Brigham and Women`s Hospital

Brigham and Women’s Hospital is a Harvard University-affiliated teaching hospital located in Boston, Massachusetts. It was founded in 1980 as a merger of three Harvard hospitals: Boston Lying In, Peter Bent Brigham and Robert Breck Brigham. It is a full-service hospital with 682 patient beds. The cath lab, part of the Cardiovascular and Diagnostic Interventional Center (CDIC) at Brigham, maintains the highest coronary intervention volume in eastern Massachusetts. We are a referral center for the most complex and highly acute cardiac patients locally, nationally and internationally, and were recently selected as one of the top five nationwide for cardiac services by U.S News and World Report. What is the size of your cath lab and number of staff members? We have 5 cath labs (1 biplane, 1 dual cardiac/peripheral room, and 3 single plane cardiac rooms), 2 biplane electrophysiology labs, a device implant procedure room, and an 18-bed prep and recovery room. The CDIC is currently staffed by: 16 attending cardiologists; 8 cardiology fellows; 9 PAs; 40 RNs; 2 RTs; 13 CVTs. What types of procedures are performed at your facility? The cath lab performs approximately 5000 diagnostic and 2100 coronary interventions per year. This past year, the EP lab performed 485 diagnostic studies, 329 ablations and 551 device implants. The cath lab is supported by a cardiac surgical service that performs approximately 1650 coronary bypass and/or valve cases per year and between 20“30 cardiac transplants per year. The cath lab performs over 200 peripheral cases per year. Does your cath lab perform primary angioplasty in acute MI? Yes, we are a tertiary teaching and cardiac research center, and many hospitals without PCI capability send acute MI transfers to our facility for percutaneous or surgical interventions. Furthermore, we serve as a primary resource for EMS transporting patients in the city of Boston for primary PCI for acute MI patients. Do you have cross training in the cath lab? Who scrubs, circulates and monitors? For the past six months, our cath lab has been cross-training the RTs and CVTs. The RTs and CVTs scrub, circulate and monitor hemodynamics. The RNs monitor the patients one-on-one and provide conscious sedation as well as documentation. The RNs are also responsible for pre- and post-procedure patient management. We are cross-training the staff by assigning a mentor to each trainee. An RT is assigned with a CVT to learn the monitoring and data collection system, as well as hemodynamics. A CVT is trained by the RT to scrub assist at the tableside with the physicians. Each person trains for approximately 6“8 weeks with his or her mentor. They are evaluated with a competency form and once they have met each competency, they may work independently. They may alternate roles to help fulfill staffing needs in each room. The staff has been very receptive to cross-training because it makes them more knowledgeable and well-rounded. This has increased job satisfaction and improved moral by making each staff member more of a team member, rather than just an individual role-player. This in turn has also helped with staffing issues and room availability when the lab is short-staffed. The cath lab director spearheaded the cross-training and helped set up goals to be met by each staff member. What are some of the new equipment, devices and products used by your lab? Our lab is a primary research center for new devices and therapies as well as a show site for cath lab equipment manufacturers. We offer: rotational and directional atherectomy, brachytherapy, rheolytic thrombectomy, IVUS, embolic protection wires, and pressure and Doppler flow wires. We are researching embolic protection devices, coated stents, drugs, sonotherapy, photodynamic therapy, brachytherapy, total occlusion wires, intravascular MRI and hypothermia for myocardial salvage. Currently, we are enrolling patients in 18 different research trials. Is your lab filmless? We have been filmless since April 2000. All procedures are acquired digitally and archived for permanent storage. This change has significantly lessened post procedure processing time and increased much-needed space for other equipment. How does your lab handle hemostasis? Hemostasis is physician and access site dependent. Our lab uses radial and femoral access in roughly equal proportions. For femoral access, we use a wide variety of closure devices, such as: Angio-Seal (St. Jude Medical, Minnetonka, MN); Duett (Vascular Solutions, Inc., Minneapolis, MN), FemoStop® (RADI Medical Systems, Reading, MA), Perclose (Redwood City, CA) VasoSeal® (Datascope, Mahwah, NJ). Radial access is closed using the Hemoband device (TZ Medical, Lake Oswego, OR). Manual compression is used in either access site when the physician deems it necessary. Post procedure, patients are sent to our recovery room either to be admitted to a hospital room or discharged. Our MDs, PAs and RNs share responsibility for follow-up management of access issues. We do have a hematoma management policy in place. Has your cath lab recently expanded in size and patient volume? Our cath lab has not only increased in size (an entire department renovation: 3 cardiac labs expanded to 5 labs and 1 EP lab expanded to 2 labs), but has steadily added significant patient volume each year. We have also expanded our recovery room from 7 to 18 beds. We are in the process of hiring new staff to lessen the effect of the increased patient volume. RN, CVT and RT staffing shortages are currently being addressed by conducting market surveys and wage adjustments to maintain a very highly competitive salary and wage program. Having made these adjustments, we have attracted new staff members. The nursing shortage has not been as much of an issue for our lab as it has been for the rest of the hospital. Our most recent staffing issue involved filling RT positions. The most recent market adjustment helped fill these positions. What measures has your cath lab implemented in order to cut costs or contain costs? We are always looking for new ways to cut costs while still providing a superior standard of patient care to all of our patients. We have switched to a product-by-consignment program as well as gateway pricing, which allows companies to bring a broad variety of products into our facility. Standardizing our procedure kits and the use of contrast multi-dose devices has also significantly saved costs. We are also currently keeping track of and working to shorten room turnover time to cut down on unnecessary overtime. How does your cath lab compete for patients? By striving to provide exemplary clinical care from pre-procedure through discharge, we hope to attract new patients and their physicians. We have allowed access to our labs for a core group of community invasive and interventional cardiologists to care for their own patients in a higher acuity setting. Other initiatives include focused care for acute MI patients, emphasizing rapid door-to-balloon times, as well as clinical trial activity, which attracts patients through access to cutting-edge technologies. At the administrative level, there are continuing efforts to expand our network of referring physicians locally, nationally and internationally. How are new employees oriented and trained at your facility? All employees have a two-day general hospital orientation, followed by a department-specific orientation and then a 90-day probation period. The employee’s previous experience and level of practice determine the length of the department orientation. During orientation, the employee works with his or her preceptor during both routinely scheduled and on-call hours until they are ready to function independently. After that time, their preceptor (or for an RN, a specially-trained mentor referred to as a clinical colleague) is available as a resource. What types of continuing education opportunities are provided to staff members? Each staff member must attend a weekly educational session during which members of each discipline in the lab present a topic of interest. Presentations have included coronary and vascular imaging, decision-making in coronary artery disease, ACLS pharmacology, anticoagulation, and antiplatelet use in the cath lab. In addition, staff members have the opportunity to attend a weekly cath conference/case review and a monthly morbidity and mortality conference. We also have educational inservices from various company clinical specialists on new products. Each staff member is responsible for maintaining their own continuing education credits in accordance with state and national license requirements. How is staff competency evaluated? New staff members are evaluated at the completion of orientation by their preceptors and nurse educator or lead technologist. The action plan is updated throughout their first year to ensure all educational needs are met and that individual growth continues. All staff members are then evaluated annually and must complete general hospital competencies in areas such as fire and electrical safety, blood-borne pathogens, hazardous materials, radiation safety, etc., at that time. All staff members are required to be ACLS and IABP certified. How does your lab handle call time for staff members? The cath lab is regularly staffed 7:30am to 8:00pm each weekday, with RN coverage extending to midnight. Call is on a rotating basis for all employees. The lab provides full coverage off-hours with a call response team consisting of an attending MD, 2 cardiac fellows, RN, RT, and CVT. One advantage to having such a large call pool is that on-call frequency is less of a burden on the staff members in our high-volume lab. What types of quality control and quality assurance measures are practiced in your cath lab? The quality of RN documentation, practice and patient education is monitored via peer review, using a quality assurance program developed by our nurse educator. The program involves pulling 20% of the case volume and reviewing documentation. To ensure radiation safety and image qualities are met, trends in radiographic equipment performance are tracked. Cine equipment and lead shielding are subject to annual quality assurance testing by an in-house engineer and staff members. Lab testing equipment is tested daily for quality assurance in compliance with JCAHO lab testing standards, to maintain our CLIA license. Mock JCAHO surveys are performed to ensure credentialing standards will be met in all other areas. Clinical outcomes, including any complications, from all diagnostic and interventional cases are tracked by our WITT system (Melbourne, Florida) and summarized at a monthly morbidity and mortality conference. We also participate in a statewide initiative to maintain an ACC-NCDR compliant database to track complications related to interventional cases. What measures has your lab employed to improve efficiencies in patient flow? Currently, two RN Assistant Clinical Directors manage the flow of patients to and from the procedure and recovery areas. They are responsible for triaging patients according to ACC guidelines, in collaboration with the physicians and also coordinating related resources. The lab also has a multidisciplinary leadership committee focused on various measures to maximize efficiency. As a result, the lab has implemented a two-RN primary clinical model, whereby, the two nurses in a specific procedure room rotate between their assigned room and the recovery area, providing continuity of care for the patient and decreasing turnover times. Other initiatives have included the tracking of reasons for case delays by analyzing in-house transport times, and collaborating with EMS, the Brigham and Women’s emergency department and community hospital emergency departments to improve transport times of acute MI patients to the cath lab. Has your lab undergone a JCAHO inspection in the past three years? Yes, we just had an inspection in the winter of 2001. Please tell us what you consider unique or innovative about your cath lab staff. One unique aspect of our lab is the size of the staff and the efficiency with which it functions. We have a large pool of RTs, CVTs, RNs, MDs and PA staff with varying backgrounds and experience. Our lab has a unified team approach, which can be difficult with such a large group of people. Another unique aspect is unparalleled access to new technologies via our clinical research programs. We are provided with the chance to see new devices and therapies long before they are released for widespread use. When you put all of these together, the Brigham cath lab is one of the premier cardiac centers in the country. Is there a problem or challenge your lab has faced? In the extremely competitive arena of Boston academic tertiary care hospitals, maintaining our position as the busiest cath lab and providing optimal clinical care is an ongoing challenge. Expanding from 4 to 7 procedure rooms, with parallel expansion of staff and patient volume, posed challenges to workflow and staff relations. These were surmounted via close interdisciplinary leadership and a consensus-building team approach. We are currently looking to add to our cath lab staff. If Cath Lab Digest readers are interested, we welcome them to contact us here at the Brigham and Women’s Hospital to become a team member of one of the foremost cath labs in the country. For all inquiries, please visit the Brigham website at: www.brighamandwomens.org