Spotlight: Durham VA Medical Center

The authors can be contacted via Dr. Sunil Rao at sunil.rao@duke.edu.

Tell us about your cath lab.

We currently have two procedure rooms, one of which is dedicated to electrophysiology (EP) procedures. Our staff is cross-trained to work both cath and EP procedures. Our lab is staffed with 8 registered nurses (RNs) and 3 cardiovascular technologists. Five RNs hold certifications as CCRN and 1 technologist holds both the registered cardiovascular invasive specialist (RCIS) and registered cardiac electrophysiology specialist (RCES) credentials. Staff longevity ranges from 8 months to over 10 years.

Tell us about the procedures performed at your lab. 

The average number of procedures performed each week is 30 (we have only one cath procedure room). This number includes 

diagnostic cardiac catheterization and complex coronary intervention. We have the full array of diagnostic and interventional equipment including fractional flow reserve (FFR) (both wire and catheter-based systems), intravascular ultrasound (IVUS), rotational and orbital atherectomy, and hemodynamic support. In addition, we perform diagnostic and interventional EP procedures, including ablations of atrial and ventricular arrhythmias, atrial fibrillation, pacemakers, and internal cardiac defibrillators. 

Our cath lab is undergoing significant renovation in the next few months. We are currently not performing transcatheter aortic valve replacement (TAVR), but we are in the process of building a hybrid operating room. This will allow us to bring structural heart disease procedures to our veterans.

Does your cath lab perform primary angioplasty without surgical backup on site? 

This has been a program in evolution. Our hospital is across the street from Duke University Medical Center and all of our physicians also work at Duke. Duke has a very high annual ST-elevation myocardial infarction (STEMI) volume and some of the best outcomes in the country. Since our physicians also cover the Duke cath lab and take call, many STEMIs go directly to Duke, bypassing the VA hospital. We do, however, perform coronary artery bypass graft surgery (CABG) at the VA and our surgeons are Duke surgeons who, like our interventional cardiologists, work at both hospitals.

What percentage of your diagnostic caths is normal?

Approximately 10-15% of our angiograms are completely normal, with an additional 5-7% having insignificant disease.

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

Our lab is “radial first.” All of our operators perform transradial procedures. Over 95% of our procedures are transradial and we have the highest radial volume in the VA system nationwide.

Who manages your cath lab? 

Nicki Fryar, RN, MBA, MHA is the Cardiovascular Lab manager. Dr. Sunil Rao is the Cardiology Services and CV Lab Director.

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

All staff is cross-trained to scrub, monitor and circulate caths and EP procedures. Only RN staff is trained in the administration of medications. This allows us flexibility in those cases of unplanned absences, planned absences, and emergencies, etc.    

Are there licensure laws in North Carolina for fluoroscopy?

Not currently.

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? 

We have a very active fellowship training program at Duke, and both diagnostic and interventional fellows rotate through the cath lab. Our goal is to train them to be the best, so they are expected to set up the shots, inject the coronaries, and pan the table. Our staff is also trained to do this, so they often support the fellows who are early in their training.

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

We are very meticulous about radiation protection and adhere to Society of Cardiovascular Angiography and Interventions (SCAI) recommendations.  Aside from the usual “ALARA” principles of appropriate personal protection, wearing radiation badges, minimizing source-to-image distance (SID), and effective use of shields, we have established a practice in which the monitor staff person notifies the physician operator if the air kerma reaches 3Gy and again if it reaches 5Gy. At 5Gy, serious consideration is given to stopping the procedure, as long as it is safe for the patient.

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

We have been very proactive at keeping current with our equipment. We were the first VA cath lab in the country to have orbital coronary atherectomy. We have also recently brought in the ACIST Navvus FFR, which is a catheter-based FFR system that allows you to use any workhorse 0.014-inch wire. This is a nice addition to our ACIST contrast injection system, which has allowed us to reduce our contrast use per case by a third. In 2015, we are looking forward to renovating both of our procedure rooms with the latest imaging equipment, including an EP “cockpit.”    

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

We have a relatively small physician staff of 5 interventional cardiologists.  Communication of new equipment, protocols, or important issues is generally done through email. When important new data that may influence practice are published or presented, we get together either in person or virtually to discuss whether our current practice should change. We also have regular cath lab staff meetings to discuss new policies and procedures, as well as review any issues that have come up.

How is coding and coding education handled in your lab? 

We are a VA hospital and traditionally, coding was not a focus of our efforts. However, recent changes have forced us to be very attentive to coding. Every provider in the VA system now has their workload measured, and for physicians, this includes Relative Value Units (RVUs). The VA also aggressively bills private insurance when the veteran has it. This has been a steep learning curve for many VA physicians, but we are now very thorough in our documentation and completion of encounter forms. We rely on a variety of sources for information on coding and are trying to stay current.

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

The overwhelming majority of procedures we do are transradial, so there is no issue with sheath removal. For the rare transfemoral case, either our nurse/technologist staff pulls the sheath or the fellow pulls it. We have a specific competency for sheath removal and new nurses, technologists, and fellows are trained in it. Staff observes the removal of one sheath and are proctored for several sheath pulls until it is determined that the trainee has mastered the skill.  

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

Patients start their prep in our Interventional Recovery Unit (IRU), which also serves as a post-procedure recovery area. Initial screening of vital signs and general physical assessment is completed, as well as insertion of IV lines and marking the site of access. After the procedure, the patient returns to the IRU with the radial hemostasis device in place. Once the recovery period is completed, the patient is either discharged home or admitted as an inpatient. Our same-day discharge program includes selective PCI cases. 

How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies?

This is a complex process in the VA system, but it does work well. Regularly used equipment like catheters are purchased through materials management. Like other labs, we have par levels and orders are placed daily. Implantable devices, including coronary stents, are ordered through the Prosthetics department, and again, orders are placed daily. If there is a capital purchase that we would like to make, we apply to an acquisitions committee for approval. The VA has been very good in allowing us to bring new technology to better serve our veterans.    

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

Our volumes have been relatively stable over time and daily volume tends to be cyclical, with certain times of the year being much busier than others.

Is your lab involved in clinical research?

We are very involved in clinical research and participate in industry-funded, NIH-funded, and VA-funded studies. We currently are enrolling in two protocols that are VA-funded trials. We tend to enroll very well in studies because we are selective about which trials we will participate in. 

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

Costs are a huge issue in the VA system because all of the resources we use are funded by taxpayer dollars. We are very attuned to being efficient with the resources we have. Some of what we have done to curtail costs in the VA includes reducing wait times for cath by restructuring our scheduling. We can offer same-day or next-day service for veterans. We also started a same-day discharge program to free up inpatient bed availability. We use automated contrast injection to reduce our contrast usage and costs.  We also reprocess many different EP cables and have instituted bulk purchasing options as another way to save cost. In addition, as we mentioned, our lab is radial first, with >90% of our procedures performed via radial access. This has significantly reduced our complications, thus saving money. 

What quality assurance measures are practiced in your cath lab?

We have an ongoing program for quality improvement (QI) that is headed up by our staff. We also participate in case reviews on a regular basis. This program is integrated into the overall QI program within the VA system. All caths and PCIs performed in the VA are required to be entered into CART-CL, the national VA cath lab database, headed by Dr. John Rumsfeld. All VA cath labs must enter data into CART-CL. This is similar to the American College of Cardiology’s National Cardiovascular Data Registry (ACC-NCDR) and provides regular feedback reports on outcomes and processes of care. CART-CL provides 100% capture of all procedures being performed in the VA system, including diagnostic cath data as well as PCIs.

Are you recording fluoroscopy times/dosages?

The CART-CL database has a field to record both fluoroscopy time and DAP, and these fields are regularly filled out by our providers. In addition, cardiovascular lab staff record fluoroscopy time and dose in each procedural record.

Who documents medication administration during the case?

Every case has a nurse who records and documents medications into the procedure record, which ultimately gets recorded in the electronic medical record.

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

As a VA lab, we do not compete for patients in the traditional sense. There are so many veterans that need cardiovascular care in our network (VISN 6), that our volumes remain quite stable. We are, however, very keen on getting veterans care within the VA and try our best to transfer any veteran who is hospitalized in the private sector to the Durham VA. We are often limited by bed availability, but are actively working to find creative solutions.

How are new employees oriented and trained at your facility? 

New employee orientations are specific to the prior experiences of the new hire. As well, the new employee completes a self-assessment that assists in determining priorities for training and education. Each employee is assigned a preceptor that works with the new employee for the entire orientation. Nurse educators and the RN managers monitor the progress of each new employee. Competencies are completed and signed off by the assigned preceptor, educator, and RN manager. Orientation is generally completed in 3 months.    

What continuing education opportunities are provided to staff members?

We have provided yearly opportunities for staff members to attend off-site educational programs that provide CEU credits. We utilize our vendors to provide in-servicing on equipment, current trends, and updates. Our physicians provide education through cardiac cath conferences offered throughout the year.   

How do you handle vendor visits to your lab?

We utilize RepTrax vendor credentialing. Vendors check in at a designated area and receive an ID badge for that visit. Each vendor is required to make an appointment prior to arrival.      

How is staff competency evaluated? 

Staff receives a performance review annually. A competency-based tool outlines specific criteria for individual staff members to complete on an annual basis and it is reviewed by the nurse manager at completion. Staff can meet these competencies by performance of procedures, use of equipment, and/or self-learning packets/videos, with completion of a post test. As well, our vendors provide a review of low-use, high-risk equipment and procedures. Advanced cardiac life support (ACLS) is required of all RNs and CVTs in our labs.

Does your lab have a clinical ladder? 

We do not use a clinical ladder process, but we have instituted a Clinical Expert Recognition program for our nurses. It requires certification in their area of expertise or a master’s degree. A monetary reward is presented upon completion.

How does your lab handle call time for staff members? 

We are not a 24-hour cath lab, because our physicians also work at Duke, which is across the street. All STEMIs go directly to Duke, so our physicians take primary PCI call at Duke.

Do you have flextime or multiple shifts? 

No.

Has your lab recently undergone a national accrediting agency inspection? 

We have not undergone any private sector national accreditation process, because the VA has its own requirements for PCI programs. We do participate in Joint Commission inspections, as well as inspections by the Office of Inspector General.    

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

Our cath lab is on the 3rd floor of the VA hospital, which is where the majority of the cardiology services are located, with the exception of electrocardiogram (EKG). The ED is on the first floor, and the OR is on the 4th floor.

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

We have noted a significant increase in the complexity of coronary disease that we are seeing. Despite this, we have maintained our “radial first” approach. We have also noted an increase in the number of patients with congestive heart failure with or without valve disease.   

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

Our lab is unique in that our pre-procedure assessment process allows us to reduce the number of unnecessary or inappropriate procedures. All patients referred for cath are seen in a pre-cath clinic where they are evaluated for the appropriate tests, one of which may be a cardiac catheterization. During this visit, we also assess their suitability for prolonged dual antiplatelet therapy. All of this is documented in the medical record. Many of the patients seen in pre-cath clinic are also consented for their procedure, which allows our lab to function very efficiently. Our cath lab staff is unique because they do both cath and EP procedures. They are very efficient at patient turnover and it is routine for us to perform 5-8 procedures in one room on a daily basis between 8am and 6pm.   

Is there a problem or challenge your lab has faced? 

We have had many challenges, given the surge in the veteran population over the past decade. Our most pressing problem a few years ago was scheduling. Our previous system was very inefficient, resulting in long wait times and paradoxically, some very low volume days. By using a “lean” process, we were able to eliminate many redundant steps in the process, significantly increase cath lab availability, reduce wait times, and save the VA money.     

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”?

The biggest influence has been the close relationship with an academic center like Duke University Medical Center. As mentioned, all of our operators have academic appointments at Duke and work there as well. This allows for sharing of “best practices” at both institutions and increases the opportunities to offer veterans the latest in cutting-edge cardiovascular care.