Spotlight: Memorial Hermann Heart & Vascular Institute-Southwest

Editor's Note: The online version of this article has been corrected from the print version regarding the correct number of CICUs (13) and telemetry beds (29) at Memorial Hermann Heart & Vascular Institute-Southwest. Cath Lab Digest apologies for the error.

Terrence Devine, RN III, can be contacted at terrence.devine@memorialhermann.org.

Tell us about your cath lab.

Memorial Hermann Heart & Vascular Institute-Southwest is part of the 12-hospital Memorial Hermann Health System, known for world-class clinical expertise, patient-centered care, leading edge technology, and innovation. With its exceptional medical staff and more than 22,000 employees, the system serves to advance health in Southeast Texas and the Greater Houston community. 

Located on the Campus of Memorial Hermann Southwest Hospital, the Memorial Hermann Heart & Vascular Institute-Southwest opened in 2006 as Houston’s first freestanding heart hospital. Dedicated, specialized programming distinguishes the Institute from other similar facilities. The Institute’s Heart Valve Clinic, for example, offers patients innovative care delivered by a multidisciplinary team of affiliated specialists who work together to diagnose and treat heart murmurs.

The Institute offers five cardiac catheterization labs, two of which are also electrophysiology labs, a 15-bed pre/post-operative area, five cardiovascular operating rooms, a 13-bed cardiovascular intensive care unit, and 29 telemetry beds. The catheterization lab staff includes six registered nurses, three registered technologists, two cardiovascular technologists, and one registered cardiovascular invasive specialist. Recently, medical experts from the Institute began treating patients and training staff at nearby Memorial Hermann Sugar Land Hospital.

Selected from more than 1,000 U.S. hospitals, Memorial Hermann Heart & Vascular Institute-Southwest is among Truven Health’s 50 Top Cardiovascular Hospitals. The hospital recently received the American College of Cardiology’s 2014 NCDR ACTION Registry–GWTG Platinum Performance Achievement Award and was awarded the Society of Thoracic Surgeons’ highest rating of three stars for quality related to heart bypass surgery.

What procedures are performed in your catheterization lab?  

With hundreds of cases a month, we perform a wide variety of diagnostic and interventional procedures, both elective and emergent ST-elevation myocardial infarctions (STEMIs), angioplasty, and stenting, including chronic total occlusion (CTO) interventions. In addition, we utilize intravascular ultrasound (IVUS), PressureWire Aeris (St. Jude Medical) for fractional flow reserve (FFR), optical coherence tomography (OCT), rotational atherectomy, and AngioJet ultra thrombectomy (Boston Scientific). We offer Maquet Cardiac Assist intra-aortic balloon pumps (IABPs) and Abiomed Impella 2.5 left ventricular assist devices for cardiac support. For peripheral vascular cases, we offer Crosser catheters (Bard), the Diamondback 360˚ Coronary Orbital Atherectomy System (CSI), and IVUS catheter systems (Volcano). We also perform temporary pacing wire insertions, permanent pacemaker implants, and carotid stenting. 

For electrophysiology studies, we offer the new MediGuide Visualization and Navigation System (St. Jude Medical), and both the EnSite Velocity Cardiac Mapping System (St. Jude Medical) and Carto 3 System (Biosense Webster) mapping platform for ablation procedures. We work with advanced systems for cardiac ablation and perform cryoablation. Our electrophysiologist implants automatic implantable cardioverter defibrillators (ICDs), biventricular ICDs, and just recently began performing subcutaneous ICDs.

If your catheterization lab is performing transcatheter aortic valve replacement (TAVR), can you share your experience? 

The Heart Valve Clinic program at Memorial Hermann Heart & Vascular Institute-Southwest began in January 2012 and we have performed about 70 TAVR cases in the last three years. The Institute is one of the few facilities in Houston outside of the Texas Medical Center approved to perform TAVR cases.

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

This approach has been used at Memorial Hermann Heart & Vascular Institute-Southwest for a number of years. We have five affiliated physicians who regularly use the radial approach, usually through the left radial artery. We have found that inserting the catheter through the radial artery in the wrist, rather than through the groin, markedly reduces major vascular complications. However, as with every procedure, we evaluate each patient’s case carefully to determine the best type of procedure to perform.

Who manages your catheterization lab?

Mario Herrera, RN, BSN, CVRN-BC, is the director of the catheterization lab at Memorial Hermann Heart & Vascular Institute-Southwest, while Charles Brooks, RN, is the program manager.

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

Cross-training is an integral part of our catheterization lab. This helps the schedule flow on a busy day and builds teamwork among the staff. While all the technologists are versatile and scrub, circulate, and monitor, the RNs circulate and monitor, with many capable of operating the table and scrubbing. For electrophysiology, new staff members are oriented after they master the catheterization lab.

Which personnel can operate the x-ray equipment (position the image intensifier, pan the table, change angles, step on the fluoro pedal) in your catheterization lab? 

All appropriately trained catheterization staff can operate the x-ray equipment with physician supervision.

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

Along with appropriate radiation protection training, all physicians and staff are fitted with their own lead aprons. Additional protection includes clear shields and a lead skirt that hang from the operating table. Radiation badges are assigned to each employee and monitored regularly. 

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

Memorial Hermann Heart & Vascular Institute-Southwest completely upgraded its monitoring software and hardware to Mac-Lab/CardioLab from GE Healthcare. We recently began using the latest percutaneous, catheter-based Impella device and updated to Biosense Webster’s Carto 3 System in order to to use the new SmartTouch ablation catheter.  

The Institute now offers a new treatment for minimally invasive heart procedures that reduces radiation exposure for the patient, physician, and associated medical staff. The hospital is the first in Texas, and the only one in Houston, to employ St. Jude Medical’s MediGuide Technology, a device that uses GPS-like technology to guide heart catheters during the surgical treatment of arrhythmia. MediGuide Technology is a 3-D visualization system that uses electromagnetic signals to evaluate a patient’s vascular and cardiac anatomy, and track its therapeutic and diagnostic devices in real time on pre-recorded fluoroscopy images. Automatic adjustments are made to the previously recorded images to compensate for cardiac motion, respiratory changes, and patient movement. This is different from the standard practice, where physicians view devices in the heart using fluoroscopy. The 3-D visualization is outstanding, but the real advantage of MediGuide is that it helps us perform safer procedures by reducing radiation exposure for all involved. We recently performed a right atrium flutter ablation using only 40 seconds of fluoroscopy.          

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

Staff meetings are held on a regular basis, along with daily emails to keep everyone up to date and brief huddles to discuss urgent information. The physicians hold monthly cardiology and interventional section meetings. To lighten things up, we make poster boards focusing on a wide range of interesting topics, from the history of cardiac catheterizations to electrophysiology studies. 

How is coding and coding education handled in your lab?  

We have a trained, dedicated catheterization lab RN who reviews procedure charge sheets and compares them to the procedure reports. Any discrepancies are brought to the team’s attention and immediately addressed.

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

All staff members are trained to pull sheaths; however, it is usually performed by the pre/post catheterization lab staff. For patients going directly to the intensive care unit, ICU nurses are also trained. Training is done by a thorough review of material, demonstrations, return demonstrations, and evaluations by the catheterization lab manager until the employee is proficient.

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

For hemostasis, Memorial Hermann Heart & Vascular Institute-Southwest has a 15-bed pre/post-operative area with seven RNs, a patient-care assistant, and an office secretary. Along with prepping and recovering patients for the catheterization lab, blood transfusions are given on an outpatient basis. This area is also used for cardioversion, tilt table studies, and transesophageal echocardiography (TEE). Staff from the noninvasive cardiology department assist with these procedures.  

How is inventory managed at your catheterization lab? 

Two trained staff members handle supplies, one specifically for the catheterization lab and one for electrophysiology. Each employee has a designated backup. To track inventory and ordering, we use a Mac-Lab program to scan all items. We use Crystal Reports by SAP SE to make inquiries into the Mac-Lab database. We use a sticker sheet system for interventional procedure supplies. By peeling off the package’s sticker for such items as guide catheters, balloons, and stents, it is a quick way to double-check items used.

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

In 2013, Memorial Hermann Heart & Vascular Institute-Southwest completely renovated one of our catheterization labs especially for procedures with the Siemens MediGuide Navigation and Artis zee Angiography System. Navigation with the St. Jude Medical MediGuide Technology uses a special electromagnetic tracking procedure to determine the position of medical devices during minimally invasive interventions. During the intervention, a miniaturized sensor integrated into the catheter can be located by receiving electromagnetic positioning signals from the MediGuide transmitters, which are incorporated into the detector housing of the Artis zee system. The MediGuide Technology then calculates the respective position and orientation of the catheter and displays it in real time on fluoroscopic images of the patient that were recorded earlier. To display the catheter’s position precisely, the technology also compensates for patient movement caused by respiration and heart motion.

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?  

Our average door-to-balloon time is 65 minutes. We work closely with our emergency department and area emergency medical services to activate and coordinate responses to an ST-elevation myocardial infarction (STEMI). Electrocardiograms can be transmitted directly to the interventional cardiologist and once confirmed, the hospital operator announces ‘Code Heart’ over the intercom system. In addition, a group page is sent out for the on-call team. We are registered with American Heart Association’s Mission: Lifeline and the American College of Cardiology’s D2B Alliance.

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

Emergency department staff transports STEMI patients during regular hours, after-hours, and on weekends. The patient is accompanied by a resident, an emergency department RN, an administrator officer, and a security officer.

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

After consultation with the physicians and STEMI team, off-duty catheterization lab staff is called in, thrombolytics are considered, or the patient is transported within minutes to another Memorial Hermann hospital by Memorial Hermann Life Flight^® helicopter. 

Is your lab involved in clinical research?

No.

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

To cut and contain costs, we have reduced our inventory levels, order items as needed, and work closely with physicians to eliminate unnecessary supplies. We also are very aware of expiration dates, use items with closer expiration dates, and verify with physicians before opening supplies. Our administration staff continuously works with vendors to review supply contracts. Staffing is another area we have looked at to cut costs. We work 9.5 hours and have four-day work weeks. We float to other departments and even to other Memorial Hermann hospitals when not needed in the catheterization lab.  

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

We use a patient survey from Press Ganey and receive monthly performance reports. Physician performance is also measured using a monthly peer review of selected procedures. We created an American College of Cardiology (ACC)-approved audit tool form to ensure core measures, such as updated patient history and physical examination, hydration protocol, and angiographic (TIMI grade) blood flow, are tracked. We have a concise checklist for automatic ICD implants to comply with the ICD registry.

Are you recording fluoroscopy times/dosages? 

Yes. We document the time and dosages of radiation on the patient’s medical record, and record this information on logbook for easy reference. Any excessive radiation exposure is immediately reported to the Radiation Safety Committee.

Who documents medication administration during the case?

Prior to the start of a case, either a technologist or an RN is assigned the task of documenting medication administration. After the case, a medication sheet is printed, and both the physician and RN sign off on it.

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

Currently, physicians dictate their reports. We are moving toward using a structured reporting tool. 

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

We use the ACC-NCDR database, the ACTION registry for acute coronary syndrome patients, the Cath PCI registry for STEMIs, and the ACC-NCDR ICD registry for defibrillator implant patients. We use the Vascular Quality Initiative (VQI) registry for carotid stents.

How does your catheterization lab compete for patients? 

The world-famous Memorial Hermann Life Flight is one element that makes patient care at Memorial Hermann unique. Life Flight is a critical care air medical transport service that serves the community within a 150-mile radius of the Texas Medical Center with helicopters and worldwide using fixed-wing transport. Founded in 1976 by James “Red” Duke, MD, who still is medical director, the service operates around the clock – weather permitting – 24 hours a day, 365 days a year. Since its inaugural flight, Memorial Hermann Life Flight has flown more than 140,000 missions. Through Life Flight and solid relationships with many local emergency clinics, Memorial Hermann Heart & Vascular Institute-Southwest regularly receives patients from outlying areas. We have the ability and reputation to care for high-risk patients with multiple comorbidities.

How are new employees oriented and trained at your facility? 

After a general hospital orientation, each new staff member is assigned a preceptor for specific department orientation. Using a skill checklist, new employees are required to keep a daily log of their progress. For someone completely new to the Memorial Hermann catheterization lab environment, orientation could be as long as four months before they reach an acceptable proficiency level to take a call.

What continuing education opportunities are provided to staff members?

Memorial Hermann Heart & Vascular Institute-Southwest offers free, online continuing education classes. Additionally, employees are provided in-depth training on all new procedures and regular reviews of existing produces. Educational opportunities are often presented by various vendors and partner organizations. Advanced Cardiovascular Life Support (ACLS) classes are provided by the hospital and employees receive reimbursement for the cost of accreditation exams.

According to the International Board of Heart Rhythm Examiners (IBHRE), Memorial Hermann Heart & Vascular Institute-Southwest is one of the few hospitals in Houston to elevate its cardiology program with the addition of a certified cardiac electrophysiology nurse. Catheterization laboratory nurse Mary Abanto, RN, BSN, received her competency certification in cardiac electrophysiology for allied professionals from the IBHRE. Recipients of this designation are recognized for professional competence, are highly respected by peers and other medical professionals, can demonstrate advanced skills in clinical practices, and represent a standard of excellence in the arrhythmia community.

How do you handle vendor visits to your lab? 

Vendors are allowed in the catheterization lab procedure room, but only when assisting with a procedure or providing training. They must go through the hospital badging process, and wear a disposable white jacket and red surgical cap to identify them as non-hospital employees. 

How is staff competency evaluated? 

We undergo yearly competency testing with 40 percent based on skills and 60 percent on customer service.

Does your lab have a clinical ladder? 

We have a Clinical Ladder program for both RNs and technologists.

How does your lab handle call time for staff members? 

We have a team comprised of two RNs and two technologists for call. Weekend call is Friday through Sunday, every two to three weeks.

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

Team members are expected to arrive within 30 minutes.

Do you have flextime or multiple shifts? 

Employees work four 9.5-hour shifts.  

Has your lab recently undergone a national accrediting agency inspection? 

Memorial Hermann Heart & Vascular Institute-Southwest recently received the American College of Cardiology’s NCDR ACTION Registry–GWTG Platinum Performance Achievement Award for 2014. The Institute is also an accredited Chest Pain Center as designated by the Society of Chest Pain Centers (SCPC). 

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

The cardiovascular OR is on the same floor, next to the catheterization lab. The ED is on the 1st floor in the next building.

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

In Texas, the Houston-Sugar Land-Baytown region has the largest Asian population — more than 300,000 people. According to the U.S. Census, Asians accounted for 3.5 percent of the Texas population in 2008, but nearly 15 percent of Fort Bend County’s population and 6 percent of Harris County residents. Memorial Hermann Heart & Vascular Institute-Southwest, on U.S. 59 near the Fort Bend-Harris county border, is located in the middle of this thriving community.

An Asian component is the latest development in a robust initiative to cater to the unique needs of the population surrounding the hospital. Memorial Hermann Southwest offers Chinese and Vietnamese interpreters throughout the hospital, bilingual nursing and clinical staff, Asian TV programming available in all patient rooms, and a guest policy allowing overnight stays in patients’ rooms.

As for procedures, we have seen an increase number of radial and pre-TAVR catheterizations.

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

Memorial Hermann Heart & Vascular Institute-Southwest offers the latest technology, state-of-the-art equipment, and high quality medical care, but our people are what make us special, beginning with the front desk, where our office secretary, Fabiola Guzman, makes patients and family members feel at ease. Our administrative staff provides the tools and supplies we need when we need them. This support, from people like Greg Blunt, our clinical support analyst who is a technical genius, is invaluable. Our catheterization lab physicians and staff, with their special, welcoming mix of backgrounds and personalities, bring a tremendous amount of talent, experience, and skill to care for each patient. The work brings us together and it brings out our best: commitment, positive attitude, and determination. It is not without a great sense of pride that we say, “I work in the Cath Lab at Memorial Hermann Heart & Vascular Institute-Southwest.”

Is there a problem or challenge your lab has faced? 

Scheduling is always a concern. One day brings challenging case after challenging case with long hours, while the next day can be slow with time to reflect. During busy times, our strong teamwork comes into play with both the manager and director jumping in to assist in the pre/post area, start IVs, pull sheaths, and even transport patients. On occasion, staff from sister Memorial Hermann hospitals float to assist us with patient care. 

What’s special about your city or general regional area in comparison to the rest of the U.S.?  How does it affect your “catheterization lab culture?” 

Houston is home to the Texas Medical Center (TMC), the world’s largest medical complex. Since opening in 1945, TMC has been pioneering patient care, research, education, and prevention. Today, TMC includes 21 renowned hospitals, 13 support organizations, eight academic and research institutions, six nursing programs, three public health organizations, three medical schools, two universities, two pharmacy schools, and a dental school. Houston, thus, is a very competitive market for catheterization lab services and patients have many choices.

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?

Memorial Hermann Heart & Vascular Institute-Southwest participates in the NCDR and a multidisciplinary group from our hospital attended the 2014 meeting in Washington, D.C. Two of the best NCDR practices we have incorporated are the hydration protocol and blood transfusion reduction effort.

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)? Does staff receive an incentive bonus or raise upon passing the exam?    

No. RCIS is not required; however, two staff members do have this credential. There is no incentive bonus, but the exam is paid for by Memorial Hermann Heart & Vascular Institute-Southwest.

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?  

Several staff members belong to the SICP.