Cath Lab Spotlight: North Shore University Hospital

NSUH uses a mix of registered nurses (RNs) (38), radiologic technologists (RTs) (11) and cardiovascular technologists (CVTs) (10) to staff the department daily. The recovery suite is open 6:00am–9:30pm and the cath labs are open 7:30am–8:00pm, Monday through Friday.  Saturday is an abbreviated schedule, 6:00am–4:00pm.

As a teaching hospital, NSUH has interventional fellows that assist in the preparation of patients, as well as scrub into procedures. In addition, nurse practitioners (NPs) (6) and patient care assistants (PCAs) (4) are staffed in our recovery suite or peri-procedural area. Some of our staff has been employed in the cath lab for over 20 years.

As a Magnet-designated hospital, professional development is supported and recognized. Seventy-three percent of RNs have a bachelor of science in nursing (BSN), 76% are certified, and 50% are on the clinical ladder. A clinical ladder was recently instituted for the cardiac technologists.

What procedures are performed in your cath lab?  

Our lab performs a variety of interesting procedures. Most frequently performed are left heart catheterization, right heart catheterization, percutaneous coronary interventions (PCIs), biopsies, and peripheral angioplasties. Our lab also performs coronary brachytherapy, atrial septal defect (ASD) closures, aortic valvuloplasty, mitral clips, inferior vena cava (IVC) placement/retrievals, and transcatheter aortic valve replacement (TAVR). Intravascular ultrasound (IVUS), optical coherence tomography (OCT), fractional flow reserve (FFR), orbital atherectomy, Rotablator (Boston Scientific), and laser are also available. Over a one-week period, our lab performs approximately 150 left heart catheterizations, 8 TAVRs, 7 peripheral angioplasties, and 60 PCIs.

Can you share more about your experience with TAVR? 

The NSUH TAVR program has grown with tremendous success since 2011. In our first year, 11 procedures were performed in our facility. This year, we are on target to hit 300. Much of the success has been as a result of the collaboration between the cath lab and operating room (OR) staff to turn around the hybrid room (Siemens) more efficiently. Since the program’s inception, we have seen a decrease in the number of permanent pacemakers (PPMs) required post procedure, a decrease in the amount of paravavular leakage, and a decrease in the number of peripheral vascular complications. The procedure has also moved to a more non-invasive process, using conscious sedation and transthoracic echocardiograms (TTE). New developments in valve technology, a decrease in sheath size, and the ability to recapture and reposition valves allow us to provide the best possible outcome for our patients.    

What is your percentage of normal diagnostic caths? 

Our normal cath rate is about 38%. This is based on the New York State Department of Health definition that any single or multiple lesions of <50% stenosis are normal. Heart function and valve disease are reported separately. Approximately one-third of our diagnostic procedures advance to PCI.

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

A large majority of our staff physicians use the radial approach as their primary choice for access. This results in about 60% of the cases being performed via this approach. If a complex procedure is planned (chronic total occlusion [CTO], high-risk PCI with Impella [Abiomed], etc.), multiple access sites are considered, including femoral. 

If you are performing peripheral vascular procedures, do any operators utilize pedal artery access when appropriate? 

Yes, our vascular interventionalists use pedal artery access when needed.

Who manages your cath lab? 

Dr. Loukas Boutis is the medical director. Dorothy Veron, RN, is the director of patient care services for invasive and non-invasive cardiology, as well as the cardiac short stay unit (CSSU). Rachael Haddock, RN, is the nurse manager of the cath lab, EP lab, and recovery suite. Dawn Zioba, RN, is the assistant nurse manager. Michael Kleinschmidt, LRT, is supervisor of the invasive cardiovascular technologists (RT[R]s and CVTs).
Do you have cross-training? Who scrubs, who circulates and who monitors? 

Nursing is responsible for circulating and technologists are responsible for monitoring. The interventional fellows program has provided the scrub assist for the physicians and it had not been necessary for staff to perform scrub responsibilities during cases until recently. We have now started cross-training the technologists to scrub. Currently, they scrub into peripheral cases and by 2019, they will be trained to scrub cardiac cases.    

Are there licensure laws in your state for fluoroscopy? 

Yes, as per New York State Department of Health regulation, other than the physician, a licensed radiologic technologist is the only staff able to turn on, test, and utilize fluoroscopy. In our lab, the physicians step on the pedal and maneuver the fluoroscopy system during the procedure. Physicians, nurses, and technologists maintain competency to work in an area that uses ionizing radiation. 

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

We practice as low as reasonably achievable (ALARA) for radiation protection. All of our designated lab staff are provided with lead kilts, vests, and thyroid collars. Lead glasses are used by physicians and fellows, and are available to anyone else who chooses to use them.  Some of the physicians have started using lead head gear for additional protection. All personnel in the procedure rooms wear personal dosimetry. Exposure levels are available to staff monthly. Anyone exceeding limits receives re-education from the hospital radiation safety officer. The supervisor of technologists is responsible for the visual and manual inspection of all lead twice a year. Any lead suspected of being in poor condition undergoes a fluoro inspection.  Color-coded discs are attached to lead that can be scanned in order to easily identify lead for inspection and electronic record keeping.

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

One of the newest devices that has been introduced into our lab is extracorporeal membrane oxygenation (ECMO). This is placed in conjunction with cardiothoracic surgery and perfusionists. We are proud to say that our lab was the first in New York State to place a RP Impella. We currently use the 2.5, CP, and RP Impella devices. With our active clinical research program, we utilize numerous novel stents and other devices that are not yet FDA approved.

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

Communication is essential to stay current with additions and changes that are constant in interventional cardiology. It remains a struggle, but monthly meetings, email, briefs, and huddles are used to communicate information. The service line has a quarterly meeting that is attended by quality coordinators, as well as physicians from the six Northwell centers performing PCI.

How is coding and coding education handled in your lab? 

Coding is handled by certified coders in a central business office. When there are questions regarding a particular case, they speak directly with the physician to clarify. In addition to reviewing all procedural and equipment usage reports, our coders provide ongoing coding education to the physicians in order to ensure documentation comprehensively reflects patient acuity and procedures done.

Who pulls the sheaths post procedure, both post intervention and diagnostic? 

Diagnostic and interventional femoral sheaths are pulled primarily by the RNs and NPs. They must perform 10 sheath pulls under direct supervision of a preceptor before being deemed competent to perform sheath removal independently. The quality department tracks and trends outcomes. Adverse bleeding events are discussed for possible re-education opportunities. Large-bore sheaths (>10 French) are pulled by physicians or fellows.

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

Patients are prepped and recovered in a 22-bed peri-procedural area, the recovery suite. An additional 20 beds located in the CSSU, adjacent to the recovery suite, can be used to prep transfer patients and recover patients who are staying overnight.  

All radial sheaths are pulled immediately post procedure in the lab by the performing physician or fellow, and hemostasis is obtained via a radial band. The radial band is removed after 1-2 hours while in the recovery suite or CSSU. Occasionally, patients are recovered from sedation and sent back to their in-patient room with sheaths or a radial band. In this situation, the NP will remove the sheath/band while the patient is on the telemetry unit. The same competency process is followed before a clinician may remove a radial band. Only about 7% of cases receive a vascular closure device to achieve hemostasis.

How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies? 

We have a procurement specialist designated to do the ordering and stocking for the supply room. Supplies are ordered based on a usage report that is run daily from Mac-Lab (DMS). A visual inventory is conducted weekly to ensure par levels are maintained. A system procurement department supports the department with new product acquisition.

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

In 2015, Northwell Health integrated two nearby high-volume, high-quality cath labs into one center of excellence. This was the beginning of the Heart Hospital at NSUH, formed in 2017, and a heart transplant program.

Is your lab involved in clinical research? 

NSUH maintains a very active role in the clinical research arena and is usually one of the top enrolling sites. Some of the interventional cardiology trials include: 

• COBRA REDUCE, a blind clinical trial to assess superiority of dual antiplatelet therapy (DAPT) over drug-eluting stents (DES) plus 3 or 6 months of DAPT; 
• Onyx, an open-label, multicenter trial to assess the safety and efficacy of the Resolute Onyx  stent for the treatment of lesions in coronary arteries amenable to treatment with a Resolute Onyx 4.5 mm – 5.0 mm stent;
• SAFE STEMI, a single-blind clinical trial examining the effectiveness of zotarolimus-eluting stents for radial PCI in STEMI and the benefits of iFR-guided complete revascularization vs infarct-only revascularization. 
•  The peripheral program at NSUH is the third-largest randomizer in the country for the ROX Hypertension Study, an interventional vascular therapy for uncontrolled hypertension.  
• The CONFIDENCE trial uses a dual-layer nitinol micromesh carotid artery stent (Roadsaver, Terumo) for sustained embolic protection.      

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?  

Our overall time is 59 minutes. We also track the times when the cath lab is open (51 minutes) and closed (67 minutes). Over the past 5 years, the D2B workgroup has made significant improvement in the overall time (72 to 59 minutes and the cath lab closed time (75 to 67 minutes). We have a monthly, interdisciplinary D2B workgroup meeting that includes leadership, physicians, and nurses from the cath lab, emergency department (ED), cardiac care unit (CCU), quality, and data registry. Guests are invited as we address ideas to improve times. We have addressed several data points: door-to-electrocardiogram (EKG), on-call team activation, and facilitating transport of the patient to cath lab anticipating team arrival. The ED re-educated staff on signs/symptoms that require immediate EKG, created “Code EKG” in the ED to prioritize the need for an EKG, and specified an ED attending to expedite the EKG read and ST-elevation myocardial infarction (STEMI) activation. The process of activating the on-call team via cell phones changed to a universal page system. The cardiology fellow and off-shift assistant nurse manager for cardiology coordinate the transport of the patient to the cath lab, no longer waiting for the team to arrive in the ED to initiate transport. If the cath lab is open, the cardiology fellow and ED staff bring the patient directly to the prepared procedure room. Our community emergency medical services (EMS) is largely supported by volunteer fire/rescue departments. Ambulances are not universally equipped with EKG transmission ability or all staffed with advanced medical technicians (AMTs).

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

EMS transports STEMI patients from referring facilities directly to the lab. In-house STEMI patients are transported by the cardiology fellow and a member of the rapid response team. 

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

The members of the on-call team grew to include 2 RNs and 2 technologists as patient acuity, activations, and technology needs increased. If the team is involved with a procedure when a second STEMI is activated, one technologist will set up a second room. In this situation, the on-call physician will use medical judgment to decide the best plan of care for the patient. There is a second on-call physician available, but this option has rarely been used. 

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

Evidence-based practice is used to guide use of products and medications. As a large healthcare system, product costs are negotiated for all 6 cath labs to contain costs. The use of bivalirudin has significantly decreased over the past few years, specifically during radial PCI. Additionally, the use of a more expensive contrast agent is limited to specific cases, generally peripheral.

What quality control measures are practiced in your cath lab?

We provide individual patient data to the American College of Cardiology’s National Cardiovascular Data Registry (ACC-NCDR) and New York State Department of Health databases. Quality outcomes are monitored and reported monthly at our quality meeting. In addition to D2B times, acute kidney injury rates, bleeding incidents, mortality and morbidities are discussed.

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

Our physicians use a power injector during the procedure and the amount of contrast can be read on the injector. The contrast dose is reported to the technologist at the end of the case for documentation. Target maximum volume of contrast is noted at the beginning of the case using 3x the patient’s creatinine clearance (CrCl). We are currently trialing the DyeVert system (Osprey Medical) with chronic kidney disease patients to evaluate patient outcome and cost benefits.

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

Our NCDR data is tracked by the registry nurses and the incidence of acute kidney injury (AKI) is discussed at the monthly quality meeting. Recently, a decision was made to standardize hydration practices for patients.

How are you recording fluoroscopy times/dosages? 

After a procedure is completed, a form is placed in the patient’s chart containing the total amount of fluoroscopy time, as well as the cumulative dose area product (DAP). The DAP has been shown to correlate well with the total energy imparted to the patient, which is related to the effective dose and overall cancer risk. Any dose over 5,000 mGy is documented and brought to the attention of the physician and nurse. The physician discusses it with the patient and the nurse educates the patient.

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

Any patient receiving extended fluoro (>5,000 mGy) receives education, verbal and written, regarding signs and symptoms of exposure. The patient receives a follow-up phone call from the cath lab assistant nurse manager after 3 weeks to evaluate any adverse reaction.  

Who documents medication administration during the case?

Electronic documentation is used by the monitoring technologist to document all aspects of the case: equipment, medication, and procedures. The physician verbally orders the medication, the nurse repeats back and administers the medication, and the technologist documents it. At the end of the procedure, the physician, nurse, and technologist review the documentation for accuracy and all sign the printed report.

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

Our physicians currently use GE Centricity (GE Healthcare) as their reporting tool.

How are you populating outside registry data records? 

The service line supports a team of nurses trained to extract data specifically for registry reporting. The two registries (ACC-NCDR and New York State Department of Health) look at data differently. The nurses attend annual conferences to stay current on reporting requirements.  The nurses are physically located off site, and review charts electronically and complete registry forms by hand.

How does your cath lab compete for patients? 

NSUH is part of the Northwell Health System and collaboration agreements to enhance clinical services and operation efficiencies are addressed through corporate negotiations.   

How are new employees oriented and trained at your facility? 

Northwell Health begins the onboarding process with a system orientation called “Beginnings”. The system president and CEO attends each orientation personally to introduce himself, as well as the mission and vision of the organization. The next day, new hires attend site orientation at their respective hospital. The following day, they begin orientation on their unit. Nursing education utilizes education pathways to ensure basic competencies are met.

What continuing education opportunities are provided to staff members?

Professional growth is encouraged. Nurses can take advantage of an on-site MSN program in leadership or education. There is also a NP program that the health system conducts in conjunction with a local university. An MBA or MHA is available through the same university.  All degree programs are either reduced rate, free, or supported with some tuition reimbursement. Certification programs are provided on site and those who successfully complete the exam are reimbursed. Our nurses and technologists are able to receive an annual stipend for program registration and continuing education time each year. Four times a year, a cath lab education day is organized by the nurse educator on a Saturday. Lectures are conducted by vendors, physicians, and staff. In addition, there are numerous continuing education programs available through nursing education on a variety of topics throughout the year. We often receive complimentary attendance at local conferences at which our physicians are presenting. Once a year, the physicians provide the opportunity for three staff to attend a national conference, usually the ACC Scientific Sessions or the Transcatheter Cardiovascular Therapeutics (TCT) meeting.

How do you handle vendor visits to your lab? 

Vendors are limited to scheduled visits each month, made with our procurement representative. NSUH utilizes a third-party credentialing agency, RepTrax, to ensure representatives meet health screening, competency, and HIPAA requirements set by the health system. Vendors enter the building through staff entrance, where they sign in via a vending machine that issues a daily pass and paper scrubs necessary for their visit. The pass is worn across the chest and visually expires after 8 hours of activation.    

How is staff competency evaluated? 

Staff competency is evaluated annually and topics are chosen on the basis of risk and volume.  Validation methods can be direct or indirect observation, simulation, or testing. The invasive cardiology staff educator (.6 FTE) works with several departments to develop ongoing competency assessment tools. Nursing education supports the cath lab for critical care assessment skills (EKG, intra-aortic balloon pump [IABP], Impella, hemodynamics, etc.), and peri-op services supports initial competency training on aseptic technique, phase I/II recovery, and malignant hyperthermia. Competency skills specific to the cath lab are developed with the support of nursing education (sheath removal, radial band removal, preparation and use of manifold, etc.).

Does your lab have a clinical ladder? 

There is a clinical ladder for nurses, technologists and PCAs. Each has a similar foundation of elements: service excellence, quality, leadership, research, and education. Each applicant selects categories with associated point values to achieve their desired level (1, 2, 3). Portfolios are evaluated by a committee of peers, educators, and leadership for validation. Clinical ladder recognition must be submitted each year for renewal. There is a financial reward associated with the clinical ladder level achieved.

Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? 

To work as a technologist in our lab, you must obtain either RCIS or CI credentials within the first 18 months of hire. There is no incentive bonus or raise upon passing the exam, as it is required. Those in the department prior to 2014 are not required to do so. Nurses are encouraged, but not required, to achieve national certification through a nursing leadership organization recognized by Magnet. They do receive an annual certification stipend. Technologists and nurses can use certification to receive clinical ladder points in the element of education.  

Does your lab have any physical (layout) bottlenecks or limitations? How do you work around the resulting challenges?

Since integration and the increased volume, the physical space of the recovery suite has presented difficulties with throughput. The CSSU was opened at the same time and has helped with movement through the department, but does not solve the bottleneck completely. By the end of 2018, we will see 5 beds added to CSSU to help facilitate throughput.

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

Our newest room has a sleek look, including ambient lighting. Last year, with our input, our staff lounge was cosmetically remodeled. The largest refrigerator was installed to accommodate the staff’s biggest wish.

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

Two RNs and two technologists are scheduled for call. This model was requested by staff to recognize the increased acuity and technology demands of the patients. If it has been a difficult call schedule, they are granted sleep time.

How does your lab schedule team members for call? 

Call time is distributed equally to staff members. They are then permitted to ‘give it away’, down to a minimum number of hours, based on their full-time employment status. Staff with more than 15 years of service in this cath lab are not required to take call.

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

The call team is expected to arrive within 30 minutes of activation. The use of the universal page has significantly improved arrival times.  

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

Our lab uses part-time, full-time, and per diem staff. The earliest shift starts at 6:00 am and the latest shift begins at 11:00 am. Our technologists mainly work 10-hour shifts, and nurses vary from 8-, 10-, and 12-hour shifts. Leadership huddles the day before to determine if the staffing schedule requires adjustment. When there are lower volume days or we finish early, paid time off is offered. In preparation of inclement weather, staffing is always reviewed to make sure we meet patient needs as well as the safety of the staff.

Can you share any staff perks? 

NSUH celebrates all staff with many recognition programs and celebration days: nurses’ week, radiology week; certified nurse day, the DAISY Award program, an employee BBQ, a holiday celebration for employee children, etc. There is an employee recognition program where anyone can nominate any employee with recognition points. Once approved by their leader, those recognized can use points to purchase gift cards, entertainment, or merchandise. There is free parking for staff.  When on call, staff can park in reserved parking closer to the hospital.

Has your lab recently undergone a national accrediting agency inspection? 

In March 2018, NSUH successfully completed a Magnet Survey. The cath lab played an important role, as the success of the D2B workgroup was featured as a successful interdisciplinary initiative.

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

With the growing number of heart failure patients, our hospital has increased resources to serve this population. A new Cardiomyopathy Clinic was instituted about 3 years ago and programs have sprouted from this initiative. The use of cardiopulmonary exercise testing (CPET), CardioMEMS (Abbott) to track high-risk patients, left ventricular assist devices (LVADs) as destination or bridge therapy, ECMO, and the heart transplant program all developed out of the clinical needs of this population. As a result of the heart transplant program, with 10 transplants completed in the past 6 months, we have seen a tremendous increase in cardiac biopsies.

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

Our cath lab is never lacking for something exciting and new to learn. The latest and most advanced treatments, including MitraClip (Abbott Vascular), Watchman (Boston Scientific), extracorporeal membrane oxygenation (ECMO), left ventricular assist devices (LVAD), and heart transplants, have all been added over the last 4 years. We are the only hospital on Long Island performing heart transplant and coronary brachytherapy. Within the past 2 months, we introduced the DyeVert Plus System to help in the reduction of AKI rates.

Is there a problem or challenge your lab has faced? 

The staff are encouraged to participate in the Collaborative Care Council for Invasive Cardiology. This is a self-governance committee run by two staff members. Currently, the co-chairs are two cath lab nurses. Leadership, including physician and nursing, attend the meetings to listen and provide answers or address concerns requiring follow-up. Cath lab staff specifically addressed the number of staff on call and requested additional nursing help. The request was escalated to the chief nursing officer, who approved the request.

What is 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”?

NSUH is located on the north shore of Long Island. The communities it serves are local; however, with the addition of niche procedures and cardiologists from other parts of the country, we are seeing more patients who fly in from other states.

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 initiatives at your facility?

• PCI Task Force (quarterly system meeting inviting physicians, department leadership, quality nurses, data extractors, service line leadership from all 6 cath labs).
• Communicate with quality department to set thresholds for outcome reporting.
• Quarterly meetings with department chair to review quality metrics negatively impacting Northshore’s performance.
• Complications negatively affecting outcomes metrics are reported monthly for peer review at cath conference.
• Weekly meetings with RNs performing data abstraction, regarding understanding of and compliance  with NCDR guidelines.
• Communication with in-service providers regarding documentation requirements. 

The authors can be contacted via Dorothy L. Veron, MSN, RN, NEA-BC, Director, Patient Care Services, Cardiology, at dveron@northwell.edu.