Spotlight: Boulder Community Health

Tell us about your cath lab. Is it part of a cardiovascular service line?  

Yes, we are part of a cardiovascular service line that includes Interventional Cardiology, Electrophysiology, Echo, Structural Heart, Open Heart Surgery, Heart Failure, Cardiac Rehab, and a cardiology physician practice that includes all of the physicians for the above programs. 

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

We are a community-owned regional health system with a 2 cath labs (one of which is a hybrid room), and an electrophysiology (EP) lab. Cath lab staff credentials include a mix of critical care registered nurses (CCRN), RNs, registered cardiovascular invasive specialists (RCIS), and radiologic technologists (RT[R]) registered with the American Registry of Radiologic Technologists (ARRT). EP staff credentials are a mix of RN, RCIS, RT(R), and certified electrophysiology specialists (CEPS). Our staffing longevity is well balanced. We have some team members who have worked in our lab for 15 years, others who have only been here a year, and the rest cover the span between.

What procedures are performed in your cath lab? 

Left and right heart catheterizations, endocardial biopsies, fractional flow reserve (FFR), intravascular ultrasound (IVUS), transcatheter aortic valve replacement (TAVR), balloon valvuloplasties, intra-aortic balloon pump (IABP), Impella (Abiomed), peripheral diagnostics and interventions, permanent pacemaker implant (PPM), implantable cardiovascular defibrillator (ICD), biventricular ICD, EP studies and ablations, including cryogenic ablation for atrial fibrillation (afib), radiofrequency ablation for afib, supraventricular tachycardia (SVT), AV nodal reentrant tachycardia (AVNRT), atrial flutter, and ventricular tachycardia (VT). We will have the WATCHMAN left atrial appendage closure device (Boston Scientific) and MitraClip (Abbott) at the beginning of 2018. 

Can you share more about your center’s structural heart program? 

The structural heart program started in October 2017 with TAVRs and balloon aortic valvuloplasties. We were fortunate to bring in a highly experienced structural heart medical director, Dr. Sirinivas Iyengar, to start the program, so the program’s implementation has been relatively smooth and our first case was well ahead of target. The cardiovascular surgeon is part of our physician group and was actually one of the key drivers behind the creation of a structural heart program at Boulder Community Health. Having a unified front between the surgeon and the structural heart director has really made for a smooth implementation. The cath lab already had a well-established and supportive relationship with anesthesia, the OR staff, and the cardiovascular surgeon, so we were able to avoid the OR/cath lab rivalry that some facilities face.

What is your percentage of normal diagnostic caths?   

As part of our quality control measures, the team reviews the indications and documentation prior to the procedure. Involving the staff in the appropriate use criteria (AUC) review helps ensure compliance, as well as gives the whole team a better understanding of the patient. This focus keeps our number of diagnostic caths low.

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

Yes. One of our physicians has been primarily radial for over 15 years. This has helped us to move forward and we are at about 75% radial.

Who manages your cath lab?  

We have an RN manager that manages cath, EP, echo, and the Cardiovascular Center, which is our pre/post area.

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

We always have one RN circulating, one RCIS/RT(R)/RN at the table and the monitor person can be either. We currently have two RNs who also scrub.  

Are there licensure laws in your state for fluoroscopy?  

No.

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 RCIS/RT(R)/RN at the table can do all of these.

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

We have an in-house physicist who oversees all radiation protection and education for staff, physicians, and patients.  

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

We have been focusing on the new equipment needed to build our structural heart program.

How is coding and coding education handled in your lab?  

We have a coding department and semi-annual coding reviews.

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

Closure devices are deployed in the labs. Manual pulls are performed by the staff. The majority are pulled in our Cardiovascular Center by the RNs there and the intensive care unit (ICU) RNs will pull the sheaths for their patients. 

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

We have a mix of observation, skill labs, and didactic training. Once training is complete, the new staff must meet the required supervised sheath removals before being signed off as competent to pull on their own.

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

We have a very dynamic and skilled Cardiovascular Center. This area preps and recovers our patients, including post anesthesia EP patients, as well as performs cardioversions, transesophageal echocardiograms, and other similar cardiac procedures. They also manage patients with sheaths and sheath removal. We do use closure devices unless restricted by anatomy or if we need to keep the vessel free for upcoming large-bore access (such as TAVR).

How is inventory managed at your cath lab? 

We manually manage the inventory with the assistance of our cardiovascular information system (CVIS) reports. Materials management places the orders with the vendors.

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

An expansion of our services to include structural heart is expected to grow the program.

Is your lab involved in clinical research? 

Not at this time.

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? 

We have worked with emergency medical services (EMS) and they are able to directly alert the emergency department for suspected ST-elevation myocardial infarctions (STEMIs). The ED can call the cardiac alert prior to the patient’s arrival. After hours, the interventional cardiologist and cath lab team are paged. 

Who transports the STEMI patient to the cath lab during regular and off hours? 

This is performed by the cath lab team.

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

This happens very infrequently. We do have an Administrative Resource Nurse on staff who helps us problem-solve in these situations and we have also called in our own staff that we knew were available. One of the benefits of a tight, close-knit team is knowing who is available.

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

We work closely with our vendors to optimize our pricing. We also work to consign as much as possible and adjust our par levels of items whenever possible. We are also part of a national buying group, which can help us keep our costs down.

What quality control measures are practiced in your cath lab?  

Physicians hold cath conferences weekly, and morbidity and mortality (M&M) meetings monthly. Physicians use these as a forum to present complex cases for peer input on plan of care as well as for review of all M&M cases. Anyone can refer a case for review. We also audit and track all patients for complications, and present any trends that need to be addressed.  

How are you recording fluoroscopy times/dosages?  

We have dose mapping and dose tracking on all of our systems. Our physicist is automatically notified of any cases that exceed thresholds.

What is the process that occurs if a patient receives a higher than normal amount of radiation exposure? 

The physicist reviews the case, and both the physician and patient receive a letter documenting this occurrence.

Who documents medication administration during the case? 

The circulating RN.

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

They use a mix of dictation and templated notes in our emergency medical record.

Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR)? 

Yes. Currently, the registry data is input manually, but we are moving toward some auto population of records.

What continuing education opportunities are provided to staff members? 

Vendors provide education, as do our physicians, and as our budget allows, staff attend conferences, including the Transcatheter Cardiovascular Therapeutics (TCT) conference.

How do you handle vendor visits to your lab? 

All vendor visits must be scheduled with the manager. Those representatives that support cases are allowed in the lab and the rest are only allowed in our meeting room. We do have restrictions on the number and frequency of these visits. Vendors are only allowed if we currently carry their products, unless we have requested information on a new product.  

How is staff competency evaluated? 

We use competency-based occupational standards (CBOS) and annual competencies.

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

No. All staff must be licensed, but it can be as an RN, RCIS, or RT(R).

How does your lab handle call time for staff members? 

We always have an RN, an RCIS/RT(R), and the third can be either. The staff is welcome to adjust their hours as long as staffing allows. We recognize the importance of work/life balance. We can’t control when the pager goes off or how long the days will be, but we can allow people to come in later, leave earlier, or take the day off, as long as the cases are covered.  

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

Our policy is 30 minutes, but most staff prefer to arrive within 20 minutes.

Do you have flextime or multiple shifts? 

We are primarily a 10-hour day lab. 

How do you handle slow periods?   

We have a team that loves to work, but also loves to get out and do things. We always have people willing to leave when it is slow.

Where is your cath lab located in relation to the OR and ED?  

We were fortunate to be involved in the design of this facility. We are in close proximity to the OR, ICU, and progressive care unit (PCU). The OR room designated for open heart surgery is just across the sterile hallway and the ED is directly below us. 

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

We have the honor of serving a highly educated and very active population, so much so that our vision statement emphasizes that we are “Partnering to create and care for the healthiest community in the nation”. Most of our patients do their research prior to their procedures and are highly involved in their care. The active, healthy lifestyle here in Boulder does impact the disease processes we see; for example, we see more “athletic hearts” than peripheral disease.  

Is there a problem or challenge your lab has faced? 

There is no shortage of cath labs in the Denver metro region. This, coupled with the increasing cost of living in the area, has made it a bit more challenging for us hire in certain departments, like our cath and EP labs. Fortunately, over the past two years, our organization has prioritized offering more competitive recruitment and compensation packages, which has enabled us to fill these open positions with great employees.

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

The staff are really what makes us unique and sets us apart. We have been able to be highly selective in our hiring process to ensure everyone we hire really adds to the team.  We have a very intelligent and invested group of professionals who take pride in their work and care about their patients. But just as important, they truly care about each other.  We love what we do and this is reflected in the care our patients receive.  

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”?  

Boulder definitely has a strong culture and those that live here really want to be here.  This directly impacts the culture of the lab. We enjoy our time at work as well as outside of work. We all appreciate the outdoors and what life here has to offer, and work hard to support each other’s endeavors to do so. We moved to 10-hour shifts to allow everyone a day off during the week and to increase the number of people covering call. We allow the team to do their own scheduling, including call and vacations, and everyone is very supportive if someone needs to make a change. You can also see the Boulder culture reflected in our physician relationships. We work closely together, and value each other’s opinions and insight. This creates a very interactive and open environment for learning.  As a community hospital, we also have the opportunity to know and work with the management team, all the way up to the CEO.