Spotlight: Sentara Norfolk General Hospital

Sentara Norfolk General Hospital, the region’s first Magnet Hospital, is a 525-bed tertiary care facility and home to the area’s only Level I Trauma Center and burn trauma unit. In 2015-16, Sentara Norfolk General Hospital was ranked for the 15th time in the U.S. News & World Report’s “America’s Best Hospitals” edition for its heart program. Sentara remains the only nationally ranked heart program in our region, and only one of two hospitals in Virginia to be ranked by U.S. News & World Report.

Tell us about your cath lab.

We have 5 dedicated cath labs, 1 hybrid operating room (OR), and a minor procedure room. Currently we have 23 staff members, with 20 registered cardiovascular invasive specialists (RCISs) who perform all cardiac, peripheral and hybrid cases. Our three registered nurses (RNs) staff the minor procedure room where cardioversions, and transesophageal echocardiograms (TEEs) are performed. We also perform dental extractions in our minor procedure lab, for those patients who are awaiting cardiac OR procedures but have an infection in their teeth. This is a unique function of our department, but has aided in improving efficiencies in our cardiac OR.

What procedures are performed in your cath lab? 

Our cath lab performs a variety of diagnostic and interventional procedures that include: 

• Left heart caths
• Right heart caths
• Myocardial biopsies
• Angioplasty (percutaneous transluminal coronary angioplasty [PTCA])
• Percutaneous coronary intervention (PCI)
• Intravascular ultrasound (IVUS)
• Optical coherence tomography (OCT)
• Fractional flow reserve (FFR)/Instant wave-free ratio (iFR)
• Chronic total occlusions (CTOs) 
• Intra-aortic balloon pumps (IABPs)
• Percutaneous ventricular assist devices (Impella [Abiomed])
• Rotoblators (Boston Scientific)
• Diamondback (CSI)
• Structural heart procedures 
  • Patent foramen ovale (PFO)/atrial septal defect (ASD) closures
  • Valvuloplasty (aortic [AO], mixed venous [MV], and pulmonary vein [PV])
• Permanent pacemakers (PPM)
• Diagnostic and interventional peripheral angiograms (renal, runoffs, PTA, and stenting)
• Transcatheter aortic valve replacement (TAVR)
• MitraClip (Abbott Vascular)
• Watchman (Boston Scientific)
• Parachute procedures (Cardiokinetix)
• Minor room procedures include:
  • Cardioversions
  • TEEs
  • Loop recorders
  • Dental extractions

Can you share your lab’s experience with TAVR?

We are proud of our TAVR program. We celebrated our 500th TAVR procedure in March 2016. The experience of launching and maintaining a busy TAVR program has been rewarding. We started the program 5 years ago. Everything was new, including the hybrid OR. Over the last 5 years, we have developed our technical expertise side by side with the cardiologists, surgeons, and OR staff.  There are three cath lab technologists in every TAVR procedure. We monitor, circulate, and scrub to prep the valves. When we started the program, we trained a core team of four and now we have seven on our team. We typically do three TAVRs two days a week, and anticipate adding one or two more days as our volume increases. Our success with TAVR has caused our structural heart program to blossom. Our MitraClip and Watchman procedure volume has picked up, and we anticipate both will increase in the next few years. Our structural heart program also includes ASD, PFO, ventricular septal defect (VSD), and perivalvular leak closure cases.

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

No, we have a busy cardiac surgery suite that operates one floor above us in the Sentara Heart Hospital. The surgical team is on call after hours and has a 30-minute response time.

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

Our 2015 volumes show a 50% radial access use by our physicians. We have increased our radial access by 10-12% over the last 3 years. 

Who manages your cath lab?

Jocelyn Dawes, RN, BSN, manages the invasive cardiology department, which includes interventional cardiology and electrophysiology. Kevin Akers, BSHA, RCIS, is the team coordinator for the cath lab. He runs the lab’s daily operations. 

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

All of our technologists are RCIS-credentialed and cross-trained to scrub, circulate, and monitor our large variety of cath lab procedures. We have special teams designated for the less frequent, high acuity procedures like CTOs, TAVRs, and MitraClips. This allows a core group of techs to master the procedure, and then share the skill set with other staff members.  

Are there licensure laws in your state for fluoroscopy?

Virginia licensure laws require that fluoroscopy practice be performed under the direct supervision of a physician.

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 RCIS Scope of Practice allows RCISs to activate fluoroscopic imaging and manipulate imaging equipment, as well as select magnification. The Registered Cardiovascular Invasive Specialist program at the Sentara College of Health Professionals is a very rigorous program. In the program, the instructors teach digital subtraction and analysis, as well as image annotation.

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

Every member of the cath lab team is custom-fitted, and issued a lead apron and lead glasses. Lead pieces are cleaned monthly and inspected annually for defects. Sentara will replace an employee’s lead piece as necessary for damage or after 10 years. We have recently partnered with Bar-Ray, a personal radiation protection company and adopted their SmartID, a web-based inspection and inventory asset management system. This management system tracks each piece of lead and other radiation accessories by serial number to ensure timely inspections and replacement. Each employee is issued a radiation badge at the start of employment that is switched out quarterly.  A report is generated that indicates amount of exposure for that quarter, as well as cumulatively. 

Currently two of the five labs have Philips DoseAware, an instant radiation detection system where a special badge is worn. While wearing the badge, a screen above the monitor boom indicates the amount of radiation exposure for the individual. This empowers the staff to manage their radiation exposure in real time.

How are you recording fluoroscopy times and dosages? 

Fluoroscopy time and dose are recorded in the electronic medical record (EMR), Radiant, and Xper monitoring system. By recording the fluoro dose in the EMR, we help keep track of the patient’s lifetime dose.  The physicians are given regular reports of their average fluoroscopy times.

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

We have been using the Impella CP for a few years, and recently acquired the Impella RP. In the past 6 months, we have acquired a new Diamondback system, the Boston Scientific Comet wire, and CardioMEMS equipment (St. Jude Medical). Our staff has had training on the new Portico valve (St. Jude Medical), we have now completed two Portico procedures. Our newest stents on the shelves are the Boston Scientific Synergy as well as the Abbott Vascular Absorb.

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

There are a lot of moving parts to our cath lab at Sentara Heart Hospital, and it takes commitment to keep everyone informed. There are several committees that meet monthly to keep physicians up to date on changes to staffing and equipment in the labs. We have a Cardiac Value Analysis Committee (CVAC) that is primarily responsible for reviewing and approving all new products and/or replacement products used in the cardiac surgical and invasive areas of Sentara Heart Hospital. The Invasive Committee oversees systems and processes to ensure quality and efficiency in the cath lab. Finally, the Acute Myocardial Infarction Committee (AMI) establishes standard treatment protocols, collects and reviews data regarding AMI management, identifies areas of improvement, and facilitates timely treatment and reperfusion benchmarks. 

To get the information to staff, we have daily huddles at the beginning of our shift. Staff meetings are also held monthly to get out information and give staff the opportunity to ask questions about anything that could have changed. Our team coordinator also emails a weekly huddle update on Fridays to recap information discussed in huddles that staff may have missed.

How is coding information handled in your department?

In December of each year, the cardiac service line leadership meets to discuss the changes in coding. We then determine what coding will be deactivated and what will take its place. Once we have determined the changes, this information is given to our cardiovascular IT team and they deactivate the old codes and enter the new codes in our Philips Xper monitoring system. Our Xper system processes the billing when our procedure is complete, so it is important that our staff know the coding. There is a cheat sheet that is created for the deactivated vs new codes for staff, but communicating this in our daily huddles is the most effective method of disseminating the information. 

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

The Cardiac Assessment Recovery and Evaluation unit (CARE unit), our 36-bed pre/post nursing unit, pulls the sheaths after diagnostic or interventional catheterization. However, all the cath lab technologists are trained to pull sheaths. Our educators organize an annual sheath pull competency to keep that skill set current. The competency includes a study packet on vascular complications, an online test, and two sheath pulls under direct observation of an experienced nurse.

Can you tell us more about the CARE unit?  

The CARE Unit functions as a pre/post procedure area and an overflow unit for cardiac inpatients and transfer patients.  All of our patients are prepped in the CARE unit. The CARE unit nurses provide pre/post care for patients undergoing cath lab, electrophysiology (EP) lab and cardiac OR procedures.  Our CARE unit nurses pull sheaths and care for patients with vascular closure devices as well.

Patients are also recovered in the CARE unit by RNs. Patients usually receive their caths by radial or femoral access, so when returning to the CARE unit, they may have a D-Stat (Vascular Solutions), TR Band (Terumo), Angio-Seal (St. Jude Medical), Perclose (Abbott Vascular), or sheaths in place. It is the direct responsibility of the nurse to either pull the sheath or remove the radial bands, but the cath lab technologists are required at times for access site management. It is for that reason that both the RNs and cath lab technologists are required to complete annual competencies on vascular complications and groin management.

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

We have a full-time inventory coordinator, Timothy Henry, who manages the inventory and purchasing of supplies and equipment.

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

Our PCI volumes have increased. The Sentara Healthcare system has moved to a centralization of care. In the past, the community hospitals would perform elective PCI, but now those patients are routinely transferred to Sentara Heart Hospital. Our TAVR volume has really expanded in the past year. This has led to reciprocal volume increases in the cath lab. All of the TAVR patients require a left- and right-heart/TAVR workup catheterization. The increase in volume has warranted more staffing and the ability to run 5 labs daily.  A year ago, we reallocated an old cath lab as a minor procedure room to accommodate the increase of TEEs due to TAVR workups.  

Is your lab involved in clinical research?

Yes, we have a long history with coronary trials. Currently we are involved with:

• The REDUAL-PCI trial (evaluation of dual therapy with dabigatran vs triple therapy with warfarin in patients with atrial fibrillation that undergo a PCI with stenting);
• ARTEMIS trial (affordability and real-world antiplatelet treatment effectiveness after myocardial infarction study). 

We are soon to be enrolling in the EVOLVE Short DAPT trial (assessing the safety of 3-month DAPT in subjects at high risk for bleeding undergoing PCI with a Boston Scientific Synergy stent). 

We are still following patients in:

• The ABSORB III trial (Absorb bioresorbable vascular scaffold [Abbott Vascular]);
• EXCEL trial (safety and efficacy of the Xience Prime/Xience V everolimus-eluting stent [Abbott Vascular] compared to coronary artery bypass graft surgery in select patients with unprotected left main coronary artery disease); and 
• BIONICS trial (study of the BioNIR drug-eluting stent [Medinol] in coronary stenosis).

We are involved in many TAVR/structural heart studies, including:

• Edwards Lifesciences PARTNER TAVR studies;
• Medtronic CoreValve trials;
• Portico TAVR trial; 
• Watchman left atrial appendage (LAA) trials; and
• SENTINEL and REFLECT trials (cerebral protection devices used during TAVR procedures).

Sentara Heart has a busy transplant service and we participate in many heart failure studies as well, including:

• The PARACHUTE trial (Parachute Implant System, CardioKinetix);
• INTERMACS registry (The Interagency Registry for Mechanically Assisted Circulatory Support); and 
• A trial looking at the effects of cardiac resynchronization therapy (CRT) and left ventricular assist device (LVAD) therapy.

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 DTB times under the mandated 90 minutes? 

We are registered with American Heart Association’s Mission: Lifeline and American College of Cardiology (ACC)’s D2B Alliance. We recently formed an initiative with the emergency department (ED) and CARE unit to lower our D2B times. We found that cath lab transport times were high because of the relatively long distance from the cath lab to the ED. The ED staff agreed to transport ST-elevation myocardial infarction (STEMI) patients to the cath lab to cut down on transport time. The CARE unit staff helps to expedite the STEMI process by turning on our x-ray and other equipment as soon as the STEMI is called. This allows the cath lab technologists to focus on arriving safely and quickly to set up the lab.  These changes have significantly decreased our D2B times. For 2015, our median D2B time, excluding transfer patients, was 56 minutes.

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

During regular hours, the cath lab staff transports the patient from the ED. Transfer STEMIs from other facilities or the field are transported straight to the lab by emergency medical services (EMS). During off-hours, an RN and a technologist from ED transfer the patient to the cath lab. 

Where is your cath lab located in relation is the OR and ED?

Sentara Heart Hospital was built in 2006 as an addition to Sentara Norfolk General Hospital. The cath lab, CARE unit and CICU are located on the second floor of the Sentara Heart Hospital. The OR is directly above us on the third floor. The ED is in a separate but connected building. By having the ED staff transport during call cases, we have been able to significantly reduce our D2B times.

How does your lab handle call time for staff members? 

Our call team consists of three RCISs. The cath lab is considered part of the cardiac suite, along with the CARE unit and cardiovascular intensive care unit (CICU). These units have nurses available 24 hours a day, if a call team were to need some additional help in a case. Our staff covers call at Sentara Heart Hospital and another Sentara community hospital. The community team serves as a backup team in the event of multiple emergencies. Our staff averages a total of 9 scheduled days of call a month.

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

Team members are expected to arrive to the lab 30 minutes after being paged.

Do you have flextime or multiple shifts?

We currently only have one part-time staff member and one flex staff position posted. The way our schedule currently works is that staff rotates shifts: one week they do 5 eight-hour days and the next week they work 4 ten-hour days. This gives staff members at least two days off a month. Our call team is our late team and finishes out the day for cases. We typically run two rooms until we get down to one doctor doing cases.

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

If the call team is in a procedure, a decision is made by the charge technologist and the physician to determine what is safest for both patients. If it is a safe stopping point and the procedure can be postponed, the current patient will be removed from the table and the STEMI patient has their intervention. Our staff covers call at a nearby community hospital, and in the case of two concurrent STEMIs, that community team serves as backup. They will be paged to Sentara Heart Hospital to do the STEMI.

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

Staff education on differing vendor pricing is one measure. We keep a bulletin board in our inventory area that lists the vendor for stents and balloons as red, yellow, or green in terms of pricing. Staff and physicians are always encouraged to use the product that is best for the patient, but when the brand of stent isn’t necessarily important, staff is encouraged to pull the most affordable option. We also use Stryker to reprocess certain equipment. Finally, we maintain a practice of not opening equipment to the sterile field before the physician asks for it.

What quality control measures are practiced in your cath lab?

We have daily, weekly, and monthly quality assurance tasks for the staff. Our daily measures include testing the x-ray systems, Avoximeter (Accriva Diagnostics) controls, and defibrillator operation. Each month, special teams perform hand-washing audits, moderate sedation chart audits, and code cart inspections. In addition to the staff’s effort, the pharmacy department performs a monthly medication inspection. The point-of-care testing (POCT) laboratory carries out six-month and annual inspections and calibrations on i-STAT machines (Abbott Labs). Lastly, our clinical engineers perform calibration of x-ray and digital imaging equipment in addition to the inspections and certification by Virginia Health Department.

Who documents medication administration during the case?

The monitor technologist documents all medication given in the Xper monitoring system during the case to serve as our legal document. The circulating technologist administers and documents medications given in the EMR for post care staff to review. Our EMR system has the safety feature that requires a barcode scan of the patient’s armband and of the medication to be administered. All medications are given by the RCIS staff under the direction of the physician.

Are your physicians dictating their cath procedure reports?

We have recently implemented the Dragon Voice Recognition Program.  Our EMR program (EPIC) allows for a variety of data entry options via personal templates physicians have created, and we still have some physicians that utilize transcription services.

Do you use the ACC’s National Cardiovascular Data Registry (ACC-NCDR) or any other outside data collection registry?

Yes, we do use the ACC-NCDR, as well as the Society of Thoracic Surgeons (STS)/ACC’s Transcatheter Valve Therapy (TVT) registry.

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

As the region’s first Magnet hospital, Sentara Norfolk General Hospital, a 525-bed tertiary care facility, is home to the areas only Level I Trauma Center, burn trauma unit, and nationally ranked heart program at Sentara Heart Hospital. In addition to a first-rate heart program, the hospital is home to Nightingale Regional Air Ambulance. We have formed alliances with many outlying community hospitals that do have the option to transfer patients to other facilities.

How are new employees oriented and trained at your facility?

The majority of our technologists are graduates of the Cardiovascular Invasive program at Sentara College of Health Sciences and completed most of their clinical hours at our hospital. This process gives our technologists an introduction to our lab before they are even hired. Once our employees are hired, they are required to go through a ninety-day hospital-based orientation period. The orientation includes EMR classes, patient safety concepts, and point-of-care testing, e.g. i-STAT machines and Avoximeters. Our department-specific orientation pairs the new employee with a preceptor for ninety days. The new employee must complete a series of competency check-offs to demonstrate proficiency in all three roles (monitor, float, and scrub) in the common diagnostic and interventional procedures. The cath lab-specialized competencies are maintained by our two staff educators, Anne Kiernan and Steve Mattke, and renewed on an annual basis.

What continuing education opportunities are provided to staff members?

Sentara Healthcare is accredited by the Medical Society of Virginia to provide continuing medical education for physicians. Every Tuesday morning, our cath lab staff is invited to join our physicians for an hour-long lecture and CME opportunity on a contemporary cardiology topic. Staff has another CME opportunity at one of the annual conferences hosted by the regional cardiology groups. Additionally, we have recently reinstated a process for our staff to attend the Transcatheter Cardiovascular Therapeutics (TCT) conference. We rotate this privilege among the interested staff members. 

How do you handle vendor visits to your lab? 

All vendors are required to complete an annual departmental orientation package and are also required to be Reptrax-approved. Reptrax is company we use to track and manage our vendor credentials, activity, and behavior before they can enter our area. Each vendor is assigned a specific day of the week that they are allowed to be in the lab. On the days that vendors are here, they are required to sign in through Reptrax, which prints a badge for them, and vendors must sign in to the lab. All vendors have an area specified for all of their educational material on the days that they are in the lab.  Vendors can speak to any physician outside of the lab, but they have to be invited into the lab. It is also a requirement that vendors change into the appropriate departmental scrubs and wear color-coded vendor hair covers. There are two Reptrax kiosks in the building that issue temporary badges to the vendors.

How is staff competency evaluated?

Staff competency is very important to our lab. As the largest and busiest cath lab in the area, we strive to be the “gold standard” in our abilities. Our staff is required to complete 12 annual skills lab competencies on high-acuity machines, such as the Rotablator (Boston Scientific) and Impella. We have annual exams on medications, moderate sedation, and vascular complications. We schedule one education day a month to complete a skills lab. At the end of the year, we have “Skills Week”, during which the staff is given an opportunity to review or make up any missed skills labs.

Does your lab have a clinical ladder?

In our lab there are three clinical levels: Junior, Senior, and Expert. Each person is hired into the Junior technologist position and upon completion of a leadership course and precepting a student, they will have the opportunity to rise to next level, Senior. In order to reach the Expert level, a technologist has to excel as a senior as well as be knowledgeable about every piece of equipment that we have. The Expert position is usually held by our educators.

Has your lab recently undergone a national accrediting agency inspection? 

DNV GL performs annual inspections in our lab. Mock surveys are useful exercises to find opportunities for improvement. They are also a good chance for the staff to practice speaking to the safety and quality measures they take every day.

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

We have a large heart failure population in the Hampton Roads region. We have seen a marked increase in our ventricular assist device (VAD) population in the past few years. We see the left VAD patients routinely for right heart caths. The indications for TAVRs have started to include a lower-risk patient profile. We have gone from doing 1 TAVR a week to doing 4 or 5 each week. The TAVR patients often have more than one procedure in the lab in preparation for the TAVR procedure (diagnostic cath, balloon aortic valvuloplasty [BAV], and/or staged PCI). In general, we are seeing more structural heart cases. Our lab has a steady volume of MitraClip, Watchman, and closure procedures.

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

Our staff has a lot of pride in being part of the cath lab at Sentara Heart Hospital and there are a few key things that make us unique:

• Our cath lab is entirely RCIS-certified. We have a few wonderful nurses that staff the minor procedure room, but the rest of the staff is RCIS. Sentara has a College of Health Professions, and their RCIS students complete their clinical requirements in our lab. The RCIS staff floats cases, gives medications, and runs the x-ray systems. Our school was actually founded by some of our cardiologists, and we have their full support in the way that we function as independent, highly trained healthcare providers.
• Our hospital is consistently ranked by U.S. News & World Report as having one of the top 50 cardiology and cardiac surgery programs in the nation. 
• Sentara Heart Hospital has a concierge service for staff and patients. The idea was proposed by one of our own staff members, and Sentara put it into action. Some of the highlighted activities the concierge department has coordinated include a hospital wedding for one of our inpatients and wrapped Christmas presents for the busy staff.

Is there a problem or challenge your lab your lab has faced?  

The biggest issue our lab has faced has been establishing a good balance between work and quality of life. Limited staffing made it challenging to accomplish anything outside of work, so we decided to switch to rotating shifts. Each staff member works a week of eight-hour shifts, followed by a week of ten-hour shifts. This schedule allows the staff to have day off every other week. Since the inception of this schedule, morale has improved. Now we have been able to make it to more teeth cleanings, hair appointments, and dance recitals for our children!

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”?

Norfolk is part of the Hampton Roads, which is a very diverse regional area. We are located in a hub for the U.S. Armed Forces, resort towns, and rural communities. Sentara Heart Hospital services Virginia Beach and the Outer Banks of North Carolina, both popular vacation destinations. During the summer months, we often treat patients that are visiting from distant places. This situation creates challenges for the staff and the patients. Having an emergent procedure performed when on vacation definitely adds anxiety to an already stressful event. It is not uncommon for us to receive a STEMI from the field, straight from the beach. The other aspect of treating vacationers in the middle of the night is that it is hard to get medical records from another state if the patient has a standing cardiac history.

There are over 10 military installations in the Hampton Roads region and their influence is pervasive. We have two staff members who are veterans. Our turnover is affected when staff members with military spouses leave the area with new orders. 

Kevin Akers, BSHA, RCIS, can be contacted at kxakers@sentara.com. Anne Kiernan BS, Senior RCIS, can be contacted at arkiern1@sentara.com.