St. Joseph Mercy Oakland

St. Joseph Mercy Oakland (SJMO) is a 443-bed, Pontiac, Michigan-based, comprehensive, community and teaching hospital that continues to receive awards of excellence in medicine. Our clinical and high-quality outcomes rank among the top 10 percent of hospitals nationwide. The SJMO Heart Institute was recognized by Thomson Reuters as a national Top 100 Heart Hospital, and SJMO was named a Blue Cross/Blue Shield of Michigan and Blue Care Network Cardiac Center of Excellence. Tell us about your cath lab and staff. We have four cath labs. Two are mainly for heart procedures, one is for peripheral vascular procedures and one is for neurovascular/electrophysiology (EP) procedures. We have a 12-bed holding unit where our patients are prepped for their procedure and recovered. The holding unit is for outpatient procedures and patients awaiting post intervention rooms. We also have a procedure room where we complete the following tests: transesophogeal echocardiogram (TEE), tilt table test, dobutamine stress testing, cardioversion, noninvasive program stimulation and transcranial doppler with bubble study. Our staff member mix includes: • 27 registered nurses (RNs) (including our director, clinical leader and educator); • 12 technologists: 2 cardiovascular technologists (CVTs), 5 radiologic technologists (RTs), and 5 registered cardiovascular invasive specialists (RCISs) • 2 patient care assistants (PCAs) • 3 schedulers in our office • 1 biller/coder Staff length of residence varies from our longest employee of 20 years to our shortest of a year. The average residence for our technologists is four years and our RNs is five years. What type of procedures are performed at your facility? We perform many different types of procedures, including: • Right and left heart catheterizations • Peripheral angiography and intervention • Cerebral/carotid angiography • Pulmonary angiography • Venography • Venous and arterial thrombolysis • Coronary intervention • Cerebral aneurysm coiling • Cerebral arteriovenous (A/V) malformation repair • Cerebral/carotid percutaneous transluminal angioplasty/stent placement • Pacemaker and implantable cardioverter-defibrillator (ICD) placement, including biventricular pacemaker/ICD placement and temporary pacemaker placement • Electrophysiology studies • Radiofrequency ablation with or without 3-D mapping • Tilt table testing • Dobutamine stress testing • TEE • Cardioversion • Bubble studies for evaluation of patent foramen ovale (PFO) • PFO closure • Inferior vena cava (IVC) filter placement • Valvular studies • Valvuloplasty • Definity contrast injection for imaging of echocardiogram • Abdominal aortic aneurysm (AAA) repair (endovascular approach) Approximately how many procedures are performed per week? We performed 155 total procedures per week in 2008. We had a total of 507 peripheral interventions in 2008. What percentage of your patients are female? In 2008, 43% of our patients were female. What percentage of your diagnostic cath patients go on to have an interventional procedure? In 2008, 74% of patients went on to intervention after the diagnostic catheterization. Who manages your cath lab? The cath lab is managed by our director and clinical leader. Both are RNs with their BSN degree. Who scrubs, who circulates and who monitors? We cross-train to some extent. Our technologists can run the computer hemodynamic gathering system, and they scrub almost all the procedures. The RNs give moderate sedation, monitor the patient and also can run our computer hemodynamic system. There are a few RNs that can scrub if needed. All of our staff can circulate and get equipment. Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab? No, but an RT has to be on site. Currently, 5 RTs are on staff in our lab. 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? Primarily, the x-ray equipment is operated by our technologists and physicians. However, there is some cross-training with our nursing staff. Can you tell us about the development of your peripheral program? Interventional cardiologists, neuro-interventional radiologists, neurosurgeons, and vascular surgeons (endograft procedure cut down) all perform peripheral procedures at SJMO. Several of our interventional cardiologists went off-site to be trained on peripheral interventional procedures. The cardiologists had to meet the following guidelines: Training: Formal fellowship training in vascular surgery, interventional cardiology, neurosurgery or cardio-vascular surgery, with demonstrated experience in peripheral diagnostic and interventional angiography, or Formal fellowship training in interventional radiology which results in a certificate of added qualification. Demonstrated experience to include a minimum: 100 diagnostic angiograms 50 interventions (25 of which the physician must perform as the primary operator) for interventional privileges. Activity to maintain privileges: Interventional privileges: 25 cases over a two-year period (cases include angioplasties, stents, filter placements, and embolization) Diagnostic privileges: 100 cases over a two-year period. A Toshiba dual-plane system (Tustin, CA) was installed in our peripheral lab, where a separate plane is used for peripheral procedures and another plane for cardiac procedures. In our neurovascular lab, we have a Toshiba bi-plane system in order to perform cerebral/brain intervention. It also has a large flat panel available for peripheral procedures. We have atherectomy equipment for the leg such as the Diamondback 360˚ orbital atherectomy system [Cardiovascular Systems Inc. (CSI), St. Paul, MN], SpideRX embolic protection device (ev3, Inc., Plymouth, MN) and the excimer laser (Spectranetics, Colorado Springs, CO). We have specific equipment for the carotid stent procedures, i.e. protective filters and stents designed for the carotid artery. Cerebral intervention requires specific guides such as the Envoy guiding catheter (Cordis Neurovascular, Miami Lakes, FL), thrombectomy with the Merci Retrieval device (Concentric Medical, Inc., Mountain View, CA) and Penumbra device (Penumbra, Inc., Alameda, CA), Wingspan stent (Boston Scientific, Natick, MA), Neuroform stent (Boston Scientific/ Target Therapeutics, Freemont, CA) and many types of coils for the aneurysm repair. Some additional therapies added to our peripheral lab include the MicroSonic Accelerated Thrombolysis system (Ekos Corporation, Bothell, WA) and Trellis Peripheral Infusion System (Bacchus Vascular, Inc., Santa Clara, CA), devices that assist with thrombolysis for both arterial and venous thrombus. Does your lab have a clinical ladder? No, we do not have a clinical ladder. What are some of the new equipment, devices and products introduced at your lab lately? We have recently added the Mynx closure device (AccessClosure, Inc., Mountain View, CA), D-stat Flowable (Vascular Solutions, Inc., Minneapolis, MN) for oozing sites, intravascular ultrasound (IVUS, Volcano, San Diego, CA), neurovascular glue for aneurysm repair, Toshiba biplane equipment and 3-D imaging for neuro patients with aneurysm/ strokes. We also have the newest drug-eluting stents, Endeavor (Medtronic, Minneapolis, MN) and Xience V (Abbott Vascular, Redwood City, CA). Radial access has increased, which has brought us the newest equipment for that approach. We have Biosense Webster (Diamond Bar, CA) mapping equipment for radiofrequency ablation and transseptal access for ablations using intracardiac echocardiography (ICE) guidance. We have begun using the Impella device (Abiomed, Inc., Danvers, MA), one of the newest left ventricular assist devices. Most recently, we have acquired a new flow reversal system for carotid intervention. Can you describe the system(s) you utilize and how they work in cath lab daily life? The Witt hemodynamic monitoring system (Philips Medical Systems, Bothell, WA) is used for all our documentation and pressure measurements; this system allows us to have all of our cases in one location. Training on one system is much easier for staff than multiple systems. We also have an archival unit for all of our digital images (Medcon, a McKesson company, San Francisco, CA). It allows physicians to review images from home or their office, which can be a life-saving measure. Does your cath lab do electives on weekends and or holidays? We do not routinely schedule cases on weekends or holidays. However, on occasion a physician may ask to schedule a procedure for a patient. The call team would be the staff to take care of the case or we may ask staff not on call to come in for that particular case. How is coding and coding education handled in your lab? We have a full-time coder in our unit that has 10 years of experience in cath lab billing and coding. She works hand-in-hand with our billing department and helps our physicians and staff document or dictate what is important to the reimbursement of a procedure. How does your lab handle hemostasis? We mostly use the Mynx closure system. We have one physician that primarily uses the Angio-Seal closure device (St. Jude Medical, St. Paul, MN). If we need to use manual pressure, we have an external hemostasis pad, D-Stat Dry (Vascular Solutions), that is used to assist with hemostasis. We also have FemoStop (Radi Medical Systems, Wilmington, MA) and c-clamp that can be used to assist in a manual sheath pull. Patients have the closure devices placed on the cath lab table. If their sheaths are left in, then they go to either our holding unit or our post interventional unit, and have their sheath pulled by the cath lab staff when their activated clotting time (ACT) is less than 160. Does your lab have a hematoma management policy? Yes, we have a policy for sheath removal and bedrest that details what steps to take as well as bedrest, vital sign, groin site and pulse check requirements. How is inventory managed at your cath lab? We use the Omnicell equipment management system (Mountain View, CA). We also have a lead tech position, and he handles all ordering of other equipment that is not able to fit in our Omnicell. Has your cath lab recently expanded in size and patient volume, or will it be in the near future? We have expanded a great deal over the last several years. Nine years ago, we had two labs. Currently, we have 4 labs (one for EP/neuro, one peripheral, two cardiac labs), a 12-bed holding unit, procedure room, dobutamine stress echo and equipment storage room. Our patient volume has tripled over the last five years due to expansion in our programs. For the future, we have been approved for new equipment for one of our cardiac labs that will be converted to a cardiac and peripheral lab. Is your lab involved in clinical research? Yes, our hospital has a research department and they involve us in many studies. Currently, we are involved in the following clinical research studies: ART-123: The purpose of this study is to see if ART-123 (recombinant human soluble thrombomodulin) decreases the number of people who die as a result of disseminated intravascular coagulation (DIC) complication of sepsis (Artisan Pharma, Inc.). ACCESS: The Boston Scientific ACCESS trial seeks to study the safety and to evaluate the success of the Fusion Vascular Access Graft for patients in need of early vascular access for hemodialysis (Maquet Cardiovascular). Alsius Thermoguard Intravascular Temperature Management: (Alsius) Ascend HF: Double-blind, placebo-controlled, multicenter acute study of clinical effectiveness of nesiritide in subjects with decompensated heart failure (Scios Inc.) IMPROVE-IT: a multicenter, international, randomized, controlled trial which compares the combination of ezetimibe/simvastatin versus simvastatin alone on cardiovascular outcomes in patients recovering from an acute coronary syndrome (Merck/Schering Plough joint venture). SAPPHIRE Worldwide: The primary objective of this study is to assess the outcomes of stenting with distal protection in the treatment of obstructive carotid artery disease. The devices to be utilized are the Precise Nitinol Stent Systems (5.5F and 6F) and the Angioguard XP Emboli Capture Guidewire (Cordis Corporation). TAMARIS: nonviral DNA delivery technology to treat critical limb ischemia (Sanofi-aventis). TRA-CER: A multinational, randomized, double-blind, placebo-controlled study of a novel oral thrombin receptor antagonist (TRA) in approximately 10,000 patients with non-ST-segment elevation acute coronary syndrome (Schering-Plough). SPIRIT V: A continuation in the assessment of the performance of the Xience V everolimus eluting coronary stent in the treatment of patients with de novo coronary artery lesions (Abbott Vascular). Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? No, we have not had any requiring emergent cardiac surgery. What other modalities do you use to verify stenosis? Are you using physiology for lesion assessment? We have the PressureWire (Radi) and IVUS to assist us in verifying stenosis and lesion morphology. We have had success in reimbursement of these items. What measures has your cath lab implemented in order to cut or contain costs? We use the Lawson ordering system (St. Paul, MN) that assigns item numbers to each product ordered. These numbers can be used for all hospitals in the Trinity Health System, which saves time and money. Many of the products are under contracts that are negotiated at the corporate level. What type of quality control/quality assurance measures are practiced in your cath lab? We have staff that are dedicated to quality control of our x-ray testing every morning, ACT machine, oxygen saturation testing machine, defibrillator testing, intra-aortic balloon pump (IABP) and refrigerator/blanket warmer temperature testing. We are actively involved in continuous quality improvement for our customers. In the last two years, we have implemented throughout the hospital, starting with cath lab, the use of a contrast nephropathy prevention protocol based on evidence-based research. Nephrology and cardiology came together with lab, pharmacy, radiology and physician offices to make sure patients are evaluated for risk factors of contrast nephropathy. All our patients get blood urea nitrogen (BUN) and creatinine ordered, and a glomerular filtration rate (GFR) calculated and history obtained regarding these risk factors. If they are found to be a risk, the patients come in early for hydration with sodium bicarb drip or normal saline, and acetylcysteine (Mucomyst). They also get certain medications held that may increase their kidney risk, such as diuretics and non-steroidal anti-inflammatory drugs (NSAIDS). The cath lab director and educator subscribe to many publications to keep current on practices in our field. Our staff attends one peripheral, one cardiac/peripheral and one EP conference each year to advance our knowledge base on all of the most recent research and devices. How does your cath lab compete for patients? Has your institution formed an alliance with others in the area? We have a number of ways we compete in our area. We advertise about our top 100 cardiovascular award, we are involved in community service such as Legs for Life, where we screen for peripheral vascular disease (PVD), and we use survey techniques to allow patients to critique their stay and make recommendations for any changes that they feel would assist in improving our hospital in any way. We keep current on all of the latest technology. Our cardiologists promote this fact and discuss it with other primary care physicians. Word of mouth is a powerful tool! How are new employees oriented and trained at your facility? What licensure is required for all professionals who work in your lab? We have a 6-month orientation process for anyone new to the cath lab environment, and we recommend that our nurses have critical care experience. Our staff must keep all their certifications up to date. Our techs must take their registered cardiovascular invasive specialist (RCIS) certification within a year of completing their CVT program. We encourage our RTs to also take a course for the RCIS and take the test for certification. All staff must also be advanced cardiac life support (ACLS)-certified. Staff is required to complete competency evaluations for all equipment that may not be used daily. What types of continuing education opportunities are provided to staff members? We have a designated educator that looks for many opportunities for continuing education units (CEUs) on a weekly basis. We also have an annual education day, called “Clinic Day,” where the lab is closed except for emergencies and speakers come in to present on topics related to our field. The educator has approval by the American Society of Radiologic Technologists (ASRT) for Category A contact hours for our RT, CVT and RCIS staff to earn on Clinic Day as well. This day provides the staff with around 7-8 contact hours at one time. We also send staff to training off-site for equipment that may earn more contact hours or Category A contact hours. For the last few years, we have been able to send staff to major conferences. Our hospital has an Education Council that plans a speaker each month on various topics, and if they attend, the staff can earn a contact hour. We have a bulletin board for education in which many article-based or web-based opportunities are displayed for the staff to take from home or during down time at work. Our hospital has a web-based learning system called HealthStream (Nashville, TN) that has some CEU opportunities available as well. How do you handle vendor visits to your lab? Any vendor must schedule their day in the lab with our lead tech. Once they have arrived at the hospital, they must check in with purchasing and get a name tag. They are allowed to remain in the lab, unless they are asked to leave for some particular reason. We can and do ask them to leave when we feel it is necessary. Vendors also schedule in-services for particular equipment and/or medications with our lead tech and educator. How is staff competency evaluated? Many different techniques are used to assess competency. We have monthly competency days, in which the staff is tested on ability and knowledge of any equipment that is not used on a daily basis. We have the nursing staff complete moderate conscious sedation, glucometer and urine human chorionic gonadotropin (hCG) testing yearly. The educator monitors the staff to make sure they are current on ACLS and basic life support (BLS), as well as their license status. The hospital systems have web-based competency evaluations scheduled for each staff member throughout the year on a number of topics, such as back safety, medication pass safety, Health Insurance Portability and Accountability Act (HIPAA) and documentation, and many other topics. Does your lab utilize any alternative therapies (such as guided imagery, etc.)? We play music during all of our cases unless a patient or physician requests otherwise. We have TV and internet access in every room in our holding unit, which allow patients to play music or watch videos related to the procedure. Our hospital has a comfort cart that has music, blankets, books, prayer books, bibles, and beautiful pictures of the ocean and other areas for patients to read or focus on during their stay. How does your lab handle call time for staff members? The RNs are on call about one day per week and every 6th to 7th weekend (Friday 7:30 pm to Monday 7:00 am) and one holiday a year. Our technologists are on call about one day per week and every 5th weekend, plus one holiday a year. Each day, we generally have two techs and two RNs on call. Occasionally, we will have three RNs and 1 tech on call. We do not have much flex time, but on occasion, the manager will look at the schedule and ask someone to be on standby. We work 12-hour shifts for the most part, but some staff are 80-hour per pay period employees that work one extra 8-hour shift every other week. Our lead tech, clinical coordinator and one other tech work 8-hour shifts. Our director also works at least 8-hour shifts. Our cath lab holding staff flex depending on the schedule of outpatients, and they work 10- and 12-hour shifts. What trends do you see emerging in the practice of invasive cardiology? We see more procedures headed to invasive cardiology that used to only be done in the OR, such as valve repair/replacement and AAA repair via endograft approach, increasing EP procedures from biventricular ICDs to many more types of ablation, and evolving types of stents, from dissolvable to absorbable. We also see a future with the development of the hybrid lab concept. Has your lab has undergone a Joint Commission inspection in the past three years? We have recently undergone a Joint Commission inspection and did very well. Plan ahead and start doing all the recommendations from the Joint Commission long before they schedule a visit. We also recommend creating pocket guides for your staff to learn those items the Joint Commission has prioritized as most important for hospitals to be achieving right now. Where is your cath lab located in relation to the operating room (OR), critical care unit (CCU) and emergency department (ED)? We are one floor up from OR, but have an elevator that will go straight there. We are right next to the CCU. Our new ED is two floors and a separate building apart. What is unique or innovative about your cath lab and staff? We have cutting-edge physicians that bring every new procedure or equipment to our facility. We also have highly qualified staff with excellent skills in emergency management and quick turnaround time. These two things, along with the extensive educational/training we provide to new staff, make our lab a unique and innovative place to work. Is there a problem or challenge your lab has faced? Our challenge has been the fluctuating census due to the auto industry and decreasing population census in Michigan. The economy can truly affect your census if people are moving out of state. We have addressed it by expanding our cath lab to include other types of procedures such as neurovascular, EP, AAA repair via endovascular approach and any other percutaneous procedures that can be treatable in the cardiac cath lab. 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 30 minutes from Detroit (the “Motor City”), which gives us a lot of great resources for fun. We have five professional sports teams in our area, four of which have been winning regularly for years. We are very lucky to have the Great Lakes close by for our boating, ice fishing and swimming pleasure. There is a lot of history in our area, as well as art and music. Our “cath lab culture” and census is affected by the migration of snowbirds going south for the winter, as well as the many people who go up north in the summer. 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? Our CVTs do take the exam, usually within one year of completion of their program. They do receive a raise for passing the exam and are placed in a higher pay grade. 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? Some of our staff are American Association of Critical-Care Nurses (AACRN) and American Heart Association (AHA) members. Our director of invasive cardiology, Kirit Kumar Patel, MD, FACC, is a member of the SICP, the American College of Cardiology (ACC), AHA, American Medical Association (AMA), Oakland County Medical Society and Michigan State Medical Society. Our director and our clinical leader are both members of the ACC. The authors can be contacted via Wendi Santavicca at: santaviw@trinity-health.org

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