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Cath Lab Spotlight
Moses H. Cone Memorial Hospital Cardiac Cath Lab
Can you tell us about your cath lab?
The Moses H. Cone Memorial Hospital Cardiac Cath Lab has 6 cardiovascular labs, 1 
electrophysiology lab and 2 peripheral vascular labs. We have 50 staff members, including management, made up of a mix of nurses, radiologic technologists [RT(R)s], respiratory therapists (RRTs) and registered cardiovascular invasive specialist (RCIS)-certified staff. The number of years of employment ranges from over 20 years to 6 months. Both cardiologists and vascular surgeons use our cath labs.
What procedures are done at your lab?
The lab performs both diagnostic and interventional cardiac and peripheral procedures, as well as pericardial taps, pacemakers, ablations, cardioversions and tilt table procedures.
The number of procedures varies each week, but the average is around 100.
What procedures do you perform on an outpatient basis?
Diagnostic peripheral and cardiac catherizations are done as an outpatient procedure, as well as tilt table procedures.
Do any of your physicians routinely utilize transradial access?
We currently have 7 physicians using the transradial approach on certain patients and are beginning to use this approach on ST-elevation myocardial infarction (STEMI) patients that are stable enough.
What percentage of your patients is female?
The female patient population in the lab is approximately 30%.
What percentage of your diagnostic cath patients goes on to have an interventional procedure?
Approximately 60% of our patients receive an intervention of some kind, leaving about 40% of the cases untreated.
Who manages your cath lab?
The lab is managed by Sheryl Booth, RT(R), MHA, Director, Wally Reynolds, RN, MHA, Assistant Director, and Matt Blue, BSN, RCIS, Bryan Robinson, RCIS, and Rodney Cox, RRT, RCIS, all supervisors. Our electrophysiology (EP) lab supervisor is Tiffany Hunter, RT(R), RCIS, BS, NASPE.
Do you have cross-training? Who scrubs, who circulates and who monitors?
All employees are cross-trained in the lab to perform all positions.
Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab?
No, but the lab usually requires a nurse to be in the room 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?
The physicians are usually the ones to operate the x-ray equipment, but the tech that is scrubbed with the physician can also perform any of these procedures, if needed.
How does your cath lab handle radiation protection for the physicians and staff that are in the lab day after day?
The film badges are monitored monthly as well as the lead aprons checked on a yearly basis. Lead shields and aprons are also available in every room.
How does your lab communicate information to staff and physicians to stay organized and on top of change?
The main form of communicating pertinent information to staff and physicians is the use of intra-office email. We also have weekly staff meetings to discuss any changes or problems the lab is currently facing.
What are some of the new equipment, devices and products introduced at your lab lately?
The lab has just completed the implementation of the Witt documentation system (Philips Medical, Bothell, Wash.). Some of the products we have introduced include the Voyager NC coronary dilatation catheter (Abbott Vascular, Redwood City, Calif.), the Promus everolimus-eluting stent (Boston Scientific, Natick, Mass.) and the iSight intravascular ultrasound echo catheter (Boston Scientific) for vascular access.
Can you describe the system(s) you utilize?
The lab uses the Witt (Philips) system to record information, eChart to look up patient information such as lab values, Vericis (Emageon, Birmingham, Alabama) to look at previous exams and the Picis system (Picis, Wakefield, Mass.) to schedule exams.
The vendors that visit the cath lab are from Boston Scientific, Cordis, Medtronic, St. Jude, ev3 and Cook.
How is coding and coding education handled in your lab?
The director and the supply manager attend coding classes, and they enter the codes for the 
equipment and procedures. They also meet with the finance department on a regular basis to review changes and new codes. The department receives coding manuals that are updated yearly.
How does your lab handle hemostasis?
The lab uses both manual pressure along with Angio-Seal (St. Jude Medical, Minntonka, Minn.) and StarClose (Abbott Vascular) to achieve hemostasis. The patients return to their rooms, if admitted, where the nurse will monitor the status of their groin.
What is your lab’s hematoma management policy?
Any hematomas are dealt with upon discovery and the cardiologist is notified of any extreme cases. The patient is not released to the floor until the hematoma is resolved. We check all inpatients the next day as part of quality control.
How is inventory managed at your cath lab?
The supply manager handles the inventory in the lab and is responsible for purchasing the necessary supplies.
Has your cath lab recently expanded in size and patient volume, or will it be in the near future?
The lab recently moved the peripheral labs into the department, which added two additional rooms and an increase in patient volume.
Is your lab involved in clinical research?
We are currently participating the CHAMPION-PHOENIX trial that is comparing cangrelor to 
clopidogrel standard therapy in patients undergoing percutaneous coronary intervention (PCI). We are also participating in the INFUSE AMI trial, looking at the standard of care of using the ClearWay catheter (Atrium Medical, Hudson, New Hampshire) and/or Export aspiration catheter (Medtronic, Inc., Minnesota, Minn.), and the PEGASUS trial, which is a study of ticagrelor compared to placebo in outpatients that are 1 year out from an MI and not currently on clopidogrel.
Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery?
There have been a couple of complications over the past year for which the patient needed emergent surgery, but the results were successful.
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 average D2B time is around 45 minutes and can be attributed to the staff arriving within 30 minutes, and the cardiology fellows and emergency medical services (EMS) properly identifying the need for catherization.
Being located in North Carolina, does your facility participate in the RACE/RACE-ER statewide STEMI program?
The RACE program has been implemented at our facility and meets monthly to discuss any issues with the cases of the previous month. The team is comprised of the Director of the Heart and Vascular Center, representatives from the lab, the cath lab, the emergency department (ED) and the pharmacy. The local EMS facilities also attend the meetings. The information gathered from the cases is reported to the state and national Centers for Medicare & Medicaid Services (CMS) databases.
What other modalities do you use to verify stenosis?
The lab uses both the FloWire (Volcano Corp., Rancho Cordova, Calif.) and intravascular ultrasound to verify questionable stenoses.
What measures has your cath lab implemented in order to cut or contain costs?
We flex staff depending on the lab’s volume and negotiate vigorously with vendor contracts. The lab is also maintaining costs by eliminating some of the more expensive continuing education courses.
What quality control/quality assurance measures are practiced in your cath lab?
We perform QA on all medical equipment in the lab and also follow Joint Commission 
standards. Medication is checked monthly for expiration dates as well as checking the x-ray equipment in the call room before the case begins to ensure the room is working properly.
Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) or any other outside data collection registry?
We do use the ACC-NCDR to evaluate data for our RACE information, as well as data for congestive heart failure (CHF), Pacemakers and Infection Control.
How does your cath lab compete for patients? Has your institution formed an alliance with others in the area?
The hospital does not have any major competition in the area, because the closest hospital that performs angioplasty is approximately 20 minutes away and does not affect our business. The hospital has an alliance with other hospitals within a 40-mile radius that do not perform catheterizations.
How are new employees oriented and trained?
New employees must complete a 12-week training program that includes scrubbing, circulating, and monitoring before working on their own. At present, there are less than 5 employees in the lab that have been there for less than 1 year.
What continuing education opportunities are provided to staff members?
Vendors give in-services to staff members on a regular basis and there are also opportunities for courses staff can attend, schedule permitting.
How do you handle vendor visits to your lab?
The vendors have to schedule a day to be in the lab and can only go into the rooms if the physician requests it. They have special badges they must wear to differentiate themselves from the staff.
How is staff competency evaluated?
The staff is required to participate in competencies on a yearly basis, with their performance evaluated by senior staff members.
Does your lab have a clinical ladder?
We do not have a formal clinical ladder, but we do have certain staff members that do additional projects for the lab, including learning the new equipment in the lab and becoming a resource for other employees and adjusting the schedule for employees that are pursing higher education.
How does your lab handle call time for staff members?
The call schedule is currently over an 8-week period and a nurse has to be on every call team.
Within what time period are call team members expected to arrive to the lab after being paged?
The call team has 30 minutes to make it to the lab after the page has been sent out. The cardiology fellow is always at the hospital and the cardiologist is usually there before the call team arrives.
Do you have flex time or multiple shifts?
The lab has a 10-hour shift, which is 7am-5:30pm, and a 12-hour shift from 7am-7:30pm.
Does your cath lab do electives on weekends and or holidays?
The only procedures that are done on the weekends are emergent and the call team is responsible for performing them.
Has your lab has undergone a Joint Commission inspection in the past three years?
The lab is going through Joint Commission currently and any lab that is going through this inspection should maintain high standards year round so the actual inspection will not be stressful.
Where is your cath lab located in relation to the operating room (OR) and emergency room (ER)?
The operating room is right down the hall from the lab and the emergency room is one floor below the lab.
Can you describe your cath lab layout?
The average lab is 22x24 feet with an attached control room. Most of the rooms are user-friendly due to maneuverability. The supply room is not centrally located, meaning it can be time-consuming to retrieve equipment.
How do you see your cardiac catheterization laboratory changing over the next decade?
I think the number of catherizations will decrease in the next few years due to the increased use of medical therapy, but the number of acute cases will increase, because of the number of uninsured in the United States.
What is unique or innovative about your cath lab and its staff?
Our lab is unique in its camaraderie between the staff and physicians. We have a great support system that carries over into daily activities, as well as in acute situations.
Is there a problem or challenge your lab has faced?
One problem the lab faced recently was the lack of a salary re-evaluation. The problem was addressed to the hospital administration and was resolved.
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 South, the diet is not as healthy as it should be, and in turn, most of the patient population we care for is overweight. I think 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 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?
The staff is not required to take the exam, but points will be taken off the yearly evaluation if the exam has not been completed. New hires must sign a contract stating they will become RCIS-certified by the first year.
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?
All supervisors are RCIS-certified, but no one in management belongs to a professional organization at the present time.
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 reports are used to review areas of question and are used to support current practices, as well as a guide to change other practices that have a need for improvement. The data is evaluated during a quarterly cardiovascular quality meeting and by the RACE committee, and includes the STEMI performance data.
————————————————————
Beth Ferguson can be contacted at Beth.Ferguson@mosescone.com
electrophysiology lab and 2 peripheral vascular labs. We have 50 staff members, including management, made up of a mix of nurses, radiologic technologists [RT(R)s], respiratory therapists (RRTs) and registered cardiovascular invasive specialist (RCIS)-certified staff. The number of years of employment ranges from over 20 years to 6 months. Both cardiologists and vascular surgeons use our cath labs.
What procedures are done at your lab?
The lab performs both diagnostic and interventional cardiac and peripheral procedures, as well as pericardial taps, pacemakers, ablations, cardioversions and tilt table procedures.
The number of procedures varies each week, but the average is around 100.
What procedures do you perform on an outpatient basis?
Diagnostic peripheral and cardiac catherizations are done as an outpatient procedure, as well as tilt table procedures.
Do any of your physicians routinely utilize transradial access?
We currently have 7 physicians using the transradial approach on certain patients and are beginning to use this approach on ST-elevation myocardial infarction (STEMI) patients that are stable enough.
What percentage of your patients is female?
The female patient population in the lab is approximately 30%.
What percentage of your diagnostic cath patients goes on to have an interventional procedure?
Approximately 60% of our patients receive an intervention of some kind, leaving about 40% of the cases untreated.
Who manages your cath lab?
The lab is managed by Sheryl Booth, RT(R), MHA, Director, Wally Reynolds, RN, MHA, Assistant Director, and Matt Blue, BSN, RCIS, Bryan Robinson, RCIS, and Rodney Cox, RRT, RCIS, all supervisors. Our electrophysiology (EP) lab supervisor is Tiffany Hunter, RT(R), RCIS, BS, NASPE.
Do you have cross-training? Who scrubs, who circulates and who monitors?
All employees are cross-trained in the lab to perform all positions.
Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab?
No, but the lab usually requires a nurse to be in the room 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?
The physicians are usually the ones to operate the x-ray equipment, but the tech that is scrubbed with the physician can also perform any of these procedures, if needed.
How does your cath lab handle radiation protection for the physicians and staff that are in the lab day after day?
The film badges are monitored monthly as well as the lead aprons checked on a yearly basis. Lead shields and aprons are also available in every room.
How does your lab communicate information to staff and physicians to stay organized and on top of change?
The main form of communicating pertinent information to staff and physicians is the use of intra-office email. We also have weekly staff meetings to discuss any changes or problems the lab is currently facing.
What are some of the new equipment, devices and products introduced at your lab lately?
The lab has just completed the implementation of the Witt documentation system (Philips Medical, Bothell, Wash.). Some of the products we have introduced include the Voyager NC coronary dilatation catheter (Abbott Vascular, Redwood City, Calif.), the Promus everolimus-eluting stent (Boston Scientific, Natick, Mass.) and the iSight intravascular ultrasound echo catheter (Boston Scientific) for vascular access.
Can you describe the system(s) you utilize?
The lab uses the Witt (Philips) system to record information, eChart to look up patient information such as lab values, Vericis (Emageon, Birmingham, Alabama) to look at previous exams and the Picis system (Picis, Wakefield, Mass.) to schedule exams.
The vendors that visit the cath lab are from Boston Scientific, Cordis, Medtronic, St. Jude, ev3 and Cook.
How is coding and coding education handled in your lab?
The director and the supply manager attend coding classes, and they enter the codes for the 
equipment and procedures. They also meet with the finance department on a regular basis to review changes and new codes. The department receives coding manuals that are updated yearly.
How does your lab handle hemostasis?
The lab uses both manual pressure along with Angio-Seal (St. Jude Medical, Minntonka, Minn.) and StarClose (Abbott Vascular) to achieve hemostasis. The patients return to their rooms, if admitted, where the nurse will monitor the status of their groin.
What is your lab’s hematoma management policy?
Any hematomas are dealt with upon discovery and the cardiologist is notified of any extreme cases. The patient is not released to the floor until the hematoma is resolved. We check all inpatients the next day as part of quality control.
How is inventory managed at your cath lab?
The supply manager handles the inventory in the lab and is responsible for purchasing the necessary supplies.
Has your cath lab recently expanded in size and patient volume, or will it be in the near future?
The lab recently moved the peripheral labs into the department, which added two additional rooms and an increase in patient volume.
Is your lab involved in clinical research?
We are currently participating the CHAMPION-PHOENIX trial that is comparing cangrelor to 
clopidogrel standard therapy in patients undergoing percutaneous coronary intervention (PCI). We are also participating in the INFUSE AMI trial, looking at the standard of care of using the ClearWay catheter (Atrium Medical, Hudson, New Hampshire) and/or Export aspiration catheter (Medtronic, Inc., Minnesota, Minn.), and the PEGASUS trial, which is a study of ticagrelor compared to placebo in outpatients that are 1 year out from an MI and not currently on clopidogrel.
Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery?
There have been a couple of complications over the past year for which the patient needed emergent surgery, but the results were successful.
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 average D2B time is around 45 minutes and can be attributed to the staff arriving within 30 minutes, and the cardiology fellows and emergency medical services (EMS) properly identifying the need for catherization.
Being located in North Carolina, does your facility participate in the RACE/RACE-ER statewide STEMI program?
The RACE program has been implemented at our facility and meets monthly to discuss any issues with the cases of the previous month. The team is comprised of the Director of the Heart and Vascular Center, representatives from the lab, the cath lab, the emergency department (ED) and the pharmacy. The local EMS facilities also attend the meetings. The information gathered from the cases is reported to the state and national Centers for Medicare & Medicaid Services (CMS) databases.
What other modalities do you use to verify stenosis?
The lab uses both the FloWire (Volcano Corp., Rancho Cordova, Calif.) and intravascular ultrasound to verify questionable stenoses.
What measures has your cath lab implemented in order to cut or contain costs?
We flex staff depending on the lab’s volume and negotiate vigorously with vendor contracts. The lab is also maintaining costs by eliminating some of the more expensive continuing education courses.
What quality control/quality assurance measures are practiced in your cath lab?
We perform QA on all medical equipment in the lab and also follow Joint Commission 
standards. Medication is checked monthly for expiration dates as well as checking the x-ray equipment in the call room before the case begins to ensure the room is working properly.
Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) or any other outside data collection registry?
We do use the ACC-NCDR to evaluate data for our RACE information, as well as data for congestive heart failure (CHF), Pacemakers and Infection Control.
How does your cath lab compete for patients? Has your institution formed an alliance with others in the area?
The hospital does not have any major competition in the area, because the closest hospital that performs angioplasty is approximately 20 minutes away and does not affect our business. The hospital has an alliance with other hospitals within a 40-mile radius that do not perform catheterizations.
How are new employees oriented and trained?
New employees must complete a 12-week training program that includes scrubbing, circulating, and monitoring before working on their own. At present, there are less than 5 employees in the lab that have been there for less than 1 year.
What continuing education opportunities are provided to staff members?
Vendors give in-services to staff members on a regular basis and there are also opportunities for courses staff can attend, schedule permitting.
How do you handle vendor visits to your lab?
The vendors have to schedule a day to be in the lab and can only go into the rooms if the physician requests it. They have special badges they must wear to differentiate themselves from the staff.
How is staff competency evaluated?
The staff is required to participate in competencies on a yearly basis, with their performance evaluated by senior staff members.
Does your lab have a clinical ladder?
We do not have a formal clinical ladder, but we do have certain staff members that do additional projects for the lab, including learning the new equipment in the lab and becoming a resource for other employees and adjusting the schedule for employees that are pursing higher education.
How does your lab handle call time for staff members?
The call schedule is currently over an 8-week period and a nurse has to be on every call team.
Within what time period are call team members expected to arrive to the lab after being paged?
The call team has 30 minutes to make it to the lab after the page has been sent out. The cardiology fellow is always at the hospital and the cardiologist is usually there before the call team arrives.
Do you have flex time or multiple shifts?
The lab has a 10-hour shift, which is 7am-5:30pm, and a 12-hour shift from 7am-7:30pm.
Does your cath lab do electives on weekends and or holidays?
The only procedures that are done on the weekends are emergent and the call team is responsible for performing them.
Has your lab has undergone a Joint Commission inspection in the past three years?
The lab is going through Joint Commission currently and any lab that is going through this inspection should maintain high standards year round so the actual inspection will not be stressful.
Where is your cath lab located in relation to the operating room (OR) and emergency room (ER)?
The operating room is right down the hall from the lab and the emergency room is one floor below the lab.
Can you describe your cath lab layout?
The average lab is 22x24 feet with an attached control room. Most of the rooms are user-friendly due to maneuverability. The supply room is not centrally located, meaning it can be time-consuming to retrieve equipment.
How do you see your cardiac catheterization laboratory changing over the next decade?
I think the number of catherizations will decrease in the next few years due to the increased use of medical therapy, but the number of acute cases will increase, because of the number of uninsured in the United States.
What is unique or innovative about your cath lab and its staff?
Our lab is unique in its camaraderie between the staff and physicians. We have a great support system that carries over into daily activities, as well as in acute situations.
Is there a problem or challenge your lab has faced?
One problem the lab faced recently was the lack of a salary re-evaluation. The problem was addressed to the hospital administration and was resolved.
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 South, the diet is not as healthy as it should be, and in turn, most of the patient population we care for is overweight. I think 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 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?
The staff is not required to take the exam, but points will be taken off the yearly evaluation if the exam has not been completed. New hires must sign a contract stating they will become RCIS-certified by the first year.
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?
All supervisors are RCIS-certified, but no one in management belongs to a professional organization at the present time.
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 reports are used to review areas of question and are used to support current practices, as well as a guide to change other practices that have a need for improvement. The data is evaluated during a quarterly cardiovascular quality meeting and by the RACE committee, and includes the STEMI performance data.
————————————————————
Beth Ferguson can be contacted at Beth.Ferguson@mosescone.com
