University of Kansas Hospital - Center for Advanced Heart Care

The University of Kansas Hospital-Center for Advanced Heart Care opened October 2006 and houses the Lynn H. Kindred, MD, Cardiac Catheterization Labs. There are three dedicated interventional labs with an additional shelled room for future use. The first room is dedicated to purely cardiac procedures. The second room is versatile for cardiac, peripheral, and structural heart disease procedures. The third room houses our first-generation hybrid suite and allows utilization by interventional cardiologists, vascular surgeons and cardiothoracic surgeons for endovascular procedures and limited open procedures. The control rooms are integrated into the interior of each cath lab. There is a central core for staff and equipment that facilitates efficient flow between all three rooms. Furthermore, the transparency of the rooms from the core allows personnel to identify needs and allocate staff to emergent or complex cases. We are currently in the process of adding a second-generation hybrid room in the cardiothoracic OR area that will incorporate the ability to have a fully functioning cath lab or operating room. This hybrid room will not only be ideal for procedures such as percutaneous aortic valve replacement, but will also allow the ability to perform robotic procedures such as left interior mammary artery (LIMA) to left anterior descending artery (LAD) bypass and non-LAD coronary stenting in one setting. Furthermore, we are planning a cath/electrophysiology (EP) hybrid room in the cath lab shelled space. We employ sixteen staff members, both full- and part-time, including registered nurses (RNs), radiologic technologists (RTs), cardiovascular technologists (CVTs), and some with registered cardiovascular invasive specialist (RCIS) certifications. This does not include EP or pre/post-op area staff. The level of experience of our staff ranges from 1 to 30 years (mean = 11.5 years and median = 12.5 years). We have cardiologists, vascular surgeons and cardiothoracic surgeons who perform procedures in the cath lab. Interventional radiology and electrophysiology perform their procedures in separate, dedicated areas. Physicians include: 6 interventional cardiologists, 1 cardiothoracic surgeon, 1 vascular surgeon, 1 interventional cardiology fellow and 7 cardiology fellows.

What types of procedures are performed at your facility?

We perform approximately 75 cases per week that include the following: • Right and left heart catheterizations • Assessment and treatment of pulmonary hypertension: o Using inhaled nitric oxide • Lesion assessment: integrated intravascular ultrasound (IVUS) and pressure wire fractional flow reserve (FFR)/coronary flow reserve (CFR) • Coronary intervention, including: - Primary percutaneous coronary intervention (PCI) using drug-eluting stents (DES)/bare-metal stents (BMS) - Rotational atherectomy - Thrombectomy using aspiration catheters and rheolytic systems - Utilization of distal bed protection systems • Peripheral venous/arterial diagnostic and interventional procedures - Peripheral atherectomy - Peripheral angioplasty and stenting - Peripheral thrombolytic and thrombectomy - Abdominal aortic aneurysm (AAA) stent endografts - Carotid stenting - Inferior vena cava (IVC) filter insertion/removal - Pseudoaneurysm thrombin injection - Vascular coiling - Fistulograms • Structural heart disease: - Patent foramen ovale (PFO) and atrial septal defect (ASD) closure - Aortic, mitral, and pulmonic valvuloplasty - Septal alcohol ablation in hypertrophic cardiomyopathy - Pulmonary vein angioplasty and stenting • Cardiac biopsy • Pericardiocentesis • Hemodynamic support utilizing intra-aortic balloon pump (IABP) and Impella (Abiomed, Danvers, MA) systems

Do you perform primary angioplasty with surgical backup on-site?

We perform primary angioplasties with surgical backup in-house during business hours. Our surgical heart team is on-call 24/7 for after-hour emergent cases.

What procedures do you perform on an outpatient basis?

Most of our cardiac procedures can be performed on an outpatient basis, with the exception of some of our endovascular procedures.

What percentage of your patients is female?

Approximately 39 percent of our patients are female.

What percentage of your diagnostic cath patients go on to have an interventional procedure?

Approximately 30 percent of our diagnostic patients go on to have an interventional procedure.

Who manages your cath lab?

Our cath lab is managed by Peter Tadros, MD, Medical Director; Nikki Harvey, RN, MSN, Cath/CTR/EP Lab Manager; Thom Lynch, RCIS, and Lynn Smith, RN, Unit Coordinators; and Mark Reichuber, RN, BSN, Cath Lab Educator.

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

We do cross-train some roles. The RNs sedate, circulate, and monitor, yet do not scrub at this time. The technologists scrub, monitor, and circulate, but do not administer medication under Kansas law.

Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab?

Our physicians manage the fluoroscopy during our procedures, so an RT does not have to be present. However, they are available.

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?

All personnel can position the flat panel and pan the table. Only physicians and radiology technologists can administer radiation by activating the fluoro pedal.

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

When we moved to our new facility in 2006, we installed new/added: • Philips FD 10 and FD 20 (Philips Medical, Bothell, WA) with 3D rotational angiography (RA)/3D cluster analysis (CA) • GE Mac-Lab (GE Medical, Milwaukee, WI) • iLab (Boston Scientific Corporation, Natick, MA), IVUS-integrated • AngioJet Ultra (Medrad, Inc, Warrendale, PA) • Artic Sun (Medivance, Louisville, CO) • Impella (Abiomed, Danvers, MA) • IABP Fiberoptic Catheters (Arrow International, Inc., Reading, PA) • Laser (Spectranetics, Colorado Springs, CO) • Crosser (FlowCardia, Inc., Sunnyvale, CA) • Jetstream atherectomy (Pathway Medical Technologies, Inc., Kirkland, WA)

Can you describe the system(s) you utilize?

We have: • Two Philips x-ray (FD 10 and FD 20) • Toshiba peripheral (Toshiba Medical, Irvine, CA) • GE Mac-Lab for our hemodynamics • Heart Lab (An Agfa Company, Westerly, RI) for our digital archiving system • Acist Injector (Acist Medical Systems, Inc., Eden Prairie, MN)

How is coding handled in your lab?

We have a dedicated staff member to manage charge capture. The Medical Records coders review cases and then code each encounter. Our Compliance Department receives any new procedure or supply information, assigns a charge code and puts the information into the chargemaster. The Financial Department notifies us when it has added the new procedure and/or supplies to the billing system. The complete chargemaster is updated and sent monthly.

How does your lab handle hemostasis?

We prefer manual pressure, but do use some vascular closure devices: Angio-Seal (St. Jude Medical, Minnetonka, MN), and Starclose/Perclose (Abbott Vascular, Redwood City, CA). Patients needing manual compression go to our post-op area where we have a trained sheath pull team to manage the access site. We also use D-stat (Vascular Solutions, Minneapolis, MN) and FemoStop (St. Jude Medical).

What is your lab’s hematoma management policy?

Our policy is to mark the edges of the hematoma and hold manual pressure. Occasionally, we will use a FemoStop at low pressure to assist with maintaining hemostasis to hold pressure if additional time is needed. Our lab uses a reporting audit tool that is completed during the sheath removal process to track complications.

How is inventory managed at your cath lab?

We manage inventory with handheld Cenbion scanners (Cenbion Medical Inc, Maple Grove, MN). New inventory is scanned as stock when it arrives. When products are used in procedures, they are scanned for billing and reordering purposes. Inventory par levels are adjusted as needed to meet the needs of the department. Our unit coordinator handles purchasing of supplies and our manager handles purchasing of equipment.

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

With the building of our new facility in 2006, we expanded from two to three labs with an additional room for future use. Currently, our additional room in the cath lab is in the design stage to become a cath/EP hybrid room. We are also in the building stages of a Cath/CVOR/EP hybrid room in the CVOR.

Is your lab involved in clinical research?

Yes, we have many active, multi-center trials, including: • SPIRIT-IV (Xience versus Boston Scientific’s Taxus stent, in patients with de novo native coronary artery lesions, Abbott Vascular) • RESPECT (Randomized evaluation of recurrent stroke comparing PFO closure to established current standard of care treatment, Agfa Medical) • SAPPHIRE Worldwide (Stenting and angioplasty with protection in patients at high risk for endarterectomy, Cordis Corp.) • PFO ACCESS Registry (Amplatzer PFO occluder in patients with recurrent cryptogenic stroke due to presumed paradoxical embolism through a PFO who have failed conventional drug therapy, Agfa Medical) • SPIRIT PRIME (regulatory trial for the next-generation Xience Prime stent, Abbott Vascular) • DURABILITY II (Long-term patency and fracture resistance in symptomatic patients with PAD in the superficial femoral and proximal popliteal arteries with Protégé® EverFlex™ self-expanding stent, ev3, Inc.) • CHOICE (Carotid stenting for high surgical-risk patients) • ZOMAXX II (Safety and efficacy of the ZoMaxx™ drug-eluting stent in coronary arteries, Abbott) • VIRGO (Variation in recovery: role of gender on outcomes of young acute myocardial infarction patients) In addition, multiple physician-initiated studies are underway.

Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery?

We had two cases that went for emergent surgery due to a PCI complication. Our unplanned coronary artery bypass graft surgery (CABG) rate as a complication of PCI typically runs 0.2 percent per year.

What other modalities do you use to verify stenosis?

We use integrated IVUS, pressure wire, and Philips 3DRA/3DCA. As we have been long-time supporters of functional lesion assessment, it has not affected our operating cash flow.

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

We have a committee that negotiates on behalf of the cath lab with industry vendors. The committee is composed of hospital administration, physicians, material management, cath lab manager and unit coordinator. The committee also oversees cath lab expenditures and actively pursues any cost savings. We have partnered with Ascent Healthcare Solutions (Phoenix, AZ) in reprocessing some of our product for reuse: inflation devices, ultrasound catheters, and expired guide wires and guide catheters. They also re-sterilize opened and unused items. We are then able to buy the product back after reprocessing at a discounted rate.

What type of quality control/quality assurance measures are practiced in your cath lab?

We have a departmental practice council and also participate in the procedural division practice council. We also participate in the Quality Safety Investigators committee. They perform department audits on mechanical and structural problems, and patient and employee safety. We participate in a multi-disciplinary morbidity and mortality conference composed of cath lab leadership, nurse managers of the telemetry and CICU units, and physicians. This committee monitors the outcomes of all patients that interface with the cath lab. Finally, we submit data to the American College of Cardiology Data Registry-National Cardiovascular Data Registry (ACC-NCDR).

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

We have a large group of cardiologists who serve more than thirteen different outreach sites in the region. It is through their efforts and consistent delivery of compassionate, quality care that we have built a loyal patient base. Patients are willing to travel a fair distance to receive care from our team. Although no formal alliances have been established with other groups or systems, we have shared our ST-elevation myocardial infarction (STEMI) protocols for our Regional Heart Attack Center with referring facilities. This encourages outside emergency department physicians to make one call to our transfer center and activate the cath lab, while simultaneously preparing the patient for transport in order to reduce door-to-balloon times for transferred patients.

How are new employees oriented and trained at your facility?

New employees attend hospital orientation before working in the lab. Once in the lab, they are paired up with a preceptor. Training length depends on previous experience, but usually lasts 3 months. All RNs must have critical care experience, basic life support (BLS), and advanced cardiac life support (ACLS). CVTs must have BLS and ACLS.

What type of continuing education opportunities are provided to staff members?

The first hour of every Tuesday is designated for educational in-services or events. We invite guest speakers, physicians, representatives or utilize one of the cath lab staff to present in-service training. Each year, several staff members are sent to training [e.g., Transcatheter Cardiovascular Therapeutics (TCT), the Cardiovascular Research Technologies (CRT) meeting, etc.]. Every Friday morning, our fellows or attending physicians will present at the cath conference. We have hosted a two-day RCIS review course, hemodynamic course, and a cardiac nursing symposium (a huge success with 200 attendees). We are researching methods to record and archive our presentations and lectures for those who cannot attend and for new employees.

How do you handle vendor visits to your lab?

We are no longer an open lab for vendor representatives. Vendors are invited into the labs only for procedural or product support. Those who want to schedule an appointment for new products must be approved through the cath lab leadership team.

How is staff competency evaluated?

Competency is evaluated during our internal cath lab annual competency fair. Each year, our educator and leadership team evaluate staff on equipment knowledge and set up.

Does your lab have a clinical ladder?

We do not have a formal clinical ladder. Techs can move from entry level to Basic Tech, and then to Senior Tech. The Senior Tech requires two years of experience in the lab, as well as more advanced competencies. The hospital has a clinical ladder for nurses, based on experience.

Does your lab use any alternative therapies (such as guided imagery, etc.)?

We do include music therapy, allowing our patients to select from a variety of musical genres, at their request.

How does your lab handle call time for staff members?

Staff members have weekday call from 3:30 pm-7 am and weekend call from 3:30 pm Friday until 7 am Monday. Call consists of one nurse and two CVTs. More than a year ago, we implemented a late team, which is similar to the call team. They manage the second room until there is only one patient left for the day.

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

Our call-back time for staff and physicians is 30 minutes. A cardiologist is not always in-house, but we have an in-house cardiology fellow. We have an integrated paging system, where one page goes to the cath lab staff, interventional physician, CICU coordinator, security, and the ED. In addition, our ED physicians can activate the cath lab directly and do not have to consult a cardiologist prior to activation. EMS also has the capabilities of direct activation from the field. Designated parking spaces are within 20 feet of the ED doors and available for our on-call cath lab staff.

Do you have flex time or multiple shifts?

All shifts are from 7 am to 3:30 pm Monday through Friday. Our late team is required to stay until at least 5:30 pm to cover the call team when additional needs persist. Thus, each day we have a call team and a late team to operate two labs, if needed.

Does your cath lab do electives on weekends and or holidays?

On weekends and holidays we only do emergent or urgent cases.

Has your lab undergone a Joint Commission inspection in the past three years?

The Joint Commission visited in May 2009 with positive reviews for our facility. During their visit, they reviewed the following: • Sedation protocols • Physician documentation (pre- and post-procedure in a timely manner) • Patient identification (time out) • Labeling of medications (especially on the scrub table)

Where is your cath lab located?

The emergency department is located one floor below the cath lab, and our operating room is one floor above the lab. The elevators are less than 10 feet from the cath lab and provide direct access to the emergency department and cardiovascular operating room.

What trends do you see emerging in the practice of invasive cardiology?

We believe the emerging trend in cath labs will be optimizing patient care through collaborating practice and procedures with other specialties. We are currently in the building phase of our second-generation cath/CVOR/EP hybrid room. We have teamed up with specialties like EP, CV and thoracic surgery to help design a room that will embrace a new practice of collaborative procedural care. Examples of these types of procedures would include: • CABG (LIMA)/PCI-utilizing robotic and off-pump LIMA-LAD surgery • Valve/LIMA/PCI • Complex lead extraction (in an OR setting) • Transcatheter valve repair • Percutaneous valve replacement • Left atrial appendage occluders Another trend we see is that coronary procedural volumes will probably remain flat. There will likely be an increase in coronary artery disease (CAD) due to the aging population, as well as the increased rates of obesity and type II diabetes. However, the increased rates of CAD will be counterbalanced by more effective treatments, including the increasing use of newer generations of drug-eluting stents, aggressive medical therapy such as statins, and positive lifestyle changes.

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

When we moved into our new facility in 2006, we incorporated front-door parking for the acute MI team. This was not an easy task to accomplish, but proved to be a simple solution in decreasing door-to-balloon times by 8-10 minutes. Another unique aspect of our center is that we have a multimedia education resource center, devoted to patients, their family members, and community members. At the White Heart Learning and Resource Center, patients and their families learn more about heart health, diagnosis, treatment options, prevention and rehab. It is staffed by a cardiac advance practice nurse, who also participates in community health programs. We are also a unique lab as defined by our staff. Although the structure of The University of Kansas Hospital-Center for Advanced Heart Care provides a truly beautiful physical environment for patients, it is the compassion and kindness provided by our staff that truly defines our facility. The amazing efforts of our staff members as they do their best for each and every patient cannot be emphasized enough. We have witnessed many specific instances where staff members take extra steps to make patients feel at ease or to ensure a case goes well. As with most things, it is the people that truly make a facility great. This level of commitment to patient care and education has resulted in consistently high patient satisfaction ratings. It is one of the reasons we were named to the U.S. News & World Report’s 2007, 2008, and 2009 “Best Hospitals” issues for our heart and heart surgery program. We also earned Magnet Designation in 2006.

Is there a problem or challenge your lab has faced?

A couple of years ago, our cath lab worked with approximately 20 different physicians. Some performed only diagnostic coronaries while other physicians performed both diagnostic and interventions. When a non-interventional physician performed a heart cath that needed intervention, we removed the patient from the table and scheduled a PCI for later in the day. With the many different physician privileges and schedules, it was difficult to have efficiency in the lab. Our solution was to staff the cath lab with only interventional cardiologists who could perform diagnostic and interventional heart caths. This increased patient, staff and physician satisfaction and lab efficiency. Also, there was a reduction in overtime for staff. One of our recent challenges was to balance the needs of the cath lab staff with regards to efficiency of starting the day and the many responsibilities of the cath lab physicians (e.g., teaching, research, clinical responsibilities outside the lab). We have addressed this issue by assigning an “early start” physician. This physician is to have the morning free of additional responsibilities to allow for a timely start of at least one of the labs.

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”?

Kansas City is just like the barbeque for which it is famous — spicy and sizzling. In the past few years, we have seen the revitalization of the downtown area as seen by the development of the Kansas City Power and Light Entertainment District, the soon-to-be-opened Kauffman Center for the Performing Arts (which will be the home for the Kansas City Ballet, Symphony, and the Lyric Opera) and the Sprint Center arena. The Sprint Center has hosted the Big 12 Championship games (Go KU!), as well as many entertainers such as Tina Turner, Elton John, Billy Joel, Nickelback, Bon Jovi, and Garth Brooks — who entertained for nine amazing shows. Kansas Speedway has drawn NASCAR and other racing fans into the area. The Kansas City metro is also the home of world-renowned Nelson-Atkins Museum of Art, which houses one of the largest Asian art collections in the country, the National WWI Museum, and the Truman Presidential Library. 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 an incentive bonus or raise upon passing the exam?

We only require our unit coordinator to take the exam. However, we do prefer everyone to take the exam and offer a yearly bonus for those who pass the exam. Last year, we hosted a two-day RCIS review course with a great success. We had 98 people attend from 29 different labs over 3 different states. We plan on making this a yearly offering. We recently started to provide a 1-hour group study session every third Tuesday of the month.

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?

Our Regional Heart Attack Coordinator, Kelly Hewin RN, MSN, is involved with the Society of Chest Pain Centers. John Florio, Executive Director, Cardiovascular Services, is President of the Alliance of Cardiovascular Professionals (ACVP). Mark Reichuber, RN, BSN, can be contacted at mreichuber@kumc.edu

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