Spotlight: Northwell Health – Lenox Hill Hospital

Tell us about your cath lab.

Lenox Hill Heart and Vascular is part of the Northwell Health cardiac service line.

What is the size of your cath lab facility and number of staff members? 

We have 6 angio suites and a 12-bed pre/post area, including a multi-specialty interventional lab and a stroke encephalo-volumetry (EVM) center where we also treat pulmonary embolism and structural heart disease. Our lab employs 41 registered nurses (RNs), 6 nursing technologists, 8 angioplasty specialists, 4 scheduling staff (for authorization), and 2 nurse coordinators. Over 25% of the staff has been here 15 years or more, 20% have been here 10 years or more, and 10% has been here 5 years or more. Approximately 40% of our staff has been here less than 5 years.

What procedures are performed in your cath lab? 

We perform many different procedures, including: 

• Cardiac catheterization with angioplasty
• Peripheral angiography/angioplasty
• Cerebral angiography
• Electrophysiology (EP) studies
• Structural heart procedures 
• Pulmonary embolectomy
• Carotids 
• Embolization
• Cerebral stenting 
• Coiling
• Use of Penumbra
• Endovascular aneurysm repair (EVAR), transcatheter aortic valve replacement (TAVR), thoracic endovascular aortic repair (TEVAR)

We perform between 100 and 125 procedures per week. 

Can you share your experience with structural heart repair? 

Our lab is performing TAVR, EVAR, and TEVAR. Cases use an integrated team approach with the operating room (OR), 2 surgeons, anesthesia, and perfusion as needed. We perform approximately 150 TAVRs/year and will open a brand new hybrid OR suite in a few months.

What is your percentage of normal diagnostic caths? 

Between 20-25% of our diagnostic caths are normal.

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

Yes, over 50% of our physicians use radial access. 

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

Yes, for advanced critical limb ischemia (CLI) cases, Dr. Mitchwell Weinberg, director of endovascular therapies, performs pedal access.

Who manages your cath lab? 

Sinead Merrick, BSN, is the cath lab nurse manager. She has been at Lenox Hill for the last 3 years, although a cath lab nurse manager for the past 10 years. She will be graduating from an MBA program in May 2017. Sinead comments, “I love being the manager of a multi-discipline interventional unit. I am privileged to be a part of a truly dynamic, passionate team that provides outstanding patient care with superior patient outcomes.”

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

Yes. RNs monitor and circulate as well as staff the pre and post area. Angioplasty specialists scrub during cases.

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

• CSI’s Diamondback orbital atherectomy system, Impella (Abiomed), laser
• Drug-eluting balloons for percutaneous transluminal angioplasty (PTA)
• Synergy stents (Boston Scientific)
• Coiling, fractional flow reserve (FFR), ultrasound, optical coherence tomography (OCT), and intravascular ultrasound (IVUS)

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

We use a variety of methods, including emailing, weekly education meetings, staff huddles, online I Learn courses, and a notice board.

How is coding and coding education handled in your lab? 

Coding is performed by the billing department.

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

Sheaths are pulled by angioplasty specialists, physician assistants, and physicians, and RNs perform radial band removal.

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

Patients are prepped and recovered in the holding area. We use Angio-Seal (St. Jude Medical) and Perclose (Abbott Vascular), as well as radial compression bands.  

How is inventory managed at your cath lab? 

The lab has 2 dedicated supply chain managers who order, stock, and maintain equipment. Purchasing of equipment is discussed with the director of the lab, who provides par levels to the supply managers. Supply managers monitor par levels to gauge usage, and increase or decrease equipment as necessary.

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

Yes, the lab has expanded over the years to support neuro intervention, arteriovenous malformation (AVM), and peripheral vascular and structural heart interventions, as well as EP. The case mix and overall volume has increased, but not the actual footprint of the lab.

Is your lab involved in clinical research? 

Yes. We are national leaders in enrollment for many and varied cardiovascular trials.

Are you registered with the American Heart Association’s Mission: Lifeline or the American College of Cardiology’s D2B Alliance? 

Yes, we were recognized with a Silver level of recognition award by Mission: Lifeline.

Who transports the ST-elevation myocardial infaction (STEMI) patient to the cath lab during regular and off hours?

Emergency department staff and physicians.

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

We have 2 call teams to support cases.

How does your lab handle on-call time for staff members? 

Our lab has 2 call teams: Team 1 and Team 2. Team 1 is the traditional STEMI team that also covers any emergencies coming to the lab after hours, neurovascular, endovascular, and structural heart. Examples include cerebrovascular accidents (CVAs), pulmonary emboli, abdominal bleeds, and high risk, valve-related emergencies. Team 2 handles late cases and any patients remaining in the holding area after hours. Additionally, Team 2 covers elective cases on weekends and can cover when a second emergency comes in.

Each call team is comprised of 2 nurses, 1 registered cardiovascular invasive specialist (RCIS), 1 fellow, and 1 attending.

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

For Team 1, we are required to be here within 30 minutes of being called for an emergency. Team 2 has greater leniency, as for non-emergent calls, and is usually given about an hour to arrive. 

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

We currently have three 11.5-hour shifts (0630, 0730, 0900) with some ability to come in earlier or later than needed. During slow periods, we are given the opportunity to complete continuing education hours, staff development classes and unit-based lectures. 

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

We are located on the 11th floor of the main hospital. The cardiac ORs are one floor below us and the ED is on ground level.

What quality assurance measures are practiced in your cath lab?

There are 3 quality assurance measures currently being measured:

• Aseptic technique (quarterly topic) 
• Time out procedure (quarterly topic)
• STEMI door-to-device time (ongoing)

Are you recording fluoroscopy times/dosages? 

Yes. We currently record fluoroscopy times and dosages. We record it within the electronic medical record (EMR). 

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

We inform the physician at 3,000 cumulative air kerma during the procedure.

Who documents medication administration during the case?

The monitoring nurse documents medications administered during the case.

Are your physicians dictating their cath procedure reports, or do they use a structured reporting tool (if so, which tool)?

It is the physicians’ choice. A few physicians dictate their cath procedure reports. Most complete a written report on the XIM system (Philips).

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

Yes, we participate in the ACC-NCDR. We have a large, dedicated quality analysis team that captures NCDR data for every percutaneous coronary intervention patient.

How are you populating the registry data records? Who is inputting the data, and is any of it accomplished through in-lab systems?

The ACC-NCDR data is collected during the case via the XIM system. 

How are new employees oriented and trained at your facility? 

We have two orientation and training programs for new employees. New employees with intensive care unit (ICU) experience go through orientation for 12 weeks. New employees without ICU experience go through fellowship program for one year. New employees are trained with assigned preceptors for their entire orientation and training.

What continuing education opportunities are provided to staff members?

Staff is encouraged to attend monthly journal meetings, and we have morbidity and mortality (M&M) conferences on Wednesdays.

How do you handle vendor visits to your lab? 

Vendors are allowed in our cath lab. They are only allowed into rooms when requested by the physician and the patient signs a vendor consent form. A badge and proper attire are mandatory prior to entering the cath lab procedure areas.

How is staff competency evaluated? 

Nursing leadership performs annual testing.

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

We have a small joint holding/recovery area that is not always able to handle the inflow of new and post procedure patients. On busy days, we stagger the arrival times of patients to allow for adequate throughput. Additionally, on busy days we have a Surge Room on our progressive care unit (PCU). The Surge Room has a single dedicated Surge Nurse, who cares for up to 4 diagnostic radial patients at once. The activation of the Surge Room allows us to free up 4 beds in our holding area.

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

Patients in the lab are generally older with more comorbidities compared to a decade ago.

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

We are a versatile lab where interventional cardiologists, cardiac surgeons, vascular surgeons, interventional radiology, and neurosurgeons all work together. Our staff is truly able to handle any vascular procedure in the entire body.

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”?

New York City is incredibly diverse and our staff is similarly so. We have a very “inclusive” staff culture. 

The authors can be contacted via Margarita Oksenkrug at moksenkrug@northwell.edu.

Two questions from the Society of Invasive Cardiovascular Professionals (SICP):

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?  

Yes, we do require staff to take the RCIS exam, and staff does receive money upon passing the exam.

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 yet, but it is being discussed.