Spotlight: Appalachian Cardiovascular Associates

What procedures are performed in your cath lab?  

• Left heart cath
• Left ventriculogram
• Right heart cath
• Abdominal aortography with and without runoff
• Temporary pacemaker
• Peripheral atherectomy
• Peripheral angioplasty with and without stent placement
• Intravascular ultrasound (IVUS)
• Renal angiography selective (unilateral or bilateral)
• External pacing
• Venogram with or without iliocaval stent placement

Currently, we perform 8 to 10 procedures per week.

What is your percentage of normal diagnostic caths?

Approximately 20%.

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

We currently offer radial and femoral artery access. Our lab has adopted a “radial first” philosophy, allowing our patients a safer procedure, and more comfortable and shorter recovery.

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

Yes, our physician has utilized ultrasound-guided pedal artery access when over the horn or antegrade access was unavailable.

Who manages your cath lab? 

Shari Hill, RN.    

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

We do have cross-training. Our goal is for everyone to scrub, circulate, and monitor within their scope of practice. Currently our technologists monitor, and our RNs scrub and circulate.    

Are there licensure laws in your state for fluoroscopy?

No. We voluntarily perform radiation physics testing and report to the state Bureau of Radiation Control.

Which personnel can operate the x-ray equipment in your cath lab? 

• Position the II – physician or scrub
• Pan the table – physician or scrub
• Change angles – physician or scrub
• Step on fluoro – physician

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

Each staff member is required to wear a dosimetry badge to monitor radiation dosage. All staff wear lead aprons and thyroid collars to aid in shielding. We also use RadPad products (Worldwide Innovations & Technologies, Inc.) to reduce radiation scatter to staff. All staff are required to take an occupational radiation test annually.

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

We have recently adopted the radial-first philosophy, and so have acquired a Rad Board (Merit Medical) and have started using the PreludeSYNC radial compression device (Merit Medical) for hemostasis.    

How is coding and coding education handled in your lab? 

We utilize off-site coding. The physician takes coding classes, and we are part of an accountable care organization (ACO) that helps us keep on top of changes to codes and coding rules. 

Who pulls the sheaths post procedure? What kind of training is mandated before someone can pull a sheath?

All staff members are trained to pull sheaths. The training process includes: observation of seasoned staff members, performing sheath pulls with direct supervision and then demonstrating competency to allow for solo sheath pulls.

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

We have a 5-bay pre and post area. We use a combination of vascular closure devices and manual pressure post procedure. One RN and one medical assistant remain with the patient at all times.

How is inventory managed at your cath lab? 

Charity Nute, RN, and Shari Hill, RN and manager, currently handle inventory. They are involved in all of our procedures, so they know which products are used, and can reorder within 24 hours. Our plan is to move to a software system for inventory control.

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

Our lab opened in late 2016 and has had a steady increase in volume. We expect that trend to continue and we have room for expansion as we continue to grow.

Is your lab involved in clinical research?

Not at this time; however, this is something we are interested in for the future.    

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

Most of the products we use are on consignment. Products that are not consigned are monitored closely. We only stock what we intend to use within a 30-day period. We also work closely with our vendors to rotate products in order to prevent expiration issues.

What quality control measures are practiced in your cath lab?

We currently monitor fluoro and contrast dosages, patient complications, patient satisfaction, and patients transferred for intervention. We also perform daily checks on equipment as part of our quality assurance process. Each of our patients receive a follow-up call 24 hours post procedure to evaluate outcomes and answer any questions the patient may have.

How do you determine contrast dose delivered to the patient during an angiographic procedure?

The ACIST system reports total contrast delivered per case. We calculate creatinine clearance (CrCL) and obtain a glomerular filtration rate (GFR) prior to every case to plan maximum dosage. We utilize a renal insufficiency protocol. We have not had any incidence of contrast-induced nephropathy (CIN) due to rigid adherence to the renal insufficiency protocol (Figure 6).

How are you recording fluoroscopy times/dosages? 

The x-ray system reports radiation exposure per case. We currently use our Mac-Lab system to document the amount of fluoro used during each procedure.

Who documents medication administration during the case?

The RN verbalizes the medication and dosage given. The monitor technologist then documents this information in the Mac-Lab report.

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

Currently, procedure reports are documented using an original template designed by Dr. Sanjeev Saxena. We are in the process of switching to a fully integrated scheduler, electronic medical record, and PACS software system. With the new system, data is populated in the procedure report during the case. When the procedure is complete, the software automatically generates a “plain English” report with images that can be emailed to the referring physician. 

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

Not at this time.

How does your cath lab compete for patients? 

We use multiple advertising techniques and reach out to referring physicians.    

How are new employees oriented and trained at your facility? 

Each new employee is assigned a “starting position”, either scrub technologist, monitor technologist, or circulator. They will be trained until competent at that position before cross-training to the next position. There are initial and annual competencies that must be completed, and basic life support (BLS) and advanced cardiac life support (ACLS) are expected within 6 months of hire.   

What continuing education opportunities are provided to staff members?

We are currently working with vendors to help provide CEUs for our different disciplines.

Are your clinical and/or managerial team members involved with any professional organizations that support the invasive cardiology service line, such as the Alliance for Cardiovascular Professionals (ACVP) or regional organizations?

Our manager, Shari Hill, is a current member of the ACVP.

How do you handle vendor visits to your lab?

Vendors make appointments prior to their visit. They must also check with the physician prior to entering the lab.

How is staff competency evaluated? 

The orientee will observe and perform the designated task multiple times with a trained staff member. After demonstrating competency, the orientee can then perform the task unsupervised.

Does your lab have a clinical ladder?

We currently do not have this in place. With one shift, and one crew, we have sufficient staff to perform cases, and we hire personnel with appropriate skills and training. 

Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? 

While we do not require staff to obtain RCIS certification, all team members are compensated according to their credentials and experience levels.

What do you like about your facility’s physical space? 

We have a very large procedure room with state-of-the-art equipment, which is well lit with LED lighting, an ionic air purification system, and emergency backup generator. The facility itself is decorated in muted rust and mustard colors, with an Asian art theme throughout.  

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

We currently have one shift for cath procedure days. All staff are cross-trained to assist with patients and other procedures in our practice. On slow procedure days, they help wherever there is a need.

Do staff members have any little or big particular perks that you might like to share? 

Free lunch on procedure days and sponsored travel to a yearly conference are a few of our perks.

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

We have been performing an increased number of venous cases for non-thrombotic iliac vein compression syndrome. This syndrome has long been undiagnosed in many individuals. We are seeing great success with this treatment. 

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

• Our lab is one of five outpatient vascular labs in Alabama.
• Our lab is the only outpatient facility in Alabama performing coronary angiograms. This is because we have a fixed ceiling mount system, not just a mobile C-arm.
• Our staff members offer multiple levels of experience. All are motivated, and willing to learn.

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”?

Fort Payne is located in a beautiful mountain valley in northeastern Alabama. The home of famed country music group “Alabama”, Fort Payne is the location of the band’s fan club and museum. Alabama and Mississippi rank 49th and 50th in education and 1st and 2nd in diabetes and obesity in the U.S. Our staff makes a concerted effort to provide patient teaching regarding healthy cooking and lifestyles.