Spotlight: Albert Einstein Medical Center

Tell us about your institution and cath lab. 

Einstein Medical Center (EMC) has a 150-year history of serving the Philadelphia community and is one of the largest, most comprehensive healthcare providers in the region. The cath lab is part of the Einstein Heart and Vascular Institute, which is a complete multi-disciplinary cardiovascular service line including cardiology, cardiothoracic surgery, endovascular medicine, and vascular surgery. Our cath facility consists of four labs: one coronary single-plane lab, one single-plane endovascular lab, and two state-of-the-art hybrid labs. 

What is the size of your cath lab facility and number of staff members? 

We have 18 full-time staff members serving the holding area and four cath labs. They comprise an experienced clinical team of 10.0 FTE registered nurses (RN) and 8.0 FTE cardiovascular technologists (CVT) holding additional certifications (RCIS). Our clinical team’s experience ranges from 1 to 25+ years and we continue to train RN and CVT students with observerships and clinical rotations. The interventional cardiology physician team includes 5 board-certified interventional cardiologists that are fellowship-trained in coronary, structural, and endovascular medicine.

What procedures are performed in your cath lab?  

We perform the entire spectrum of diagnostic and interventional coronary, structural, and peripheral procedures via radial, brachial, jugular, femoral, and tibial access. Procedures include right and left heart catheterization; coronary angiography, balloon angioplasty and stenting; coronary chronic total occlusion (CTO) interventions; rotational, orbital, and laser coronary atherectomy; cutting and scoring balloon angioplasty; rheolytic and mechanical thrombectomy; intravascular ultrasound (IVUS), optical coherence tomography (OCT), and fractional flow reserve (FFR); intra-aortic balloon pump (IABP) and percutaneous left and right ventricular assist device (VAD); pericardiocentesis and endomyocardial biopsy; percutaneous closure of atrial septal defect (ASD), patent foramen ovale (PFO), patent ductus arteriosus (PDA), and ventricular septal defect (VSD); alcohol septal ablation; aortic and mitral balloon valvuloplasty; transcatheter aortic valve replacement (TAVR); left atrial appendage (LAA) exclusion; peripheral arterial atherectomy, angioplasty, and stenting; angioplasty and stenting of carotid, upper extremity, aortic, renal, mesenteric, and lower extremity vascular beds; endovascular thoracic and abdominal aortic aneurysm (AAA) repair; superficial venous radiofrequency ablation; deep venous stenting; inferior vena cava (IVC) filter placement and retrieval; and thrombectomy for deep venous thrombosis (DVT) and pulmonary embolism (PE). We perform in the range of 70-80 procedures each week.

Can you share your experience with TAVR thus far? 

We perform TAVR weekly in our hybrid cath lab. It is a team approach between interventional cardiology, cardiothoracic surgery, echocardiography, anesthesia, and cath lab and surgical staff. We have performed 70+ TAVRs at our facility and over 100 between our facility and other campuses.

What is your percentage of normal diagnostic caths?

Less than 50% of our coronary angiograms are normal diagnostic caths.

Do any of your physicians regularly gain access via the radial artery?

Access is determined primarily on an individual case basis, specifically catering to the patient’s needs, requests, and best outcome. About 50% of our coronary cases are performed via transradial access.

If you are performing peripheral vascular procedures, do any operators utilize pedal artery access when appropriate?

Our endovascular physicians are highly experienced in pedal and tibial artery access, utilizing them routinely for complex and limb salvage cases. Furthermore, they host training courses for pedal access and complex peripheral interventions for other physicians. 

Who manages your cath lab? 

Our cath lab is managed by a physician medical director and a nurse administrative manager. The medical director works closely with the nurse manager to handle the administrative duties for the cath lab. The clinical manager for the lab works closely with the staff to handle all the day-to-day issues and concerns for efficient running of the lab. 

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

Some of our RNs are cross-trained to scrub and monitor. The remaining RNs are in the process of being cross-trained. Our CVTs are all trained to scrub and monitor. The RNs circulate and administer medications. We also have interventional and general cardiology fellows who scrub into cases, which frees up the CVTs to perform additional supportive duties.

Are there licensure laws in your state for fluoroscopy?

Pennsylvania does not have fluoroscopy licensure laws.

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 fellows generally control fluoroscopy, occupy the assisting position, change imaging angles, and pan the table. The scrub CVT is also available to assist with these duties when the fellow is not available.

How does your cath lab handle radiation protection for the physicians and staff?

Radiation protection for the cath lab personnel includes annual radiation safety training, radiation badges that are monitored monthly, and posting radiation exposure every month. All operators are provided customized lead aprons, thyroid collars, and lead glasses as needed. Each room has an adjustable lead shield on a boom, and a portable lead skirt for use under the table. Furthermore, portable lead shields are also available for use by the circulating RN.

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

Einstein has maintained its position at the forefront of cutting-edge technology with two state-of-the-art hybrid cath labs, and integrated IVUS, OCT, and FFR assessment capabilities. We recently became one of the few sites in the region to purchase the CorPath robotic percutaneous coronary and peripheral intervention system (Corindus) to improve accuracy and minimize radiation exposure. Our array of novel endovascular devices includes OCT-guided chronic total occlusion crossing and atherectomy devices to further minimize contrast and radiation exposure. 

How does your lab communicate information to staff and physicians to stay organized and on top of change?

Technology is everchanging with emerging new data from new clinical trials. A weekly staff educational conference with cath lab fundamentals, daily huddles with the cath lab team at the beginning of the day, communication boards with notification of novel technology, and monthly unit-based council meetings are some of the ways of keeping everyone apprised of change.

How is coding and coding education handled in your lab? 

The physicians and staff are trained to code the procedures performed during each case for accurate documentation. However, final coding for procedures is handled by a separate institutional billing department.  

Who pulls the sheaths post procedure, both post intervention and diagnostic? 

Hemostasis is typically attained using closure devices after most diagnostic and interventional cases. We currently use Angio-Seal (Abbott), Perclose (Abbott Vascular), Starclose (Abbott Vascular), and Mynx (Cardinal Health) for femoral access, and VascBand (CHS Interventional) or TR Band (Terumo) for radial access. Occasional sheaths post-procedure are pulled by fellows, although some staff are trained for sheath removal and radial band removal.

What kind of training is mandated before someone can pull a sheath?

Current protocol for sheath removal includes observation, proficiency with proctored removal, quota for independent removal, and checklist with policy and procedure.

Where are patients prepped and recovered (post sheath removal)? 

Our cath lab has a 14-bay holding area. Most outpatient sheaths and radial compression devices are removed within this holding area and the patient is discharged directly from the bay. 

How does your lab handle hemostasis?

Hemostasis is primarily achieved using closure devices, as mentioned above. Outpatients are discharged directly from the holding area, while inpatients are monitored in the cardiac interventional care unit on telemetry post procedure.

How is inventory managed at your cath lab?  

We have a dedicated inventory manager and a full-time inventory assistant staff member.

Who handles the purchasing of equipment and supplies?

Our purchasing department for the hospital handles all contracts and pricing. Ordering is performed by our inventory manager for re-orders of existing supplies and by the purchasing department for new equipment.

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

We just recently opened our 4th state-of-the-art hybrid cath lab in January 2017, and completed renovation and expansion of our holding area and inventory storage.  

Is your lab involved in clinical research?

Einstein Medical Center continues to be at the cutting edge of research and science for patient care by participating in a variety of clinical trials. We are currently involved in a total of 14 trials within the interventional cardiology department with the help of three full-time, experienced research coordinators.

Can you share your lab’s average door-to-balloon (D2B) times and some of the ways employees at your facility have worked together to keep D2B times under the mandated 90 minutes? 

Our cath lab has an average D2B time of 70 minutes. We maintain the standard of 90 minutes or less by having a strong partnership with the emergency department (ED), facilitating education for local EMS teams and by reviewing the ACTION registry Executive Summary for quality outcomes. We are registered with the American Heart Association: Mission Lifeline and receive the quarterly Mission Lifeline report.

Who transports the ST-elevation myocardial infarction (STEMI) patient to the cath lab during regular and off hours?

The ED team brings the STEMI patient to the lab. If the patient is an inpatient, the cath lab staff assists in the transport of the patient to the lab.

What do you do when the call team is already busy doing a procedure and a STEMI comes into the ED?

Our current priority is to safely complete the case on hand, while stabilizing the STEMI patient in the ED. The STEMI patient is then transported to the first available lab.  

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

Our lab is one of the few to implement a perpetual inventory system utilizing a bi-directional interface between our centralized enterprise resource planning (ERP) system (Lawson), and our clinical hemodynamics system (GE Centricity, GE Healthcare). This systematic interface helps us to manage the labs within our ERP system, and provides an abundance of data to help improve demand forecasting, utilization trends, cost per case, automated reorder points, intra-departmental logistics, and much more. At any point, we can develop and review advanced reports that give us visibility for where we can focus our efforts for improvements related to containing, and often cutting, costs. We also have a hybrid team comprised of system developers, CVIT professionals, supply chain administrators, and department representatives to work towards improving our current technology, and adding new features to our interface in order to push our data collection and analysis capabilities a step further. 

Every month, we also have our value-analysis committee meeting, and discuss new products and areas for inventory improvement with cardiology administration, physicians, and purchasing and contract management representatives. With all of the data readily available, we are able to have productive discussions on inventory that has accumulated over time and not getting used due to emerging technologies, products, and clinical techniques that evolve over time.

What quality assurance measures are practiced in your cath lab?

Recent changes in the cath lab and quality/compliance leadership created an opportunity for a great partnership. This collaboration allowed the cath lab team to maintain quality assurance measures that were already in place, such as meeting the <90-minute door-to-balloon time. It also presented the opportunity to create new measures such as monitoring and reducing peri-procedural vascular complications.

Are you recording fluoroscopy times/dosages? 

Our cath lab records both fluoroscopy times and radiation dosages for every case. We record mGy as well as DAP for fluoroscopy. It is recorded and documented in the GE case report.

What is the process that occurs if a patient receives a higher than normal amount of radiation exposure? How is the patient notified and what follow-up do they receive?

After 30 minutes of fluoro or 5 Gy exposure, the physician is notified. We document every 15 minutes thereafter in the chart. The patient is also notified and educated by the physician. The dose is noted in the patient chart, as well as the GE report. High exposures result in the patient being brought back for follow-up and close evaluation.

Who documents medication administration during the case?

The RNs document medications administered during the case.

Are your physicians dictating their cath procedure reports, or do they use a structured reporting tool?

Our physicians currently use dictations for their reports, but we are in the process of moving towards structured physician case reporting.

Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) or any other outside data collection registry?

We use the ACC-NCDR to capture our cardiac cases, including LAAO, ACTION, and TAVR registries. We also use Lumedx to capture the CATH/PCI registry due to its analytic capabilities, which we have found to be of great value.

How are you populating the registry data records? Who inputs the data, and is any of it accomplished through in-lab systems?

The data for all the registries is collected and populated manually. There is no ADT feed that provides any transfer of data. The clinical data analyst team is comprised of 5 RNs (2 of the RNs are full time, and 2 are per diem, in addition to the manager, who abstracts approximately 20% of the time). 

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

The cath lab has a referral base by which patients enter into our system via referrals from primary care physicians, referring cardiologists, and our interventionalists who see patients in the office. 

How are new employees oriented and trained at your facility?

New staff members attend hospital orientation, followed by one-on-one training and orientation with a preceptor. They traditionally have a 12-week orientation period, but it is modified as needed, based on performance during that period. 

What continuing education opportunities are provided to staff members?

We have weekly educational conferences for the cath lab staff by our attending physicians and fellows. There are many other opportunities for education, both within our facility as well as through sponsored medical conferences. 

How do you handle vendor visits to your lab? 

Vendors are scheduled through a vendor calendar. We prefer only a single representative per area visit per day (for example, 1 peripheral, 1 cardiac, 1 electrophysiology). They must be credentialed and verified through VendorMate upon arrival. Additional vendors are allowed on a daily basis per physician request for support of cases.

How is staff competency evaluated? 

Staff competency is assessed utilizing annual evaluation by managers. We have a plan to move toward peer review.

Does your lab have a clinical ladder?

At this time, the lab does not have a clinical ladder in place. There are opportunities for RNs and CVTs to receive monetary compensation for obtaining specialty certifications.

Does your lab have any physical (layout) bottlenecks or limitations? 

With continued growth, we could use a larger holding area. Patient volumes on busy days overwhelm our holding area bays. Same-day patients and discharges also hold up bays. Furthermore, bed availability in the hospital can also delay turnover of bays.

How does your lab handle call time for staff members? 

Call time is currently from 6 pm to 7 am. We use at least 1 RN and 1 CVT, and the third staff person on call can be either an RN or CVT. We are flexible with our staff with late night and early morning call-ins. We often offer the opportunity to leave early, go home, or come in late after a call in the late night and early morning call-ins on weekdays.

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

We have a mandatory 30-minute response time.

Do you have flextime or multiple shifts? How do you handle slow periods?

We have recently transitioned to 7:30 am to 6 am for our scheduled staff in our procedural area. Our holding area has 2 shifts: 6:30 am-5:00 pm and 7:30 am-8:00 pm.  This facilitates early arrival of patients to the holding area to prepare for the procedure, and covers late discharges and any issues waiting for beds for patients. During slow periods, staff is expected to organize equipment and rooms, check expiration dates and ensure product is stocked and properly rotated, coordinate education and training, and they also have the option to use paid time off (PTO) and go home.

Has your lab recently undergone a national accrediting agency inspection? 

We successfully passed the Joint Commission inspection with the rest of the institution.  We follow majority of the operating room standards of care.

Where is your cath lab located in relation to the operating room (OR) and ED? 

We are located on the second floor of the Heart and Vascular Center. The OR is located in the adjoining building on the fourth floor. The ED is located on the ground floor in another adjacent building. All of these buildings are internally connected for efficient patient transport. 

What trends have you seen in your procedures and/or patient population? 

Trends of increasing cardiovascular disease around the country are replicated within our community. Furthermore, being located in an under-served inner city community, Einstein Medical Center has seen trends of increasingly complex and advanced cardiovascular disease.

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

The cath lab staff at Einstein Medical Center is comprised of highly technically skilled personnel. They are very motivated and work well with the physicians as a team to take care of some of the most complex patients in the hospital.  

Is there a problem or challenge your lab has faced? 

Due to our geographic location and the demographics of the community, we are challenged with hiring consistent adequate staff that is able to respond within the 30-minute response time for emergent cases. We, therefore, also rely on highly skilled contracted staff and a local staffing solution partner to keep adequate staffing numbers to meet the demands of the lab.

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 serve a population of people that includes multi-cultural and economically diverse subsets. We also serve an underprivileged community that often has limited access to primary care. These factors keep us acutely aware of the importance of creating a culture of acceptance, understanding, teaching, and patient advocacy. 

Two questions from the Society of Invasive Cardiovascular Professionals (SICP):

1. Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? Does staff receive an incentive bonus or raise upon passing the exam?  

An RCIS credential is currently a requirement to maintain position as cath lab staff. If a new hire is not RCIS certified, they have 1 year to obtain certification. There is a certification bonus of $500 given annually to staff who are RCIS certified. 

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 managerial team members are encouraged to be involved with interventional societies such as American College of Cardiology (ACC), Society for Cardiovascular Angiography and Interventions (SCAI), and the Society of Invasive Cardiovascular Professionals (SICP) at the local, regional, and national levels.  

A question from the American College of Cardiology’s National Cardiovascular Data Registry: 

How do you use the NCDR Outcome Reports to drive quality improvement initiatives at your facility?

Quality and process improvement initiatives within our service line are formed from the quarterly outcome reports that we receive. The quarterly reports are reviewed in depth by way of set monthly meetings. These meetings include the division chair, attending physicians, the cath lab manager, the service line administrator and the quality & compliance manager. By identifying the metrics that fall below the U.S. 50th percentile, it gives our team an opportunity to prioritize the outliers, put a process in place for improvement, and set a timeline for reassessment.

The authors can be contacted via Jon C. George, MD, at jcgeorgemd@gmail.com.