Genesis Healthcare Cardiac Catheterization Lab

Genesis HealthCare System is an integrated health care delivery system based in Zanesville, Ohio, located one hour east of Columbus, Ohio. The system includes a 334-bed, not-for-profit acute care hospital that operates at two Zanesville sites — Genesis-Bethesda and Genesis-Good Samaritan. The system also includes an extensive network of more than 300 physicians and multiple outpatient care centers throughout the region. The Genesis mission is to provide compassionate, quality health care, and the system continually strives to meet the needs of the community. The Cardiac Catheterization Lab is located at the Genesis-Good Samaritan Campus. 

Genesis was the first organization in the nation to receive Atrial Fibrillation (AF) Certification by the Society of Cardiovascular Patient Care in 2011. Genesis is in the planning stages of a new, expanded medical center to support its ongoing commitment to provide the highest quality care at the lowest cost and to meet the growing needs of the community. The new facility, which is scheduled to open in 2015, will feature a state-of-the art surgical/procedural tower designed to create the ultimate patient experience.

Tell us about your cath lab. 

Our cardiovascular invasive/interventional program has four cath labs. These include two dedicated coronary labs, one dedicated electrophysiology (EP) lab and a fourth lab used mostly for peripheral vascular procedures.

We currently have 23 full-time staff members: 9 registered nurses (RNs), 9 radiologic technologists (RTs), an office administrator, a multi-skilled technician, a clinical coordinator (RT), a chest pain and heart failure coordinator (RN), and a nurse manager. 

What procedures do you perform?

We provide a full spectrum of coronary diagnostic and interventional procedures, including treatment of high-risk cases. Some of the peripheral work done our lab includes diagnostic and interventional procedures on the abdominal aorta, lower and upper extremities, carotids, renals, and mesenteric arteries. Approximately 80-90 procedures are performed each week. We do not perform transcatheter aortic valve replacement (TAVR), but a hybrid lab is in the planning phases.

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

Our cath lab is backed up by cardiovascular surgery around the clock, enabling us to provide primary angioplasty facilities with full-time surgical backup.

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

The decision to get access via the radial or the femoral artery is made on a case-to-case basis.

Who manages your cath lab? 

Ravin Miller, RN, MSN, is the cath lab operational nurse manager. Sue Palmer, RT, is the clinical coordinator, and Cheryl Jorge, RN, MSN is the overall director of heart and vascular services. 

Who scrubs, who circulates and who monitors? 

All cath lab staff is cross-trained to monitor and document procedures. The RTs exclusively scrub all cases and the RNs exclusively circulate all cases.

Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab? 

Yes. Our x-ray equipment is operated solely by the physicians and RTs.

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

We make every effort to decrease radiation exposure to everyone in the lab, including the patient. Our methods include education, usage of minimal frames/sec, placing the image intensifier (II) closer to the patient, lead aprons, eye protection, and lead shields. For each individual staff member and physician, radiation exposure is monitored by the Ohio Department of Health through monthly reports taken from dosimetry badges. 

How does your lab communicate information to staff and physicians? 

The primary methods of communication are by email, monthly staff meetings and a communication book. All staff members are held accountable in staying up to date and must initial all postings in the communication book. The communication book is centrally located in the cath lab break room and is readily accessible to all staff members. It documents immediate updates on technical or process changes, equipment updates, and general messages to staff. Entries are submitted by the manager and clinical coordinator only. To streamline communication and discuss change, three meetings are held per month (heart and vascular service line, cath lab morbidity & mortality, and STEMI committee) and are attended by physicians, directors, managers, support staff and ancillary departments associated with the heart and vascular service line.

How is coding and coding education handled in your lab? 

Our cath lab has three dedicated cardiology coders managed by the health information management (HIM) department. The coders, along with cath lab management, attend annual coding and reimbursement seminars discussing Centers for Medicare & Medicaid Services (CMS) changes, enabling the department to capture maximum reimbursements. The cath lab management team has established open lines of communication with cardiac coders and works collaboratively to make necessary changes to ensure the accuracy of coding. 

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

We use closure devices on approximately 90% of our cases. When a closure device is not used, the sheaths may be pulled intra-department by the RTs, who receive on-the-job training. RNs are responsible for groin care and achieving hemostasis in the recovery unit and on the floors. RNs are considered competent after three successful supervised sheath removals. Sheath removals are a required element at the annual education competencies, where attendance is mandatory for all RNs working in the critical care unit and cardiovascular floors.

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

Outpatients arrive to the interventional recovery unit (IRU) two hours prior to their scheduled procedure to be prepped and assessed. In-patients are prepped on the floor they are located. 

Cath lab patients are recovered in two areas. For outpatient diagnostic procedures, patients return to the IRU. Post-PCI patients go directly to the cardiovascular intermediate unit (CVIU) for an overnight stay. All ST-elevation myocardial infarction (STEMI) and unstable patients are admitted to the critical care unit (CCU). The RN is responsible for groin care and achieving hemostasis on these floors.

If no closure device is used, the RT is responsible for groin care and hemostasis after the sheaths are pulled. Some of the closure devices that we use include Perclose (Abbott Vascular), Starclose (Abbott Vascular), Mynx (AccessClosure) and Angio-Seal (St. Jude Medical).

How is inventory managed at your cath lab? 

The clinical coordinator manages inventory. All interventional product and equipment stickers are placed on a charge sheet per procedure and are reordered daily by the administrative assistant. Interventional equipment orders are verified by the clinical coordinator. Diagnostic equipment is re-ordered by materials distribution. The heart and vascular services director is responsible for approving all capital purchases.

Is your lab involved in clinical research?

Yes, we have been involved in several research studies. Below are just a few of the studies in which we have participated:

• IMPROVE-IT: Examining outcomes in subjects with acute coronary syndrome: Vytorin (ezetimibe/simvastatin) vs simvastatin 
• PLATO: A comparison of ticagrelor and clopidogrel in patients with acute coronary syndrome 
• TRITON–TIMI 38: Prasugrel vs clopigogrel in patients with acute coronary syndromes
• TRILOGY ACS: A comparison of prasugrel and clopidogrel in acute coronary syndrome subjects
• EMINENCE: Evaluation of M118 in percutaneous coronary intervention
• EUCLID: A study comparing cardiovascular effects of ticagrelor and clopidogrel in patients with peripheral artery disease
• ACCELERATE: A study of evacetrapib in high-risk vascular disease 
• ABSORB: A clinical evaluation of the Absorb bioresorbable vascular scaffold system 

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

For 2012, Genesis HealthCare System had a median D2B time of 55 minutes, with 100% of the emergency department (ED) STEMI patients achieving a D2B time of 90 minutes or less. We have worked very hard over the past several years to make improvements to our STEMI program. This has been accomplished by utilizing a multi-disciplinary approach:

Emergency Medical Services (EMS): Grant funding was secured to help purchase 12-lead ECG transmission equipment in an effort to have earlier activation for our STEMI patients. Our goal is to have 100% of our EMS agencies capable of acquiring and transmitting a 12-lead EKG to the ED. Currently we have 75% of the agencies equipped. EMS personnel receive education and feedback on a STEMI board in their break room to show images, and D2B and First Dispatch-to-Balloon (F2B) times. Our chest pain coordinator attends county EMS meetings on a quarterly basis to provide feedback, give updates, and answer questions from EMS personnel.

ED: The ED has developed specific roles and responsibilities for team members who assist with the STEMI patient in an effort to streamline care, and ensure that all necessary steps are completed before sending the patient to the cath lab. Two essential members of the ED team are the clinical educator, who works with staff to ensure that cardiac education is provided and competencies are kept up to date, and the ED physicians, who activate the STEMI through a one-page system. The ED has their own STEMI committee that meets quarterly to review their STEMI data and processes, celebrate successes, and look for areas of improvement.

Cardiac cath lab: The cath lab team has been innovative in staying prepared for a STEMI patient at all times. We have utilized staff from around the hospital to help get the cardiac cath lab rooms ready when a STEMI arrives after normal business hours. After a Code STEMI activation, the radiology staff arrive to turn on the x-ray equipment, and the nursing supervisor unlocks all the cabinets and checks the crash cart and activated clotting time (ACT) machine to verify that they are working and ready. This allows for the cath lab team to call for the patient immediately upon their arrival. The staff is required to arrive at the facility within 30 minutes of the STEMI activation. The ED staff and rapid response nurse stay in the cath lab to help get the patient ready for the procedure.

Quality assurance: Monthly STEMI meetings are held to review data, discuss successes, and identify areas for improvement. Interventional cardiologists, emergency physicians, and leaders from various departments are invited to attend. Process improvement projects are identified, developed, and feedback provided to the ED and EMS. By continually reviewing the STEMI process, Genesis has seen improvements in metrics every year.

Genesis HealthCare System has several staff participating with Mission: Lifeline of Ohio workgroups. Recently, we have been selected as a Mission: Lifeline STEMI Systems Accelerator site. Genesis will share data with the American Heart Association and Duke Clinical Research Institute in an effort to enhance and improve patient care, and develop an organized regional STEMI system.  

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

STEMI transports are a team effort regardless of the time of day. The house nursing supervisor and the rapid response team (RRT) nurse respond to every STEMI. The nursing supervisor ensures that bed placement occurs, and takes care of the patient’s family to offer support and answer questions. The RRT nurse assists with getting the patient ready for transport and gathering the portable defibrillator (Zoll Medical) and oxygen tank. The RRT nurse, ED nurse, and a clinical technician take the patient to the cath lab, and remain to assist with prepping the patient. Once the patient is ready, they are released to go back to their respective departments.

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

If the call team is doing a procedure when a STEMI is called, all efforts are made to stop the procedure if possible and move the patient off the table. The ED staff and RRT nurses facilitate getting the STEMI patient to the CCL and prepping them while the call team is transitioning. There have been times when a second call team has been required. Extra cath lab staff is willing to come in for the second emergency, if needed.  

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

Both interventional heart and vascular services and the electrophysiology lab have partnered in an umbrella contract dedicating market share in order to cut costs. The purchasing department and cath lab management continue to review, negotiate, and renew contracts on an annual basis.

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

Internally, we hold monthly heart and vascular service line meetings, STEMI committee reviews, and morbidity & mortality meetings to enhance communication opportunities, discuss challenges, and implement new processes. We participate in the American College of Cardiology’s National Cardiovascular Data Registry (ACC-NCDR) Cath/PCI and ACTION registries, to benchmark data with facilities nationwide. The Healthcare Facilities Accreditation Program (HFAP) and Ohio Department of Health are our regulating bodies. 

Are you recording fluoroscopy times/dosages? 

Yes, we do document fluoroscopy times. The fluoroscopy times are recorded by the staff monitoring the procedure in the Philips (XIM) system and are an element in the ACC-NCDR Cath/PCI registry.

Who documents medication administration during the case? 

The staff member monitoring the case documents medications in the XIM system. The circulator ensures that the medication, time, and dose are accurate. After all documentation is verified, an electronic signature is required from the staff monitoring and circulating the procedure.

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

Genesis HealthCare System is the only percutaneous coronary intervention (PCI) center in our six-county region. We collaborate with the non-PCI centers to streamline the transfer process using a one-call transfer system. All of the necessary information is collected and a three-way call between the referring physician, the accepting physician, and the transfer center nurse takes place to arrange a seamless transfer process.  Patients who come to Genesis for an acute MI and/or PCI are referred back to their home physicians and local cardiac rehab centers for follow-up. Feedback on all patients is given to the primary care provider. Genesis has also formed an affiliation with another area hospital. 

How are new employees oriented and trained at your facility? 

New employees receive a 12-week orientation with a designated preceptor. The preceptor of choice is a staff member that has tenure in the cath lab. An orientation guide/list is given to the new hire and it is the preceptors’ responsibility to ensure progression and to provide adequate feedback to the manager. The manager is responsible for listening and communicating on the growth of the new hire. After three months, a mandatory “new hire” evaluation is completed by the manager. 

What continuing education opportunities are provided to staff members? 

Education services works very closely with the heart and vascular department to ensure that the educational needs of the staff are met and we are in compliance with accreditation standards. An innovative approach has been to hold a one-hour general education session every Tuesday morning at 7:30 am. There are a wide variety of topics, but the last Tuesday of every month is dedicated to a cardiac subject. In addition, with the support of Genesis, the staff is able to attend national conferences. Management continually works with external vendors to provide education on new and existing equipment and procedures. 

How do you handle vendor visits to your lab?

Vendor visitation is dependent upon contractual agreements. The vendors representing our primary contracts are permitted in the lab once per week and all other vendors are permitted one or two times monthly unless requested by a physician. We do not allow competing vendors in the department at the same time. 

All vendors must be registered with the purchasing department and receive a visitor badge to be displayed when present on the premises. Vendors are scheduled through the cath lab administrative assistant and the visit is placed on a calendar transparent to cath lab management and purchasing to monitor visitation compliance.

How is staff competency evaluated? 

Staff competency is evaluated by completion of the orientation guide/list and “new hire” evaluations, and an annual department-specific education day and bi-annual management evaluations thereafter. 

Does your lab have a clinical ladder? 

The organization provides a clinical advancement program (CAP) for RTs and RNs. The CAP program has three levels and the employees are compensated depending upon level of achievement. Advancement of a degree, enrollment in school, participation in department committees and projects, volunteer time and providing presentations are all elements acknowledged by CAP.

How does your lab handle call time for staff members? 

RTs and RNs complete a self-call schedule for intervals of six weeks. The call team consists of three staff members. The mix of credentials required for call is 1 RT and 2 RNs.

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

All staff members are required to arrive with 30 minutes of page. Arrival times are monitored by management and are an element on the departmental scorecard, which is linked to compensation during annual evaluations. 

Has your lab recently undergone a national accrediting agency inspection? 

Genesis HealthCare System is an Accredited Chest Pain Center with PCI through the Society of Cardiovascular Patient Care (SCPC). The accreditation process forces facilities to examine their entire cardiovascular program. The key elements developed by the SCPC serve as a guide to perform a gap analysis, and identify areas that are performing well and areas that need improvement. Necessary for the achievement of accreditation are strong physician and administrative support, guideline-based therapies, and a team approach. Through utilizing a team approach, barriers between departments are broken down and staff work together to achieve a common goal. Cath lab personnel are a vital part of the cardiovascular team, and their experience and ideas are valuable. We would recommend their inclusion in many aspects of the accreditation process, such as attending committee meetings, helping to develop standardized policies and procedures, and brainstorming on process improvement projects. With any accreditation inspection, the entire team should feel ownership and have a strong desire for success. 

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

The cath lab and surgery are both located on the third floor of the Good Samaritan campus. Surgery is located just down the hall from the cath lab. The two departments share waiting areas. The emergency department is located on the second floor.

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

At Genesis, there has been a slight decrease in volume related to diagnostic procedures. The patient population at Genesis is challenged in regards to compliance and education. To overcome these challenges, we have hired an AMI navigator, who is responsible for providing education on disease processes and managing a chronic illness to the STEMI and high-risk PCI patients and families. The navigator provides group and individual educational sessions prior to discharge. The navigator also schedules patients for cardiac rehab. She follows up with patients via phone once they are discharged. This has provided the cardiovascular service line with a comprehensive approach to STEMI/PCI care.

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

Our cath lab staff is very team oriented and has a strong commitment to quality patient care. Many members help with updating and writing policies and procedures, attend various committees, and participate in project work. They have been vital to developing STEMI roles and responsibilities, adding ideas and thinking ‘outside the box’ to try to decrease door-to-balloon times. Several staff members are computer ‘gurus’ who have become the department experts on the XIM and LifeNet Alert software. They are the resource that others go to when there is a question that needs answered or for trouble-shooting. They have also helped in the Genesis AED project, which used earmarked funds to donate 19 AEDs and supplies to area schools to better equip them in case of a medical emergency.

What’s special about your facility in comparison to the rest of the U.S.?  

Genesis is an integrated healthcare delivery system that offers a level of care not typically found in a community of its size. Genesis offers patients a broad continuum of care and the most comprehensive scope of services available in southeastern Ohio. Genesis is the primary setting for acute care with 80.7% market share in Muskingum County. Genesis’ primary service area is the following six counties: Coshocton, Guernsey, Morgan, Muskingum, Noble, and Perry; the secondary service area includes portions of the following six adjacent counties: Licking, Athens, Washington, Monroe, Belmont, and Tuscarawas.

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? 

We currently do not require staff to take the RCIS exam.

2. 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? 

Not at this time.  

The authors can be contacted via Cathy Huggins, MSN, RN-BC, CNL, CCRN, at chuggins@genesishcs.org, or cath lab operational nurse manager Ravin Miller RN, MSN, at rbarnesmiller@genesishcs.org.