Spotlight: North Mississippi Medical Center

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

The North Mississippi Medical Center (NMMC) cath lab is encompassed within the North Mississippi Medical Center Heart and Vascular Institute, which contains the electrophysiology, cardiology, and vascular service lines. 

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

There are twenty full-time employees (FTEs) supporting the cath labs and hybrid room, and another eight FTEs supporting electrophysiology (EP). 

The cath lab area is comprised of four labs to support cardiac and endovascular procedures, as well as a hybrid OR for lead extraction, transcatheter aortic valve replacement (TAVR), and complex vascular procedures. In addition, there are two bi-plane rooms dedicated to EP, which is separate from the cath lab.

Half of the cath lab FTEs are nurses, and the other half are radiologic technologists (RTs). The average tenure of the present cath lab FTEs is 10 years. 

There is another team of 25 FTEs that staff a cardiac observation unit for elective patients, managing admissions and post-procedure recovery.

What procedures are performed in your cath lab? 

Cardiovascular: diagnostic cath, angioplasty, stent implantation (including bioresorbable scaffolds), coronary atherectomy, atrial septal defect/patent foramen ovale (ASD/PFO) closure, septal alcohol ablation for hypertrophic cardiomyopathy (HCM), coronary intravascular ultrasound (IVUS) and optical coherence tomography (OCT), pericardiocentesis, pulmonary embolus mechanical thrombolysis, intracardiac echo, carotid stenting, subclavian stenting, renal stenting, iliac stenting, peripheral atherectomy using TurboHawk (CSI) and laser, peripheral angioplasty and stenting, alternative access peripheral intervention including pedal access (three of our operators use the pedal approach), and peripheral vascular mechanical thrombolysis. 

Hybrid procedures include laser lead extraction (performed by EP), TAVR (combo cases with cath lab staff and OR staff), and endovascular aneurysm repair (EVAR) for thoracic aortic aneurysms (TAA), abdominal aortic aneurysms (AAA), and dissection (performed by OR staff).

Our EP lab performs pacemaker implants, transvenous and subcutaneous implantable cardioverter defibrillator (ICD) implants, diagnostic EP studies, atrioventricular (AV) node ablation, atrial flutter ablation, afib ablation, ventricular tachycardia (VT) ablation, accessory pathway ablation, and left atrial appendage (LAA) closure. 

Approximately 100 procedures are performed weekly. 

Can you share your experience with TAVR?

We were the seventh commercial start hospital performing TAVR. We have performed 115 TAVR procedures. In those with no surgical options, the one-year survival is >85% (exceeding the PARTNER trial data).

What is your percentage of normal diagnostic caths?

20%.

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

Yes, presently 70% of all diagnostic caths and interventions are done using the radial approach.

Who manages your cath lab?

Carla Durham, RN.

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

Yes, there is cross-training. Nurses and RTs rotate on who might scrub, circulate, and monitor. A nurse always is in the room to administer meds and monitor conscious sedation. 

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? 

Most of the time, the doctors operate the table. When they do not, an RT operates the table for the case.

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

We have a dedicated radiation safety officer. Staff and physicians are monitored with monthly radiation badges. As Low As Reasonably Achievable (ALARA) is strongly encouraged and education is provided.

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

We have recently implemented:

• Toshiba dual-plane room for cardiovascular 
• OCT imaging 
• Vascular ultrasound 
• Absorb (Abbott Vascular) bioresorbable scaffold implantation 
• Impella LV and RP (Abiomed)
• Cardioform ASD closure (Gore)
• Watchman LAA closure (Boston Scientific)
• Philips bi-plane room for EP 

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

We huddle daily with staff for updates and we meet with the doctors monthly. 

Service line meetings and door-to-balloon time meetings are held quarterly. 

The cardiology section meets on a quarterly basis.

How is coding and coding education handled in your lab?

Education updates are held annually, and in conjunction with the hospital and physician office staff.

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

We have adopted a philosophy of closure first for femoral access cases. Our doctors perform the closure device placement. When femoral closure is not possible, specially trained nurses pull the sheaths. There are differing protocols for post-diagnostic and post-intervention cases. All trained nurses go through an educational didactic training followed by supervised, proctored sheath removals.

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

Outpatients are prepped in their pre-procedure room. Inpatients are prepped in their hospital room or in the procedure room itself. Outpatients are recovered in their observation room. 

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

Utilizing the McKesson Inventory system, our inventory is maintained at par levels pre-set by the management team. Many supplies are bought in bulk and held in our logistics center for use. The cath lab management team, which includes physicians, determines needed purchases of equipment and supplies. Diane McNeil is charged with maintaining supply levels. Mike Switzer, as VP of Purchasing, assists with equipment acquisitions.

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

Yes, the addition of three new vascular surgeons has increased percutaneous vascular procedures; therefore, this has increased the need to add additional staff.

Is your lab involved in clinical research?

Yes.

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

At present, 63 minutes. There is a multi-disciplinary committee that meets quarterly to review procedures and protocols. We are part of the American Heart Association: Mission Lifeline.

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

Cath lab personnel.

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

There is a second team on call.

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

We have a co-management agreement with the physicians. This agreement, in part, rewards the physicians for high quality care, but also for cost containment. This agreement passed Office of Inspector General (OIG) scrutiny and serves as the national model.

What quality assurance measures are practiced in your cath lab?

We participate in several registries (American College of Cardiology-National Cardiovascular Data Registry [ACC-NCDR]) that allow comparison to national averages. Also, we rotate assessment of quality metrics selected by the management team every six months for additional review.

Are you recording fluoroscopy times/dosages? 

Yes, we record fluoroscopy times on all cases in all rooms. Recently, we updated rooms to provide radiation doses given to patients.

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

As we now have the technology described above, we are presently developing those policies and procedures with our radiation safety officer.

Who documents medication administration during the case?

 A nurse assigned to medication administration and conscious sedation.

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

Our physicians use structured reporting via McKesson Cardiology. NMMC is actually one of the national McKesson Cardiology Demonstration sites.

How are you populating registry data records? 

Most of the registry data is pre-populated through the McKesson Cardiology system. There are required fields to assure adequate data collection. Any remaining needed data is added by one of two registry coordinators devoted to the cardiovascular service line.

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

NMHS consists of five spoke hospitals and three other aligned hospitals for referrals. Additionally, we compete through promoting our outcomes.

How are new employees oriented and trained at your facility?

New employees go through a pre-set hospital orientation, and then a more specific, six-month cath lab training.

What continuing education opportunities are provided to staff members?

Staff members are provided access to regional CME programs and attend national programs on a rotating basis.

How do you handle vendor visits to your lab? 

Vendors have pre-arranged cath lab dates. All representatives are tracked through RepTrax. Representatives are not allowed into the cath lab space or control rooms unless requested by the physician.

How is staff competency evaluated?

Staff undergoes an annual review that includes core competency assessments and anonymous peer review.

How does your lab handle call time for staff members? 

Call is assigned on a rotating basis. Each call team consists of two nurses and two radiologic technologists. Staff members post-call are allowed to leave early.

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

Within 30 minutes.

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

No. Staffs are asked to leave early during slow times.

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

The cath lab is across the hall from the OR, and two floors directly above the ED with ready elevator limited access.

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?

No.

Are your clinical and/or managerial team members involved with any professional organizations that support the invasive cardiology service line?

Yes, the outcomes team for the facility follows the SICP [now merged with the Alliance of Cardiovascular Professionals (ACVP)].

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

We have seen an increase in outpatient procedures and vascular procedures.

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

Given the rural nature of north Mississippi, we believe it is unique to support a high number of increasingly complex cardiovascular procedures at such a high level of competency. We face all issues with a multi-disciplinary team to discuss challenges and find solutions.

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”?

NMMC-Tupelo is the largest non-metropolitan hospital in America. NMMC is a 2006 recipient of the National Malcolm Baldrige award and is affiliated with North Mississippi Health Services, a 2012 Malcolm Baldrige award recipient. Our reputation, not just regionally, but also nationally, drives a strong commitment to quality care. 

A question from the American College of Cardiology’s National Cardiovascular Data Registry:  

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

We have used our outcomes report to changes processes and order sets to improve outcomes. We have tried to hardwire things like medications and cardiology rehab orders.

Carla Durham, RN, can be contacted at cdurham@nmhs.net.