Spotlight: Beaumont Trenton Cath Lab/Interventional Radiology

Tell us about your cath lab. 

We have two labs at Beaumont Trenton. They are state of the art and provide services for both cardiac and interventional radiology procedures. Beaumont Trenton gained approval and accreditation to perform elective percutaneous coronary intervention (PCI) on March 30, 2016. Beaumont Trenton was the second in the state of Michigan to perform elective PCI without surgical backup. Our first elective PCI was performed on April 18, 2016 by Dr. Abedlrahim Asfour. Since then, we have performed 200 elective PCI interventions.  

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

We have two labs. Our medical director is Dr. Abedlrahim Asfour. Lisa M. Landry, MBA, is director, imaging and cardiology. Our clinical manager is Katie Sturgill, RN. We have 6 full-time registered nurses (RNs), 1 part-time RN, 1 contingent RN that takes on-call only, 4 registered radiologic technologists [RT(R)s], 1 business office assistant, and 1 office manager. We have staff who have been with us for more than 15 years, as well as new staff. Our total years of experience for RNs and technologists equals 65+ years. 

What procedures are performed in your cath lab?

Cardiac procedures include left heart catheterization with possible intervention, peripheral angiogram with intervention, Ocelot (Avinger), EKOS/thrombolysis (both for pulmonary embolism and deep vein thrombosis), permanent pacemakers, implantable cardioverter defibrillators (ICDs), transesophageal echocardiogram (TEE), direct current cardioversion, and loop recorder insertion. Interventional procedures also performed in the labs include nephro tube placement, myelogram, lumbar puncture, kyphoplasty, drain placement, Quinton (Covidien), permacath, inferior vena cava (IVC) filter, mediport placement, coils, and thrombectomy.

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

Yes. Physicians gain radial access approximately 83% of the time.

Do any operators utilize pedal artery access for peripheral vascular procedures when appropriate?

Yes. Most of the time, pedal access is ultrasound-guided. We have the ViperWire Advance (CSI) and Ocelot (for chronic total occlusions) that can be advanced through a 4 French (F)/5F sheath.

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

Our interventional radiology (IR) technologists are cross-trained to monitor and scrub. RNs circulate procedures and rotate into the cath lab holding area to care for patients pre and post procedure.

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? 

The IR technologist and cardiologist can perform all of the above.

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

The use of protection devices, including lead aprons, vests, thyroid shields and glasses, are mandatory for all staff when in procedures utilizing ionizing radiation. All staff and physicians are provided with dose oximetry badges monthly. Badges are sent out for analysis and a monthly report is posted in the department highlighting individual exposure. Leads are checked and logged every 6 months by the cath lab IR technologist and replacement leads are ordered accordingly. There is a protective shield at the head of the table and an extra protective leaded skirt hanging from the side of the table.

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

We have intravascular ultrasound (IVUS)/fractional flow reserve (FFR), Ocelot, Pantheris (Avinger), EKOS for pulmonary embolism and deep vein thrombosis, the Indigo venous thrombectomy device (Penumbra), Impella (Abiomed), and a capital request complete for Avox (Accriva Diagnostics).

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

For physicians:

• Cardiology Process Improvement business meeting monthly
• Quarterly Interventional Cardiology Process Improvement
  • Meetings include cardiovascular surgeons from Beaumont Dearborn (tertiary site), intensive care unit (ICU), cardiac rehab, quality specialist, data extractor for the American College of Cardiology’s National Cardiovascular Data Registry (NCDR)/ The Blue

Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2)

• Changes/updates regarding scheduling, protocols, and new equipment are sent to each physician via memos and emails on a regular basis.

For cath lab staff:

• Daily morning huddles
• Communication board
• Monthly staff meeting held by clinical manager
• Monthly staff meeting held by our director with imaging and cardiology
• Designated staff RN attends the clinical practice council monthly
• Department unit council 

How is coding and coding education handled in your lab? 

A group known as McGladry visits annually in our department to audit charts and give the latest updates and upcoming changes with coding and billing in compliance with Michigan regulations. The clinical manager and lead IR tech receive important changes and reminders via e-mail.

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

All IR techs pull sheaths and intra-aortic balloon pumps (IABPs). They are initially trained by a competent senior staff member and complete an annual competency.

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

We have an 11-bay holding area for both pre and post patients. We use Angio-Seal (Terumo), Mynx (Cardinal Health), and TR Bands (Terumo) for closure. All sheaths are removed in the holding area by an IR tech, with the exception of the ICU patients. Those patients can go to the ICU with a sheath, but the IR tech is responsible to pull the sheath when appropriate. All patients who have received coronary intervention go to 3ICU/3IMC. Any diagnostic or same-day discharge post intervention is managed and discharged from our holding area. 

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

The lead IR tech is responsible for inventory and ordering product. A few hours each morning is dedicated to be sure that this is done. The staff as a whole does continuous monitoring of supplies so that a real-time inventory is kept. Staff communicates to the lead IR tech when a specific supply needs replacement.

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

On September 1, 2015, we expanded from 1 to 2 labs, and from 5 bays to an 11-bay holding area. This includes a medication room, staff lounge and locker room, physician consultation room, and comfortable lounge area for patient family members. On April 18, 2016, we performed our first elective PCI and year-to-date, our heart catheterization volume is up 150%!

Is your lab involved in clinical research?

No, not 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?  

We are 100% D2B <90 minutes. We are 100% cath lab team arrival <30 minutes.

Many of our physicians that take STEMI call do not live within 30 minutes of the facility. As a result, we began to provide in-house accommodations for physicians to stay overnight beginning in September 2016. Since the institution of the on-call room, our physician arrival time is 94% <30 minutes.

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

An RN and/or a resident or physician from the emergency department (ED).

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

We finish as quickly and efficiently as we can. Because we have 2 labs, we move into the second lab for the STEMI. We have a diversion guideline, but it is a last resort.

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

We stagger shifts, work to decrease casual overtime, and send staff home on days that are not busy. Beaumont Health also has a value analysis team that looks at cost savings through high-volume supply purchases. Through this initiative, the lab has been able to reduce the cost of supplies.

What quality control measures are practiced in your cath lab?

We have daily checks of x-ray equipment, temperature and humidity in rooms, and crash cart and defibrillator functionality. ACT and glucometer are tested for accuracy.

How are you recording fluoroscopy times/dosages? 

We record fluoro time and dosage on every case in our hemodynamic monitoring system. The time and dosage are reported in the patient’s procedural report.

What is the process that occurs if a patient receives a higher than normal amount of radiation exposure? How is the patient notified and what follow-up do they receive?

There is a policy in existence for this. We educate the patient at discharge. All patients receive a follow-up phone call by a cath lab staff member where we would ask for signs/symptoms of a radiation burn.

Who documents medication administration during the case?

The RN documents all medications given in EPIC on the sedation narrator.

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

The physician dictates post procedure in EPIC. No structured reporting tool is utilized.

How are you populating the registry data records? 

Amber Thompson is our quality consultant who extracts data for PCI. She uses a program known as Armus that requires manual entry. We do not have a system that communicates directly with our hemodynamic monitoring system (Xper [Philips]) at this time.

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

In our geographic area, Beaumont Hospital, Trenton is well known as a patient-centered community facility that provides compassionate, exceptional care every day. We also offer seminars on peripheral vascular disease to the public. We offered tours and information sessions with the opening of new cath labs. We have an excellent rapport with referring physicians and specialists, and also work with the media (Trenton’s local newspaper, The News-Herald) for marketing purposes.

How are new employees oriented and trained at your facility? 

The orientation period can last anywhere from 6-12 weeks, depending on prior experience. Each new staff member is paired with an experienced mentor who provides education and training. We have an orientation manual for each new employee with policies, guidelines, important information for reference, and checklists that are completed by their preceptor.  The lab manager sits down with each new employee and their preceptor weekly in order to get an update on their progress and how they are feeling about the orientation. Progress is documented weekly and a final evaluation is completed at the end of the orientation period to document competency in all areas. 

What continuing education opportunities are provided to staff members?

Certified education units (CEUs) are provided with many in-services in the department and off-site with new equipment, products and techniques. We offer annual renewal of basic life support (BLS) and advanced cardiac life support (ACLS). Seminars and conference opportunities also are provided annually.

How do you handle vendor visits to your lab? 

Vendormate is the program used for vendor sign in. They must have a badge printed for the day. We ask that each vendor notify the lab for approval before planning to come. Product specialists required intra-procedure are permitted to enter the lab, but visiting vendors are not allowed in the procedural areas.

How is staff competency evaluated? 

Competency is verified annually for groin management, point-of-care testing (activated clotting time [ACT], Accu-Check [Roche], hCG), IABP setup and monitoring, and understanding of IVUS/FFR through either online modules, or via demonstration of knowledge and skill to a senior staff member.

Does your lab have a clinical ladder? 

Not at this time. This is a goal for the Beaumont health system for 2017.

How does your lab handle call time for staff members? 

On call is self-scheduled. We have a 4-person call team with 2 RNs and 2 technologists. A member from perfusion is also on call for STEMI cases to assist with IABP setup.  Depending on the caseload for the day, staff is permitted to leave early or start later after working through the night. In many cases, we offer staff the day off, if possible.

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

All staff members are required to arrive within 30 minutes of being paged.

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

The staff may choose to use CTO (combined time off) for pay or VTO (voluntary time off) without pay during slow periods. 

Has your lab recently undergone a national accrediting agency inspection? Do you have any recommendations or advice?

Yes. Corazon made 2 visits initially for final accreditation for elective PCI. They have been back to evaluate at 3 months and 6 months after accreditation was granted. We are anticipating them in May 2017 for our 12-month evaluation then biannually thereafter.  
We passed all three visits with accolades. Some statements from our last Corazon visit include:

• “State-of-the-art cath labs”
• “Quality performance is outstanding”
• “Performance improvement follow-up is quick and responsive”
• “Excellent radiation exposure monitoring and infection control”

Our advice would be to keep an open mind when an accrediting body makes suggestions and make changes where you feel there is an opportunity for improvement. Upon return visits, they have appreciated the fact that we identify an opportunity and work to solve it.

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

The cath lab is on floor 2R. The ED is just below the cath lab on the first floor and the OR is ½ floor above us on floor 2. 

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

Patients are getting younger. Patients are waiting longer to come to the hospital and arriving sicker; most of the time, this is for lack of insurance.  

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

The staff has come from all different types of backgrounds with a wealth of knowledge to offer the team. We all live within the community, and take pride in the care and services that we deliver.

Is there a problem or challenge your lab has faced? 

Our cardiologist arrival time for STEMI was over 30 minutes due to the fact that all physicians live >30 minutes from the facility. We proposed the idea of an on-call room to be available each night for physicians. Since the beginning of September 2016, we have offered accommodations on site for the physicians to stay the night. Since the institution of the on-call room, our physician arrival time is 94% <30 minutes. 

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

1. 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?  

We do not have RCIS in the cath lab here at Beaumont Trenton.  

2. 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?

Not at this time.

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?

With the information reported quarterly at the performance improvement plans (PIPs) meeting, we are able to track and trend performance. For example, are we hydrating our patients prior to a cath? If this measure is low, we can put an action plan in place and monitor quarter to quarter to see if we are improving. This is where the glomerular filtration rate (GFR) ratio below 3 goal came from, pre/post medication administration came from, and so on. All of these initiatives are to create better outcomes for our patients and follow best practice. 

Katie Sturgill, RN, BSN, Clinical Manager, can be contacted at katie.sturgill@beaumont.org