Spotlight: Mercy Health Springfield

Tell us about your cath lab. Is it part of a cardiovascular service line?

We are part of the cardiovascular service line that consists of the cath lab, electrophysiology (EP), cardiovascular operating room (CVOR), cardiovascular intensive care unit (CVICU), heart center (stress testing, electrocardiogram [EKG], echo, cardiac computed tomography [CT], tilt table testing, enhanced external counter pulsation [EECP]), and cardiopulmonary wellness. 

What is the size of your cath lab facility? 

We have four labs, two of which are hybrid labs, and one of which is a dedicated EP lab. We have a 19-bed holding area for pre and post procedures. Staffing consists of 19 registered nurses (RNs), two radiologic technologists, one respiratory therapist, one nursing assistant, one cardiovascular analyst, and one secretary. We have nine cardiologists, of which a total of six perform interventions and one is an electrophysiologist. We have three cardiovascular surgeons. Depending on the case, our staffing mix is 2 to 3 RNs with one radiologic technologist or respiratory therapist. Experience ranges from 1 to 20 years. 

What procedures are performed in your cath lab?  

• Diagnostic heart catheterizations: 170/month
• Percutaneous coronary interventions (PCI): 70/month
• Peripheral vascular angiograms: 35/month
• Peripheral vascular interventions: 25/month
• ST-elevation myocardial infarction (STEMIs): 6-10/month
• Impella (Abiomed), intra-aortic balloon pump (IABP), atrial fibrillation and SVT ablations: 25/month
• Temporary pacemaker, implants (pacemaker, implantable cardioverter defibrillator [ICD], bi-v pacemaker, bi-v ICD): 15-20/month 
• Peripheral abdominal aortic aneurysm (AAA) stenting, carotid angiograms: 4-8/month 

We are not doing transcatheter aortic valve replacement (TAVR), but plan to start in the near future. AAA repair is performed in the hybrid lab. We also do fistulagrams and fistulagram declotting.

What is your percentage of normal diagnostic caths?

Our rate of normal diagnostic caths is approximately 28 percent.

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

They all utilize femoral and radial access, but we have three physicians that primarily do radial procedures.

If you are performing peripheral vascular procedures, do any operators utilize pedal artery access when appropriate?

Yes.

Who manages your cath lab?

Lori Blanton RN, MSN, is the Cardiovascular Service Line Director and Dan Price BS, RRT, EMTP, is Manager of Cardiology.

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

Everyone is cross-trained to do all three roles, although only RNs pass meds. Everyone is also cross-trained in the pre and post holding area. 

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

All can position the II, pan the table, and change angles. Only radiologic technologists and physicians can step on the fluoro pedal.

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

All staff is fitted for their lead. There are lead barriers on the table, an adjustable one from the ceiling that protects from the II, and we also have a mobile barrier. 

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

We have a dedicated phone that the assigned charge nurse carries. All calls go through her. We have a large scheduling whiteboard in the center core.

How is coding and coding education handled in your lab?

We have a dedicated coder in the cath lab and we also use IRCoder.com.

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

All cath lab staff pulls sheaths post intervention (if held in post-op holding) and diagnostic and post intervention patients are admitted to the cardiac step-down unit, where their sheaths are removed by the unit nurse. Everyone that pulls sheaths goes through the cath lab for training.

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

Outpatients are prepped and recovered in our pre/post holding area. If they are PCI patients, they will go to the cardiac step-down unit. Inpatients are prepped in their room and recovered in their room. We still do a lot of manual holds, but will use Angio-Seal (Terumo). We use the TR Band (Terumo) for radial procedures.

How is inventory managed at your cath lab? 

The cardiology manager and supply clerk manage inventory, plus we have Pyxis (BD) in the labs. The cardiology manager and cardiovascular service line director handle the purchasing. Routine daily supplies are ordered by supply clerk. We also have a value analysis committee where we review possible new equipment and supplies. 

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

We are expanding our peripheral vascular program and planning on adding TAVR, so patient volume will increase.  

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 D2B time averages 57-59 minutes. We use Lifenet so medics can transmit an EKG and ask for a cardiac alert. At that time, STEMI is paged out. When the cath lab team is on site, patients coming from the field bypass the emergency department and go directly to the cath lab. 

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

Squad personnel and ED staff.

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

A second page goes out and a member of the call team or house nursing supervisor will call other cath lab staff to come in. Staff is very good at helping each other out — the patient always comes first. 

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

Our core value analysis team meets on a monthly basis to look at new requests, consignment opportunities, corporate contracts, and phase out unutilized inventory and equipment. 

What quality control measures are practiced in your cath lab?

We review National Cardiovascular Data Registry (NCDR) data with physicians, administration, and staff. Staff participates in monthly performance improvement projects and quality control projects. 

How do you determine contrast dose delivered to the patient during an angiographic procedure?

This is physician driven. 

Are you tracking the incidence of contrast-induced acute kidney injury in patients? 

We track this through our data collection. Post procedure BUN and creatinine are performed on all PCI patients. 

How are you recording fluoroscopy times/dosages?

We record in McKesson, which transfers to the patient chart as well. 

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

Full disclosure is given to the patient. The radiation safety officer is notified. Follow-up is per physician order.

Who documents medication administration during the case?

The person monitoring the case does all documentation, which is then reviewed by the administering RN at the end of the case.

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

We are using McKesson structured reporting. 

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

Yes, we use the PCI, ICD, and PVI registries, and also report to ODH (Ohio Department of Health).

How are you populating the registry data records? 

We utilize Cedaron for assistance with data input. We have a CV analyst inputting the data. 

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

We have no alliance with other facilities at this time. We do advertise on billboards, in the newspaper, on social media, and occasionally on TV, and via word of mouth.

How are new employees oriented and trained at your lab?

We usually start out training in circulating, then scrubbing a straight heart cath with a mentor scrubbed in, then PCI with a mentor, and lastly, they learn the monitoring. This takes place over a minimum of 6 months. After they become proficient in the heart, we will train in peripheral cases.   

What continuing education opportunities are provided to staff members?

We have assigned computer iLearns, and will review 1-2 items per month such as orbital atherectomy, nstantaneous wave-free ratio (iFR)/fractional flow reserve (FFR), Impella, etc. Vendors give training as well and staff can also attend seminars.

Are your clinical and/or managerial team members involved with any professional organizations that support the invasive cardiology service line, such as the Alliance for Cardiovascular Professionals (ACVP [now including the Society of Cardiovascular Professionals, SICP]) or regional organizations?

Yes, we are involved with the ACVP.

How do you handle vendor visits to your lab? 

Vendors sign in with VendorMate. They must have a badge to get into the cath lab or anywhere, for that matter. Representatives must sign in at the front desk in the cath lab holding area. For their first visit to our lab, they must sign a contract that explains the rules. Vendors are only allowed at a desk in the center core where if physicians can speak to them if they wish. Vendors are only allowed in the monitor room or cath lab if a physician asks for their assistance or they are there for particular case. If they are in the lab on physician request, they are not permitted to sell or push for new supplies or equipment.

How is staff competency evaluated?

Evaluations are based on competency checklists, written tests, and direct supervision for teach and observe return demonstrations. 

Does your lab have a clinical ladder? 

Not at this time, but we are looking into it.

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

We encourage them to take it but it is not required at this time. There is no raise or bonus for passing.

Does your lab have any physical (layout) bottlenecks or limitations? How do you work around the resulting challenges?

We have a good layout and are just down the hall from the OR. The ICU and CVICU are on the same floor and just as close. The only drawback is majority of our patients go the cardiac step-down unit and that’s on another floor.

How does your lab handle call time for staff members? 

Call is every fourth weeknight and every fourth weekend. Call starts at 4:30pm and ends at 6:00am Monday through Friday. Weekend call starts at 6:00am Saturday and ends 6:00am Monday. If staff is called in during the night and staffing permits, we send them home early. We have four staff on call, and must always have at least two RNs (usually it ends up as three RNs and one technologist).

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

Staff must arrive within 30 minutes, with no exceptions. It is the same for physicians.

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

Cath pre/post has two shifts. Start times are 5am and 7am. The two that come in at 7am stay until the last patient is discharged. All staff is rotated through. During slow periods, we offer the option to take time off with or without pay. Some staff has chosen to cross train to other areas within cardiology as well. 

Has your lab recently undergone a national accrediting agency inspection? 

We were surveyed this year by ODH (Ohio Department of Health) and the Joint Commission. We had no recommendations.

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

We are seeing much younger STEMI patients and younger patients in general. We have moved to radial cases more often. 

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

Staff is very involved in helping to make the lab a high-quality environment for patients and their families. They coordinate multiple team-building activities such as potlucks for birthdays and holidays. The team is very dependable and always willing to come in on days off or for second call team if needed. They work with the physicians to continue to learn and grow in their roles. Staff also plays an active role in education of other nurses throughout the facility on cath lab procedures and sheath pulls. 

Is there a problem or challenge your lab has faced? 

We have trouble hiring. These days, it seems no one wants to take call. We continue try to recruit. Also, we do not hire to just fill the open position, we hire for the right person with the right attitude: the right fit.

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”?

We are the only community hospital within a 25-mile radius and are located directly between two larger cities, Dayton and Columbus. Most of the primary market share, approximately 80%, is maintained for cardiology at this facility. Our cath lab is very busy. We have state-of-the-art labs and equipment, as well as nationally known cardiologists and CV surgeons working in our lab. 

Daniel S. Price can be contacted at dsprice@mercy.com