Eastern Maine Medical Center

What is the size of your cath lab facility and number of staff members? EMMC’s cardiac cath lab consists of 3 cath labs, 1 electrophysiology lab, and a 9-bay prep and holding area. Our EP lab is currently undergoing an expansion and renovation project. We are using a mobile cath lab to maintain capacity until the project is completed. A multi-disciplinary team staffs the cath lab, consisting of: 20 registered nurses 12 radiology technologists 2 cardiovascular technologists Other members of the cath lab team include the Cath Lab Supervisor, an Information Systems Coordinator, an Inventory Manager and a dedicated group of secretarial staff instrumental to ensuring that the lab runs smoothly and efficiently. A unique member of our team is a Hearing Dog by the name of Bailey. Although his official job description is hearing dog for one of our staff members, he has also acquired the added responsibility of stress management facilitator for the rest of the staff. The cath lab has many long-term staff members. Some of our more senior staff members have been working in the lab since the start of the program back in the 1970s. In fact, 15 members of the team have been working in the cath lab at EMMC for over 10 years. The cath lab team works with a single group of cardiologists, consisting of 18 physicians. All of the cardiologists perform diagnostic catheterizations. In addition, 6 of the cardiologists also perform PCI procedures, 3 also perform electrophysiology procedures and 4 also perform pacemaker and ICD implants. What type of procedures are performed at your facility? EMMC’s cath lab performed over 6,200 procedures last year, including over 4,000 diagnostic catheterizations, 1400 coronary interventions, 240 electrophysiology studies and ablations, and 400 device implants, including cardiac resynchronization devices (biventricular pacemakers and ICDs). PCI procedures include stents, coronary brachytherapy, PTCA, and rotational and directional atherectomy procedures. We recently started performing renal stent procedures as well. We are currently performing an average of 127 procedures per week and a busy week can be as high as 150 procedures. Does your cath lab perform primary angioplasty with/without surgical backup? Although we have been performing primary angioplasty for some time now, it has been the treatment of choice, 24/7, for ST-elevation MI for over 6 months. Our goal is to achieve a door-to-open-artery time in 90 minutes or less. The cath lab works closely with the emergency department to monitor our performance. We have on-site surgical back-up, but we do not keep the Cardiac OR on standby when we perform primary angioplasty. If surgery is needed during normal operating hours, patients are transferred to the next available OR suite. After hours, the surgical team is available on call. Who manages your cath lab? The cath lab operates under the direction of the Heart Center administrator and the cath lab medical director. Cath lab managers include the department head nurse for cardiology services and the cath lab supervisor. Both managers, as well as the Heart Center administrator, are registered nurses. Cath lab staff participate in the management of the cath lab through the Cath Lab Operations Group (CLOG). Members of this committee include cath lab staff, managers, the medical director of the cath lab and our administrator. Nursing staff also make staffing plan recommendations through a departmental staffing committee. Do you have cross-training in your lab? We believe that cross-training is essential from the standpoint of staff satisfaction, as well as scheduling flexibility. RNs are responsible for circulating cases and medication administration, as well as pre- and post-procedure patient care in the holding area. State of Maine regulations restrict the operation of radiation equipment to licensed radiographers or licensed practitioners, so only RTs are assigned to assist the physician in obtaining angiographic data by operating the c-arm and panning. The RTs are also responsible for the radiation protection of patients and staff. Both RN and RT staff cross-train to scrub and monitor hemodynamics. Our two CVTs have extensive knowledge in the use of physiologic analytical equipment, and the recognition and interpretation of hemodynamic data. They are the key resource personnel for cross-training RNs and RTs to the hemodynamic monitoring role. What are some of the new equipment, devices and products introduced at your lab lately? Intracardiac echo (ICE) is the newest technology that we have introduced into the cath lab. ICE is being used in the electrophysiology lab during atrial fibrillation and other complex arrhythmia ablations. We anticipate using it for PFO closures in the future. Cardiac resynchronization devices are also fairly new in our lab. We have been implanting biventricular pacemakers since November 2001 and biventricular ICDs since July 2002. Vascular brachytherapy has been performed in the cath lab since June 2000, using the Novoste Beta-Cath system (Norcross, GA). Other relatively new products that are used in the cath lab to facilitate PCI procedures include the following: RADI PressureWire® (Reading, MA) PercuSurge® GuardWire distal balloon protection system (Medtronic, Inc., Santa Rosa, CA) AngioJet® thrombectomy system (Possis Medical, Minneapolis, MN) The newest piece of imaging equipment to be introduced at our cath lab is a Siemens Artis biplane EP system (Malvern, PA) that is scheduled to be installed this spring. We are anxiously anticipating the release of drug-eluting stents and hope to be able to offer that technology to our patients shortly thereafter. Is your cath lab filmless? In 1998, the cath lab embarked on a plan to convert the labs to digital technology. Our first filmless lab was installed in December of 1998 and the last lab was upgraded to digital in October 2000. All three cath labs were connected to a Siemens ACOM network and archiving system in January 2001. Image review stations are located in the control room of each lab, in the physician’s reading room and in each of the two cardiac surgical suites. We have recently added review stations on the telemetry units and in the cardiac critical care unit. The cardiologists are now able to review studies on the patient care units as they are consulting on patients, which has become a real time-saver for them. How does your lab handle hemostasis? Hemostasis is managed by cath lab nurses in the holding area. Angio-seal (St. Jude Medical, Minnetonka, MN) and Perclose® (Perclose, An Abbott Laboratories Company, Redwood City, CA) closure devices are used in our lab on approximately 28% of our cases; a c-clamp or manual pressure is used to achieve hemostasis on the rest of our patients. Closure devices are deployed before the patient leaves the procedure room and are used primarily on patients who have had interventional procedures. This eliminates the need to keep patients in the holding area until the ACT reading is within acceptable parameters. Does your lab have a hematoma management policy? We do not have a written hematoma management policy, but the standard practice is to apply manual pressure and contact the cardiologist. How is inventory managed at your cath lab? Inventory is managed using a computerized inventory management system. Supply utilization is tracked through an interface between the Siemens CathCor hemodynamic monitoring system and Lumedx Apollo32 inventory program (Oakland, CA). Staff document supplies used during the procedure by selecting the item from a pick list on the CathCor or by scanning the product bar code. Our inventory manager generates electronic purchase orders through Apollo, which are sent to the Purchasing Department. Automatic product usage reports are used to guide adjustments to inventory par levels and re-order points. Using the Apollo inventory system, we have been able to implement a successful just-in-time delivery program and it has enabled us to negotiate discounts with our vendors and to take advantage of special programs that have resulted in substantial savings. Has your cath lab recently expanded in size and patient volume? EMMC’s Heart Center has experienced continued growth each year that we have been in operation. Cath lab volume has increased an average of 14.2% annually, since a dedicated cath lab opened in 1987. Volume actually doubled from 1990-1994 and then doubled again from 1994-2002. We added our third cath lab in December 1998 and we would like to add a fourth cath lab in the near future. In, fact, we are considering keeping the mobile lab after the EP lab project is completed. The plan would be to operate it as a fourth lab until a permanent lab can be built. We are also considering adding a pacemaker procedure room. Is your lab involved in clinical research? Yes, the cath lab has participated in clinical studies for both experimental devices and drugs. The cardiology group employs a nurse who oversees all cardiovascular clinical research. We are currently enrolling patients in three studies: 1. EMMC has the highest enrollment in the northeast in the SYNERGY study for acute coronary syndrome. 2. Patients are also being enrolled in the AT-BAT study, which involves the use of Angiomax® (The Medicines Company, Parsippany, NJ) during PCI, for patients who are allergic to heparin. 3. The third study is CAPTIVE, a study for distal protection devices used during saphenous vein graft interventions. We are also considering participating in a study for ST-elevation MI. There are three other device studies that we have participated in (MADIT, SERF and ASSURE). These studies are in the follow-up phase but are closed to enrollment. Does your lab perform elective cardiac interventions? Yes, we do schedule elective cardiac interventions. However, regardless of whether interventions are elective or urgent, approximately 66% are performed as ad hoc procedures, eliminating the need for patients to return for a repeat procedure following the diagnostic cath study. Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? As stent technology has improved over time, we have seen the number of patients sent emergently for cardiac surgery due to a cath lab-related complication decline. Our emergent CABG rate is considerably less than the American College of Cardiology/ Society for Cardiac Angiography & Interventions standard. What measures has your cath lab implemented in order to cut or contain costs? We are continuously looking for opportunities to reduce costs. Some of our cost reduction initiatives include the following: With few exceptions, inventory is stocked on a consignment basis. We negotiate with vendors for best pricing based on volume and market share. Incentive rebates are earned through participation in Novation Stent and Cardiac Rhythm Management Standardization programs (Irving, TX). We began reprocessing EP catheters in August 2002. We make quarterly bulk purchases for stents, balloons, pacemakers, and ICDs at further discounted pricing. Standardizing contrast use to Omnipaque (Amersham Health, Princeton, NJ), has significantly reduced contrast cost. Prior to standardizing, we used a combination of Visipaque (Amersham Health) and Omnipaque. By tracking and working to decrease cath lab delays and turnover times, we hope to improve efficiency and reduce overtime. What type of quality control/quality assurance measures are practiced in your cath lab? The Heart Center of EMMC is a member of the Northern New England Cardiovascular Disease Study Group. NNECDSG is a regional consortium of hospitals from Maine, Massachusetts, New Hamp-shire and Vermont that has been involved in continuous quality improvement for cardiac surgery and cardiac interventional patients since 1987. Through an extensive database contributed to by all members, this group continually examines patient outcomes and makes recommendations on ways to improve processes. The cath lab contributes data for the PCI registry. In addition to participating in quality improvement activities and monitoring outcomes through NNECDSG, we also monitor other quality indicators, including patient satisfaction, efficiency and cost-effectiveness. We are currently working collaboratively with the emergency department to track the time to reperfusion for primary angioplasty. Through regular feedback to service and staff members, we have been able to further identify opportunities for improving the care of patients with ST-elevation AMI. This has resulted in a continued reduction in the variation of door-to-open-artery elapsed times and an improvement in the number of patients meeting the goal of 90 minutes or less. It has also helped us improve processes for identifying and responding to the outliers. We are also monitoring cath lab efficiency by tracking first case start times as well as room turn-over times and the reason for delays when they occur. By just talking about how we’re doing, we’ve been able to significantly improve our on-time start rate since we started tracking it. By tracking and trending delay reasons, we’re now in a position to develop a corrective action plan to address delays. We are monitoring cost-effectiveness by tracking our cost per procedure and our performance in meeting established cost reduction targets. We have just started to track patient satisfaction through surveys administered by Avatar International (Dallas, TX). The survey is designed to measure how patients rate their cath lab encounter as compared to their expectations. Avatar also allows us to compare our patient satisfaction results to both internal and external benchmarks and provides an improvement matrix which will help us select our improvement targets. How does your cath lab compete for patients? Has your institution formed an alliance with others in the area? Up until recently, EMMC had the only cardiac cath lab in the northern two-thirds of the state. In October 2002, a diagnostic cath lab opened at a hospital in northern Maine, and another diagnostic cath lab opened in January at a smaller community hospital here in Bangor. Both hospitals refer their high risk and interventional patients to our full-service cath lab, where complex cases, ad hoc interventions and primary angioplasty can be done. The cardiologists provide outreach clinics to many hospitals within the region, allowing easier access to cardiology consultations for patients, who would otherwise have to travel long distances. Many patients seen in these outreach clinics are referred to the cath lab at EMMC. Does your lab have an outpatient program? We perform a variety of procedures on an outpatient basis, including diagnostic caths, EP studies and pacemaker/ICD battery changes. Patients are admitted and discharged from a short stay unit that serves all of the surgical/procedure departments at EMMC. How are new employees oriented and trained at your facility? In addition to attending a two-day general hospital orientation, staff are oriented to each role or function within the cath lab using a competency-based orientation plan. Our orientation plan was developed using the Society of Invasive Cardiovascular Professionals (SICP) and the Alliance of Cardiovascular Professionals (ACP) standards of practice as a guide. New employees are assigned to a preceptor who works with them throughout their orientation. Prior experience and learning needs determine the length of each staff member’s orientation. Regular conferences are held with each orientee, their preceptor and the cath lab supervisor in order to review progress and provide feedback. We have found The Cardiac Catheterization Handbook, edited by Morton J. Kern, published by Mosby, to be a very useful tool in orienting new employees to the cath lab. What type of continuing education opportunities are provided to staff members? EMMC provides continuing education programs, including seminars, institutes, workshops and other programs, through our Education and Training Center. Nursing staff are granted, per contract, up to 24 paid educational hours per year and up to $75.00 per year for educational expenses. The cath lab also holds regular educational inservices presented by our vendors’ clinical specialists. Staff also have the opportunity to attend national conferences. How is staff competency evaluated? Competency is evaluated at a minimum, on an annual basis, using a performance evaluation tool that is specific to each employee’s job description. A combination of direct observation, peer evaluation and input from physicians is used. We also use iCare, an Internet program to evaluate general compliance and regulatory issues (https://www.icare.com.au/). How does your lab handle call time for staff members? Is there a particular mix of credentials needed for each call team? Do you have flex time or multiple shifts? Our call team consists of 2 RNs, 1 RT and either a CVT, RN or RT who will perform the hemodynamic monitoring role. Weekday call starts at 5:30 pm and ends at 7:00 am the following morning. Weekend call starts on Friday at 5:30 pm and ends Monday morning at 7:00 am. The average call assignment is 1 to 2 evenings per week and every 5th-6th weekend. The cath lab is staffed using 10-hour shifts (7:00-5:30). The holding area is staffed from 6:30 am - 7:00 pm. We are currently evaluating the need for multiple or staggered shifts for the procedure rooms, in order to extend operating hours and reduce overtime. What trends do you see emerging in the practice of invasive cardiology? We’ve definitely seen a trend toward performing more interventional procedures as ad hoc (during the same setting as the diagnostic cath procedure). Ad hoc interventions have increased by 13% over last year. Our cardiologists are expressing an increased interest in performing peripheral interventional procedures. Our capital budget will include a proposal to upgrade one of our labs to a larger field II and to add digital subtraction software. The physician group practice is recruiting a cardiologist with peripheral interventional experience. Has your lab has undergone a JCAHO inspection in the past three years? EMMC’s last JCAHO survey took place in July 2001. The cath lab received no deficiencies and the survey team concluded that we have a high-tech, high-quality facility that has not lost site of its mission or of the population that we serve. Please share with us what you consider unique or innovative about your cath lab and its staff. When they visit the cath lab at EMMC, people are surprised to find such a large program and one that is so technologically advanced, given the fact that we are so far away from any major metropolitan area (Boston is 210 miles away). We are able to offer the same high-quality, current state-of-the-art, cost-effective care that is offered at other major medical centers. Is there a problem or challenge your lab has faced? One challenge is the impact that ad hoc interventions have had on cath lab scheduling. With all labs operating at full capacity, there is little wiggle room to adjust the schedule when a cath turns into an intervention. Compound that with a 24/7 commitment to primary PCI, and challenges with patient satisfaction and staff overtime are sometimes the result. We would appreciate hearing from Cath Lab Digest readers who have successfully implemented an ad hoc intervention program in their lab. What’s special about Bangor, Maine, in comparison to the rest of the U.S.? How does it affect your cath lab culture? Although many think of Maine as vacationland, we consider it a great place to live and to work. Bangor is located in east/central Maine, within an hour or two of the coast, Acadia National Park and Bar Harbor, Moosehead Lake, Baxter State Park, Sugarloaf Ski Resort, Mount Katahdin, and the Allagash wilderness waterway. Bangor’s proximity to these attractions draws visitors from around the world and not only makes it a wonderful place to visit, but also to live. The city of Bangor has been recognized as a safe place to live and has been rated by MacMillan’s Places Rated Almanac as the Nation’s Best Small Metropolitan Area. It is also listed by Reader’s Digest in the top 20 Best Places to Raise a Family, and in the top 10% of statistics offered by American Demographics, as a region representing A Strong Hometown. Author Melinda Durrange, RN, BSN, Department Head, Cardiology, Eastern Maine Medical Center, can be contacted at mdurrange@emh.org or (207) 973-7180.

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