Spotlight: Sanford Health Cardiac Cath Lab

Tell us about your cath lab.

We have 5 cath lab rooms in total with 3 designated for cardiac cath, vascular, and structural heart procedures, and 2 designated for electrophysiology. We have approximately 40 staff members in our lab. Our team consists of radiologic technologists, registered cardiac electrophysiology specialists (RCES), registered cardiovascular invasive specialists (RCIS), and registered nurses (RNs). Members on our team providing care to patients in the cath lab have from 1 year up to 35 years of experience.

What procedures are performed in your cath lab?

We perform many procedures, including:

• Left and right heart catheterizations along with percutaneous intervention as necessary;
• Intracoronary ultrasound
• Rotational atherectomy
• Balloon pump insertion;
• Impella (Abiomed) insertion;
• Peripheral, cerebral, and renal angiograms along with intervention as necessary;
• Valvuloplasty
• Transcatheter aortic valve replacement (TAVR); 
• MitraClip percutaneous mitral valve repair (Abbott Vascular); 
• AngioVac procedures (AngioDynamics);
• Atrial septal defect (ASD), ventricular septal defect (VSD), and patent foramen ovale (PFO) closure
• Left atrial appendage closure; 
• Antegrade and retrograde chronic total occlusion percutaneous coronary intervention; and 
• Catheter-directed thrombolysis for pulmonary embolization.      

We perform an average of 75 procedures per week.

Can you share your experience performing TAVR? 

We have performed more than 200 TAVR procedures in 2½ years. The patients’ care is coordinated by 2 valve coordinators, who work with the patient from the beginning of the process all the way through the end of the procedure and in follow-up. All patients that are referred for this procedure are seen in consultation by an interventional cardiologist and a cardiovascular surgeon in our cardiology clinic. Patients receive a pre-TAVR work-up. If the patient meets appropriate criteria, the TAVR procedure is scheduled. Post procedure, patients are in the hospital for 2-3 days and are discharged home. Patients are scheduled for a follow-up appointment in the cardiology clinic.  

What percentage of your diagnostic caths are normal?   

Less than 10% of our caths are normal.

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

Yes, we perform more than 70% of our cases via the radial artery.

Who manages your cath lab? 

The Sanford Health Cardiac Cath Lab is managed by Jana Hart, RN, BSN, in collaboration with Paul Burud, RN, BSN, MSSL, the Director of Cardiovascular Services, and John Wagner RN, BSN, MHA, Vice President of Heart, Radiology, and Surgical Services. 

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

Yes, staff is cross-trained and rotate through different roles within the cath lab, such as scrubbing, recording, and circulating.

Are there licensure laws in your state for fluoroscopy? 

Yes, the lab must have a radiologic technologist in each case. The radiologic techs and physicians can operate the x-ray equipment.

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

We have an internal physics department that oversees radiation exposure and maximizes protection to physicians, staff, and patients. We monitor radiation doses monthly through each staff member wearing a radiation badge. We receive a monthly report that is posted for staff to review their levels. All staff is provided with lead to wear during cases; in addition, we have lead shields and lead glasses available. We are currently in the process of implementing real-time dose aware, which gives us real-time exposure doses to staff and patients during the procedure, assisting with reduction in radiation exposure.

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

We continue to introduce new technologies and procedures as they become available. Most recently, we have started performing MitraClip (Abbott), AngioVac procedures (AngioDynamics), and ultrasound-accelerated thrombolysis treatment for pulmonary embolization (EKOS Corporation). We have plans to start performing the Watchman Left Atrial Appendage Closure (LAAC) device (Boston Scientific) and RP (Right Sided Percutaneous Support) Impella for severe right ventricular failure.

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

In our lab, we hold daily huddles every morning before we start performing cases. We have weekly meetings with the cardiologists to discuss cath lab operations.

How is coding and coding education handled in your lab? 

Coding and coding education is handled through Sanford Health’s coding department.

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

Sheaths can be pulled by a registered nurse or a cardiovascular technologist (CVT) who has completed the initial orientation for this task.  

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

Our patients are prepped in the day unit. Depending on the procedure performed, patients will either go back to the day unit or to a hospital bed for observation following the procedure. We utilize vascular closure devices along with manual pressure. Hemostasis is achieved in the cath lab prior to transfer.

How is inventory managed at your cath lab? 

Inventory is managed through a barcoding process built within the Mac-Lab System (GE Healthcare) that is managed through the GE application. We also use a two-bin system for minor supplies used on a daily basis. This process is managed by supply chain management. Our cath lab manager and director, along with supply chain management, handle purchasing of equipment and supplies. 

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

We have continued volume growth in our lab. Most recently, we have expanded our lab to perform TAVR, MitraClip, AngioVac and catheter-directed thrombolysis procedures. We will continue to expand and provide treatment as new technologies become available through the FDA.  

Is your lab involved in clinical research? 

Yes, currently our lab is involved in:

• GLAGOV (GLobal Assessment of plaque reGression with a PCSK9 antibOdy as measured by intraVascular ultrasound);
• Sanford interventional cardiologist Dr. Thomas Haldis is a principal investigator of an investigational TAVI study (Cognitive Functioning Improves Following TAVI: Cerebral Perfusion Trumps Embolic Injury) to look at cognitive function and MRI use. 
• We are participating in the RESOLUTE ONYX clinical trial, a multicenter study to evaluate the next generation drug-eluting stent built on the Medtronic Resolute Integrity drug-eluting stent.
• In addition, Sanford Health has been selected as a site for the BIOFLOW-V: BIOTRONIK – A Prospective Randomized Multicenter Study to Assess the SaFety and Effectiveness of the Orsiro SiroLimus Eluting Coronary Stent System in the Treatment Of Subjects With up to Three De Novo or Restenotic Coronary Artery Lesions – V. 

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 44 minutes. We have a ST-elevation myocardial infarction (STEMI) coordinator who works with local and regional EMS teams to improve processes and decrease D2B times. We have partnered with regional facilities and provided education on how to treat a STEMI and transfer them to us as quickly and efficiently as possible. We have regional hospitals broken down into zones associated with average transfer times. Based on the identified transfer times, we will have sites administer lytics prior to transfer. We have the ability to transmit EKGs to the ED and interventional cardiologist’s mobile phone from the ambulance and Life Flight while the patient is in route. This allows for early identification of a STEMI and early activation of the cath lab team prior to the patient arriving at the hospital. For hospitalized patients, we have implemented an ICU chest pain nurse consult team. For all patients who experience chest pain or have EKG changes, an ICU nurse chest pain consult is initiated. The RN will come to assess the patient, review the EKG, and activate the cath lab team if ST elevation is present on the EKG. We also hold mock STEMI drills in the hospital and evaluate the process. Sanford Medical Center is an accredited Chest Pain Center through the Society of Cardiovascular Patient Care and an accredited Mission: Lifeline receiving center through the American Heart Association.

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

During regular and on-call hours, patients who are having an acute MI and are being transferred by ambulance or life flight are transferred directly to the cath lab. These patients bypass the emergency room and are directly admitted to the cath lab from EMS or life flight. If the patient arrives in the emergency room and a STEMI is identified, the emergency room staff transports the patient to the cath lab when the cath team is ready.  

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

Patients are triaged by the interventionalist. If the current patient can’t be removed from the table and the delay is anticipated to exceed the window for primary PCI, we have TNKase (tenecteplase) available.  

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

We have standardized processes, along with product. Product standardization is very important, since it reduces inventory and overall cost. We work very closely with our physician partners when decisions are made about products and utilization. We also monitor all our wasted products and evaluate how to reduce waste.

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

We are looking at our contrast use per physician and scrub tech, looking for trends in high or low administration and how we can reduce contrast use.  

Are you recording fluoroscopy times/dosages? 

Yes, we are documenting fluoroscopy times in the procedure report within the GE Mac-Lab.

Who documents medication administration during the case?

The circulating RN documents medication administration during the case.

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

Physicians are using structured reporting that is done in the Cardiology GE reporting system.  

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

We participate in the ACTION Registry–Get With the Guidelines (GWTG), Cath PCI Registry, and the ACC/Society of Thoracic Surgeons (STS) Transcatheter Valve Therapy (TVT) Registry.

How does your cath lab compete for patients? 

There are other facilities that provide heart care in our region. We have built alliances with many healthcare providers and organizations in the region. We have established referral relationships with these hospitals and providers, and their patients are able to receive cardiac services we offer that are not available at their location, such as TAVR, MitraClips, PFO closures, diagnostic heart caths, and STEMI care. 

How are new employees oriented and trained at your facility?

New employees are assigned a primary preceptor who provides direct training. They have a competency checklist that needs to be completed prior to performing skills independently.

What continuing education opportunities are provided to staff members?

Staff members attend our annual competency skills fair and are also given the opportunity to attend the Cardiovascular Symposium that is held annually. Education for new procedures and products that are being introduced into the lab is provided as needed. 

How do you handle vendor visits to your lab? 

All vendors need to make appointments prior to arrival. When they arrive to the lab, they need to check in, provide identification, and adhere to the standards of the hospital vendor policy.

How is staff competency evaluated? 

Staff competency is evaluated through initial competencies and ongoing yearly competencies.

How does your lab handle call time for staff members? 

Each call team consists of an RN to circulate, a cardiovascular scrub tech, an additional RN or scrub tech for monitoring, and a radiologic technologist. Staff is on call approximately every sixth weekend, and one weeknight every other week.

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

Staff members are expected to arrive to the lab within 20 minutes.

Do you have flextime or multiple shifts? 

We have part-time and full-time employees. We have a combination of 10-hour shifts and 8-hour shifts. All shifts start at 0700.

Has your lab recently undergone a national accrediting agency inspection? 

Our lab recently obtained dual accreditation with Chest Pain Accreditation and Mission: Lifeline.  

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

Our cath labs are adjacent to the OR. The ED is on the floor below the cath lab.

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

We have seen an increase in volume with structural heart cases, along with an increase in our coronary interventional volumes. We have seen a shift from procedures going from inpatient to outpatient procedures, and patients going home the same day.

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

Our team is extremely dedicated to providing quality care. We have a highly engaged team that is eager to learn, along with a dedicated team of physicians who enjoy teaching and introducing new technologies and techniques into our lab to better serve our patients. 

Is there a problem or challenge your lab has faced? 

We have been working on our in-house STEMI process and cath lab times. In 2013, we identified significant delays with patients who developed chest pain and were having a STEMI while in the hospital. We have implemented an in-house chest pain consult team. This is a team of critical care nurses who have been specially trained with EKG interpretation and management of patients with chest pain. The team evaluates patients who are actively having chest pain. These nurses are able to activate the cath lab team if a STEMI is identified on the EKG. We have educated nurses and staff throughout the hospital about this process. We hold mock STEMI drills and walk through the process, including transporting routes to the cath lab. Our in-house STEMI times went from an average of 73 minutes to 54 minutes.

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 population of the Fargo and the surrounding area is 228,000. Our service area includes North Dakota, South Dakota, and western Minnesota. Our area is different from many parts of the United States, because it is in a rural setting and in some cases, patients come to receive care from more than 300 miles away. 

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?

Outcome reports are reviewed monthly. Clinical processes are reviewed and changes are made as necessary to improve quality care. We partner and collaborate with internal medicine and emergency department providers, as well as hospitalists, to implement a comprehensive plan of care to manage our patients.

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

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?

If staff does not have their RCIS upon hire, they are required to obtain it within 1 year of hire. Staff does not receive a bonus or raise for obtaining their RCIS.

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? 

Yes, our clinical team members and leaders are members of the ACC and Society for Cardiovascular Angiography and Interventions (SCAI).