Watauga Medical Center Cardiac Catheterization Lab

Watauga Medical Center is fully accredited by the Joint Commission for the Accreditation of Healthcare Organizations and licensed as a 117-bed regional medical complex. Watauga Medical Center offers both primary and secondary acute and specialty care, and is located in the Blue Ridge Mountains of Boone, North Carolina. WMC has also earned The Joint Commission’s Gold Seal of Approval^™ for certification as a Primary Stroke Center. In addition to the main hospital, the campus includes The Cardiology Center of ARHS, The Sleep Center, The Wound Care Center and the Seby B. Jones Regional Cancer Center. 

Tell us about your cath lab.  

The Cath Lab at Watauga Medical Center is vital to the area, as Boone is geographically isolated on top of a mountain. This program has been an essential addition to our area, because other facilities performing catheterizations are over an hour away by car. Watauga Medical Center Cath Lab began doing interventional catheterizations in late 2012. 

Currently, four physicians share a single procedure room: an interventional cardiologist, an electrophysiologist, and two interventional radiologists. The cath lab has five full-time staff members [3 registered nurses (RNs), 1 cardiovascular technologist (CVT), and 1 radiologic technologist (RT)] and 1 full-time RT manager to cover the 3 holding rooms and procedure room. Cardiac procedures include diagnostic and interventional catheterizations, and pacemaker and implantable cardioverter defibrillator (ICD) implantations. Interventional radiology procedures include kyphoplasty, portacath, permacath, peripherally inserted central catheter (PICC) line placements, and peripheral vascular procedures.

In 2013, Watauga Medical Center surpassed the facility’s annual goal for heart catheterizations. The facility has also received a Certificate of Need for a second procedure room, which will be used by the interventional radiologists to enhance the peripheral vascular program.

Does your cath lab perform primary angioplasty without surgical backup on site?

Yes, we perform percutaneous coronary intervention (PCI) without onsite surgical backup under American College of Cardiology guidelines. If a patient needs surgical intervention, Watauga Medical Center has contracts with three close tertiary facilities, and care is coordinated with one of the three. Ground transportation is arranged for stable transfers and critical care helicopter transport is arranged for patients who need immediate intervention.

What percentage of your diagnostic caths is normal?

Approximately 30% of our heart catheterizations were normal in 2013. 

Do any of your physicians regularly gain access via the radial artery?

Our primary interventional cardiologist does not use the radial artery unless otherwise indicated. However, the physicians from Wake Forest Baptist Health Medical Center, who cover when our primary interventional cardiologist is out of town, regularly use the radial artery to gain access.

Who manages your cath lab?

The cath lab is managed by Mary Finley, RT(R)(M)(VI), and our Director of Cardiology is Lesley Hastings, RN, BSN, MHA.

Do you have cross-training?

Yes, cross-training (within profession) between monitoring, sedating and scrubbing in with the physician is essential for our cath lab, because we have so few staff members.

How does your cath lab handle radiation protection for the physicians and staff?

The staff and physicians wear lead aprons and dosimeter badges are mandated. Radpads (Worldwide Innovations & Technologies, Inc.) are utilized when appropriate for cases that require higher doses of radiation. Physicians also wear protective eyewear and use shielding devices. 

How does your lab communicate information to its staff and physicians to stay organized and on top of change?

Our staff meets monthly, but updates that require immediate attention are communicated to all via the cath lab manager.

How does your lab handle hemostasis?

The majority of our patients receive the Mynx closure device (AccessClosure, Inc.) for hemostasis, which is deployed by the interventional cardiologist. For other patients, hemostasis is obtained by holding manual pressure. All cath lab staff is trained and capable of maintaining hemostasis by using manual pressure. 

Who pulls the sheaths post procedure?

Everyone in our department has been trained on pulling sheaths. The intensive care unit (ICU) nurses in our hospital have also been trained on how to pull sheaths post procedure. A minimum of 5 successful sheath pulls, under direct supervision, is required before someone can pull sheath indirectly supervised. All staff is encouraged to have someone available as a second set of hands for assistance if needed. 

Where are patients prepped and recovered?

Patients are usually prepped prior to coming to the cath lab. Once the patient arrives in our holding area, the cath lab staff completes any needed preparations. After any procedure requiring sedation, our patients are recovered for 30 minutes in our holding area before being transferred back to outpatient, their patient floor, or ICU, as deemed appropriate. 

How do you handle the purchasing of equipment and supplies?  

General supplies are ordered on an as-needed basis. Procedural supplies are re-ordered as they are used. Our cath lab software (GE MacLab/DMS) handles recording inventory and creating a purchase order for needed supplies.

Has your cath lab recently expanded in size and patient volume?

We have recently moved all our transesophageal echocardiograms (TEEs), cardioversions and cardiac stress tests into a cardiac diagnostic center located on the first floor of the hospital. The move has allowed more of a focus on diagnostic/interventional cardiac catheterizations, device implantations and interventional radiological procedures. Watauga Medical Center is in the early phases of planning to construct a second peripheral vascular room, as well as a fourth holding room. After the second procedure room is complete, more staff will be added. Since the interventional cardiology program began in November 2012, our total cath volume has quadrupled to approx 475 cases per year, with approximately 30% of these patients undergoing successful PCI/stenting. Our patients are no longer routinely transferred “off the mountain,” as was the case prior to opening the PCI program. Thankfully, this has been accomplished with no deaths or serious complications. So far, no patient has required emergency transfer because of failed PCI. 

Is your cath lab involved in clinical research?  

No, we are not involved in any clinical research at this time.

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 the mandated 90 minutes? 

Training and education have been the biggest factor in recognizing and intervening on ST-elevation myocardial infarctions (STEMIs). We have put into practice EMS bypassing the ED and have them bring STEMI patients directly to the cath lab. Continued review of cases post procedure has gone a long way in guiding the process of bringing D2B times within mandated compliance times. Watauga Medical Center’s 2013 median D2B time is 67 minutes.

Who transports the STEMI patient to the cath lab during regular and off hours?

For consistency in the care of the patient, the cath lab staff transports the STEMI patient to the cath lab from within the hospital during regular hours. If the patient is coming by emergency medical services (EMS), they are met by security and escorted to the cath lab. We are providing STEMI coverage from 7:30 am-4:30 pm M-F. Policies are in place to transport STEMI patients to providing hospitals during off hours.

What do you do when the team is already busy doing a procedure and a STEMI comes into the emergency department?  

The ED notifies the cardiologist, who consults the patient in the ED. The cardiologist confers with the interventional cardiologist to determine the most appropriate treatment of the patient. If possible, we finish the procedure or determine if the patient can be removed from the table and monitored in our holding area, so we are able to place the STEMI patient on the procedure table. We have implemented a STEMI page. A page is sent out to alert the in-house supervisor, the interventional cardiologist, and the cath lab when a STEMI is called.

What quality control and assurance measures are practiced in your cath lab?

Cath lab staff complete monthly chart reviews to compliance with Joint Commission requirements. A performance improvement log is documented for each case. Documentation for this changes quarterly. A “time out” board has been placed in the procedure room listing the current date, patient, procedure, physician, allergies, and lab results for each case. Cardiac intervention cases are randomly reviewed in a blinded fashion for appropriateness and technique by the outside quality control company AllMed, based in Portland, Oregon.

Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) or any other outside data collection registry?

Yes, all our percutaneous cardiovascular intervention and ICD cases are reported to the ACC-NCDR.

How are you recording fluoroscopy times and dosages?  

Fluoroscopy times and dosages are recorded in our prodcedural documentation as well as kept on a separate log for quick reference as needed. If overexposure occurs, the individual is notified by letter from Landauer (a radiation safety monitoring company). The radiologic technologist in charge will notify the physician and have him/her sign a letter with a detailed explanation of what is being done to decrease exposure.

Who documents the medication administration during the case?

Medication doses, amounts and route given are relayed to the monitoring person and recorded on our official MacLab procedural documentation. The physician, procedural nurse and monitoring person all sign the procedural document. The holding area, where a nurse recovers each patient post procedure, is also utilized. Any additional medications given are signed with that documentation.  Both documents are placed in the patient’s chart and placed in the electronic medical record.

How are new employees oriented and trained in your facility? 

New employees attend a general hospital orientation first and then participate in a department orientation and training that includes a competency checklist and skills practical. Online courses and regular in-service training on equipment also regularly occur.

How is staff competency evaluated?

We have an annual competency checklist, as well as skills lab on a quarterly basis. 

Where is your cath lab located in relation to the operating room (OR) and emergency department (ED)? 

We are on the same floor as the OR and are separated from the ED by one floor with elevator access. 

What trends have you seen in your procedures and/or patient population?

“If you build it…they will come.” Watauga Medical Center has already surpassed the number of cardiac procedures expected for the year. We are averaging 600 cardiac procedures and 400 interventional radiological procedures annually.

What is unique or innovative about your cath lab staff?

Watauga Medical Center Cath Lab staff is a diverse group of individuals. Two of our RNs have trauma/ED backgrounds. One RN, who has spent the majority of her nursing career in the cath lab, recently moved to the mountains from the West Coast. One CVT was a paramedic before entering the cardiac cath lab arena. One RT has over 10 years of cath lab experience. Our manager, also an RT, was with the interventional radiology group before joining the cardiology group. 

Is there a problem or challenge your lab has faced? 

Our biggest challenge is coordinating and supporting the procedure caseload. We have four physicians with only one room. Plans are underway to construct a second procedure room. 

What is special about your city or general regional area in comparison with the rest of US? How does it affect your “cath lab culture”?

Boone is located in the northwest corner of North Carolina, with an average temperature in the summer of 70 degrees and only 35 degrees during the winter months, with a typical snowfall of approximately 3 feet. Weather has often played a major role in coordinating care for our cardiac patients. Being able to provide such an essential service locally has alleviated significant risk by not requiring transfers of cardiac patients to another facility. 

Boone is also home to Appalachian State University and has a residential population of 14,122. When the university is in session and with year-round tourism, our population usually rises even higher. Our cardiac cath lab patient population consists of local residents of all ages, and includes a large population of retirees from Florida during the summer months.

Two questions from the Society of Invasive Cardiovascular Professionals (SICP): 

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?

Staff is always encouraged to continue their education and to take the RCIS; however, it is not required. Staff members are given a 4% raise upon passing the exam.

Are your clinical and/or managerial team members involved with any professional organizations that support the invasive cardiology services line, such as the SICP, ACVP, or regional organizations?

Watauga Medical Center’s cath lab team is not involved with any cardiovascular professional organizations as this time.  

Cynthia Ann Dixon, BSN, RN, CEN, can be contacted at cdixon@apprhs.org.

A question from the American College of Cardiology’s National Cardiovascular Data Registry:

How do you use the NCDR Outcome Reports to drive QI initiatives at your facility

The Director of Cardiology Services and the Vice President of Quality meet with the interventional physicians on a quarterly basis to review the reports and determine which items we will follow to improve quality outcomes. These measurements are reported in our quarterly cardiovascular service committee.