Nacogdoches Medical Center

Can you tell us about your cath lab?

The Nacogdoches Medical Center cath lab facility has 1 room (we are a single lab), and we have 4 full-time and 4 part-time staff members. The mix of credentials at our lab consists of registered nurse (RN), radiologic technologist (RT), and licensed vocational nurse (LVN). These 8 staff members have experience ranging from one to 20 years. Nacogdoches Hospital is proud to have received the 2011 “Get with the Guidelines” Heart Failure Gold Performance Achievement Award. We are also a recipient of the American Heart Association’s 2010 “Get with the Guidelines” Heart Failure Silver Performance Achievement Award, 2009 “Get with the Guidelines” Coronary Artery Disease Silver Performance Achievement Award, 2009-2011 HealthGrades Cardiac Surgery Excellence Award and 2010-2011 HealthGrades Five Star Rated Coronary Bypass Surgery Award.

What procedures are done at your lab?

Procedures done in our lab include heart caths, coronary interventions, peripheral diagnostic interventions, intravascular ultrasound (IVUS), fractional flow reserve (FFR), cryoplasty, peripheral atherectomy, automated implantable cardioverter defibrillators (AICD), bi-ventricular device implants, pacemakers, inferior vena cava (IVC) filter implant and removal, the Trellis peripheral infusion system (Covidien, Mansfield, Mass.), abdominal aortic aneurysm (AAA) stenting, and renal stenting. We perform about 12 to 15 procedures in a week.

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

Angioplasties are routinely performed with a cardiovascular surgeon on standby.

What percentage of your patients is female?

Forty-eight percent (48%) of our patients are female.

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

Thirty-two percent (32%) of our diagnostic cath patients have nonobstructive coronary artery disease (CAD) less than 50% and 37% of our diagnostic cath patients have medical therapy and/or counseling.

Do any of your physicians routinely utilize transradial access?

Not at this time.

Who manages your cath lab?

Laurie Lee, RN, the cath lab supervisor, is responsible for the day-to-day operations and directly reports to Mark Burgess, the cath lab director.

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

We have cross-trained staff within their scope of practice. RTs and nurses have been trained to scrub, circulate, and monitor patients. All staff is required to have advanced cardiac life support (ACLS) certification and pass an electrocardiogram (EKG) test.

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

Yes.

Which personnel can operate the xray equipment (position the II, pan the table, change angles, step on the fluoro pedal) in your cath lab?

We cross-train for all positions, but only RTs and physicians are certified to execute fluoroscopy.

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

All of our personnel must wear a radiation badge. Lead aprons are closely monitored and traffic is controlled. Monthly reports are received with exposure levels as far as time, distance, and shielding.

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

A new cath lab was completed in the second quarter of 2009. The angiography system was upgraded to the Toshiba Infinix-I. We also utilize IVUS as a diagnostic tool and physiologic tool with an Intable Volcano system.

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

We are an intimate group that due to the small nature of our department, we work and communicate with each other on a day-to-day basis. Three staff members rotate call and are
available via pagers or cell phones. We have a monthly cardiology review meeting that involves all cardiologists, cardiovascular surgeons, hospital senior leadership, the cath lab director and the cath lab supervisor.

How is coding and coding education handled in your lab?

Staff members attended a coding seminar and the CPT update is reviewed annually. Coordination occurs between coding department and cath lab in order to accurately reflect the procedure.

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

Outpatients are prepared in the same day surgery area. Post procedure, patients are transferred to the PACU or ICU for recovery time. Hemostasis is managed by utilization of closure devices such as the Mynx (Access-Closure, Mountain View, Calif.) and Angio-Seal (St. Jude Medical, Minnetonka, Minn.). Manual compression hemostasis is assisted with the use of hemostatic bandages such as DStat (Vascular Solutions, Minneapolis, Minn.) and a femoral compression system (FemoStop, St. Jude Medical).

What is your lab’s hematoma management policy?

Staff is responsible for sheath removal. Staff members are required to complete additional training and must demonstrate competency by pulling 5 monitored sheaths. Cath lab staff is available to assist with any complications that develop post intervention. Complications are tracked and reported
to the cardiac review committee.

How is inventory managed at your cath lab?

Every team member plays a vital role in utilization. We have a computerized inventory system with established par levels. Daily supplies and equipment are managed through our inventory management system. Larger purchases or new equipment must go through a products committee that conducts a value analysis.

Has your cath lab recently expanded?

Although relocated and updated, we continue to operate with a single lab in close proximity to the CVOR. Our patient volume remains steady, with the intention to grow cardiac and peripheral services.

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?

No, we have not had any cath labrelated complications requiring surgery in the past year.

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

Yes. We contribute data to the Cath-PCI registry and ICD registry.

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?

Currently, our D2B time averages 47 minutes. Our shortest D2B time was 26 minutes. A STEMI algorithm was developed that outlines the process for activating the cath lab team for a STEMI or acute MI. Call team personnel, an RN and 2 RTs, have a required response time of 20 minutes or less. Once a page is placed, all personnel must call back within 5 minutes. This includes the interventional cardiologist. If applicable, EKGs are faxed from the field. Within our current system, 99% of the time patients experience a < 90-minute D2B time.

How does your lab handle call time for staff members?

Call is rotated on a biweekly basis; three team members must be on call at any one time. A minimum balance of credentials is necessary: the call team must consist of at least one RN and one RT.

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

Call team members must be onsite within 20 minutes of being notified. The attending cardiologist is not on site, but is expected to respond to calls within five minutes.

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

We have initiated a multi-disciplinary team that reviews the cost of implants, supplies and length of stay (LOS). We have negotiated tiered pricing on drug-eluting stents (DES) and limited the number of vendors. Implant costs are reviewed monthly and we have initiated a preapproval process for AICDs and cardiac resynchronization therapy (CRT) implants. We also do not allow new products to
be introduced without a value analysis committee review.

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

We have a monthly cardiac review meeting that conducts a retrospective review of 10% of each physician’s caseload, complications, and mortalities. Declared emergent cases, STEMIs, and case appropriateness are also reviewed by the committee.

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

Nacogdoches Medical Center has a multi-faceted approach to marketing the cardiac services at the hospital. We offer free educational seminars to the public and we actively promote through traditional and digital advertising campaigns such as billboards, newsletters, and social media. We try to involve our cardiologists in each of these approaches. Several of the practicing cardiologists have private cath labs for diagnostic procedures and admit their interventions to the hospital.

How are new employees oriented and trained at your facility?

New employees are trained by a preceptor with at least 2 years of cath lab experience. Competencies and skill checklists are utilized to guide a complete training process. We currently have one employee with less than a year of cath lab experience. The registered nurses all have critical care and CVICU experience. The RTs have a range of 4 to 20 years experience in the cath lab. RTs must, at a minimum, have a state medical radiologic technologist license, while RNs must have a current RN license and ACLS.

What continuing education opportunities are provided to staff members?

Online continuing education is provided through HealthStream (Nashville, Tenn.), vendor in-services and physicians also take an active role in providing education for the cath lab staff.

How do you handle vendor visits to your lab?

We have a very stringent vendor policy. Vendors must first be cleared by the cath lab director or supervisor. They must sign into and out of the hospital with materials management, and wear a vendor badge at all times. Vendors are not allowed to introduce new products without prior approval
from the value analysis committee.

How is staff competency evaluated?

Staff competency is evaluated during the orientation period. High-risk, low-volume procedures are reviewed annually.

Does your lab have a clinical ladder?

Not at this time.

Do you have flextime or multiple shifts?

We make every effort to meet the needs of the patients and physicians. When prescheduled we have the ability to begin cases prior to the 7:30 opening and beyond the 3:30 close. This is coordinated with the cathlab supervisor. We currently do not have the volume to support multiple shifts.

Has your lab has undergone a recent Joint Commission inspection?

In 2009, the cath lab was inspected and accredited during the Joint Commission’s hospital-wide tri-annual survey.

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

The cath lab is within the surgery area, “behind the red lines.” The emergency room, cath lab, and OR are all in close proximity on the main floor of the facility.

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

Patient trends seem to be leading to multiple co-morbidities, including obesity and diabetes. Some of our patient population is empowered with vast knowledge regarding their disease process and treatment options.

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

We are a small rural hospital that is full service in nature. Our staffing is accomplished with a minimal number of licensed professionals. Therefore, we must be extremely flexible and respectful
to ensure that we are able to provide the community with the necessary services.

Is there a challenge your lab has faced?

Limited staff poses unique staffing issues that must be equitably addressed and resolved within the staff ranks.

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”?

Nacogdoches is about 1.5 hours southwest of Shreveport, Louisiana, and almost 3 hours from both Dallas and Houston. Known as the “oldest town in Texas,” it is rich in history, culture, and tradition. We have a population of about 30,000 in town and 100,000 in the service area. We are a college town, with Stephen F. Austin State University providing the arts, music, and athletics that a town this size wouldn’t ordinarily offer. We are also a certified retirement community through the state of Texas, with an active, growing senior population. The 153-bed hospital is part of the Tenet Healthcare network and has over 30 sub-specialties. With the support of Tenet Healthcare, Nacogdoches Medical Center has the resources to provide similar advanced cardiac care of larger cities, allowing patients to have the comfort and convenience of being close to home for their cath lab procedure.

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?

No, we do not require or provide a bonus for achievement of the RCIS credential.

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?

The hospital participates in the Leapfrog Group, STS (Society for Thoracic Surgeons) National Database, and the ACC-NCDR.

The authors can be contacted at mark.burgess@tenethealth.com.

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 review the data at the cardiology service line meeting once a quarter. All of our PI/QI initiates have been developed as a result of the outcome indicators from the NCDR.