Lancaster General Hospital

24 registered cardiovascular invasive specialists (RCISs) 8 registered nurses (RNs) 7 patient care assistants one cath lab manager one clinical supervisor one education coordinator 3 patient care facilitators 2 image librarians 2 billing coordinators 2 secretaries one transporter one housekeeper In addition, there are 3 additional staff members who support the entire CV service line related to materials management, information technology and decision support. Of our procedure room staff, 92% are credentialed as an RCIS and several specialists are co-credentialed either as an RN, respiratory therapist, registered radiologic technologist or paramedic. With the current staffing tenure and our policy requiring RCIS credentialing within 3 years of employment, we expect 100% RCIS credentialing to be achieved within the next year. The average tenure of our employees is 12 years and 15 members of the team have been with our organization for greater than 15 years. Our registered nursing staff, which staffs our Pre/Post procedural area, has a combined 80 years of service with Lancaster General. What types of procedures are performed at your facility? Our cath lab performs diagnostic and interventional procedures. Diagnostic procedures include left heart cardiac catheterizations (LHCC), right heart cardiac catheterizations (RLHCC), Swan-Ganz insertions, multi-med line insertions, fractional flow reserve (FFR) measurements, coronary ultrasound, and pulmonary angiography (PA-grams). Interventional procedures include angioplasty, stenting, rotational atherectomy, thrombectomy, atrial septal defect/ patent foramen ovale (ASD/PFO) closure, intra-aortic balloon pump (IABP) insertion, and vena cava umbrella (VCU) insertion. We support many of our interventions with distal protection devices, and actively participate in numerous research studies. We perform approximately 4,500 diagnostic procedures and 1,400 interventional procedures annually. At this time, we do not routinely perform peripheral interventions in the cath lab. All electrophysiology procedures are performed in our highly recognized and skilled electrophysiology department, which is totally separate from the cath lab and is supported by its own staff. Does your cath lab perform primary angioplasty with surgical backup? Our facility has an established open heart surgery program. Our routine interventional cases do not utilize direct operating room (OR) backup; however, we do have a system in place which utilizes what we call an A window for high-risk patients. When a case is identified as an extremely high-risk procedure (determined by the cardiologist), an OR room is set up and a surgical team put on standby. Our charge specialists coordinate this effort with the OR and cardiothoracic surgeons. Should the need for emergent surgical backup arise during a routine interventional case, our cath lab-to-OR time is minimal. What procedures do you perform on an outpatient basis? We perform diagnostic cardiac catheterization, FFR measurements and coronary ultrasound procedures on an outpatient basis. What percentage of your diagnostic cath patients go on to have an interventional procedure? Thirty-one percent of all diagnostic procedures turn into interventional procedures. The majority of interventional cases are diagnostic procedures that roll directly into intervening on the culprit lesion. However, high-risk interventional procedures and staged multi-vessel interventions occasionally return the following day to be completed. Who manages your cath lab? Our cath lab manager, Richard Hinkle, is an RCIS as well as a registered nurse. He has been with Lancaster General since 1984 and transferred to our cath lab in 1987. Richard has functioned as a specialist, sedation nurse, interventional and hemodynamic specialist, electrophysiology specialist, clinical supervisor, and education coordinator. He has been the manager of our cath lab now for five years. We also have a clinical supervisor who manages the day-to-day operations in the cath lab and pre-post procedure area. We utilize charge techs to run the daily patient schedule in the cath lab; they communicate between the nursing floors, physicians, the clinical supervisor and cath lab staff. Do you have cross-training? Who scrubs, who circulates and who monitors? Our staff is comprised of a melting pot of credentials, including RCIS, RT, RN, RT(R), RRT, and EMT-P. Our entire staff is cross-trained in all positions within the cath lab. Cross-training takes place via our clinical ladder process, utilizing formal didactic education and clinical experiences to achieve competency. All staff members, having passed the required competency exams, are permitted to scrub, record, circulate and administer medications on the cath lab formulary in the cath lab setting. Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab? No, an RT does not need to be present in the room during procedures. 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? All of our staff members are trained to pan the table, position the II and change angles. The physician is responsible for stepping on the fluoro pedal and administering ionizing radiation. Could you share the details of your lab's clinical ladder? Our clinical ladder has evolved over the last 15 years. Currently, a new employee (with little or no experience) begins the clinical ladder as a CVT trainee. During the initial 3-month period, the trainee completes orientation rotations through all positions in the lab, including circulate, scrub, and record. Once the individual has all competency checklists completed, scored a passing grade on an entry-level pharmacology test, and can perform independently in the circulate, scrub, and record positions, the CVT trainee enters an apprentice program. The apprenticeship is a two-part program, through which the employee has an opportunity to take advantage of numerous lectures offered within our institution. These lectures prepare the new employee for a series of pharmacology and core knowledge examinations, and are in addition to clinical skills trainees are required to learn and fine-tune. The maximum time allotted for completion of the apprenticeship is 24 months from the date of hire. Following completion of our apprenticeship program, the employee is referred to as a CVT. At this time, a department specialty must be declared. A specialty is an area in which the employee will focus their education and clinical skills. Specialties in our lab include intervention, hemodynamics, charge specialist, pharmacology/sedation and research. We also require that all CVTs attain the RCIS credential within 1 year of completing the apprentice program (no longer than 3 years from the date of hire). At this point, all minimal requirements for employment are complete; however, an RCIS can choose to go one step further and be declared a Senior RCIS. The Senior RCIS candidate is one who has mastered the outlined objectives and skills in their chosen specialty. The Senior RCIS must submit an annual portfolio that describes in detail how they demonstrate expertise in their cardiovascular specialist role. This is for the specialist that goes above and beyond what is expected on a daily basis in order to better themselves, the care of our patients and the cardiovascular invasive specialist profession. New specialists that are hired with previous experience may have a shorter orientation period, but must still challenge all examinations required of the clinical ladder. This requirement is to ensure all of our specialists have been presented with the same opportunities and requirements. What are some of the new equipment, devices and products introduced at your lab lately? We are currently using drug-eluting stents (DES) and bare metal platforms when clinically appropriate. A full array of interventional guide wires are available to the cardiologists, including the recently added Steer-it (Cordis Corp., Miami, Florida). We utilize the AngioJet® (Possis Medical, Minneapolis, MN), triActiv FX® Embolic Protection System (Kensey Nash Corp., Exton, PA), Filter Wire (Boston Scientific, Maple Grove, MN), Spider (ev3, Plymouth, MN) and QuickCat Extraction Catheter (Kensey Nash Corp.) to combat thrombus. Pressure Wire (Radi Medical Systems, Wilmington, MA) and Galaxy IVUS (Boston Scientific) are employed for diagnostic information. The Tornus Specialty Catheter (Abbott Vascular Devices, Redwood City, CA) is being used for chronic total occlusion interventions. Amplatzer® Septal Occluder (AGA Medical Corp., Golden Valley, MN) devices are used for septal and PFO closures. The Starclose vascular closure device (Abbott Vascular Devices) has been a recent addition to our groin management options, and the MEDRAD Avanta Fluid Management Injection System (Indianola, PA) has been put into operation throughout the departmental procedure rooms. Can you describe the system(s) you utilize and how they work in cath lab daily life? We have 3 GE digital labs (Waukesha, WI), with a fourth GE digital lab that is equipped to be used by cath or EP; however, it is primarily used for EP procedures. We utilize Siemens Acom.Net (Malvern, PA) for image archive and diagnostic quality image distribution. We also have Siemens AcomWeb, which provides compressed image distribution throughout our intranet for review of quality images. This enables our physicians to view images at multiple locations throughout our facility as well as in their offices. How is coding and coding education handled? Departmental billing is managed by two billing persons. They are responsible for charge entries specific to all procedures we perform, as well as billable equipment. Charge entries are performed within 24 hours of the procedure, reviewed the following day, and then sent to our coding department. Final coding is performed by the hospital's clinical coding department. Department billing personnel, financial services and coding personnel work together to constantly update our charge master and amend our billing practices to adhere to all regulatory demands. How does your lab handle hemostasis? All patients (other than ICU patients) return to the post procedure holding area to have their lines discontinued. Our hospital primarily uses Syvek and Syvek NT Patches (Marine Polymer Technologies, Inc., Danvers, MA) for line removal. We have trained our patient care assistants (PCA) to discontinue lines, and they are responsible for the majority of sheath removals. When a PCA is not available, the scrub tech assigned to the case is responsible for the line management. We have also set up a line removal training system for the ICU PCAs. After hours, the ICU PCA staff is responsible for the removal of indwelling lines. There has been limited but increasing use of the Angio-Seal (St. Jude Medical, St. Paul, MN) and Starclose vascular closure devices post intervention. Does your lab have a hematoma management policy? If a hematoma is developing, pressure is applied both proximally and over the site, for 3 minutes, and then over the site for a minimum of 20 minutes or until hemostasis is achieved. The hematoma is then marked, timed, dated and monitored for any changes. Hematomas are not manually compressed at our facility. How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies? Inventory is managed and tracked via our cath lab database. Bar code scanning of supplies used during the procedure generates data for our patient record, reordering and patient billing. Requisitioning of supplies is completed by interventional specialists, our holding area patient care assistants and an RCIS that is dedicated to ordering supplies. Equipment procurement is the responsibility of the materials manager of the heart center who works directly with the purchasing department. Has your cath lab recently expanded in size and patient volume, or will it be in the near future? We have not increased the number of procedure suites in the past 14 years. We currently operate three multi-purpose (cath/intervention) procedure rooms and have access to a fourth room that is primarily used by EP. The most dramatic change we have experienced is the expansion of our pre-post procedure area(s), from 8 beds to 24 beds. This change has allowed us to begin managing outpatient cath lab services from admission to discharge. It not only streamlines services, but also enhances the customer's experience, minimizes way-finding issues and eliminates multiple transfers throughout the facility. We are currently evaluating our facility, its existing capabilities, limitations and future needs. We are exploring the feasibility of developing a comprehensive cardiovascular service line facility to manage all the needs of our patients with cardiovascular disease. The introduction of DES, coupled with the use of statin therapy, has reduced diagnostic patient volumes over the past two years. More recently, we have seen a slight increase in patient volumes. The overall impact of cardiac CT/MRI remains to be seen. Is your lab involved in clinical research? Our cath lab has been involved with clinical research for many years. Senior research specialists work in conjunction with the hospital research nurses to develop and implement research protocols within the cath lab setting. These research specialists also work in conjunction with the cath lab manager to produce quality improvement data, which is used to better our customer service. We are currently involved in the following clinical trials: COOL MI II, COOL RCN, TargeGen, AMIHOT II, and Neuroflo. Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? Our complication rate relative to emergent open heart surgery is superior to benchmark. What measures has your cath lab implemented in order to cut or contain costs? We are constantly exploring opportunities with our vendors to improve our buying power. We have a dedicated materials manager for cardiovascular services that works closely with our purchasing department for all pricing/contract negotiations and product acquisition. The Manager of Invasive Services (Cath Lab) and the materials manager meet monthly with the Cardiac Catheterization Committee, which has representation from physicians, middle management and executive management. Opportunities to control operating expenses are routinely on the agenda of this committee. What type of quality control/quality assurance measures are practiced in your cath lab? The Cardiology Performance Improvement (PI) Committee, chaired by the vice-chief of the cardiology division, meets quarterly to assess the care provided in our division. The Committee encourages a collaborative, interdisciplinary approach. It includes members of the cardiology division, senior management, departmental managers, the quality assurance department, as well as line staff from the Heart Center. The PI Committee reviews and approves an annual plan, which incorporates goals and objectives from four standing committees (Cardiac Catheterization Laboratory, Electrophysiology & Pacing, Noninvasive Cardiology, and the Cardiac Rehabilitation Committees). Other key initiatives developed within the Heart Center during the fiscal year may be added to the PI plan, along with reports and issues referred by the Cardiology Care Management Team. This team establishes a system to continuously monitor patient care outcomes for specific cardiology patient populations. They look at national best practices, as well as national benchmarks and outcomes, in order to attain the best practice for our community. The PI Committee may initiate focused reviews pertaining to a specific case, individual physician's performance and/or a specific quality of care concern. The PI Committee also receives referrals from other sources, such as other hospital committees or medical staff departments and divisions, for investigation and/or recommendations. The results of the Division of Cardiology Performance Improvement activities are reported to the Department of Medicine Performance Improvement Committee and then to the Hospital Performance Improvement Committee, Medical Executive Committee, Joint Conference Committee and as appropriate, the Board of Directors. Information or changes that are considered relevant to the improvement of patient care are communicated during cardiology divisional meetings, department of medicine departmental meetings and are published in a bi-monthly news publication for hospital staff and medical staff. How does your cath lab compete for patients? Has your institution formed an alliance with others in the area? We currently reside in a very competitive market. There are three cath labs within a ten-mile radius, two of them within a for-profit organization. We have secured a transfer agreement with the remaining small, community hospital-based cath lab. However, our main focus is centered on providing the superior, cutting-edge, quality care you would find at a larger teaching institution, with a small-town compassionate and caring attitude. We feel that this standard speaks for itself and it has produced very positive community feedback. What type of continuing education opportunities are provided to staff members? Educational opportunities are fortunately abundant within our department. We set aside an hour-long staff meeting each Tuesday morning. We have numerous vendors that offer CEU programs, as well as internal education from our own Department of Education and Professional Development. This time is also used to cover departmental updates and concerns that arise, as well as competency testing and an occasional social celebration. On occasion, a new device or piece of equipment will emerge which staff need to know about before a staff meeting can be organized. Vendors are then welcomed to join us in our staff lounge to inservice the specialists and physicians as they get an opportunity to stop by. Every effort is made by the clinical supervisor to see that each staff member gets time during that day to attend an inservice. As part of our clinical ladder, there are several programs offered to our employees. We offer pharmacology, hemodynamics, and basic intervention programs, to name a few, all taught by our Senior RCIS staff. Classes are typically taught in the afternoon, when staff is in abundance. Our courses have an outlined curriculum that is constantly being evaluated and updated. Examinations are used to assess the working knowledge gained during classes. Our department also budgets for an educational fund. This money is used for new text and reference books as well as funding for local seminars and symposiums. How do you handle vendor visits to your lab? Vendors must follow our purchasing department's guidelines, which are provided in booklet form. Vendors schedule visits through the materials manager. Visits are scheduled in half- or full-day increments. When new products are introduced, vendors are permitted to be present for up to one week at a time. Vendors must have a physician's invitation before entering the cath lab procedure rooms. How is staff competency evaluated? Our competencies are evaluated on an annual basis (July through June). For the fourth year in a row, our lab has organized a Competency Day. Each year, a different theme is highlighted for the Competency Day; for instance, one year a tropical paradise was created in a conference room, complete with palm trees, non-alcoholic margaritas, and of course, stations set up for the relevant competencies on which staff members were evaluated. This format makes the (often dreaded) evaluations fun and enjoyable for the staff while being efficient for the evaluators. Other competencies are spread out between July and April so that each is completed in time for the performance appraisal process that begins in May. Some of our competencies are evaluated with written tests or quizzes, while others are more of a hands-on nature. It is unusual that the staff would not perform well. Remediation and coaching is provided to those that may need a little extra help. Does your lab utilize any alternative therapies (such as guided imagery, etc.)? Currently, our cath lab does not utilize alternative therapies. Our hospital does offer holistic or complimentary services through our wellness center. Yoga, guided imagery, massage, qi gong and reiki therapies are offered along with weight loss, smoking cessation, and stress relief programs. How does your lab handle call time for staff members? Our cath lab runs on two shifts: 0700-1530 and 0900-1730. Our staff is grouped into four call teams. Each team is comprised of five to six members, four of which compose the active team that responds during the night. Each team rotates on a schedule of one week on call and three weeks off call. During their call week, team members work 1000-1830 or until the work is finished. After 1830, four team members are required to have a response time of thirty minutes for all emergent cases. The call week begins Monday and ends at 0700 Monday morning of the following week. Since we are all cross-trained and able to administer medications, there are no credentialing requirements for our call team members. What trends do you see emerging in the practice of invasive cardiology? Our experience with DES has been very positive. Repeat diagnostics for follow-up studies are declining and we have eliminated our brachytherapy program. As noted, the impact of our cardiac CT/MRI has yet to be seen. Our 64-slice cardiac CT program will be up and running within the next few weeks. We are excited to see what influence it has on our invasive cardiology numbers. We have performed some cardiac MRIs, but not for the purpose of coronary anatomy evaluation. Cardiac CT/MRI services are staffed by personnel appropriately trained and credentialed for these procedures. Cath lab staff members will not be involved with the administration of CT/MRI services. Has your lab undergone a JCAHO inspection in the past three years? We did have a recent survey and all went extremely well, without any type I recommendations. IV moderate sedation is a very hot topic. Consistent implementation and documentation of IV moderate sedation across our organization has been a successful strategy. Clinical competence and documentation of ongoing competencies is a must. Policy review was extensive be prepared. Where is your cath lab located in relation to the OR department, ER, and radiology departments? The invasive cardiology and the OR departments are both located on the second floor of our hospital, while the ER and radiology departments are located on the first floor. Please tell readers what you consider unique or innovative about your cath lab and its staff. Our cath lab is a high-volume, progressive lab, in a facility recently recognized as twenty-sixth in the nation for heart and heart surgery care, according to US News and World Report. We pride ourselves on combining the technical and innovative excellence of a big-city teaching institution with a small-town approach of compassion, understanding, and individualized care. Our team is a very unique team in several ways. Due to our mandatory requirement that staff members acquire RCIS credentialing, as well as our extensive education and evaluation program, all team members cross-train and operate on equal standing. We do not segregate our team with divisions drawn between differing credentials. This allows our staff to perform all aspects of patient care, including advanced hemodynamic data interpretation, medication administration, x-ray equipment manipulation, advanced interventional procedures, creation and implementation of research protocols, as well as administration of moderate sedation. Having an education coordinator dedicated entirely to invasive cardiology is also a very unique aspect of our institution. We are also very proud of the additional steps, beyond performing heart caths, which our staff members take to further combat heart disease. In addition to the duties involved in the day-to-day operation of our catheterization lab, our staff members are very active in educating our community about the risks, prevention and treatment of heart disease, as well as other health-related topics. Several team members belong to the Lancaster General Speakers Bureau and are available to provide educational lectures to groups and organizations throughout our community. Many members of our team are committed to furthering the field of invasive cardiology and the RCIS credential, having been instrumental in establishing the Keystone Chapter of the Society for Invasive Cardiovascular Professionals (the only SICP chapter currently organized in Pennsylvania). Eighty percent of our staff are members in the chapter. On a more clinical side, team members have decided to share their technical expertise and years of hard-earned experience with future healthcare professionals. Several members travel to local high schools, providing educational lectures about career opportunities within the cardiology field. Through a partnership between J.P. McKaskey High School in Lancaster, our team members have had the fortunate experience of being mentors for high school students performing internships within the hospital. Along with mentoring high school students, our team members serve as clinical preceptors and adjunct instructors for the Lancaster General College of Nursing and Health Science's Cardiovascular Invasive Specialty Program. Together, we are training the future of our health care system. 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? Located in southeastern Pennsylvania, Lancaster is the oldest inland city in the United States. Rich in culture, Lancaster is home to Franklin and Marshal College, Pennsylvania Collage of Art and Design, the estate of former President James Buchanan, the Fulton Opera House, and just recently, the Atlantic League's Lancaster Barnstormers baseball team. Just a few short miles outside the city limits, the roar of cars turns into the rhythmic clip-clop of horse and buggy transportation as you melt into the heart of Amish country. Gently rolling farmland presides throughout the area. Winner of a 2001 Family-Friendly Travel Award, Lancaster is the second-best family destination in America, according to FamilyFun magazine readers, who selected Lancaster as the #2 Top Pick Tourist Town in the nation. Lancaster is also just a short drive to major cities like Philadelphia, Baltimore, Washington, D.C. and New York City. Tim Martin can be contacted at timartin@lancastergeneral.org

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