Spotlight: Norwalk Hospital Komansky Cardiac and Vascular Center

The authors can be contacted via Diane Augustine, RN, CCRN, at Diane.Augustine@Norwalkhealth.org.  

Tell us about your cath lab.

Located on the shore of Long Island Sound, and with a view of Manhattan on a clear day, is Norwalk Hospital, a 328-bed, not-for-profit, acute care teaching hospital serving the 250,000 residents of lower Fairfield County, Connecticut. In our single cath lab, we have a dual-plane Toshiba Infinix system with a cardiac and a peripheral C-arm. Outside of our lab, we have two-bed room that serves as both a pre-op and post-op area. Staffing consists of three full-time registered nurses (RNs) and two part-time RNs, as well as a full-time radiologic technologist (RT) and a part-time RT. Together, our RNs average more than 20 years of critical care experience.  

What procedures are performed in your cath lab?

We perform diagnostic catheterizations, emergency percutaneous coronary intervention (PCI) for ST-elevation myocardial infarctions (STEMIs), temporary and permanent pacemaker insertions, as well as automatic implantable cardioverter defibrillator (AICD)/biventricular (Bi-V) implants. 

We perform diagnostic electrophysiology (EP) studies and radiofrequency ablations. Using our peripheral arm, we do peripheral diagnostic and interventional procedures. We utilize intravascular ultrasound (IVUS), the Trellis thrombectomy system (Covidien), AngioJet (Medrad), the EkoSonic Endovascular System (Ekos Corp.), the Crosser catheter (Bard Peripheral Vascular), the Diamondback 360 (CSI), and fiber-optic intra-aortic balloon pumps (Maquet). Currently, we average sixty procedures per month. Our nurses assist with elective cardioversions and transesphageal echocardiography in our recovery area, administer Definity (image enhancer) (Lantheus Medical Imaging) for cardiac echo studies housewide, and administer medications for nuclear stress tests.

Does your facility perform transcatheter aortic valve replacement (TAVR)?

Our hospital does not perform TAVR, but we often complete the preoperative testing that is needed for local patients. We are currently evaluating the need for a hybrid room in the OR, as well as doing a product review with a variety of vendors.

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

Yes. We have been successfully performing primary angioplasty for STEMIs for 4 years, and have an active transfer agreement with a neighboring hospital for emergent back up. We have also emergently transferred post STEMI intervention patients to other facilities for extracorporeal membrane oxygenation (ECMO) and Impella (Abiomed) support, by both helicopter and ambulance.

What percentage of your diagnostic caths is normal?

On average, 47.8% of our cardiac catheterizations are normal.

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

Yes, about 50% of our current cases are done from the radial approach. All of our practicing physicians are competent on the radial approach.

Who manages your cath lab?

Dr. David Lorenz is the medical director of the cardiac lab. Dr. Michael Pittaro is the medical director of the electrophysiology program. Karen Palaia, RN, is the manager of the cardiac vascular center, and Anne Bartolone, RN, is the director. The executive service line director is Kelli Stock.

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

Yes, most of our nurses have cross-trained to scrub and pan at the table. Nurses currently circulate and monitor on the Mac-Lab (GE Healthcare). Our technologists usually scrub and are cross-trained to monitor. The technologists also are cross-trained to assist with stress testing and electrocardiograms (EKGs) in the department.

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

Any team member may position the image intensifier, pan the table, or change the angles, but only a credentialed physician or a radiologic technologist may step on the fluoro pedal.

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

Balan Kodery is our radiation safety officer. He reviews and manages exposure data on a quarterly basis, and handles any ALARA (as low as [is] reasonably achievable) reports. Team members all wear protective lead and lead eyewear. Lead shielding surrounds the table, and radiation scatter pads are used for our pacemaker/ICD inserts. Dose meters are provided for each team member and followed monthly. Leads are inspected annually for integrity and logged into a database. One safety feature we recently started is to have the RT ask if everyone is “leaded” as part of our time-out procedure.

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

We were the first hospital in the State of Connecticut and one of the first non-trial sites in the nation to implant drug-eluting peripheral stents (Cook Zilver PTX).  Ultrasound-accelerated thrombolysis for treatment of pulmonary embolus and deep vein thromboses has been added within the last year. We have also begun an emergency neuroendovascular interventional program for acute strokes that fail tPA therapy.

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

Since we are a small, close-knit group, we communicate easily amongst ourselves, our primary physicians, and with other departments. We hold monthly staff meeting to review labs changes and updates, and participate in weekly cardiology conferences with physicians and staff. All STEMI cases are reviewed at a monthly multidisciplinary meeting. Dr. Lorenz communicates medical issues with his interventional partners who take call at our hospital.

How is coding and coding education handled in your lab?

Initially case coding is done by the monitoring RN and reviewed by a second RN if there are any questions. We often reference our trusty current procedural terminology (CPT) book and Code Correct for clarification. Charges are entered manually into the billing system by our secretary. Coding is reviewed by hospital “scubbers” in the billing department. Our manager works with the finance department and brings coding changes to staff meetings on a regular basis. Code charge sheets are updated at least annually.

Who pulls the sheath post procedure? 

Sheaths are usually pulled by the primary physician; however, any qualified personal is able to remove sheaths. Sheath removal training begins with a review of the policy, observations of the removal, and repeat demonstrations with a preceptor. Physician assistants also assist in sheath removal for vascular cases. Annual competency is maintained.

Where are patients prepped and recovered? 

Patients are prepped and recovered in our two-bed pre/post room. Our recovery area provides for two patients only, so on busy days, we provide care in other areas in the department to keep the flow of patients steady. Ninety percent of closure is done at the table, using a variety of closure devices such as Angio-Seal (St. Jude Medical), Mynx (AccessClosure), Perclose (Abbott Vascular), or manual pressure. Radial sheaths are pulled in the lab by the physician or trained personnel, and a compression band is applied. Inpatients return to the critical care floors with the radial compression device in place. 

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

With multiple service lines, we have a large assortment of inventory. Last year, we made improvements to our inventory management utilizing LEAN principles. We right-sized our supplies based on our volume, initiated a visible kanban system for reordering, and transitioned some of the routine supply restocking responsibilities to the stockroom personnel. Every employee in the lab is now responsible for a particular product line or cart, and maintains their inventory with weekly checks for par levels and expirations. We have one RN and one tech handling the ordering of supplies through our PeopleSoft system (Oracle), and have simplified the process with the use of a scanner gun. Capital items are ordered by the manager after budget approval.

Has your cath lab recently expanded in size and patient volume, or will it be in the near future?

No, we are not planning for an expansion at this time.

Is your lab involved in clinical research?

We are participating in the St. Jude Medical AnalyzeST trial. This trial is designed       to use special capabilities in a single or dual chamber ICD to analyze a patient’s ST segment and alert the patient when an ST shift occurs. The goal is to get the patient to the hospital as soon as the ST shifts occur, and sometimes before symptoms are realized.

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

Our average D2B time is 67 minutes. Since we initiated our STEMI program, we have utilized group paging, designated parking for the on-call team, created a STEMI flow sheet and order sets in the emergency department (ED), and keep our cath lab STEMI supplies grouped in an easy-to-reach bin. We provide on-call rooms for our staff for bad weather days. At our monthly review of STEMI cases, we break down the response times for each group to identify areas needing improvement. Our ED medical director shares the ED response times with the ED physicians at their monthly staff meetings. Emergency medical services (EMS) is represented at the monthly STEMI case reviews and provides feedback to the EMS crews. Case reviews (positive EKG, pre and post coronary intervention snapshots, and a brief story) are posted outside of the ED for review by the ED and EMS staff involved.

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

Almost always, the cath lab staff transports patients to the lab.

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

With only one cath lab, we have a protocol for just that scenario. If there is a patient on the table that cannot be safely removed in a timely manner, the cath lab team will divert the STEMI patient to our interventional radiology (IR) room after consulting with the IR physicians. With our complicated vascular procedures and pacemaker insertions, this occurs 3-4 times a year. We split our staff so that our nurses and technologist work with the interventional cardiologist in the IR room, and the other staff complete the procedure in progress in the cath lab. One staff member from the department is designated as the runner to take additional supplies and equipment between the two rooms.

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

We try to consign as much product as possible. For most products, the purchasing department utilizes a reverse bid process on an annual basis for standard stock items. On occasion, we have also done bulk buys on our pacemaker and ICD leads and generators.

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

In addition to our daily quality checks of equipment, we are responsible for monthly departmental quality checks that are documented and kept on file. Our manager meets monthly with the quality department to review core measure data and quarterly with the procedural sedation quality committee. Our monthly STEMI review meetings are multidisciplinary. Our staff is responsible for completing      annual competencies, online HealthStream modules, performing yearly lead checks, reviewing individual radiation doses, and monitoring high fluoro dose cases. Patient satisfaction scores are reviewed monthly. 

How are you recording fluoroscopy times and dosages? 

Fluoroscopy times and doses are recorded for each patient in their Mac-Lab report, as well as in a radiation procedure log that is kept on the unit. The technologists keep an additional record of any cases with fluoro time greater than 60 minutes.

Who documents medication administration during the case?

The nurse that is monitoring the Mac-Lab is responsible for medication documentation. If an anesthesiologist is involved in the case (usually for an pacemaker insertion or EP ablation), there is an additional medication log from them. All medications that are given after the Mac-Lab case is closed are documented in the hospital computer base. The Mac-Lab report, along with any other forms used during the case, is scanned into the electronic medical record.

Are your physicians dictating their cath procedure reports, or do they use a structured reporting tool?

Our doctors are still dictating.

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

Yes, we currently use the ACC-NCDR for PCI and ICD.

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

The majority of our patients are from our primary 5-town service area. Many of our vascular patients are referred from surrounding towns for the complex venous procedures being done by our vascular surgeons in the cath lab. Our hospital has formed an alliance with the Western Connecticut Health Care Network.

How are new employees oriented and trained at your facility?

Following a hospital-based orientation, new members in the cath lab receive an extensive orientation to the operations of our lab. Our nurses are required to have critical care experience. All new staff members are assigned a preceptor and complete a formal 8-week orientation in the lab.

What continuing education opportunities are provided to staff members?

We organize many inservices to stay up to date on the newest trends in cardiovascular techniques. We utilize our local American Association of Critical Care Nurses (AACN) chapter for educational opportunities. We have frequent new product inservices from vendors. Our nursing department recently partnered with an online program for continuing education. Our staff also conducts educational presentations to the hospital nursing staff on cardiac topics and post-procedural patient care.

How do you handle vendor visits to your lab? 

Vendors are required to call ahead for an appointment with the lab or are booked ahead of time by the physician for a specific case. All vendors are registered with a vendor system and are required to stop at security.

How is staff competency evaluated?

All cath lab employees are required to complete yearly competencies that include computer based HealthStream training, basic life support (BLS)/advanced cardiovascular life support (ACLS), yearly competencies modules with return demonstrations, and moderate sedation certification. We have weekly cardiac conferences and many active continuing education unit (CEU) programs available throughout the year. Staff members are encouraged to complete outside certifications.

Does your lab have a clinical ladder?

Yes, the nursing clinical ladder program began in 2013.

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

Currently, two RNs and one RT make up the on-call team. We have an additional per diem nurse and tech that take some of the call assignments. However, with such a small staff group, call is frequent.

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

Thirty minutes.

Do you have flextime or multiple shifts?

We currently have a combination of eight- and ten-hour shifts.

Has your lab recently undergone a national accrediting agency inspection? 

Over 3 months, we were inspected by three accrediting groups: the State of Connecticut for licensure, the Joint Commission, and the Society of Chest Pain Centers (SCPC). Norwalk Hospital is currently being reviewed for membership in the Society for Chest Pain Centers. Under the State and Joint Commission inspections, there was a great deal of focus on patient safety: time outs, labeling fluids on the sterile field, and handoffs. In the SCPC inspection, we saw a heavy focus on data.

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

Our cath lab is located directly behind the emergency department (about 100 feet) and has a direct-flow elevator to the operating suites.

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

Our vascular procedures have seen innovations in crossing devices that are being utilized. We also perform many venous procedures for May-Thurner syndrome, thoracic outlet syndrome and deep vein thrombosis clot extraction.

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

We describe ourselves as “the best little cath lab in Connecticut”. We are a one-room lab, but do a wide variety of procedures. Our team is small and extremely devoted to the lab, working closely with our physicians. Our goal is to uphold the highest standards, and to provide the best in patient-focused care. Our physicians respect our skill base, and our knowledge of procedures and supplies, and often ask for our assistance during complex OR cases. Our nursing staff serves as a resource throughout the hospital.

Is there a problem or challenge your lab has faced? 

Connecticut is a certificate of need state. Our application for an elective angioplasty program was recently denied, despite being the sixth largest city in Connecticut and having no competing programs in our service area. We must continue to transfer large numbers of cardiac patients to neighboring hospitals for elective interventional procedures. 

We have also recently seen a shift in some of our vascular volume, from the cath lab to several off-site vascular centers in our area.

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 located in southern New England, and service a very diverse economic and cultural community. There are many providers in our area, as well as easy access to facilities in New York City. We embrace our role as a community hospital and work hard to service the community’s needs.

A question 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?

Certification is encouraged, but not required. The hospital does provide a monetary incentive for certification. 

A question from the American College of Cardiology’s National Cardiovascular Data Registry: 

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

Quarterly NCDR data are initially reviewed by the manager and medical directors. Any problem areas are identified and addressed. The data and our findings are reviewed by the hospital’s chief of medicine and by the quality director.