Spotlight: Osceola Regional Medical Center

E. Kristine Hammer can be contacted at edith.hammer@hcahealthcare.com.

Tell us about your cath lab.

Our lab is approximately 3200 square feet and employs 30 staff members. In June 2015, we will be beginning an expansion project that will increase our size to approximately 4400 square feet. We have 4 rooms, including 1 electrophysiology (EP) lab and 2 catheterization labs utilizing GE Innova imaging, and 1 hybrid lab utilizing Philips imaging. Our lab has a mix of credentials. Our staff includes registered nurses (RNs), registered radiologic technologists (RT[R]s), registered cardiovascular invasive specialists (RCIS), and registered cardiac electrophysiology specialists (RCES), some of whom hold more than one licensure and/or credential. Our staff rotates through the roles of monitor, circulator and scrub.

What procedures are performed in your cath lab?  

Our lab performs a variety of cases, including but not limited to left heart cath, percutaneous coronary intervention (PCI),

Rotablator (Boston Scientific), coronary orbital atherectomy (CSI), Impella insertion (Abiomed), intra-aortic balloon pump (IABP) insertion, carotid angiography, peripheral angiography and intervention, cryo and radiofrequency ablation with and without transseptal puncture, device implants, and valvuloplasty, and assists with thoracic endovascular aortic repair (TEVAR) and endovascular aneurysm repair (EVAR); additionally, when the interventional radiology (IR) lab schedule is full, IR procedures can also be accommodated in the cath lab. We have three RNs and three technologists that are cross-trained to do IR procedures; however, when a complex case is completed in the cath lab, for the physician comfort, we bring up one of our IR teams.

We average approximately 110-115 cases per week.

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

We have a fully functioning hybrid room and Osceola Regional Medical Center is preparing for our first TAVR, planned for May. 

What percentage of your diagnostic caths are normal? 

42.6% of our diagnostic catheterizations are normal.

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

Our lab has a strong radial program, with 28% of our cases completed via the radial artery, including ST-elevation myocardial infarction (STEMI) patients.

Who manages your cath lab? 

Our lab has a dynamic leadership team, with two coordinators as the first level of leadership (one RN and one RCIS), followed by the cardiac cath lab/EP/staging/IR manager and directors.

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

We do have cross training; however, our RCISs and RT(R)s are only able to monitor and scrub, as our facility prefers that only RNs give medications. Our RNs can monitor, circulate, and some can scrub. We are currently in the process of training all of our RNs to scrub.

Which personnel can operate the x-ray equipment in your cath lab? 

All of our staff can position the II, pan table, inject and handle the manifold, and only the physician or RT(R) can step on the pedal. In our state (Florida), the laws regarding fluoroscopy state that only a registered radiologic technologist or physician can step on the fluoro pedal.

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

Our facility has a radiation safety officer (RSO) for the hospital and each radiology area has a RSO delegate. We have a delegate for our labs and this person is responsible for monitoring all aspects of radiation protection and exposure. 

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

The Osceola Regional Medical Center Cardiac Cath Lab was the first lab in all of Central Florida to place the new LINQ device (Medtronic), a loop recorder that is the size of a matchstick. We were also the first lab in the area to place the new Boston Scientific subcutaneous implantable cardioverter defibrillator (S-ICD), and are currently one of the few facilities implanting the CardioMEMS heart failure monitor system (St. Jude Medical).

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

We have monthly staff meetings, weekly huddles, and frequent emails to keep our staff up to date on all changes and new information.  

How is coding and coding education handled in your lab? 

Coding is handled by the two coordinators and by the manager. All coding education presented by our division is completed by this team.

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

Everyone in all of our labs and staging area has been trained on proper sheath pulling technique. All staff is required to have 10 pulls with the preceptor present prior to doing a sheath pull without supervision.

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

We have a 6-bay staging area and are beginning an expansion project in June. 

How does your lab handle hemostasis? 

Patients post procedure my have vascular closure device such as an Angio-Seal (St. Jude Medical) or Mynx (AccessClosure) placed by our physicians in the lab at the end of their procedure or the physician may order a manual pull for hemostasis. 

Our program boasts a cardiovascular tower that manages all our cardiac patients. All of our patients requiring 23-hour observation or who are inpatient status post cardiac cath are sent to our cardiovascular unit on the 5th floor of our tower. This floor is able to care for patients post diagnostic or interventional cath. Patients may be brought to this floor post intervention with their sheath intact for monitoring until their activated clotting time (ACT) reaches our policy set level. Our diagnostic patients that have not received a closure device will have their sheath pulled immediately post procedure in our staging area, prior to transfer to the unit.

How is inventory managed at your cath lab? 

Currently our two coordinators are responsible for inventory management. Our coordinators and manager handle the purchasing of all equipment and supplies in unity with our supply chain.

Can you share more about the reason and expectations for your planned June 2015 expansion? 

Our cath lab averages about 4,000 cases a year and as mentioned previously, will be expanding our staging area to accommodate further expansion of our cardiovascular service line offerings. We anticipate further growth of our EP and cath lab service lines, as well as our interventional radiology program. We have many new services on the horizon that we hope to be able to offer to our community in the near future.

What are your plans for working through the construction?

We will be adjusting our staffing to be able to accommodate performing procedures later in the evening. Some construction will be completed at night; however, most will be completed during the day. This will require the construction team to complete the work in phases. Each phase will require shut down and enclosure of the area where work will be completed.

Is your lab involved in clinical research? 

Yes, we are currently involved in several trials. One example is INOVATE-HF (INcrease Of VAgal TonE in Heart Failure), which is comparing the safety and effectiveness of the CardioFit system (BioControl Medical) plus optimal medical therapy to optimal medical therapy alone for the treatment of heart failure.

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 corporation holds us to a higher standard in regards to door-to-balloon time. Our current threshold for D2B must be under 60 minutes. We have used a collaborative approach with our emergency department (ED), emergency medical services (EMS) teams, cath lab teams, and physicians to ensure our patients that come through the ED are treated urgently and prepped immediately for cath while our cath teams are en route. Our mean D2B time for the last quarter was 57 minutes. If the patient is brought in by EMS, our EMS teams are fabulous in identifying ST elevation, and can alert our ED and cath teams to a STEMI patient prior to arrival at the ED, allowing for the early initiation of further time-saving measures. 

We are registered with the American Heart Association’s Mission: Lifeline, and Osceola Regional Medical Center has Level 3 Chest Pain Center accreditation. We recently submitted for Level 4 accreditation.

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

Our STEMI team transports all of our STEMI patients to the cath lab during both on and off hours. 

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

In the rare incidence during off hours that our call team is already in a STEMI case, we have several staff members and a cath lab manager who are willing to come in despite not being on call. Thrombolytics are also reviewed with the physician as a viable option. During all other hours, a team is always available.

Who documents medication administration during the case? 

We use our Mac-Lab (GE Healthcare) system to document everything occurring during the case; additionally, the RN documents the medications in the patient’s chart via Meditech.

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

The physicians utilize our dictation line to dictate their reports.

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

We report to the NCDR for our ACTION (STEMI and non-STEMI) cases, as well as CathPCI for all interventional cases. We use the Society of Thoracic Surgeons (STS) database for our open-heart program and will be beginning participation in the STS/ACC TAVR registry.

Are you recording fluoroscopy times/dosages? 

We monitor fluoro times and dose area product (DAP), and report these to the NCDR. 

How does your cath lab compete for patients? 

Our lab advertises, like most facilities; however, we also have physicians that prefer to send their patients to our facility to receive a higher standard of care.

How are new employees oriented and trained at your facility? 

All new employees are put through our standard facility orientation and then are provided a comprehensive training period with an experienced preceptor. 

What continuing education opportunities are provided to staff members? 

Our facility is constantly providing in-house educational opportunities from outside vendors, as well as assisting in the coverage of educational expenses for training completed outside of the facility. Each year, Osceola Regional Medical Center holds a stroke symposium and cardiovascular symposium. These learning opportunities provide up to eight hours of CEUs/CNEs. 

How do you handle vendor visits to your lab? 

All vendors are now required to be verified through our parent companies’ verification system. Once they have passed the verification process, vendors are required to wear a printed badge from our facility. They must check in with our coordinator and have limited access to the facility. 

How is staff competency evaluated? 

Our staff is constantly assessing the skills of their team members. Each member’s competency is re-evaluated by leadership each year. We utilize a standard set of competencies and the RN or technologist must be watched to ensure they are fully competent. In cases where a specific competency cannot be visually verified (i.e. watching a specific procedure performed) the staff member must verbalize each step in a mock scenario.

Does your lab have a clinical ladder? 

We have a clinical ladder in that there is always the availability to move up into a leadership role and then up through the leadership ladder. The current director and manager both started as nurses in the cath lab. 

Is there a particular mix of credentials needed for each call team? 

Our call team consists of two RNs and 2 RCISs. Our facility requires our technologists to have either ARRT or RCIS credentialing.

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

Our team is required to arrive at the facility within 30 minutes of call.

Do you have flextime or multiple shifts? 

We allow our teams to self-schedule and have no flex-time requirements. Our teams utilize a hospital-wide scheduling program where they schedule themselves for the days they prefer. This allows the flexibility for our staff to go to school or take care of personal concerns. The schedule is posted two weeks before the start of the schedule and is closed a week prior to allow the leadership to adjust the staffing to meet the needs of the unit.

Has your lab recently undergone a national accrediting agency inspection? 

We recently underwent our tri-annual survey by The Joint Commission. We would encourage hospitals to reach out to each other and exchange learning opportunities between their facilities. Ensure proper hanging storage of your lead, as this was something they ensured we did properly. 

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

Our cath lab is located on the second floor directly above the ED and is situated between the CVOR and the CVICU to allow for smooth transition of the patient based on their needs. 

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

Based on the new appropriate use criteria (AUC) guidelines, we have seen a small decrease in our procedural numbers as we hold our physicians to tight standards in regards to AUC. Despite that, we continue to have a high number of diagnostic cases as well as EP cases as in our region. We have a high number of patients visiting our area.   

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

We have a very low turnover rate. Some staff has been with our lab for almost 20 years. We have a very close-knit team. We are constantly seeking new challenges and are excited to be gearing up for TAVR.

Is there a problem or challenge your lab has faced? 

The largest challenge we have faced is the high patient population and limited staging area. We begin construction on an updated area in June. 

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”? 

Our facility is located in the heart of the tourist capitol of the world, Orlando, Florida — specifically Kissimmee, Florida — the home of Mickey Mouse. We are within a 40-mile radius of 3 theme park destinations, accounting for 10 amusement parks, as well as multiple large entertainment areas. Guests come from around the world to visit our area, and sometimes end up in our lab. This unique conglomerate of patients allows us the uncommon opportunity to interact with cultures from around world.

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? 

We do require our team members to be (or become) RCIS credentialed or to have their ARRT. Our facility will cover the cost of the exam and the team member receives additional compensation once they receive their certification. 

Are your clinical and/or managerial team members involved with any professional organizations that support the invasive cardiology service line?

Our team members are involved with the SICP, ACC, and Heart Rhythm Society (HRS). 

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 initiatives at your facility?

We present the data to our physicians and utilizing this data, as well as the NCDR Physicians dashboard, we assist them in adjusting their practices to meet appropriate use criteria. We utilize nationally reported percentiles to set goals for our physicians, staff, and lab.