at this time, but we do require staff to flex their time depending on case volume. We offer self-scheduling, allowing staff to sign up for the days they would like to work.

Has your lab recently undergone a national accrediting agency inspection? 

We had a Joint Commission Survey in June of 2012. The Joint Commission takes a very thorough approach to evaluating conscious sedation and medication labeling. Another area to focus on is pre-procedure history and physicals, and completion of an immediate physician post op note, including multiple components that must be completed before the patient leaves the lab. 

Banner Thunderbird Medical Center has also received our Chest Pain Accreditation, which required involvement from the cath lab as well as other departments. After application, we had an on-site survey and were expected to do a mock demonstration of how we handle chest pain patients coming in through the emergency department, as well as in-house patients. 

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

We are adjacent to the emergency department and one floor below the operating room.  

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

We have seen an increase in acuity and a decrease in age (younger patients with more co-morbid conditions). We have also seen a decrease in coronary interventions and an increase in electrophysiology procedures, peripheral procedures, pacemakers, and defibrillator implants.  

What is unique about your cath lab and staff?

We cross-train staff to perform many roles within the cath lab. The nurses cannot operate the radiology equipment and the RTs cannot administer medications; all other roles can be performed by either an RN or RT. Having nurses perform the scrub role is unique to our lab in the Banner system. We also staff daily with a resource person who manages the board and the flow of cases. In addition, we utilize a “floater RN” who can assist in each of the labs as needed. Our turnover rate was 15% for 2013. Several of our employees hold 20+ years of experience.  

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”?

Our area has a large volume of senior winter visitors. This creates high volume during winter months and low volume during the summer months, affecting our staffing needs.

Is there a problem or challenge your lab has faced?

Flexing staff hours has been a challenge, as we are all required to become more productive. It has allowed resources to be utilized during our high-volume days and reduced during low-volume days.

Can you tell us more about your cath lab layout?

We moved our labs 2.5 years ago, to an already existing area of the hospital, so we did have space limitations. We were able to design 4 lab spaces, approximately 25 square feet, that all open to a central control room area and a supply area. Access to the supply area has been a great feature, allowing us to avoid having to stock large amounts of supplies in the actual cath rooms. This has been especially valuable for low-use, high-cost items.  

Our EP room and the bi-plane room, also about 25 square feet, are shared with the imaging department, and do not open to the central control room or supply room, making for more of a supply challenge in these rooms.

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

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

At this time, Banner Thunderbird Medical Center does not require RCIS certification. Our RNs and RTs are encouraged to receive certification, however, and we currently have 4 staff members who have received a CVRN certification and 1 who has received RCIS certification.

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

We have staff members who are involved with the American College of Cardiovascular Nurses. 

The authors may be contacted via Tereasa Lehan RN, BSN, CVRN, RN Senior Manager Cardiology, at tereasa.lehan@bannerhealth.com.