Mt. Carmel West Cath Lab

We all have a peripheral lab that can be used for coronary diagnostic and interventional procedures. Our recovery area is a separate unit with 14 bays, of which five are used to admit outpatients. We have 23 licensed staff: 15 RNs (1 is RN, RCIS) 7 RT(R)s one (CVT) RCIS. We also have an inventory manager, one unit coordinator, 28 cardiologists and three vascular surgeons. We have staff dedicated to maintaining our documentation and database system, and an RN committed to education for the staff. What type of procedures are performed at your facility? We do 4300 diagnostic caths and 1400 percutaneous coronary interventions (PCIs) annually. Diagnostic coronary procedures include right and left heart caths, valve assessments, imaging of native coronaries and bypass grafts. Interventional coronary procedures include stenting [bare metal and drug-eluting stents (DES)], Rotablator (Boston Scientific Corp., Maple Grove, MN), cutting balloon (Boston Scientific), AngioJet (Possis Medical, Inc., Minneapolis, MN), intravascular ultrasound (IVUS), and Filterwire (Boston Scientific). We opened up a dedicated peripheral lab in September of 2004 and have since averaged 31 diagnostic procedures and 8 interventional procedures per month. Peripheral procedures include diagnostic and intervention of subclavians, superior mesenteric arteries (SMAs), celiacs, aorta, renals, and legs. We are doing diagnostic carotid angiograms and actively screening for a patient upon which to perform carotid stenting. Our EPS lab does over 1000 procedures annually, which includes diagnostic EPS studies as well as ablations, implantable cardioverter-defibrillators (ICDs), pacemakers and bi-ventricular devices. Does your cath lab perform primary angioplasty with surgical backup? Yes. We do primary angioplasty in our cath lab with our door-to-balloon time below the time standard set by JCAHO. The cardiologist ultimately decides which surgeon he wants consulted in case a patient needs to go to open heart, but there is also an on-call list available 24/7 which is posted daily for emergencies. What percentage of your patients are female? During calendar year 2005, 42% of our patients were female. What percentage of your diagnostic cath patients go on to have an interventional procedure? Twenty-seven percent of our caths go on to have an intervention. Who manages your cath lab? Kathy Clegg, RT(R) is our Clinical Manager. Kathy manages all operations and staff and assists with cases as needed. Karen Holt, RN is our Director. Her primary focus is contracting, fiscal budgeting, working with vendors and assisting with procedures as needed. Our Administrative Director is Deb Thompson, RN, whose responsibilities include operations and physician relations. Do you have cross-training? Who scrubs, who circulates and who monitors? Our RTs and RNs scrub, monitor and circulate. RNs are responsible for administering medications. Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab? Yes, an RT must be present for all procedures. Which personnel can operate the x-ray equipment in your cath lab? Whoever is scrubbed, whether RN, CVT, or RT(R), can position the II, pan the table and change angles. The physician doing the procedure operates the fluoro pedal. Does your lab have a clinical ladder? The hospital offers a clinical ladder called the Professional Excellence Program, which is only available for RNs. What are some of the new equipment, devices and products introduced at your lab lately? We use the PolarCath (cold therapy) for peripheral interventions and FoxHollow SilverHawk (Redwood City, CA) for peripheral atherectomy. Our x-ray equipment is Siemens XT (Malvern, PA) for peripheral and coronary procedures. We utilize IVUS for peripheral arteries. Can you describe the system(s) you utilize and how they work in cath lab daily life? We have been filmless since the fall of 1997 and presently utilize the Medcon system (McKesson Corp., San Francisco, CA). It has been a great advantage for the physicians in that they can review their images immediately. Physicians can also view the images at our west, east and St. Ann’s campus. They also have access to Medcon’s MDWeb, which allows them to review the images from any PC in the hospital. Currently, we are in the process of sending our peripheral images directly to the radiology archival system (PACS) from our Siemens system as well as sending images to the system. We are also looking at sending cardiac images from our 64-slice CT to the Medcon system. It is also the repository for our echo and vascular images. How is coding and coding education handled in your lab? Our cardiac charges are created in Witt (Philips Medical Systems, Bothell, WA), our documentation system, and are sent to the HBOC Star (McKesson Corp.) for billing. Peripheral procedures are reviewed and billed manually on a daily basis. We get a report from Star the following day in order to check the charges that were billed and make any corrections. We have an RN who codes the peripheral procedures and attempts to stay knowledgeable by attending coding conferences and accessing websites such as Code Correct. She also gets monthly case studies from Medlearn (St. Paul, MN) and has access to coding books such as Interventional Radiology Coder and Cardiology/Cardiothoracic Surgery/Vascular Surgery Coding Companion. Our charts are also audited and any discrepancies between what was billed and coded are identified. We are in the process of trying to get a dedicated coder/biller. How does your lab handle hemostasis? The lab uses Angio-Seal (St. Jude Medical, St. Paul, MN) and Perclose (Abbott Vascular Devices, Redwood City, CA) for closure. The patients go to our recovery area and are generally placed on the clamp with a patch if they have not received a closure device. Manual pressure and FemoStop (Radi Medical Systems, Wilmington, MA) are also utilized when indicated. Does your lab have a hematoma management policy? We do have a hematoma prevention and management policy. We developed a protocol to help identify patients at risk for hematomas called She BLEEDS. She – female IIB/IIIa inhibitors (abciximab statistically significant) Less than 100 lbs. or > 250 lbs. Elderly Experienced multiple procedures Drugs affecting coagulation, such as fibrinolytics, heparin, etc. Skin integrity This protocol received national recognition at the American Association of Critical-Care Nurses’ annual meeting, NTI (National Teaching Institute). How is inventory managed at your cath lab? Our inventory is managed by Judy Fansler. The purchasing of equipment/ supplies is done through a new products committee, which consists of physicians and administrators who review products and supplies, and make recommendations for product trials. Has your cath lab recently expanded in size and patient volume, or will it be in the near future? Our volume of peripheral cases has increased by 400% from 2005 to 2006. Is your lab involved in clinical research? We are currently not involved in a research project, but have been in the past. Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? In calendar year 2005, there were 5 patients who went to coronary artery bypass graft surgery (CABG) emergently. All were diagnostic caths. One had a known dissection of the aorta, three had left main disease and one had a catheter-induced dissection of the left main. What other modalities do you use to verify stenosis? The modalities we use to verify stenosis are IVUS, the PressureWire (Radi Medical Systems), and qualitative analysis. What measures has your cath lab implemented in order to cut or contain costs? It is an ongoing process. Preferred contracts are utilized for DES and balloons. We collaborate with our two other hospitals concerning standardization of inventory. Staff are educated to make them aware of cost and help reduce waste. Our clinical manager, by working in the lab, and staff have come up with great ideas to decrease cost. What type of quality control/quality assurance measures are practiced in your cath lab? We do PI (performance improvement) every month. We have daily responsibility sheets for each lab. Bio Med supports and does quality control on our equipment. Data is submitted to the American College of Cardiology and EP/ICD registry. Quality assurance is done for JCAHO and we have a cardiovascular scorecard to measure outcome indicators. How does your cath lab compete for patients? Has your institution formed an alliance with others in the area? There are three hospitals that are part of the Mount Carmel Health System (Mt. Carmel East, West and St. Ann’s) and the health system is a member organization of Trinity. There is currently an initiative to develop general practitioners in order to funnel more patients into specialty areas. Also, the organization is in the process of hiring physicians to improve collaboration and ownership. How are new employees oriented and trained at your facility? New employees have a 90-day orientation with a primary and secondary preceptor. Orientation may not be 90 days if the employee has had prior cath lab experience. The licensure required is RN, RT and RCIS for our CVTs. What type of continuing education opportunities are provided to staff members? We have lunchtime inservices that offer CEUs. We also have been able to access CEUs online from our vendor websites. The hospital also offers online CEUs that are currently only for RNs. How do you handle vendor visits to your lab? All vendors/suppliers are required to meet vendor certification requirements. Vendor badges are issued with a 1, 2 or 3 level of access to patient areas. Vendors must sign in with Safety and Security and their schedules (for cath lab) are controlled by Karen Holt, Department Director. How is staff competency evaluated? Staff competency is evaluated yearly by administrative observation, by online testing and ongoing continuing education. There is a Skills Evening once a year, with a main speaker. Vendors are present to go over new products and to review existing products with staff. Does your lab utilize any alternative therapies (such as guided imagery, etc.)? Our cath lab does not currently use any alternative therapies. How does your lab handle call time for staff members? Call is taken on a nightly basis Monday thru Thursday. On-call is for all shifts over the weekends. Three people take call, a mix includes at least one RT and one RN. Our shifts are 10 and 12 hours. We do not have flex time, but the staff currently self-schedule. This summer we will be implementing an automated scheduling system for all staff members. What trends do you see emerging in the practice of invasive cardiology? Use of multi-slice CT is one emerging trend. Also, there is a trend of fewer patients going on to open heart surgery and decreased restenosis rates since the introduction of DES. Another emerging trend is carotid stenting in the cath lab setting and outpatient PCIs. Has your lab has undergone a JCAHO inspection in the past three years? Yes, our lab underwent a JCAHO inspection in 2005. Our main focus was on medication dispensing and labeling. This mainly concerned those medications given by the physicians during cath lab procedures, i.e., lidocaine, heparin, IC NTG, IC nipride, IC adenosine, etc. We also needed to make sure the H&Ps were current within 30 days of admission and were updated within 24 hours of a procedure. In order to comply with these changes, critical analysis of the institution’s current practice was implemented. This included review of current practices and policies. We also got physician leadership involved. We maintain constant readiness by quality control of radiation safety, and weekly chart review concerning H&Ps and physician findings. Where is your cath lab located in relation to the OR department, ER, and radiology departments? The cath lab is located directly above the OR and ER. Our helipad is directly above us. Radiology is located in another section of the hospital Please tell the readers what you consider unique or innovative about your cath lab and its staff. Mt. Carmel West Cath Lab provides a wide variety of services and is able to treat complex cases. Our main goal is to take care of the patient and to treat them as an individual instead of a number. All our heart services are located on the same floor in order to optimize the patient’s overall experience from admission to discharge. The staff do their best to work with the physicians to provide quality of care for the patient. We enjoy the type of work that we do and find satisfaction in the outcomes. Self-scheduling is done as one way of trying to provide work-life balance for staff. Is there a problem or challenge your lab has faced? How was it addressed? In November of 2003, the East campus started doing PCIs. At that time, our lab lost about half of our business. We then began promoting our peripheral program, which has since increased by 400%. We have also recruited vascular surgeons. 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? We are unique in that we have one of the country’s largest universities (Ohio State University). We are in a very competitive health care environment between other major health care organizations. There are smaller community hospitals in surrounding areas that are now starting cardiology programs. These programs have cut into our cardiac patient business. Teri Schmidt can be contacted at TSchmidt@mchs.com The Society of Invasive Cardiovascular Professionals (SICP) has added two questions to our spotlight: Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? Do staff receive a bonus or raise upon passing the exam? Our CVTs are required to pass the RCIS. We also have one RN who has passed RCIS. Are your clinical and/or managerial team members involved with any professional organizations that support the invasive cardiology service line? No.

NULL