Spotlight: Yuma Regional Medical Center

Tell us about your facility and cath lab. 

Yuma Regional Medical Center is a 406-bed acute care hospital. Our cath lab has 3 angiography suites, a hybrid suite and an electrophysiology (EP) suite. Our prep/recovery area has recently expanded from 14 to 29 beds to accommodate our growing program.  We currently have 7 full-time registered nurses (RNs) and 10 full-time radiologic technologists (RT[R]s) in the procedure area. According to the American Registry of Radiologic Technologists (ARRT) census, Arizona has 40 RT(R)s credentialed in Cardiac Interventional Radiography (CI), and 8 of them are in our lab. In addition, one of our techs has her Cardiovascular Interventional Radiography (CV) credential, one has her Vascular Interventional Radiography (VI) credential, and both are registered cardiovascular invasive specialists (RCISs), with much of our staff scheduled to obtain further credentials. We take great pride in this accomplishment. In the prep/recovery area, we have 11 full-time RNs. Our staff experience ranges from 1 to 18 years in the cath lab setting. We average 7.5 years amongst all of us. 

What procedures are performed in your cath lab?   

We routinely perform right and left heart catheterizations, percutaneous coronary interventions (PCIs), diagnostic and interventional peripheral procedures to include carotid stenting, CRM device implantation (pacemaker, implantable cardioverter defibrillators [ICDs], BiV, Sub Q ICD, loop recorder), inferior vena cava (IVC) filter placement, pericardiocentesis, temporary pacemaker insertion, biopsies, valvuloplasy, device implantation (pacemaker, implantable cardioverter defibrillators [ICDs], BiV, Sub Q ICD, loop recorder), inferior vena cava (IVC) filter placement, pericardiocentesis, temporary pacemaker insertion, biopsies, valvuloplasy, endovascular aneurysm repair (EVAR), thoracic endovascular aneurysm repair (TEVAR), transcatheter aortic valve replacement (TAVR), EP studies and ablations, cardioversions, transesophageal echocardiogram (TEE), and tilt tables. For coronary interventions, we utilize intravascular ultrasound (IVUS) OptiCross (Boston Scientific), Rotablator (Boston Scientific), AngioJet (Boston Scientific), and the pressure wires Aeris (St. Jude Medical) and Comet (Boston Scientific). For cardiac support, we use Arrow balloon pumps (Teleflex), and the Abiomed Impella. For our peripheral vascular cases, we use the Peripheral Rotablator (Boston Scientific), the Pathway/Jetstream (Boston Scientific), IVUS, Outback (Cordis), Frontrunner (Cordis), and orbital atherectomy (CSI). We perform approximately 150 of procedures/week. 

 

We have been performing TAVRs for over two years and have implanted over 150 valves. We implant both the Sapien 3 (Edwards Lifesciences) and the Evolut R/ Pro (Medtronic) valves. The experience has been great. We have a dedicated TAVR team that is present for every case so that we are consistent in our care. We felt that this was an important step in starting and maintaining a successful structural heart program. 

 

 

Yes, several of our physicians do gain access via the radial artery. About 60-70% of our cases are done via this approach.

 

 

Our cath lab manager is Greg Titensor, MSN, RN. Greg has been an RN for over 17 years. He worked in the ICU for 2 years, and then came to the cath lab, where he worked as an RN for 7 years. Greg has served as director for over 8 years.  

 

 

Yes, we do cross-train in scrubbing, circulating, and monitoring. RNs administer medications and RT(R)s control the x-ray equipment. 

 

 

Per Arizona state laws, a radiologic technologist must be in the room and in control of the x-ray equipment, along with the physician, at all times. 

 

 

We provide lead aprons, lead glasses and lead-lined scrub caps for all employees. We also provide monthly monitoring of radiation dosage with film badges that are reviewed by the hospital radiation safety officer. We utilize all lead shields available and practice “As low as reasonably achievable” (ALARA), as well as basic radiation safety precautions.

 

 

The newest equipment introduced to the lab includes the Sapien 3 and the Evolut Pro valves. In the peripheral world, we have recently acquired the Tigris and balloon-mounted stents (Gore). All of our EP equipment is new in our EP suite, to include the Carto 3 mapping system (Biosense Webster), Stockert RF generator, and Soundstar ICE catheter (Biosense Webster), as well as Biosense Webster diagnostic and ablation catheters. 

 

 

We have monthly staff meetings to keep everyone up to date on our growing heart program. We also utilize email and our resource coordinators to help keep us informed of pertinent information between meetings. During the summer, which is our slow season, we schedule in-services with vendors to keep up with any changes to our products. 

 

 

Our department has a designated coder who handles our coding in the lab. She has over 10 years of experience in cardiovascular coding and has her CVC and CIRCC credentials. In addition, she currently in pursuit of her CCC and CCVTC credentials. 

 

 

All RT(R)s and RNs are trained to pull sheaths. They must perform 10 supervised successful sheath pulls to be deemed competent. Sheaths are pulled in the lab or in the recovery area depending on anticoagulation and scheduling. 

 

 

Patients are prepped and recovered in our prep/recovery area. We currently use Angio-Seal (Terumo), and Perclose (Abbott) for femoral closures. For radial approaches, we use the TR Band (Terumo) and Vasc Band (Vascular Solutions). We hold manual pressure in the lab or recovery whenever closure devices are contraindicated. All staff is trained for sheath pulls and groin management. 

 

 

Our lab has an inventory specialist who keeps track of supply levels and orders equipment as needed. 

 

 

Within the past four years, we have built a hybrid OR suite and an EP suite. We have also expanded our prep/recovery area from 13 to 29 beds. The expansion is due to the growing need for these technologies in Yuma.

 

 

Yes. We are currently involved (enrolling/follow-up) in the ILLUMENATE Pivotal trial, FSS OPEN, CROSS X4, ISCHEMIA, IMPERIAL, TOBA II, and TOBA II BTK trials.

 

 

Our average door-to-balloon time is 63 minutes. We have worked closely with our emergency department (ED) to facilitate the movement of the patient to the lab, which has resulted in lower D2B times than previous years. Recently, we have integrated new equipment into the local EMS that sends in-field EKGs to the hospital and the cardiologist on call. This will allow for earlier activation of the on-call STEMI team. We are registered with the American College of Cardiology’s D2B Alliance.

 

 

During regular and off hours, the ED RN transports the STEMI patient to the lab.

 

 

If a STEMI comes in and the call team is busy, we will do our best to quickly and safely complete the current procedure and get the current patient off of the table. 

 

 

We utilize LEAN processing, which has led to a significant drop in costs to the lab. We also adjust par levels based on utilization of supplies. Our inventory staff is very efficient at keeping any of our close-to-expiration equipment marked so that we can use them first before they do expire. Staying up to date with vendor contracts is also another way we have reduced costs to the lab.

 

 

We use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) reports to help improve on any areas that are below national standards. Our physicians also have peer meetings to discuss any complications that they may have. After our patients are discharged, some are randomly selected to participate in a follow-up survey about their experience and care with us. We use that data to help drive our quality of care for our patients.  

 

 

We are recording both fluoroscopy times and dosages in our hemodynamics charting system (Xper, Philips) as well as in the imaging system. Our cath reports that are charted on Xper then get archived into the patient’s medical record.

 

 

The charter/monitor documents medication administration during the case. 

 

 

Our physicians are dictating their cath reports into the EMR via the Dragon software (Nuance Communications).

 

 

Yes, we have recently started using the ACC-NCDR for our heart cath/PCI data.

 

 

About 23% of our diagnostic caths are normal.

 

 

Yuma Regional Medical Center is the only hospital in the area; therefore, we have no need to compete for patients. With our growing facility and procedure list, we are also able to keep our patients in town instead of referring them to out-of-town facilities. 

 

 

 All new employees go through new employee orientation through the hospital. After that is completed, they are paired with a seasoned cath lab employee to precept them throughout their training period, which ends when they begin STEMI call on their own. 

 

 

Throughout the year, we are afforded many opportunities for continuing education. We are sent to conferences, off-campus training on equipment, and vendors come in for in-services. Most of the opportunities come in the summer when we are slower.

 

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

 

We do not require staff members to take the RCIS exam, but we highly encourage it. There is a raise upon passing the exam, following the hospital protocol and job descriptions. 

 

 

Vendors are allowed into the lab when we schedule an in-service for new equipment, or per physician request. In order for them to be in the facility, they must check in at the front desk and obtain a vendor pass. 

 

 

Our staff undergoes yearly competency evaluation. Competency evaluation may be required from the lab as well as the hospital. Most are due in the summer, as this is our slow season. We take that opportunity to fulfill competencies as well as get updated on equipment and procedures through in-services and other educational opportunities.  

 

How does your lab handle call time for staff members? 

 

Our call team consists of three members. One RN, one RT(R) and the third can be of either credential. We generally have one call night a week, and one weekend a month. 

 

 

The call team must be in the lab within 20 minutes of being called in. 

 

 

We do have flextime shifts. Our morning cases start in 30-minute increments and the teams are flex scheduled accordingly. We work four 10-hour shifts.

 

 

In the fall of 2016, our facility underwent inspection by Healthcare Facilities Accreditation Program (HFAP) and did very well. 

 

 

The OR and ED are both on the first floors of the hospital and we are on the ground floor (one floor below).

 

 

Due to the gentle winter climate in the desert southwest, we see a large influx of winter residents every year. This in turn increases our patient load.

 

 

We are a “young lab” with the median age being 37.5 years old. Most of our cath lab staff is bilingual in Spanish and English, because of our close proximity to the Mexico border. We are able to provide excellent care to our patients by comforting them without a language barrier present. 

 

 

In the past 5 years, the growth of our city has increased our volume in procedures, and need for new technologies. To accommodate that growing need, we have expanded our lab from 3 to 5 rooms, and our prep/recovery from 13 to 29 beds. We have also started our EVAR, TAVR, and EP programs in an effort to keep all of our patients’ care here in Yuma. They have appreciated not having to travel out of town to have procedures done. 

 

 

Yuma, Arizona borders California and Mexico, so we have very large Hispanic population. In the lab, being bilingual is an asset to provide excellent patient care, since a lot of our patients are Spanish-speaking only. Our winters are beautifully mild as well, so our population booms with “snowbirds” from the northern states and Canada. This also causes an influx of patients to the lab. 

 

How do you use the NCDR Outcome Reports to drive quality improvement initiatives at your facility?

Our facility receives the reports and we find the areas where we are below the national average. We then create an initiative to improve in those areas.

 

The authors can be contacted via Soo Jung VanWinkle at skimvanwinkle@yumaregional.com.