Lane Cardiovascular Center

Can you tell us about your cath lab?

Lane Regional Medical Center’s Cardiovascular Center has one cath lab with a Toshiba Infinix (Tustin, Calif.) system and one 64-slice computed tomography (CT) room. Our program first began with a modular unit in January 2007 (supplied by Modular Devices, Inc. [MDI], Indianapolis, In.), and the new, permanent Cardiovascular Center opened in August 2008.

We are staffed with a mix of employees who hold various credentials and qualifications. Our team consists of 11 employees. We have 4 registered nurses (RNs), 4 radiologic technologists (RTs), one clinical schedule coordinator, and one clinical coder. Our adjacent CT scanner is staffed by a CT-certified RT. We have two employees who have been with us since the cardiology program started in 2006 and one that just recently joined our team. Combined, we have a total of 50 years of cath lab experience. Credentials obtained by staff include one nurse who is critical care certified (CCRN) and one radiologic technologist that is certified in CT. Two nurses are currently studying for the registered cardiovascular invasive specialist (RCIS) exam, and two nurses are certified advanced cardiac life support (ACLS) instructors. We provide care for a wide a range of patients that are serviced by three cardiology groups and one vascular surgery group.

What procedures are done at your lab? 

Our cardiology center is very diverse and able to do a wide range of procedures. We perform diagnostic left and/or right heart catheterization, diagnostic peripheral artery angiography, carotid angiography, venograms, fistulograms, etc. Interventional procedures such as coronary angioplasty, coronary stent placement, both elective and emergent (i.e., acute myocardial infarction [MI]), peripheral angioplasty and peripheral stenting, including carotid stenting, are routinely performed. Other procedures include the insertion of intra-aortic balloon pumps (IABPs), temporary transvenous pacemakers, vena cava filters, and loop recorders as well as implants of permanent pacemakers and implantable cardioverter-defibrillators. We use several atherectomy and thombectomy devices on a routine basis. We are also using multiple crossing devices. For intravascular imaging we utilize intravascular ultrasound (IVUS) (we have both Boston Scientific and Volcano systems). Additionally, for lesion assessment, we use a pressure wire (Volcano, San Diego, Calif.).

Our most recent addition is the Impella 2.5 percutaneous left ventricular assist device (LVAD) (Abiomed, Inc., Danvers, Mass.).

Our 5 bay pre-op/recovery area is also utilized for such procedures such as transesophageal echocardiograms, tilt table tests, cardioversions, and pseudoaneurysm decompression. On an average, we perform 24 cases a week and about 20 CT 64-slice scans per week.  

Does your cath lab perform primary angioplasty with surgical backup on site?

No, however, our cardiologists work well with cardiovascular surgeons in town. The surgeons are available 24 hours a day to accept patients who require surgical intervention. Should a patient need to be transferred to another facility in town, the surgeons and cardiologists have privileges at our hospital and the accepting facility, which allows for greater continuity of care.

What percentage of your patients is female? 

Forty-two percent of our patients are female and 58% are male.

What percentage of your diagnostic cath patients goes on to have an interventional procedure?

Approximately 13.2% of all diagnostic caths are “normal” and approximately 32% of diagnostic caths go on to have an interventional procedure. We very frequently use imaging and physiological lesion assessment prior to proceeding to intervention.

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

Three of our interventional cardiologists regularly gain access via the radial artery. The other physicians prefer groin access, but will do a radial access case if requested by the patient or if it is necessitated by the patient’s condition. Overall, approximately 80 percent of our coronary interventions are performed via the radial approach.

Who manages your cath lab?

Our cath lab director is Rob Lawrence, RRT, and our cardiology services director is Laura Peel, RN, CGRN. Deepak Thekkoott, MD, FACC, FSCAI, FSCCT, FRCP(E) is our cardiology medical director.

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

All staff in the lab is cross-trained to each modality. The nurses primarily serve as the circulator due to medication administration duties; however, nurses do scrub if staffing permits. The pre- and post-op recovery area is primarily staffed by the nurses. The techs rotate “in” the pre/post area post scrubbing to help out as needed. This has really stretched our manpower during crunch times. Primarily, however, the techs monitor and scrub in with the performing physician.

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

Yes, this is the Louisiana law.

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 physicians and techs can position the C-arm, pan the table, change camera angles and step on the fluoro pedal. RNs can do the same, with the exception of stepping on the fluoro pedal. The physician presses fluoro when a nurse scrubs a case.

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

Our physicians and staff are all fitted and provided with lead aprons. A dosimetry badge is worn by each staff member during all cases. We have an in-house radiation safety officer that monitors all radiation readings. The readings are also posted on our bulletin board for all to review. To reduce exposure, staff rotation limits the amount of time staff is in the room during cases. The lab is equipped with lead shields and lead skirting, protecting those at the scrub table. Leaded glasses are also provided.

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

For a new cath lab in the region, we are highly advanced and sophisticated. Here at Lane, we have many of the firsts in Baton Rouge area. These include intravascular imaging devices like the Boston Scientific iLab IVUS system (Natick, Mass.), the Volcano IVUS and fractional flow reserve (FFR) system, multiple radial access and closure systems, and multiple crossing devices such as the Crosser device (Bard Peripheral Vascular, Tempe, Arizona), Pioneer catheter (Medtronic Vascular, Santa Rosa, Calif.) and many other advanced crossing catheters. We have an array of atherectomy devices as well, such as the Diamondback 360 (CSI, St. Paul, Minn.) orbital atherectomy device, the SilverHawk and TurboHawk (ev3 Endovascular, Plymouth, Minn.), and the JetStream (Pathway Medical Technologies, Inc., Kirkland, Wash.) device. We also have thrombectomy devices, such as the AngioJet (Medrad Interventional/Possis, Minneapolis, Minn.) and Trellis catheter (Bacchus Vascular, Inc., Santa Clara, Calif.). We keep infusion catheters for regional thrombolysis. Recently, we added Guideliner catheters (Vascular Solutions, Inc., Minneapolis, Minn.).

We are excited to have the Impella 2.5 percutaneous LVAD system as the most recent addition to our armamentarium. Our center has had excellent results with the device in terms of complex interventions and life-saving management of severe cardiogenic shock not responding to pressors and an IABP.

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

Our hospital provides staff with intra-hospital email that is accessible on site at all times. We have monthly unit meetings and the minutes are posted for all to review. In the lab control room, we utilize a bulletin board where important information is posted. All hospital staff is encouraged to attend monthly “lunch and learn” inservices provided by the cardiology team.

How is coding and coding education handled in your lab?

Coding for all cases is handled by our certified coding specialist, Tina Nations. She is on site for all cases during routine business hours. One of our more experienced nurses has also attended a coding seminar to assist when Tina is absent. Our clinical audit reimbursement specialist, Melissa Lachney RN, CRRN, CLNC, CCA, also assists with coding questions and chart audits. Several staff members have been cross-trained to enter charges in the computer on a case-by-case basis.

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

All outpatient procedures enter through the pre/post cath area, where they are checked in and prepped for their procedure. They return to their same room after the procedure for their recovery and bed rest. All closure devices are placed in the lab while manual compression is done in the post-op area. The cath lab staff has trained the nurses in the ICU and IMC (intermediate care area) in manual compression post sheath removal. Manual compression is the method of choice for sheath removal, but closure devices are utilized when the patient’s condition warrants.

TR Bands (Terumo Interventional Systems, Somerset, New Jersey) are used almost exclusively for radial artery closure. Occasionally, manual pressure is used.

What is your lab’s hematoma management policy? 

We have developed a hematoma management policy to better keep track of all groin complications. All hematomas are reported to the cath lab via our in-house hematoma hotline. Information such as size and post-op interventions required are included in the report. A cath lab staff member is available to assist in evaluating and resolving the hematoma as needed.

We are happy to say as we transformed to a predominantly radial lab, we have reduced hematomas significantly.

How is inventory managed at your cath lab?

Our inventory is managed by our director and our most experienced radiologic technologist, Chris Benoit, RT, through collaboration with the hospital’s materials management director. Our hospital participates in HealthTrust Purchasing Group (HPG) purchasing contracts (Brentwood, Tenn.), thus allowing us the most cost-effective purchasing practices.

Has your cath lab recently expanded in size and patient volume, or will it be in the near future?

Three new physicians have started a cardiology practice in our area and this has increased our patient volume considerably. Preliminary talks have begun about converting our adjacent 64-slice CT scan room to a second cath lab and expanding our pre/post area. Our lab layout works very well; however, we are outgrowing the space. With an increase in case load and severity, a second lab would be beneficial, thus requiring the need for a larger pre/post area. Discussion has also begun on a state-of-the-art radial lounge. The radial lounge will allow for patient recovery in a more relaxed atmosphere, allowing patients to move about freely, watch television, surf the web on computers and recover in a reclining chair instead of a stretcher.

Do you have a hybrid cath lab, or are you planning to build one?

No, we are not looking for a hybrid lab at this time.

Is your lab involved in clinical research?

We are in early discussions for participating in atherectomy and stent trials for peripheral vascular disease. We are also in the process of establishing a full-time employed position for cath lab-based research and American College of Cardiology data collection for various quality control programs.

Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery?

No.

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?

Our hospital is registered with the American College of Cardiology’s D2B Alliance. We constantly strive to decrease our D2B time. For the past quarter, our average D2B time was 69 minutes. Recently, the cath lab nurses did an evidence-based project focusing on our call-out procedure. The call-out process was taking 12 minutes for communications to notify all on-call staff via phone. Our evidence showed a “one-call” system could simultaneously alert all staff with a single page. This would decrease the notification time from 12 minutes to less than 1 minute. We submitted our data to the ICU committee and cath lab medical director for approval. After implementation of our “one call” system, our D2B time decreased by 11 minutes. Additionally, East Baton Rouge Parish has just received a grant that provides all emergency medical services the ability to transmit electrocardiograms (EKGs) to the emergency department prior to the patient’s arrival. Our physicians also have the ability to view patients’ EKGs from their own computers.

What other modalities do you use to verify stenosis?

Our physicians utilize direct angiogram. Questionable lesions are quantified by the uses of IVUS and/or FFR. Pre-cath testing with CTA (computed tomography angiography) and ankle-brachial index have both been important screening tools used in identifying patients who might need further evaluation. 

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

Annually, contracts are renegotiated with our vendors to ensure the most competitive prices. Inventory is kept on consignment when possible. To decrease shipping costs, large-volume supplies are stocked in our on-site warehouse. The utilization of closure devices has been reduced. Staffing assignments have been adjusted to allow for maximum utilization of personnel.

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

We monitor and document radiation exposure for each patient. Monthly radiation exposure is measured and recorded on each staff and physician. D2B times, as well as antibiotic administration within one hour of incision for device implants, are documented and reviewed quarterly.

Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) or any other outside data collection registry?

Yes, our lab is a member of the American College of Cardiology National Cardiovascular Data Registry.

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

Our hospital serves the city of Zachary and the neighboring communities of Baker, Clinton, Central, St. Francisville, and southern Mississippi. Because of our unique location, many patients from our area choose Lane to provide medical care for themselves and their family instead of driving into Baton Rouge. Also, Lane has alliances with several outpatient clinics that refer to our hospital.

How are new employees oriented and trained at your facility?

The orientation process has recently been restructured by the nurses. Each new employee is paired with a preceptor for a minimum of 3 months. During this time, the orientee is trained in all aspects and jobs in the cath lab and pre/post area. The preceptor continues to serve as a “go-to” person for the orientee, even after the orientation process is complete. All staff is required to have an active state license as either a registered nurse (RN) or registered radiologic technologist (RT).  We currently have one nurse with less than one year of cath lab experience. He previously worked in our ICU. We also have one radiologic technologist with less than one year of cath lab experience. He previously was employed at another hospital and worked in MRI. Combined, our staff has over 50 years of cath lab experience.

What continuing education opportunities are provided to staff members?

Inservices for the cardiology staff are usually provided by our numerous vendors. Many offer free CEUs. Free continuing education is offered to all employees. Staff members also attend the New Cardiovascular Horizons Symposium every year, which is held in New Orleans, La. This is a comprehensive 4-day seminar on the latest theories, technologies and advances in cardiac and peripheral vascular care.

How do you handle vendor visits to your lab?

Vendors are required to call ahead of time and schedule appointments. They check in at the front desk and are required to wear a visitors badge at all times. Vendors are allowed in the lab at the discretion of the physician performing the procedure.

How is staff competency evaluated? 

Employee clinical competency is evaluated annually. This consists of a hospital-wide “BASH” week where each employee is re-certified in hospital-mandated competencies as well as those requiring specialties, such as use of the ACT machine and the glucometer. Employees also receive annual evaluations from their manager that take into consideration reviews from their peers. 

Does your lab have a clinical ladder?

The clinical ladder is available to all nurses. There is no specific clinical ladder for employees of the cath lab.

Does your lab utilize any alternative therapies (such as guided imagery, etc.)? 

Soft music is played at the request of the patient. Lighting in the cath lab can be adjusted to the patient’s satisfaction.

How does your lab handle call time for staff members?

All staff members are required to take call, an equivalent of every other week. Each call team consists of 2 RNs and 2 RTs.

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

All on-call staff is required to arrive at the hospital within 30 minutes of notification. The cardiologists are not always on site. If not, then they are expected to arrive within 30 minutes of their page.

Do you have flextime or multiple shifts?

No, but staffing times are occasionally adjusted to accommodate patients and the schedule.

Has your lab recently undergone a national accrediting agency inspection?

Our CT scan lab received CT accreditation in 2008 and is due for re-accreditation again this year. The cath lab was last surveyed by the Joint Commission in 2009.

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

The cath lab is located down the hall from the ED on the first floor. The OR is located on the second floor. 

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

We have established, in a short duration, a center of excellence in advanced coronary and complex endovascular care. We pride ourselves in providing world-class care, brought to a city which has lagged in adopting new invasive cardiology technologies. For the same reason, we are attracting patients from nearby states who are deemed to be high-risk interventions.

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

Our staff is truly unique; each member is trained to perform all tasks in the cath lab and pre/post recovery area. Larger hospitals have dedicated electrophysiology rooms, specials labs, etc. Our cardiology team is able to assist physicians with all these specialties in one lab.

For a new lab, the staff is exposed to best and latest technology and procedures. Staff appreciates the fact that for a single lab, Lane Cardiovascular Center offers highly advanced care, including use of a percutaneous left ventricular assist device.

Is there a problem or challenge your lab has faced?

Our hospital, like others around the country, has been forced to consider ways to cut or decrease costs while providing the same excellent care to our patients. We have been able to accomplish this at our hospital, and more specifically in our lab, through staffing adjustments, cross-training, and great leadership from our management team.

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 small-town cath lab sitting next to a fairly busy state capital. There are well-established hospitals and cath labs in the city that obviously compete for patients. We believe in the policy of providing the most advanced and current treatment to all patients. This leads to constant striving for excellence. The medical staff is highly complimentary towards the cath lab’s small but highly trained staff and we are always busy setting up safe systems of practice.

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

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?

Staff is not required to take the RCIS exam. Upon RCIS certification, the staff is compensated with a salary differential.

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?

No.

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

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

We use the NCDR to track our ICD insertions. This data is reviewed for proper indications and timely antibiotic administration. We plan to start us- ing NCDR data to track door-to-balloon times as well.

Eric Rome can be contacted at lsufans_2@cox.net.

Learn more about MDI and visit the website at www.modulardevices.com