Spotlight Interview: Piedmont Henry Hospital

Tell us about your cath lab.

Piedmont Henry Hospital is a 215-bed, not-for-profit, community hospital located in Stockbridge, Georgia. We serve the southeast region of Atlanta. As of January 1, 2012, we officially became the newest member of the Piedmont Healthcare system.

Currently, our facility accommodates two cardiovascular angiography labs, one electrophysiology (EP) lab and 11 admit/recovery rooms.

On February 28th, 2011, our cath lab successfully performed its first coronary angioplasty.  In the year since, we have done 487 cardiac interventions. Prior to this date, we were a diagnostic lab, performing interventional peripheral and radiology procedures.

Our dedicated team consists of 18 registered nurses (RNs), four registered cardiovascular invasive specialists (RCISs), and five registered technologists in radiography (RT[R]s). They have been part of our team over a period ranging from six months to 25 years.

The team operates efficiently next to highly skilled and experienced physicians, including diagnostic and interventional cardiologists, electrophysiologists, vascular surgeons, and interventional radiologists, who all perform procedures in our area.

What procedures are performed at your lab?

The cath lab performs various diagnostic and interventional cardiac and peripheral procedures, as well as interventional radiology and vascular access procedures. These include right and left heart catheterizations, angioplasty, stenting, AngioJet (MEDRAD, Inc.), intravascular ultrasound (IVUS), fractional flow reserve (FFR), intra-aortic balloon pump (IABP) use and temporary pacemaker insertions, as well as peripheral run-offs and atherectomy cases. Percutaneous nephrostomy placements, Infusaport insertions, kyphoplastys, cholangiograms, embolizations, arterial-venous fistula/graft angiography and interventions, Permacath and inferior vena cava filter insertions are also done in the cath lab, in addition to other invasive procedures.

The EP lab performs electrophysiology studies with and without mapping, ablations and device implant, removal and upgrades.

Also, our team in the Admit Recovery Unit (ARU) assists in transesophageal echocardiograms and cardioversions, as well as in pre and post procedure care.

Together, our labs average about 115-120 cases per week.

Does your cath lab perform primary angioplasty without surgical backup on site?

Yes. Our facility does not have surgical backup for angioplasty procedures. In the event that a patient needs a surgical intervention, s/he is referred to a cardiothoracic surgeon at a nearby facility. In emergency cases, an intra-aortic balloon pump catheter is typically inserted to stabilize the patient and the staff expedites a critical care ambulance service to transport the patient to the appropriate hospital.

What percentage of your patients is female?

Females make up about 41 percent of our patient population.

What percentage of your diagnostic caths is normal?

Approximately 14 percent of our procedures are diagnosed as normal.

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

Yes, about 40 percent of our procedures are performed via the radial artery. 

Is your lab involved in clinical research?

Not at this time.

Who manages your cath lab?

Shelly Selby, RN, MSN, CCNS, CCRN, Director of Cardiovascular Services, is head of the leadership team, consisting of: Carrie Clayton RCIS, manager of the Cardiovascular Angiography Lab; Jo Pike, RN, manager of the Admit Recovery Unit; and Mogregory Morgan, RT(R), manager of the Electrophysiology Lab and Noninvasive Cardiology. Our co-medical directors are Rajasekhar Reddy, MD, FACC and Vikram R. Mandadi, MD, FACC.

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

Every team member is expected to cross-train in at least two positions. All disciplines are permitted to scrub, circulate and monitor. However, only registered nurses are allowed to administer medication.

Having multi-skilled team members is encouraged to strengthen our foundation of knowledge.  It creates a more proficient and cohesive environment, and enables all members of the group to appreciate and understand all steps involved in a procedure.

Who documents medication administration during the case?

Medication administration is documented by the monitor for the procedural record, the circulating nurse on a physician order sheet, and on the medication administration record (MAR).

Are you recording fluoroscopy times and doses?

Yes, fluoroscopy times/doses are recorded on every patient as part of the procedure record.

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

No. The physician as well as RT(R)s and RCISs are trained and credentialed to operate the X-ray equipment. The physician, as his practice dictates, determines how the scrub assists in the procedure.

Other personnel must obtain the appropriate credentials as determined by the state of Georgia to operate the fluoroscopy, but they may operate all other aspects of the equipment (i.e. panning and positioning).

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

Radiation levels are monitored on a monthly basis using a badge system. Education about time, distance and shielding are provided annually and are mandatory for all our staff. The use of lead shields, glasses and aprons with thyroid coverage is required.

Has your cath lab recently expanded?

Yes. We have experienced approximately a 12 percent growth in volume over the past year. In the spring of 2012, we will be upgrading and relocating our electrophysiology lab. The new equipment will also be able to accommodate overflow from our two existing cardiovascular angiography suites.

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

Over the past two years, as we began the implementation of our coronary angioplasty program, we had to bring in supplemental products to meet the needs of the interventional cardiac procedures. These included new IABP devices with fiber optic capabilities, IVUS and FFR equipment. Prior to this new endeavor, our lab already used the AngioJet, Jetstream (Pathway Medical Technologies), Diamondback 360˚ (CSI, Cardiovascular Systems, Inc.) and various other peripheral equipment.

We have recently added a mapping system to our electrophysiology lab in order to provide more extensive services to our patients who require ablations. 

Do you have a hybrid cath lab, or are you planning to build one?

No, not at this time.

How is inventory managed at your cath lab?

A designated staff member coordinates inventory and works with the hospital’s supply chain to maintain supplies for the department.

Who handles the purchasing of equipment and supplies?

Our leadership team, in conjunction with the healthcare system supply chain, procures equipment and supplies, based on needs initiated by the staff and physicians.

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

Information is communicated most often via email and information boards. A Communication Book contains minutes from meetings and other pertinent data to provide consistency. Call team members are notified by text-to-cell phone and page-to-beeper for emergency procedures after hours. Safety huddles are held on every morning and department meetings occur once a month.

How is coding and coding education handled in your lab?

A dedicated team member handles our charges, coding and education. She is an RCIS who works alongside a certified coder for the hospital. Together they ensure all regulations are met, and all supplies and charges are accurate.

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

Patients are prepped and recovered in our Admit Recovery Unit, located adjacent to the cath lab. Our staff is highly skilled in hemostasis and site management. This team handles all sheath removals for outpatients and non-critical care inpatients. The Critical Care Unit staff has been trained and is proficient in sheath removal.

Our physicians use closure and radial compression devices when appropriate.

What is your lab’s hematoma management policy?

Our hematoma management protocol is to notify the physician and hold pressure for 30 minutes or until hemostasis is achieved, and mark the circumference in order to gauge an increase/decrease in size. The patient remains on bed rest; if necessary, pain management is assessed and treated per physician order. All staff is trained to continue to assess the patient closely every 15 minutes for one hour, then every 30 minutes for the next two hours, then hourly, until bed rest is complete.

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

Our lab provides a full spectrum of diagnostic and interventional cardiovascular services. We house the only electrophysiology lab within 25 miles south of metro Atlanta and 50 miles north of Macon. When we became part of the Piedmont Healthcare system, the partnership allowed valuable access to state-of-the-art resources, which has strengthened our service line. As a hospital, we strive to educate our community with health fairs, classes, literature and support. By providing some of the world’s best physicians, nurses, and technologists, the latest in medical technology, and lots of genuine, heartfelt concern, we empower patients to take charge of their healthcare.

How are new employees oriented and trained at your facility?

As part of their introduction to Piedmont Healthcare, new employees are required to attend a three- to four-day hospital orientation. They then progress into the department and are assigned a preceptor who familiarizes them with the cath lab. Orientation and training is customized for each individual, depending on past experience and knowledge. An orientation book is provided to help guide a progressive pathway for the each new team member. New employees must successfully complete testing to each specific role in order to be considered competent. 

What types of continuing education opportunities are provided to staff members?

Inservices are provided on various subjects determined by physician selection, group interest or new services/equipment requiring proficiency. These are offered at least once a month or more as needed. Our staff has access to many educational opportunities within our region, due to our proximity to Atlanta. 

Our education team leader provides weekly educational updates and ensures all staff maintains competencies. We have department-specific annual proficiencies and medication testing to verify knowledge of procedures and equipment. Piedmont Henry Hospital’s education department has designed several specialized classes pertaining to cardiovascular services, including the percutaneous coronary intervention program, and a hemodynamic monitoring and intra-aortic balloon pump course. These are in addition to existing hospital-required teaching.

How do you handle vendor visits to your lab?

Our vendors are required to schedule visits to the department in advance. On the day of the visit, the vendor is required to visit the hospital’s materials management department to sign in.  Vendors are allowed in control rooms and labs as requested by physicians.

How is staff competency evaluated?

Competencies are evaluated annually by proficiency and medication testing, as well as by hospital-wide net learning. 

Does your lab have a clinical ladder?

Not at this time.

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

Our cardiovascular angiography team takes approximately nine days of call each month to provide 24/7 coverage for ST-segment elevation myocardial infarction (STEMI) and other emergency procedures. The four-person call team must consist of at least one registered nurse, as well as a team member proficient at monitor and scrub roles.

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

Team members are allotted 30 minutes from time of contact to arrival in the lab.

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

Our average D2B time is currently 53 minutes. In an effort to keep our times under 90 minutes, our ED works diligently alongside us to expedite each and every STEMI patient to the lab. Close communication between the team and the physician allows for fast and safe patient care.

We are registered with the American College of Cardiology’s D2B Alliance.

Who transports the STEMI patient to the cath lab during regular hours? During off hours?

To maintain consistency, during both regular and after hours, the ED transports a STEMI patient to the cath lab. When possible, one of our staff will go to assist with the transfer.

What do you do when the call team is already busy doing a procedure and a STEMI comes into the ED?

The action plan is dependent on the scenario of each patient. The cardiologist will initiate the plan of care for the STEMI patient until the procedure in progress is completed or the procedure will be aborted at a safe time in order to expedite the STEMI patient. The physician may also choose to treat the STEMI patient with thrombolytics.

Do you have flextime or multiple shifts?

Yes. Variable shifts and per diem staff are utilized in order to meet the fluctuating needs of the hospital.

Has your lab recently undergone a national accrediting agency inspection?

The Joint Commission visited Piedmont Henry Hospital in May 2011. At the time of our most recent survey, the focus within the department was on informed consent, the time out procedure, and history and physical. It is always prudent to maintain an ongoing readiness, as this impacts quality of care.

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

Cardiovascular Services and the ED are both on the first floor of the north tower. Just a short corridor and a doorway separate the two. As we do not have surgical backup, the surgery area is not visited very often by our patients.

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

Over the past year, we have made many changes in order to contain costs, beginning with renegotiating purchasing contracts, which resulted in significant cost savings. We have restricted the number of vendors for high-cost items. Additionally, we changed to the use of one contrast agent versus two and reduced the amount of supplies on hand to limit expiration. The lab previously used Isovue 370 for cardiac procedures and another agent for peripheral cases. We decided to replace our peripheral agent with Isovue 250.  Isovue 370 remains the standard for other procedures.

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

We have a peer group that assesses for trends and issues. This group is currently comprised of seven staff members, including an RCIS, a RT(R), two RNs, a quality control coordinator and leadership. We monitor all aspects of STEMI procedures and site complications, as well as compliance with Joint Commission and other national quality of care standards.

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

Our cath lab has seen a marked increase in radial access for diagnostic and interventional cardiac procedures over the last several years.

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

Currently, we are in the process of forming an Interdisciplinary Shared Governance Model for Cardiovascular Services that aligns decision-making and accountability, beginning with front-line employees on to departmental leadership. There are five councils within the model: Practice/Research, Supply/CVIS, Scheduling/Service Excellence, Education/Quality, and the Coordination Council. The first completed work from the model was the Mission, Vision, and Values of the department. The Values are trust, excellence, advocacy and motivation (T.E.A.M). These are key behaviors considered vital to the team. We hold ourselves and each other accountable to these standards.   

Is there a problem or challenge your lab has faced? How was it addressed?

An ongoing challenge since the start of our coronary interventional program has been the integration of vascular and interventional radiology procedures with cardiac diagnostic and interventional cases. Continued communication between team leaders and physicians about patient satisfaction and scheduling accommodations has improved the situation greatly.

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”?

Henry County is located south of Atlanta, with a continually increasing population that currently stands at more than 200,000 people, making Henry County one of the fastest-growing counties in the United States. With the continual growth, Piedmont Henry Hospital has seen an exceptional increase in procedures across the board.  Our “cath lab culture” has always been based on our love for what we do and excellent patient care. This commitment to continued growth in knowledge has enabled us to accommodate the rapid changes.

Questions from the Society of Invasive Cardiovascular Professionals (SICP):

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?

At present, there is no requirement for our clinical staff to take the registry exam for the registered cardiovascular invasive specialist (RCIS). Team members are always encouraged to seek continued education, as it is beneficial to patient care and team building.

We do not currently offer an incentive bonus upon passing the exam.

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?

Yes. Various staff members belong to the following:

• American Association of Critical Care Nurses (AACN)
• American College of Cardiology (ACC)
• Society of Chest Pain Centers (SCPC)

Readers may contact the authors via Twiggs Judkins at Ngarangi.Judkins@piedmonthenry.org. 

A question from the American College of Cardiology's National Cardiovascular Data Registry (ACC-NCDR):

How do you use the NCDR Outcome Reports to drive QI initiatives at your facility?

We use our data in comparison to the benchmark data provided to identify opportunities for improvement. We monitor hematoma and infection rates in order to reduce complications.