Wentworth Douglass Hospital Cardiovascular Lab

Can you tell us about your cath lab?

The Wentworth Douglass Hospital Cardiovascular Lab has 2 interventional Artis Zee suites (Siemens Medical, Malvern, Pennsylvania) that perform both cardiac and peripheral procedures. We have 5 new private patient holding rooms, as well as a nursing charting station. In our lab, we have 14 staff members. There are 8 technologists and 6 nurses. The staff holds an assortment of credentials including registered nurse (RN), respiratory therapist (RRT), radiologic technologist [RT(R)], and registered cardiovascular invasive specialist (RCIS). Two of our nurses currently have their CCRN credentials as well. The staff here has a wide range of employment history at this hospital, ranging from 10 years to 6 months.

What procedures are done at your lab? 

Our cardiovascular suites perform a variety of diagnostic procedures, including cardiac and peripheral interventions. Additionally, we insert permanent pacemakers, abdominal aortic aneurysm (AAA) stent grafts, and dialysis catheters, as well as perform pericardialcentisis, transesophageal echoes (TEEs), and cardioversions. The staff works with both cardiologists and vascular surgeons. Each week, we perform an average of 25 procedures.

Does your cath lab perform primary angioplasty with surgical backup on site?

We do perform primary angioplasty without surgical backup on site. If a patient requires emergent surgical intervention, they are transferred to a local regional hospital where a cardiothoracic team is readily available.

What percentage of your diagnostic cath patients goes on to have an interventional procedure?

Our lab has approximately 39% of patients proceed to percutaneous coronary intervention after a diagnostic cardiac catheterization.

What percentage of your patients is female? 

Our female patient population is close to 43%.

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

We have two interventional cardiologists who regularly gain access via the radial artery. There are also several diagnostic physicians who are beginning to train in radial techniques.

Who manages your cath lab?

Our cardiovascular lab is managed by a collaborative group: Cindy Harris, RN, MBA, Director of Cardiovascular Services, Ann Dupuis, RT(R)(CV), Cardiovascular Manager, Christian Comeau, RT(R)(VI)(CI), RCIS, Invasive Cardiovascular Supervisor, and Brian Smith, RN, CCRN, Nurse Manager. 

Do you have cross-training? Who scrubs, who circulates and who monitors?

Specialists scrub all procedures in our lab and nurses circulate, because they administer medications. All staff members are trained to monitor procedures.

Who documents medication administration during the case?

In our lab, we use the McKesson hemodynamic system, which allows us to have a monitor person outside the room documenting hemodynamics and a nurses’ charting station in the room, used for documentation of medications. Both cardiovascular technologists and nurses may document medications during the case. All medication is reviewed and signed by the nurse before the case is finalized.

Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab?

Our hospital does not require a radiologic technologist (RT) to be present in the room.

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?

Physicians primarily control the fluoro/cine pedal during procedures and the specialist performs the other operations of the x-ray equipment, but the specialist is able to perform all controls.

Are you recording fluoroscopy times/dosages?

We document fluoroscopy times in our hemodynamic system; it then creates a report that is entered into the patient’s medical record.

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

The standard for our staff is generally the same as across the country. We do have monthly monitoring of dosimeter badges and staff lead aprons are checked annually by our radiology department. One of our newer measures in radiation safety is the SorbX angiography shield (AngioSystems, Inc., Ducktown, Tennessee). Our labs also have full-height radiation barriers that are used by the circulating staff to protect from extra radiation in the room. The staff has also been provided with leaded eyewear.

What are some of the new equipment, devices and products introduced at your lab lately?

Recently, we purchased hemodynamics monitoring and PACs reviewing systems (McKesson, San Francisco, California), IntelliVue bedside monitors (Philips Medical, Bothell, Washington), the Radi fractional flow reserve (FFR) wireless system (St. Jude Medical, Minnetonka, Minn.), and two Artis Zee x-ray systems (one floor-mounted and one ceiling-mounted). Some of the other new equipment we have been using is the Jetstream G3 (Pathway Medical Technologies, Kirkland, Washington), Rad Board (Radial Assist, Roswell, Georgia), various radial-specific equipment, and i-STAT (Abbott Laboratories, Abbott Park, Illinois).

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

In our lab, we have designated a board coordinator who is in charge of the daily schedule. Any additional cases added on by the physicians are filtered through the board coordinator and assigned to one of the cardiovascular teams. The board coordinator is responsible for maintaining efficient flow throughout the scheduled day.

How is coding and coding education handled in your lab?

Our charge master is hard coded for cardiovascular procedures. All cardiovascular charges are reviewed and finalized by a designated coder in our department. The coder is available to answer questions for staff.

Who pulls the sheaths post procedure, both post intervention and diagnostic? What kind of training is mandated before someone can pull them?

Currently only cath lab staff removes arterial sheaths throughout the hospital. Venous sheaths may be removed by nursing staff on the floor. There is a competency sheet that all staff has to be signed off on before pulling sheaths. This competency sheet entails five successful achievements of hemostasis.

Where are patients prepped and recovered (post sheath removal)?

Patients are prepped and recovered in one of our five private holding rooms. Specialists are mainly responsible for achieving hemostasis, whether by manual compression or a mechanical closure device, such as Angio-Seal (St. Jude) or Mynx (AccessClosure, Mountain View, California).

Once hemostasis has been achieved, patients are sent to one of our nursing floors, or recovered in one of our holding rooms, where they are monitored during their bed rest. Interventional procedure patients generally remain in the hospital overnight, whereas most of our diagnostic procedures allow patients to return home the same day.

What is your lab’s hematoma management policy? 

The hospital’s groin management policy is overseen by the cardiovascular lab. Our hospital protocols are in place to direct actions based upon the level of bleeding and size of the hematoma. Cardiovascular staff members are the resident experts and always make themselves readily available for groin management issues. Any time a staff member of our lab assists in the care of a patient regarding groin management, a note is documented in the patient’s chart for medical staff to review.

How is inventory managed at your cath lab?

Inventory is managed directly by two staff members and the help of our Pyxis Supply system (CareFusion, San Diego, California). These staff members are in charge of ordering and maintaining lab supplies. All staff members are responsible for maintaining expirations in the lab.

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

Our cardiovascular suites have expanded and been upgraded recently with a 3.6 million dollar renovation. The existing room was replaced and a second cardiovascular suite was added, along with 5 private holding rooms, and a new digital cardiovascular PACs and hemodynamic monitoring system.

Is your lab involved in clinical research?

Not at this time.

Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery?

The cath lab rarely has emergent complications during procedures, but is prepared to transfer the patients for immediate surgical intervention. 

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? 

Average door-to-balloon time was 61 minutes for all STEMI patients in 2010. We have established a multidisciplinary team to address any concerns between departments and other personnel involved with patient care. Forming this committee has had a positive effect among all care providers, extending from emergency medical services (EMS) providers to cardiovascular lab staff.  Wentworth-Douglass Hospital purchased a system for EMS providers to transmit ECGs directly to our emergency department (ED).

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

The cath lab staff transports all STEMI patients during regular hours and off hours.

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

The hospital has written a “bump” policy for this situation. If the call team is involved in a non-emergent case, the case would be postponed at a reasonable stopping point and continued after the STEMI has been handled. The “bump” policy activates our nursing supervisor and other support staff to assist moving and triage of patients based on the physician’s assessment. 

What other modalities do you use to verify stenosis?

The lab currently possesses an S5i for intravascular ultrasound (IVUS) imaging (Volcano Corporation, San Diego, California) and also uses FFR. We are the first lab in New England to have a wireless FFR system installed in both of our labs.

What measures has your cath lab implemented in order to cut or contain costs?

There has been careful review of our charge master to ensure up-to-date and accurate pricing for equipment and procedures. The lab has also re-negotiated pricing agreements and consignment inventory with all major vendors to reduce overhead and per-case costs.  Some equipment has been eliminated due to redundancies of stock and unused supplies.   

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

Our hospital is accredited by the Joint Commission and our waived testing is governed by CAP (College of American Pathologists). Any quality standards inherent to these accrediting bodies are followed to ensure compliance and quality. We also track our STEMI initiative to ensure 90-minute compliance for CMS. 

The hospital uses Lean Six Sigma for process improvement initiatives. The cath lab supervisor has undergone Green Belt Training for Six Sigma and regularly uses tools within the Six Sigma process to improve processes within the department.   

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

We submit to the ACC-NCDR and also the Northern New England Cardiovascular Disease Study Group (NNECDSG).

How does your cath lab compete for patients? Has your institution formed an alliance with others in the area?

Wentworth-Douglass Hospital has a strong connection with the community. There are several hospitals in the area. The hospitals have specialized in separate areas of care. Electrophysiology (EP) is done at a facility close by in Maine and cardiothoracic surgery is done at a facility 12 miles away in Portsmouth, New Hampshire. Wentworth-Douglass has a clinical affiliation with Massachusetts General Hospital. This alliance covers several clinical collaborative areas.  

How are new employees oriented and trained at your facility?

New employees follow a set schedule of competencies to bring them up to speed within the environment. They are assigned a preceptor to mentor them within the lab. The preceptor may change based on the ability of the new member to accomplish tasks within the lab. The lab looks for a background in critical care and ED experience, if we do not have a candidate with invasive procedure experience. We have one staff member with previous experience in the ED and post anesthesia care unit (PACU) that has been in the lab for less than one year. Nurses must hold a current license and all staff must have current basic life support (BLS) and advanced cardiac life support (ACLS).

What continuing education opportunities are provided to staff members?

There are monthly cardiovascular conferences held in our department and all staff is able to attend. Additionally staff members do have equal opportunities to travel to conferences or symposiums with the approval of the director. Currently, we are setting up a skills day for all staff members to either learn or refresh skills on equipment used in the cardiovascular labs.

How is staff competency evaluated? 

Staff competency is currently evaluated by the supervisor and senior staff members. RNs have a yearly skills day that is mandatory for the hospital.

Does your lab have a clinical ladder?

Wentworth-Douglass has a hospital-wide clinical ladder for nursing. There are currently two levels in the clinical ladder for cardiovascular specialists.

How does your lab handle call time for staff members?

Staff is on call one day a week and one weekend a month. Our lab has a four-member call team consisting of at least one nurse and one scrub tech. The other two positions may be filled by any other combination of staff. There are four set call teams that follow a rotation to give all members a predictable schedule for the year.

Within what time period are call team members expected to arrive to the lab after being paged?

Staff members on call are expected to respond to the hospital within 30 minutes. We do not have a cardiologist on site at all times after hours. The interventional cardiologist that is on call is expected to respond to the page within 5 minutes and arrive to hospital as soon as possible. 

Do you have flextime or multiple shifts?

Staff currently works 8-hour shifts. The lab is available 24/7 for acute/emergent cases and normal hours of operation are 7am to 3:30pm, Monday through Friday.  

How do you handle vendor visits to your lab?

Vendors are allowed in the lab area on days that they schedule. Only one company is permitted on a given day, unless requested by a physician for case support. Vendors are not in the cardiovascular suites unless they are requested by the physician and are assisting staff with education of new equipment. The vendors must check in with our materials management department and receive a badge to identify themselves. The hospital uses Vendor Clear (Eden Prairie, Minnesota) before the vendors are allowed in the facility.

Has your lab recently undergone a national accrediting agency inspection?

Our lab is a Joint Commission-accredited lab. We underwent our Joint Commission inspection in September 2010.

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

Our cardiovascular lab is located on the third floor. The OR is located just below on the second floor and the ED is located on the ground floor. There are set of elevators located outside of the ED that have direct access to the OR and cardiovascular labs.

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

As the transradial approach gains popularity and is featured in the press, we have seen more patients request a cath via this approach.  

What is unique or innovative about your cath lab and staff?

Wentworth-Douglass uses Press Ganey to provide patients with the opportunity to give feedback and get a comparison with other facilities. Furthermore, the cath lab staff at WDH is highly knowledgeable, with 7 of 8 technologists holding the RCIS registry with Cardiovascular Credentialing International.

Is there a problem or challenge your lab has faced?

The recent construction to the cardiovascular department has been a challenge for staff and patients.  The supervisors for the department worked hard to provide information to the staff on what was happening at any time and also worked to have staff provide input on what they needed in our new spaces. With apologies and honest answers, the patients were also forgiving of inconveniences.

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”?

The staff and community here support the hospital in efforts to grow and provide services. The community has been very generous, providing private contributions to assist in building the cath labs and other projects at Wentworth-Douglass. Our staff is thankful for the support of the community and it is our pleasure to support them when they need us.    

The Society of Invasive Cardiovascular Professionals (SICP) has added two questions to our spotlight:

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?

The RCIS is required to obtain a Specialist 2 position in the hospital, not for the Specialist 1 position. Currently, our hospital does not give an incentive bonus upon passing the exam. If the staff member has met all other criteria for obtaining a Specialist 2 level, then they would receive a raise.

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?

Two of our registered cardiovascular invasive specialists (RCIS) are currently members of the SICP.
The cath lab supervisor is involved with the ASRT (American Society of Radiologic Technologists) and recently was part of the sub-committee that edited the Cardiovascular (CV) Practice Standard. Currently he is on the committee for RT advocacy working to advance the CARE Bill through Congress.

Lisa Conway, RCIS, and Christian Comeau, BSRS, RT(R)(VI)(CI), RCIS, can be contacted at lisa.conway@wdhospital.com and/or christian.comeau@wdhospital.com.