Considerations When Staffing the Cath Lab

Choosing to staff a cath lab at a bare minimum, in terms of personnel and skill levels, is not sufficient to meet the variable demands placed on this department and the healthcare needs of its patients. To avoid such a scenario, cath labs should have a specific staffing plan in place to improve retention, encourage training and continuing education, drive recruitment based on facility needs, and outline the staffing ratios and required skills needed to safely and efficiently operate the cath lab. The staffing plan should take into consideration the size of the facility, type of procedures being performed, number of cases each year, and current patient-to-staff ratios (Figure 1). Yet staffing today’s cath lab is both an art and a science. Labs staff with one credential or a mix of credentials, vary in the tasks staff are permitted to perform and can employ different numbers (or types) of staff for similar situations. Following are some considerations to take into account when staffing a cath lab. Consider Number of Staff, Skills and Certification The Society of Invasive Cardiovascular Professionals (SICP, www.sicp.com), in its position statement, “Staffing in the Cardiac Catheterization and EP Lab,” states, “There are three primary roles of the cardiovascular invasive specialist: hemodynamic monitoring/documenting, circulator, and scrub assistant. Minimal optimal staffing for diagnostic and therapeutic cardiovascular procedures allows for staff to assume these individual roles.” [Ed. note: Please see the SICP section in this issue of CLD for the full position statement.] Although this SICP statement does not differentiate the need for additional staff during interventional procedures versus diagnostic procedures, it does indicate the need to take into consideration the acuity of a patient’s current condition in determining appropriate staffing levels. The SICP also recommends that all non-physician team members possess the Registered Cardiovascular Invasive Specialist (RCIS) credential. Offered by Cardiovascular Credentialing International (cci-online.org), the RCIS represents attainment of all the fundamental knowledge required to work in a cardiac catheterization laboratory. Many cath labs across the U.S. encourage staff (sometimes with financial compensation) to obtain this credential.1 The Association of Radiologic & Imaging Nursing (ARIN) emphasizes that quality care for all patients is the primary responsibility of nurses;2 therefore, ARIN states that at least one member of the invasive cardiology team should be a registered nurse possessing the necessary experience and credentials to administer moderate sedation and provide safe, quality patient care. Larinda Walston, a traveling critical care nurse, says that while “cath lab staffing is unique to each hospital, it is always necessary to have a nurse administering medications and monitoring the patient. This is generally a conscious sedation procedure; therefore, it is imperative that the patient is appropriately monitored by the guidelines set by the hospital, the Joint Commission, and patient safety quality boards.” She went on to say that “in larger facilities, such as teaching facilities, the physician may have a fellow and/or resident assisting by scrubbing in for the procedure. The radiologic technologist is responsible for equipment management (i.e., fluoroscopy). Depending on the situation, another technologist may be monitoring and documenting in the control room. This process is also an opportunity for nursing staff. In smaller facilities, the nurse may be scrubbed in with the physician or another technologist. This does not discount the need for a clinician (nurse) to be at the patient’s side. The exception may be if anesthesiology is present for the procedure. However, a circulating nurse is still a vital part of that team configuration. Cath lab technologists may be able to perform laboratory testing such as arterial or venous blood gases; however, nursing continues to have the responsibility of administering medications, monitoring and ensuring the patient’s safety.” The American Society of Anesthesiologists and the American Nurses Association have developed guidelines for the administration of procedural sedation. These recommendations indicate that the registered nurse monitoring the patient should have no other duties to perform during the sedation and recovery process. Both the SICP and ARIN emphasize the need for invasive cardiovascular professionals (technologists and nurses) to demonstrate the knowledge and competency to perform and assist with interventional procedures. A cath lab supervisor in Pennsylvania notes that all new staff at her facility are provided with at least three months of orientation to the unit and, upon successful completion, they are paired with a senior staff member on each case. In setting the expectations with her new hires, the cath lab supervisor is able to inform them that they will not “feel comfortable” until they have one full year of experience in the cath lab. At the very least, skills validation should occur on an annual basis. All members of the invasive cardiology team should also be ACLS-certified. Gain Staff by Cross-Training Across Departments Considering the current economic conditions, hospitals need to find efficiencies and reduce costs. One way to achieve these goals is to maximize the productivity of each employee, often accomplished through cross-training and the development of multi-functional roles. While developing these roles, it is imperative that the healthcare professional be provided with the appropriate education and training, as well as a means to validate their skills in cross-functional roles. One example is cross-training across departments, for example, utilizing an interventional radiology nurse in the cath lab. Although the roles are considered similar in both settings, it is essential that the nurse be provided additional training in order to develop the full competency in the expanded role. Remember that there are additional “soft” costs attributed to inadequately training staff, including employee dissatisfaction, lower productivity, and higher turnover, as well as increased liability. Consider Documentation Needs Nancy Robertson, an interventional radiology nurse in Massachusetts who also works in the diagnostic cath lab, points out that “it is also important to consider the documentation requirements of the department in determining staffing ratios.” Robertson’s department uses the MacLab IT Hemodynamic Documentation System (GE Medical, Waukesha, WI), which requires a dedicated team member responsible for documenting the procedure. Documentation is often done at a monitoring station outside the cath lab. At her facility, Robertson, an RN, attends to the patient and administers the procedural sedation, an invasive cardiology technologist acts in the scrub role assisting in the procedure, while the third team member documents the procedure. In the event of problems during the case or should the need arise for more assistance from a dedicated circulator, this staffing mix can pull the nurse from her primary responsibilities to the patient, especially in the absence of any additional “float” personnel in the department. The Use of Float Staff and Feedback “It is important to consider not only your scheduled cases when determining appropriate staffing, but also any potential emergent cases that may come in during the day,” stated Eleni Flanagan, manager of the interventional cardiology lab at Johns Hopkins Hospital in Baltimore. Flanagan is evaluating room turnover rates at different staffing levels and then determining the most efficient staffing model. Another factor playing into Flanagan’s staffing mix is that for several diagnostic cardiology labs in the surrounding area, Johns Hopkins serves as a referral center if any patients require an interventional and potentially emergent procedure. “I have found it most beneficial to have float staff available to be able to cover for breaks, obtain any additional equipment needed during procedures, transfer patients and ensure the next case on deck is properly prepped and ready to go to ensure the most efficient turnover of cases,” she comments. Johns Hopkins, a Magnet facility, relies on feedback from the nurses and techs in the department to help to determine the best staffing ratios. “It is important to know what your magic number is based upon the department’s hours of operation and calculating for call-outs and a certain amount of non-productive time,” adds Flanagan. Johns Hopkins is a large teaching hospital, with a total of six interventional cardiology labs and two electrophysiology (EP) labs. Their hours of operation are 7:30 am to 5:30 pm and the EP labs run until 7:30 pm. She recently has been faced with the challenge of trying to find someone willing to work a 10 am to 2 pm shift, as this is the time frame in which the need for an extra set of hands to cover lunch breaks is most crucial. “Nurse-Heavy” vs. “Tech-Heavy” Staffing Registered nurse James Pachter has worked in a variety of different cath lab settings, both as a travel nurse and a staff nurse. According to Pachter, typical staffing in a cath lab that does not have a cardiology fellowship program is one registered nurse, one scrub tech or nurse and one tech to document and circulate. “Rotoblator cases or cases involving the left main, what we call the ‘widowmaker,’ will have two nurses in the room and potentially even an extra tech as well,” he says. Pachter indicated that if the hospital is more “nurse-heavy,” it may be more typical to have two nurses in the room and one tech. A cath lab that sees more complex or critical cases would certainly benefit from having a larger number of nurses on staff, where a more flexible staffing structure could accommodate a rapid critical admit. A more “tech-heavy” hospital, however, will typically staff two techs and one nurse for each procedure. “I have been involved with cases where the patient is coding,” stated Pachter. “In that situation we closed one of the cath lab suites and we had two teams working on that patient.” Pachter says most invasive cardiology professionals appreciate the flexibility and variability of being able to function in both the scrub and circulating roles. Hospitals with Fellowship Programs The cardiology cath lab supervisor in Pennsylvania noted that her hospital has an invasive cardiology fellowship program. As a result, each procedure is staffed with a minimum of two physicians, one circulating invasive cardiovascular tech, and one registered nurse. She will add another staff member on any complex or high-risk cases. Additionally, if the patient’s status is critical, necessitating ventillatory support or vasoactive medications, she will have a second nurse involved with the procedure. At Hopkins, also a facility with a cardiology fellowship program, Flanagan says that standard staffing for a non-complex interventional case is one nurse to administer procedural sedation, one tech or nurse to monitor and document, and one scrub tech to pan and assist, while the attending and cardiology fellow perform the procedure. Additionally, float staff will be available in the department to retrieve supplies, prep the next patient for the room, and be available to assist in any room when needed. Flanagan admits that her staffing may be more generous than most, but she has found that this improves patient satisfaction, decreases delays in turning over rooms, and improves the overall efficiency of the department. Retention is Crucial: Professionals Still in Demand According to IMV, a medical imaging marketing and research company, the numbers of invasive cardiology procedures performed in U.S. cath labs have been on the decline in recent years. In 2008, 3.75 million cath cases were performed in the U.S. at 2,020 sites with one or more cath labs — a 9 percent decrease from the 4.21 million cases performed in 2006.3 IMV attributes the decline in part to the rise of computed tomography angiography (CTA) for diagnostic procedures and the controversy over drug-eluting stents, prominent in the media in 2005-2006.3 (We would also argue that clinical trial results, like those of COURAGE,4 published in early 2007, also played a role). Despite these recent decreases, the need for invasive cardiology and interventional radiology professionals has continued to increase significantly over the last few years. Cynthia Kinnas, president of Clinical One, a healthcare staffing company specializing in travel contract staff, states that she has seen a consistent increase in needs for both registered nurses and radiologic technologists specializing in the invasive cardiology lab setting. One can deduce that the industry may be stabilizing and poised for further growth at this time. Clearly, there continues to be a shortage of highly specialized professionals, supporting the need to motivate and empower current staff. Involving them in staffing recommendations and/or decisions, encouraging continuing education and supporting advanced certification, and involving staff in quality management activities helps employees take ownership of performance and results, while improving retention and productivity. Certainly, ensuring that the lab is appropriately staffed with the proper mix of professionals possessing the necessary competency is an essential component in achieving employee and patient satisfaction goals. Melissa Knybel can be contacted at melissa.knybel@clinicalone.com or at (800) 919-9100.

1. Are You Being Paid Fair Market Value in 2008? A Cardiac Cath Lab Professionals Survey by Cath Lab Digest and the Society of Invasive Cardiovascular Professionals. Cath Lab Digest 2008 Mar; 16(3):14. Available online at http://tinyurl.com/ntojv5 (or) http://www.cathlabdigest.com/articles/Are-You-Being-Paid-Fair-Market-Value-2008. Accessed August 14, 2009.

2. Association for Radiologic & Imaging Nursing. Clinical Practice Guideline. Moderate Sedation and Analgesia. Available at http://tinyurl.com/mkal7d (or) https://www.arinursing.org/practice-guidelines.html. Accessed August 13, 2009.

3. IMV. Press Room. IMV’s latest Cardiac Cath Market Summary Report shows that the variety of cases performed in cath labs has broadened as coronary cases decline. Available online at http://www.imvinfo.com/index.asp?sec=abt&sub=prs. Accessed August 14, 2009.

4. Boden WE, O’Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 2007; Apr 12;356(15):1503-1516.