Sanford USD Medical Center Cardiac Cath Lab

Sanford Health, an integrated health system, is headquartered in Sioux Falls, South Dakota, where the Sanford USD Medical Center is located. The hospital has 545 beds with more than 4,000 employees. Sanford Health as a whole has 39 medical centers, 140 clinics, more than 26,000 employees, and more than 1,300 physicians in 80+ specialties. Sanford Health is the largest rural, non-profit health care system in the nation. It has developed and continues to develop international clinics in countries such as Israel, Ghana, and Mexico. Sanford Children’s Clinics are also located in Oklahoma, California, and Oregon.

Tell us about your cath lab.

The main Sanford USD Medical Center has five cath labs and one procedure room. In March 2012, the Sanford Heart Hospital opened, adding an additional two cardiac cath labs and a procedure room. The combined total over both locations is seven operating labs and two procedure rooms. Construction is currently underway to add an additional two labs in the Sanford Heart Hospital, meaning a total of nine labs and two procedure rooms will be in use once construction is complete.

The two newest labs will be ready for the first patients in the end of November. Over the next few years, construction will continue as five more labs and one more procedure room are outfitted.

Both registered nurses (RNs) and registered cardiovascular invasive specialists (RCISs) work in our lab. Staff has experience ranging from 26 years to recent new hires. 

What procedures are performed in your cath lab?  

Procedures performed in the cardiac cath lab include: 

• Diagnostic and interventional cardiac catheterizations
• Diagnostic and interventional peripheral catheterizations (mesenteric, renal, etc.)
• Atrial septal defect (ASD) closure
• Transesophogeal echocardiogram (TEE)
• Cardioversions
• Venous closures
• Carotid angiograms
• Aortograms
• Venograms
• Fistulograms
• Inferior vena cava (IVC) filter insertion and removal
• Tunnel cath insertion and removal
• PowerPort insertion and removal (Bard Access Systems)
• Permanent pacemakers 
• Implantable cardioverter-defibrillator (ICD) placement
• Generator changes
• Loop recorder insertion and removal
• Electrophysiology studies
• Atrial fibrillation ablations
• Transcatheter aortic valve replacement (TAVR; performed in our hybrid OR)
• Pediatric procedures
•  Central line insertions
• Valvuloplasty
• Chronic total occlusion (CTO) procedures
• Procedures with the CorPath robot (Corindus Vascular Robotics)
• Left atrial appendage procedures
• Several device clinical trials

The cath lab does approximately 200 procedures per week.

Can you share more about your TAVR experience?

We have been performing TAVR procedures since September 2012. As of late August 2013, we have completed 42 procedures with excellent results. We use both transfemoral and transapical approaches. TAVR procedure days are scheduled twice per month, with two cases being performed each day. The cases are approximately 2-3 hours in length, from patient on the table time to transfer to the intensive care unit after closing time. During the procedures, we have two scrubbers, a monitor, a circulator, and a pacer nurse from the cath lab staff, and two surgical techs are scrubbed in at all times with an entire OR team on standby. The TAVR physician team consists of two interventional cardiologists, one diagnostic cardiologist, a vascular surgeon, and a cardiothoracic surgeon. The other teams in the room consist of anesthesia [physician and two certified registered nurse anesthetists (CRNAs)], an echo tech, and a perfusionist. 

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

The cath lab started performing procedures with radial access on November 16, 2009. Since then, all the cardiologists have been trained on how to use the radial artery. The percentage of patients having a radial puncture site continues to increase. Currently, about 84% of patients have a radial access site. 

What percentage of your diagnostic caths is normal?

Approximately 15% of our diagnostic caths are normal.

Who manages your cath lab? 

The cath lab has four clinical care coordinators who work varying shifts and are responsible for ensuring the cases stay on schedule, placing employees into each case, and allowing cases to be scheduled appropriately. The clinical manager for the cath lab is responsible for the day-to-day operations and oversees all of the employees. The clinical manager also keeps the staff up to date on the happenings in the lab and provides new information on upcoming events. In addition, we have a director over the cardiovascular service area.

Who scrubs, who circulates and who monitors? 

Every RCIS is able to work in the role of scrubber, circulator, and monitor. Every RN is able to work in the role of nurse and circulator. We have two RNs that can monitor and two that can scrub.

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

We do not have any RTs on staff.

Which personnel can operate the x-ray equipment in your cath lab? 

Both the physician and RCIS can position the image intensifier, pan the table, change angles and step on the fluoro pedal.

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

Each staff member and physician is provided lead to be worn in the lab along with lead glasses during a procedure, and two radiation badges are provided every month for every employee in the lab. If an employee is pregnant, they are also supplied with a fetal radiation badge, and in our cath lab, they are kept out of the room in any case that is using radiation. Every staff member goes through radiation education every year and is supplied with a radiation readout each month that shows their exposure level. Each lab also has portable lead shields and hanging lead shields at the table to that help protect the staff and physicians. 

What are some of the equipment, devices and products that have been recently introduced at your lab? 

The Edwards Sapien TAVR valve, the Corindus CorPath Robotic System, left appendage ligation, and the Bridgepoint CTO system, which consists of the CrossBoss CTO crossing catheter and the Stingray CTO re-entry system (Boston Scientific).

How does your lab communicate information to staff and physicians to stay organized?

The clinical manager has huddles twice a week to keep staff informed. Once-a-month department meetings are held that are also attended by the director. The clinical manager and director discuss any change affecting physicians directly with them. 

How is coding and coding education handled in your lab? 

Coding is done by the coders in the health information management (HIM) department. We have a specialized RCIS staff member that works with HIM to ensure that cath lab staff is kept current with any new procedures or changes to billing that occur each year. This RCIS staff member also provides education to the cath lab staff when changes occur.

Who pulls the sheaths post procedure, both post intervention and diagnostic? 

The RCIS who scrubbed the procedure is responsible for the sheath after the procedure is complete. If it is a large sheath, some of our physicians prefer to take the responsibility for pulling their own sheaths (for example, intra-aortic balloon pumps and 12 French or greater arterial sheaths). All techs are required to have full knowledge of all closure devices and are monitored for the first 10 patients where they hold pressure or use closure devices.

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

The short stay unit is responsible for the prep and recovery of the outpatient and some of the inpatient population for the cath lab.

How does your lab handle hemostasis?

Our lab achieves hemostasis at the puncture site through manual compression, vascular closure devices, and mechanical compression devices. Manual compression is held in the lab right after the procedure is complete, or the patient is transferred to the short stay unit or ICU and the line is pulled there. The main closure devices we use are: Angio-Seal (St. Jude Medical), Starclose (Abbott Vascular), Mynx (AccessClosure), Catalyst II and III (Boomerang) (Cardiva Medical), FemoStop (St. Jude Medical), Safeguard (Maquet Cardiac Assist), and radial bands. Patients who receive a Catalyst II or III will go to the short stay unit or back to their inpatient room with the device. These patients receive one-to-one nursing care until the Catalyst is pulled. The RCIS will go to the patient at the time the device can be pulled, pull the device, and apply manual compression to the site. The RN taking care of the patient stays in the room during the pull and monitors the patient. Vascular closure devices are placed in the lab, and mechanical compression devices are placed in the lab or in the patient’s room, depending on the situation.  

How is inventory managed at your cath lab? 

We have two inventory coordinators who do all the ordering of supplies with the help of our lead RCISs. We have three lead RCIS techs in our lab: one for coronary, specialty and pediatric procedures, one for peripheral procedures, and one for electrophysiology procedures. Each tech is responsible for notifying the inventory coordinators regarding what products to order for each specific procedure.

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

Yes. In March 2012, the Sanford Heart Hospital opened, adding two labs, a biplane and single plane, for coronary procedures. Over the next year, two more labs will be outfitted in Sanford Heart Hospital. Both these labs will be equipped with electrophysiology equipment, will be biplane, and one lab will be a fully dedicated electrophysiology lab.

Is your lab involved in clinical research?

Yes, our lab is involved in several different research studies.

Can you share your lab’s average door-to-balloon (D2B) times?  

Our average D2B time is 58 minutes, with our fastest D2B times including two 9-minute D2Bs, an 11-minute D2B, and two 14-minute D2B times. We have an ongoing “muscles to minute” project in which the cath lab and emergency department (ED) work closely together to make changes and keep the D2B below 90 minutes. During this project, many things have been discovered that were either causing delays or had the potential to cause delays to the patient in getting to the cath lab. As a result, the ED now places the order for the procedure prior to the patient coming to the cath lab. An electrocardiogram (ECG) tech from the ED comes and turns on the X-ray during off hours when our staff is not present. The cath lab implemented a second call team when the project first started over a year ago, to ensure staff are available to care for a second patient that may come through the door. 

Sanford USD Medical Center has also received Chest Pain Center accreditation and is registered with the American Heart Association’s Mission: Lifeline.

Who transports the ST-elevation myocardial infarction (STEMI) patient to the cath lab during both regular and off hours?

During regular hours, a STEMI that comes through the ED is transported by the cath lab staff. During off hours, the cath lab staff will go to the ED to get the patient, but ED staff may help transport the patient if needed. If the STEMI is an inpatient, the staff from the sending unit will transport the patient to the cath lab.

How does your lab handle call time for staff members? Is there a particular mix of credentials needed for each call team? 

The first call team consists of two RNs and two RCISs, and the second call team consists of one RN and three RCISs. 

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

Staff members are required to arrive to the lab within 20 minutes of being paged. Staff is notified if their call-in time is over 20 minutes.

Do you have flextime or multiple shifts? 

We have multiple 8-, 10- and 12-hour shifts to staff the lab from 0530-1900 Monday through Friday.

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

Sanford participates in a group purchasing organization (GPO). We have a value analysis committee and an RN/BSN contract portfolio manager for all new products, bulk buy values, and benchmarking of prices to see what others are paying for supplies compared to our facility.  

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

We perform monthly audits on charting, time-outs, and the environment. We do weekly audits on hand hygiene. Feedback is provided to staff about our D2B times and how we can improve. Information is shared with staff on areas in which we are excelling and on areas that need improvement.

Are you recording fluoroscopy times/dosages? 

Yes, the fluoroscopy times/dosages are recorded in the documentation record of the procedure. Follow-up is completed on all patients who have a fluoro time of 60 minutes or greater.

Who documents medication administration during the case?

The RNs are responsible for documenting medication administration during the case.

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

Yes. We currently submit data to the CathPCI, ACTION< IMPACT, and ICD registries.

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

Our cath lab competes by bringing new technology and procedures to the hospital. New clinics and hospitals continue to open up in the Midwest under Sanford Health. A merger occurred between Sanford Health and Fargo, ND based MeritCare in 2011 that also helped grow the service area for Sanford Health.

How are new employees oriented and trained at your facility? 

New employees are oriented for a total of 12 weeks. Orientation involves several online learning modules and cath lab validation classes. Each employee is placed with a mentor who helps to orient them to the units, cath lab department, and the different cases. The first two weeks of orientation is spent at our learning center where employees learn general information about the hospital and go through simulation labs. Computer training is provided to employees during those first two weeks of orientation as well. New employees also spend a day in the ED, short stay unit, and with an RCIS in the scrub and monitor role. 

What continuing education opportunities are provided to staff members?

Several on-site conferences are held throughout the year and staff is encouraged to attend. Every Friday morning, we have a cath or a non-invasive conference where we discuss complicated procedures. Every Tuesday, there are electrophysiology and ECG classes held, and every Friday, pediatric education occurs. The hospital provides Grand Rounds and M&M Rounds, which are education opportunities for employees once every quarter. At our facility, we have also recently started a cardiology fellowship program. The fellows participate in our entire cardiovascular program, including the cath lab, echo lab, stress/nuclear medicine, clinic, and outpatient and inpatient care.

How do you handle vendor visits to your lab? 

Cardiac rhythm management (CRM) representatives have badge access to the cath lab, and all other vendors are limited to one day a month, scheduled through the cath lab manager, unless the physicians request a representative’s support.

How is staff competency evaluated? 

Validations occur once every quarter and staff also takes online competencies throughout the year. Our validations consist of a 3-4 hour session in which we have ECG tests, scavenger hunts, check-offs on various equipment and procedures, and sessions with our simulation center mannequin on STEMI and code situations.

Has your lab recently undergone a national accrediting agency inspection? 

We have recently undergone inspections from The Joint Commission, American Nurses Credentialing Center – ANCC (Magnet), Society of Chest Pain Centers, and the American Heart Association’s Mission: Lifeline accreditation group. We look at these as opportunities to show the greatness of our facility and also to learn what we can do to make ourselves better.

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

The cardiovascular OR is located in the new Sanford Heart Hospital, three floors above our new labs and about a five-minute walk from our existing labs. The ED is located within close proximity to the existing labs.

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

We have seen an increased number of procedures with the new technology we offer. Our average patient population is between 50 and 70 years old.

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

We are always aspiring to achieve greatness by bringing in new procedures and technology to help the patients we serve. Our staff is very close. It does not matter what your title is; we are here to take care of the patients and we help each other out in any way possible. We are one of the first five sites in the nation to have the Corindus Robotics program and have performed over 40 cases in the first two months of our go-live with the device We have completed 52 robotic cases in Sioux Falls. Our lab is unique in that 60% of our volume is cardiac/electrophysiology casework and 40% is peripheral casework.

Is there a problem or challenge your lab has faced?

The biggest challenge our lab faces right now is being located in two separate locations and being fully staffed. With the new Sanford Heart Hospital, our entire lab will reside inside one building, once the remaining lab construction is complete. With the opening of Sanford Heart Hospital and more labs, we needed to hire additional employees. At this time, we are still in a hiring period and continue to look for people who will be a good fit in our lab. We also do clinical preceptorships each year for RCIS students. This year we have three RCIS students.

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”?

We are in a rural area and that affects the population of patients we serve. We care for patients from Minnesota, North Dakota, Iowa, Nebraska, and South Dakota. Access to medicine is not easily accessible in parts of our state, and we strive to have Sanford Health in several different regions, so patients are able to get help and get transferred to the main hospital for treatment if needed. 

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

Cath lab technologists are required to pass the RCIS exam before they can start working in the cath lab and must continue to keep their RCIS credential current.

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, Alliance of Cardiovascular Professionals (ACVP), or regional organizations?

Our facility encourages and supports our team in joining professional organizations that support their practice, including both the SICP and ACVP.

The authors may be contacted via Danielle Schievelbein, MSN, RN, at danielle.schievelbein@sanfordhealth.org.