Spotlight: Saint Mary’s Regional Medical Center Cath Lab

Tell us about your cath lab.

We have a three-lab facility that is supported by a dedicated four-bay pre and post area as well as our radial lounge. Our staging area employs four RNs. We have two registry nurses who are cross-trained to work in the lab as well as our pre and post area. Our lab employs 10 staff members. All of our staff are RNs with the exception of our two radiologic technologists (RT[R])s. Our staff has a diverse mixture of experience ranging from 2 to 27 years in the cath lab.

What procedures are performed in your cath lab? 

We perform between 50 and 75 cases a week. Our lab provides a variety of services, including right and left heart caths, percutaneous coronary interventions (PCIs) including chronic total occlusions (CTOs), pulmonary hypertension studies, Impella (Abiomed) insertion, cardiac device pacemaker/implantable cardioverter-defibrillators (ICDs), transesophageal echocardiography (TEE), cardioversion, LINQ loop recorder (Medtronic), tilt tables, electrophysiology studies with ablation, and left atrial appendage (LAA) closure with the LARIAT Suture Delivery Device (SentreHeart, Inc.).

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

Our facility has an overall radial access utilization rate of 65% and our radial access utilization rate for interventions, including ST-elevation myocardial infarction (STEMI), is 90%. Devang Desai, MD, FACC, FSCAI, heads our Radial Access Training Program with Terumo and performs more than 95% of his cases via the radial artery. Our training program invites physicians from across the country to receive a one-day medical license in the state of Nevada and receive hands-on experience/training in radial access. Secondary to our high use of radial access, we have one of the few dedicated prep and recovery radial lounges on the west coast. Our radial lounge consists of four pods that each host one patient and visitor as well as a separate locker/changing room for patients. Patients are remotely cardiac monitored and equipped with a pulse oximeter. 

Can you tell us about your plans to incorporate transcatheter aortic valve replacement (TAVR) procedures at your hospital?

We just finished a yearlong expansion project that included the construction of a hybrid room. We have started utilizing the room for non-TAVR cases to acclimate ourselves to the new room and train on the new equipment. We do not yet have a start date for TAVR, since we are still in the beginning stages.

How long did it take to plan and build the hybrid room?

Planning was the longest part of this process and took well over a year. Construction of the lab took 8 months. We staged construction so that our other two labs could remain functional during the build.

What are some of the important elements of your hybrid room?

Our hybrid room is a low-fluoro room and has cut radiation exposure by a third.

Is the hybrid room located in the cath lab area or the OR? 

Our hybrid room is located in the cath lab and is under cath lab management.

Do you have advice for readers who may be adding a hybrid room to their lab?

Our greatest challenge in this process was/is changing from a procedural area to a surgical area.  We now have a red line in the cath lab and that has required practice changes for the cath lab staff, physicians, housekeeping, and ancillary staff.  Structural heart technology is new to our lab and devising a schedule for all employees to receive training and practice has been crucial to success.   

Who manages your cath lab? 

Our manager, Jenna Beadell, RN, PCCRN, is on-site in the cath lab Monday through Thursday. On a daily basis, Jenna designates a staff member from the cath lab and one from our pre and post area to disseminate information and collaborate to manage the flow of patients.

Who scrubs, who circulates and who monitors?

Our nursing staff is cross-trained in all positions and rotates every case to minimize radiation exposure and maintain competency in all roles. The only function our RT(R)s do not perform is medication administration. Allowing nurses to perform in all roles has led to an increase in job satisfaction, resulting in a low turnover rate.

Are there licensure laws in your state for fluoroscopy?

Yes, Nevada has extensive licensing laws covering limitation of useful beam, activation of the tube, exposure rate limits, barrier rate limits, indication of potential, current, source-skin distance, mobile fluoroscopes, and control of scattered radiation. 

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? 

Our entire staff positions the image intensifier (II), pans the table and changes the angles.  Only our licensed diagnostic/interventional cardiologists and RT(R)s step on the fluoro pedal.

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

All staff has their own fitted lead and eyewear that is checked regularly. Radiation badges are worn by all staff members and monitored for excessive exposure. Every case we rotate circulator, monitor, and scrub to minimize the amount of exposure to any one staff member. We also emphasize radiation safety and follow ALARA (as low as reasonably achievable) standards. Our new equipment includes the RaySafe i2 dosimetry system (Fluke Biomedical), so we will be able to identify unnecessary exposure in real time.

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

We have recently introduced optical coherence tomography (St. Jude Medical), pressure monitored ablation, cryoablation (Medtronic), LARIAT (SentreHeart), S-ICD (Boston Scientific), and LINQ (Medtronic).

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

Our manager holds biweekly meetings with Devang Desai, MD, FACC, FSCAI, physician director of the cath lab, and emails the physicians regularly with updates, including a STEMI synopsis/STATS with every case. Our physicians meet quarterly with the hospital representatives and Lisa Pistone, RN, BSN, MBA, CNML, Director of Cardiovascular Services, at our Cardiology/STEMI meetings. The physicians hold a monthly cath conference with the staff where education/case studies can be presented. Our manager communicates with staff during a daily huddle and staff meetings are scheduled when a topic requiring more time needs to be discussed. 

What is your percentage of normal diagnostic caths?

25.2%.

How is coding and coding education handled in your lab? 

Peggy Lee, RN, is one of our cath lab RNs who works closely with the hospital’s coding department. She educates the cath lab staff annually on coding changes and updates. 

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

Sheaths are pulled in the lab or the staging recovery area. Staff in both areas are certified to pull sheaths. Prior to being signed off, the trainee observes and is educated on sheath removal in the cath lab. The trainee is then observed pulling a sheath and holding manual pressure or placing the TR Band (Terumo) on radial cases. Observations are continued until the trainee is signed off with a passing score, and feels comfortable and confident in their ability to maintain hemostasis.

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

Patients are prepped and recovered in our pre and post staging area, as well as in our radial lounge. For femoral diagnostic cases using 4 French, manual pressure is the primary method used for homeostasis, and can occur in the lab or in our pre and post area. To aid in hemostasis for femoral cases utilizing larger than a 4 French size, our staff is certified in the placement of the Angio-Seal closure device (St. Jude Medical). Unfortunately, the Nevada Nurse Practice Act prohibits RNs from placing stitches, so the Perclose device is only placed by RT(R)s and physicians. For radial access cases, we employ the TR Band with a wrist splint to maintain visual access of the site while neutralizing the wrist. 

How is inventory managed at your cath lab? 

Supply utilization is tracked during each case and documented in the Mac-Lab (GE Healthcare). Trent Foust, one of our cath lab RNs, runs a supply report, then places orders through the hospital’s purchasing department so that a par level of supplies is maintained.

Has your cath lab recently expanded in size and patient volume?

In January of 2013, Saint Mary’s expanded their cardiology service line, recruiting several of the area’s leading cardiologists. The new cardiology team led to cath lab volumes nearly tripling. We maintained steady growth in 2014 and 2015. 

Is your lab involved in clinical research?

Yes, Saint Mary’s has a growing cardiac research program, with several trials involving the cath lab and its patient population.

Can you share your lab’s average door-to-balloon times and some of the ways employees at your facility have worked together to keep door-to-balloon times under the mandated 90 minutes?  

We achieved this goal by adopting the goal of a 60-minute door-to-balloon time. Our year to date average is 40 minutes door-to-balloon. We worked with and educated the emergency department (ED) staff as well as our Emergency Medical Service (EMS) partner REMSA, creating a Code Cardiac protocol and providing/reviewing times for every case. We are registered with Mission: Lifeline and are cycle IV Chest Pain Center certified with PCI. In September 2015, we received the Mission: Lifeline Receiving Center Silver award for our first medical contact to reperfusion times.

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

The Code Cardiac team, comprised of an ED RN, ED tech and Critical Care RN transport our STEMI patients during regular and off hours.

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

Our facility has several contingencies for this situation. If the current procedure can be finished without causing a delay of care, it is finished while the STEMI patient is brought to the staging area and prepped. If the current procedure cannot be finished without causing a delay of care and can safely be postponed, access is maintained and the patient is monitored in the staging area until the STEMI procedure can be completed. In the situation where our team is already in an emergent case, thrombolytics are utilized and PCI is performed at a later time. 

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

After extensive market and price structure research of the northern Nevada and California areas, Saint Mary’s implemented capitated pricing. Our lab is open to all vendors and products as long as they are willing to comply with the capitated pricing, which is evaluated annually. We have also encouraged stewardship for all our staff in trying to minimize costs where possible and appropriate. Our hospital uses a front line, staff-driven approach to process change. Using a combination of Lean and Six Sigma tools, we improved our patient experience, wait times, and flow of patients into the cath lab. These process changes led to faster turnaround times, and decreased physician and patient wait times, giving us the ability to perform more cases in a day.

What quality control/quality assurance measures are practiced in your cath lab?

We recently implemented the use of an outpatient cardiac cath indication form. This form is filled out by the ordering physician and efficiently communicates medical history as well as cardiac presentation to aid interventional cardiologists in decision-making for the appropriate use of PCI.   

Are you recording fluoroscopy times/dosages? 

We document fluoroscopy times and dosages at the end of each case on a radiation report. Some of our physicians utilize this report in their procedure dictations.

Who documents medication administration during the case?

The circulating position documents medication administration during the case and staff can receive assistance from the monitor in situations where multiple time-sensitive drugs are being started or titrated. To ensure accuracy in documentation, closed loop communication is used and the procedure report is reviewed by both parties before it is signed.

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

Our physicians dictate their reports. We have implemented Vincari, a program for surgical structured reporting designed to increase accuracy and ease dictation while meeting ICD-10 regulatory requirements. The report becomes immediately available in the electronic medical record.

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

Our lab is involved in the ACC-NCDR Cath/PCI, ICD, and ACTION-GWTG registries. We also collect and submit for the STS Adult Cardiac registry.

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

We have formed an alliance with our EMS, REMSA and Truckee Meadows Fire Department. We support both agencies with cardiac education. Education is formally provided most months by Devang Desai, MD, FACC, FSCAI, covering topics such as STEMI, 12-lead EKG, and arrhythmias.  

Our lab provides an observation day along with CEUs for RNs, EMTs, paramedics and dispatch personnel. REMSA attends our quarterly STEMI meetings and has a standing agenda time allotted to them. We have two-way sharing with REMSA so that STEMI times can be easily tracked between entities. The collaborative working process we have in place has established a relationship that has doubled the number of cardiac patients we see.

We have a secondary alliance with rural hospitals in our area, including Susanville, California, Redding, California, and Yerrington, Nevada. These hospitals are supported by our cardiologists who hold clinics there monthly and see patients.  

How do you handle vendor visits to your lab?

Vendors contact our manager, Jenna Beadell, RN, PCCRN, who schedules specific days in the cath lab that are then put on our calendar.

How are new employees oriented and trained at your facility? 

Our facility has its own hospital orientation and competencies that must be completed within 30 days of being hired. The cath lab allots 90 days for a new employee to complete unit-specific competencies. An employee new to the cath lab can expect a formal, six-month orientation process. During the formal orientation process, the employee becomes the fourth member of the team during the day and on-call schedule. New employees are assigned a preceptor and they follow their preceptor during the day as they rotate from role to role. Our employees learn all roles simultaneously (circulator, scrub/x-ray, and monitor). We have found that performing each role every day prevents knowledge loss that was occurring when roles were taught separately over two-week increments. We incorporate mock cases into the orientation as well as a sim lab for practice.  

What continuing education opportunities are provided to staff members?

We have a very active and growing electrophysiology (EP) program, and have sent our staff to several conferences of their choosing and supported them in the registered cardiac electrophysiology specialist (RCES) certification process. We have weekly vendor-supported education and the hospital provides all RN staff with 24 paid CEUs annually. 

How is staff competency evaluated?

New employees are evaluated at 30 days, 90 days, and annually. After the first year, evaluations are performed annually. Our lab holds an annual skills day where high-risk, low-volume procedures are reviewed and performed. 

Does your lab have a clinical ladder? 

No, but Saint Mary’s is currently investigating reestablishing its clinical ladder.    

How does your lab handle call time for staff members? 

Our call team is comprised of three members, one of which is required to be an RN. Our staff is on call two nights a week, one to two weekends a month, and two holidays a year. Anyone wanting to take an extra call is permitted, as is trading or swapping days.  

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

Our facility has a 30-minute response time mandate for all call positions.

Do you have flextime or multiple shifts? 

We have flextime shifts.

Has your lab recently undergone a national accrediting agency inspection? 

We recently underwent Chest Pain Center with PCI and Mission: Lifeline accreditations. Even though some of these accreditations seem solely cardiac- or cath lab-focused, we found that the process involved the entire hospital. We needed involvement and participation not only from clinical departments like ED, telemetry, and the critical care unit (CCU), but also non-clinical departments like outpatient offices, marketing, outreach, and environmental services. The accrediting process also caused us to work closely and develop our relationship with our EMS provider, REMSA.   

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

Our lab is located on the fifth floor directly next to the cardiac OR and cardiac intensive care unit. Our ED is located directly under us on the first floor.

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

Improved medical management has led us to see patients later in the disease process, resulting in more complex cases. The use of drugs such as methamphetamines has increased the number of patients we see with pulmonary hypertension and patients in need of cardiac devices, while decreasing the mean age of our patients.     

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

We are associated with Joseph Stevenson, DO, FACC, Associate Clinical Professor at the University of Nevada Medical School. Dr. Stevenson operates the only full-service pulmonary hypertension (PH) clinic in the state of Nevada, including prostacyclins. We are in the process of becoming a certified center of excellence for PH. We are integrated into a progressive medical model where patients diagnosed with PH have applications for medication submitted within 24 hours of their right heart cath and are taking their medication within seven to ten days of diagnosis. We are part of a unique education process involving physician patient counseling. Patients also receive videos to educate themselves and their families on PH. Additionally, we host a PH support group every four months at the hospital.

Is there a problem or challenge your lab has faced? 

When the cardiology group came to Saint Mary’s in 2013, they brought expectations of how the lab would function and perform. At the same time, they exponentially increased our case load. In a very short period of time, we had to cut our turnaround time in half while training the lab staff to function in new roles. Our pre and post area was instrumental in decreasing our turnaround times, transporting patients to and from different areas of the hospital and prepping them, and pulling sheaths as needed. The staff showed great enthusiasm toward the cardiologists and had a willingness to learn. Our cardiology group volunteered to hold a monthly cath conference primarily led by our interventional physicians Frank Carrea, MD, FACC, Devang Desai, MD, FACC, FSCAI, and Eric Drummer, MD, FACC, where educational needs could be addressed and training could be provided to the staff by the cardiologist they would be working with. We had to deal with some growing pains, but the process has elevated our lab and staff to a new level of excellence and instilled a desire to continue improvement.

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 population of Nevada as a whole has led our state to be categorized as frontier land. Reno is a cosmopolitan area, but we service over a 300-mile area that is mostly rural. Our cath lab is a microcosm of the area we serve. We have employees that live rurally on farms, some with young families living in the suburbs, and others live the cosmopolitan life. Despite the diverse lifestyles, we all live within 25 minutes of the hospital.

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?

Our staff is not required to take the exam, but we highly encourage and incentivize them to do so. We financially support educational classes and employees receive an annual bonus upon passing the exam. We currently have several RNs working on obtaining their RCIS: Trent Foust, RN, and Mike Hagstrand, RN, while Jeremy Shea, RN, and Nichole Gocke, RN, are both working toward the RCES.

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

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

The NCDR Outcome Report is presented at monthly meetings with cath lab and cardiology representation. We have used this report to identify several QI initiatives. Our most recent process change was with cardiac rehab referrals. With the use of the Outcome Report and the drill-down feature, we were able to identify a patient population that was frequently missed for cardiac rehab. After educating our physicians and improving documentation, we had a compliance increase from 48 percent to 85 percent, and are continuing to improve. With the use of the outcomes report, we identified several areas that appeared to be under-reporting on the pre-procedural status of our outpatients. As a result, we implemented an outpatient cardiac cath indication form. The use of this form has improved the accuracy and quality of the data we collect and submit.