Spotlight: ProHealth Care – Cardiac Cath Lab Waukesha Memorial Hospital

Tell us about the cardiovascular service line and the cath labs at ProHealth Care.

The service line is a multidisciplinary group that includes cardiologists, interventional radiologists, hospitalists, emergency room physicians, family practice, nurse practitioners, finance, marketing, diagnostics areas, billing and coding, materials management, and other ancillary support staff and departments. The overarching goal of the service line is to engage key stakeholders around cardiac services, to inform and deliver on the strategic vision of the organization, drive out variation, and enhance access to care, resulting in exceptional clinical care, and improved patient throughput and satisfaction, as well as increasing market share.  

The interventional department at ProHealth Care consists of services at 3 geographic locations with over 40 staff and support personnel. Waukesha Memorial Hospital is our main site, which consists of a dedicated electrophysiology (EP) lab (that can also perform cath procedures), 2 cath labs, a hybrid operating room (OR) suite, an 8-bed holding area, and 2 interventional radiology (IR) suites. Oconomowoc Memorial Hospital has 1 cath lab and 1 IR suite. ProHealth Care’s new Cancer Center location also has an IR suite and a 4-bed holding area.  

Staff is a mixture of registered nurses (RNs), radiologic technologists (RTs), registered cardiovascular invasive specialists (RCISs), and other licensed professionals. Our staff members are a very loyal group, with well over half having at least 10 years of tenure with ProHealth Care.

What procedures are performed in your cath lab? 

We perform a variety of procedures: advanced diagnostic and interventional EP exams, including a-fib ablations, cardiac rhythm management services such as pacemakers, defibrillators, loop recorders, and CardioMEMS implants (St. Jude Medical), transcatheter aortic valve replacements (TAVRs), atrial septal defect (ASD) closures, laser lead extractions, diagnostic and interventional catheterizations, transesophageal echocardiograms, tilt table tests, and dobutamine stress echos, IR procedures such as central lines, peripheral angiography and interventions, acute stroke treatments, and radiofrequency ablations. Across this spectrum, we perform well over 100 procedures/week.

Can you share your experience with TAVR? 

We started performing TAVR procedures in September 2015; to date, we have done 20 procedures. By creating a multidisciplinary team and utilizing a team-based approach, our program was able to integrate TAVR procedures into the current case mix in an efficient and effective manner. The team is made up of cardiothoracic surgeons, interventional cardiologists, a dedicated cardiac anesthesiologist, dedicated radiologists for imaging, cath lab RNs and technologists, OR RNs and technicians, and support staff, as well as a valve clinic coordinator.

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

At Waukesha Memorial Hospital, we have full surgical backup. However, we do not have on-site surgical backup at Oconomowoc Memorial Hospital; numerous processes have been integrated that allow us to perform interventions in a safe and effective manner at this location.

Who manages your cath lab?

An outstanding group of individuals form the leadership team and manage the Interventional Services department at ProHealth Care. The team consists of the cardiovascular service line administrator, a manager, 2 team leads, 3 nursing care coordinators, and an educator. Weekly leadership meetings focus on training, education, cross training, project management, and day-to-day operations, as well many other factors that affect our environment.  

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

Currently, our RTs and RCISs scrub and monitor procedures. RNs circulate, provide patient care and monitor, and some RNs also scrub procedures. We are striving for cross-functionality across all of our modalities to include the cath lab, holding room, and IR.  

Who documents medication administration during the case?  

The administration of medications is documented by the circulating RN in the patient’s electronic medical record (EMR).

What percentage of your diagnostic caths is normal?  

By American College of Cardiology (ACC) standards, approximately 25-30% may be categorized “within normal limits”.

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

We have multiple physicians who utilize the radial approach. Radial procedures have had a positive impact on patient satisfaction and throughput. The key to transitioning from a femoral approach to a radial approach has been education and training for physicians and staff members.

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

We do have physicians who will access the pedal artery when appropriate.

Are there licensure laws in your state for fluoroscopy? 

There are laws regarding fluoroscopy in Wisconsin. Currently, technologists can pan and move the table, while the physician steps on the pedal that creates the radiation.  

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

Safe and effective radiation protection, monitoring, and reporting are a vital aspect of our services. Staff and physicians are educated annually concerning radiation safety and are continually monitored regarding dosage. The organization has recently acquired a GE product called “Dosewatch” in which we can track and trend the amount of radiation delivered during specific exams. It adds another tool to our arsenal in an effort to protect our patients and staff from excessive radiation doses.

Fluoroscopy times and dosages are recorded, trended and reported to our radiation safety committee. We have an RT who tracks, monitors, reports, and consults with our physicist to ensure we are proactive in the management of radiation doses. 

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

If a patient receives a higher dose than normal, the occurrence is registered in our incident tracking system. We notify the physician, who in turn notifies and examines the patient for any possible injuries. All information/data is then documented in the EMR and the incident tracking system. The patient will receive a form notification follow-up through their physician in conjunction with the physicist, compliance officer, and patient safety officer.

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

Recent equipment, device and product additions to the ProHealth Care’s repertoire include CardioMEMS implantation, TAVR procedures, and laser lead removals. We are currently upgrading our hemodynamic system, replacing our inventory management system, and upgrading our PACS system to integrate structured reporting. We have chosen the Medstreaming PAC’s system for echo, vascular and cath lab. We are also upgrading and integrating our Philips Witt hemodynamic monitoring system. Both of these systems will tie into our Lawson POU inventory management system as well as our EPIC medical record.

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

The service line model utilized by ProHealth Care offers numerous opportunities for effective communication across a wide spectrum of individuals, departments, committees, and physician practices. Our program communication comes through the Service Line Executive Committee, with additional sub-committees on patient experience, clinical practice, TAVR, credentialing, EP, clinical informatics, and quality improvement projects. We have monthly cardiology division meetings, and monthly departmental staff and educational meetings, as well as numerous other meetings in which the staff, physicians, and ancillary personal participate in education and improvement initiatives.  

ProHealth utilizes a shared governance model that focuses on quality, education, and clinical practice. We have shared decision-making between staff, administration, and providers. 

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

Cath lab staff, holding room staff, telemetry staff, intensive care unit (ICU) staff, and Heart Care Unit staff can pull sheaths. We have a detailed competency that all staff must accomplish successfully prior to pulling sheaths independently.

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

Cath lab patients are prepped and recovered in the cath lab holding room. Physicians deploy closure devices in the cath lab. Patients who leave the lab with their sheaths will have them manually removed in a variety of clinical settings.

How is coding and coding education handled in your lab?

CPT codes are updated twice a year, during the budget and at the beginning of each calendar year when changes occur. The cath lab has a detailed process for reviewing procedure codes and supply changes for each exam.  We have a dedicated individual who oversees the coding and subsequent education of the staff.

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

We have a value analysis team. This is a committee that includes cath lab leadership, staff, service line leadership, and materials management personnel. They continually work to increase/create effective materials management solutions that meet the needs of the clinicians and are fiscally responsible. We are in the process of transitioning to a new inventory management system. The cath lab works in conjunction with materials management on major equipment acquisitions. Currently our cath lab and IR staff order, receive, and put away our supplies.

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

Our hybrid OR/cath lab suite opened in August 2013 and we recently integrated an off-site cancer center into our organization.

Is your lab involved in clinical research?  

Currently we have 4 ongoing research trials in which we are participating.

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 current D2B times are 58.42 minutes for Waukesha Memorial Hospital and 57.61 minutes for Oconomowoc Memorial Hospital. We are working on cath lab accreditation as well as Chest Pain Center accreditation and participation in a national database. 

How does your lab handle call times for staff members?  

The call team consists of 2 technologists and 2 RNs. The call team covers both Waukesha Memorial Hospital and Oconomowoc Memorial Hospital. 

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

Staff has 30 minutes to come in to the hospital.

Who transports the ST-elevation myocardial infarction (STEMI) patient to the cath lab during regular and off hours?  

We are incredibly lucky to have outstanding emergency departments (ED) that will not only transport a patient to the cath lab, but will also stay and help with the management of the patient until the entire on-call staff and cardiologist have arrived.  

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

While it is a rare experience, our process is to send out a group page/notification message that denotes the urgent need for a second team. In the last year and a half, we have used the process and the response has been positive and very timely.

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

In conjunction with our Lawson point of use inventory management system, we are participating in a project to reduce our “owned” inventory and utilize consignment opportunities more. We have worked to adjust our scheduled work hours (8- and 12-hour shifts) in an effort to be more effective and efficient in regards to our patient throughput and in addressing late procedures. We also work closely with our materials management department in an effort to strictly adhere to any contractual savings we may realize as part of a large buying group.

What quality assurance measures are practiced in your cath lab? 

ProHealth Care utilizes a shared governance model, which focuses on three areas: clinical practice, education, and quality. Data concerning core measures, outcomes, and appropriate use, as well as various other pertinent data, is monitored, trended, and discussed in an effort to improve patient care, outcomes, and throughput.

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

Currently, we are not utilizing structured reporting; however, in an effort to integrate structured reporting into our processes, we are upgrading our current hemodynamic and PACS systems. 

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

Yes. Right now, we are only collecting PCI data; however, with our planned PACS and hemo system upgrades, we will expand our database to include diagnostic procedures.  

How are you populating the registry data records?

Currently forms are created and abstracted by staff from the quality services department. Registered nurses in the quality department are abstracting charts from the EMR. Future practice will integrate this process into the cath lab.

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

We compete with several large systems in the greater Milwaukee area based upon quality, timeliness, access, and clinical outcomes. We are currently number one in the market with a share in the high 40s. At this time, our cardiothoracic surgery program is a partnership between ProHealth Care and IU Health, which is based in Indianapolis.  

How do you handle vendor visits to your lab?  

Vendors are either invited or they inquire about opportunities to visit the labs. All vendors are required to wear appropriate and current vendor badges. All new products go through a rigorous process that involves our new technology committee. The process is very detailed and each supply is examined based upon clinical effectiveness and fiscal responsibility. Vendors meet with the director of cardiology and the VP of materials management quarterly.

How are new employees oriented and trained at your facility?

We are incredibly lucky to have a dedicated educator who creates a very detailed orientation process based upon the new employee’s education and experience. The process entails a detailed overview/guide, weekly meetings, tests, updates, hands-on, and classroom training. New staff is assigned a preceptor for clinical rotations, and the preceptor works with our employee and educator to ensure a seamless onboard and training process for new staff.  

What continuing education opportunities are provided to staff members?  

Staff members are provided with multiple educational opportunities per month. There are sessions offered by industry representatives, our educator, and the organization. Computerized programs are also available.  

How is staff competency evaluated?

Competencies are evaluated through observation, education/training/in-servicing, and testing. The organization has computer-based learning modules (CBLs), and the interventional departments have multiple learning resources and assessment processes to evaluate and assess the cognitive and physical skills associated with various clinical competencies.

Does your lab have a clinical ladder?

The clinical advancement program recognizes the expertise of nurses who make a difference at the bedside and provides them a pathway to grow professionally in their practice. The clinical ladder is comprised of 4 levels and is grounded in the Benner Model of Skill Acquisition model. Nurses are advanced in the program as they develop their skill in 4 domains of practice: clinical knowledge and decision-making, caring, collaboration, and leadership. Nurses seeking advancement are evaluated by a panel of their peers who evaluate the data they provide regarding their practice in the 4 domains.

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

We have no physical bottlenecks or limitations; however, we are challenged with gaps in the schedule during the workday, and the associated staffing and productivity challenges. 

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

Our staffing model is a combination of differing length shifts with staggered start and finish times. We flex our staff to meet the needs of the service line and make every effort to cross train. We work on quality and accreditation processes during slow times.

Where is your lab located in relation to the OR and the emergency department (ED)? 

The cath lab is located between the ED and the OR. Our hybrid room connects the OR and the cath lab, while the ED is approximately 40 feet down the hall.

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

For cardiac procedures we have seen a slight downturn; however, in other areas we have seen growth.

What is unique or innovative about your lab and staff?  

Staff at PHC demonstrates a genuine concern for the welfare of each and every patient. We have a spirit of cooperation and understanding, and value the knowledge, skills, and talents of our staff. We have the right mix of staff to create an environment that fosters community.  

Is there a problem or challenge your lab has faced? 

For several years, we struggled and searched for a strong manager and at the end of 2014, we found one, using a national search firm. Our manager, a RCIS with over 25 years of experience, started about a year ago. 

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”?

The Milwaukee area has a strong relationship with physicians and physician groups; many independent providers only practice at ProHealth Care. Waukesha County, outside of Milwaukee, is about halfway between Milwaukee and Madison giving us that entire geography to enjoy. We can be in downtown Milwaukee in 25 minutes and enjoy everything that the city offers. Summer is a great time to be in our cities, with all the different festivals that we can enjoy, as well as outside music concerts. 

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

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?

At this time, it is not required. If staff chooses to takes the exam and pass, the exam is paid for. They also receive a bonus.

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?

Yes, we have several team members who are very active in several societies.

A QUESTION FROM THE AMERICAN COLLEGE OF CARDIOLOGY’S NATIONAL CARDIOVASCULAR DATA REGISTRY:

How do you use the NCDR outcomes report to drive QI initiatives at your facility?

We are currently working on our documentation and data abstraction practices concerning appropriate use criteria. The basic premise for the improvement is to become proactive/concurrent in our documentation and data abstraction processes versus retrospective. We also hope to better understand and address variances in the documentation process.