Sunnybrook & Women`s College Health Sciences Centre

Our team consists of: 30 RNs 3 RN coordinators for cardiac catheterizations and percutaneous coronary interventional (PCI) procedures 3 secretaries 3 patient service associates 2 patient administration associates 1 patient care manager 1 clinical educator 7 interventional cardiologists 3 in-house invasive cardiologists 2 outside invasive cardiologists 3 interventional cardiology fellows What is the mix of credentials at your lab, and how long have staff members been in residence? All RN staff are ACLS-certified and hold either a coronary care or critical care certificate. Of the RN staff, 68% have CCU, CVICU or critical care nursing experience, and the remaining 32% have a cardiology nursing background. Thirty-six percent of the RN staff has completed the Canadian Nurses Association Specialty Exam in either cardiovascular or critical care nursing. Our most experienced RN staff member has been in the cath lab for 15 years and our most recent staff member joined the team in June 2005. Our cardiologists have between 2 and 36 years of cath lab experience, with a median of 12 years. What types of procedures are performed at your facility? As of the current fiscal year (begun April 1, 2005) we anticipate performing the following procedures in our cath labs: 1800 PCIs 3400 diagnostic caths 150 electrophysiology (EP) studies 101 EP ablations 300 pacemaker implants 150 implantable cardioverter-defibrillator (ICD) implants (including biventricular ICDs) 170 other procedures, such as intra-aortic balloon pump (IABP) insertions, pericardial taps and insertion of temporary transvenous pacing wires. Approximately how many are performed each week? On a weekly basis, we perform approximately: 36 PCIs 68 diagnostic caths 5 EP procedures 2 EP ablations 6 pacemakers 3 ICDs 3 other procedures. Does your lab perform peripheral interventions? No. Our lab is strictly a cardiac centre. Peripheral interventions are performed in the interventional radiology suite. There is some preliminary discussion regarding research; however, there are no concrete plans to move peripheral interventions to the cath lab. Does your cath lab perform primary angioplasty with surgical backup? We perform primary PCI with full cardiovascular (CV) surgical backup. At S&W, we have a full-service cardiac surgical program, on call 24/7. What procedures do you perform on an outpatient basis? Diagnostic caths, EP studies and pacemaker implants are all offered on an outpatient basis. What percentage of your patients are female? Approximately 30% of our cath and PCI patients are female. What percentage of your diagnostic cath patients go on to have an interventional procedure? In the most recent fiscal year, 23% of our diagnostic cath population went on to have an ad hoc PCI. Of our PCI patients, however, about 45% had their PCI at the same sitting as their diagnostic cath. Since there are several high-volume cath labs in the Toronto area that perform only diagnostic angiography, many of our PCI referrals are from these outside hospitals and by definition do not have the PCI at the same sitting as the diagnostic cath. Who manages your cath lab? Our patient care manager and the cath lab medical director manage the cath lab collaboratively. Operational issues are discussed at monthly cath lab management committee meetings in order to foster team decision- making. This committee includes the director of operations, the patient care managers of the cath lab and cardiology, and the medical directors of the arrhythmia program and the cath lab. The entire cath lab team meets quarterly to address any issues related to team function and/or to communicate to the group joint issues and upcoming events. Does your lab have cross-training? All cath lab RN staff are cross-trained for many roles traditionally handled by cardiovascular technologists. This became necessary several years ago because of a shortage of trained cardiovascular technologists (there is only one training program in Canada) and the absence of a formal credentialing mechanism or professional body for technologists in Ontario. Cross-training has allowed us to increase the complement of RNs to address patient care and on-call issues, and is consistent with the hospital’s philosophy of Patient-Focused Care. The expanded scope of the RN role has enhanced job satisfaction, and the opportunity to regularly rotate through the control room and take the lead apron off reduces fatigue. On the other hand, there have been some challenges ensuring adequate familiarity with specific tasks such as complex hemodynamics. A small number of RNs have undergone additional training and serve as our resource staff for more complex cases. Who scrubs, who circulates and who monitors? Registered nurses perform all of these duties. The roles are rotational on a case-by-case basis in a collaborative atmosphere. There is a great deal of flexibility in this model. Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab? No. We no longer have radiation technologists in the cath lab. As the technology changed and the move was made from film to digital acquisition and archiving, their skill set was needed more acutely in the medical imaging department. We have been a filmless lab for nearly a decade and have had full online image storage since mid-2000. 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? Position the II: Physicians and registered nurses Pan the table: Physicians and registered nurses Change angles: Physicians and registered nurses Step on the fluoro pedal: Physicians only. This is a Regulated Controlled Act under the Regulated Health Professionals Act in Ontario. It cannot be delegated to RN staff, as stated by the College of Nurses of Ontario Practice Guidelines. Does your lab have a clinical ladder? No. There is no formal clinical ladder in our institution. RN staff salaries are determined by seniority as negotiated by the Collective Agreement. Staff are expected to maintain their competency according to the College of Nurses Guidelines. There are no steps per se; however, RNs are required to participate and record their attendance and participation in educational events. Onsite opportunities include weekly research rounds facilitated by the Department of Cardiology, combined cardiology/CV surgical rounds, and a monthly Cath Lab Practice Council. Two RN staff also represent the cath lab at a hospital-wide Nursing Council, which also meets monthly. Professional growth is supported by a cath lab education fund, which is used to support attendance at national cardiac meetings. Staff have attended such events as: Canadian Cardiovascular Congress Cath Lab Digest Symposium Heart Rhythm Society (NASPE) Transcatheter Cardiovascular Therapeutics (TCT) A number of live demonstration courses in Canada, including the Montreal Heart Institute Live Course and Cardiovascular Innovations Day (University of Toronto). Other various related workshops, i.e., hemodynamics and 12-lead ECG interpretation. Our institution requires RN staff to be current in advanced practice competencies, and therefore allots staff education time for Recertification Days every two years. This full day provides a review of skills such as IABP therapy, post-anesthesia (PA) line management, and pacemaker management, as well as administration of life-saving drugs and defibrillation. What are some of the new equipment, devices and products introduced at your lab lately? Being a busy referral centre, we have the latest technology for use with our patients. Some examples include: Multi-Link Frontier bifurcation stent (Guidant Corporation, Santa Clara, CA) MicroDriver stent (Medtronic Inc., Santa Rosa, CA) Cypher (Cordis Corporation, Miami Lakes, FL) and Taxus drug-eluting stents (DES) (Boston Scientific Corporation, Maple Grove, MN) were introduced in 2003 and are used extensively in our lab. However, cost pressures make it difficult to expand the use of DES beyond 50“60% of patients. At times, products are available in Canada prior to their release in the U.S., such as the X-Sizer thrombectomy catheter (ev3 Inc., Plymouth, MN) and the Taxus DES. Can you describe the system(s) you utilize and how they work in cath lab daily life? Our lab went filmless in 1997 and we moved to full on-line image storage in 2000 with installation of the Philips Inturis network (Bothell, WA) and a Storage Tek archive system (Louisville, CO). We recently upgraded to the newer Philips Xcelera digital archive. By virtue of being digitally-based, this system is very user-friendly. We can archive and retrieve cases quickly as well as burn or upload to or from CDs. We are currently training all staff on its use, since this is one of the functions of the control room person. The system can also be accessed by the surgeons in their offices or in the OR, as well as by the interventional cardiologists in their offices. Can you describe the layout of your lab? The layout of our lab is quite expansive due to the number of labs, storage rooms and offices. We are in close proximity to the cardiology ward that receives the PCI patients as well as the outpatient area that receives the prep and recovery patients. Importantly, we are close to the CCU and 3 floors directly above the emergency department. Although we don’t travel often to the CVICU and to the OR, they are a short elevator ride to a floor below. Since our growth occurred in stages, there is no central area for supplies, necessitating small quantities of inventory in each lab. This does lead to duplication of supplies and is not ideal from an efficiency point of view. This is one of the ongoing challenges working within an older hospital in a publicly funded system. How is coding and coding education handled in your lab? This is not applicable for the purposes of patient-level billing in Canada, since all cath lab procedures and equipment costs are covered for patients under their universal government-run health insurance. However, we do code procedures for the purpose of accounting between the hospital and the Ministry of Health, which is the payer for all of our work. RNs enter the procedure type in a simple cath-lab specific administrative database on completion of each case. How is coding communication handled with the billing department? The institution is funded via the Ministry of Health and Long Term Care. Our funding is tied to target volumes determined by the Ministry. If we are unable to achieve the target volumes, the institution must repay the Ministry for the amount dedicated per case. The volumes are reported to the Ministry on a monthly basis. Hospitals in Canada are run on a not-for-profit basis. The precise amount of procedure-specific funding is established by the Ministry of Health and often lags behind the cost of new technologies. However, we do have some flexibility in the use of residual funds (when they exist). For example, any money saved because of a reduction in the price of bare metal stents can be applied to the purchase of additional DES. Physician billing is done primarily via a physician-services corporation that represents all full-time hospital physicians (10 of our 12 cath lab physicians). How does your lab handle hemostasis? We utilize both manual clamps and arterial closure devices. We use Angio-Seal (St. Jude Medical, Minnetonka, MN) as our primary closure device and Perclose® (Abbott Vascular Devices, Redwood City, CA) as our secondary device. Anticoagulated patients tend to receive an Angio-Seal and diagnostic cath patients are managed with compressor clamps. FemoStop (Radi Medical Systems, Wilmington, MA) is used for failed closure device management of bleeds. Elective angioplasty patients are admitted after their procedure to a short stay bed for an overnight stay on the inpatient cardiology ward. Emergent or hemodyamically unstable patients recover in the CCU. Elective cath patients from home or those transferred from other hospitals (flyers) are prepped and recovered on the outpatient cath unit. They are either discharged home or returned to their sending hospital after their recovery period. This unit is staffed by the cath lab RNs as part of their scheduled rotation. Medical responsibility for the patient lies with the cathing physician. What other modalities do you use to verify stenosis? Are you using physiology for lesion assessment? (If yes, how has this affected your operating cash flow?) Both IVUS and PressureWire (Radi Medical Systems) are utilized for assessing stenosis. PressureWire is used on a limited scale, so there is not an enormous impact on the budget. How is inventory managed in your cath lab? Who handles the purchasing of equipment and supplies? Inventory is managed in collaboration with the clinical resource nurse and the patient service associates (PSAs). The resource nurse has the big picture of the various supply issues and the PSAs are responsible for unpacking of delivered supplies and stocking of the labs. Inventory is ordered through a variety of methods. Many of our basic supplies, i.e. custom packs, linen, control syringes, etc., are on a standing order and are delivered according to schedule. Other specific products, such as balloons, stents, guide wires, catheters, and niche items like Rotoblators® (Boston Scientific Corporation), and intravascular ultrasound (IVUS) supplies are ordered online via a company called Global Healthcare Exchange (Westminster, CO). Templates for our products, containing the various sizes and shapes we utilize, are created by the purchasing department. The clinical resource nurse, administration assistant and the patient care manager all have access to order supplies via this web browser. We can use a desktop computer or many of our devices are scanned using the industry bar codes. The orders are sent directly to the vendors as well as copied to our receiving department. We have found this process to be an enormous time saver as well as decreasing errors in transcribing product code and lot numbers to a paper requisition. Has your cath lab recently expanded in size and patient volume, or will it be in the near future? Our lab will soon add an additional research-oriented suite, called the Imaging Research Centre for Cardiac Intervention (IRCCI). This combined x-ray and MRI facility will be staffed by cath lab RNs when clinical procedures are performed. In addition, we have submitted a proposal to the Ontario Ministry of Health to add a fourth clinical suite, oriented primarily toward ICD and pacemaker implants, and potentially endovascular procedures. After several years of rapid growth, our cath and PCI volumes have been relatively stable for the past 2-3 years as our capacity approaches full utilization. We have had considerable growth in ICD implants and other electrophysiology procedures. Is your lab involved in clinical research? S&W participates in many research projects. We have four full-time interventional cardiology research RNs. Examples of recent studies include OAT, COURAGE, TAXUS II, TAXUS V-ISR, TAXUS-Atlas, C-SIRIUS, APEX AMI, TRANSFER-AMI, REPLACE-2, SYNERGY, OASIS-V, ACUITY, and so on. The study nurses collaborate with the cath lab staff to ensure accurate data collection and adherence to protocols. Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? Each year, two or three patients still require emergent surgery as a result of either cath-related or PCI-related complications. Our rate of PCI-related emergency coronary artery bypass grafts (CABG) has remained below 0.3% for several years. What measures has your cath lab implemented in order contain costs? Contract negotiations with commitments to vendors (e.g., % of total volumes) have been successful in supply price reductions. What type of quality control/quality assurance measures are practiced in your lab? At S&W, we have many quality control indicators. The Unit-Based RN Practice Council discusses professional issues relating to best practice guidelines. Weekly Royal College of Physician & Surgeons of Canada-accredited rounds include interventional cardiology research rounds; combined interventional cardiology/ CV surgery rounds and electrophysiology rounds. Participation in the Cardiac Care Network of Ontario database enables us to monitor our wait times and the number of cases we perform quarterly. The network has recently initiated a reporting process for all PCI hospitals in Ontario for mortality and emergency surgery following PCI. Quality assurance rounds are held quarterly to review cases and provide opportunities to improve practice. A patient satisfaction survey and follow-up form is in development for the outpatient area. PCI patients are included in S&W’s patient satisfaction surveys, which are reviewed on a quarterly basis. How does your cath lab compete for patients? Has your institution formed an alliance with others in the area? Being a referral hospital, we do not compete with other centres for patients. Our referrals are prioritized based on symptoms, facilitated by the triage and referral infrastructure of the Cardiac Care Network of Ontario (CCN). If lengthy wait times are identified as barriers to patient care at one hospital, the Central Triage office will locate a hospital with a shorter wait time and facilitate a transfer. An urgency rating score (URS) based on clinical factors is calculated for all patients referred in Ontario, and is used to assist in triage decisions as well as a basis for monitoring access to care. How are new employees oriented and trained at your facility? What licensure is required for all professionals who work in your lab? New RN staff are given an intensive 8-week orientation, composed of six theory days, with the remaining time spent with a preceptor, gradually increasing independence. Knowledge of advanced practice competencies (such as defibrillation, administration of life-saving drugs) is ensured by written tests, followed by a return demonstration in a simulated environment. After a certain comfort level is obtained in the lab, the RN is then trained in the pacemaker OR for implants, ICDs and pacemaker pack changes. Several months later, the novice cath lab RN is trained in the control room. The College of Nurses of Ontario licenses our all RN staff annually. Licensing includes completion of a quality assurance assessment (self-review, peer review and a learning plan based on goals and objectives). What type of continuing education opportunities are provided to staff members? We are very fortunate to have educational opportunities for both physician and RN staff. Staff can apply to a hospital-subsidized bursary or the cath lab education fund for funding to attend conferences and workshops. There is strong representation at the Canadian Cardiovascular Congress, the Cath Lab Digest Symposium, NASPE, Cardiac Innovations and various other interventional/cath lab conferences. RN staff is allotted three education days per year. RNs also have the opportunity to attend cath lab-specific workshops, as well as cardiac-related sessions such as 12-lead ECG interpretation or hemodynamic workshops. Since ACLS is a perquisite of employment in the cath lab, it is offered on-site twice per year. Our Lunch and Learns are well-attended by all staff and provide updates on new equipment, procedures and research studies. The model we use for implementing new equipment is to train superusers. These superusers are given an in-depth orientation, and they in turn provide support to the remainder of the staff. How do you handle vendor visits to your lab? Vendors must adhere to the new Personal Health Information Protection Act, which protects the privacy of the patient. They must sign waivers in order to enter the lab. Vendors are assigned a certain number of days per month and they then sign up for actual days. While these vendors are very helpful in providing education, we have certain stipulations, such as only one vendor in the lab per day. For patient safety concerns, we ask the vendors to remain in the control room. How is staff competency evaluated? Initially, we have a certification process for advanced practice competencies such as administration of life-saving drugs, defibrillation, IABP therapy, and arrhythmia interpretation. Every two years, all staff must embark on a recertification process, which involves a skills review day and includes a take-home test. From there, learning needs are identified and resources are sought to achieve those goals. Does your lab utilize any alternative therapies? We do not utilize any alternative therapies at the present time. How does your lab handle call time for staff members? In order to meet the demands of our patient population, we have recently expanded our hours. This has necessitated adding a third shift to our staffing plan. We have a 0730-1730 shift in the lab, and a 0700-1700 shift, 1000-2000 shift and a 1200-2200 shift in the outpatient prep and recovery area. In our lab, the RN staff is trained in the outpatient area as well as the cath lab, enlarging our staff base. The call team includes an interventionalist and three RNs. On occasion, we may only call in one or two of the RNs for a procedure such as a temporary pacemaker or an IABP insertion. The RN team members are on call approximately 4-5 times per month, including one weekend in six. In general, the frequency of callbacks is increasing on average, the on-call team will be in a couple of times over a weekend and at least a couple of nights per week. Primary PCI for ST-elevation myocardial infarction (MI) is not our standard practice after hours because of concerns regarding our ability (with our current staffing model) to achieve benchmark door-to-balloon times. During the winter season, weather conditions can impact on our call-back response time. Interventional cardiologists work as a single group and have a rotating call schedule, usually changing daily during the week but covering a full weekend as a block. What trends do you see emerging in the practice of invasive cardiology? We are excited about the role of new imaging technology, including multi-slice CT and cardiac MR, although the precise impact of these technologies isn’t yet clear. From a practical point of view, the hospital stay will continue to shorten as we discharge PCI patients either to home or back to their referring hospital on the same day as their procedure. Has your lab undergone a JCAHO inspection in the past years? In Canada, we are accredited by the Canadian Council on Health Services Accreditation (CCHSA). Their mandate is to examine all aspects of the institution’s services and patient outcomes in order to identify areas of improvement. At our last review in November 2004, our institution received a 3-year accreditation. For labs undergoing this review, we would recommend working as a team, and collaborating to identify strengths and opportunities for improvement. Please tell the readers what you consider unique or innovative about your cath lab and its staff. We have been early adopters of a number of new devices and/or adjunctive drugs, such as DES, closure devices, bivalirudin, etc. We were also among the first in our region to cross-train RNs for the technologist role. Looking forward, we see the combined x-ray/MR intervention suite as a very unique and innovative aspect of our cath lab. Is there a problem or a challenge your lab has faced? In 2003, our city was plagued by severe acute respiratory syndrome (SARS). It was a difficult and traumatic time at Sunnybrook, as we took a leading role in containing and treating SARS. Sunnybrook and Women’s admitted the largest number of SARS patients in the greater Toronto area. Our entire hospital was under strict surveillance and every person entering the hospital was screened. This laborious task meant that all staff, patients and their limited visitors had to be identified, have their temperature taken and a screening tool completed. The lab was under this lockdown as well. The cath lab was closed for two weeks, only performing emergency caths and interventions for Sunnybrook & Women’s inpatients. It meant a reduction in our caseload, and closely monitoring anyone with a cough. Patients and staff alike were required to wear oppressive and restricting personal protective equipment while under the watchful eye of our infection control service. Once we were able to get our patients into the lab suite, we then needed to protect all our equipment. This necessitated covering all the monitors with a thick plastic, which hindered visibility. The room also needed to be draped in plastic to protect the inventory from accidental exposure. The preparing and dismantling of the lab added much extra time to each case. To add to the challenges we encountered, there was also the emotional toll of seeing some of our colleagues becoming ill with this devastating illness, with little information and limited treatment options. The biggest fear was inadvertently transmitting SARS to one of your loved ones. It was a difficult time that has changed the practice in our lab forever. On a positive note, each of us have a keen awareness of infection control practices and we have new policies to prevent the transmission of any organism. Most importantly, as a team, we know we can overcome any challenge. What is special about your city? How does it affect your cath lab culture? Toronto is unique in North America and indeed in the world, for the diversity of ethnic and cultural backgrounds of its residents. Our patients are from many ethnic backgrounds and our staff reflects a similar mix. We provide culturally sensitive, patient-focused care in order to meet their needs. As Canada’s largest city, Toronto is known as safe and clean with a population of 2.5 million in the city itself and over 5 million in the greater Toronto area. Located on the shore of Lake Ontario, Toronto has become a leading cultural centre, with live theatre and film ranking among the most active in the world. Our city boasts of many specific attractions, such as the world’s tallest building (CN tower), many fine museums and art galleries, and of course, shopping. Our city’s competitive spirit can be seen in our major league sports teams, including the Toronto Maple Leafs (NHL) and the Raptors of the NBA, both of which make their home at the Air Canada Centre, as well as the American League Blue Jays, based at the Skydome. 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? No, these are American Specialty exams, hence not as accessible or applicable to Canadian RN staff. Salary rates are determined by the Provincial Nursing Unions and are not dependent on additional courses taken. The Canadian Nurses Association has a specialty examination in Cardiovascular Nursing. RNs are encouraged and supported with funding to write this specialty exam, however it is not cath lab-specific. 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? No. These associations are not in Canada. The Ontario Cath Lab Managers meet approximately every 2 months as an informal group to share ideas and issues. At the Canadian Cardiovascular Congress annual meeting, there is a cath lab managers meeting, which is very well attended. Anne Forsey can be contacted at Anne.Forsey@sw.ca

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