Spotlight: Palmetto General Hospital

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

Yes, our cath lab is part of the Heart Institute at Palmetto General Hospital (PGH). We also partner with several regional Tenet hospitals, including Delray Medical Center, in order to offer our patients a complete range of percutaneous and minimally invasive complex procedures. We have a heart team, spearheaded by our structural heart clinic, to help identify, evaluate, and treat complex cardiovascular patients in a multi-specialty approach. 

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

We have 3 cath labs, one with subtraction angiography for peripheral procedures, a 6-bed pre/post procedure area, and we use the hybrid room for complex structural heart procedures. Our lab employs 1 director, 1 assistant nurse manager (ANM), 12 registered nurses (RNs), 2 registered cardiovascular invasive specialists (RCISs), 4 cardiovascular technologists (CVTs), 2 radiologic technologists (RTs), 1 RCIS-inventory coordinator, and 2 transporters. Over 35% of the staff has been working with us at least 10 years; nearly half of the staff has been here more than 5 years. We’ve also added some employees in the last few years to meet the demands of our growing program.

What procedures are performed in your cath lab?  

We perform all types of coronary procedures, including high risk percutaneous coronary intervention (PCI) using left ventricular (LV) support, atherectomy, balloon aortic valvuloplasty, atrial septal defect (ASD) and patent foramen ovale (PFO) closures, peripheral angiograms and interventions, carotid angiograms, electrophysiology (EP) studies, ablations, device implants, loop recorders, tilt table tests, transesophageal echocardiogram (TEE), and cardioversion. The total number of weekly procedures is approximately 60 to 80.

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

We opened our state-of-the-art hybrid suite 18 months ago and began our TAVR program a few months later. We developed a multidisciplinary heart team for TAVR, a cohesive group including interventional cardiologists, cardiothoracic surgeons, clinical cardiologists, anesthesiologists, and a cross-trained structural heart team consisting of dedicated members from both the cath lab and the cardiac surgery services. We are averaging 25 TAVRS per year with plans to expand the program, which is coordinated by Jackie Wheatley, ARNP.

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

We have a busy ST-elevation myocardial infarction (STEMI) program that offers primary 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?

Between 20-25% of our diagnostic angiograms are normal.

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

Yes, some of our operators use the transradial approach for almost 100% of their cases and over 90% of our total cases are transradial. 

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

No pedal artery access is used at this time.

Who manages your cath lab?

Dayami Rodriguez, ARNP-BC, is the cath lab director. She has been in the cath lab at PGH for the last 11 years, and part of the management team for the last seven. She commented “The cath lab is not my work place; it is my passion. I am privileged to be part of a truly committed and enthusiastic team that provides outstanding patient care with excellent patient outcomes.”

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

We plan to cross-train our nurses to scrub cases in the future. But now we have a team of 3-4 staff members by procedures according to the need and complexity, where usually 2 nurses circulate, and the technologists scrub and record data on the monitor. 

Are there licensure laws in your state for fluoroscopy?

We follow the guidelines, protocol, and practices of the hospital radiology committee, which are based on Florida regulations. 

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.

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

We were traditionally a high-volume Rotablator (Boston Scientific) cath lab, but have been using orbital atherectomy (CSI) regularly for the last year. We are also getting ready to launch the SHIELD 2 trial. This trial will give us the opportunity to use the Thoratec HeartMate PHP device in comparison to Impella (Abiomed), which we have been using for several years. We recently started our percutaneous mitral valve repair program using the MitraClip device (Abbott Vascular) and we have an active CTO program that is always eager to try out new equipment in this rapidly evolving field. Other new products include the Supera peripheral stent from Abbott, near-infrared spectroscopy (NIRS) (Infraredx), used for a recent trial, and the Dye Vert system (Osprey Medical) for minimizing contrast exposure.

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

We use different methods, including email, weekly education meetings, staff huddles, online “I Learn” courses, and a monthly Cardiovascular Lab Committee meeting.

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? What kind of training is mandated before someone can pull a sheath?

The sheaths are pulled by our cardiovascular technologists, RCISs, and interventional cardiology fellows. They need to have appropriate competencies and at least 5 lines pulled without complications.

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

Our patients receive pre/post care in the holding area. We use radial compression bands, ProGlide (Abbott Vascular), and Angio-Seal (Abbott) for hemostasis. A small percentage of our patients still receive manual compression for hemostasis.

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

We have 2 staff members dedicated to inventory and orders in the lab. The cath lab director oversees new equipment orders and par levels.  

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

We added a third cath lab in December 2015 and have increased our non-coronary volume by 30% in the last year. We plan to continue increasing our volume through high risk PCI, structural heart cases, CTO procedures, and EPS/mapping studies.

Is your lab involved in clinical research?

Yes. In the last year, we have participated in the Lipid-Rich Plaque (LRP) study testing NIRS infrared technology. We are also an enrolling site for the COMPLETE trial (Complete vs Culprit-only Revascularization to Treat Multi-vessel Disease After Primary PCI for STEMI) and will soon start to enroll in the SHIELD 2 trial testing the Thoratec Heart Mate PHP device vs Impella for high risk PCI patients.

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?  

During the last 3 quarters of 2016, our average D2B time was 57 minutes. We maintain a standard below 60 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?

During regular hours, the emergency department (ED) staff transports STEMI patients. During off hours, the cath lab staff transports STEMI patients.

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

Our primary responsibility is always to complete the procedure on the table safely or at least reach a point where the procedure can be staged without danger to the patient. Having three cath labs has made our cath lab much more flexible when it comes to dealing with STEMI patients without having to disrupt our daily schedule. 

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

We evaluate cost vs volume monthly, we evaluate new options in the market in an effort to reduce costs, and we have a strict policy for the use of contracted products whenever possible.

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 are you recording fluoroscopy times/dosages? 

We use 2 different systems, Mac-Lab (GE Healthcare) and Sensis (Siemens Healthineers). 

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

We notify the physician when any higher than usual amount of radiation is used. As part of our CTO program, we plan to develop specific protocols for patient education and follow-up recommendations when excessive radiation dose is reached for a given case.

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 do they use a structured reporting tool?

We use a dictation system mostly, with some physicians using templates in the electronic medical record (EMR) to document their findings.

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

Yes, we report to the NCDR database and we meet quarterly to review it. 

How are you populating the registry data records? 

This is the responsibility of the Quality Department. 

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 for attracting referrals is our experienced and dedicated staff. 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 PGH 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 previous appointment and are only allowed in the treatment rooms when specifically requested by the physician. A vendor badge 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.

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

We have a small holding/recovery area (6 beds) that is not always able to handle the inflow of new and post procedure patients. This is our most frequent challenge. We try to navigate the situation by using some beds in PACU (surgical recovery area) when necessary. This year, we are working to create a post radial access unit closer to the lab. 

Is there a particular mix of credentials needed for each call team? Are staff permitted to leave early or start later after a night of on-call?

We have a call team consisting of 1 interventional cardiologist, 1 interventional fellow, 2 nurses and 2 cardiovascular technologists (RCIS/CVT). They are allowed to start later the day after a busy call night, according to staff needs. 

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

They must be in the lab within 30 minutes.

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

We have 4/10 and 3/12 shifts. During slower periods, we schedule in-service sessions for the staff or they work on their mandatory education units. Also, we flex volunteers without affecting patient care. 

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

We have Joint Commission inspections every 18 months. Avoiding shortcuts and doing things the same way every day makes it easier to prepare for an inspection.

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

The cath lab is located on the second floor with a direct access elevator to the OR. The ED is on the ground floor. 

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

Coronary disease and structural heart disease is growing more complex each year. Procedures are more challenging than ever before, but fortunately, technology is keeping pace with these developments and allowing us to deliver complex percutaneous treatment to patients previously considered too risky for the cath lab. 

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

Our cath lab is a multicultural team working together in a very challenging environment. They combine significant clinical experience with impressive academic credentials, and are always willing to learn and take on new challenges, and develop new programs. The educational level for our nurses has increased tremendously during the last 4 years. Seventy-five percent of our nurses have BSN or masters degrees in nursing. 

Is there a problem or challenge your lab has faced? 

We faced some significant scheduling challenges in 2014 and 2015 as our cath lab volume continued to expand. Fortunately, we were able to add a third cath lab that helped improve our efficiency and patient satisfaction.

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”?

We have a very high number of non-English-speaking patients in our community, as well as recent immigrants. As a result, we have a very high incidence of advanced, untreated vascular disease that often presents for the first time under emergency situations. This often places a burden on our team to deliver good outcomes under difficult circumstances. The positive result has been a cath lab team highly trained and experienced in treating complex patients with severe vascular disease. This has provided an opportunity for the staff to more easily transition and pivot toward complex structural heart procedures quickly and without apprehension. 

The authors can be contacted via Patty Vila at patricia.vila@tenethealth.com.

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?  

This not a requirement for our staff at this time, but we are strongly encouraging them to take the RCIS test. We pay for the test and they receive a salary raise once they pass the exam. 

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?

We work with the American Heart Association and the Hispanic Chamber of Commerce to create some initiatives for the community. 

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

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

We have a very strict screening tool to increase some of the metrics related to the NCDR data and we present the results monthly in our Cardiovascular Lab Committee meeting.