Staffing Complex Procedures at Deborah Heart and Lung Center

Can you tell us about the cath lab at Deborah Heart and Lung Center?

Currently, we have three cath labs, with an additional lab under construction. We also have a dedicated endovascular lab for peripheral procedures that is housed within the Radiology department.  The three cath labs are primarily cardiac cath labs; however, we do perform peripheral and structural procedures in those labs as well. The fourth lab, which will hopefully be open and functioning by August of this year, will be a swing lab, outfitted for cardiac, peripheral, and structural procedures.

What are the different types of procedures you do?

We do the entire spectrum of coronary procedures, from diagnostic catheterization and angiography to complex cardiac interventions. We are proficient in all the adjunctive interventional devices and equipment, including fractional flow reserve, intravascular ultrasound, rotational and laser atherectomy, intra-aortic balloon pumps, and percutaneous left ventricular assist devices. With regards to peripheral procedures, we again perform the entire range of peripheral angiography and interventions from head to toe, including carotids, subclavians, renals, mesenterics, iliacs, femoral, and even below the knee for limb salvage. Aortic interventions, including percutaneous coarctation repair and endovascular abdominal aortic aneurysm repair, are also performed by our interventionalists in conjunction with the vascular surgeons.

You also have a congenital and structural heart program.

We have been involved in congenital heart procedures for a long time, but we have recently expanded to include advanced structural heart procedures as well. We perform percutenous closures of atrial septal defects (ASDs), ventricular septal defects (VSDs), patent foramen ovale (PFO), and patent ductus arteriosus (PDAs). We also perform coiling of anomalous coronary pulmonary fistulas and arteriovenous malformations. We have recently begun repairing paravalvular leaks in the aortic and mitral positions, in addition to aortic and mitral balloon valvuloplasties.

Can all your labs accommodate congenital and structural procedures?

Yes, but we tend to do them in our largest lab with biplane imaging, which also has anesthesia lines, allowing immediate access to general anesthesia when needed. We also have a hybrid OR under construction, which will allow the performance of complex cases within that lab.

Are you also doing transcatheter aortic valve replacement (TAVR)?

Not currently, but upon completion of our hybrid OR in 2013, we anticipate having this cutting-edge technology. It will not only be a collaboration between interventional cardiologists and cardiothoracic surgeons, but also between the cath lab staff and the OR staff within the new space of the hybrid OR.

Are all the physicians utilizing your lab interventionalists?

Yes, our cath lab physicians are interventional cardiologists that are employed by the hospital. All of them do coronary, peripheral, and structural cases, allowing our physicians to cross-cover all hospital cases.

Does your program train fellows?

Yes. In fact, Deborah Heart and Lung Center has the largest osteopathic cardiology fellowship program in the country (18 fellows). Moreover, this is also the largest osteopathic interventional cardiology fellowship program (4 fellows) and the only osteopathic endovascular training program in the country. There are one to two fellows (usually 1 general and 1 interventional cardiology fellow) and 1 attending scrubbed into every case in the cath lab.

Tell us about your staff.

At this time, our staff consists of 15 members, with varying credentials. We have registered nurses (RNs), radiologic technologists (RTs), cardiovascular technologists (CVTs), registered cardiovascular invasive specialists (RCISs), and cardiac-interventional radiographers (CIs). We have no licensed practical nurses (LPNs).

How many staff is needed per procedure?

There are usually two staff members in the actual procedure room and one recording, for a total of three staff members assigned to each case. One of the two staff members in the procedure room will be an RN, but the others assigned to the staff can be any mix.

Nurses circulate and technologists scrub in?

Correct. The nurses circulate and administer medications while the tech is either scrubbed in or feeding the table, making sure that the physicians have all the equipment they need. However, nurses are able to and encouraged to scrub in whenever necessary.

Do you encourage your staff to take the registered cardiovascular invasive specialist (RCIS) exam?

I do encourage my staff to get the RCIS. Currently, we have two RTs that are studying for their RCIS exam.  And for RNs, we encourage them to get a critical care nurse certification (CCRN) and the RCIS as well. There is also the CI credential (cardiovascular intervention), offered by the American Society for Radiologic Technologists — I do have one CI staff member.

How does staff typically come into your lab?

RNs must have at least three years of critical care experience and be advanced cardiac life support (ACLS) certified. Usually CVTs come in with at least one to two years of experience either in specials, interventional radiology, or even cath lab experience. On occasion, we have even hired some RTs that are green, with no experience, and trained them ourselves.

Do congenital procedures require any additional staff or certain staff only?

No, although at first, only a select team did these procedures. We don’t believe that this experience should be limited to certain staff members. I strongly believe that every staff member should be able to participate in all cases. Everyone in our lab has been or will be exposed to congenital and structural procedures.

Generally, we maintain three staff members to the room; however, the complexity of the case will determine whether we need to increase staffing. If we feel that there may be increased staff requirements for a given case, we may boost the staffing to four members.

Would that typically be another RN?

Yes, at that point, if I do have to bring in another staff member, I would try to add an RN.

Do you ever need to bring in staff from the OR or any staff specific to anesthesia?

Occasionally, based on the needs of the given case. For our paravalvular leak repairs and some of our structural heart cases, the patient does need to go under general anesthesia, requiring the presence of the anesthesiology team in the lab.  Some of the complex structural heart cases are guided with transesophageal echocardiogram (TEE), requiring representation from the echocardiography team. The TAVR cases will require integration of interventional cardiology, cardiothoracic surgery, echocardiography, and anesthesiology teams.

How does your lab handle staff education?

All staff members are encouraged to attend major cardiovascular conferences. In effect this year is a policy whereby we will send staff members to three major conferences per year. We also have regional symposia that will be attended by some. We periodically send staff members to other hospitals for training and observation. Also, we have a monthly staff meeting, where new cath lab procedures are reviewed by our staff. Finally, there are weekly Cath and Vascular conferences, where cases are reviewed and staff members are encouraged to attend.  

How do your physicians encourage staff education?

They encourage staff going to major conferences and feel that there is great deal of benefit from doing so. Our physicians are extremely supportive of the vision that all staff members should be able to perform all procedures and are even agreeable to delay lab start times for staffing education and equipment in-service as needed.

How do you handle call?

We take one week of call at a time. It starts on a Friday night and goes until the following Friday morning. With that, there are always three to four staff on call. Currently, according to our staffing ratio, staff are on call one out of every four to five weeks.

What about pre and post procedure care for complex procedures?

Outpatients that arrive the same day of their procedures come into our intake and recovery unit. The unit does a basic assessment, and asks general questions as far as medications, allergies, and so on. IVs are started and the patient is prepped for the procedure. The patient will then come up to the cath lab holding area, located within the cath lab. Again, a final check is done to make sure that there has been appropriate prep and that we have functional IVs. If the patient needs any type of premedication, that is addressed at this point.

If the patient has general anesthesia during the procedure, they will need to go to our surgical ICU for anesthesia recovery. If the patient does not receive general anesthesia, the difficulty of the case will determine whether the patient needs to go to an intensive care unit or the interventional unit post-procedure.

What are the differences between a standard intervention and a paravalvular leak repair?

Paravalvular leaks are done under general anesthesia and with TEE guidance, and require a greater amount of equipment in the room. These cases require additional staff, including the anesthesia and echocardiography team members. These patients will be recovered from their anesthesia in the cath lab and then transferred to the holding area, and subsequently to the SICU. While standard interventional patients go home the next day, a paravalvular leak patient may stay for an additional day.

When you prep paravalvular leak patients, is it standard groin prep?

Yes, it is a standard groin prep. Generally those patients get a Foley, and depending on anesthesia, they may get an arterial line. We also may use a warmer for patient comfort.

What about medication?

Diagnostic and interventional cardiac and peripheral patients will usually receive conscious sedation. They may also get some type of an anxiolytic premedication, whether it is Valium, Ativan, or Xanax, prior to the procedure. However, our carotid patients will not receive any type of sedation whatsoever, due to the need to assess appropriate neurologic status throughout the duration of the procedure. Our congenital and structural patients routinely get moderate sedation, although if they need TEE guidance, they will get general anesthesia. Conscious sedation to moderate sedation is administered by a trained cath lab nurse who is ACLS certified. Obviously, general anesthesia is administered by an anesthesiologist.

What about pulling sheaths?

Most outpatients receive vascular closure devices post-procedure for earlier ambulation and discharge. However, if it is a manual sheath pull, it is generally done by our staff in our cath lab holding area.

What has been most challenging as your program has grown?

As our program developed, we were very short-staffed, so we had to bring new staff members on board. It was challenging, because our experienced staff members needed to be brought up to speed and trained, and then into that mix, we brought brand new staff members who needed even more training. Learning about the different procedures and equipment was all very challenging. Even now, with the amount of peripheral and structural procedures that we are involved in, education is still a work in progress.  From the staff’s standpoint, I think their biggest challenges would be education and becoming comfortable with these types of procedures.

Behind the scenes, another issue we face is dealing with inventory. These cases, not only congenital and structural procedures, but with everything our physicians are doing, put a big demand on inventory: Where are we going to put it? Does everyone know what it is? How are we going to work with the vendors to bring it in? Education and inventory are probably my two biggest issues.

What is your system for inventory?

Our current system involves every piece of equipment being entered into our monitoring system. We do have ancillary staff members, including cath aides, who are solely dedicated to inventory. They pull from the computer everything that has been used, and based on par levels, order new supplies accordingly.

How do you handle getting new devices or infrequently used devices?

Generally, when devices first come in, they arrive on consignment. We do try to have most of our inventory on consignment for those things that are not frequently used, or we try to accommodate a deal wherein we get a discount for a larger stock.

What about billing?

We have a billing department that works very closely with the cath lab. There are several levels of review to ensure that we are billing appropriately and receiving the appropriate reimbursement, especially on those complex cases.

Is your cath lab involved in research?

Yes, a significant amount of clinical research is going on now at Deborah, with almost 30 active clinical trials. This allows us to be involved in many unique and cutting-edge procedures.  We are involved in: CONNECT II (Avinger), evaluating the safety and efficacy of Ocelot, a chronic total occlusion catheter incorporating optical coherence tomography; SYMPLICITY (Medtronic), assessing renal denervation for refractory hypertension; CANOPY (Abbott), following carotid artery stenting for standard risk patients; LEVANT (Bard), evaluating a drug-eluting balloon for superficial femoral arterial (SFA) lesions; and EXCITE (Spectranetics) using laser atherectomy for in-stent restenosis; just to name a few. Research is a big component of our work at Deborah and we anticipate additional growth within this area in the near future.

Do you have research nurses?

Yes, we have a research department that employs research RNs to handle all our active trials. They also provide in-services for the staff to educate them on the protocols. The research nurses are always present for the study procedures.

Then you have an additional staff member in the room for the research cases?

Yes, they are in the control room, offer support as needed, and make sure that they get all the appropriate documentation.

How do you keep a sense of unity among staff?

We are definitely trying to merge the realm of RT and RN, in the sense that we want everyone to feel comfortable in the cath lab and in their roles. We want everyone in the lab to feel important in contributing to the success of the procedure. Obviously, we know the limitations — RTs are not going to administer medication, and RNs are not going to deliver radiation. However, in trying to merge those realms, it helps to build a real team mentality and ownership.

Valerie Harris, RN, can be contacted at HarrisV@Deborah.org.