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Cath Lab Spotlight
Maury Regional Medical Center
Can you tell us about your cath lab?
Maury Regional Medical Center (MRMC) is a 250-bed facility serving an eight-county region in middle Tennessee. Maury Regional Medical Center Outpatient Cardiology includes two cardiac cath labs, both of which are capable of performing radiologic procedures and implantable rhythm management devices. The lab also includes a 5-bed holding area located within the department.
Staff consists of:
We provide services for five cardiologists, including four interventional cardiologists, 1 electrophysiologist and 1 physician assistant. All physicians are board-certified in cardiovascular medicine and most are fellowship-trained in interventional cardiology. We have one pulmonologist specializing in pulmonary hypertension.
What procedures are done at your lab?
We perform cardiac and peripheral diagnostic and interventional procedures, implantation of cardiac rhythm management devices (CRMs), transesophageal echocardiograms (TEEs), and cardioversions.
On average, we perform 40 cardiac catheterizations per week and 15 interventional procedures. We perform around two peripheral procedures and approximately three pacemaker(PM)/implantable cardioverter defibrillator (ICD) insertions per week.
Do any of your physicians routinely utilize transradial access?
Yes. We started our radial program late 2009. Currently 80% of our cases are being performed via the radial approach.
What percentage of your patients is female?
The female patient population in the lab is approximately 45%.
What percentage of your diagnostic cath patients goes on to have an interventional procedure?
Twenty-two percent (22%) are interventional and 52% are normal or treated medically.
Who manages your cath lab?
Valerie Yeiser, RN, BSN, CCRN is the manager of outpatient cardiology, which includes the cardiac cath lab, cardiac diagnostic testing and cardiopulmonary rehab. Kevin Maquiling, MD, is the medical director of the cardiac cath lab.
Do you have cross-training? Who scrubs, who circulates and who monitors?
Yes. RNs cross-train to scrub, monitor and circulate, and RTs cross-train to scrub and monitor.
Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab?
No, we do not always have RT present in lab for 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?
Staff members who have been trained to scrub can position the image intensifier (II)/ flat detectors, pan the table and change the angles under the cardiologists’ direction. The cardiologists operate the fluoro and cine pedals.
How does your cath lab handle radiation protection for the physicians and staff that are in the lab day after day?
All staff and physicians wear a film badge. These are monitored thru Landauer (Glenwood, Ill.). We have a radioisotopes committee meeting regularly to review overexposures. Lead aprons, glasses, and shields are checked on a routine basis.
How does your lab communicate information to staff and physicians to stay organized and on top of change?
Staff meetings are held within each department on a monthly basis. Any procedural changes, concerns, and/or case reviews are done at this time. The cath lab medical director meets quarterly with the staff to discuss upcoming changes, voice concerns and educate the staff on new technology or procedures as the need arises. The cath lab manager meets with the cardiovascular advisory group, which consists of the cardiovascular service line director, cardiologist, emergency department medical director, chest pain center coordinator, and quality assurance managers, every other month to facilitate opportunities for improvement between departments.
What are some of the new equipment, devices and products introduced at your lab lately?
Intravascular ultrasound (IVUS) is available in our lab (iLab, Boston Scientific, Natick, Mass.). The Diamondback (CSI, Inc., St. Paul, Minn.) atherectomy system is used for peripheral cases. Fractional flow reserve (FFR) (PressureWire, St. Jude Medical, Minnetonka, Minn.), and the Xience V everolimus-eluting stent (Abbott Vascular, Redwood City, Calif.) are being successfully used in our lab. For our radial cases, we use the Terumo radial access kit, as well as the TR Band (Terumo Corp., Somerset, New Jersey) for the sheath pull. We currently use 90% Medtronic PM/ICD devices (Minneapolis, Minn.).
How is coding and coding education handled in your lab?
Coding is managed by our coding department, with collaboration and review by the nurse manager, coder and finance. The cath lab staff is very involved in the charging process and reviews charges daily.
How does your lab handle hemostasis?
In our lab, we do use vascular closure devices such as Perclose (Abbott Vascular) and Angio-Seal (St. Jude Medical). When manual pressure is required, we use the SyvekPatch (Marine Polymer Technologies, Danvers, MA), and the TR Band is used for radial procedures. Post-procedure patients are managed for 15 minutes in cath lab before being transferred to critical care or a stepdown unit. Outpatients are recovered in the holding area prior to being discharged home. At times, we employ a FemoStop device (St. Jude Medical), usually for intra-aortic balloon pump (IABP) removal or persistent bleeding.
What is your lab’s hematoma management policy?
If a hematoma is noted, manual pressure is applied. Once hematoma is controlled, the size is documented along with distal pulses and assessment data. High-risk patients are transferred to critical care for further monitoring.
How is inventory managed at your cath lab?
We currently utilize the Pyxis system (CareFusion, San Diego, Calif.). Purchasing of equipment and supplies involves a physician and the manager to present new items to the hospital’s Products Committee for review and approval. Staff monitor inventory levels and communicate with materials management, who reorder supplies.
Has your cath lab recently expanded in size and patient volume?
Volume has slightly increased and we are seeing more critically ill patients than in the past. We do plan to add an electrophysiology (EP) program.
Is your lab involved in clinical research?
Not at this time.
Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery?
Our average emergent cath-related complication rate is less than 1%.
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 current door-to-balloon time average is 63 minutes. MRMC’s D2B goal was lowered to 75 minutes in July 2009. MRMC is an accredited cycle III chest pain center with percutaneous coronary intervention (PCI). The chest pain center committee, which includes front-line staff and managers from the ED, emergency medical services (EMS), cath lab, pharmacy, lab, cardiologist, ED physicians, air ambulance, quality assurance, Mended Hearts volunteers (www.mendedhearts.org), and the hospitalist group, meets monthly to discuss metrics, case reviews and opportunities for improvement. MRMC paramedics call ST-elevation myocardial infarctions (STEMIs) from the field and activate the cath team and cardiologist. The ED has a STEMI kit that contains all supplies and medications to expedite the care of the STEMI patient through the ED to the cath lab. The ED also has a red STEMI folder that has the four forms needed by everyone. ED, EMS and cath lab staff participates in mock drills throughout the year to look for areas of improvement. Our chest pain center coordinator is a resource for the surrounding city hospitals and EMS. She follows all STEMI patients and reports back to the transferring facility and EMS. These are just some of the tools that have been instrumental in helping us achieve our goals, decrease our D2B times, and provide excellent care to our patients.
What measures has your cath lab implemented in order to cut or contain costs?
We are continuously evaluating our procedure codes and charges. We work with our materials management to keep supply cost down. Nurse auditors review our charts for correct codes and charges. All procedures are reviewed to determine revenue compared to cost. This information is shared with physicians along with cath lab financial updates. Staffing productivity is also monitored closely. Cost containment is implemented when volumes are low.
What quality control/quality assurance measures are practiced in your cath lab?
The STEMI program or D2B time core measure is our most aggressive quality measure.
The department also participates in an outpatient surgical infection quality measure for pre-procedural antibiotic administration.
Maury Regional Hospital has also been awarded the Bronze Performance Achievement Award for heart failure by the American Heart Association.
The lab participates in American College of Cardiology (ACC) National Cardiovascular Data Registry for cath, PCI, and defibrillator data collection and analysis.
Outpatients receive a follow-up phone call to check recovery status and ensure they understand discharge instructions.
The staff rounds on inpatients to assess access sites and answer any post procedural questions.
Inpatient MI is also being reviewed. We utilize a CAT (Critical Access Team) for inpatient chest pain.
How does your cath lab compete for patients? Has your institution formed an alliance with others in the area?
Maury Regional Medical Center is an Accredited Chest Pain Center.
The hospital has been recognized with the following awards:
ED is located on the ground floor, cath lab on the first floor and OR on the second floor.
How do you see your cardiac catheterization laboratory changing over the next few years?
We plan to add an EP lab, and expect increased radial procedures and peripheral procedures.
What is unique or innovative about your cath lab and its staff?
The staff and cardiologists truly have a passion for their profession, their hospital, and in working with each other. The staff and cardiologists work very well together. Each member brings a special skill to the team.
As a result of our continuous monitoring of quality measures (D2B times, inpatient MIs, surgical infection rates) and patient satisfaction scores, we have put processes in place to ensure excellent patient care.
Maury Regional Medical Center is also unique in that we have one cardiology group that is very dedicated to cardiology services in the hospital. The group covers all cardiac-related consults for both inpatients and referrals. They read all stress tests, EKGs and echos performed in the facility. The cardiologists also provide coverage for the CardioPulmonary Rehab department.
Is there a problem or challenge your lab has faced?
Being a community hospital, it is a challenge to stay competitive with larger metropolitan medical centers within our area. Maury Regional Medical Center has addressed this challenge by striving to be the best, not only in our region or state, but the best in the country. Our motto is “Extraordinary People, Extraordinary Care.”
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”?
Being in the southern U.S., the diet is not as healthy as it should be, and in turn, most of the patient population we care for is overweight. A healthier city would see fewer patients, but there is only so much exercise one can do; ultimately, it is all about the genes.
The following two questions are courtesy of the Society of Invasive Cardiovascular Professionals (SICP):
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?
No, the exam is not required. If staff chooses to take the exam and become registered, incentives are available.
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?
We do have one team member involved with the SICP.
New! A question from the National Cardiovascular Data Registry:
How do you use the NCDR Outcome Reports to drive QI initiatives at your facility?
The NCDR reports are reviewed quarterly with the staff and with the cardiologists. It is also discussed in our Chest Pain Committee meetings. This data provides a guide for best practice. Even though we review every STEMI case, this data drives our quality initiatives. Specifically, the team has worked on decreasing the door-to-balloon times, arrival time for STEMIs from transferring facility, decreasing post procedure complications, and decreasing patient length of stay.
*RCVT is the previous name for the registered cardiovascular invasive specialist (RCIS) credential offered by Cardiovascular Credentialing International.
Valerie Yeiser can be contacted at vyeiser@mauryregional.com
Maury Regional Medical Center (MRMC) is a 250-bed facility serving an eight-county region in middle Tennessee. Maury Regional Medical Center Outpatient Cardiology includes two cardiac cath labs, both of which are capable of performing radiologic procedures and implantable rhythm management devices. The lab also includes a 5-bed holding area located within the department.
Staff consists of:
- Six full-time registered nurses (RNs)
- One cardiovascular radiologic technologists (CVRT)
- One registered cardiovascular technologist/registered cardiovascular invasive specialist (RCVT*/RCIS)
- One licensed practical nurse (LPN)/paramedic/ scrub tech
We provide services for five cardiologists, including four interventional cardiologists, 1 electrophysiologist and 1 physician assistant. All physicians are board-certified in cardiovascular medicine and most are fellowship-trained in interventional cardiology. We have one pulmonologist specializing in pulmonary hypertension.
What procedures are done at your lab?
We perform cardiac and peripheral diagnostic and interventional procedures, implantation of cardiac rhythm management devices (CRMs), transesophageal echocardiograms (TEEs), and cardioversions.
On average, we perform 40 cardiac catheterizations per week and 15 interventional procedures. We perform around two peripheral procedures and approximately three pacemaker(PM)/implantable cardioverter defibrillator (ICD) insertions per week.
Do any of your physicians routinely utilize transradial access?
Yes. We started our radial program late 2009. Currently 80% of our cases are being performed via the radial approach.
What percentage of your patients is female?
The female patient population in the lab is approximately 45%.
What percentage of your diagnostic cath patients goes on to have an interventional procedure?
Twenty-two percent (22%) are interventional and 52% are normal or treated medically.
Who manages your cath lab?
Valerie Yeiser, RN, BSN, CCRN is the manager of outpatient cardiology, which includes the cardiac cath lab, cardiac diagnostic testing and cardiopulmonary rehab. Kevin Maquiling, MD, is the medical director of the cardiac cath lab.
Do you have cross-training? Who scrubs, who circulates and who monitors?
Yes. RNs cross-train to scrub, monitor and circulate, and RTs cross-train to scrub and monitor.
Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab?
No, we do not always have RT present in lab for 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?
Staff members who have been trained to scrub can position the image intensifier (II)/ flat detectors, pan the table and change the angles under the cardiologists’ direction. The cardiologists operate the fluoro and cine pedals.
How does your cath lab handle radiation protection for the physicians and staff that are in the lab day after day?
All staff and physicians wear a film badge. These are monitored thru Landauer (Glenwood, Ill.). We have a radioisotopes committee meeting regularly to review overexposures. Lead aprons, glasses, and shields are checked on a routine basis.
How does your lab communicate information to staff and physicians to stay organized and on top of change?
Staff meetings are held within each department on a monthly basis. Any procedural changes, concerns, and/or case reviews are done at this time. The cath lab medical director meets quarterly with the staff to discuss upcoming changes, voice concerns and educate the staff on new technology or procedures as the need arises. The cath lab manager meets with the cardiovascular advisory group, which consists of the cardiovascular service line director, cardiologist, emergency department medical director, chest pain center coordinator, and quality assurance managers, every other month to facilitate opportunities for improvement between departments.
What are some of the new equipment, devices and products introduced at your lab lately?
Intravascular ultrasound (IVUS) is available in our lab (iLab, Boston Scientific, Natick, Mass.). The Diamondback (CSI, Inc., St. Paul, Minn.) atherectomy system is used for peripheral cases. Fractional flow reserve (FFR) (PressureWire, St. Jude Medical, Minnetonka, Minn.), and the Xience V everolimus-eluting stent (Abbott Vascular, Redwood City, Calif.) are being successfully used in our lab. For our radial cases, we use the Terumo radial access kit, as well as the TR Band (Terumo Corp., Somerset, New Jersey) for the sheath pull. We currently use 90% Medtronic PM/ICD devices (Minneapolis, Minn.).
How is coding and coding education handled in your lab?
Coding is managed by our coding department, with collaboration and review by the nurse manager, coder and finance. The cath lab staff is very involved in the charging process and reviews charges daily.
How does your lab handle hemostasis?
In our lab, we do use vascular closure devices such as Perclose (Abbott Vascular) and Angio-Seal (St. Jude Medical). When manual pressure is required, we use the SyvekPatch (Marine Polymer Technologies, Danvers, MA), and the TR Band is used for radial procedures. Post-procedure patients are managed for 15 minutes in cath lab before being transferred to critical care or a stepdown unit. Outpatients are recovered in the holding area prior to being discharged home. At times, we employ a FemoStop device (St. Jude Medical), usually for intra-aortic balloon pump (IABP) removal or persistent bleeding.
What is your lab’s hematoma management policy?
If a hematoma is noted, manual pressure is applied. Once hematoma is controlled, the size is documented along with distal pulses and assessment data. High-risk patients are transferred to critical care for further monitoring.
How is inventory managed at your cath lab?
We currently utilize the Pyxis system (CareFusion, San Diego, Calif.). Purchasing of equipment and supplies involves a physician and the manager to present new items to the hospital’s Products Committee for review and approval. Staff monitor inventory levels and communicate with materials management, who reorder supplies.
Has your cath lab recently expanded in size and patient volume?
Volume has slightly increased and we are seeing more critically ill patients than in the past. We do plan to add an electrophysiology (EP) program.
Is your lab involved in clinical research?
Not at this time.
Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery?
Our average emergent cath-related complication rate is less than 1%.
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 current door-to-balloon time average is 63 minutes. MRMC’s D2B goal was lowered to 75 minutes in July 2009. MRMC is an accredited cycle III chest pain center with percutaneous coronary intervention (PCI). The chest pain center committee, which includes front-line staff and managers from the ED, emergency medical services (EMS), cath lab, pharmacy, lab, cardiologist, ED physicians, air ambulance, quality assurance, Mended Hearts volunteers (www.mendedhearts.org), and the hospitalist group, meets monthly to discuss metrics, case reviews and opportunities for improvement. MRMC paramedics call ST-elevation myocardial infarctions (STEMIs) from the field and activate the cath team and cardiologist. The ED has a STEMI kit that contains all supplies and medications to expedite the care of the STEMI patient through the ED to the cath lab. The ED also has a red STEMI folder that has the four forms needed by everyone. ED, EMS and cath lab staff participates in mock drills throughout the year to look for areas of improvement. Our chest pain center coordinator is a resource for the surrounding city hospitals and EMS. She follows all STEMI patients and reports back to the transferring facility and EMS. These are just some of the tools that have been instrumental in helping us achieve our goals, decrease our D2B times, and provide excellent care to our patients.
What measures has your cath lab implemented in order to cut or contain costs?
We are continuously evaluating our procedure codes and charges. We work with our materials management to keep supply cost down. Nurse auditors review our charts for correct codes and charges. All procedures are reviewed to determine revenue compared to cost. This information is shared with physicians along with cath lab financial updates. Staffing productivity is also monitored closely. Cost containment is implemented when volumes are low.
What quality control/quality assurance measures are practiced in your cath lab?
The STEMI program or D2B time core measure is our most aggressive quality measure.
The department also participates in an outpatient surgical infection quality measure for pre-procedural antibiotic administration.
Maury Regional Hospital has also been awarded the Bronze Performance Achievement Award for heart failure by the American Heart Association.
The lab participates in American College of Cardiology (ACC) National Cardiovascular Data Registry for cath, PCI, and defibrillator data collection and analysis.
Outpatients receive a follow-up phone call to check recovery status and ensure they understand discharge instructions.
The staff rounds on inpatients to assess access sites and answer any post procedural questions.
Inpatient MI is also being reviewed. We utilize a CAT (Critical Access Team) for inpatient chest pain.
How does your cath lab compete for patients? Has your institution formed an alliance with others in the area?
Maury Regional Medical Center is an Accredited Chest Pain Center.
The hospital has been recognized with the following awards:
- Leadership Award for Clinical Excellence for CHF
- Achievement Award by TNCPE, 2007
- Bronze Performance Award by American Stroke Association, 2007
- Top 100 Hospitals by Thomson Healthcare, 2008
- Achievement Award by TNCPE, 2008
- PRC 4-Star Award by PRC, 2007 & 2008
- Bob Thomas Advanced Life Support Award by Tennessee Ambulance Association, 2008
- EMS Star of Life Award by Tennessee Emergency Medical Services, 2009
- Premier Award for Quality by Premier Healthcare Alliance, 2009
- Silver Performance Award by American Heart Association, 2010, for heart failure
- Top 50 Heath Systems by Thomson Healthcare, 2009
- Excellence Award by TNCPE, 2009
- Top 100 Hospitals by Thomson Reuters, 2010
- Premier Award for Quality by Premier Healthcare Alliance, 2010
ED is located on the ground floor, cath lab on the first floor and OR on the second floor.
How do you see your cardiac catheterization laboratory changing over the next few years?
We plan to add an EP lab, and expect increased radial procedures and peripheral procedures.
What is unique or innovative about your cath lab and its staff?
The staff and cardiologists truly have a passion for their profession, their hospital, and in working with each other. The staff and cardiologists work very well together. Each member brings a special skill to the team.
As a result of our continuous monitoring of quality measures (D2B times, inpatient MIs, surgical infection rates) and patient satisfaction scores, we have put processes in place to ensure excellent patient care.
Maury Regional Medical Center is also unique in that we have one cardiology group that is very dedicated to cardiology services in the hospital. The group covers all cardiac-related consults for both inpatients and referrals. They read all stress tests, EKGs and echos performed in the facility. The cardiologists also provide coverage for the CardioPulmonary Rehab department.
Is there a problem or challenge your lab has faced?
Being a community hospital, it is a challenge to stay competitive with larger metropolitan medical centers within our area. Maury Regional Medical Center has addressed this challenge by striving to be the best, not only in our region or state, but the best in the country. Our motto is “Extraordinary People, Extraordinary Care.”
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”?
Being in the southern U.S., the diet is not as healthy as it should be, and in turn, most of the patient population we care for is overweight. A healthier city would see fewer patients, but there is only so much exercise one can do; ultimately, it is all about the genes.
The following two questions are courtesy of the Society of Invasive Cardiovascular Professionals (SICP):
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?
No, the exam is not required. If staff chooses to take the exam and become registered, incentives are available.
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?
We do have one team member involved with the SICP.
New! A question from the National Cardiovascular Data Registry:
How do you use the NCDR Outcome Reports to drive QI initiatives at your facility?
The NCDR reports are reviewed quarterly with the staff and with the cardiologists. It is also discussed in our Chest Pain Committee meetings. This data provides a guide for best practice. Even though we review every STEMI case, this data drives our quality initiatives. Specifically, the team has worked on decreasing the door-to-balloon times, arrival time for STEMIs from transferring facility, decreasing post procedure complications, and decreasing patient length of stay.
*RCVT is the previous name for the registered cardiovascular invasive specialist (RCIS) credential offered by Cardiovascular Credentialing International.
Valerie Yeiser can be contacted at vyeiser@mauryregional.com
