Rochester General Hospital

Tell us about your lab.

Rochester General Hospital has 4 angiography suites, 2 electrophysiology (EP) suites, and a 26-bed pre/post procedure area. Staff is a mix of registered nurses (RNs), radiologic technologists (RTs), licensed practical nurses (LPNs), intra-aortic balloon pump (IABP) techs, and patient care technicians. We have 48 staff members, with many staff members having over 10 years of experience. 

What procedures are done at your lab? 

Our cath lab performs cardiac diagnostic and interventional procedures including angiography, EP studies, fractional flow reserve (FFR) and intravascular ultrasound (IVUS), percutaneous coronary intervention (PCI) (balloon, stent, Rotablator [Boston Scientific, Natick, Mass.], etc.), EP studies, ablations, generator changes, and implantable cardioverter-defibrillator (ICD) and pacemaker implants. Peripheral diagnostic and interventional procedures are also performed. Our overall volume last year was over 6,800 cases.

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

Yes. Our cardiothoracic (CT) surgeons are available at all times, but we do not hold an OR. If during the procedure it is determined the patient requires surgery, the CT surgeon is paged immediately and responds directly to the lab for consult with the cardiologist.  If the need is not urgent, the patient is transferred to our post procedure area until seen by the CT surgeon. The surgeon will then assess the patient and schedule appropriately. We have never had a delay when emergent surgery is needed.

What procedures involve same-day discharge?

Procedures being discharged the same day include diagnostic procedures in both the angio and EP labs: coronary angiogram, intracoronary ultrasound, FFR, EP studies and some ablations. Generator changes are also done on an outpatient basis. Some PCI patients meeting strict criteria are being discharged on the same day as the procedure.

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

Approximately 65% of our patients go on to an interventional procedure and 35% of our patients have only a diagnostic procedure. 

Who manages your cath lab?

Our cath lab manager is Aileen Mancini, BSN. Dr. Thomas Stuver is the cath lab director and our director of cardiology services is Dr. Gerald Gacioch.  

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

We are very supportive of cross-training. Cross-training is limited only by licensure.  RNs are cross-trained to all aspects of the lab, including monitor, circulating, and IABP placement. Some RNs are cross-trained to scrub assist at the table. RTs are cross-trained to monitor and circulate, though their primary responsibility is as a scrub assistant at the table. All of our staff is oriented to our pre/post procedure area first and then trained in the assigned lab. Cross-training is an investment in our staff and has definitely aided us in retention of staff and times of peak volume.

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

While it is preferred to have an RT in each room, it is not required. Our practice is to ensure there is a RT on the unit at all times, whenever fluoroscopic procedures are in progress.

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 cardiologist is the one to position, pan and change angles. The cardiologist is the primary operator and the radiologic technologists provide support and assistance.

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

Radiation protection is a very serious concern. All members in the room are protected with a lead apron and they must wear a radiation badge whenever they are on the unit.  Those operating close to the gantry have additional shielding in the form of a ceiling-mounted shield (for those scrubbed) or a portable full-length shield for those circulating.  All staff members are required to turn in their badge monthly for measurement of exposure. The hospital physicist monitors these readings monthly to ensure staff and physician safety.      

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

We have kept up-to-date with all the advanced technology available to cath labs. Our most recently incorporated devices include FFR, Impella (Abiomed, Danvers, Mass.) and CryoCath (Medtronic CryoCath, Pointe-Claire, Canada) ablations.    

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

We have several physicians who prefer to use the radial artery for procedures. At this time, we are doing approximately 60% of our cases through radial access. The Allen’s test is done immediately preceding the procedure to ensure adequate blood flow for patient safety. These patients are generally prepped anticipating using the right wrist with the right groin as an alternative. The waveform is recorded post procedure along with color, motion, and sensitivity (CMS).

How is coding and coding education handled in your lab? 

We have a close relationship with our coding and billing department. Regular monthly reviews identify any outstanding billing concerns and quarterly meetings with our financial department ensure the latest updates to our charge capture process. Billing sheets within the cath lab are updated as new devices or procedures are added to our inventory and/or there are revisions to the insurance reimbursement codes. We close the loop with education to the staff and posting of the updates. One-on-one updates are given to those who may be away at the time of the new additions.    

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

We use a number of vascular closure devices, including StarClose (Abbott Vascular, Redwood City, Calif.), Perclose (Abbott), and Angio-Seal (St. Jude Medical, Minnetonka, Minn.), for patients meeting the criteria. The device is deployed in the lab at the end of the case, allowing patients to go directly to their room for recovery, inpatient admission or discharge. We have had a significant increase in radial procedures,  which allow for earlier discharges for our outpatients or a more timely admission to the inpatient cardiac units. We use Neptune pads (TZ Medical, Inc., Portland, Oregon) for manual sheath pulls/holds that are done by the RNs in our post procedure area. A yearly competency is required for all staff to demonstrate clinical expertise in this regard. 

What is your lab’s hematoma management policy?

Hematomas are complications that are tracked in our quality process for any identification of trends in complications. This most recently resulted in a change of product and process for our labs. When a hematoma is noted, the nurse applies manual pressure to regain hemostasis. The patient is reassessed by the cardiologist or a midlevel practitioner before discharge or transfer. 

How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies? 

We have a materials coordinator for the entire department who reorders product according to established par levels. Par levels are adjusted according to physician practices. Materials are ordered on a daily basis, as needed, to reduce waste and control cost. Most of our products are on consignment and we work closely with company representatives to monitor usage. Representatives from each company are allowed access to the department once each month to review inventory levels, present new product, and change out any product that may be close to expiration.  

Has your cath lab recently expanded in size and/or patient volume?

Our cath lab opened in a brand new unit in 2010. We have 4 angio labs and increased our EP labs to 2. Our pre/post procedure area doubled in size, from 13 to 26 beds, to accommodate both admissions and recovery services in one area adjacent to the labs. We expanded our recovery of PCI patients by accommodating select cases that can be discharged the same day as the procedure is performed.

Is your lab involved in clinical research?

We are involved in clinical research and have nurses from the research department of the hospital monitor our research to ensure recruitment and compliance with all guidelines.

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

We are certainly seeing an increase in more critically ill patients. We have had patients require emergent surgery for severe coronary artery disease and on rare occasion, coronary artery perforation. Having surgical access directly adjacent to the labs allows a response time of minutes, as well as excellent results. It emphasizes the importance of having emergent surgical support available onsite for emergent cases.

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 cath lab is proud to have a consistent, average, door-to-balloon time of 75 minutes.  We have a team of staff members and physicians representing cardiology, emergency medicine and quality that meet monthly to review cases and identify any weak points in the process. When our door-to-electrocardiogram (EKG) times were beyond the 10-minute range, we immediately made adjustments in the emergency department (ED) to decrease that time to 5 minutes and a physician was made available to triage quickly. Continuous monitoring and a strong relationship with our emergency medical technician (EMT) ambulance crews also decreases delays by allowing the ED physician to review EKGs from the field and contact the cardiologist even before arrival to the hospital, thereby allowing quicker access to the cath lab in the event of an acute myocardial infarction. Our on-call team for the cath lab has a very quick response time, averaging 15-20 minutes. Many of our staff members live within 15 minutes of the facility and the first person to arrive calls for the patient from the ED to reduce delays.

What other modalities do you use to verify stenosis?

We use the FFR and IVUS to assist in determining degree of stenosis. We do not currently have statistics on the financial benefits, but have seen reimbursements for our use of these measurement tools. 

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

We regularly review our consignment products and adjust par levels according to utilization. Over 80% of our products are consigned and other products are purchased on an as-needed basis. Our supplies are maintained in a central area adjacent to all the labs to decrease waste from expired product or damaged packaging. 

Cross-training of our personnel also aids in cost containment by the decrease in overtime and flexibility with scheduling. 

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

Competition for cardiac services is always present. We are one of three hospitals in the Rochester area that perform PCI and EP services, and one of two hospitals that perform CT surgery. We have aligned ourselves with several surrounding-area hospitals for cardiac services. Being a Magnet Hospital and achieving our Top 100 Heart Hospital recognition for 9 years has certainly helped our relationship with the general population and surrounding facilities. In addition to referrals from these facilities, we often see patients from outside of our immediate service area — some patients from as far away as 150 miles. Several cardiologists have set up satellite practices in neighboring counties and offer conferences for primary physicians to aid them in their care of patients. 

How are new employees oriented and trained at your facility?

All employees go through about 7 days of a core hospital orientation to learn hospital policies. Upon starting in the cath lab, the new employee is paired with an experienced staff member. They have the same schedule and work side-by-side. As skills are demonstrated and mastered, the preceptor gives more responsibility to the new staff member until independence is reached. The orientation begins in the pre/post procedure area and then moves to the lab area in which they will be working. Orientation is geared to individual needs based previous experience and skill mastery.  There is no set time limit. We support an ongoing progress and continued mentoring even when the “orientation packet” is completed. The majority of our licensed staff members have critical care, special procedures, ED and cardiology experience, which has aided them in transitioning to the cath lab.

What continuing education opportunities are provided to staff members?

Continuing education is encouraged. Staff members are encouraged to present an in-service each year for their peers, and staff is encouraged to attend local, regional, and national symposiums to bring back information to the unit to share with colleagues. One hour each week is set aside to allow for presentations by staff, physicians, or clinical representatives from various companies. An educational fund specifically set up for the cath lab allows for some reimbursements of EP and cath lab conferences. This fund is supported through donations from patients, families and colleagues. The hospital also has a generous education reimbursement policy for those continuing in formal college classes. 

How do you handle vendor visits to your lab? 

Vendor visits are allowed in the EP and cath labs once per month to allow for education, review of consignment, and presentation of new products. If there is a significant change in product or new procedures to be implemented, more time is allotted for the representatives. They are required to change into hospital scrubs and wear specific ID badges (distributed by VeriREP [Bowmansville, New York] to ensure compliance with hospital standards.). Representatives are here in a supportive role for physicians and staff. They are allowed into the lab area for observation. Patients are always informed of their presence to maintain patient confidence and privacy.

How is staff competency evaluated?

National, hospital, and unit competencies are required annually. The clinical resource nurse is responsible for ensuring all competencies are demonstrated and completed by staff annually. All competencies are documented in the individual’s file. 

Does your lab have a clinical ladder? 

Our hospital-based Clinical Nurse Advancement System (CNAS) is a significant source of pride. Our CNAS process was presented at the 2006 Magnet Conference and we have published in Nursing Management (2008) and in Critical Care Nurse (2009).

We are always willing to assist other facilities in developing or improving their clinical ladder process. Currently our department has 13 RNs who have advanced in this system. 

How does your lab handle call time for staff members? 

Our call guidelines require each staff member to be on call one night per week, one weekend per month, and two holidays per year. A complete call team is comprised of two RNs and 1 RT, and 1 additional staff member to monitor. We have self-scheduling for our daily schedule as well as for on-call. Staff signs up based on department needs in balance with their personal needs. Two staff members have assumed responsibility to assure the schedule is complete.     

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

The call team is expected to be ready in the room within 30 minutes (most are here within 20 minutes). An attending cardiologist is not always on site. During off hours (late evenings and nights), technology allows them to review EKGs off site. They respond immediately and are here within 15 minutes. 

Do you have flextime or multiple shifts?

The angiography labs are staffed using 8-hour shifts staggered to cover 7am to 7pm. The EP labs and the pre/post procedure area have a combination of 8-, 10- and 12-hour shifts. Staff is rotated through the department areas as needed throughout the day to cover breaks, lunches and transfers. Staff flexibility is our strength. Staff is flexed when case volume is light or they have been here on call for an extended amount of time. 

Does your cath lab do electives on weekends and/or holidays?

No elective cases are scheduled on the weekends or holidays.

Has your lab undergone a Joint Commission inspection in the past three years?

We have recently finished with a Joint Commission inspection. An area of focus during our inspection was observation of our “time out” process and “hand off” reports from staff to staff. Labeling of all fluids and meds on the procedure table was critical.  Moderate sedation policy and procedure was reviewed extensively. 

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

Our cath lab is immediately adjacent to the OR and cardiothoracic intensive care unit. We are directly above the ED, with a dedicated elevator for our patients. Other cardiac units are directly above our floor, with easy access using this same elevator.  

How do you see your cardiac catheterization laboratory changing over the next few years?

We will continue to pursue peripheral procedures and transition to same-day PCI where clinically indicated. We anticipate expanded volume with patent foramen ovale (PFO) closures and services to include carotid interventions and peripheral valve implants. The recently installed 64-slice CT scanner will also influence the type of procedures we do and the volume we will see.

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

We have staff members cross-trained in many “roles” in the cath lab department. Staff is also cross-trained to assist in the EP lab and the pre/post procedure area. Our flexibility with staffing allows us to maintain strong team dynamics and meet the changing needs of our physicians and patients. Lab turnover is kept to 15 minutes or less due to strong teamwork. Our new location, rapid response, and continued education of the team allow us to address emergencies without delay and manage a volume generally seen in hospitals with more EP and angiography suites. Flexibility, cross-training and ongoing team building are essential to providing our patients quality care in an efficient and cost-effective manner. A strong Unit Council, with staff from all three areas of the department, assures timely communication with staff regarding challenges, changes and concerns. This council also champions community service work and coordinates staff participation.  

Is there a problem or challenge your lab has faced?

The 2010 renovation for our unit was completed in stages. The 4 cath lab suites and 2 EP labs were operational in October 2009. The pre/post area remained on the opposite side of the hospital until September 2010. During that year, we changed many processes and patient flow to manage the distance our staff and patients were required to travel from the pre-procedure area to the cath labs, and back to the recovery area. We are proud to say that there was no impact on the quality of our patient care. The distance and transport time were certainly affected. Also, we had additional staff meetings and team-building sessions to keep the staff feeling still like one team despite these distances. Staff, physician and patient engagement was a balance to the challenges we faced. When the renovation was complete, the staff was extremely excited to have an open house for hospital personnel and the general public.

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”?

Rochester is a very diverse community and we are positioned within the city limits. The lakes, mountains and farmlands that surround our city are major attractions in western New York State. Many chose to live in these outlying areas, so our rural population is significant. Large international communities and religious sects are located here in western New York, so we provide interpreting services and sensitivity training for our staff to meet the cultural and religious needs of our community. The ease of access to our hospital, off one of the major state routes, makes us a referral center for the outlying rural hospitals. We have great transport services with our ambulances and medical airlift transportation. These services, along with the 15-20 minute response time of our staff, allow us to serve our acute MI patients within national standards established for door-to-balloon times.

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? Does staff receive an incentive bonus or raise upon passing the exam?

We are requiring radiologic technologists to obtain their cardiovascular certification and RNs are encouraged to obtain their cardiovascular certification as well. The hospital compensates employees for holding an advanced certification.

Are your clinical and/or managerial team members involved with any professional organizations that support the invasive cardiology service line?

Our manager is involved with NYONE and GVNA. Our clinical resource nurse is a member of AACN.

Christy Hoover can be contacted at christy.hoover@rochestergeneral.org.