Spotlight Interview: Johns Hopkins Heart and Vascular Institute

The physicians and staff of the Johns Hopkins Heart and Vascular Institute (HVI) work diligently around the clock to provide the highest quality of comprehensive care for their patients. Our department—the Cardiovascular Interventional Laboratory (CVIL)—is one of the teams that comprises the HVI. CVIL is home to the cardiac catheterization and electrophysiology (EP) laboratories. It consists of 12 procedural suites—five dedicated catheterization suites, five dedicated EP suites, one cardiac magnetic resonance imaging (MRI) suite and one cardiac computed tomography (CT) suite. Both the EP and catheterization service lines have hybrid procedure suites. These hybrid labs provide a mutually conducive environment for complex procedures that require the partnership of the interventional and surgical teams. 

In April 2012, the HVI moved into a new location in the Sheikh Zayed Tower. The move was the culmination of years of forethought and planning. Our lab needed “all hands on deck” for the actual move day to ensure a successful transition into our new home.

Prior to the move, HVI services — cardiology, cardiac surgery, vascular surgery and imaging — were located on different floors and buildings of our historic hospital building. The Sheikh Zayed Tower was designed to centralize care by placing all of these specialties on the same floor. This allows our patients and their loved ones convenient and complete access to the cardiac services needed. 

What is the goal of your lab?

The goal of our lab is aligned with the mission of Johns Hopkins Medicine:   

“To improve the health of the community, and the world, by setting the standard of excellence in medical education, research and clinical care. Diverse and inclusive, Johns Hopkins Medicine educates medical students, scientists, health care professionals and the public; conducts biomedical research; and provides patient-centered medicine to prevent, diagnose and treat human illness.”

Tell us about your cath lab.

Our lab consists of five dedicated cath suites. Two suites were constructed as hybrid rooms. These rooms can perform procedures that range from minimally invasive to full surgical operations. Throughout the department, we have the imaging capabilities to perform cardiac and vascular procedures for our adult and pediatric patients. We share our department with EP; however, EP has its own separate procedure rooms and staff. Our department also houses both an MRI unit and a CT scanner. 

We currently employ 18 radiologic technologists (RTs) and 13 registered nurses (RNs) for cath. Both teams of healthcare professionals are licensed by the state of Maryland. A majority of the technologists have advanced certifications, such as cardiac-interventional radiography (CI), cardiovascular-interventional radiography (CV), and registered cardiovascular invasive specialist (RCIS). Many RNs have earned their cardiovascular and critical care certifications as well. All staff members are advanced cardiac life support (ACLS) certified. 

Is the cath lab separate from the EP lab? Are employees cross-trained?

Due to the size of our lab and case complexity, the cath and EP RTs operate as two separate teams. However, all staff members are encouraged to learn and grow together within their respective teams. There are EP technologists who are cross-trained to cover cath cases when staffing and volumes are favorable. The nursing team has several “hybrid” RNs who are cross-trained to cover cath and EP procedures. This provides flexibility for high volumes, acuity, vacations and sick calls. CVIL also partners with the department of anesthesiology on multiple cases per week.

Who manages your cath lab?

We have a robust leadership team that oversees the staff, operations, and clinical development in the cardiac catheterization lab:

• Jon Resar, Director of the Adult Cardiac Catheterization Laboratory, Director of Interventional Cardiology and Associate Professor of Medicine/Cardiology;
• Kevin Hsu, Administrative Director of Cardiac Services;
• Lauren Johnson, RT Manager;
• Kim Sweitzer, RN Manager;
• Kelly Hagin, Inventory Manager;
• Carol Tunin, Financial Manager.

What procedures do you perform in your cath lab?

The cath lab represents five service lines: adult cardiac catheterization, pediatric catheterization, cardiomyopathy/heart failure, structural interventions, and peripheral vascular imaging and intervention.  

• Some common procedures performed in our labs include:
• Diagnostic and interventional cardiac catheterization
• Peripheral vascular procedures
• Chronic total occlusions (CTOs)
• Pediatric interventional procedures
• Right heart catheterization
• Right ventricular biopsy
• Adult congenital procedures, including atrial septal defect (ASD) and patent foramen ovale (PFO) closure, patent ductus arteriosus (PDA) closure, aortic coarctation treatment and ventricular septal defect (VSD) closure 
• Balloon valvuloplasty (aortic, mitral, pulmonary)
• Mitral clip treatment
• Transcatheter aortic valve replacement (TAVR) 
• Coronary imaging and pressure differential (intravascular ultrasound [IVUS], fractional flow reserve [FFR], and optical coherence tomography [OCT])
• Cardiac support device insertion (intra-aortic balloon pump, Impella [Abiomed], TandemHeart [CardiacAssist])
• Research protocols, including stem cell therapy

Note: We have a separate EP workforce that handles ablations, devices, and lead extractions.

Ancillary equipment

We have a complete spectrum of ancillary equipment on hand for patient needs, including:

• IABP
• Impella
• TandemHeart
• FFR
• IVUS
• OCT
• Rotoblator (Boston Scientific)
• AngioJet (Boston Scientific)
• Laser
• Intracardiac echo (ICE)
• ACIST CVi contrast injection

Have you recently upgraded your imaging technology?

In preparation for the expansion and move to our new clinical building, we purchased three brand-new Philips rooms, two single-plane units and one biplane system. Additionally, our pediatric interventional team had a new Toshiba biplane system installed. This room can be utilized for pediatric and adult cardiac and vascular cases. Our fifth room is a Toshiba dual plane system equipped with a separate cardiac and vascular tube. This unit was relocated from our previous location.  

Our first hybrid room functions as a cardiac/vascular lab that can expand into an operating suite if needed. We most often utilize this hybrid room for our TAVR procedures or peripheral vascular cases that that may require surgical intervention.

The second hybrid suite functions primarily as the pediatric room. The hybrid design allows the pediatric team to implant Melody transcatheter pulmonary valves (Medtronic), and facilitate joint interventional and surgical procedures.

There are integrated Volcano IVUS/FFR units in four of our procedure rooms. ACIST CVi consoles are utilized in three of our procedure rooms. The other two rooms utilize a standardized 3-port manifold for selective imaging and Medrad auto-injectors for large-contrast injections.  

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

Yes! We perform radial access coronary procedures in approximately 80 percent of our patients. That number will continue to increase with the development of more radial-specific tools and protocols.  

How are ST-segment elevation myocardial infarction (STEMI) cases handled at your lab?

In 2012, we achieved door-to-balloon (D2B) times of less than 90 minutes in 96 percent of our core measure cases. Our median D2B was 66 minutes. It is important to note that 100 percent of our field-activated cases met a D2B time of less than 90 minutes. Our heart attack team conducts a multidisciplinary meeting each month to review all STEMI case events. Representatives from the emergency department, cath lab, quality improvement, and transport team examine each element from activation to completion to look for areas of improvement. We are very proud of our success, especially in light of the challenges involved in opening a new clinical building. This hard work has not gone unrecognized. In 2013, Johns Hopkins was the recipient of the Delmarva Foundation’s Excellence Award for Quality Improvement in Hospitals. The Joint Commission also recognized The Johns Hopkins Hospital as a Top Performer on Key Quality Measures. 

How does your lab handle call time for staff members? 

STEMI call is covered by a five-member team — one interventional attending, one interventional fellow, two RTs, and one RN. Each week, one RN and one RT participate in the call model. That team does not come in to work during normal business hours. They are expected to cover all cases after 5:30pm on weeknights and any emergent case over the weekend. The second on-call RT rotates daily and is filled on a voluntary basis.

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

After a page is sent out, one fellow, one nurse, and one radiologic technologist are expected to arrive to the cath lab within 30 minutes. A second radiologic technologist will arrive within 45 minutes.  

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

Johns Hopkins Medicine sends daily news updates to staff members via email, publications, and electronic message boards throughout the institution. CVIL leadership highlights key institutional messages to staff via email and during staff meetings. There is a monthly management meeting that includes stakeholders from the RT, RN, inventory, case management, quality improvement, scheduling, administration, and medical teams. The division of cardiology hosts grand rounds each week to discuss various cardiac topics, image interpretations, and research updates. Physicians and staff meet weekly during a morbidity & mortality conference to discuss cases and procedural techniques. The department hosts a monthly comprehensive unit-based safety program (CUSP) meeting for all staff members to address safety concerns and develop action plans. Departmental information, policies, schedules, photos, and updates are housed on our unit’s SharePoint site.

How is staff competency evaluated?

Various skills are evaluated for competency on a yearly basis. Competencies may be mandated by the state, the hospital, or by our department. Our primary focus for competencies is on high-acuity, low-incidence scenarios. One unique opportunity offered by our department is a full ACLS/basic life support (BLS) course taught by members of our own unit. We feel that practicing critical scenarios as a team helps us to perform more proficiently in times of duress.  

Additionally, every RT is expected to provide a minimum of one educational in-service per year for their co-workers. This practice helps to facilitate and promote an environment that endorses continuous education and growth.

RN staff members are currently implementing the Donna Wright Competency Model to streamline competency-based assessments.

What continuing education opportunities are provided to staff members?

Weekly in-services pertaining to a variety of clinical applications are provided for the team. We offer a minimum of 12 CEUs per year for our staff. New procedures, devices and equipment are accompanied by a launch period and in-servicing to assist all team members in becoming comfortable with that technology.  

Do you participate in any registries?

We participate in several American College of Cardiology National Cardiovascular Registry (ACC-NCDR) Registries: ACTION, CathPCI, and IMPACT. We participate in the Society of Thoracic Surgeons (STS)/ACC TVT registry for transcatheter valve replacement procedures.

How do you use the NCDR outcome reports to drive quality improvement initiatives?

NCDR outcomes are reviewed with the leadership team on a quarterly basis. Action plans are created to address any areas of opportunity or to build on positive clinical momentum. Key elements from the registries are included in our annual Key Performance Indicator (KPI) dashboard. This dashboard is reviewed and revised by the leadership team. KPI success is aligned to annual performance review ratings for managers. Outcomes are highlighted for all staff during the annual “State of the Union” address given by administration and leadership teams.

Can you tell us about your TAVR program?

We instituted our TAVR program in 2011. Since its inception, we have steadily built our case volume. We have performed over 250 TAVR procedures with both iliofemoral and non-iliofemoral access, including subclavian, direct aortic, and apical alternative access. We currently implant the Medtronic CoreValve under both research and commercial programs.   We also implant the commercially available Edwards Sapien XT valve and the new CoreValve Evolut R valve by Medtronic.

We have four dedicated TAVR days per month and frequently perform additional cases each week as needed. We average two cases per day. We anticipate continued growth and success in the structural heart field over the next few years and will be participating in the pivotal clinical trials of several new TAVR devices.

We partner with anesthesia, cardiac surgery, and perfusion for all cases as part of our multidisciplinary approach. The TAVR team meets weekly to discuss the program, upcoming patients, and best practices.

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

Kelly Hagin is our inventory manager. She has a team of dedicated cath inventory specialists who meet the various demands of our department. Inventory specialists oversee supply usage of assigned procedure rooms and storerooms, perform visual inspection of supplies for proper rotation of inventory (first in, first out), perform supply cycle counts to eliminate discrepancies, and collaborate with clinical staff on a daily basis to address supply needs.  

Capital equipment is purchased through a collaborative effort between clinical leadership, physician leadership, and materials management. Disposable supplies are purchased through the SAP program. All supplies are set up in SAP with minimal par levels and maximum stock needed. At the time of scanning of the manufacturer bar code, the supply is automatically decremented from inventory and reordered if it meets the minimal stocking criteria.

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

Our physicians actively participate with hospital administration and corporate purchasing on cost reduction initiatives. The team has been focused on formulating new contract negotiation strategies, developing actionable performance and supply benchmarking data, and aligning the product selection process across the Johns Hopkins Health System. The catheterization lab was able to achieve more than $1.5 million in savings over the past three years on supplies.

Management actively monitors staff schedules and case volumes to minimize overtime. The department strives to achieve on-time starts for 70 percent of its first cases. Starting our first cases on time greatly increases our room utilization, decreases our overtime, and creates provider and staff satisfaction.

How does your lab handle vendors/visitors?

The Johns Hopkins Health System Corporation, in response to The Joint Commission recommendations, has engaged the services of  Vendormate to credential and assist in monitoring vendor representatives that provide services to The Johns Hopkins Health System. Vendormate is a web-based system that enables Johns Hopkins to upload new or revised policies, medical or educational requirements, and any other notifications to vendors via a Vendormate e-blast. This system requires vendors to read and acknowledge notification within a two-week window.  

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

At the department level, we have a senior radiologic technologist who is deemed the Radiation Safety Officer. This person implements policies and procedures set forth by the institutional Radiation Safety Officer, and is responsible for educating staff on radiation safety on a regular basis. As part of orientation, new physicians and staff members attend a course with the radiation physicist, and are expected to complete an annual radiation safety refresher course. The radiation physicist is also available to consult on special projects, i.e., a new product entering the lab or a potential research study, to guide lab staff on the recommended safety precautions.

How are coding and coding education handled in your lab?

Coding is handled by certified coders who are part of the medical records group for the institution. However, cardiology has a departmental documentation application that will suggest coding based on the procedure notes entered.  Internal medical coders provide education and updates to physicians and fellows on a yearly basis, and free online training through vendors and reimbursement specialists can be used to supplement. Profee billing is handled through certified medical coders in the physician practice association.

Who pulls the sheaths post procedure, both post intervention and diagnostic? What kind of training is required?

All femoral sheaths are pulled by the post anesthesia care unit (PACU) nurses, as long as the patient meets the criteria outlined in the nurse sheath-pulling policy. If the patient does not meet the nurse sheath-pulling criteria, then the cardiology fellow will pull the sheath. Nurses must complete a written exam and perform ten observed sheath pulls before they can remove sheaths independently. 

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

Outpatients are undressed and prepped with an IV for their procedure in the pre-PAC area, whereas inpatients come directly to the procedure room. Post procedure patients will either return to the PACU or to the inpatient unit, depending on the level of care they will require post procedure. 

How does your lab handle hemostasis? 

Radial access is our preferred method to achieve vascular access. For our radial patients, we use either the Vasc Band or D-Stat Band (both from Vascular Solutions). For femoral access we utilize manual pressure, Angio-Seal (St. Jude Medical), Perclose (Abbott Vascular), or Boomerang (Cardiva Medical). The physician will remove the radial sheath and apply the Vasc Band or D-Stat Band, or remove the femoral sheath and deploy any percutaneous closure device while the patient is in the procedure room. For patients requiring manual pressure, sheath removal will be done in the PACU or on the inpatient unit. 

The PACU and our designated inpatient units are prepared to care for post cardiac catheterization patients. This includes vascular closure devices and post manual pressure removal in accordance with post cardiac catheterization protocols and guidelines. 

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

Our physicians do not dictate their reports.  We currently utilize a computer-based reporting system where physicians enter text case notes and a report is generated into the EMR. This report is automatically sent to the selected referring physician. We are moving to the EPIC electronic health record system, which will contain our reports in the near future. 

The authors can be contacted via Jessica Moore, MHA, at jmoor101@jhmi.edu.

A question from the Society of Invasive Cardiovascular Professionals (SICP):

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?

The RCIS is not a requirement for clinical staff members. We strongly encourage the Cardiac Interventional Boards to obtain the ARRT credential. Staff members are incentivized to work towards this certification, as it places them on a leadership track and makes them eligible for a Senior RT position. The hospital will reimburse the individual for exam fees if a passing score is achieved.