Cox South Medical Center

Can you tell us about your cath lab?

Cox Health has five procedure labs. While all five labs have the ability to accommodate coronary interventions, we routinely schedule electrophysiology (EP) and peripheral vascular procedures in designated labs. We have 32 co-workers who staff the procedure rooms: Eleven registered nurses (RN), fourteen registered radiology technologists (RT[R]s) and seven surgical scrub technicians. We operate a three-person team for most procedures that includes one RN, one RT(R), and one scrub tech. We provide extra staff as necessary for complicated or emergent procedures. Several RT(R)s have cross-trained to work in the scrub position. Our most experienced employee has worked for Cox for more than 38 years, with the majority of that experience in the cath lab.

What procedures are done at your lab? 

On a weekly basis, we do:

• Coronary diagnostic...51
• Peripheral diagnostic...14
• Coronary interventions...15
• Peripheral interventions...8
• Cardioversions...6
• Permanent pacer implants...5
• Permanent defibrillator implants...3
• Bi-ventricular implants...4
• EP studies...1
• EP studies with ablation...3
• Patent foramen ovale closures...2
• Head-up tilt table (HUTT)...2

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

Yes, surgical back up is available on site.

What percentage of your patients is female?

Approximately 30% of our patients are female.

What percentage of your diagnostic cath patients goes on to have an interventional procedure?

Approximately 25-30% of our diagnostic cases receive primary percutaneous coronary intervention. We began abstracting data for diagnostic-only cases through the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) CathPCI database this year in order to better assess current practice patterns.

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

Not currently.

Who manages your cath lab?

Alan Kettelkamp, RT(R), is the cath lab manager. He first began working in a cath lab in 1987 and transitioned into supervisor, manager and director positions over the length of his career at different hospitals, with only a one-year exception, when he worked as a clinical applications person for GE Medical. Alan’s experience includes managing anywhere from small, one- and two-room cath labs up to large, nine-room cath labs. 

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

Several RT(R)s have cross-trained to scrub. Everyone in the room is responsible for watching the monitor throughout the procedure. The RN role is focused primarily on patient care, including monitoring vital signs, administration and monitoring of procedural sedation, and administration of therapeutic and emergency medications. We are currently expanding our cross-training program to include nurses to scrub.

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

The state of Missouri does not require that a radiology technologist be present for all fluoroscopic procedures. Our policy at Cox is that, in the best interest of patient safety, at a minimum, one RT(R) is assigned to each room.

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?

Our interventional cardiologists maintain responsibility for positioning the x-ray equipment, panning the table, changing angles, and stepping on the fluoro pedal.

Are you recording fluoroscopy times/dosages?

Yes. The fluoroscopy times and dosages are recorded in the patient record in the electronic procedure record. Much of this information is pushed from the GE x-ray system automatically into the GE MacLab.

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

Personal radiation protection equipment is provided to physicians and staff, including lead aprons, thyroid collars, and lead glasses. Lead glass shields are also installed in all rooms, and lead finger shields are mounted on tables.  

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

We have recently begun doing laser lead extraction and using the left ventricular support device Impella (Abiomed).

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

Communication is a challenge that doesn’t seem to have an end-all answer. With multiple types of shifts, including night and weekend shifts, it is very difficult to communicate effectively. We conduct monthly staff meetings. All information is emailed, posted in a communication book that is kept in the break room, and also posted on a bulletin board in the hallway. If the information is time-sensitive, we also post it on the control board for immediate viewing. 

How is coding and coding education handled in your lab?

Our procedure coding system is currently manual, with data being entered into a charging system by our team members. Our cath lab business manager has the responsibility of ensuring compliance with all coding and billing. She works with our billing and coding department to be sure everything is accurate, and is responsible to help educate the staff that does the up-front collection of procedure charges. All charges are reviewed before being sent to billing. The hospital also sends team members to training classes as they are offered.

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

Patients undergoing outpatient elective procedures are admitted and prepped in our same-day surgery department. Diagnostic-only patients who are discharged the same day as their catheterization are also recovered in and discharged from this department. Our physicians, cardiology and peripheral, are dedicated to closure device deployment when appropriate — and our closure device use rate is above 90%. Angio-Seal VIP (St. Jude Medical) is the predominate platform; however, we also carry the Mynx (AccessClosure, Inc.).

What is your lab’s hematoma management policy?

While we do not have an explicit hematoma management policy, we have implemented a series of steps to trend this complication and to minimize hematoma development. Our cath lab teams document hematomas in designated complications fields in our electronic procedure record. These fields are harvested and data is reported when trends are identified.  

How is inventory managed at your cath lab?

We are working towards utilizing the inventory module in our MacLab system. Currently, it is a manual procedure, and it is delegated to individuals within the department to watch levels and reorder. The cath lab director is responsible for negotiating with vendors. We do have a group purchasing organization and are working collaboratively with other hospitals with cath labs to negotiate better pricing.

Has your cath lab recently expanded in size and patient volume?

Yes, our fifth procedure room opened in January 2010 to accommodate our increasing volume and to enhance patient throughput.

Do you have a hybrid cath lab, or are you planning to build one?

Discussions regarding construction of a hybrid procedure room were initiated at our cardiovascular services strategic planning meeting in 2009. We continue to investigate the feasibility of this innovative concept to improve service to our patients and providers. Currently, advancement of this process is restricted by limitations on physical space, as well as organizational resource allocation to more pressing needs, such as a new intensive care tower.

Is your lab involved in clinical research?

Though our cardiovascular research program only started less than two years ago, we currently host studies investigating cardiac as well as peripheral vascular issues. All of our studies are sponsor-driven. Our peripheral studies include the:

• COMPLIANCE 360˚ trial: Directly compare Cardiovascular Systems’ Diamondback 360^® Orbital PAD System versus balloon angioplasty in the lower extremities.
• DEFINITIVE LE trial: Evaluating the intermediate and long-term effectiveness of stand-alone atherectomy treatment with the ev3 Silverhawk for peripheral arterial disease in the lower extremities.
• TAXUS Liberté Study: Cox has enrolled more than 100 participants.

Our cardiac studies include:

• APPROPRIATE trial: Examining patients who received a dual-chamber Boston Scientific Altrua 60 pacemaker with active atrial and ventricular leads. The primary objective was to determine whether an improvement in peak VO2 is greater using the minute ventilation (MV) sensor compared to using the accelerometer (XL) sensor in coronary intervention patients.
• TAXUS Liberté Post Approval Study
• Longitudinal Surveillance Registry (LSR) of ACUITY Spiral: Evaluate and report on the long-term performance of the Boston Scientific Acuity Spiral LV lead.
• TAO trial: The effect of otamixaban versus unfractionated heparin + eptifibatide in patients with unstable angina/non ST elevation myocardial infarction undergoing early invasive strategy (Sanofi-Aventis).

Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery?

Over the last year, we had one patient taken emergently for bypass surgery due to cath lab complications.

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 use our ACC-NCDR data to benchmark our internal processes. Our median door-to-balloon time for the most recent rolling four quarters (at the time of this writing) was 64 minutes. We are registered with the ACC D2B: An Alliance for Quality.

Our acute myocardial infarction (AMI) Throughput Team is designated to oversee our door-to-balloon process. This team meets quarterly and is attended by leaders from the emergency medical service (EMS), emergency department (ED), cath lab, and inpatient nursing. The team is facilitated by our cardiovascular services quality coordinator and serves multiple process oversight roles. Trend and outlier review provides surveillance. Performance improvement initiatives are identified and implemented using Focus-PDCA (plan, do, check, act) methodology.

Case-specific feedback is provided to participating areas for most ST-elevation myocardial infarction (STEMI) cases within 72 hours of arrival. 

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

The ER transports our acute patients to the cath lab.

What other modalities do you use to verify stenosis?   

We have both intravascular ultrasound (IVUS) and fractional flow reserve (FFR) (St. Jude Medical). We have seen increasing use of both over the last four quarters.

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

At the organizational level, we have sole vendor contracts for implantable devices and stents. We also participate in a regional purchasing cooperative in order to leverage group pricing. At the department level, procedure charge accuracy and supply utilization is continuously monitored. To improve charge capture, we are currently in the process of implementing a bar-code system (GE MacLab).

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

Operationally, we focus on radiation safety. We perform annual physics inspection of personal protection equipment. Education is a valuable tool to be sure everyone is aware of best practices for minimizing unnecessary radiation exposure. We teach “As Low As Reasonably Achievable” (ALARA). We also have cath lab team members who participate on our organizational radiology safety team and partnership council.

Departmentally, we rely heavily on our ACC-NCDR reports to inform improvement of our clinical processes and outcomes. Case complication reporting is monitored via our clinical documentation tool. Select cases are discussed monthly by our physicians at a case review. Finally, mortality cases are reviewed in a peer-protected environment, a minimum of quarterly when necessary.

To which registries within the ACC-NCDR does your lab submit? Do you use any other outside data collection registry?

We submit data to the ACC-NCDR for both the CathPCI registry and the implantable cardioverter defibrillator (ICD) registry. Over the last 12 months, we have formed a registry team to optimally balance registry data integrity and clinical workflow. This initiative has improved data integrity and allowed a dramatic increase in registry case reporting volume, to the extent that we are now submitting diagnostic cath procedures in addition to our interventional procedures.

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

Cox is one of two major health systems within Springfield, Missouri, with full interventional cardiology capabilities in addition to surgical and ancillary support, and with systems capable of supporting among the largest patient volumes in the state. Additionally, both facilities have their own EMS systems that operate in overlapping areas of the region. As such, these two institutions have traditionally tended to co-exist rather than compete.

CoxHealth has joined the Missouri Department of Health and Senior Services (DHSS) on an innovative and aggressive initiative to improve STEMI care for Missourians. Legislation creating the Time Critical Diagnosis (TCD) system provides structure to support systems for trauma, stroke, and heart attack. This continuing effort has taken shape over the past few years through collaboration among stakeholders from across the state. The ultimate vision is the establishment of a system of care for STEMI patients that would allow for patients to enter the system via EMS or at participating facilities, and to be triaged, treated, and transported when indicated. Ideally, the system will align systems of care toward pursuit of a common goal: efficiently delivering STEMI patients to definitive care.  

However, the recent advent of ‘open-access’ insurance plans by large independent payers is sure to place an increased focus on patient satisfaction and access, quality of care, and efficiency of service. Toward those ends, we look forward to continuing to be the best for those who need us. 

How are new employees oriented and trained at your facility?

We assign a proctor to work one-on-one with our new employees. They work together in procedures. First the new employee watches, then slowly transitions into doing more and more, until they are working independently to the point that both the preceptor and new employee feel comfortable with them working independently.   

What continuing education opportunities are provided to staff members?

We have established a fund in the hospital foundation that we use primarily for education. As in most hospitals, the education budgets have been eliminated and the fund allows for us to have some dedicated money. This money may be tax-deductible donations from the staff, physicians or philanthropists. Some money is brought in by surveys completed by staff that is deposited into this fund. Most recently, we have brought in speakers to help prepare staff to sit for the registered cardiovascular invasive specialist (RCIS) exam and for continuing education points in early January. This was actually supported by our physician group (Ferrel Duncan Clinic), which graciously donated money to our Foundation Fund. This money helps send staff to conferences and helps with any expenses associated with education.

How do you handle vendor visits to your lab?

Vendors are allowed to visit monthly, with scheduled visits. They must adhere to our hospital policy guiding vendor access, which requires registration with our purchasing department.

How is staff competency evaluated?

Staff has an annual evaluation and competency is evaluated at that point in time.  Evaluations are performed by the director of the cath lab. Recertification of core compentencies is completed annually.

Does your lab have a clinical ladder?

Our nursing co-workers can be recognized by participating in our STAR clinical ladder. It rewards nursing staff for participation in areas of education and research, community involvement, clinical excellence, and nursing leadership. Our radiologic technologists also have a clinical ladder that operates in a very similar way.

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

We have a dedicated night crew four nights during the week that assist with emergent cases, in addition to performing stocking, clerical, and data collection duties. Additionally, we recently implemented a weekend team to provide cath lab coverage during daytime hours on Saturdays and Sundays, working 12-hour shifts. A back-up call team is available during off-weekend hours and nights for cases of concurrent emergency procedures.

Do you have flextime or multiple shifts?

Yes, we have team members who work 8-hour, 10-hour, and 12-hour shifts, starting at multiple times to help with better utilization of work time.

Has your lab recently undergone a national accrediting agency inspection?

Over the last 12 months, we have been surveyed by the Joint Commission, as well as state and federal health agencies.  

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

Our cath lab suite is located on the fourth floor of the main tower on our campus. The operating suite is located on the lower level of the same building, accessible from the cath lab by an adjacent bank of patient care-only elevators.

In October of 2010, we opened a new, state-of-the art emergency department, attached to the south side of our main building. The ED is on the lower level and connects to the main building on that level, as well as via a patient-only-hallway on the second floor.  

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

Over the past four years, all procedure volume has shown a net 20% increase, with electrophysiology and ICD procedures leading growth.  

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

Having a night team and weekend option team helps set us apart. This is beneficial for many reasons. There is no delay caused by waiting for the call team to arrive for acute patients. Stocking and cleaning of the procedure rooms can be completed much more easily and consistently, without accruing overtime. The call burden has been reduced dramatically. Even though staff still takes what we call “back-up call,” the odds of being called in are very minimal. The most important point is the safety aspect it brings. In the past, we have expected our staff to be fully competent immediately after working a full day shift, and being called into the hospital in the middle of the night, sometimes multiple times. Yes, our staff is very competent, but the biggest chance of making a mistake is while being sleep deprived. By rearranging our duties (ACC registry data collection, etc.) to these off hours, it can be done effectively and still be within productivity standards.

Is there a problem or challenge your lab has faced?

Call once was the biggest problem, but has been resolved with the night and weekend option teams. Communication is and probably will always be an ongoing challenge.   

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 hospital has 9 counties that we consider our primary referral area, but Springfield is also surrounded by a large, rural community. We have an additional 13 counties that also refer to our hospital. We are also very close to Branson, a popular city for many retirees. 

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

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?

Currently, we only require our radiologic technologists to have a certification from the RCIS, or the CI or VI from the American Registry of Radiologic Technologists (ARRT). We have had a big push for our RNs and scrubs techs to also obtain the RCIS, but it is currently not required. The scrub technicians who do obtain the RCIS are moved to a higher job classification and are compensated.

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?

We have one team member who is a member of the ACVP. Now that we have so many RCIS-credentialed employees, we should re-look at a SICP chapter.

The authors can be contacted at alan.kettelkamp@coxhealth.com.