Cath Lab Digest Email Discussion Group

(Thank you to Roberta Sparks of Good Samaritan Hospital in Downers Grove, Illinois, for last month’s discussion group question, below). I am doing research on the actual daily operations of a cath lab: 1. What are normal hours of operation? a. Do you flex hours? b. Do you cross-train or is staffing included in recovery? c. Do you recover all your own patients? d. Do you pull your own sheaths or follow through post-closure device? 2. If you have more than one lab, how do you do your scheduling? a. Does each doctor have a scheduled time? b. Is it based on physician skill? c. Do you start your day and keep on going until everything is done? d. Would a call-in team cover late cases? e. Do you find yourselves working late on average? f. Do you have a cut-off time or number of cases you can do in a day? g. Do you do your interventions in the same setting as caths? 3. Are you involved in recovery, EKGs, echos or are you cath lab procedures only? 4. How many people do you base your labs on: a. Skill level (credentials) b. Procedure involvement c. Do you do your own transporting and recovering? d. If you are doing your own recover, are your staff cross-trained or unit-specific? 5. I know it is hard to count procedures, because everyone has their own way of doing it, but what are your numbers for patients, procedures, and interventions? HAVE A SUGGESTION FOR A FUTURE QUESTION? Email us at cathlabdigest@aol.com Group Members’ Responses to The Daily Operations of a Cath Lab Our lab is open 24 hours a day. Normal hours are 0800“1730. We have two teams on Monday and Wednesday. The day crew starts at 0700“1730. The call crew starts at 0800 “ cases finished. On Tuesday, Thursday, and Friday, we have three teams (also working 0700“1730) and a late crew that works 0900“1930. We work 10 hour shifts, and we work late a few days a week on average. It’s our policy that no elective cases are supposed to be put on the table after 1900; however, this is rarely observed. Here’s a rough estimate of our volume: Diagnostic caths (RHC, LHC, combo): 1950 PCI: 1250 Biopsy: 350 Pacemakers: 140 AICD: 30-40 RFA: 60 EPS: 100 We have one staff that just works the cath lab, and we are not involved in echos, EKGs or recovery. We have the following: RN, RT, CVT, MA, a secretary and an equipment employee. There are four people in each room: 1 RN, 1 RT, 1 CVT, and the fourth can be any of the above. We transport and recover our own patients, and pull our own sheaths. An RN rotates through the holding room where sheaths are pulled and the patient is brought pre-procedure. We do our interventions in the same setting as our caths, unless no backup OR is available or the intervention MD is not available. For scheduling (we have more than one cath lab), the MD’s office calls the cath lab and they request cath lab times. It’s on a first-come, first-serve basis. From: annie.rupert@sharp.com Our normal hours of operation are 0630“1700. Two rooms are open at 0630. Room One: 0730“0930-1130. It is closed after the finish of the 1130 case so staff gets lunch and goes home by 1500. Room Two: 0730 - 0930 - 1130 - 1330 - 1530 - 1730 TF as needed. The call team comes in at 1030. They give lunches to both rooms, take lunch, and then replace the staff in Room Two in order to finish cases for the day. The original 0630 staff goes home at 1500. Staff are guaranteed four hours by contract. If there are only 1-2 cases after 1030, staff are sent home once the call team arrives. All staff can scrub all cases, whether they are RNs or CVTs. All cases are TF, even though they have scheduled times. The call team comes in at 1030, unless we call them off because staff already here can finish the scheduled cases. If this happens, the call team starts being on call at 1030 and is available to help out if an emergency case comes in. We are usually done by 1800. Room One closes after the 1130 case is finished. Room Two runs until it is done. Ninety-five percent of the time, we do our interventions in the same setting as our caths. We don’t do EKGs or echos. For doctors, scheduling is on a first-come, first-serve basis. It is not based on physician skill. We have 3 staff per case. One RN must circulate, 1 staff member must be CVT-trained (some RNs are also RCIS), but all staff can scrub any case. We transport patients only if the transporter is in code or at lunch. Patients are recovered in Ambulatory Outpatient/CSICU/Telemetry. Floors pull sheaths and the Angio-Seal suture is clipped on the floor. Procedures Total patients: 1300 Diagnostic-only patients: 800 Pacemaker-only patients: 100 Interventional patients: 400 From: Bill Colditz, Manager, Cath Lab Mercy San Juan Medical Center, Sacramento, California Wcolditz@chw.edu Our hours of operation are normally 7:00am“7:00pm, with the last ELECTIVE case posted at 3:30pm. Urgents, emergencies or schedule delays continue until the work is done. We do flex hours. If a schedule starts later, staff come in later, and leave early on light days (very few!). Generally, we have to work late every day. We don’t have a cut-off time or number of cases we are limited to in a day. It’s all based on the time of day and what the next day’s schedule looks like. The call team covers late cases. We have separate staffing for the lab versus the holding area, but most are cross-trained to help in both areas. We recover our own patients we currently have a 7-bed area and are getting ready to expand to 10. It is staffed with RNs and paramedics.We do pull our own sheaths, using the holding area during work hours, and the fourth call team member nights and weekends. Interventions are done in the same setting as caths.We also manage diagnostic, but we have a supervisor for that area. Since we have only one lab at this time, scheduling is on a first-come, first-serve basis. If the MD wants to move cases into a block of time, the MD is responsible for making arrangements with the other MD(s) this way, the staff stays out of the middle! We have a mix of RCISs, CVTs, RNs, and paramedics. We average 4 per lab, especially for interventions, although we will do with 3 if necessary. Transporting and recovering are handled by holding area staff. We require ACLS for post transport of our patients, and transporters have a kit to carry during transport. Post intervention patients are monitored back to the unit. All cath lab staff are cross-trained to the holding area; most of the holding area staff are cross-trained to at least circulate in the lab, though many do float and scrub. We do not cross-train holding area staff that do not show aptitude or a willingness to work in the lab. Primary UOS: Each diagnostic as 1, PTCA as 1, stent as 1, IABP as 1. This is per our state’s CON criteria. We have also established a secondary UOS basically minor procedures or patient care outside of that directly needed for the diagnostic or interventional procedure. These count internally for FTE justifications as well as some revenues. Example: The holding area performs cardioversions, tilt tables, assists w/ TEEs for conscious sedation and recovery. Sheath pull, cardiac arrest, sedation monitoring are among others. From: pam_ragland@bshsi.com Our hours of operation are 7:00am until the day is done. We only flex hours for the part-time people. In our lab there are radiology technologists, nurses and echo techs. The nurses circulate and monitor, the rad techs scrub and monitor, and some echo techs scrub, and some only monitor. At present, we don’t have a separate recovery area for patients. We pull our own diagnostic sheaths. The floor doesn’t always have the personnel to pull the sheaths after angioplasty, so we do get called up there for that. For angioplasty, we use Perclose, Angio-Seal and the SyvekPatch. We recently had eight physicians that broke away from the HMO setting and they schedule one physician in the lab for the day. The HMO physicians then use slots as needed. It depends on when they call as to when their case is scheduled. It is a first-come, first-serve situation presently. Our first case is scheduled at 8:00am, with hourly slots beginning after that. The call team covers late cases. If we need to run two labs after hours, it is by a volunteer system. We find ourselves working late more often recently, and we are not sure why there has been a sudden influx of patients. Our cut-off time is when the patient load is done for the day. We like to have 3 people per room; either one nurse and two techs, or two nurses and one tech. Everyone is cross-trained to do monitoring. For transporting, we use the hospital-wide transport system. We recover as needed. We average 8 cases per day: EP, pacers, ICDs, caths. Interventions are done in the same setting as caths. The cath lab is under the heart center, whose services include echo, treadmill and EKG. Some nurses are cross-trained to do treadmill and our echo techs are cross-trained to do echo and cover the cath lab. From: csgehin@yahoo.com Our normal hours are 7:30am“6pm. Everyone works 10-hour shifts. Our hours are not flexible. Cases are scheduled beginning at 8am. Each patient is scheduled by the MD, according to the time slots available. Emergencies are placed in the next available room. Everyone is cross-trained. Due to the lack of staff, we have an agency RN covering the holding area. Most patients are sealed. Diagnostics receive VasoSeal. PCIs receive Angio-Seal, although some PCIs are closed with Perclose. We have four labs, but only have enough staff to run three labs. We have been at this manpower level for over a year. Each room is given to a different MD. Once the day starts, we keep going until 5pm. At 5pm, two labs finish their cases. The last lab is staffed with the call team and they finish the remaining cases. Elective cases that cannot be done are rescheduled for 8am slots the next day. All of our coronary cases are considered possible PCIs. We are required to staff the Right Heart room, where potential heart transplant patients are studied 4 days a week. The RHCs are scheduled for 8am. We have to shut down a room to staff this separate entity. Each room is supposedly staffed with four personnel: 1 RN and 3 techs, or 2 RNs and 2 techs, or 3 RNs and 1 tech. The RNs are all experienced former critical care nurses. The techs are mostly rad techs. Currently we do not have any RCIS folks. I am cross-certified ARRT (CV) and CCI (RCIS). None of the other folks are cross-certified. All team members are expected to function at all levels of expertise. We transport our own patients to their rooms and we do our own recovery. This year we did about 4800 patients. Seventy to seventy-five percent were PCIs. We do many PCIs as referrals from outside diagnostic labs. Check with the Society of Cardiac Angiography and Interventions (www.scai.org). They can give you the most accurate method of counting procedures. From: Chuck Williams, RT(R), (CV), RCIS, CPFT Emory University Cath Lab codywms@msn.com Our hours of operation are 6am-6pm. We do not flex hours. We are cross-trained and currently staff our own recovery area. Each physician has a scheduled time (it is not based on physician skill). Physicians pull sheaths and follow through on closure devices. We start our day and keep on going until the last case is done. On average, we work late. Our cut-off time depends on the doctors and the on-call team. We do our interventions in the same setting as our caths about 90% of the time. We do not do EKGs or echos. We have 4 CVTs, 3 LPNS who are also RCIS, 7 RNs and 1 transport aide. The CVTs monitor and scrub and the LPN/RCIS and RN staff monitor and circulate. We do our own transporting and recovering. RNs are the only staff allowed to recover. We see about 5000 patients per year, with about 1500-2000 as interventions. From: lizrd65@yahoo.com Our hours of operation are usually 0600 “ 1700. Our first cases are scheduled at 0700. First team(s) are in at 0600. If no early cases are scheduled, staff are in at 0800. This rarely happens. Our call team comes in at 0900 and stays till all cases are finished. Outpatients are recovered in Short Stay Surgery. Inpatients are taken to the floor. We usually use VasoSeal. Interventions have the lines pulled by floor nurses when the ACT is below 150. Our scheduling is time-dependent. The physician is given a time and uses whichever lab is available. It is on a first-come, first-serve basis. Most procedures are scheduled for a one-hour time slot. More complex procedures are allotted more time. In essence, we start our day and keep on going until cases are done. If we find we are ahead of schedule, we will often try to move cases up. More often than not, we are behind because the physicians are usually late. The call team stays until the work is finished. We work late on a daily basis. We usually gear down to just the call team by 1800. We transport our own patients. Recovery is done by floor or short stay. Any diagnostic case can become an intervention. We do not do EKGs or echos. Our standard team per case is three people; scrub, circulate, and control room. More are added for difficult cases. Most of the people are cross-trained as much as possible. If we have a new person or someone who is not fully trained, they are usually tied with a more experienced staff member. Last year, we did: Diagnostic caths: around 3100 Interventions: 700+ Device implants: 200+ EP studies: around 150+ From: rhood@communitymedical.org Our normal hours are 7am until everything is done. We do not flex hours. We have cath lab nurses and recovery nurses. Some are cross-trained and some are not. This causes a lot of tension. We recover our own patients, and use Perclose and VasoSeal. Interventional sheaths are usually left in and pulled in the ICU by orderlies. We have a to-follow schedule. Four medical groups work here; we try to keep them in the same room in which they do their first case of the day. This way, they are following themselves or another in their group. There are no blocked times or skill criteria. When we reach a point that only one group or physician is working, then the call people take over.We work late nearly daily. There is no cut-off time or limited number of cases. Interventions are done in the same setting probably 60% of the time. We have cath lab, special procedures, recovery room, echo, vascular US, and will inherit EKG in the next couple of months. In the cath labs, we have two radiology techs and one RN. Techs scrub and circulate, and nurses monitor. We have transporters 10 hours a day. Recovery nurses are ICU trained RNs; some can work the cath lab, some can’t. We do approximately 2500 heart caths and 450 interventions/year. From: Bob, BCole@ftsm.mercy.net Our normal hours of operation are 7:30am“7:00pm. The Cardiac Clinical Decision Unit (CCDU) is open at 6am Monday and closes at 3:15pm Saturday 24 hours a day, 5 days a week. I guess our hours are flexed, since we don’t limit the number of cases scheduled and we stay till the work is done. We have a call team that works 9:00am“5:30pm and a second team scheduled late to help finish cases if needed. The time we spend working late varies. Typically, the call and late teams can cover the needs after hours, freeing other staff not scheduled to stay late to go home. We don’t have a cut-off time or limit to the number of cases we can do in a day. If a physician wants an earlier stick time, we will try to accommodate them. We have separate holding area staff for patient recovery. Outpatients and inpatients without a bed are admitted and recovered to our 24-bed CCDU. We do our own transporting. Diagnostic sheaths on inpatients returning to a med-surg unit are pulled in our holding area. Critical care units pull their own. If there is an interventional sheath elsewhere in the hospital, the staff from the CCDU pull the sheaths. We have four labs. We use a modified block schedule, with two physician practices determining who has block time on specific days. It is not based on physician skill. Whether or not we do our interventions in the same setting as our caths depends on physician preference some do, some don’t. We do not do EKGs or echos. We use 3 professionals per case, one of whom is an RN. The others may be CVTs, or a CVT and a scrub tech. If it is a difficult or complex case, we send additional people as needed. Procedures: 4800 diagnostics, 2200 interventions From: ccole@carilion.com Our hours of operation are 6:30am“11pm. We have 8, 10, 12, and 16-hour shifts. We do cross-train and have radiology technologists, nurses and respiratory therapists. Patients go out to our post-angio recovery unit or to the recovery room. We pull our own sheaths for diagnostics, but not for angioplasty. We use Perclose, Angio-Seal and VasoSeal. The first slot of the day is set for the physicians, and then each physician follows in the turn in which they have been added to the schedule. We have two rooms open until 11pm (4 staff per room). If an emergency should come in while both rooms are working and it can’t wait until a room opens, then the call team comes in. We do find ourselves working late on occasion. Most of the time 9-ish is the latest. Our cut-off time is 10:00pm, unless it is deemed an emergency. There is no limit. We have L&cors and L&Cor possible. If a physician thinks he will do an intervention then he will book it as a L&cor poss. Otherwise, he must call it an emergency. The cath lab is under cardiovascular services, which includes echo, treadmill and EKG. Some nurses are cross-trained to do treadmill and some techs are cross-trained to do echo to cover if needed. We like to have 1 nurse, 1 tech and one therapist per room. Currently, we have three respiratory therapists on staff, so sometimes this mix is hard, but we always have at least one nurse and tech per room. Everyone is cross-trained to do all aspects of the cath lab. We have two full-time transporters. We do not recover. Procedures: 11,416 procedures last year (2001) 2032 PTCA, 1009 stent placements, 162 PTA, 126 peripheral stents From: scoggint@methodisthealth.org Our normal hours of operation are 0700“1630, unless cases are running long (Monday through Friday only). Call crews handle anything that needs weekend attention. We normally start at 0700 in one room, and 0800 in the other room. There is potential for an 0600 case. The call team would be notified. It’s rarely utilized, however. We only flex hours in the case of the 0600 case noted above. Generally, we start our day and keep on going until everything is done. We can schedule two 1600 cases, which are covered by a call team and designated late staff. After 1600 cases, we close down to one room. We work late two to three days a week and always on Friday We are in the Department of Radiology, so all our techs are cross-trained to Special Procedures. Nurses are all cross-trained to Special Procedures, CT, US, MRI, Nuclear Medicine, etc., for monitoring and conscious sedation, pharmaceutical stress testing, etc. A small group of nurses are also trained to EP. Ninety-nine percent of the time, interventions are done in the same setting as caths. Outpatient recovery handles most of our patients. Otherwise they go to the inpatient units. We may do some short term recovery if beds are tight. Fifty percent of our patients receive manual pressure, all of which have sheaths pulled by the cath lab during daytime hours (M-F). The cath lab call crew handles all sheaths after hours and weekends, except for ICU patients. Individual physicians do not have their own scheduled times. Not all physicians do intervention in our lab, but it rarely affects how things are scheduled. For each case, we have either 2 RNs and 1 RT/CVT or 2 RT/CVTs and 1 RN. The call crew is always 2 RNs and 1 RT/CVT. The RT/CVTs scrub or monitor. The RN circulates or monitors. We do all transporting after cases, but little before, unless it is after hours. We transport all ED patients both ways. We do only short term recovery. 1800 diagnostic cases and 750 interventional is a good estimated average. From: JJenisch@rcrh.org, Jan Jenisch, Rapid City Regional Hospital Rapid City, South Dakota Continue the discussion on our message board, the Cath Lab Digest "Discussion Forum"!

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