Spotlight: Mercy Medical Center Cardiovascular Lab

Tell us about your cath lab. 

Mercy Medical Center’s cardiovascular lab in Cedar Rapids, Iowa, provides services for cardiac revascularization, cardiac electrophysiology, peripheral revascularization, and interventional radiology. We also have a ten-bed patient care area to monitor patients pre and post procedure. Mercy was recently approved for cardiothoracic surgery and our lab is part of a rapidly growing cardiology service line. Earlier this year, we hired an additional interventional cardiologist and a cardiothoracic surgeon; this is a very exciting time for our department and hospital. 

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

Our lab consists of four procedure rooms equipped with Siemens x-ray equipment and has a pre/post area including ten patient care areas. Our staff consists of seven procedure room nurses, eight cardiovascular radiologic technologists, four recovery bay nurses, one scheduling coordinator, one patient care tech, one administrative assistant, one quality and safety specialist, and one cath/electrophysiology (EP) lab manager. A majority of staff has been within our department less than five years. 

What procedures are performed in your cath lab?

Procedures include right and left heart catheterization, percutaneous coronary intervention (PCI), coronary thrombectomy, coronary atherectomy, intra-aortic balloon pump (IABP), Impella (Abiomed), intravascular ultrasound (IVUS), fractional flow reserve (FFR) assessment, peripheral angiograms and intervention, endovascular aortic aneurysm repair (with OR staff), cardioversion, permanent pacemaker implant, implantable cardiac defibrillator, loop recorder implants, EP studies and ablation, along with interventional radiology procedures.

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

Our lab does perform percutaneous coronary interventions without surgical backup on site. Currently, we have options to transfer to three hospitals within a 30-minute radius. When our cardiothoracic surgeon starts this summer, we will have on-site surgical backup. We are excited to add this new service line so patients can stay within Mercy, their preferred hospital.  

Is your lab planning to start performing transcatheter aortic valve replacement (TAVR)?

We are making plans to start a TAVR program. Two of our interventional cardiologists have experience performing TAVR. We are anxious to start a TAVR program after our surgical valve program is up and running with sufficient numbers. 

What is your percentage of normal diagnostic caths?

Approximately one-third of our cases are considered normal.

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

Yes, we have four interventional cardiologists and all of them perform radial access. We currently do 82 percent of our cases with radial access, including ST-elevation myocardial infarction (STEMI).

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

We do not routinely perform pedal artery access in our lab; however, we have performed this access when appropriate.  

Who manages your cath lab? 

Our cath lab is managed by a nurse manager who works with the medical director in making decisions for the lab and its future. The manager reports directly to the vice president of outpatient services for the hospital.      

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

We cross train all of our staff. A nurse will start in the nursing role of the room, which includes patient assessments and sedation monitoring. We then cross train our nurses into a scrub role and eventually into the monitor role. Our nurses are also trained to work in the pre/post area, if needed. Radiologic technologists start in the circulating role, which includes pulling appropriate equipment and positioning the x-ray equipment. They set up angles and pan for the physician as they inject the contrast agent. We cross train our radiologic techs into the scrub role and eventually into the monitor role as well. 

Who documents medication administration during the case?

The RN in the room has a workstation on wheels that documents patient assessments along with medications given during the procedure. 

Are there licensure laws in your state for fluoroscopy?

Yes.

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 radiologic technologists and cardiologists perform the actions listed. 

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

Radiation safety is extremely important to us at this institution. We use protection devices including shields that hang from the ceiling, lead aprons, vests, thyroid collars, and lead-lined sterile drapes (i.e., RadPads [Worldwide Innovations & Technologies, Inc.]). The physicians also use radiation protection safety caps and radiation protection glasses. Every staff member and physician involved in radiation cases is given dosimetry badges and monitored monthly. This report is reviewed bi-monthly and presented at a quarterly radiation safety meeting. The lead aprons, vests, and thyroid collars are checked annually and upgraded as needed. In addition, the manager tracks monthly fluoroscopy times and doses, and presents this information at a cath quality meeting held monthly. The cardiologists are always conscious of staff in relation to the x-ray tube. 

How are you recording fluoroscopy times/dosages? 

Our staff enters the radiation time in our electronic medical record within the procedure log. Dose and fluoroscopy times are also captured within the Siemens equipment and reported to the manager at the end of the month to present at the cath quality meeting.  

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

The hospital has an established protocol for tracking cases with more than 60 minutes of fluoro time. The patient’s physician is notified, and reports any clinical concerns.  

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

In the past year, we have added the Impella device. We have used this device primarily for staged complex PCI; however, all staff are trained in case it is needed for an emergent situation. We recently upgraded our FFR equipment to incorporate iFR technology from Philips Volcano. This has been a useful tool and patient satisfier. We have also upgraded our activated clotting time (ACT) monitoring device to the Accriva Hemochron (Accriva Diagnostics). Our previous device would take five to ten minutes to receive a result, but the new device provides a result in less than three minutes. This has been a physician satisfier, especially in PCI cases and EP procedures. It has also allowed us to cut costs by increasing our heparin usage. 

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

Staff members are updated with monthly meetings, email, face-to-face, or small group huddles, as necessary. The cardiologists have a monthly medical director meeting and a bi-weekly cardiology clinic meeting to talk about changes and updates on projects. 

How is coding and coding education handled in your lab? 

Our radiologic techs put in the procedure codes for the procedure performed. Our quality and safety specialist then reviews for accuracy. A coder assigned to our area reviews this information. The coder emails daily edits they make, and educates occasionally at staff meetings on recurring mistakes. 

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

Outpatients are prepped in our pre/post recovery bay area. This area has ten bays that can provide patient care. Cardiologists prefer to have inpatients come down to our pre area before their scheduled cases, so our staff can get them ready and verify meds have been given appropriately; however, the nursing floors have a checklist they follow that details what needs to be done before patients are taken down for a procedure, if taken directly to the procedure room. 

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

We do more than 80 percent of our cases via radial access, and hemostasis is achieved using a compression device that is applied in the room upon completion of the procedure. The other 20 percent of cases are managed using a closure device or by manual pressure. Our manual holds occur in our recovery bay, the nursing floor, or in the procedure room. The procedure room is not a preferred choice, since we want our room to be open for emergent cases. Because of our high radial usage, femoral sheaths are not as common in the hospital as they use to be, and it has been difficult to keep nursing staff on the wards competent in removal and groin management. Currently, the cath lab staff members are the “experts” in the hospital for sheath removal. We are working with nursing units to develop sheath removal teams on their floor so the cath lab staff does not need to be present. The cath lab staff has a checklist in their orientation packet that requires at least three sheath pulls with a preceptor before being independent. 

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

We have a designated staff member that helps order stock items and a designated staff member that orders non-stock items. We use a Kanban system for reordering products. Staff members also check for product expirations at the beginning of each month and look ahead for future expirations. To ensure best pricing, all products are reviewed with the manager and our purchasing department. 

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

We recently renovated a state-of-the-art EP procedure room with biplane x-ray equipment. This room is treated as an OR suite with strict infection control measures and can function as a hybrid OR. We have added a new interventional cardiologist; this has increased our procedure volume. Our cardiologists enjoy the option of running two cath rooms at the same time, with the option to flip into the next room if it is available. We have begun talking about space available to create additional procedure rooms and adding to our pre/post area. 

Is your lab involved in clinical research?

No, we do not currently participate in any clinical research. 

Can you share your lab’s average door-to-balloon (D2B) times?

Our facility averages a monthly D2B time of less than 60 minutes. Having a response time of 20 minutes has helped with our amazing D2B times. We have also worked on processes between local emergency medical services (EMS), emergency department (ED) physicians, and cardiologists to streamline the emergent patient quickly into the cath lab. 

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

Our staff sets up the room and once this is complete or near complete, the RN and another staff member will get the patient from his or her location.       

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

During daytime hours, we have four rooms that can handle STEMI patients. If all rooms are occupied, we triage the patients in those rooms, and decide who can finish quickly, or who is at a stopping point and can be taken off the table. 

During off hours, we have a protocol in place to triage the status of the lab and available options to assist. Our staff is known to go above and beyond, and off-call staff, including cardiologists, have assisted in dual STEMIs in the middle of night. This type of passion and commitment shows the dedication our staff members have to to our patients and their health.  

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

We use a value analysis team to help coordinate the best prices on the market with the products we use. We also communicate savings opportunities to the staff and cardiologists at cath lab quality meetings and steering committees. 

What quality control measures are practiced in your cath lab?

The manager monitors trends in radiation, sheath access, medications used, closure devices, complications, and patient volumes. This information is presented at the monthly cath quality committee meeting. We also have a clinical specialist that works with our clinical improvement and accreditation department. This person helps us facilitate care and current standards of practice.

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

We are currently using Siemens’ SyngoDynamics for our structured reporting system, but this process will be changing. We anticipate using EPIC to document all of our case information in the near future. 

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

We are registered to use the ACC-NCDR CathPCI registry and ICD registry. Our staff is capturing data during the case and then a second person double-checks their work after the case. We make corrections in our documentation system, if needed, and have a staff member in the quality and accreditation department submit the data. 

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

This information is reviewed to monitor trends in the nation. We look at how we compare to the national averages and strive to exceed those. 

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

There are two PCI-capable hospitals in our area. Our cath lab currently does not compete for patients, per se. We have not formed alliances. Some of our providers do hold outreach clinics in surrounding communities. Local EMS is excellent at taking patients to the hospital of their preference. 

How are new employees oriented and trained at your facility? 

New employees come in with a variety of previous work experiences, so we tailor our orientation to the person. We have an orientation manual that is given to the new employee, which outlines a plan for their first 16 weeks. We try to implement a one-preceptor model of learning in order to facilitate education. The manager keeps an open-education model in the department, meaning we are all continuously learning and asking questions.

What continuing education opportunities are provided to staff members?

We take advantage of educational opportunities provided by vendors. We also try to do monthly lectures on topics submitted by staff for furthering education. The manager has required all new hires to complete the “Back to Basics” education program sponsored by Medtronic within their first year. This program has a lot of good information for both new and experienced staff. 

Are clinical staff members required to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? Does staff receive an incentive bonus or raise upon passing the exam?

We do not require staff to take the RCIS exam. We do not have an incentive program currently for passing the exam; however, management is working on creating an incentive level program including certification.

How do you handle vendor visits to your lab? 

We do not allow vendors to come into the lab to wait for cases to arrive, but if we know of a case that will require vendor support, we reach out to them and let them come in for the case. They sign into Reptrax before they are allowed into the department, and we also try to coordinate education as well since they will be in our lab. 

How is staff competency evaluated? 

The hospital uses modules in our intranet that keep us competent on hospital and state competencies. We also have a simulation lab where we do annual competency testing to keep us up to date with sedation. The manager also does performance evaluations annually and is active in the lab to view work performance issues. 

Does your lab have a clinical ladder? 

Our hospital has a clinical ladder program in which all clinical staff can participate. The levels have pay incentives for the employee if they provide the proper paperwork. This can be a rewarding program to keep employees engaged and compensated for their excellent work performance. 

Does your lab have any physical (layout) bottlenecks or limitations? How do you work around the resulting challenges?

Our pre and post area is limited to ten patient care areas and our department is growing rapidly. The supervisor and manager look ahead to form a game plan on where to place patients, how long it will take to recover, and who can sit in recliner versus a flat cart. Procedure results can be hard to predict, and sometimes the patients go directly to the cardiac telemetry floor to be observed overnight. Backup plans have consisted of utilizing other recovery areas in the hospital if needed. 

How does your lab handle call time for staff members?

If staff members are called in the middle of the night, they are still expected to report for the morning shift if they were scheduled to do so. The manager looks at the schedule that day and works with the supervisors to decide if the call team can be relieved and sent home early. We currently have three call teams in our department. The teams consist of four people that can scrub, circulate, nurse, or monitor. Not everyone is able to function in certain roles, so we pair call teams to make them as strong as possible. Currently, staff members take call two nights per week and every third weekend. Our future goal, once staffing is in place, is to make four call teams to reduce the workload for staff. 

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

We require a 20-minute response time. 

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

We do flexed scheduling in our area. If procedures do not start until later in the morning, we will keep the staff assigned in that room at home and have them be on call. If an emergent or add-on case occurs, we call them in. During slow periods in the day, we clean rooms, put away supplies, check for expiration dates, and work on education materials. 

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

Our cath lab is located within close proximity to the ED. The OR is directly above the cath lab. There is a large elevator next to the cath lab for transport, and the intensive care unit is next to the OR as well. 

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

Procedure volumes have increased in all areas (cath, EP, and interventional radiology). We have noticed an increase in complex PCI cases this past year, which may reflect a small change in our patient population. With the recent renovation of our EP lab, we have also seen a significant increase in ablations, as we expected. 

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

Our cath lab staff is very team-oriented and works well with one another. This helps with morale and patient interaction. There are times when the job can be stressful and busy, but it can be amazing to watch a team of people work so hard and well with each other, and accomplish the same goal at the end of the day. The physician and staff interaction has been collaborative and positive in nature. The cardiologists are always willing to educate and are very involved with staff satisfaction. This brings the department together and provides better care overall to our patients.

Is there a problem or challenge your lab has faced? 

One challenge we have faced has been maintaining competency in femoral sheath management, given the shrinking number of femoral cases we do. We are working towards developing a core team of “femoral champions” on the floors who maintain competency and can train other nurses to pull femoral lines. The other issue we face is training our relatively young and inexperienced staff during a period of rapid growth. It can be hard to properly staff multiple rooms with new staff and more experienced staff learning new roles. One way we continue to progress is by blocking one room for emergency cases in order to promote a safe and effective learning environment in the other cath room. 

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”?

Cedar Rapids has a population of about 125,000. Eastern Iowa is a rural area, and so we care for a rural population covering a very large area. We try to promote same-day discharge after PCI when possible; however, serving a rural population presents challenges with same-day planning. We try to accommodate our patients with the benefits of same-day discharge when possible, but our primary focus is always safety. 

The authors can be contacted via Richard Joens, RN, BSN, Cardiac Cath and EP Lab Manager, at rjoens@mercycare.org.