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The Indiana Heart Hospital
We also have three service specialists working under our managers. Unlike managers, however, these specialists have network-wide responsibility to support their individual service. Our EP Service Specialist is Viji Isaiah, BSN, RN, our Cath Service Specialist is Jerry Boyle, RCIS, LPN, and our PV Service Specialist is Scott Shultz, RT(R)(CV). The service specialists are considered the experts in their area of the department. They coordinate the education along with our clinical educator and also help with supplies. Jerry keeps the Mac-Lab (GE Healthcare, Waukesha, WI) data up to date. Scott is responsible for the radiation badges and checking the lead, as well as monitoring our exposure. Viji helps train EP staff and orders the specialty supplies.
What types of procedures are performed at your facility?
TIHH provides cardiovascular surgical support; therefore, our services are more diverse. However, as a network, the cardiac cath labs provide diagnostic and therapeutic services relating to both coronary and peripheral vasculature, electrophysiology, and implantation for purposes of cardiac rhythm management and resynchronization. With some new additions to our physician groups, valvuloplasty and septal repair have now been added to our services. As a network, our weekly patient encounters average 142, with an average of 350 procedures. Approximately 450 therapeutic peripheral procedures are done annually, although the program is expanding across the network.
Your cath lab performs primary angioplasty with surgical backup?
We do have open heart surgery at TIHH, but no formal backup. We perform percutaneous coronary intervention (PCI) at CHE and CHS without backup. However, those patients are within 40 minutes via ambulance from TIHH.
How is surgical backup scheduled?
Surgical backup is not formally coordinated with cath interventions, but we are able to respond quickly to any clinical emergency regardless of the time of day, due in large part to the fact that TIHH is a dedicated heart hospital with an EMR.
What procedures do you perform on an outpatient basis?
TIHH performs the following procedures on an outpatient basis (provided the procedures remain uncomplicated or are not complex in nature): cardiac caths, some percutaneous transluminal coronary angioplasties (PTCAs), EP studies, permanent pacemakers, implantable cardioverter/defibrillators (ICDs), ablations, vascular stenting, cardioversions and trans-esophageal echocardiograms (TEEs). These procedures can all be inpatient if the physician provides supporting documentation indicating a rationale to support an inpatient stay.
What is the female patient percentage?
Forty percent.
What percentage of your diagnostic cath patients go on to have an interventional procedure?
Thirty-eight percent.
Who manages your cath lab?
Rosalyn Brown, MSN, RN is the Director of Network Cath Labs. She is responsible and accountable for the coordination, organization, evaluation, and continuous quality improvement within the Cath Lab division of the Cardiovascular Service Line. We have four excellent clinical managers. Michelle Nelson, BSN, RN, and Tina Thomas, NP, MSN, RN manage the cath labs at The Indiana Heart Hospital on the North Campus. Lury Kutruff, MA, ASN manages the labs at the Community Hospital East Campus and Kathy Cook, RN manages the labs at the Community South campus.Do you have cross-training? Who scrubs, who circulates and who monitors?
In our lab, only RNs can circulate; however, we train all of our RNs to the monitor and scrub roles as well. In addition, we have cross-trained emergency department (ED) staff to work in the cath lab. Some of the ED staff have been trained to set up our supplies and make sure the rooms are ready for cath lab staff when emergencies occur on the off-shift. Some of the nurses in the ED have also been trained to circulate and monitor, and can help out staff in a difficult emergency. If someone from the ED staff can monitor during an emergency, a technologist or nurse who is more familiar with where supplies are kept is freed up to assist during the case. Our door-to-balloon time has been drastically reduced since the labs are ready when the call team arrives.
Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab?
No, except for the PV procedures. Our physicians pan the table and RTs normally assist by injecting contrast.
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?
Only physicians and radiology technologists are permitted to perform these actions.
What disciplines are involved in PV procedures?
Radiology technologists support our PV procedures. Our PV lab is an open lab where interventional radiologists, cardiologists and vascular surgeons all perform procedures. Scott Shultz, RT(R)(CV) serves as the PV Service Specialist for our network of hospitals.
How did you begin performing peripheral cases?
In 2003, when we initially built our heart hospital, our Chief Nursing Executive, Susan Holbrook-Preston, MSN, RN and our Chief Medical Executive, Dr. Michael Venturini, worked with physician groups to establish policies, guidelines and credentialing criteria supporting open access of all qualified physician modalities.
What specific equipment was instituted and/or dedicated towards peripheral cases?
We purchased a standard large-format image intensifier system and image workstation that supports access to subtracted images. Eventually, we would like to upgrade to a digital flat-panel X-ray system.How is inventory management handled for the peripheral equipment, particularly with the varying lengths and sizes of the stents?
Inventory is managed in the same manner for all services across the cath lab network. Generally, sterile medical/surgical supply items are provided through the services of Materials Management as stockless (JIT) supplies. Service-specific items, like stents, are maintained in a perpetual inventory. As they are used, these items are charged, inventory is decremented, and the expended items are reordered using integrated applications designed for these purposes. Each supply item has a unique internal item number which is associated with an individual product description, vendor catalog number and an internal charge code.
Does your lab have a clinical ladder?
The entire hospital has a program for staff called ÒSkill Levels.Ó RNs in the cath lab all must be a Level Two within 12 months of the start date, maintained annually. Skills are assessed with both competency verifications and written tests. For Level Three, RNs must be able to work in at least two different areas of the lab as well as be cross-trained to another department in the hospital. Level Four involves more leadership skills as well as teaching roles.
For technologists, we have three levels: Invasive Cardiology Tech (ICT) I, II and III. A person in the role of ICT I is a non-licensed or certified staff member that has completed orientation. Level II requires a certification (i.e., paramedic), a degree in an allied health field, a recognized state license (i.e., LPN) or registered cardiovascular invasive specialist (RCIS) credentialing. Level III would be the certified, licensed staff member with a degree that has obtained their RCIS.What are some of the new equipment, devices and products introduced at your lab lately?
In August of 2006, we performed our first percutaneous closure of a patent foramen ovale (PFO). We have new physicians joining our practice who anticipate doing more atrial septal defect (ASD) closures. In addition, we perform percutaneous valvuloplasty.
Can you describe the system(s) you utilize and how they work in cath lab daily life?
We utilize GE Mac-Lab IT and GE Innova imaging systems in the cath labs. In addition to providing a log of the cath lab procedures, the Mac-Lab is utilized to assist in completing the physicianÕs electronic cath report and to generate an inventory report. The inventory report is sent electronically to the hospital Materials Management department. The circulating nurse documents in the hospital electronic medical record (EMR) as well as entering any verbal orders. Physicians place their own orders in the computer and any verbal order must be entered so it can be validated by the physicians.
Does your cath lab do electives on weekends and or holidays?
The lab does not routinely schedule for weekend or holiday cases. If the caseload is heavy on a Friday or the eve of a holiday, management asks for volunteers to do elective cases so the call team will be available for emergencies.How is coding and coding education handled in your lab? How is coding communication handled with the billing dept.?
Patient charging for the cath lab network is performed by two finance support staff at TIHH. Patient-charging staff reviews the event record provided by the cath lab for each case. Procedure descriptions associated with CPT-based (Current Procedural Terminology) codes in the charge master are selected accordingly in the charging application. Staff is trained on the job with the use of published references to coding convention, internal charging aids which associate coding convention with internal charging processes, and attendance of ÒwebinarsÓ and off-site seminars.
How does your lab handle hemostasis?
Post-procedure, most of our patients go to Daybeds (a procedural preparation and recovery area.) The staff in this department obtains hemostasis on patients, including inpatients. The majority of the time, manual pressure is utilized to obtain hemostasis. On occasion, the physician may ask for VasoSeal (Datascope Corp., Mahwah, NJ) or on-site closure devices, which are done in the cath lab. We recently trialed Safeguard (Datascope) for hemostasis, but no decisions have been made on its use.
Does your lab have a hematoma management policy?
We do not have a hematoma management policy per se, but we do have ÒArterial Sheath Management, Removal, and Hemostasis GuidelinesÓ for post-procedure care. We also have instructions for managing hematomas in our cardiac intervention policy. Incidence of hematomas is routinely collected and monitored. How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies?Materials Management (MM) maintains stockless (JIT) supply. Managers adjust stockless availability and on-hand quantities in direct coordination with MM staff. Two finance support staff maintain the perpetual inventory, and perform a number of related tasks, including setup in multiple databases, quarterly inventories and periodic cycle counts, as well as adjustment of on-hand quantities based upon reported product usage.
The purchase of equipment for the labs is accomplished by cath lab managers in coordination with an assigned buyer in the purchasing department. The cath labs have enjoyed some success in the standardization of inventory, and continue their focus on process improvement through the use of product analysis along with committees designed to facilitate dialogue between physicians, clinicians and administrators. The goal of these efforts is to make products which provide optimum outcomes for patients available at the best possible price.
Has your cath lab recently expanded in size and patient volume, or will it be in the near future?
Our cath volumes have begun to plateau while our EP and PV numbers have steadily increased. However, we expect our cath numbers to increase sharply due to the recent introduction of many new physicians.Is your lab involved in clinical research?
Our cath lab has been involved in numerous clinical research trials. We have done studies involving drug-eluting stents (DES), stent data registries, acute coronary syndrome (ACS) therapies, and closure devices (looking at reducing manual hold times). Currently, we are participating in a study comparing the GE VCT computed tomographic angiography (CTA) system with diagnostic cath. The cath lab staff is inquisitive when presented with new treatments and therapies.
Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery?
We did not have any atypical complications requiring emergent cardiac surgery.
What other modalities do you use to verify stenosis?
We use fractional flow reserve (FFR), intravascular ultrasound (IVUS) and CTA.
What measures has your cath lab implemented in order to cut or contain costs?
It is our philosophy that effective management of inventory includes the elements of cost containment and, where possible, cost reduction.
What type of quality control (QC)/quality assurance (QA) measures are practiced in your cath lab?
We do QA audits and report these metrics monthly to our QA committee. We hope to automate some of this data capture and reporting. In addition, we monitor safety metrics on a weekly basis.
How does your cath lab compete for patients? Has your institution formed an alliance with others in the area?
As part of a large hospital network, we get a steady flow of patients from within our network. We also have a Director of Provider Relations who regularly meets with community physicians in order to determine how TIHH can best serve their needs. Some of our physicians often accompany the director to these meetings. We also have a very nimble and active patient satisfaction process, whereby we attempt to meet all of our patientsÕ concerns as soon as possible. This helps us maintain our status in our community as an excellent cardiac hospital and ensure repeat patient visits.
How are new employees oriented and trained at your facility? What licensure is required for all professionals who work in your lab?
New employees have a 10-to-12-week orientation. The majority of the training is on-the-job. For staff with no cardiac background, we have a Cardiovascular Institute twice a year, which offers a variety of classes along the cardiac spectrum. Each employee must pass a basic ECG test or take a class on dysrhythmias. Each new employee is assigned a primary preceptor. The new employee has an orientation guide that must be completed by their preceptor and returned to the educator.
In regard to licensure, RNs are the only ones trained to circulate. We have 5 RTs on staff to cover call for peripheral procedures. No other licensure is required. All of our staff must be ACLS-certified within one year. All ICTs are to be RCIS-certified within two years of employment.
What type of continuing education opportunities are provided to staff members?
Annually, our hospital provides an 8-hour conference on cardiac-related issues. The cost is minimal and the staff earns 7.5 CEUs. Many of our vendors provide education opportunities for staff. We have also purchased licenses for the Wes Todd RCIS Review CDs, and these are available to the staff on various computers throughout the department for their review.
How do you handle vendor visits to your lab?
All vendors must schedule time with the cath lab. Vendors are only allowed in the lab when they are assisting the physician. They have to wear a certain color of scrub so they are easily identified. These scrubs are given to them when they sign in at the reception desk. Between cases, vendors are required to wait in the waiting rooms.
How is staff competency evaluated?
Competency for the RNs was explained in the area of clinical ladders. For the other staff, all are required to take two radiation safety courses per year as well as passing a dysrhythmia test.
Does your lab utilize any alternative therapies (such as guided imagery, etc.)?
We always try to make our patients feel as comfortable as possible, but so far, we have not yet tried using alternative therapies.
How does your lab handle call time for staff members?
Each call team must have an RN to act as the circulator and a radiology technologist for any PV procedures. Our full-time staff works four 10-hour shifts, with call one night per week and every fifth weekend. They are always off on the day after their call night (unless they trade call or pick up extra call). The EP lab takes call, but this only consists of staying late if necessary until all procedures are complete. Our group is very good about helping out the call team by staying late when necessary to help finish any outstanding cases.What trends do you see emerging in the practice of invasive cardiology?
We will continue to see more peripheral vascular procedures. In terms of equipment, we will see more 3-D reconstruction and eventually integration and/or some replacement of cath imaging with CT and MR. Vulnerable plaque is still on the horizon. Devices will probably include bioabsorbable DES.
Has your lab has undergone a JCAHO inspection in the past three years?
We had a JCAHO inspection during the month of July 2006. We passed inspection with no requirements for improvement (RFIs). Prior to our inspection, teams of administrators toured all departments of the hospital and did mock surveys, including tracer methodology. Administration will continue to do mock inspections on a monthly basis to look for problem areas.
Where is your cath lab located in relation to the OR department, ER, and radiology departments?
When our hospital was planned and constructed, there was a great deal of consideration given to patient and information flows. The OR, cath labs, radiology and ER are all on the same floor with logical, efficient and direct routes between them. Our architect, BSA Life Structures (Indianapolis, IN), and our building have both won several awards for excellence in design.
Please tell the readers what you consider unique or innovative about your cath lab and its staff.
The staff is very good at change. We have a totally wired platform where nearly all documentation is done on the computer. We are still tweaking input in order to maximize output and workflow, and changes can occur frequently. Staff adapt quickly to the many changes that have occurred. Staff also has a unique relationship with the physicians. They obtain information during procedures and enter it into the Mac-Lab so physicians have the necessary data to complete the cath report at the end of the procedure. This data must be entered in a specific format for the physician report to read correctly.
Is there a problem or challenge your lab has faced?
We were faced with the task of creating a completely paperless lab when we opened the hospital. Staff input on changes to the electronic charting was accepted. Although there were challenges in the beginning, the process has been streamlined.
All documentation is validated via an electronic sign-on and a HIPAA-compliant log of staff activities is attached to each patient's record for both nurses and physicians. This data is made immediately available to all personnel taking care of the patient. A wireless intranet connection was made available throughout the lab for ease of accessibility. Cath lab monitoring staff enters data based on physician responses to questions during an intervention, populating the physician cath report so the physician can quickly complete it immediately following the procedure. A report showing all inventory utilized is electronically sent to the billing department, where they perform a second audit. 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"? Indianapolis has a very competitive cardiovascular marketplace, with all 4 of the major health provider networks developing CV specialty facilities or programs within the past 4 years. Everyone receives an annual bonus if they maintain a certification not required for their position. The actual role for our CV Techs is Invasive Cardiology Tech (ICT). The RCIS certification is a required credential for the ICT Tech III position. 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? Yes, there are many such organizations supported and represented by our staff. These include SICP, ACCN, ACC, RSNA, AANP, HRS, AORN, VHA and ISNA.
