About Howard Regional Health System`s Cardiac Catheterization Laboratories

Continued from Successful Implementation of a Cardiac Interventional Program Without On-site Surgical Backup at Howard Regional Health System The Howard Regional Health System cardiac catheterization lab (CCL) team is diverse, with a plethora of experience bringing unique gifts and talents to the CCL table. We have a preceptor with 12 years of CCL experience. Most of our RNs have years of critical care experience. One was previously the manager of an ICU and one was a House Supervisor. Our RTs are equally special. One graduated summa cum laude with a specialty in CT and MR, and one RT has the certification of CVIT. We have 27 total FTEs for invasive catheterization services in three areas. 1. Prep & Hold: 4.5 FTE RNs, 1.0 FTE Secretary This team prepares and recovers all outpatient diagnostics. 2. The cath lab team is divided between two labs: peripheral and cardiac. 1 FTE CCL Nurse Manager 1 FTE Cardiac Nurse Specialist 1 FTE Data entry 8.5 FTEs RNs 1.6 FTEs RTs 0.5 FTE RT that is also CVIT 0.5 FTE Transporter/Room Turnover 1 FTE Transcriptionist/Biller Coder 1 FTE Secretary Total dedicated CCL FTEs: 14.5 3. Our Post Cath Intervention (PCI) Unit has 6-8 beds; 2 surgical beds 5 FTEs RNs 2 FTEs Secretary/Monitor Tech Total FTEs: 7.0 We currently have one GE combo lab, the Advantx LCV+ (Waukesha, WI) and one dedicated cardiac lab equipped with a Philips Allura ceiling-mount Flat Detector (New York, NY). Our hemo units are GE Mac-Lab 7000 (see floor plan). The HRHS CCL performs all types of diagnostic and interventional peripheral and cardiac procedures. We utilize intravascular ultrasound (IVUS) for both modalities. HRHS performs 40 cases per week, with one to two acute cases per week. Our volumes continue to increase (Figure 2). Patients undergoing cardiac interventions and renal interventions usually spend one night in the hospital and are discharged the following day. Other procedures performed in the CCL include:

Left heart catheterization Right heart catheterization Percutaneous coronary intervention(s) Insertion temporary pacemaker Insertion permanent pacemaker Revision of permanent pacemaker Pulmonary angiography Arch and bilateral carotid arteriogram(s) Abdominal aortogram with femoral run-offs Vascular intervention(s) Epidural/sacral iliac steroid injection(s) Other vascular procedures

Our management structure for CCL daily operations involves an RN Cath Lab/PCI Manager (Jolene Windt RN, BSN). She reports directly to the Executive Director of Cardiovascular Services, who in turn reports to the Vice President of Clinical Support Services. The VP reports to the Chief Operating Officer, who ultimately reports to the Chief Executive Officer. QA Measures Quality Assurance (QA) is reported to our Medical Director of Cardiology and then to Medical Audit and Review Committee. CCL QA measures are:

Negative rate Hematoma over 2 cm Stroke MI Death Other: hemorrhage, retroperitoneal bleed, arrhythmia requiring intervention

Hemostasis On approximately 90% of our patients, we use one of the following products to obtain hemostasis:

Perclose® (Abbott Vascular Devices, Redwood City, CA) Angio-SeaI (St. Jude Medical, Minnetonka, MN) Syvek Patch® (Marine Polymer Technologies, Danvers, MA) Chito-Seal (Abbott Vascular Devices, Redwood City, CA)

Occasionally, we use FemoStop® (RADI Medical Systems, Reading, MA) to help control small amounts of oozing in those patients who are on an IV continuous GPIIb/IIIa inhibitor. Inventory We have an Omnicell system (Lebanon, TN) in the lab for inventory control. This implementation was difficult at first, as it encompassed training of staff with a new process as well as determining accurate PAR levels. Once this was refined, we found Omnicell makes inventory control, counting and ordering much easier and more efficient. We have two preferred vendors for each product line. We are also part of the Voluntary Hospital Association (VHA) buying group. Having an inventory control system, utilizing consignment inventory and appreciating pricing from a large buying group such as VHA have helped us to control our costs. Vendor visits Our CCL secretary and Cardiac Nurse Specialist schedule all vendor appointments. Vendors have a signed HIPAA business associate agreement on file with HRHS and check in upon arrival in order to obtain a vendor pass from Materials Management prior to reporting to the CCL. New employees and education New employees in cardiovascular services are assigned a preceptor on a one-to-one basis for three to six months, depending on their level of previous experience and the opportunity to check off all CCL skills on our orientation skill list. We have a generous continual education fund. HRHS offers a tuition reimbursement program for all college credits in which a grade of C or above is obtained. HRHS has graciously sponsored 18 RNs through Indiana University, to obtain a Master’s in Community Health Nursing as Clinical Nurse Specialists. Our CCL has five RNs currently enrolled in this program, specializing in the cardiovascular community. Funding also provides for each CCL staff member to attend one major CCL conference per year. Vendors also provide additional educational opportunities. Staff competency Our staff competency is maintained with CCL core competencies. Currently, they include, but are not limited to: IABP ACLS Conscious Sedation Aseptic Technique Medications & Calculations ACT II Machine Closure Device/Sheath Pull IVUS Mechanisms of IABP Counterpulsation Sonosite Radiation Safety Heart Smart Cardiac Intervention Ultegra Zoll Monitor/ Defibrillator Vascular PTA/Stent Procedures GE Mac Lab Multi-Cultural Care Philips Integris GE Advantax Combo Lab #1 FemoStop Avoximeter Phlebotomy Blood Administration AccuChek Glucometer Restraints Bed Safety Age Specific Care MedGem Indirect Calorimeter Dysrhythmia AngioJet Medrad Aseptic Technique Skin Prep Pacemaker Call Team Cath lab hours are Monday-Friday from 6:00 a.m.-6:00 p.m. The cath lab call team at HRHS consists of two RNs and one RT or three RNs. Rotation is one in four weeks. We have the call team report to work later on their call day to accommodate any add-ons that day. We never send staff home with mandatory "unit not busy" time off. In the event of a rare light day, we always have staff willing to volunteer to go home as our schedule is normally very grueling. JCAHO & Time Outs We went through a very successful JCAHO Survey two years ago and are currently preparing for our upcoming survey in March 2004. We have implemented a time out policy in the CCL. Time Out I is taken immediately after patient is placed on the cath table. At that time, the follow information is determined and documented in the MacLab system by the monitor staff person: 1. Patient wrist band information is confirmed verbally (name and date of birth) with patient; 2. Patient verbally confirms procedure to be performed; 3. Chart is checked for informed consent consistent with patient confirmation; 4. In the event the patient is unable to provide the above information, it is verified with family, POA and/or MD. Time Out II is taken with the arrival of the MD. A member of the cath lab staff confirms the documentation of the patient’s history and physical with the MD. At this time, the MD verbalizes the following, which is documented in the MacLab system by the monitor staff person: 1. Correct patient; 2. Correct procedure; 3. Correct equipment is available. As an enhancement to patient safety, we also use two identifiers. The patient must provide us with their name and their date of birth prior to arm banding by a RN. If the patient is confused, a direct family member must provide this information. In the CCL, we assess and document pain as the 5th vital sign. With each vital check, we assess pain. Prior to procedure, the patient’s acceptable level of pain in established using a 1-10 pain scale. We assess each patient with a modified Aldrete scale and a Conscious Sedation scale pre, during and post procedure. HRHS Success We feel the key components that have led to our success include:

An experienced interventionist: Dr. Michael E. Ritchie Exceptional leadership: medical, administrative and financial support Excellent non-invasive services: nationally accredited echo and vascular services utilizing GE Vivid 7 Cardiovascular Ultrasound Equipment Exceptional equipment A dedicated cardiac room A room large enough to work in (Figure 3) Our second lab: Philips Integris Allura 9 with Dynamic Flat Detector 24/7 CCL call Dedicated staff: wanting to learn, wanting to be the very best Dedicated education and training funds

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