Spotlight: Billings Clinic Heart and Vascular

Tell us about your center.

The Billings Clinic Heart and Vascular at Community Medical Center represents a new partnership for Missoula, Montana. The cath lab team performs ST-elevation myocardial infarction (STEMI) and multivessel coronary interventions, electrophysiology (EP) studies including radiofrequency ablation and cryoablation, and all endovascular procedures, with the exception of endovascular abdominal aortic aneurysm repair (EVAR) and carotid stenting. We collaborate with Community Medical Center’s Wound Healing & Hyperbaric Center by providing endovascular therapies for critical limb ischemia and limb salvage, commonly involving chronic total occlusions and multilevel peripheral arterial disease. The wound center is managed by Healogix, and in the last year was designated as a Center of Excellence based on heal rate, median days to heal, and patient satisfaction. Our new Heart & Vascular program started in the fall of 2017, and between our first and second years, we experienced a 55% increase in our cath lab volumes.

As part of the Billings Clinic cardiovascular service line, one of our missions is to establish rural outreach clinics, making subspecialty cardiology services more readily available to patients living as far as 200 miles away. We are an American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR) Chest Pain-MI Registry Platinum Performance Achievement Award recipient.

Can you describe your facility and cath lab?

Community Medical Center in Missoula has 151 beds, including 8 intensive care unit (ICU) and 5 progressive care unit (PCU) beds. We currently have two cath labs. Our primary cath lab is located in our Heart and Vascular Center, with adjacent private holding rooms, clinics, and noninvasive imaging rooms. Our second and newest lab is a hybrid OR-cath lab, used primarily for EP procedures and radiology procedures. Our cath lab team consists of two interventional cardiologists who perform endovascular procedures, one EP cardiologist who also performs percutaneous coronary intervention, 2 cardiovascular technologists (CVTs), and 5 nurses. Credentials currently held by our cardiologists include coronary angiography and PCI, peripheral angiography and endovascular therapies, and EP services including ablation therapies, pacer, implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy (CRT) device implants. Our CVTs assist in all cath lab procedures, and each have more than 5 years of tenure working in our hospital. Of our 5 cath lab nurses, only 2 have more than 3 years of tenure. We also use traveling nurses.

What procedures are performed in your cath lab?

We perform diagnostic coronary and bypass graft angiography, STEMI procedures, multivessel and chronic total occlusion (CTO) PCI, intra-aortic balloon pump (IABP) and temperature management/cooling catheter insertions, with plans for integrating Impella (Abiomed) support in the future. Endovascular therapies include subclavian, mesenteric, renal, aortoiliac, superficial femoral artery (SFA)/popliteal and tibial interventions, including atherectomy and CTO therapies using distal filter embolic protection, and use of ultrasound-guided pedal access. Ultrasound-guided radial and ulnar artery access is used for the vast majority of all PCI cases, and is also being used for endovascular cases, with the exception of distal SFA and tibial artery disease. For cases involving elective PCI using radial access, same-day discharge is pursued for all patients, including those receiving multivessel PCI. These patients receive either pretreatment with clopidogrel or loading with ticagrelor on the day of their PCI. This is facilitated by the use of three private rooms in a holding area adjacent to the primary cath lab. These rooms are named Blackfoot, Rock Creek, and Bitterroot, after three of the “blue ribbon” trout streams nearby. Regarding our EP procedures, same-day discharge is pursued for all elective dual chamber pacer implants, generator changes, and cryoablation procedures.   

Patients needing structural heart interventions are referred to a nearby hospital in Missoula, with three cardiologists and two cardiac surgeons providing these services. At this time, there are no plans to expand into structural heart therapy.

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

We currently have no cardiac or vascular surgeons on staff, and perform all coronary and endovascular interventions without surgical backup. Since radial access is used for the vast majority of coronary and for many peripheral vascular interventions, access site complications have been fortunately rare. Femoral artery access complications have been addressed using endovascular techniques including Viabahn stent grafts (Gore Medical).  Patients requiring coronary artery bypass graft (CABG) surgery urgently are transferred to a second hospital in town that is staffed by two cardiac surgeons.

What is your percentage of normal diagnostic caths?

The percentage of diagnostic caths that are found to have normal coronary arteries is 18%.

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

Over the last year, 78% of PCI cases were performed using radial access. One interventionist (RM) uses ultrasound-guided radial access for 95% of PCI cases, including 80% for STEMI. Left radial access is used on patients with bypass grafts, including left internal mammary artery (LIMA) grafts, and for some CTO PCI cases.   We are also using radial access for peripheral angiographic procedures, and for endovascular interventional procedures that do not involve the distal SFA or tibial circulation.

Do any operators utilize pedal artery access in peripheral vascular procedures?

Ultrasound-guided radial access is being used for more than one-half of peripheral vascular procedures. Ultrasound-guided pedal access is used selectively for endovascular interventions, primarily involving SFA/popliteal lesions in patients with relative contraindication to antegrade or contralateral femoral access. Conditions where we use pedal access include morbid obesity, heavily scarred groins, the presence of aortobifemoral bypass grafts or bifurcating endografts, and “flush” SFA occlusions.

Who manages your cath lab?

The Billings Clinic manages our cath lab with a regional manager. The Billings Clinic is the only organization in Montana with an affiliation with the Mayo Clinic.

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

Currently, only our CVTs scrub and assist on cases, with our cath lab nurses circulating. Both CVTs and nurses monitor cases.

Are there licensure laws in your state for fluoroscopy?

Montana does currently have fluoroscopy licensure laws for the cath lab. Only CVTs and cardiologist operate tables, change imaging intensifier angles, and perform fluoroscopy in our cath lab.

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

Radiation use is measured and documented in all procedural reports. In addition to shields, RadPads (11 inches x 34 inches) (Worldwide Innovations & Technologies, Inc.) are used for all cases. Extension tubing for manifolds is used for all radial cases to allow cardiologists to stand further away from image intensifiers during cases, usually at the level of patient’s thigh or knee. All cath lab staff and cardiologists wear monitoring badges to measure radiation exposure. All staff complete annual online training modules regarding ALARA (As Low as Reasaonably Achievable), and hospital policies and procedures covering radiation use. A nursing-initiated project is underway, in collaboration with the hospital radiation physicist, to identify new opportunities for reducing radiation exposure. After implementing recommended changes, we plan to prospectively study impacts on staff and cardiologists’ badge dosimetry measurements, as well as on individual patient dose exposure.

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

In the fall of 2018, one of our cardiologists (ES) brought new EP services to our lab, including radiofrequency ablation and cryoablation. All EP procedures are being performed in a new hybrid OR-cath lab. VasoStat wrist compression devices (Forge Medical) are now being used in addition to TR Bands (Terumo) following radial, ulnar and tibial access procedures. The new Terumo 119 cm, 6 French hydrophilic-coated sheaths are being used for radial access for aortoiliac, femoral and proximal SFA endovascular interventions. We currently stock most CTO crossing and re-entry devices available for peripheral vascular procedures.

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

We hold monthly staff meetings and incorporate cardiologist-directed training.

How is coding and coding education handled in your lab?

CVTs assist in procedure report generation including billing coding, with final coding decisions and coding education performed by hospital billing staff.

Who pulls the sheaths post procedure?

Cath lab nurses monitor all patients undergoing radial or femoral access for angiography and/or interventions when same-day discharge is planned. These patients remain in recovery rooms adjacent to our primary cath lab prior to discharge to home. Femoral access sheaths are pulled by cath lab staff, with new staff required to train with 5 proctored sheath pulls. For patients requiring hospital admission, ICU staff remove wrist compression bands, but cath lab nurses pull femoral sheaths.

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

Patients are prepped and recovered in 3 private rooms adjacent to our primary cath lab.  These rooms all have windows looking towards trees and mountains, and provide reclining chairs for patients and family members. Radial access compression bands and femoral closure devices are placed in the cath lab by cardiologists with CVT assistance.  Cath lab nurses monitor hemostasis in the recovery rooms when same-day discharge is planned, with ICU nurses monitoring hemostasis for patients admitted to the hospital.

How is inventory managed at your cath lab?

Our lead CVT manages inventory, and coordinates all purchasing with the hospital purchasing department and CFO.

Has your cath lab recently expanded in size and patient volume, or will it be in the near future?

We experienced a growth in patient-procedures of 55% in the first two years of our new partnership, related in part to rural outreach clinics staffed by our interventional and EP cardiologists. We recently added a hybrid OR-cath lab, configured for EP procedures and future EVAR therapy for abdominal aortic aneurysms (AAA).

Is your lab involved in clinical research?

We recently completed enrollment in a prospective, randomized clinical trial initiated by one of our cardiologists (RM). This trial compared the TR Band to the VasoStat wrist compression device, following coronary and peripheral diagnostic and interventional procedures. The study compared measurements of hand perfusion before, during and following wrist compression, incorporated patient satisfaction surveys regarding comfort level and complications, and measured radial artery patency and blood flow after 30 days using duplex ultrasound. We anticipate submitting the trial results for presentation at an upcoming national cardiology meeting.

Can you share your lab’s door-to-balloon (D2B) times?

One of our cardiologists (DW) leads a statewide initiative through the American Heart Association’s (AHA) Mission:Lifeline to help non-PCI/critical access centers in rural Montana meet the following guidelines: (1) door-to-electrocardiogram (ECG) within 5 minutes, (2) door-to-lytic needle within 30 minutes, and (3) door-in door-out within 50 minutes. This also included more rapid transmission of ECGs to one of only 9 PCI centers in Montana, and coordination of EMT and helicopter transfers. All STEMI cases transferred to our center go directly to the cath lab through an entrance adjacent to the emergency department (ED) and helicopter landing pad. We currently require cath lab staff to arrive within 20 minutes of STEMI page notification. Our center’s average door-to-balloon time is 66 minutes.

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

Cath lab nurses assist ED nurses in transporting STEMI patients to the cath lab.

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

Elective cases are taken off the table, with arterial sheaths remaining in place, to allow rapid care for STEMI cases. If an urgent case is already being performed, either thrombolysis is used or transfer is immediately made to a second hospital in town.

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

The following measures have been taken to reduce costs:

1) Eliminating the use of bivalirudin in favor of unfractionated heparin;

2) Monitoring carefully the opening of products and interventional devices during cases;

3) Selecting longer coronary stents and longer drug-coated peripheral balloons in an attempt to achieve a 1:1 ratio of device/arterial lesion;

4) Participating in a corporate purchasing programs for discounts and rebates;

5) Favoring lower-cost products whenever possible;

6) Prioritizing efforts to expand same-day discharge following elective interventions; and

7) Collaborating with hospitalists to reduce hospital lengths of stay.

What procedural quality control measures are practiced in your cath lab?

Observational feedback from staff and cardiologists, with input from the cath lab director and the hospital Peer Review Quality Committee.

How do you determine contrast dose delivered to the patient during an angiographic procedure?

Contrast use is measured directly by circulating nurses and recorded in all cath lab procedure reports.

Are you tracking the incidence of contrast-induced acute kidney injury in patients?

No current formal tracking process is in place. For patients with any degree of chronic kidney disease, follow-up creatinine measurements are ordered for all patients within 5-7 days of cath lab procedures.

How are you recording fluoroscopy times/dosages?

Automated measurement of time and dose is performed, with results recorded in all cath lab procedure reports.

What is the process that occurs if a patient receives a higher than normal amount of radiation exposure?

Email notification to staff and attending cardiologist, with plans for patient skin examinations at the time of a scheduled follow-up clinic appointment, made within 30 days of cath lab procedures.

Who documents medication administration during the case?

Monitoring nurses document all medications administered, with all medication obtained using Pyxis (BD) and recorded in our EMR. Medication waste documentation requires two nurses for signing off.

Are your physicians dictating their cath procedure reports, or do they use a structured reporting tool?

Cardiologists use structured templates for completing dictations, with voice-recognition software.

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

We participate in the ACC-NCDR Cath-PCI, Chest Pain-MI and ICD registries, and also the AHA Get With the Guidelines CAD Registry.

How are you populating the registry data records?

One of our CVTs has CPHIMS (Certified Professional in Healthcare Information and Management Systems) certification, and inputs all data into registries and data recording systems for the hospital.

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

Cardiologists travel to several outreach clinics, as far as 85 miles away from the hospital. Same-day outpatient consultations are provided in our cardiology clinics, with walk-in patients being accommodated as well. Advertisements through billboards, search engine marketing, direct mail, online display ads, social media, radio, local newspapers, and outreach efforts are used to promote services provided, including radial access and same-day discharge following interventional procedures. Educational programs are being developed for the podiatry community regarding new endovascular therapies for multilevel and below-the-knee tibial arterial disease.

How are new employees oriented and trained at your facility?

New nursing graduates receive ICU training for one month, complete formal competency book and online training modules, and must also undergo a 6-month preceptorship program.

What continuing education opportunities are provided to staff members?

Staff members receive education through cardiologist-initiated training sessions, AHA and hospital HealthStream online training modules, and through attending conferences.

How do you handle vendor visits to your lab?

Vendor visits require scheduling and Vendor Credentialing Service (VCS) kiosk check-in at our hospital. Vendors are allowed to be present for cath lab procedures, and stand in the lab wearing scrubs and lead aprons.

How is staff competency evaluated?

Observational, with annual online peer-review surveys.

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?

CVTs are required to become RCIS certified, and receive pay raises upon passing the examination.

Does your lab have any physical (layout) bottlenecks or limitations?

Our EP lab is located physically on the opposite side of the hospital from the primary cath lab. Dedicated staff are assigned to staff EP cases on their scheduled days, and EP inventory is kept in this separate lab.

What do you like about the physical space in which you work?

Cath lab work space provides desk space for all nurses and CVTs, with 3 adjacent private holding rooms, and with windows overlooking trees and mountains. Western art is displayed, with reclining chairs for patients and family in holding rooms equipped with LCD TVs. Cardiology clinic office rooms, and rooms for echocardiography, stress testing, and nuclear imaging, are all located adjacent to the primary cath lab.

Is there a particular mix of credentials needed for each call team?

Each call team is comprised of one CVT and two nurses. All cath lab nurses and CVTs are cross-trained for coronary, peripheral and EP procedures. Staff are permitted to leave early after a night of on-call.

How does your lab schedule team members for call?

Cath lab nurses share call equally for weeknights, weekends and holidays. Cath lab CVTs take call in blocks of time, shared equally. Call averages are one in three weekends for nurses, and one in two for CVTs.

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

Call team staff and cardiologists are expected to arrive to the lab within 20 minutes of being paged.

Do you have flextime or multiple shifts? How do you handle slow periods?

Voluntary flextime is followed. During slow periods, cath lab nurses complete pre- and post-procedural patient calls, contact patients for reminders regarding upcoming outpatient clinic appointments, perform telephone follow-up for heart failure clinic patients, provide inpatient heart failure education, participate in data abstraction for ACC registry input, and assist in stress testing performance.

Do staff members have any perks that you might like to share?

Staff have free parking and opportunities to travel to attend educational conferences.

Has your lab recently undergone a national accrediting agency inspection?

The cath lab was accredited by the Joint Commission last year.

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

As patients live longer, we are frequently encountering individuals in their late 70s and 80s requiring treatment for coronary artery disease and other vascular disease, with multivessel coronary disease more commonly encountered. Given Montanans’ reduced access to primary care providers, especially in rural communities, late presentation of cardiomyopathy and valvular heart disease is frequently seen. Patients requiring endovascular procedures for SFA/popliteal and tibial disease represent the largest growth area in our cath lab.

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

Our team rapidly adopted a same-day discharge policy for all elective PCI and endovascular interventional cases performed using radial access. Radial access has become the “default” approach for all STEMI and most coronary cases. We are continuing to push the envelope by also using radial access for endovascular procedures. We are providing input to industry for the development of longer sheaths and devices to better reach into SFA and tibial arteries from the radial approach.

Is there a problem or challenge your lab has faced?

One of our biggest challenges is hiring qualified nursing and CVT staff, given the higher costs of living in a “mountain town” in a beautiful setting in western Montana. We also have a requirement that call staff be able to arrive in the cath lab within 20 minutes of being paged.

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”?

Physically, Montana is the fourth largest state, although our population is just over 1,000,000, with only 9 PCI centers. Our state is often referred to as “Big Sky Country” and “The Last Best Place.” Missoula is located in the far western part of the state, less than 3 hours from Glacier National Park, and 4 hours from Yellowstone National Park. Missoula is the home of the University of Montana, and the location for the book “A River Runs Through It.” The Blackfeet and Salish & Kootenai reservations are just north of Missoula, where we staff one of our outreach clinics. Our region is one of the fastest growing in Montana, with many retirees over the age of 55 moving to nearby rural areas for the outdoor scenery and wildlife, blue-ribbon trout fishing, hiking, camping, skiing, and quality of life. Billings Clinic Heart and Vascular at Community Medical Center is committed to having their cardiologists travel to rural outreach clinics each week to provide state-of-the-art cardiology and vascular care. Our “cath lab culture” incorporates our desire to maintain a great work-life balance for our staff, with our passion for delivering “best practice” interventional services to our fellow Montanans. Feedback from patients following same-day discharge after radial artery access has been excellent, as many patients must return as quickly as possible to responsibilities for caring for their livestock and wheat fields on ranches.

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

How do you use the NCDR Outcome Reports to drive quality improvement (QI) initiatives at your facility?

We present to the administrative senior leadership team all STEMI cases within 48 hours, with feedback reports provided to EMS team involved in the case, and to cath lab and ED staff. Quarterly institutional reports are reviewed by cardiologists, cath lab staff, and administration. QI initiatives are generated from these reports, and progress is tracked. 

Dr. Robert Minor can be contacted at rminor@billingsclinic.org.

Dr. Douglas Waldo can be contacted at dwaldo@billingsclinic.org.