The Robert J. Dole VA Medical Center

What is the size of your cath lab facility and number of staff? The Robert J. Dole Veteran Affairs Medical Center contains two cath labs, a GE Innova 3100 lab and a GE Innova 4100 lab (GE Medical Systems, Waukesha, WI). In these labs, we not only do cardiac caths and coronary interventions, but interventional radiology and vascular procedures as well. We have a 6-bed cardiac observation area where patients are monitored before and after their procedure. We recover our outpatients and send them home directly from this area, which also serves as the area for doing the transesophageal echocardiograms (TEEs) and cardioversions. Four cardiologists and 1 radiologist use our labs. The cath lab manager is a radiologic technologist [RT(R), CVT] with an advanced registry in cardiovascular imaging through the American Registry of Radiologic Technologists (ARRT), held also by two other x-ray technologists [RT(R)s]. We currently have 5 registered nurses (RNs) on staff. Most of our current staff has been with the cath lab since it first opened in August 2006. Our staff has been working in the field for quite some time. Several employees came to us with 20+ years of experience. What types of procedures are performed at your facility? We do cardiac procedures such as right and left heart catheterizations, angioplasty, stenting, thrombectomy, intravascular ultrasound (IVUS), use of an intra-aortic balloon pump (IABP) and use of the Radi PressureWire (St. Jude Medical, Minnetonka, MN) to measure fractional flow reserve. We also put in pacemakers and automated implantable cardioversion defibrillators (AICDs), and do TEEs and cardioversions. We do approximately 12 cardiac procedures per week. We do peripheral vascular procedures as well, performing carotid stenting, abdominal aortograms with runoffs, renals, fistulas, embolization procedures, peripheral thrombectomies, and transjugular intrahepatic portosystemic shunts (TIPS). We do approximately 8 vascular procedures per week. Does your cath lab perform primary angioplasty with surgical backup on site? No, we do not have cardiac surgical capabilities at our VA facility. We are using the national guidelines set up by the VA, which require an ambulance on site, ready to transport a patient to a nearby facility for emergent bypass surgery if needed. We adhere to strict guidelines so that our patients are getting the best care possible in this situation. Prior to our opening the cath lab, patients were transported out to have their heart cath procedures. Since opening our own cath labs in August 2006, we are able to offer a tremendous service to our veteran population. Out of the 415+ angioplasty cases that we have completed, we have had to use the ambulance service twice to transport patients to nearby facility, both times with great success. We also have the Jomed covered stent (Jomed International AB, Helsingborg, Sweden) in case it is needed. What procedures do you perform on an outpatient basis? We routinely perform right and left heart caths, TEEs, cardioversions, most vascular cases, and some simple pacemaker cases as outpatient procedures. If an intervention is done, we will keep the patient overnight. If there are mitigating circumstances, any patient could possibly be kept for 24-hour observation or a full admission at the discretion of the physician. What percentage of your patients is female? Like most other VA medical centers, only 3.7% our patient population is female. Most of the patient population that we see currently is from an era when women did not predominately serve in the military. As time goes on, we believe that this number will increase, but probably never to the range of non-VA facilities. How many diagnostic cath patients go on to have an interventional procedure? Approximately 30% of our diagnostic patients go on to have an interventional procedure. Do any of your physicians regularly gain access via the radial artery? Yes. We have protocols in place for radial artery access, and also use special catheters and sheaths. Who manages your cath lab? Ruth Russell, RT(R), CVT, is the manager of the cardiac cath lab. Wassim Shaheen, MD, is the medical director of the cardiac cath lab and Abid Mallick, MD, FACC, is the director of cardiology services. Do you have cross-training? All of our members are cross-trained to what their specific scope of practice allows. Nurses will cross-train to scrub, monitor and circulate, as well as work in our pre and post op area. Techs are trained to scrub and monitor, and assist in the pre and post op area with a nurse. Medications are given only by an RN or physician. Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedure in your cath lab? One RT(R) is always present in each cath lab 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 physician usually changes the angle on the II, and whoever is scrubbed in pans the table. The physician is the one who steps on the fluoro pedal for the actual x-ray exposure. How does your cath lab handle radiation protection for the physicians and staff? Everyone has a radiation badge and ring, and they are required to wear them on a daily basis. Radiation exposure is monitored by our radiation protection officer. We provide lead aprons and glasses for staff and physicians. We also have lead shields on the tables for additional protection. What are some of the new equipment, devices and products recently introduced to your lab? Our lab is relatively new, having only been in operation since August of 2006, so our equipment still seems very new to us. We have the ability to perform intravascular ultrasound with Virtual Histology (Volcano Corporation, Rancho Cordova, CA), and can measure fractional flow reserve (FFR). We are also installing GE’s Innova 3D spin feature on our cardiovascular lab as well. We use the GE MacLab for our hemodynamic and clinical data monitoring, and GE Centricity for image archiving. What systems are used to encourage the communication of information in your lab? We have monthly staff meetings with just the cath lab staff as well as monthly cardiology meetings with the staff from nuclear medicine, echo, and stress lab, as well as our cardiology clinic. We may have impromptu meetings when new policies or procedures present themselves. How is coding and coding education handled in your lab? We have a master sheet and the monitoring person circles all codes for the performed procedures. A secretary enters the codes into the system used at the VA. Any new procedure code is communicated to the individual who inputs the new codes into the system. How does your lab handle hemostasis? We currently have 3 methods of obtaining hemostasis: Angio-Seal (St. Jude Medical), Starclose (Abbott Vascular, Redwood City, CA), and manual compression using the D-Stat Dry Closure Pad (Vascular Solutions, Minneapolis, MN). Whoever scrubs in deploys the device. We have had great success with all of these products and any staff member that deploys a device has completed appropriate competencies. If a closure device was not used, the sheath routinely gets pulled in the lab by whoever scrubbed the case. If we need to use the room immediately after a case, we have a post-procedure area where we can move the patient and pull the sheath. Post intervention, cases are sealed when appropriate and if not, manual pressure with a D-Stat Dry is used by the nurse in the ICU area. What is your lab’s hematoma management policy? We track any hematomas and report them to a committee once a month. We feel very fortunate to have had very little problem with hematomas in the cath lab. Has your cath lab recently expanded in size and patient volume, or will it be in the near future? Since we are a fairly new department in a hospital that has been around for a long time, word is still spreading about the services we have to offer. Our numbers are climbing slowly, but steadily, as the patient population learns that we can take of their needs. There have also been inquiries from nearby VA facilities to see if they can refer patients here for cardiac procedures. What measures has your cath lab implemented in order to cut or contain costs? A very large percentage of our inventory is consignment, which, of course, helps a great deal. We each routinely ask and verify before opening product during a case, which has helped in making sure that the wrong product is not opened and wasted. What types of quality/control assurance measures are practiced in your cath lab? We monitor several items in the lab. We do chart reviews and make sure that the proper documentation is in place for certain markers such as time-out performed, consent signed and various other items. We track complications, and moderate sedation occurrences for our TEEs and pacemakers, if needed. We also do random checks on employees using universal precautions. Phone calls are done post procedure to make sure that the patients are doing well and to answer any questions that they may have. We also monitor our hospital policy regarding verbal read-back orders and patient identification. We track physician fluoro and procedure times, as well as dye counts on each case. For every interventional procedure completed, the patient’s lab values are checked to make sure there is not a drop in the hematocrit or a rise in the creatinine or white blood cells. These values are checked the day of the procedure, as well as the next day, and are reported monthly. How does your cath lab compete for patients? Our situation is unique in the sense that only veterans or active military can use our facility. We do, however, compete to make sure veterans know what we have to offer, and that we are very competitive with equipment and procedure offerings. For the most part, most veterans like to have their procedures done here at the VA and prefer to stay here rather than go outside for treatment. We do have to have alliances with other hospitals, since we do not perform cardiac surgery. We have a contract with a local hospital and surgery group to take any patients that either need emergent or scheduled bypass or valve surgery. Some of these patients can get transferred to another VA, but many are done at our contracted hospital. How are new employees oriented and trained at your facility? A new employee is teamed up with a mentor. If it is a technologist, they would generally team up with a technologist, and similarly, a nurse will team up with a nurse. Most of our staff came to us from other cath labs in the area. We require an RT (radiologic technologist) license for technologists and nurses are required to be an RN. All of the staff is required to have basic life support (BLS) and advanced cardiac life support (ACLS). The staff is also credentialed with the Kansas State Board of Healing Arts. What continuing education opportunities are provided to staff members? The VA is a great place to work and get your CEUs. They are currently funding the RT CEU program through an outside source. All of our technologists’ CEUs can be obtained through this site. Nurses are offered many opportunities as well, ranging from online programs through the education department to on-site programs. The education program strives to provide everyone with many opportunities to learn. How do you handle vendor visits to your lab? Vendors sign up on our vendor calendar. They will either call ahead to see what date will work for them or schedule while they are here for their next visit. They are allowed to come up to the lab, and visit with the staff and cardiologist, but we try to keep their exposure to patients to an absolute minimum, because of privacy concerns. If a vendor has to come into the lab, it is explained to the patient, and it is only with the patient’s signed permission that a vendor may be present during a certain procedure. How is staff competency evaluated? Competency for new employees is initially evaluated by preceptors. Annually, we check off a staff competency sheet. We adjust the sheet as new products are brought in throughout the year. High-risk, low-volume items such as the IABP are evaluated more than once a year to make sure everyone is competent. ACLS is required of all staff and rhythm/waveform education is periodically reviewed. How does your lab handle call time for staff members? Since we do not have cardiac surgery here, we do not take call. Do you have flextime or multiple shifts? Currently, we have not felt the need to have multiple shifts. We work 7 am-3:30 pm, with two people assigned to late-night duty for recovery purposes if needed. This assignment gets rotated throughout the staff. Has your lab undergone a Joint Commission inspection within the past three years? We did have an inspection by the Joint Commission just recently and we are pleased to say that our department did very well. The only advice is to do what you do every day by giving the best care possible to each of your patients. How do you see your cath lab changing over the next decade? We see our veteran population changing. Currently, we are serving many of the veterans from the Korean War and WWII, and see some Vietnam veterans as well. Each of these veteran populations has specific needs and we must be aware of these at all times. With the Gulf War veterans and the Iraqi War veterans coming to us within the next decade, we will have to adjust to meet their needs as well. What is unique or innovative about your cath lab and staff? We have the distinct honor of giving back to those who gave so much to us, our veterans. It is such a privilege to take care of those who gave up and risked so much for each one of us. The veterans we serve are a special population, with a rich background of stories to tell and share. The staff is a very small group and it feels like family, as we all must work very closely with each other and get along. Since most of us have been here from the time the cath lab first opened, it has been a “growing up” process for us — witnessing the beginning of the lab and its continued growth each month. 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”? Wichita, Kansas is centrally located in the United States and is called the “Air Capital” because of the many airplane manufacturers located in the area, including Hawker Beech, Boeing, Bombardier, Cessna, and Spirit, just to name a few. Wichita is also home to McConnell Air Force Base, which actually formed a joint venture with our cath lab. The base purchased one of our cath labs using Department of Defense funds, with the understanding that we would serve the military personnel from McConnell. Of course, it is our pleasure to take care of these individuals currently serving our country. It truly is an honor and a blessing to take care of our men and women that served our country with such bravery and commitment. Excellent care is just one small way in which we can repay them. The Society of Invasive Cardiovascular Professionals (SICP) has added two questions to our spotlight: 1. Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? Do staff receive and incentive bonus or raise upon passing the exam? No, this is not required, but it is encouraged for any staff member who would like to take 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? Some staff members are associated with the American Heart Association. Ruth Russell can be contacted at ruth.russell@va.gov