Texas Health Presbyterian Hospital Dallas

Can you tell us about your cath lab? Texas Health Presbyterian Hospital of Dallas (THD) is a 1000-bed, faith-based, non-profit hospital. We are the “flagship” hospital for a 24-hospital health system. We currently have four cath labs, two of which are combo cardiac/ peripheral rooms, a pre/post observation area, and two electrophysiology (EP) labs. In the cath lab, we have 13 staff: 7 registered nurses (RNs), 4 registered cardiovascular invasive specialists (RCISs), and 2 radiologic technologists [RT(R)s]. Our observation area has 5 RNs and 1 patient care technician (PCT). Our EP lab has 7 staff: 5 RNs, 1 RCIS and 1 RT(R). All areas are staffed separately, with the exception of a few crossover individuals. The majority of our staff has been employed here for approximately 5 years. Experience levels range from 2-20 years. What procedures are performed at your lab? In our cath lab, we perform cardiac diagnostic and interventional procedures, including percutaneous transluminal coronary angioplasty (PTCA), stenting, Rotoblator (Boston Scientific Corp., Natick, Mass.) atherectomy, AngioJet (Medrad/Possis, Warrendale, Penn.) thrombectomy, patent foramen ovale (PFO) closures, and pacemaker and implantable cardioverter defibrillator (ICD) implants. We also do peripheral diagnostic and interventional procedures, including PTCA, cryoplasty, stenting, atherectomy [Diamondback 360˚ (CSI, Inc., St. Paul, Minn.), SilverHawk (ev3, Plymouth, Minn.), and Jetstream (Pathway Medical Technologies, Kirkland, Wash.)], thrombectomy, abdominal aortic aneurysm (AAA) endografts, and carotid stenting. Our cath lab averages around 70-80 procedures a week with the majority (70-80%) being peripherals. Does your cath lab perform primary angioplasty with surgical backup on site? Yes, we perform primary angioplasty with surgical backup on site. The surgeons are available 24/7. What percentage of your patients is female? Around 50% of our patients are female. What percentage of diagnostic cath patients go on to have an interventional procedure? Roughly 40% of diagnostic caths go on to an interventional procedure. Do any of your physicians regularly gain access via the radial artery? We have one physician that regularly gains access via the radial artery. The majority uses the femoral approach. Who manages your cath lab? Chris Lee, RN, is our clinical nurse supervisor and manages the day-to-day operations. Zoe Terral, RN, is our director over all invasive and non-invasive cardiology departments. Jon Gardner is our administrative director over the heart and vascular service line for all Presbyterian hospitals in the Dallas region. Last, but certainly not least, we have two medical directors. Dr. James Park is the cath lab medical director and Dr. Tony Das is our peripheral vascular director. Do you have cross-training? Who scrubs, who circulates and who monitors? All staff in the cath lab is cross-trained to monitor. At the moment, only the RNs circulate and the techs scrub. Everyone is cross-trained to monitor. We only have one RN that is cross-trained to scrub, but are in the process of cross-training the remaining RNs to scrub. Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab? No. 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? Everyone that is trained to scrub can operate the x-ray equipment with the exception of the fluoro pedal. That responsibility is on the physicians or the RT(R)s. How does your cath lab handle radiation protection for the physicians and staff? Each member is provided with the appropriate aprons and glasses, which are checked annually for cracks and tears. X-ray equipment is regularly maintained through service contracts, as well as by our radiation safety officer. What are some of the new equipment, devices and products introduced at your lab lately? Some of the new technologies that have been introduced to our lab include the Diamondback 360˚ (CSI), Jetstream (Pathway), Crosser wire (FlowCardia, Sunnyvale, Calif.), and Frontrunner and Outback re-entry devices (Cordis Corp., Miami, Fl.). Can you describe the systems you utilize to organize staff and communicate necessary information? We communicate necessary information to staff either via e-mail or regularly scheduled staff meetings. We currently utilize self-scheduling for the staff. We work four 10-hour days and staff is required to take at least 1 night a week and 1 weekend of call per month. Daily staffing of the individual rooms is done daily by the supervisor. Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) or any other outside data collection registry? Yes, we report to ACC, ICD, and the carotid registries. How is coding and coding education handled in your lab? We have a dedicated coder who handles all the coding for the department. Since this person is not clinical, we have trained 2 RNs to double-check all charges (they are sent to coding classes throughout the year). How does your lab handle hemostasis? Most of our hemostasis is done with manual pressure and a pressure belt. Some of our physicians routinely use closure devices, including Angio-Seal (St. Jude Medical, Minnetonka, Minn.), Mynx (AccessClosure, Inc., Mountain View, Ca.), and Perclose (Abbott Vascular, Redwood City, Ca.). We also use the D-Stat Dry hemostatic patch (Vascular Solutions, Inc., Minneapolis, Minn.). What is your lab’s hematoma management policy? Any post-diagnostic cath patients that do not get a closure device of some sort come out to our holding area for a sheath pull. Post-intervention patients are transferred to our Heart and Vascular Intervention Unit (HVIU). The HVIU is where the sheaths are pulled when ACT levels are within range. For the patients that develop hematomas, a cath lab staff member is sent to assess and compress it out if necessary. How is inventory managed at your cath lab? We have a materials manager, Ronda Jones, who handles ordering of supplies and stocking. Any new products are first reviewed by our new products committee before a trial period is established. We are currently in process of consolidating inventory products with our OR and Special Procedures department. We use the Pyxis system (CareFusion, San Diego, Ca.) for inventory control and reordering. Has your cath lab recently expanded in size and patient volume? Our patient volume continues to grow. Although the actual lab size has remained the same, we have plans of expansion in the near future. Is your lab involved in clinical research? Yes, we are or have been involved with the following trials:

• ACT-1: Comparing carotid artery stenting (CAS) to carotid endarterectomy (CEA) surgery for the treatment of patients who are symptom-free and at standard risk for surgery.
• SAPPHIRE: Stenting and angioplasty with protection in patients at high risk for endarterectomy. A randomized comparison of CEA with CAS using distal protection.
• CHOICE: Choosing the right pacing mode in heart failure - Do biventricular pacemakers offer any advantage over conventional pacemakers in patients with heart failure who require pacemakers? (St. Jude Medical).
• CABANA: Catheter ablation vs antiarrhythmic drug therapy for atrial fibrillation.
• iCARUS: A study to evaluate the safety and effectiveness of Atrium Medical’s iCast iliac stent system for primary stenting of the target lesion.
• MOBILITY: Studying the safety and efficacy of the Absolute Pro peripheral self-expanding stent system (Abbott) in patients with iliac artery disease.
• SUPERB: Comparison of the Supera peripheral stent system to a performance goal derived from balloon angioplasty clinical trials in the superficial femoral artery (IDEV Technologies).
• HERCULES: A safety and effectiveness study of the Herculink Elite renal stent to treat renal artery stenosis.

Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? In the past year, we have had one complication which required emergent surgery. This complication was a known possible risk and the outcome for the patient was good. Can you share your lab’s average door-to-balloon (D2B) times and some of the ways employees at your facility have worked together to keep D2B times under 90 minutes? On September 9, 2009, we were honored to have received our Cycle III Chest Pain Accreditation, which was exclusive to Dallas County. We are continuously working hard to improve our process. By collaborating with our emergency department (ED), emergency medical services (EMS), outlying hospitals, and the communities we serve, we were able to successfully improve our D2B times. Our average after-hours D2B is 60 minutes. We average 30 minutes for our D2B time during work hours. Our average D2B time from outlying hospitals is around 80-90 minutes. Our record for D2B time is currently 26 minutes. We use a one-call system, where one phone call activates the physician and cath lab team. Many times, the cath team is activated by EMS in the field. We are working with different EMS stations to train their personnel. We have the EMS transmit the patient EKGs directly from the field to our ED. Our cardiologist are on a rotating call schedule just to cover STEMIs. When feasible, we also have the EMS bypass the ED and go straight to the cath lab. It is always a work in progress, but we are always looking at ways to improve. Within what time period are call team members expected to arrive to the lab after being paged? Call team members have a 30-minute response time. We do not have a cardiologist on site unless they happen to be here. Where is your cath lab located in relation to the OR and ED? We are directly across the hall from the ED and one floor up from the OR. What other modalities do you use to verify stenosis? We use intravascular ultrasound (IVUS) and fractional flow reserve (FFR) through the Volcano system (San Diego, Ca.). What measures has your cath lab implemented in order to cut or contain costs? We have gone to a sole vendor (Boston Scientific) for coronary balloons and stents. Since we use the Pyxis system, we have also decreased the par levels for all supplies. We have also gone to re-processing some catheters in the cath and EP lab through an FDA-approved processor. What quality control/quality assurance measures are practiced in your cath lab? We monitor hand hygiene, 2 patient identifiers, and the pre-procedure pause. We also track IV antibiotic times for pacemaker/ICD implants. We use the Apollo system (Apollo Health Street, Conshohocken, Penn.), which helps keep data on everything. We have tracked case length times, turnaround times, and physician response times, to name a few. How does your cath lab compete for patients? Our hospital and our physicians work hard at reaching out to other hospitals and physicians for referrals. We recently started a women’s health clinic, where cardiac and peripheral vascular screenings are done. We also work closely with the wound care clinic. How are new employees oriented and trained at your facility? New employees are paired with a preceptor for anywhere from 3-6 months, depending on their experience levels. We currently have no employees with less than a year’s experience. The licensure requirements we require are RN, RCIS, or RT(R). Everyone is basic life support (BLS) and advanced cardiac life support (ACLS) certified. What continuing education opportunities are provided to staff members? Our hospital offers many continuing education courses for the employees throughout the year. We also have funding set aside to be able to send employees to conferences such as Transcatheter Cardiovascular Therapeutics (TCT), Vascular Interventional Advances (VIVA), and the American College of Cardiology (ACC) Scientific Sessions. Once a month, we have a Cath Conference. How do you handle vendor visits to your lab? We are very strict with vendor visits. All vendors must be vendor-cleared before they can be in any patient care area. Vendors are also limited to one day a month unless requested by a physician, in which case, they can only be in that physician’s room. All vendors must have an appointment to enter. They are given a vendor badge for the day. All special circumstances must be cleared by the supervisor or the director. We do this to limit the amount of people in the department and also to help control competing vendors. How is staff competency evaluated? We have an annual competencies check-off, and arrange to have vendors come in for that one day to do the competencies on various equipment and devices. Does your lab have a clinical ladder? We have a clinical ladder for the RNs. Does your lab utilize any alternative therapies (such as guided imagery, etc.)? There is music available in every room for the patients. How does your lab handle call time for staff members? Every staff member must take 7 days of call per month and one weekend a month. We have at least one RN, and one RCIS or RT(R) on call. Our call time goes from 5:30pm until 7am on weekdays, and 24 hours on the weekends and holidays. We also do self-scheduling. Do you have flex time or multiple shifts? Our regular hours are from 7 am – 5:30 pm. However, depending on the schedule, sometimes we will stagger staff work hours. During slow, non-productive days, we flex off staff or float them to other departments. Has your lab has undergone a Joint Commission inspection in the past three years? We had a Joint Commission inspection two years ago and did extremely well. I feel that the most important thing to remember when preparing for an inspection is communication. Meet with staff regularly to update and test on Joint Commission questions and updates. During an inspection, we close the department to any vendors and students. The hospital also performs mock inspections with or without any notice. How do you see your cardiac catheterization laboratory changing over the next few years? I see big changes related to cost-saving measures. With so many new technologies coming out, it is a constant battle of need versus want. We work with vendors for cost savings on products. We are also consolidating certain items with the special procedures department and the OR. What is unique or innovative about your cath lab and its staff? We hold many teaching days in our cath lab. At least one to two days a week, we are holding some sort of proctoring program for visiting physicians, nurses, techs, and vendors. We do courses for peripheral interventions as well as for pacemaker and ICD/bi-ventricular ICD implants. We have also broadcast live cases to as many as 1,000 viewers at various conferences such as VIVA, TCT, and the ACC Scientific Session. Is there a problem or challenge your lab has faced? How was it addressed? The most recent challenge we have faced is decreasing our D2B times. Working closely with our ED, EMS, outlying hospitals, and the community, we have been successful in decreasing our times. 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 a large metroplex, serving over 6.1 million people, with multiple competing hospitals. As a health system, we have the largest market share of heart and vascular patients. Dallas County has been selected by the AHA as the exclusive national region to develop a regional STEMI model. THD, along with other hospitals in Dallas County, has been selected to lead this initiative. 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? All of our techs must pass the RCIS exam, except for the RT(R)s. All other staff members are not required to take it. We do not have an incentive bonus or raise for taking the exam.
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, Alliance of Cardiovascular Professionals (ACVP), or regional organizations? All staff members are members of the ACVP.

New! A question from the National Cardiovascular Data Registry: How do you use the NCDR Outcome Reports to drive QI initiatives at your facility? The data is reviewed by the multi-disciplinary team from the Cardiovascular Process Improvement Committee. Based on the data review, initiatives are identified. Two recent examples are our hematoma initiative, led by Dr. Cherif, and the development of our renal protection protocol. The authors can be contacted at chrislee@texashealth.org