Jennifer Rasp-Vaughn, RN, BS, RCIS, can be contacted at jenniferraspvaughn @sheridanhospital.org.

Tell us about your facility and cath lab.

Licensed for 88 beds, Sheridan Memorial Hospital (SMH) is a progressive, state-of-the-art facility located along the valley of the eastern slope of the Big Horn Mountains in beautiful Sheridan, Wyoming. The SMH Cardiac Cath Lab was opened on January 21, 2013, and developed as a two-room system: the dedicated ST-elevation myocardial infarction (STEMI) room has a Siemens Artis zee floor-mounted system, and the second cath lab has a Siemens Artis zee ceiling-mounted system with a 56-inch high-resolution, 8-megapixel monitor that can take up to 24 inputs. Both labs are equipped with a fully stocked Pyxis (CareFusion), an Arrow intra-aortic balloon pump (IABP), and crash cart with LifePak 15 with EtCO2 monitoring for transport. The second lab is also set up for interventional radiology procedures, and has an AngioJet (Boston Scientific) for peripheral cases.

Our cath lab team consists of 2 interventional cardiologists, 4 registered nurses (RNs), and 2 radiologic technologists (RTs). One of the nurses currently holds the registered cardiovascular invasive specialist (RCIS) credential, one RT is studying for her RT(CI), and the second RT is RT(R)(M)(ARDMS). Each team member is currently making strides to gain further certification and/or education to enhance patient outcomes. Each of the team members currently performs at least two of the three roles of the cath lab team (monitor, circulating nurse, and scrub). The cath lab team started in January of 2013, but our cath lab and cardiology team member experience ranges from two years to 28 years. Our Big Horn Heart Clinic team consists of one office manager who is a respiratory therapist, two full-time RNs and one part-time RN, one echocardiographer, two schedulers, and one records person. Staff clinical and cardiac experience ranges from one year to 29 years.
Our interventional radiology (IR) team consists of two interventional radiologists, 13 RTs, and a radiology practitioner assistant (RPA). Among these team members, many hold advanced certifications such as (M) and (ARDMS).

What procedures are performed in your cath lab?

The Sheridan Memorial Hospital is a low-volume, non-surgical percutaneous coronary intervention (PCI) center, which means that we must follow certain guidelines to ensure best patient outcomes. We avoid performing high-risk procedures, as indicated in the 2014 Update on Percutaneous Coronary Intervention Without On-Site Surgical Backup.1 That all being said, we currently perform left and right heart caths, stenting, angioplasty and temporary pacemakers, insertion of IABPs, pericardiocentesis, peripheral angiography and intervention, implants such as permanent pacemakers, automated implantable cardioverter defibrillators (AICDs), and loop recorders, transesophageal echocardiograms (TEEs), and direct current cardioversions (DCCVs). We also take STEMI call Monday through Friday and two weekends a month.
Since we opened two years ago in January of 2013, we have performed 165 diagnostic cases, 67 interventional cases (not including STEMI), 21 STEMIs, 54 implants, 52 DCCV/TEEs, and 2 pericardiocentesis cases. This is significantly above the original projections for the cath lab, and we are gaining speed.

What percentage of your diagnostic caths is normal?

Approximately 62% of our diagnostic heart catheterizations are normal.

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

Currently, our interventional cardiologists do not gain access via the radial approach. On rare occasion, the cardiologists have used a brachial approach due to femoral occlusions.

Who manages your cath lab?

We have an RN/RCIS that manages the cardiac cath lab and cath lab team on a daily basis, and her responsibilities range from personnel to quality improvements, budgetary management, and policy development and review. The manager recently began reporting to the director of surgical services.   

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

Each member of our team is cross-trained in at least two of the three positions in the cath lab. The RNs all circulate and then either scrub or monitor. The two RTs are cross-trained in monitoring and scrubbing. The team also performs various duties outside of the procedure room related to performance, including quality assurance/performance improvement measures, marketing, hospital employee education, and community awareness projects.
Due to our hospital’s size, our RNs are also cross-trained in IR procedures, including kyphoplasty, biopsies, nuclear medicine cardiac stress tests, and thrombectomies. Our RTs can perform in various modalities, including nuclear medicine, ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), and angiography.

Are there licensure laws in your state for fluoroscopy?

The licensure in Wyoming states that a physician with credentialing and RTs under the guidance of the physician can administer fluoro. Maneuvering the c-arms are not under those same guidelines, so the RNs that scrub are allowed to move the c-arm; there are current conversations at the Board of Nursing regarding the ability for nurses to administer fluoro. The nurses in the SMH cath lab do not currently administer fluoro.

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?

The cath lab members that have been trained and show proficiency in operating the c-arm can position the II, pan and change angles; however, at this time, only the cardiologist/radiologist steps on the fluoro pedal.

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

Our cath lab safety officer is in communication with the radiology safety officer regarding the cath lab team radiation protection and dosing. The dosimeters are changed out on a monthly basis, and reporting is handed to individuals with dosing issues. The cath lab safety officer also gives an annual radiation safety in-service, answering any questions regarding radiation safety. This same person is responsible for ensuring the quality of the cath lab lead, and has developed an electronic recording system for easy access.

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

Since the SMH Cath Lab opened in 2013, everything in the lab is new. We have an Artis zee floor-mounted system (Siemens) in the cath lab and an Artis zee ceiling-mounted system in the IR lab, with integrated fractional flow reserve (FFR)/intravascular ultrasound (IVUS) (Volcano Corporation). Our power injector is a Mark 7 Arterion (Medrad), and we have the AutoCAT2 WAVE intra-aortic balloon pumps (Arrow International). Our main PCI vendor is Abbott (we use the Xience stent), but we have supplies from many vendors. We have the Jostent Graftmaster (Abbott) available for our bailout system. We also have the AngioJet (Boston Scientific) for thrombectomy in the IR lab.

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

Although we use the EMR (electronic medical record) for scheduling purposes, and are in communication with our radiology and heart clinic teams, our cardiac team uses smartphone technology to communicate with each other throughout the day. Because the team is in various places throughout the day to make the cath lab and IR workflow function, updates in scheduling (including changes in recovery locations, patient conditions, etc.) are done via text. Due to the low volume, our team stays well informed on patient condition throughout the hospital without compromising HIPAA via text.

How is coding and coding education handled in your lab?

Coding is performed by our SMH coding department; however, each case’s charges are entered and checked by in two-part system. The circulating nurse and scrub will go over the case post procedure, ensuring that all supplies are accounted for in the Pyxis. A billing sheet is then composed through our Sensis (Siemens) monitoring/documentation system, and rechecked by one of the team members at a separate time to ensure that all charges are accounted. Finally, the manager and coders are in email communication regarding any coding concerns.

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

All cath lab staff has gone through training and is checked off yearly for proficiency in pulling sheaths. Both RNs and RTs are expected to pull both diagnostic and interventional sheaths per cardiologist orders. The ICU is currently starting training and proficiency check-offs for sheath pulling.

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

Patients with elective cases are brought to the ICU for prep of their heart cath. Post procedure, the heart cath patients return to the same ICU room for post-op care. Being able to see the same staff take care of them throughout their hospital/cath experience gives the patient quality continuity of care.

Depending on the patient’s conditions and disease process, the patient either receives a closure device immediately after the procedure end with either a Starclose (Abbott) or Angio-Seal (St Jude), or has sheath(s) pulled in the ICU after anti-coagulants have worn off.

How is inventory managed at your cath lab?

Our inventory is managed in a coordinated effort between the cath lab team and materials management team through Pyxis systems and Keane electronic ordering. We have a certified purchasing agent that is dedicated to ensuring best pricing for the cath lab department.

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

Currently, our patient volume has exceeded our hospital’s one- and two-year goals. We do not have any plans in the near future for expansion of the department.

Is your lab involved in clinical research?

SMH is not involved in clinical research at this time. Our focus is on excellent patient care and outcomes.

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 low?

Our institutional outcomes report through the National Cardiovascular Data Registry (NCDR) just came out last month, and gave us a rolling four-quarter D2B time of 59 minutes. We feel that this is an outstanding endeavor, considering that our new cath lab was opened from scratch just two years ago.

We have been working in a joint effort with local emergency medical services (EMS) and the hospital’s emergency and ICU departments to ensure best patient outcomes, including a 90-minute D2B on all STEMI patients. We use a group paging system to activate the entire cath lab at once. We have members of both the EMS and the hospital that are very active in the American Heart Association (AHA) Mission: Lifeline Wyoming (M:L/WY) initiative and committees, and use many of the tools that have been a product of the committees with M:L/WY, including the use of a STEMI guideline and checklist in the emergency department (ED). Our cath lab and ED have recently been added to the AHA M:L sites.

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

Due to the cath lab’s close proximity to the ED, all STEMI patients are being transported from the emergency department to the cath lab by the cardiologist and circulating RN. This transport time, from wheels up to wheels down, is typically around two minutes.

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

We have two scenarios available for our team if there is currently a patient on the table, and a STEMI arrives to the ED. Our first option is: if our second cardiologist is available and the second cath lab/IR lab is open, we assemble our second cath lab team, and perform the STEMI in our second lab. It is well furnished with the same items as the dedicated STEMI room.

If we only have one cardiologist available, and the cath lab/IR room is in use, then we will stabilize the case in progress, transport them to the ICU for observation, and turn the room around for the STEMI patient. Again, the second cath lab team is assembled, and prepares the room for an emergent case.

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

The hospital as a whole has tried to be very competitive in pricing. We have done this by being very lean in our pricing structure. The cath lab and materials management departments have also taken measures to account for waste, including comparing the cost of disposable supplies versus the use of sterile processing and reusable supplies, as well as dropped and contaminated supplies. Finally, our certified purchasing agent focuses on best pricing options through our two group purchasing organizations (GPO), Novation and MSS. We have also been able to consign most of our products, and have close relations with our vendors to rotate products out that have a six-month or less expiration date. Finally, one creative way that has helped cut costs to the hospital as a whole has been in integrating the cath lab team into IR department procedures. Due to the low volume of the lab, both RNs and RTs will assist in other cardiac and interventional areas of the hospital to help with echocardiograms, sedation, monitoring and scrubbing. This helps the hospital cut costs in wages (i.e. not bringing in large volumes of travelers), and helps the team stay proficient in their various skills (echo, IV starts, port accessing, lab draws, moderate sedation and recovery, and ambulatory clinic assessments).

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

We have two RNs and one RT dedicated to collecting data and monitoring trends within the cath lab environment. We specifically look at D2B for STEMI, contrast and fluoro usage per case and per physician, complications ranked by the NCDR, patients being transferred for coronary artery bypass surgery (CABG), and a new moderate sedation tool to ensure adherence to policy.

Are you recording fluoroscopy times/dosages?

Fluoro times and dosages are recorded by the Sensis (Siemens) hemodynamic monitoring system, electronically sent to our final cath lab report, and transcribed into the final physician dictation.

Are your physicians dictating their cath procedure reports?

The cardiologists dictate all cath lab reports via a phone system, and those transcriptions are then placed into our electronic medical record.

Who documents medication administration during the case?

Medications given in the cath lab procedures are documented by the monitor role during cases. To ensure that there is understanding, we use a “call-back” style of communication, as discussed in TeamSTEPPS (www.ahrq.org). This simply means that when a medication is given, the nurse calls out, for example, “1mg of Versed”, and the monitor person responds by stating, “Heard” or “1mg Versed”. This concept of communication started because the monitor person was separated by a lead window, and wasn’t always hearing the advancement of the procedure or medications given. It has decreased the amount of documentation errors.

What registries do you participate in with American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR)?

Sheridan Memorial Hospital submits data to the ACC-NCDR for ACTION-GWTG, ICD and CathPCI registries.

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

Like most of Wyoming, Sheridan is very remote to most other facilities and cath labs in the state. Up until July 2014, Sheridan was only the third cath lab in the state. With our partnership with AHA’s Mission: Lifeline Wyoming, we have continued and strengthened our relationships with the regional medical centers in our state, as well as in Montana. Since we are a non-cardiovascular surgical PCI center, we must always keep open communication with our partnering cardiovascular surgical centers.

How are new employees oriented and trained at your facility?

New employees to the cath lab go through a weeklong hospital orientation, including skills training, and are then oriented to the cath lab for 6 weeks to 3 months, depending on the first role. Our cath lab is continuously training and orienting to new procedures, skills, and roles, so the training really never stops.

What continuing education opportunities are provided to staff members?

Like many cath labs, Sheridan’s cath lab receives continuing education through vendor support and training days. We also partner with regional medical centers in the region for cardiac-specific educational opportunities. SMH also subscribes to HealthNet (Texas Tech University Health Sciences Center) for online continuing educational credit. We take every opportunity to learn and advance our practice and experience.

How do you handle vendor visits to your lab?

Vendors reserve appointments through the cath lab manager and are placed on our schedule in order to ensure that there are no concerns or conflicts. When vendor representatives arrive, they must check in via our RepTrak system and arrive to the lab immediately.

How is staff competency evaluated?

Staff has a yearly competency that coincides with their evaluation. We also have a skills fair every July, where we use high-fidelity simulation in the lab for high-risk, low-volume procedures. Last year, our focus was on insertion and transport of a patient on an IABP to the regional medical center two hours away. This included our local EMS transporting the “patient” from the cath lab table to the ambulance, and then to the airport for a simulated fixed-wing transport to our regional medical center for CABG. We decided to perform this full-transport training to work out positioning issues within the ambulance and fixed-wing planes.
We also try to include our local EMS and fire department in all cardiac training since they are our first responders, our first eyes and ears on the patients in the field, and they are potentially our transporters for patients that need CABG.

Does your lab have a clinical ladder?

At this time, our cath lab does not have a clinical ladder specific to the department; however, each team member has specific professional goals that they have set to increase their growth in the organization. The hospital does have a clinical ladder called the Professional Incentive Program (formally known as the Clinical Ladder Program), which is available for all RNs, LPNs, surgical techs, CNAs and unit coordinators. There is no clinical ladder for RTs at this time.

How does your lab handle call time for staff members?

Our cath lab call team consists of the same mix of staff as any other case; we must always have one RN for sedation, but the scrub and monitor roles can be performed by either RN or RT, as long as they have been oriented, trained, and checked off for STEMI compliance for the role. There are many times when the cardiologist is assisted with one RN and two RTs.

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

Our call team is expected to be ready to assume care of the patient 30 minutes after being paged, meaning at 30 minutes the team has arrived, supplies are available, and the table is set up.

Do you have flextime or multiple shifts?

The cath lab schedule usually consists of two shift start times. If the team member is on call, then the start time is 0700; if the team member is not on call, then they have an 0800 start time. Some of the team members have made a pact that they will always be available at 0700. All shifts are scheduled for eight-hour shifts, but the team understands that there may be opportunity to leave early or stay late, depending on the caseload and patient needs.

Has your lab recently undergone a national accrediting agency inspection?

Yes, our cath lab recently underwent certification by The Joint Commission. The auditor spent two days going over our processes, policies and practices, and we were found to have no issues. We are very proud of this first visit, and look forward to the opportunities and education from future visits.

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

The cath lab is located on the ground floor of the hospital, and the STEMI doors are located approximately 50 feet from the trauma rooms of our ED. We were strategically placed between the ED trauma rooms, radiology, surgery, and the ICU. There is no more than a two-minute transport time from either cath lab room to any of the three other departments.

Tell us about your cath lab layout and design.

Our cath lab was designed by Mark Averett (TSP, Sheridan, Wyoming), who specializes in healthcare architecture. The best feature of our layout includes the STEMI doors within feet of the trauma bay area of the ED, which is where STEMIs are taken upon arrival to the hospital.

Because the architecture firm was integrating into a first story area of the hospital for one of the labs, we were not able to mirror the large screen display for our STEMI room. It would have been perfect if we could have the large screens in both labs.
On a humorous note, the only layout issue in our department is that our ice machine, albeit a great invention, is right next to the nurse station/dispatch, which means that any time ice is being made, the machine is very loud and annoying to work around.

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

At this time, we are still taking data points for trending purposes. Recent AHA data shows that the state of Wyoming, as a whole, continues to trend closely with national data. Our typical STEMI patients are 60- to 65-year-old males. The cath lab, hospital administrators and community leaders have been working closely to develop public service announcement and community awareness of cardiac disease in both men and women, and the use of 911 at the first sign of a heart attack.

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

Our cath lab was only the third cath lab built in the state of Wyoming when we opened. As stated before, due to our location within the hospital, we have a two-minute or less transport time to the ED, ICU, and surgery.
Our team ranges from new graduate RTs to tenured RNs with 26+ years of ICU experience. We are in constant learning mode, and are able to quickly help in other areas of the health system for cardiac-related needs, including filling in at the heart clinic. The cardiologist recently stated that we are “the best unit for our cardiac patients”; we have all of the necessary supplies and ingredients for our patient’s outcomes. We work as a very cohesive team, and are able to predict each other’s next steps.

Is there a problem or challenge your lab has faced?

There are two challenges that Sheridan’s cath lab faces. Like any rural hospital, we are challenged with getting the right mix of personalities for staffing. Wyoming has a significant nursing shortage and we are no exception. To try to circumvent this issue, we always try to market the cath lab as a great specialty for students and new nurses, and keep in contact with our partners throughout Wyoming and Montana for staffing opportunities.

Our second challenge is in regard to our goal of cardiac disease prevention and STEMI recognition. Through the grant with AHA Mission: Lifeline Wyoming, we have all participated in various activities to get the word out about cardiac health, and what to do if you are having a heart attack. We have made great strides as a hospital, and continue to work on this with our marketing department, the AHA, and various entities within our community and county.

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”?

Sheridan is nestled at the base of the Big Horn Mountains. Our population during the summer usually increases significantly in size due to tourism in the area. One interesting item about our STEMI situation when we first opened is that 9 out of the first 16 STEMI cases were not from Sheridan, Wyoming.

However, the beauty of the mountains in the summer translates to a huge challenge in the winter. The weather comes in over the mountain with such force that there are MANY times throughout the year that we are not able to use a helicopter to fly our patients out on non-STEMI weekends. Our ED is very well organized in ensuring quick turn-around time on door in/door out when they must “fibrinolize” and ship out patients. n

Reference

1.     Dehmer GJ, Blankenship JC, Cilingiroglu M, Dwyer JG, Feldman DN, Gardner TJ, Grines CL, Singh M. SCAI/ACC/AHA expert consensus document: 2014 update on percutaneous coronary intervention without on-site surgical backup. Circulation. 2014 Jun 17;129(24):2610-26. doi: 10.1161/CIR.0000000000000037.

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?

Our cath lab staff members are not required to sit for the RCIS certification at this time; however, they are all encouraged to move forward on educational opportunities and certifications. With the new caseload requirements for RCIS, each team member has a while before we hit the 600 case requirements.

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?

Not at this time, but we are expanding our endeavors. Our clinical team has been deeply involved with American Heart Association Mission: Lifeline Wyoming since 2012, and will be wrapping up that full-force project soon.

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?

We have just received our first rolling four-quarter report from the NCDR, and are looking forward to starting QI initiatives for Sheridan. We have just started reading into the report, and looking at opportunities for improvement within our healthcare system.