Cath Lab Spotlight: Houston Methodist San Jacinto Hospital

Marsha Stevens, MBA/MHA, Director of Cardiology Services, can be contacted at mestevens@houstonmethodist.org. Jack Holmes, RN/Manager, can be contacted at jdholmes@houstonmethodist.org.

Houston Methodist San Jacinto Hospital has been serving Baytown and Houston with quality medical care since 1948. Through the years, the hospital has grown with the community, enhancing and expanding services every step of the way. Houston Methodist San Jacinto Hospital was recently ranked No. 10 out of 99 Houston regional hospitals and was recognized in six high-performing specialties (geriatrics, nephrology, neurology and neurosurgery, orthopedics, pulmonology, and urology) by U.S. News and World Report. The Houston Methodist Hospital System has been recognized as one of FORTUNE Magazine’s 100 Best Companies to Work For. Houston Methodist San Jacinto Hospital recently received certification as an ISO 9001:2008 facility by DNV (Det Norske Veritas). ISO certification is by far the most-used and well-known standard for quality management systems in the world.

Today, Houston Methodist San Jacinto Hospital offers comprehensive care for patients at every stage of life. As the area’s only not-for-profit, church-affiliated medical center, Houston Methodist San Jacinto Hospital continues to meet the needs of our community and region with cutting-edge medical services and technology.

In 1987, Houston Methodist San Jacinto Hospital’s Board of Directors made the decision to construct a new major health care facility, enhancing and expanding the range of services available to residents of East Harris County, and the surrounding counties of Chambers, Liberty, and Montgomery.

Tell us about your cath lab.

Houston Methodist San Jacinto Hospital’s Cardiovascular Catheterization Lab has three procedure labs. Two of the labs are diagnostic/interventional labs and one is dedicated to electrophysiology (EP). Adjacent to the labs is an eight-bay pre-procedure/post-procedure holding area. On staff are eight registered radiologic technologists (RT[R]s), ten registered nurses (RNs), one registered invasive cardiovascular specialist (RCIS), and one cardiovascular technologist (CVT). The lab also staffs one secretary/American College of Cardiology (ACC) data entry specialist and a materials management specialist. The experience level of the cath lab team ranges from 1 to 25 years.  

What procedures does your lab perform?  

Houston Methodist San Jacinto’s cath lab is a full-service lab. Procedures currently performed in the cath lab include

• Left and right heart catheterizations (coronary, peripheral, and carotid stenting);
• Percutaneous coronary and peripheral interventions;
• Intravascular ultrasound;
• Fractional flow reserve (FFR);
• Intra-aortic balloon pump;
• Impella (Abiomed);
• Temporary and permanent pacemakers;
• Implantable cardioverter defibrillators (ICDs);
• Loop recorders; 
• Rotablator (Boston Scientific).

Non-invasive procedures performed include transesophageal echocardiography (TEE), cardioversions and tilt tables. The cath lab also performs diagnostic and complex EP procedures including atrial fibrillation (pulmonary vein isolation) and 3-D mapping. The lab performs approximately 65-70 procedures, including emergent cases, each week.

Does your hospital offer transcatheter aortic valve replacement (TAVR)? 

TAVR is not offered at this hospital, but the main medical campus of the Methodist Hospital System, approximately 25 miles from the Baytown location, offers the TAVR procedure. Houston Methodist San Jacinto currently has a hybrid room located in the operation room/cardiovascular OR suite.

Does your cath lab perform primary angioplasty without surgical backup on site?   

We have surgery on site. Our coronary artery bypass surgery program (open-heart program) was instituted in 2010.  

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

Three physicians working in the cath lab are trained to perform radial procedures and do so regularly. 

Who manages your cath lab? 

Marsha Stevens, MBA/MHA, BS, is the director of the cath lab. Jack Holmes, MBA, BSN, RN, CCRN, is the clinical manager. Dr. Sarma Challa, interventional cardiologist, is the medical director of the cath lab.

Who scrubs, who circulates, and who monitors? 

The nurse’s primary responsibility is to monitor. RNs, RTs, and CVTs scrub and share the circulating duties. 

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? 

Only the radiologic technologist and/or the physician are allowed to administer fluoroscopy in the state of Texas. An RT or CVT can position the II, pan the table, and change angles. The physician or RT is responsible for executing fluoroscopy. 

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

All staff is required to wear a film badge. Each team member receives a monthly radiation dosimeter report, reviewed by the radiation safety officer and cath lab leadership team. The reports are available for the team to review and in order to help guide the radiation safety program. A cath lab staff member serves as the radiation safety liaison, attends the radiation safety meetings, and assists with implementation of the radiation safety program. Staff competency in radiation safety practices is assessed annually. Education on radiation safety is mandatory and essential for both staff and physicians.

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

Most recently, Houston Methodist San Jacinto purchased the St. Jude optical coherence tomography (OCT) system. The VantageView integrated monitoring system (St. Jude Medical) was recently integrated into the labs, along with wireless FFR technology.

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

Information is communicated through daily huddles called “The Daily Line-up” that disseminate information to staff. In addition, the team has monthly staff meetings to discuss new products or procedures. The cardiology group meets quarterly and monthly as needed to discuss cath lab business. The hospital has implemented a new system (PerfectServe) to page and contact the physicians for routine communication and issues related directly to their procedures.  

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

They are dictating their cath reports.

How is coding and coding education handled in your lab?  

Houston Methodist San Jacinto Hospital has a Transaction Management CDM Team that oversees the coding process for the hospital. The cath lab works closely with this team to ensure complete and accurate procedure coding and billing. The team receives timely training on all pertinent updates, including annual and quarterly coding and billing updates. 

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

The cath lab utilizes closure devices in the majority of cases. When a closure device is not used, sheaths may be pulled by a competent member of the cath lab team. The entire team, including the RTs, CVTs, and RNs, is proficient in pulling sheaths and managing groin care.  

What kind of training is mandated before someone can pull sheaths? 

New employees complete an orientation process and prove competency under supervision. There are at least 10 supervised sheath pulls before a staff member is competent.

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

The lab has a team of qualified technologists and nurses who can deploy vascular closure devices on select patients. The cath lab operates its own eight-bay pre- and post-operative area that is located in the cath lab and is adjacent to the procedure rooms. We have a dedicated team of RNs whose primary responsibility is to provide for our patients pre- and post-procedure. The entire cath lab team is qualified to support patients with hemostasis.

How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies?  

A materials management specialist on staff has the primary responsibility for supply and inventory management. The director/system purchasing department is responsible for the purchasing of equipment.  

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

The cath lab underwent a major renovation involving the EP room, with the addition of an Innova IGS 630 biplane imaging system (GE Healthcare). Our resulting ability to offer complex EP services has made an impact, increasing our volumes of patients requiring specific EP studies.

Is your lab involved in clinical research?  

Not at this time, but we hope to be involved in research in the near future.

Can you share your lab’s average door-to-balloon (D2B) times?  

The average D2B time at Houston Methodist San Jacinto Hospital for 2013 was 76 minutes. The Chest Pain Committee team was key in implementing an ST-elevation myocardial infarction (STEMI) program that has led to achieving Chest Pain Center Level III status. Currently, the lab is seeking Chest Pain Center Level IV status. We are also registered with the ACC’s D2B Alliance. 

The Chest Pain Committee consists of the cath lab team, emergency department (ED) team, emergency medical services (EMS) coordinator and supporting personnel. The Chest Pain Committee has worked exclusively with local and regional EMS to implement a field activation protocol to reduce overall D2B times. 

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

During regular hours, the STEMI patients are transported to the cath lab by the cath team with support from the ED team as needed. During off hours, the cath lab team is supported by the ED team, ICU team, and nursing house supervisor as necessary.

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

If the call team is doing a procedure when a STEMI is called, all efforts are made to stop the procedure if possible and move the patient off the table. Additional staff members are called in as needed after hours. The ED staff, the rapid response team, and the nursing house supervisor are available to assist in these situations.

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

Weekly, internal materials management meetings are conducted with the team, including the materials management specialist. Purchasing, contracts, and pricing are managed at the system level to optimize cost savings. In addition, Houston Methodist San Jacinto works with the physicians to standardize equipment and supplies, which reduces overall inventory. The MARS inventory management system (Oracle PeopleSoft) enables the lab to practice “just-in-time” ordering, which keeps par levels low.  

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

A weekly STEMI quality meeting is attended by ED, cath lab, quality, and electrocardiogram (EKG) representatives to review STEMI cases and identify any issues.  The cardiologist group attends a quarterly quality meeting and it is open to other staff members in the cardiology department and hospital. Also, a contrast reduction program and radiation management program are in place and monitored for each patient.  

How are you recording fluoroscopy times/dosages? 

Fluoroscopy times and dosages are recorded in the hemodynamic system and the imaging system, and a manual log is kept. This is a quality initiative and benchmarked against ACC databases.

Who documents medication administration during the case?  

Medication administration is the responsibility of the monitoring RN. 

How does your cath lab compete for patients? 

The Houston Methoodist San Jacinto Hospital cath lab has contracts with other freestanding emergency centers in the area. The cath lab’s goal is to strive to provide comprehensive cardiac care so that these services can be offered in the community.   Partnerships have been established with EMS providers to support training and education regarding the services provided at our facility. The cath lab also supports community education and services.

How are new employees oriented and trained at your facility? 

All new employees attend an extensive new employee orientation program. During the orientation process, each new employee is introduced to a program called “The Methodist Experience,” which gives insight into the hospital’s Methodist culture. Departmentally, new employees are assigned a preceptor or ‘buddy’ whose major role is to provide ongoing training and support while they orient to their new position.

What continuing education opportunities are provided to staff members?  

Numerous continuing education opportunities are sponsored by the Houston Methodist system. There is an online continuing education option, and a CE Direct online option (ContinuingEducation.com) is available to RNs. The cath lab sponsors numerous continuing education opportunities throughout the year. The cath lab staff also has the option to attend conferences such as Transcatheter Cardiovascular Therapeutics (TCT) and the ACC Scientific Sessions, as well as Cath Lab Digest-sponsored opportunities. This is done with the support of hospital administration.

How do you handle vendor visits to your lab? 

Vendors are allowed in the cath lab on an appointment-only basis. They are required to sign in through a kiosk, the VCS (Vendor Credentialing Service) system at security, and are to wear at badge during their entire visit. Vendors are expected to stay in a designated break area and are brought into the procedure areas only if they have an appointment.

How is staff competency evaluated? 

Staff competency is evaluated through a routine annual credentialing process. Members of the team serve as validators, and have received specialized training and/or have advanced experience in the area or technology under evaluation. Mandatory education classes are held to support new products and procedures.

Does your lab have a clinical ladder? 

Currently, there is a clinical ladder for RNs throughout the hospital system.  

How does your lab handle on-call for staff members? 

Staff members are on call, on average, one night a week from 1730-0700. Weekend call is from 1700 Friday night through 0700 Monday. Our emergency on-call staff team consists of two RNs, two RTs or CVTs, and one interventional cardiologist. The call team members are expected to arrive to the lab within 30 minutes of being paged.

Do you have flextime or multiple shifts? 

The majority of our team works 10-hour shifts. Our hours of operation are from 0700 until 1730, Monday through Friday. To cover after-hour cases, the team is given the option to flex their shift as needed to accommodate complicated cases that may arise.

Has your lab recently undergone a national accrediting agency inspection? 

Houston Methodist San Jacinto Hospital is an Accredited Chest Pain Center III with PCI through the Society of Cardiovascular Chest Pain Centers (SCCC). The lab is in the process of applying for Chest Pain Center Level IV.

Houston Methodist San Jacinto Hospital received Pathway to Excellence recertification in 2013 and is working toward becoming a Magnet Hospital.

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

The cath lab and ED are both located on the first floor of the Garth Road campus at Houston Methodist San Jacinto Hospital. The OR is on the third floor of the Garth Road Campus.

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

The population is increasing in age and there has been a slight increase in volume related to diagnostic procedures. Since implementing a new EP program that offers full-service EP, we have seen our EP procedures grow significantly, also with an increase in the average patient age.

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

Our cath lab staff is very team oriented and experienced. The retention rate of the team is very high, with minimal turnover of staff. The entire staff is very innovative and eagerly embraces new technology and programs/procedures offered at Houston Methodist San Jacinto Hospital. The team strives to offer the highest quality care and is proud to provide cardiology services in our community.

Is there a problem or challenge your lab has faced? 

With our continued growth, space constraints at our hospital continue to be a challenge.  There are plans to add a unit to provide care for post-cath patients.

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 city of Baytown has multiple chemical plants and refineries, and is home to the largest refinery in the world. Baytown is also located in close proximity to the Houston Ship Channel. Being a regional hospital, we provide service for a geographic area that extends up to 40 miles.

A question from the American College of Cardiology’s National Cardiovascular Data Registry: 

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

On a quarterly basis, the NCDR outcomes are reviewed at the Cardiology Committee meeting. The goal is to review data and processes, celebrate successes, and use the data to drive initiatives toward improvement.

Questions from the Society of Invasive Cardiovascular Professionals (SICP):

1) Do you require your clinical staff members to take the registry exam for the Registered Cardiovascular Invasive Specialist (RCIS) credential? Does staff receive an incentive bonus or raise upon passing the exam? 

The RCIS certification is currently not a requirement, but all staff is highly encouraged to take the RCIS. A majority of the staff holds either the RCIS or other professional specialty certifications. All staff members who successfully pass a certification exam are eligible for incentive pay.

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, there are cath lab team members who are involved with both national and regional organizations.