Owensboro Medical Health System

What is the size of your cath lab facility and number of staff members? Owensboro Medical Health System serves an 11-county region in western Kentucky and southern Indiana. The hospital’s mission is to heal the sick and improve the health of the community, with a vision to meet the region’s healthcare needs by actively listening and partnering with those it serves. OMHS is a full-service hospital, employing a workforce of over 3,200. OMHS is one of only 270 hospitals to receive the HealthGrades Distinguished Hospital for Clinical Excellence Award™, placing us in the top 5% of hospitals in the nation for quality. This distinction is based on an independent study released on January 27, 2009, by HealthGrades. OMHS is one of only five Kentucky hospitals to receive this distinction for 2009. In the OMHS Heart Center, we have three cath labs, two of which are cardiovascular labs, and one of which is an electrophysiology (EP)/cardiac lab. The cath lab staff consists of 13 full-time registered nurses (RNs), 11 full-time radiologic technologists (RTs), 1 scheduling secretary and 2 holding room technicians. We provide services for 10 cardiologists, including eight interventionalists and two electrophysiologists. All physicians are board-certified in cardiovascular medicine and most are fellowship-trained in interventional cardiology. Roshan Mathew, MD, FACC, FACP, serves as medical director for the OMHS cath lab. What type of procedures are performed at your facility? We perform both cardiac and peripheral diagnostic and interventional procedures, as well as electrophysiology procedures. We start our first cases at 7:00 am and are staffed until 11:00 pm Monday through Friday, with the last scheduled case starting by 9:00 pm. Last fiscal year we did 2,635 cardiac procedures, 432 peripheral procedures and 538 EP or device implant procedures. Does your cath lab perform primary angioplasty with surgical backup on site? Yes. Surgical back-up is typically informal, without a specific room or surgeon held for a specific case; however, the cardiologist may request formal back-up if they desire for a particular case. What procedures do you perform on an outpatient basis? We have a seven-bed pre- and post-procedure unit in the Heart Center which provides care for 12 to 15 of our patients daily, depending on length of stay post procedure. Diagnostic caths and generator replacements are often done as outpatient. Approximately 55% of our patients spend the night in an inpatient bed, but go home the next morning, maintaining an outpatient status. Do interventional radiologists and cardiologists perform procedures in the same area? Cardiologists perform all of our peripheral diagnostic and interventional procedures. They are assisted by a three-person team of RNs and RTs – either mix. We no longer have a special procedures lab at OMHS. Our radiologists do not do any interventional work. Who manages your cath lab? Sharon Graybill, RT, is the clinical supervisor of the OMHS cath lab. She has worked in the cath lab for 25 years. She coordinates the staff assignments and the flow of patients through the department, as well as coordinating our supply inventory and charge capture processes. Ronda Rodgers, RN, BSN, is the Heart Center manager, which includes the cath lab, electrodiagnostics and Heart Center recovery. She has been in this role for 14 years. Do you have cross-training? Who scrubs, who circulates and who monitors? Yes. All RNs and RTs cross-train the scrub and monitoring/charting roles. The RNs give all medications and the RTs do all the panning. Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab? Yes. An RT must be present for any procedure requiring operation of the x-ray equipment. 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? Only the RTs position the image intensifier (II)/flat detectors, pan the table, and change the angles. Only 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 are provided and expected to wear film badges. These are monitored through Landauer (Glenwood, IL) and reports are presented monthly through our radiation safety committee. We do area monitoring as well. Staff members and physicians are also provided and expected to wear lead vests and aprons, thyroid collars and lead glasses as appropriate. Each room has lead skirting on the table and an adjustable lead shield on a boom. Lead doors are also present for the sedation nurse to utilize. How does your lab communicate information to staff and physicians to stay organized and on top of constant change? We maintain a “Read & Sign” communication book for routine memos the staff needs to review. Information that needs to be seen immediately is posted just outside the control room on the door to the physicians’ changing room. Acute myocardial infarction door-to-balloon time results are posted there — resulting in some competition among call teams! Quality reports are distributed to the physicians at their cardiac department meetings. The clinical supervisor communicates any supply changes, location changes or practice changes to the staff members one-on-one, utilizing a staff roster to be sure everyone gets the information. What are some of the new equipment, devices and products introduced at your lab lately? We have recently added Volcano Corporation’s (San Diego, CA) integrated intravascular ultrasound (IVUS) in each cath lab. We have upgraded the x-ray equipment in our EP/cardiac room to a GE Innova 2100 (GE Medical, Waukesha, WI). We utilize the Acist device (Acist Medical Systems, Inc., Eden Prairie, MN) for contrast delivery in each cath lab. We are now doing patent foramen ovale (PFO) closures and carotid stenting in the cath lab. We have also recently completed training and begun actively implanting the Abiomed Impella 2.5 circulatory assist device (Danvers, MA), enabling us to successfully tie in both surgeons and interventional cardiologists for a collaborative approach to bypass surgery, as well as high-risk angioplasty. We have recently upgraded our EP recording system, and have added a Carto XP Mapping and Navigation System (Biosense Webster, Inc., a Johnson & Johnson company, Diamond Bar, CA). Do any of your physicians utilize transradial access? One of our interventional cardiologists utilizes transradial access frequently with excellent results. How does your lab handle hemostasis? This varies depending on the case and the physician — we do some manual pulls in the cath lab, and some are pulled in the Heart Center recovery unit. We have recently begun using the D-Stat Dry pad (Vascular Solutions, Inc., Minneapolis, MN) with manual pulls. Some of the cardiologists do utilize vascular closure devices — primarily Angio-Seal (St. Jude Medical, Minnetonka, MN), with an occasional Mynx closure (Access-Closure, Inc., Mountain View, CA). How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies? We utilize Omnicell (Mountain View, CA) for 99% of the cath lab inventory. The supervisor prints daily usage reports and reorders the disposable supplies accordingly, to maintain minimal par levels. We have overnight delivery arrangements with most vendors. The manager coordinates the selection and purchasing of all capital equipment. How is coding and coding education handled in your lab? Coding is done by the coding department. All cath lab staff members are taught by the cath lab supervisor how to select the correct procedures in the MacLab for accurate documentation, but we do not do the actual coding. Has your cath lab recently expanded in size and patient volume, or will it be in the near future? We have maintained a consistent volume for the past few years. With the addition of a second electrophysiologist, we have seen growth in EP case volume, and device implant cases. We anticipate growth as new physicians are recruited to this area. We will expand into a new facility in 2013. Is your lab involved in clinical research? Yes. OMHS has a clinical research coordinator who evaluates potential studies and works with finance and ancillary departments to determine appropriateness and feasibility. Projects are then presented to the IRB for review. We are currently enrolled in the PROTECT II trial: a prospective, multi-center, randomized controlled trial of the Impella Recover LP 2.5 system versus intra aortic balloon pump in patients undergoing non-emergent, high-risk percutaneous coronary intervention. 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 runs between 72–80 minutes. We have established an acute myocardial infarction (MI) task force consisting of representatives from the cath lab, the emergency department (ED), critical care unit (CCU), the quality department and one of our cardiologists. We meet quarterly to review our current status and plan interventions for improvement. Two changes that had a big impact on our D2B time were the implementation of cath lab “All Call” from the ED as soon as a ST-elevation MI (STEMI) is recognized, and the emphasis on feedback. All cath lab staff receive the page simultaneously, and only those on call respond. This gets the call-out process started sooner, and eliminates the need to call each person individually. Feedback is posted in the cath lab and ED the next day after an acute MI, and the staff involved in the case are recognized. Some of the cardiologists will take a moment to call the ED and let them know the total time and what a great job they did. This has a huge impact! How does your lab handle call time for staff members? Is there a particular mix of credentials needed for each call team? Monday through Thursday, the call team can be 1 RN and 2 RTs, or 1 RT and 2 RNs. One of the RNs and one of the RTs must have completed Level 2 skills. Friday – Sunday nights there are 2 RNs and 2 RTs on the call team. We are staffed till 11 pm, but call starts at 7 pm, in case there’s an acute MI while the scheduled staff is still doing a scheduled case. Our evening shift staff members only take call on Friday night, Saturday and Sunday. Having this fourth person on the weekend assures safe staffing for acute MIs and productive turnover if more than one case is required during a call out. We are currently preparing additional staff members and plan to provide a 4-person call team at all times beginning in January 2010. Within what time period are call team members expected to arrive to the lab after being paged? The expectation is that the on-call team members should arrive within 30 minutes. The cardiologist on call is also expected to be here in 30 minutes or less. If the patient has a STEMI, the ED directly activates the cath lab all-call. What other modalities do you use to verify stenosis? We utilize IVUS and fractional flow reserve (FFR) measurements to assess stenosis. What measures has your cath lab implemented in order to cut or contain costs? In the past year, we have decreased our owned inventory in the cath lab 15% by eliminating rarely used products, increasing our consignment levels on drug-eluting stents (DES) to equal our par levels, and encouraging standardization on as many product lines as possible. We have pricing contracts with our primary vendors and do not allow new products or devices to be introduced until pricing agreements are reached. All products must be approved by a value analysis team before trialing during procedures. What type of quality control/quality assurance measures are practiced in your cath lab? Our quality department submits our data to the American College of Cardiology – National Cardiovascular Data Registry (ACC-NCDR). We receive HealthGrades reports quarterly, and report all our quality dashboards monthly to physician groups and to the staff. We also partner with Arbor Associates (Petoskey, MI) for patient satisfaction and receive monthly reports. In addition to formal reports, we currently monitor D2B times, time-out compliance, labeling on the sterile field, sedation monitoring, first case “ready” times and quarterly staff skill-levels through staff peer review. Can you tell us more about your peer review process? Staff competencies are reviewed quarterly in a peer review format. Each staff member does a self assessment and reviews three other team members. They also submit four names for nomination for a staff review team. The manager compiles all the peer review reports, typing all comments to maintain anonymity, and the four staff members with the most nominations serve as a review team to determine whether each staff member is maintaining their level of expertise. Comments and recommendations for improvement are reviewed with staff members individually by the manager. All staff members also complete an annual skills competency where specific skills are demonstrated. Physician peer review is done confidentially by a group of physicians from varied specialties appointed by the Board Quality Committee. What type of continuing education opportunities are provided to staff members? The hospital provides a regular rotation of classes in basic dysrhythmias recognition, critical care classes, advanced cardiac life support (ACLS) and basic life support (BLS). There are frequent educational offerings provided by clinical representatives from pharmaceutical companies or by product vendors. How does your cath lab compete for patients? Has your institution formed an alliance with others in the area? We are the regional center for an 11-county area. We own or partner with clinics in surrounding counties that refer patients to OMHS. How are new employees oriented and trained at your facility? We hire experienced RTs or RNs with a critical care, ED or surgical background. New staff members complete general hospital orientation and are then assigned a preceptor and receive most of their initial training working alongside that experienced staff member. We have established specific skill sets (Entry Level, CIS Level 1 = diagnostic, and CIS Level 2 = interventional). New employee skills are evaluated quarterly, and they are recognized as each level is completed. We currently have 3 RTs who have been in the cath lab less than a year. One has experience in diagnostic radiology, one came from a special procedures lab at another hospital, and one worked at a fluoro unit in our surgery department before transferring to the cath lab. How do you handle vendor visits to your lab? Vendors call the cath lab supervisor to schedule time in the lab. Preferred vendors may schedule entire days in the lab. Others may come for specific cases when requested by a cardiologist. Competitors may not be in the lab at the same time. All vendors must maintain current records in materials management. They are to sign in and out from that department and must wear a vendor badge with a photo ID. Does your lab utilize any alternative therapies (such as guided imagery, etc.)? Not specifically. We do have painted butterflies on the ceiling above the tables and sometimes play music during cases. Do you have flex time or multiple shifts? Most of our staff work 12-hour shifts, either 0630–1900 or 1030–2300, 3 days/week. We have a couple of staff members working some 8-hour shifts as well. Does your cath lab do electives on weekends and or holidays? No. We don’t do any elective cases on weekends or holidays. All after-hours cases are reviewed for appropriate urgency by the patient safety committee monthly. The call team must be available for acute MIs. Has your lab undergone a Joint Commission inspection in the past three years? Yes. We have had a Joint Commission inspection and a full Centers for Medicare & Medicaid Services (CMS) inspection in the past year. They were very pleased with our processes regarding activated clotting times (ACTs) in the cath lab. There is currently a great deal of focus on the two patient identifiers, time-outs, labeling on the sterile field and moderate sedation documentation. Where is your cath lab located in relation to the operating room (OR) and emergency room (ER)? We are located on the first floor, with the OR just above us. The ED used to be lateral to the cath lab, but a new ED was built several years ago, requiring it to move to the other side of the hospital. How do you see your lab changing over the next decade? OMHS will be relocating to a new site in 2013. We are currently in the final design stages and look forward to an entirely new facility, adding a fourth cath lab, and incorporating lean processes throughout! What is unique or innovative about your cath lab and its staff? Our greatest strength is our fabulous staff — they are committed to the safe and effective care of our patients above all. Ninety percent of the staff, both RNs and RTs, can scrub any case that comes through the door, which gives us great flexibility in scheduling. They take care of each other throughout a crazy day. They work as a team alongside our cardiologists to ensure our patients receive the best care possible. Is there a problem or challenge your lab has faced? How was it addressed? Several years ago, we were without a cardiac surgeon for a period of time. It was a struggle in many ways. The program has rebounded beautifully and our cardiac surgery program has now received a 5-star rating from HealthGrades. We now have two world-class cardiac surgeons! The Society of Invasive Cardiovascular Professionals (SICP) has added two questions to our spotlight: 1. Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? Do staff receive an incentive bonus or raise upon passing the exam? No. It is not required, and there is not a specific incentive for completion. We do pay for the exam fee upon successful completion. 2. 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 manager is a member of KONL (KY Organization of Nurse Leaders). The authors can be contacted at rrodgers@omhs.org

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