Spotlight: Florida Medical Center

Tell us about your cath lab. Is it part of a cardiovascular service line?

The cardiovascular cath lab at Florida Medical Center is one part of a comprehensive endovascular service line inclusive of cardiac intervention, peripheral intervention, neuro intervention, and electrophysiology (EP) procedures. We work collaboratively with cardio-thoracic surgery, neurosurgery, and vascular surgery to provide a comprehensive endovascular-cardiac program to satisfy our patient needs.

What is the size of your cath lab facility and number of staff members? 

Our team is comprised of 7 registered cardiovascular invasive specialists (RCISs), 1 cardiovascular technologist (CVT), and 5 registered nurses (RNs). We also have 1 assistant nurse manager and a nursing director. The two most senior of the staff have been in the cath lab for 16 years and the newest member is the nursing director, who started in August 2017. We have a total of 5 procedure rooms, including 2 cath lab suites, one bi-plane where we perform our neuro interventions, one EP suite, and one hybrid operating room (OR). Three of our rooms have multi-endovascular capability to perform interventional and cardiac procedures. 

The hybrid OR has the capability of integration of imaging with multiple modalities (i.e., computed tomography [CT], magnetic resonance imaging [MRI]), and we can perform 3-D imaging, 3-D roadmapping, Xper CT (Philips), and multi-modality matching. 

What procedures are performed in your cath lab?

Because we are a comprehensive endovascular and non-vascular lab, our procedures include the following: left and right diagnostic catheterizations, cardiac intervention with percutaneous transluminal coronary angioplasty (PTCA), balloon pump, left ventricular (LV) support, fractional flow reserve (FFR), intravascular ultrasound (IVUS), and patent formen ovale (PFO) closure. We are a comprehensive stroke center and perform neuro interventions with diagnostic cerebral angiograms, and intervention, including thrombus retrieval devices and cerebral embolization. We perform a variety of peripheral arterial and venous system cases. The team also performs various elective interventional radiologic procedures, both vascular and non-vascular. Our EP program performs diagnostic EP studies and ablations, including cryo atrial fibrillation procedures, supraventricular tachycardia (SVT) and ventricular tachycardia (VT) ablations. We collaborate with the cardiac surgeons to perform epicardial VT ablations, and convergent a-fib surgery. We also use this suite to do our implant procedures inclusive of pacemakers, implantable cardioverter defibrillators (ICDs) and bi-ventricular devices, and loop recorders. We perform approximately 35 procedures per week. 

If your cath lab is performing transcatheter aortic valve replacement (TAVR), can you share your experience? 

We are looking to grow our hybrid program to include a TAVR program. 

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

Florida Medical Center has a cardiothoracic surgical program on site for emergency back-up. We have a busy ST-elevation myocardial infarction (STEMI) program that offers primary percutaneous coronary intervention (PCI) 24 hours per day with surgical backup on site during the day and available on call during off hours.

What is your percentage of normal diagnostic caths?

Currently, about 50% of our diagnostic catheterizations are negative.  

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

Yes, some operators do use the transradial approach and 90% of our total cases are transradial.

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

Many of our physicians will use pedal artery access when appropriate.

Who manages your cath lab?

We currently have an assistant nurse manager, Dawne Garcia, RN, who works in the rooms and takes call. Our Nursing Director, Cinthia Rodrigues, RN, recently joined our lab in August, and our Lead Tech, Gilberto Benitiz, RCIS, has been in the lab for over 16 years.

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

We do cross train the technologists to do multiple job functions and cross-train for all modalities. This allows us greater flexibility with our staffing. 

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? 

Our physicians position the tube, change angles and step on the fluoro pedal.

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

Our cath lab director is in communication with the hospital radiology safety committee regarding radiation protection and dose readings. The dosimeters are changed out on a monthly basis, and high readings are flagged and reported. We evaluate the quality of all lead protection equipment on a regular basis and appropriate eye protection with leaded glasses is strongly encouraged. We rotate the staff involved in complex procedures like chronic total occlusions (CTOs) and peripherals. We also monitor radiation exposure during each procedure, keeping track of increased exposure cases.

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

We have excellent open lines of communication with our physicians. Routine information is usually passed along via email and staff meetings, and we have monthly Cardiovascular Care Committee meetings. Neuro intervention has weekly meetings to go over cases and programs.  We also have regional director meetings that take place quarterly. The director’s office is strategically placed within the workings of the lab, so staff and administration are involved in the day-to-day of the department.  

How is coding and coding education handled in your lab?

The coding and charges are performed by an RCIS in the cath lab who works very closely with our finance and coding departments. She does a great job of educating our nurses and technologists regarding accurate coding. 

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

The sheaths are pulled by our cardiovascular technologists, RCISs, and RNs. They must have appropriate competencies and at least 5 lines pulled without complications. 

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

We have a 5-bay holding area where patients are routinely prepped for their procedures and can be recovered or held if needed. Patients who receive monitored anesthesia care (MAC) or general anesthesia recover in the post-anesthesia care unit (PACU). Sheath pulls, when performed in the lab, are done by both technologists and nursing, but most of our patients are either sealed, or if done transradially, have a TR Band (Terumo) placed.

Has your cath lab recently expanded?

We have not increased in size, but recently upgraded an existing lab.  

Is your lab involved in clinical research?

At the current time, we do not participate in any research studies in the lab, but we are looking to develop the research infrastructure at our facility.

Can you share some of the ways employees at your facility have worked together to keep door-to-balloon (D2B) times under the mandated 90 minutes?  

According to our National Cardiovascular Data Registry (NCDR) statistics, D2B times in 2016 averaged 53 minutes and to date, our D2B time in 2017 averages 64 minutes. We have a protocol for each department involved with STEMIs, and our goal is to have the patient on the table and ready for vascular access within 40 minutes of hospital arrival. 

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

STEMI patients are always transported by nursing and helped by technologists if necessary.

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

We have a second call team on backup for patient readiness so the physician can follow if the case is activated after hours.

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

Cost savings are implemented through regional purchasing initiatives and discounting contracted by our parent company, and tracking of compliance is tracked at our regional quarterly meetings.

What quality control measures are practiced in your cath lab?

We work very closely with the quality department and we have some performance improvement (PI) mandatory markers like pain assessment, hand washing, and moderate sedation. We also have some specific markers for the department like D2B time, PCI appropriate use criteria (AUC), cardiac cath AUC, and noninvasive tests prior to cardiac cath.

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

Contrast dose is based on contrast directly delivered to the patients, based on 100 cc bottles used, less any known waste and unused volume.

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

Yes, we are tracking AKI using National Cardiovascular Data Registry (NCDR) benchmarks and creating action plans based on this metric.

How are you recording fluoroscopy times/dosages?

Fluoroscopy dosing is directly recorded by our Philips and McKesson PACS system.

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

We notify the performing physician when dosing over the nominal amount of radiation is used. The physicist is also notified. This is also communicated to the nurse caring for the patient on the floor, so that patient education can take place.

Who documents medication administration during the case?

The monitoring nurse documents medications administered during the case.

Are your physicians dictating their cath procedure reports or are they using a structured reporting tool?

Some physicians still use the dictation line, while others do their reports on the McKesson Physician reporting system, and our interventional radiologists use PowerScribe.

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

Yes, we report to the NCDR database and we meet quarterly to review this information. For neuro intervention, we report to Get With the Guidelines®-Stroke.

How are you populating the registry data records?

We have two chest pain nurses that do our data gathering and reporting for ACC-NCDR and a neuro nurse navigator who reports to Get With the Guidelines®-Stroke.

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

We keep a close relationship with the clinical cardiologists in the area, who have always supported our cath lab. We also have a busy marketing department that is always working on different campaigns to highlight our cath lab services in order to attract both patients and new referring physicians. Our strongest asset is our experienced and dedicated staff, and high standards for quality. We are currently working closely with other regional Tenet hospitals to develop and expand our cardiovascular service line.   

How are new employees oriented and trained at your facility?  

All new employees at Florida Medical Center must attend a general orientation for 2 weeks and a department orientation. They work with a preceptor for the first 3-4 weeks, according to their previous professional experience.

What continuing education opportunities are provided to staff members? 

Staff is encouraged to attend monthly education meetings, quarterly hospital educational fairs, and we schedule monthly in-service sessions related to the new products, procedures, and equipment introduced to the cath lab.

How do you handle vendor visits to your lab?  

Vendors are allowed in our cath lab with a previous appointment and are only allowed in the treatment rooms when specifically requested by the physician. A vendor badge (Reptrax) and proper attire is mandatory prior to entering the cath lab and procedure areas.

How is staff competency evaluated?  

General staff competencies are evaluated annually by the nursing leadership and with the introduction of every new system or product.

Do you require your clinical staff to take the registry exam for the Registered Cardiovascular Invasive Specialist (RCIS)? Does staff receive an incentive bonus or raise upon passing the exam?

We are proud that 6 of our technologists are RCIS-credentialed and our CVT is sitting for the exam in November.  The staff does receive a raise upon passing the exam.

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

Call teams are expected to respond to the call of activation within 30 minutes. They are responsible for reporting that they are on their way within 5 minutes of the activation and if they do not, a secondary communication is sent out.

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

We do have flextime. But with multiple disciplines being serviced in our lab, we very rarely flex our staff.

Has your lab recently undergone a national accrediting agency inspection? 

We have Joint Commission inspections every 18 months. Doing things the right way creates good habits, so you are always prepared for an inspection.

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

We are on the same floor and next door to the OR, and down the hall from the ED and our CT machine for our stroke alerts. Our hybrid room opens between the cath lab and the OR.

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

We are seeing much sicker patients with an extensive disease process. Procedures and technology are continually changing in allowing us to deliver the best care for our patients.

What is unique about your cath lab and staff?

We are unique because we perform cardiovascular, endovascular, interventional, electrophysiology, and neuro interventional procedures in one lab, with a cross-trained staffing model.

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 Fort Lauderdale area sees a large number of tourists per year both from within the United States and internationally. Fourteen million visitors a year visit the area for our beaches and our rich cultural diversity; this also brings a large number of patients to our hospital that we treat and facilitate their safe return home. 

Cinthia Rodrigues, RN, can be contacted via Patricia Vila at patricia.vila@tenethealth.com.