Lahey Clinic

The length of tenure in our lab ranges from 2 years to 6 months. We are very lucky that we have low staff turnover. What type of procedures are performed at your facility? We perform approximately 90 procedures per week, ranging from simple diagnostic to more complex coronary, peripheral and structural repairs (i.e., patent foramen ovale [PFO] closure, atrial septal defect [ASD] repairs, etc.). Our annual volume of coronary diagnostic and interventional procedures is 4,395. Our annual peripheral procedure volume is 255. Does your cath lab perform primary angioplasty with surgical backup? We do perform our procedures with surgical backup. It is scheduled via our cardiac liaison nurse. What procedures do you perform on an outpatient basis? Any procedure which does not require intervention can be scheduled as an outpatient with the possibility of the patient being discharged home the same day. What percentage of your patients are female? Thirty-four percent of our patients are female. What percentage of your diagnostic cath patients go on to have an interventional procedure? Seventy percent of our patients convert from a diagnostic to an interventional procedure. Who manages your cath lab? Karen Walsh, RN, BSN, is the acting nurse manager for the Cardiac Cath Lab, EP Lab and Interventional Cardiac Holding Unit. Do you have cross-training? Who scrubs, who circulates and who monitors? All of our staff are fully cross-trained with the exception of nursing delivering all medications. Diagnostic and interventional fellows generally scrub in on cases, but if needed, RNs, RTs and CVTs are trained to scrub in. Panning, circulating and monitoring are shared functions by all staff members. Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab? Yes, an RT has to be present in the room during cases. 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 physicians and the RTs are responsible for positioning the II, panning, changing angles and stepping on the fluoro pedal. If your lab performs peripheral interventions, what disciplines (physician and non-physician) are involved? One or two of our cardiologists perform peripheral procedures in our lab. We also have vascular surgeons and neuro-interventional radiologists sharing our lab to perform peripheral procedures. The director of the cardiac cath lab, Dr. Tom Piemonte, has developed a very collaborative relationship with the neuro-interventional radiology and the vascular surgery departments to continually advance the peripheral program. What specific equipment was instituted and/or dedicated towards peripheral cases above and beyond what is used for coronary cases? We have a dedicated peripheral laboratory with Siemens equipment (Malvern, PA) containing a 12-inch II and with digital subtraction capability. In addition, we have many lines of standard peripheral equipment (balloons, stents, wires and guide caths specific to peripheral procedures). Equipment is regularly discussed at new product committee meetings. Committee members are made up of MDs, the management team and our materials coordinator. What training was instituted so staff could be competent and skilled? Our peripheral training consisted of training by vendors, our clinical educator, and some of our RT staff who have a background in special procedures. Do interventional radiologists and cardiologists perform procedures in the same area? During carotid stenting procedures, the neuro-interventional radiology chief participates in the actual case with our interventionalist. Does your lab have a clinical ladder? We do not have a formal clinical ladder at Lahey Clinic, but our hospital is currently in the process of achieving Magnet status and it may be a possibility in the future. However, we have strongly encouraged (and have had recent buy-in from administration to assist) the staff in becoming RCIS-certified, and in the EP Lab, to pursue NASPE certification. We do have a preceptor workshop and charge role for which the staff is compensated if they attend and perform these duties while working. What are some of the new equipment, devices and products introduced at your lab lately? Some of the new products introduced recently have been cryoablation for peripheral intervention, optical coherance tomography (OCT), InfraReDx Near Infrared diffuse reflectance spectroscopy (InfraReDx, Burlington, MA) and the Outback® Catheter (Cordis Endovascular, Warren, NJ) for chronic total occlusions. Can you describe the system(s) you utilize and how they work in cath lab daily life? The systems we utilize in our daily operations consist of Siemens Axiom Artis cardiac cath labs, Siemens Axiom Sensis hemodynamic recorders, Siemens ACOM.net digital archiving system, an ECMS (electronic content management system) and a bed tracking system called BedTracking® (Tele-Tracking Technologies, Pittsburgh, PA). How is coding and coding education handled in your lab? We are very lucky to have a coder in our department who handles all coding issues. If we perform new procedures, we include her to help us sort out appropriate CPT codes and HCPCS codes. How does your lab handle hemostasis? We utilize different closure devices, including Angio-Seal (St. Jude Medical, Minnetonka, MN), Perclose® (Abbott Vascular Devices, Redwood City, CA), FemoStop® (Radi Medical Systems, Wilmington, MA), radial bands (Hemoband Corporation, Portland, OR) and the C-clamp, as well as manual compression. Many of our patients go to our holding unit post procedure, where the RN staff is trained in sheath removal and post-access management care. Does your lab have a hematoma management policy? If complications arise beyond what the holding unit RN can manage, we have cath lab attending physicians, cardiac fellows and a cardiac mid-level team (consisting of NPs and PAs) that can help manage these situations. The cardiac mid-level team consists of 3 physician assistants and 5 nurse practitioners who are assigned on a weekly basis as part of the holding unit support team as well as participating in interventional patient care rounds out on the units. We have a number of radial and groin management policies related to the different closure devices and potential issues associated with each different device. How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies? We have a materials coordinator who manages supplies in all three labs using PeopleSoft software. In addition, any capital equipment is a group decision involving MD leaders, our administrative team, management team, business manager, and the purchasing and finance departments. Has your cath lab recently expanded in size and patient volume, or will it be in the near future? In 2003, we completed Phase 1 and 2 of our expansion. It included three new cath lab suites, a seven-bay interventional cardiac holding unit (ICHU) and two new EP labs, as well as a supply room, reading room, utility rooms and office space. We will be continuing the expansion within the next year and a half to two years, possibly adding a third EP lab and expanding the ICHU. Is your lab involved in clinical research? Our cardiac cath lab is actively involved in a number of research studies under the direction of Sergio Waxman, MD as our Principal Investigator. As one example, we are currently part of the CAPTURE 2 Registry for asymptomatic carotid stenoses. We are also involved in the Immediate Trial, in which ACS patients in the field are given glucose, potassium and insulin in order evaluate whether this impacts outcome. The Spectacle Study involves new infrared spectroscopy imaging catheters for early identification of vulnerable plaque. The Coral Study compares renal artery stenting versus medical management for patients who are taking 2 anti-hypertensive agents for a systolic blood pressure > 155. Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? In the rare instance of a patient requiring emergent cardiac surgery as a result of a cath related complication, the cardio-thoracic attending physician is STAT-paged and an O.R. is made immediately available. I cannot recall such an instance having occurred over the past year. What other modalities do you use to verify stenosis? To verify stenosis, we use intravascular ultrasound (IVUS) and the Radi PressureWire (to measure fractional flow reserve, or FFR). What measures has your cath lab implemented in order to cut or contain costs? One substantial move that has helped with cutting costs has been the hiring of a dedicated materials coordinator to manage all inventory within our cath lab, EP lab and ICHU. She utilizes cycle counts to adjust par levels, shipping and freight charges, and monitors consignment, no-movement items and expired products. What type of quality control (QC)/quality assurance (QA) measures are practiced in your cath lab? To maintain quality controls in our areas, we do daily and monthly QC on specific equipment, internal audits, maintain our American College of Cardiology NCDR database and monitor results. We monitor and track our door-to-balloon times and participate in an Interdepartmental Core Measure Acute Myocardial Infarction (AMI) Committee. How does your cath lab compete for patients? Has your institution formed an alliance with others in the area? Lahey Clinic is the tertiary oversight hospital for the C-PORT trial for Lowell General, Saints Memorial Hospital, Southern New Hampshire Hospital and Beverly Hospital. How are new employees oriented and trained at your facility? Our RNs and technologists receive a 12-week orientation with a preceptor. During this period, they are not counted in the staffing mix. RNs are required to have a current RN license and at least a year of critical care experience. RTs are required to have a current RT license and we encourage our CVTs to become RCIS-certified. One of our CVTs and one of our RTs are RCIS-certified at this time, and another of our CVTs is in the process of studying for the exam. All staff is required to be BLS- and ACLS-certified. What type of continuing education opportunities are provided to staff members? Staff members are provided with a number of different educational opportunities, including vendor inservices, pharmacological inservices, interdisciplinary inservices, infectious disease inservices, annual radiation safety and annual hospital competencies, and many opportunities for CEU attainment. Our lab also has its own nurse educator who provides many additional inservice opportunities. Lahey Clinic offers tuition reimbursement and loan forgiveness programs for staff pursuing advanced education. How do you handle vendor visits to your lab? Vendor visits are managed by our materials coordinator, who manages a sign-up calendar. We instituted a policy limiting visits to one vendor per day from 10am to 2pm. Vendors are not allowed in the control room or procedure room unless specifically requested by the physician. We also have one week per month that is a no-vendor week! How is staff competency evaluated? Staff competency is evaluated on an ongoing basis, tracked yearly by the clinical educator and is judged on written competencies and observation. Staff is evaluated by the clinical educator and the other members of the leadership team, consisting of the nurse manager and assistant nurse manager. Does your lab utilize any alternative therapies (such as guided imagery, etc.)? As far as alternative therapies, we provide headsets for patients in the holding unit and each holding bay has a digital picture above the bed to simulate a calming nature scene (consisting of autumn scenes, the ocean, lakes, flowers, etc). We also try to accommodate any special requests that may be related to a patient's cultural needs. How does your lab handle call time for staff members? Call is managed by either 2 RNs or 1 RN and 1 RT/CVT, since we have a fellowship program. Call is four times one month and the next month is just a weekend requirement. We have three shifts: 7am-7:30pm, 9am-7:30pm and 7am-5:30pm. If volume allows, staff are able to flex down. We also have compensated sleep time if the staff gets called in during the night. What trends do you see emerging in the practice of invasive cardiology? The number one trend is the adoption of peripheral procedures being done in the cath lab setting and the development of cardiovascular centers. Another trend noted is the lower number of restenosis patients with the advent of drug-eluting stents. Has your lab has undergone a JCAHO inspection in the past three years? We just finished a JCAHO inspection in December of 2005. I would recommend that you document, document, document! The biggest focus in our area was on universal protocol and moderate sedation. Where is your cath lab located in relation to the OR department, ER, and radiology departments? We are located on the fifth floor directly next to the CCU, Non-invasive Cardiology and the Telemetry floor (this floor takes 90% of our patients). The ER, OR, and Radiology are located on the second floor. Each of our three cath labs are 650 square feet and are laid out in a row, with a scrub room between each lab and a control room in the front of each lab. One thing that was very desirable the addition of a huge supply room which provided more square footage for storage. One thing I wish we had was a different configuration of the supply room one that stretched the length of all three labs with direct access from each lab. Please tell the readers what you consider unique or innovative about your cath lab and its staff. What is unique about Lahey Clinic cath lab (and EP lab) is the bi-annual participation by staff in Project Pacer. This is a project where staff and physicians travel to third-world countries and provide humanitarian procedures (including valvuloplasties, coronary angiograms, EPS studies, pacer and ICD implants, and atrial fibrillation [AF] ablations). This is a joint effort including the cath lab and EP lab staff (nursing, technologists, PAs and physicians are all involved) and is very rewarding. The most recent place that Lahey Clinic participated in a Project Pacer mission was in September of 2006, traveling to Hospital Viedma in Cochabamba, Bolivia. Selected medical and nursing members of the cath lab and EP lab staff participated, including Thomas Piemonte, MD, David Martin, MD, Roy John, MD, Christopher Pastore, MD, Eugene Chung, MD, Karen Walsh, RN, and Kathleen Malewicki, RN. While there, the teams participated in mitral valvuloplasty, pacemaker and defibrillator implants, EP studies, and catheter ablations. Additionally, approximately 150 people were seen in follow-up visits from previous missions. 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? Having a cath lab in New England creates a fast-paced environment of competition, due to the fact that there are many teaching hospitals in the Boston area. We therefore have many educational opportunities available to us, not only within Lahey Clinic, but also in surrounding health care facilities and university settings. 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 strongly encourage our cath lab staff, technologists and RNs alike to become registered. Our nurse educator working with four surrounding hospitals to pool resources and staff in order to obtain an RCIS exam review. Study materials are distributed to staff members weekly, with mock exam question discussions. At this time, Lahey Clinic is pursuing Magnet status, so we are looking at a clinical ladder structure to reward professional certifications. 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? The Lahey cath lab management team and educator are members of SICP and regularly log on to the SICP website (www.sicp.com) for the most current information. Diane Cronin can be contacted at Diane.M.Cronin@lahey.org

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