Cayuga Heart Institute Cardiac Catheterization Laboratory at Cayuga Medical Center

Cayuga Medical Center at Ithaca (CMC) is a not-for-profit, 204-bed community hospital in upstate New York. Our facility is a Certified Stroke Center, a Comprehensive Community Cancer Center by the National Cancer Institute, and a Certified Chest Pain Center. We are currently seeking Certified Chest Pain Center with Percutaneous Coronary Intervention (PCI) certification. 

The Cayuga Heart Institute (CHI) is home to our cath lab. We have a cardiac area with four patient bays and two procedure rooms in addition to our lab. There is an operating room designated to CHI for pacemaker and implantable cardioverter-defibrillator (ICD) implantations. CHI has over 50+ years of experience working together as a team. There are 12 registered nurses (RNs) who hold a BSN, CCRN, or are chest pain coordinators (CPC); some are currently working towards their CCRN and BSN. The team also includes three cardiovascular radiologic technologists, two cardiovascular technologists, three echo sonographers, two of which have dual licensure (one as an RN, one as a respiratory therapist), a hospital aide, and a receptionist.

What procedures are performed in your cath lab?

The Cayuga Heart Institute performs all procedures related to cardiac services. This includes inpatient and outpatient procedures. The team performs a multitude of procedures, such as electrocardiograms (EKGs), stress tests, cardiac catheterizations, pacemaker and ICD implantations, cardioversions, and transesophageal echocardiograms (TEEs). As many as 30 EKGs can be completed on a daily basis. Cardioversions and TEE volumes change from week to week. We complete about 10 outpatient stress tests per week and approximately 20 inpatient stress tests. We provide 24-hour Holter monitors, ambulatory blood pressure monitors, and implantable event monitors. The team helps implant single and dual pacemakers or ICDs at a rate of about 100 a year. We provided 400+ caths last year, both interventional and diagnostic. Consistent with national trends, our cath volume has recently decreased.

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

Yes, we have a PCI center without onsite cardiac surgery. We have rigorous case selection criteria adopted from the C-PORT trials and from the Society for Cardiovascular Angiography and Interventions (SCAI) Expert Consenus Document.

What percentage of your diagnostic caths is normal?

We have four cardiologists with cardiac cath privileges, and combined, they have a normal percentage of less than 15%.

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

At this time, we do not have any cardiologists that utilize the radial access technique. On occasion, they will utilize the brachial technique.

Who manages your cath lab? 

Our cath lab is managed through our Vice President of Service Lines, Ellen Dugan; Nursing Director Sandy Fuller, RN, CCRN, CPC; Sharey Selover, RN, CPC Manager; Matthew Hill, CVT, RT Radiology Supervisor; and two on-site physicians, Dr. Malcolm Brand, Medical Director and Dr. Paul Stefek, Interventional Cardiac Cathetization Lab Director. We have an off-site Cardiac Catheterization Lab Director, Dr. Thomas Stuver, from Sands-Constelletion Heart Institute at Rochester General Hospital. 

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

Yes, all of our nurses and technologists are cross-trained within their profession. We believe that cross-training is essential to our goals. Our RNs perform stress tests, cardioversions, TEEs, administer moderate sedation, circulate in cath and pacemaker/ICD procedures, and monitor cardiac caths. Some of our RNs are also trained in surgical scrubbing for pacemaker implantations. Our technologists are cross-trained to monitor caths, scan and apply Holters, perform EKGs, and assist in sheath pulls. The RTs can scrub all cases, provide fluoroscopy, assist with sheath pulls, and perform EKGs.

Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab?

All cases that require fluoroscopy have an RT present.  

Which personnel can operate the x-ray equipment (position the II, pan the table, change angles, step on the fluoro pedal) in your cath lab? 

The RT provides positioning of our C-arm or imaging intensifier, pans the table and changes angles. Our physicians step on the fluoro pedal. We have a floor-mounted C-arm with a flat-plate detector for all of our cardiac caths and a portable C-arm for our pacemaker/ICD procedures.

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

Cayuga Medical Center takes radiation safety very seriously. Currently, the Radiation Safety Committee meets once a month and our representative is Radiology Supervisor Matthew Hill, CVT, RT. This committee has created an extensive program to monitor patients and staff. We provide cumulative dose review for our patients by follow-up phone calls and follow-up visits with the physician. Through this committee, Matthew has been able to keep the cath lab staff and physicians apprised of updates or new trends following radiation. Matthew and the interventional cardiac catheterization lab director, Dr. Paul Stefek, have also created a unique annual cath lab radiation educational program for physicians and staff. Matthew provides monthly dose meters for team members and reports to them their cumulative doses. Team members help to protect themselves from radiation by wearing protective leads and leaded eye wear. Matthew counsels any team member that may have an unusually high radiation dose.

What are some of the new equipment, devices and products that have been recently introduced in your lab? 

The interventional lab was added in November 2010, so we have been introduced to a new Siemens fluoro suite, the AngioJet (Medrad), fractional flow reserve, i-STAT (Abbott), and a transport intra-aortic balloon pump (IABP) (Arrow/Teleflex).

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

A cath conference with staff and physicians is held every month, allowing us to review cases, new studies, techniques, and equipment. We have a staff education conference monthly to educate each other as we each learn new techniques. The team also learns from in-services provided by the vendors of the equipment we use, such as AngioJet and Arrow/Teleflex for our IABPs.

How is coding and coding education handled in your lab? 

Coding is utilized through procedural charging and our charge master. Nurses, RTs, and technologists fill out a charge sheet for every procedure, then an RT enters the charges into our electronic medical record. The management team and coding department attend conferences and webinars to keep the system up to date. As the CPT codes are updated and/or coding changes, the charge sheet will reflect the changes, and the team is updated.  

Who pulls the sheaths post procedure, both post intervention and diagnostic? What kind of training is mandated before someone can pull?

Sheaths are pulled by certified personnel. Every RN, RT, and technologist is trained on our policy and procedure, must take a competency test, and undergo hands-on experience. They are first given the policy and procedure to review, and then we ask them to observe one or two sheath pulls. Staff is asked to pull 5 sheaths with a certified RN, successfully obtaining hemostasis, before being signed off as certified.

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

Outpatients are prepped in our holding area, located in our cardiac area of the Cayuga Heart Institute. An inpatient can be prepped in their room or brought to the holding area.  The patient’s cardiac catheterization results dictate where the patient will be recovered.  An outpatient with a diagnostic cath only will be recovered in our cardiac area. An outpatient or inpatient who underwent a PCI is recovered in our intensive care unit and will be admitted, have extended recovery or OBV (observation) status for a minimum of one night and possibly more. Patients with a recent myocardial infarction are admitted to the intensive care unit until they meet discharge criteria, which can take up to three days. An inpatient with a diagnostic cath requiring a sheath pull is placed in our holding area. The sheath will be removed with manual pressure and a hemostasis pad. Once hemostasis is achieved, they are then returned to their inpatient room. The physicians can utilize vascular closure devices, including Angio-Seal (St. Jude Medical) and Mynx (AccessClosure). When the patient receives a closure device, they are able to return to their inpatient room directly from the lab. All patients, whether they receive a closure device or manual pressure with a hemostasis pad, have a physician-ordered bed rest period of 2 to 8 hours. All patients are recovered by an RN that follows our post moderate sedation protocol.

How is inventory managed at your cath lab?

Inventory is managed by the RTs, techs, and purchasing department. Through our procedural charging, weekly and monthly inventory counts, and expiration checks, we are able to control and maintain our inventory. 

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

In late 2010, we went from a diagnostic-only cath lab to an interventional cath lab with primary intervention. Just prior to the transition, we started increasing RNs and RTs to prepare for on-call and an increase in volume with two new interventional cardiologists. We went from a 13-person team to a 25-person team. It allows us to have three separate call teams and gives us the ability to have our cath lab available 24/7.

Is your lab involved in clinical research?

We are not involved in any clinical research at this time.

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 under the mandated 90 minutes? Are you registered with the American Heart Association’s Mission: Lifeline or the American College of Cardiology’s D2B Alliance?

Over the past year, our average D2B time has been 45 minutes. To help keep our D2B time under 90 minutes, the team completed a Six Sigma project. They defined the ST-elevation myocardial infarction (STEMI) process from the emergency department (ED) to the cath lab. We have the opportunity to train with community emergency medical services (EMS). We are located in a rural area with five different volunteers and paid EMS, so it is important to include them. We have had mock drills and education to enhance everyone’s knowledge as to when to report a STEMI. Some EMS personnel have the ability to transmit their EKGs prior to the patient’s arrival. This allows the STEMI team to be activated early. If EMS is unable to transmit the EKG, they will give a verbal report and the ED physician will activate the STEMI team. Team members are able to stay on-site during inclement weather or if they live outside of a 30-minute response time. Currently, we are not registered with the American Heart Association’s Mission: Lifeline or the American College of Cardiology’s D2B Alliance.

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

To provide a standard of care, the cath team transfers the STEMI patient from the ED to cath lab during both regular and off hours.  

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

If the call team is in the cath lab with another patient, our county call cardiologist will consult on the STEMI patient in the ED. They will then communicate with the interventionalist and together they decide the best course of action. We can give thrombolytics or if possible, interrupt or finish the current procedure and prepare for the STEMI. 

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

We have an agreement with Stryker to reprocess some of our equipment that was expiring before utilization. An example of this equipment would be an AngioJet catheter or specialized interventional wires; items that are not used often and can be costly to purchase and replace. We also review our inventory quarterly with the interventionalist for utilization and need, which helps to keep our inventory up to date and concise.

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

The Cayuga Heart Institute in combination with the ED guides the Chest Pain Committee. Quality control and assurance measures are very important to the committee and Cayuga Medical Center. We follow the turnaround time of a few laboratory (blood) results, a time frame of arrival to disposition in the ED, our D2B times, door-to-EKG times, first medical contact (EMS) to first intervention times, and other EMS and facility data.  

How are you recording fluoroscopy times/dosages?

We record fluoroscopy times and dosage on every patient. These measurements are included in the final cath report and logged in our radiology time book. We report our time and dosage in the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR). We have a detailed policy and procedures on radiation safety and care in our lab. All patients receive a follow-up call or visit before discharge and radiology exposure is reviewed with each patient, especially if there is an unusual dosage or time. In that case, during the patient’s follow-up visit with the physician, the area of radiation exposure is reexamined.

Who documents medication administration during the case?

All medications are documented by the cardiac cath hemodynamic monitor during the case and signed off on by the RN who administered the medication, after the case.

Do you use any data collection registries?

In addition to our participation in the ACC-NCDR data registry, we are also participating in the New York State (NYS) Health Department Percutaneous Coronary Intervention Reporting System (PCIRS) Registry.

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

Cayuga Medical Center provides community events to help educate and inform our surrounding areas with information on the new procedures we provide. The cardiologist gives lectures to the public on current heart health concerns. Our team goes out into the community and participates in health fairs. We also hold educational events at our facility and invite the public to come, learn about health issues, and tour our facility. There are also many updates in local and surrounding area media, for example, in radio podcasts, and newspaper, billboard, and public transportation ads.

We have recently formed a collaborative partnership with Schuyler Hospital. Cayuga Medical Center and Schuyler started working together in 2011 to increase the services and treatments available to their patients. Our cardiologists are providing coverage to Schuyler Hospital on a regular basis. They can consult and refer patient to our cardiac cath lab for procedures. This enhances our working relationship outside of our own area and increases our clientele. 

Although it is not in the immediate area, Rochester General Hospital (RGH) Sands-Constellation Heart Institute Cath Lab and Cardiac Surgery has an alliance with the Cayuga Heart Institute.

How are new employees oriented and trained at your facility? 

Each new employee has a three- to six-month orientation education program. They are assigned to one of our preceptors for the term of orientation. They have a weekly or biweekly check-in with management to assess how the training is progressing. Part of the training program is to spend a
week at our off-site cath lab in Rochester, NY. There, the trainee participates in a higher volume of cardiac caths. While they are located in Rochester, the trainee also participates in emergency cath call as an observer. Near the end of orientation, the employee will begin to take emergency cath call with their preceptor. Once the training is complete, all competencies are signed off, the team is ready, and the employee feels comfortable, then orientation will be completed.  Orientation can be extended by the team and/or by the employee if there are concerns or questions. Orientation is never cut short and team dynamics depend on everyone being able to work with each other.

What continuing education opportunities are provided to staff members?

The staff has the opportunity to participate in monthly Peak Development (a continuing education program) and any education provided by our education department, such as classes, critical care skills days, and lectures. Within the department, we hold monthly cardiac cath conferences where case reviews or education on guideline updates or practices is provided. Staff provides monthly in-services to each other on different topics revolving around cardiac services.  Staff is always encouraged to seek out new education to share with each other and attend conferences. Recently, we have added two new positions, an Educational Clinical Leader and an Educational Team Leader. Our educators Monica Cluff, RN, and Mary Kay Hasenjager, RN, are formulating in-services in medications, processes, and case reviews.  They are leading the classes in a recently acquired program for Cardiac Credentialing International (CCI). All cath lab staff will be assigned the course and become a registered cardiovascular invasive specialist (RCIS) upon completion.  

How do you handle vendor visits to your lab? 

Vendor visits are approved in advance and all vendors for Cayuga Medical Center must participate in the Veri-Rep program. The color of the badge will let the team know whether or not the vendor can access the cath lab. At each visit, the vendor must sign in and have a dated sticker with their badge to confirm they have all necessary clearance to enter the cath lab and patient care areas. Some vendors do not enter the lab at all, and only provide in-services on new and upcoming changes or on products utilized in the cath lab.  

How is staff competency evaluated? 

Staff competency is evaluated by the educators through a hands-on skill test, written test, and/or verbal test. Each team member has a competency book that must be completed and signed off yearly, as well as any time there is a change or update to a competency. Each competency/skill/equipment is supported by our Educators for questions and concerns.  Every team member has an annual evaluation by the Director of the Department.

Does your lab have a clinical ladder? 

Cayuga Medical Center provided nurses with a clinical ladder program in July of 2012. The Clinical Advancement Reflecting Excellence (CARE) program has recognition of levels I through IV. Any staff nurse can apply for the CARE program, depending on their qualification, and previous education depends on which level they may achieve in a year.  Each level has different requirements, such as community service, education of staff, research, being published, or initiating patient care change. Each level of the CARE program has financial compensation.

How does your lab handle call time for staff members? 

Call time is scheduled on a rotating basis up to three months at a time. The call team is comprised of 2 RNs, 1 cath monitor (RN or CVT), and 1 radiologic technologist. Each team has a total of 4 people schedule for call time. If the team is called in, they are the first to go home that day or possibly the next day. The team works together to provide time for each other to be with their family, go on vacation, or give each other a break when needed.

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

The team follows the national and state guideline of being able to respond in 30 minutes. For those who live outside a 30-minute response time, Cayuga Medical Center has a call house on property for them to stay in when they are on call. The call house is large enough to hold one full team at a time.

Do you have flextime or multiple shifts? 

Currently, we have five separate shifts that expand from 630am to 5pm, Monday through Friday. 

Has your lab recently undergone a national accrediting agency inspection? 

Our chest pain coordinators recently submitted a re-accreditation application. The Society of Chest Pain Centers has received our application and we are looking forward to their site visit.  

Where is your cath lab located in relation to the operating room (OR) and emergency department (ED)? 

The physical location of the cath lab is on the same floor and within the same area as the OR. We have separate prep/holding areas. The ED is one floor below our cath lab. We have an elevator between the cath lab and ED. It is a shared elevator, so the cath lab is being provided a key to help eliminate delays.

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

The trend over the past few months has been male patients in their early 60’s. Over the past year, we have approximately 2 male patients for every one female patient. Ithaca has a very transient population with multiple cultures, due to our university and colleges.  This allows us to have several different patients with different cultural backgrounds. Acute coronary syndrome/myocardial infarction do not affect only one culture, or only males vs females; the disease affects all people of all cultures and ages.

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

The cath lab is a part of the Cayuga Heart Institute, and our team covers every aspect of cardiology for the hospital. The nurse that performed your EKG could be the same nurse who assists in your stress test, cardiac cath, or even your pacemaker/ICD implantation.  The cath lab staff performs every procedure within the scope of cardiology at Cayuga Medical Center, which aids in educating our patients about heart disease. It also gives our patients a sense of security or less anxiety, knowing beforehand the nurse or staff that will be with them through the procedure. 

Is there a problem or challenge your lab has faced? 

The challenge that faces us, as it does many cath labs throughout the country, is volume. Our volume has decreased as our community gets healthier and people have become more educated. We have started reaching out to those communities outside of our normal service area to update them about the procedures we can perform.  

Another challenge is recruitment of experienced cardiac cath RNs or RTs. Our team is comprised of surgical, emergency, intensive care, vascular, and telemetry personnel. We are advertising in media outside of our community for experienced cardiac cath recruits.  We have posted positions in nursing journals and have reached out to the surrounding metropolitan areas. When the lab was first starting out, we had travelers that provided outside knowledge and helped train the team. As the team has become more educated and more comfortable in their roles, we feel the addition of trained personnel will help alleviate extra call and bring more knowledge to our team as a whole.  

Currently we are orientating three RNs to the cath lab. Once they have completed orientation and are added to the call schedule, we will be fully staffed. The call will decrease for the current staff and a regular schedule with call rotation will be available.

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”?

We are a standalone cardiac cath lab. The closest surgical unit is a 15-minute medical flight or 40 minutes by ground medical transport. Due to this fact, all of our cardiac cath lab RNs are trained to transport our patients with an IABP. We run drills with local EMS to help keep everyone prepared for when we have to transport. We have a couple of nurses trained to fly with the IABP. We continually look for ways to decrease our transfer of patient care or loading time. The team trains with EMS and the flight staff about the IABP as well. We have a culture of team care where each patient is the center of that care. At Cayuga Medical Center at Ithaca, the “Center” is the patient. The facility prepares by performing drills or patient care in a team fashion. We all have different backgrounds, and working with EMS has given everyone a greater understanding of individual backgrounds and facilitated a more cohesive working relationship. Training with EMS, ground or flight crews has given us an enhanced “cath lab culture.”

The Society of Invasive Cardiovascular Professionals (SICP) has added two questions to our spotlight:

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?

We recently purchased an educational program, Todd’s Cardiovascular Review (available at www.westodd.com), which all cardiac staff will complete. This cardiovascular orientation is for the staff to work on becoming RCIS-credentialed. At this time, there is not a financial incentive for the staff. The education that is provided to us will allow us to succeed at our patient care in a specialized area. Our educators are providing Q&A sessions for the course. They have created handouts to aid in studying. We have all embraced this education and are looking forward to obtaining our certification. 

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?

The Cayuga Heart Institute director and manager are certified chest pain coordinators for the Society of Chest Pain Centers. They are also both members of the American Association of Critical Care Nurses (AACN). 

Sharey Selover, RN, CPC, Manager of Cayuga Heart Institute, can be contacted at sselover@cayugamed.org.