Cath Lab Spotlight: Sentara RMH Medical Center

What procedures are performed in your cath lab?  

We routinely perform right and left heart caths and percutaneous coronary intervention, along with the use of intravascular ultrasound (IVUS), instantaneous wave-free ratio (iFR), fractional flow reserve (FFR), intra-aortic balloon pump (IABP), Impella (Abiomed), and Rotablators (Boston Scientific) as needed for our cases. We also perform pericardiocentesis and temporary pacemakers. Our EP lab performs all types of ablation procedures, and places pacemakers and implantable cardioverter defibrillators (ICDs), as well as biventricular ICDs. With the addition of our structural heart program, we have expanded services and are performing transcatheter aortic valve replacement (TAVRs) as well as valvuloplasty, atrial septal defect (ASD) closure, pulmonary embolism (PE) treatment with the EKOS system (BTG), and laser lead extractions. In our recovery area, we routinely perform transesophageal echocardiograms (TEEs), cardioversions, tilt table tests, and loop recorders, as well as teaching for upcoming procedures. 

Can you share your lab’s experience with TAVR?   

We have been performing TAVR procedures since January of 2017. Our hybrid OR was a new space that was built on an open rooftop and is 1064 square feet. We had considered combining two smaller ORs into one, but the size and shape would have been too limiting. We performed 24 TAVR procedures in 2017 and 30 thus far in 2018, using the Sapien 3 (Edwards Lifesciences) and Evolut R valve (Medtronic). We also use the ACIST system for our TAVR procedures. The ability to keep a pressure showing with minimal breaks for injections has been very helpful. We have 3 dedicated cath lab staff (2 RNs and 1 technologist) with 3 additional cath lab-trained team members that assist with the TAVRs. We work alongside our skilled cardiothoracic OR team for these cases. 

What is your percentage of normal diagnostic caths?  

Our percentage of normal caths is 39%, lower than the national average.

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

All of our physicians are performing radial access for elective cases, unless the patient’s anatomy directs us to the femoral site. We routinely perform an Allen’s test on all cath patients. 

Who manages your cath lab? 

Our cath lab manager is Linwood Williams, RT(R). Linwood has been with SRMH in the cath lab since 2010. Along with managing the unit, Linwood takes call 1 weekend a month and 1 day a week. Competency is held to the highest standard at SRMH.

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

Our interventional technologists scrub all cases; they are responsible for using the ACIST injection system, panning the table, controlling the x-ray equipment, and assisting the physician. Our RNs circulate, assess, and monitor all cases. We have 3 technologists that have cross-trained to monitor some cases when the need arises.

Are there licensure laws in your state for fluoroscopy? 

Per Virginia law: A physician assistant working under the supervision of a licensed doctor of medicine is authorized to use fluoroscopy for guidance of diagnostic and therapeutic procedures provided such activity is specified in his protocol and he has met the following qualifications. 1. Completion of a least 40 hrs. of structures didactic educational instruction and at least 40 hrs. of supervised clinical experience as set in the Fluoroscopy Educational Framework for the PA created by the American Academy of Physician Assistants (ASRT) and  successful passage of the American Registry of Radiologic Technologists. (ARRT) Fluoroscopy Exam. 

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 technologists are very knowledgeable and talented. They are trained to operate the x-ray equipment, pan the table, work the c-arm to change the angles, and set up and control the ACIST injection system. 

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

All staff receive inservices on radiation protection yearly and are monitored monthly. The technologists and physicians are very observant of safe practices and will pause for the RN to finish administering meds or assessing the patient before stepping on the x-ray pedal. We routinely evaluate lower fluoroscopy rates to determine if the loss of quality is low enough as to not affect safety. The EP lab has been using low fluoro rates for several years now and has seen a marked reduction in x-ray exposure. The EP lab also utilizes the Zero-Gravity radiation cabin (Biotronik) during ablations, which has greatly reduced the exposure to the physician and technologist.

What are some of the new devices recently introduced at your lab? 

We use the Synergy (Boston Scientific) and Onyx (Medtronic) stents primarily. We have added Penumbra and EKOS for PE treatment. We have a new ultrasound intra-cardiac echo (ICE) system that is shared by the labs. We have started to perform laser lead extraction with our new laser. We are using and have become very skilled at Impella and Rotablator procedures.  

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

Email is probably overused, so rounding and weekly Friday morning updates are very important to disseminate info that needs to be communicated quickly. This information is reinforced at the monthly department and staff meetings. Our director provides a weekly newsletter with updates for the department. 

How is coding and coding education handled in your lab? 

Any coding questions go to the manager who then has access to both electronic systems and trained coders to assist him.

Who pulls the sheaths post procedure? 

For cardiac cath procedures, most femoral sites are closed mechanically by the physician before the patient leaves the table, using Angio-Seal (Terumo), Starclose (Abbott Vascular) or Perclose (Abbott Vascular). The cardiac technologist pulls the radial sheaths while the patient is still on the table and applies a TR Band (Terumo). Venous sheaths and a small number of femoral arterial sheaths go to our pre/post holding area, where they are pulled by either a technologist or RN. All RNs and technologists are trained to pull arterial and venous sheaths, with the requirement of 10 supervised pulls to become competent and proficient.

Where are patients prepped and recovered post sheath removal? 

Outpatients are prepped and recovered in the cath lab holding area. Inpatients briefly come to the holding area for a check-in and an assessment by a RN. Post procedure, inpatients stay 15-120 minutes in our holding area, depending on their floor assignment and level of care needed. Outpatients are recovered and discharged home if patients are stable. Unstable patients or patients with special needs are admitted to the hospital for further monitoring. 

How is inventory managed at your cath lab? 

Our cath lab has 2 technologists that manage the supplies and equipment, as well as monitoring for expiration dates. Each technologist that scrubs the case orders the interventional equipment used in their case. 

Is your lab involved in clinical research? 

Not currently, although we have, in the past, been involved in trials.

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

From the latest American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR)/CathPCI Registry, our D2B time is 54 minutes. First medical contact-to-balloon time is 73 minutes.   We have a very collaborative relationship with EMS and share each field ST-elevation myocardial infarction (STEMI) with EMS to help improve first medical contact to balloon times. We are registered with the American Heart Association’s Mission:Lifeline and also participate in the Virginia Heart Attack Coalition.

Who transports the STEMI patient to the cath lab?  

The cath lab RNs go to the emergency department (ED) or inpatient floor, and bring the patient back to the lab, with assistance from the ED/floor RNs. 

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

Everyone gets the STEMI pages, on call or not. This team is so dedicated to the patients and to their teammates, that if second STEMI is called, people drop what they are doing and begin calling in to see if they are needed. This has occurred twice in the past few months and there was no delay in patient treatment. If a secondary team is not available, SRMH protocol is to use tPA in the ED; however, this has not had to be utilized.

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

Being part of a larger system does give an advantage on pricing and the ability to shuttle short-dated product to other facilities. We take part in bulk purchases that have given a significant savings. Staff  are very cognizant of their time and normally leave when the work is done.

What quality assurance measures are practiced in your cath lab?  

A cardiac scorecard is reviewed with the physicians at a monthly heart council meeting. This scorecard covers many of the quality indicators on the CathPCI and Chest Pain MI registries.

Are you recording fluoroscopy times and dosages? 

Both are recorded in both our hemodynamic system and in our electronic medical record.

What is the process that occurs if a patient receives a higher than normal amount of radiation exposure? 

We notify our safety officer if fluoroscopy time exceeds 45 minutes per case. If high exposure is noted, the physician in charge of the case will be notified and the patient is followed by our safety officer. This high exposure is reported to the patient by the physician. 

Who documents medication administration during the case? 

The circulating RN is in charge of all medication administration and Epic documentation in the cath lab. The monitoring RN is in charge of documenting the medications in our hemodynamic system. 

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

Our physicians utilize Dragon software (Dragon Systems) to dictate directly into our EMR.

Can you tell us about your cath lab’s participation in the ACC-NCDR or any other outside data collection registry?  

We have participated in the NCDR registry since approximately 2006. We also participate in Mission:Lifeline, the Society of Thoracic Surgeons (STS) database, and the Vascular Quality Initiative (VQI) Vascular Ultrasound Registry. 

How are you populating the registry data records? 

The RN begins the data sheet as they check the patients in, but a dedicated abstractor completes the data gathering process. Data are sent to the NCDR registry through Armus (Armus Corporation).

How does your cath lab compete for patients?

We are the only hospital facility within 30 miles, as well as the only hospital with an open heart program/surgical back-up within 60 miles. We market new procedures through advertising and outreach.

How are new employees oriented and trained at your facility? 

New staff have a 2-3 month orientation period before taking STEMI call. They are assigned a mentor/preceptor who is primarily responsible for ensuring the training is complete and accurate. 

What continuing education opportunities are provided to staff members? 

Our hospital participates in a clinical ladder program that encourages continuing education. Our RNs are eligible to participate in the hospital clinical ladder program, which goes from Level 1 (new hires) up to Level 5. We also utilize vendor training and education via the local chapter of Alliance of Cardiovascular Professionals (ACVP), and our cardiologists are very proactive and schedule monthly cath conferences. Staff also participates in national conferences. 

How do you handle vendor visits to your lab? 

Vendors must check in through Vendormate and wear the badge that is given to them. Vendors are only allowed in the cath lab when they have a new product to launch or their assistance is requested. Lunches or gifts are not allowed.

How is staff competency evaluated? 

We perform yearly competencies for electrocardiogram (ECG), IABP, Code Blue scenarios, devices, Rotablator, etc.

Does your lab have any physical (layout) bottlenecks or limitations? 

Our hospital is new as of 2010. We have a beautiful facility. The major limitation is a lack of storage as we expand services.

How does your lab handle call time for staff members? 

We have 4 set teams of 2 RNs and 1 technologist. Each team has a set day of the week for call and rotates every 4th weekend. Depending on the schedule and time of “call-in”, every effort is made to let the call person leave early or arrive late. 

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

The call team is expected to be here within 30 minutes. 

Do you have flextime or multiple shifts? How do you handle slow periods?  

Our staff all work 10-hour shifts, 7:00am-5:30pm. During slow periods, inventory is cleaned up and online training is completed. Medication audits are performed. Some staff float to other units, but many go home during slow times. We have designated “late” people if cases or recoveries run past scheduled shift. We have instituted 12-hour staff to accommodate late recoveries.

Has your lab recently undergone a national accrediting agency inspection? 

Yes, we just finished our yearly DNV survey (Det Norske Veritas Healthcare), with very favorable remarks. 

Where is your cath lab located in relation to the OR and ED? 

We are located about a minute walk down the hallway from the ED. We have an elevator adjacent to the cath lab suites that opens directly into the OR suites.

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

We are performing more complex PCIs, normally staging procedures to ensure that the patient and families understand the risk. Our right heart volume has increased as the cardiologists are working closely with Pulmonology and our Critical Care Unit. A distressing trend that we see among patients is the increased number of STEMI patients driving themselves to the ED in order to avoid an ambulance expense. 

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

Our team is unique due to their focus on safety. They have been given a toolkit for safety and all are comfortable using it. They respectfully challenge physicians and management when they find an issue. The physicians have come to respect this culture and accept questions about procedures or orders graciously.

Is there a problem or challenge your lab has faced? 

The first several months of 2016 brought several large-scale changes for our teams. New EP software was installed, a cath lab system was upgraded, a hemodynamic system changed, and we began using a brand-new electronic medical record (EMR). Careful planning and staff involvement were keys to success. More recently, our hospital has dealt with nursing shortages and we have had to hold cath/ EP patients in our holding area for extended periods of time. We have addressed this shortage by increasing several staff members to work 12-hour shifts to allow for patients having to stay more than 4 hours post procedure. This has also allowed us to increase our staff by 2 extra employees. 

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”?  

Harrisonburg is part college town and part farming community. We have 48 different languages spoken in the service area of the hospital. There are many cultures represented, and we make every effort so that everyone is treated with dignity and respect.

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

Prior to our merger with a larger system, the RCIS was not required. We have a great deal of respect for all of the professions in the cath lab and do not see how one credential in particular holds any more weight than the others. 

Are your clinical and/or managerial team members involved with any professional organizations that support the invasive cardiology service line, such as the ACVP or regional organizations?  

We are involved with the ACVP and the Virginia Heart Attack Coalition (VHAC).

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 (QI) initiatives at your facility?  

We had always utilized the outcomes report for a QI measuring stick. We now have a corporate scorecard that is based strongly around the outcomes report and is visible to upper administration.

The authors can be contacted via Linwood N. Williams, RT(R), Manager, Invasive Cardiovascular, at Lnwilli1@sentara.com.