A Dream Team: Four cath lab nurses come together with education in mind

Julie Logan, RN

You’ve traveled to cath labs all over the world. Tell us how that came about.

I have been extremely fortunate over the years with the opportunities that presented themselves. My background was primarily ICU-CV and neuro. Early in my career, I signed on as a travel nurse with my first assignment in Hawaii. Towards the end of my stay, I was told that San Diego was a good transition back to the “mainland.” I accepted my next assignment in San Diego, which was the turning point in my career. While caring for an aortic valvuloplasty patient, I met Dr. Maurice Buchbinder, one of the busiest interventionalists for the hospital. Over the coming months, I worked with him on several additional patients. In 1999, he offered me a position on his team as a clinical specialist. This role soon evolved and I scrubbed all of his interventional cases (coronary, peripheral and structural). Scrubbing on so many different cases gave me the opportunity to learn and anticipate Dr. Buchbinder’s every move. I began participating with him in live case demonstrations around the world. I believe I’ve now scrubbed on nearly every continent. Cath lab setups across the United States vary, so you can imagine the difference from country to country. We realized that keeping some constancy was important. I scrubbed, took care of the setup and equipment, and Dr. Buchbinder focused on teaching. It was the perfect arrangement. As part of this unique experience, I have been able to spend time in different labs around the world. I particularly enjoyed working in Singapore. The lab was very welcoming and the staff was amazing. I could scrub one case and come back the next year, and they would remember exactly what we needed. I have also been fortunate enough to work in several cities in China, Thailand, Taiwan, Korea, Austria, France, Germany and Italy, just to name a few. In 2001, we began working on a novel percutaneous mitral valve repair system developed by Dr. Buchbinder and a team of engineers at Edwards Lifescience. In 2005, while in Milan, Italy, I was fortunate enough to work with Dr. Ottavio Alfieri, the surgeon who developed the “Alfieri” stitch for edge-to edge repair of leaking mitral valves. I had the good fortune to scrub on the first case actually referred by Dr. Alfieri himself for “percutaneous” repair. Almost single-handedly, I was able to convert his OR into a true cath lab. We successfully performed our very first mitral edge to edge procedure in that very OR/cath lab. I’ve had many unique opportunities to mingle with various physicians, engineers and management personnel. In drawing from these experiences, I’ve been able to enjoy a good mix of clinical, research and business exposure. I have been able to sit in on engineering work for many companies and help with both pre-clinical studies and clinical (human) studies. I learned how to handle all necessary regulatory application submissions such as CE Mark for Europe and the spectrum from start-to-finish for U.S. applications. Again, I have been very fortunate to work with both small start-up companies, where most of the devices are developed, and larger companies who acquire them. I feel comfortable in most aspects of product development from design to clinical testing. Over the years, I have gained the trust of many senior physicians, like Dr. Buchbinder, who has empowered me to evaluate various technologies on his behalf. We have created a nice team in that aspect. But let’s not forget about my day job. Presently, my main focus is clinical research. I am the Chief Operating Officer of a “non-for-profit” research and education organization in La Jolla, California, called Foundation for Cardiovascular Medicine. I am extremely proud of this organization and its contributions to the San Diego community and the cardiovascular field in general.

You have participated on a medical advisory board.

That is something I am very proud of and excited about. Back in 2000-2001, Edwards Lifesciences decided to branch into the peripheral vascular arena. At that time, the head of product development and marketing, who was working with Dr. Buchbinder, decided to recruit both of us to join their peripheral advisory board. We did a lot of experiments with their new stent, which is presently the only FDA-approved stent for treatment of superficial femoral artery disease. I helped develop their protocol and launch a clinical trial. The advisory board started with nine physicians and myself, along with representatives from the management team at Edwards Lifesciences, and grew from there. The peripheral division was recently sold to Bard. Many key opinion leaders were a part of these advisory meetings. It was truly fascinating to see what goes on behind the scenes. We helped the company understand what truly happens in the cath lab, not what they think is happening. It was a great experience. Every day in cath labs, various catheters and devices are used without much attention to what it took to get these devices into the lab. Behind each device are people sitting in conference rooms for numerous hours developing the idea and with the help of talented engineers, devices are born. Following completion of the design work, the struggles and frustrations of first human trials begin. Finally, after many months and sometimes years, there is success and the commercialization of a new device. This track is unbelievably hard and I’ve been fortunate to work through the entire life cycle of many such devices. Every time I pick up a device in the cath lab, I can appreciate what it took to get to that point.

How did you first get involved with the CRT Nurse and Technologist Symposium?

I was invited to the first PCR nursing symposium, before it was EuroPCR, back in 2000. At that time, the session was small, but soon grew to grab international attendees. Several years later, while I was chairing a session, an American attendee kept asking questions. It happened to be Regina Deible. At that time, Regina was working with Dr. Waksman to develop a nursing program for the CRT meeting. Regina invited me to co-chair and assist with the upcoming meeting. We started our working relationship and brought Marsha Holton on board about one or two years later. Tina Evans joined us thereafter. This consortium allowed us to develop a true “cardiovascular professional” symposium geared towards both nurses and technologists. Each of us brings a unique perspective to this effort. Regina is very active in the cath labs on a daily basis. Tina is a manager at one of the busiest cath labs in the U.S., while Marsha is “Miss Education.” I bring to the table little of each of those areas. Over the past eight years, the CRT Nurse and Technologist symposium has grown tremendously and has become an important part of CRT as we know it today. I am very proud of my association with this dynamic group.

Regina Deible, BSN, RN, NIH Heart Center at Suburban Hospital, Bethesda, MD

How did you come to the field of invasive cardiology?

I was one of those fortunate people that was in the right place at the right time. I came into the field of cardiology in the mid-to-late 1980s, when invasive cardiology was at its most formative stage. I was at Georgetown University, where Dr. Kenneth Kent (one of the seminal pioneers of angioplasty) worked, and when he and Dr. Lowell Satler went to the Washington Hospital Center, they encouraged me to come with them, but on the research side. I went from hands-on nursing to research nursing at the WHC in 1990. That was definitely the device era, when technology was just exploding in the cath lab. It was a great time to be in the field, because there were only a few balloons and perhaps one stent, and I was able to work on every single iteration of every single device that came to the cath lab at the Washington Hospital Center for 16 years.

How has the nature of the cath lab team changed since you’ve been in the field?

I think that might be a regional thing, and even within regions, hospital-to-hospital differences exist. What I know with certainty is that versatility and flexibility have became mandates. Technology, economic impacts, competition and volume changes set the stage for the transformation of the cath lab environment. In order for cath lab teams to not only succeed, but survive, there needed to be a gradual shift from a traditional “coronary lab” to a multi-purpose environment which includes peripheral interventions, electrophysiology and even non-invasive testing such at transesophageal echocardiograms (TEE), cardioversions and tilt table testing. Cardiovascular medicine as a whole started to become more centralized in many hospital settings. As a nurse in the lab, there are endless options. At the NIH Heart Center at Suburban, you can play any role, which makes the job more interesting. Whether you are manning the computer, scrubbing at the table or circulating in the lab, or running the non-invasive section in the holding area, you get a good feel for every single capacity. As a learning experience, it’s tremendous, and the way more cath labs are now becoming.

Has new staff and turnover always been an issue in the cath lab?

It’s definitely a niche field. If you get in there and if it’s right, you’ll absolutely love it. But I’ve seen people come in and realize they just can’t handle the experience. There is turnover everywhere in the field of medicine, but I’ve been noticing high turnover more recently, especially in the bigger cath labs, where staff are privy to new technology. Nine times out of ten, the companies creating new technology grab experienced personnel, and they start working in industry. Part of the success of a program, would, by nature, define how its staff is lost. If you do well in your program, you’re also exposing your staff to industry, with its scientists and innovators, and often people are enticed to join that sphere. That is something that is part and parcel of the world of the cath lab.

What is your current position?

I am working at the NIH Heart Center as what they call their “utility player.” I’ll work pre-cath, post-cath, in the cath lab, gathering outcomes — wherever they need me. I also consult for the medical industry on the side, so I maintain a good grasp of what’s going on in the research field also. I work for different companies looking at their device trials. I’ll consult on the creation of a protocol or medical monitoring. I also visit sites just to make sure they are adhering to the protocol of the study in which they are participating.

Can you tell us about the NIH Heart Center?

Suburban Hospital, in a unique alliance with NIH and Johns Hopkins, launched the NIH Heart center program about two and a half years ago to create a more comprehensive cardiovascular program. Dr. Kent, one of the physicians from the Washington Hospital Center, came over to direct the interventional program. The NIH Heart Center is a smaller cath lab, with only three rooms, but we do everything, both interventional (cardiac and peripheral) and electrophysiology work. Suburban has a very strong cardiovascular surgical program, a noninvasive program and something else rather intriguing, which is a mobile heart unit. It’s run strictly by volunteers, and people come from around the area for free consultations every Thursday. The staff of the NIH Heart Center volunteer their time to do some community service in the unit. There’s actually not enough time for everybody who wants to volunteer!

How did you get involved with the CRT meeting?

Of the four of us, I am the only one that’s been involved since CRT’s inception many years ago. When it first began, “CRT” actually stood for the “Cardiovascular Radiation Therapy” program, and that was when vascular brachytherapy was in its reign. CRT (now “Cardiovascular Research Technologies”) has grown enormously since then. I was working for the Cardiovascular Research Institute at the time with Dr. Ron Waksman, and sort of fell into the meeting. Dr. Waksman was generous enough to give me the freedom to create a unique program that truly focuses on the needs of the nurse and tech. I have been involved as a director for many years, and I quickly found that the weight of being a singular director is a heavy one. I was sitting on a panel for eight straight hours trying to be timely, clever, provocative and knowledgeable. It just gets exhausting. I needed to have some partners to share that with! I’m very fortunate to now share this role and am thankful for my co-directors’ valuable input. It’s tough to duplicate the practical experience and knowledge that this particular group has gathered over the years.

What are some of the highlights of this year’s nurse and technologist meeting?

Every year, the challenge in creating this meeting lies in trying to keep it fresh. We’re not at a time like we were in the 1990s, when technology was changing so quickly. Now we are in more of a slow-but-steady stage. Outcomes data is always important, and advancements in the field like treatment of peripheral vascular disease and structural heart disease are hot. Of course, acute coronary syndrome is always a major focus for everyone. Staff turnover is such a huge reality that it remains extremely important to stress the fundamentals. That will always be a focus in every lab, in every hospital across the country. Complex patient care, especially diabetic and renal-impaired patients, cannot be ignored. That’s what makes our meeting a challenge to create, because you want to entice people with new technology, but you also want to lure the hospital staff that may be new, and they are the ones that can get the most out of this meeting. The new staff need to review the fundamentals over and over again. We have made a concerted effort to make this a meeting that focuses on the technologists, nurses and allied health professionals. The design of our meeting is such that our panel sessions always include a nurse, a tech, a physician and one other professional, whether it’s another nurse or tech, in order to reflect the real world that we are immersed in daily. The physicians actually ask to come back and be a part of this meeting because they value the input of the experienced staff that works by their side. To be frank, as someone that is not enamored with endless data talk, you need practical information that staff can incorporate into their workday. It’s not the kind of meeting where people would be afraid to go up and ask a question or two. It’s actually very interactive. Year-to-year, that quality came up on evaluations as the most valuable part of the meeting. We have faculty that is truly open to any question that you could throw at them and a visionary course chairman, Ron Waksman, who supports us every year with our goal to provide information sharing and industry improvement among our peers.

Johanna (Tina) Evans, RN, MSN Manager, Cath Lab, Washington Medical Center, Washington, D.C.

How long have you worked in the cath lab?

I have worked at the Washington Hospital Center for 21 years, and in the cath lab for 19 of those years. I started off admitting patients for the cath lab, which was non-invasive but affiliated with the cath lab, and then I went into being a cath lab nurse. From a cath lab nurse, I moved to a cath lab clinical manager, and from clinical manager, here I am as a manager. I was operations clinical manager at the Washington Hospital Center for about five years, and now, in managing the lab, I’m going into my fourth year.

What are some of the challenges you face?

My number-one challenge is staff; mainly, nurses, because no one likes call. We have our own cardiovascular technologist program in the hospital. Clinicals are done here and didactics are at Howard Community College (Columbia, MD). We have people leaving, whether going into industry or relocating, and we have not filled all of those positions. I actually have just offered a couple positions to new CVT techs that have come out of our program. We currently have 11 senior CV techs. Mostly, the high turnover is with the nurses. Nurses like 12-hour shifts, but we don’t have a lot of 12-hour shifts, and nurses don’t like call. They have to do 36 hours a month. We have 25 FTE nurses, which includes our holding area. On a daily basis, I need at least 14-15 nurses in the lab, and I need at least 10 in our holding, short stay and short-term recovery area. We need at least 28 CV techs per day. Our lab also faces challenges with equipment and supplies. The physicians want everything that comes out, but there has to be a balance of what’s on the shelf that can be used and what we are eliminating. It’s a big challenge.

How many physicians use the lab?

We have over 40 that can use the lab, and daily we may have anywhere from 7 to 10. Last year, we did 13,000 procedures.

Can you describe your involvement with CRT?

This is my second year as co-director for CRT. I was recruited by Dr. Ron Waksman, the chairperson for CRT. As a group, we run all of our thoughts by each other and then slim down the list of topics. Topic areas are also based on our manager’s conference, held earlier in the year so local cath lab managers can express topics of interest and what they think would be important for their staff. We use the manager’s meeting like a think tank, and had one before last year’s meeting as well. New this year is the CRT manager’s symposium, a day before the actual CRT meeting, which will look at several topics of interest, including inventory and how different facilities may share products between departments. We’ll look at questions such as, how much should EP buy if the cath lab already has a particular product? We will also be discussing team building and accountability, as well as staffing issues.

Marsha Holton, BS, CCRN, RCIS, FSICP President and Founder Cardiovascular Orientation Programs, Indian Head, MD

You have a long history in the cath lab.

That’s true, but not as long as others. My background has always been in critical care, since 1979. I have been in the cath lab since 1990. My entry into the lab was as the staff educator, a.k.a. scrub nurse, a.k.a. educator… I loved it from the minute I stepped into the room. And I was scared to death most days. But, the people in the lab were fun to work with and are still friends. That is what struck me first – that everyone there was truly comfortable with each other. It felt like a small family, not a work environment. I love to teach, and suggested that I could teach others how to work in the lab and take care of patients, as soon as they taught me how to work in the lab and take care of those patients. And so, it started: watch, learn, develop a method to teach and teach it. I truly believe that there are many brilliant people in our field that have dedicated their life to helping others learn. I have been fortunate to have met and learned from many of them.

You’ve been on the faculty at many different meetings.

That’s true, and sometimes I pinch myself to make sure I’m not dreaming. I have been faculty at TCT, EuroPCR, New Cardiovascular Horizons, SCA&I/ i2 and New Cardiovascular Horizons. The organizers of all of these scientific sessions have come to realize that the people standing next to the physicians also enjoy being up to date with the newest and greatest technology, so nurse/technologist sessions were born. They asked me to participate, and of course, I said I would be honored. The CRT is a forum where all come together to share and learn. It is a group of talented people from all backgrounds coming together to learn and help others deliver the best patient care possible. All of the teaching, simulation, hands-on and paperwork all has that same purpose, to identify the best way we can meet the needs of our patients. What we share and learn at scientific sessions, we share with our students at Howard Community College, a cardiovascular school of technology in Maryland. We have students at many sites in the greater Washington area. In 2008, we opened a new level of training at the school, a radiology program, so I am envisioning a turf-less field, a truly invasive field of professionals: a multi-disciplinary lab team with a common goal — get the patient the best care possible. I love being in the middle of it all. I love watching the student’s eyes brighten when they get it. Whatever you just said — it could have been the smallest thing — but whatever you just said made it work. They light up like a Christmas tree.

Have you seen a change over the years in terms of staff experience and interest in the field?

Something has certainly changed. High turnover rates were not always been the case. There have always been shortages, but if you go back to when I first went into the cath lab in 1990, there was actually a waiting list of people who wanted to come into the lab as full-time employees. As soon as someone either relocated or had to leave, most places had a numbered system to determine who was next on the list. Then, things changed. From what I could see, it was the combination of several things. First, we had a lot more patients, but we didn’t have the quantity of staff to be able to do procedures safely. So people — and this is across the world, not just in the U.S. — had to go onto the fast track of training. While we could have worked with new staff for a few months to let them understand the whole process, that whole didactic edge was filled in piecemeal. Then the educational budgets were trimmed, and opportunities were cut for staff to travel to these sessions. The problem was that the more patients we got, the more busy it got, and then the less didactic time new people had to learn the field. So, at the beginning of 2000, Wes Todd and I and a lot of very talented cath lab people got together and developed an educational program, the end result being our accredited on-site teaching tool and method. Second, meanwhile, technology went through the roof. We now have very smart machines analyzing everything put into them. The problem is that unless you know exactly what you are putting in and why, and whether it’s a good number, you could conceivably create an event log for a patient that has bad data. The last thing that impacted the staffing-patient ratio was when people left the umbrella protection of the hospital to work for agencies and became contract staff. These three things have all changed the environment and the ability to teach in the cath lab. But we’re taking that back. We’re showing them that we need to slow down and get everything in line. Wes and I have 40 sites up now, not a lot when you figure there are perhaps 3000+ cath labs in the U.S. It’s still a start.

Can you tell us about some of the highlights of the CRT symposium?

This year’s highlights are going to be as much fun as last year’s, and last year was the best in the overall response to the program. We created modules where we had a physician, nurse and technologist talk about the drugs, devices and the process as different types of patients went from door to discharge door. We allowed time throughout each module for questions from the audience. And it was a blast! This year is more of the same and offers even more. For example, the STEMI session. If you have a patient coming in with an acute myocardial infarction, you see how the team was notified, how the patient got on the table quickly and how the research department was integrated. The panel discusses what devices the patient needs, what drugs they got, how staff recovers this patient and who follows them up afterwards. We do the same thing for a patient with severe peripheral vascular disease or structural heart disease. We had vendor training and simulation, with many cases where staff could actually go up and do simulated training: be the physician, be the first assist, switch roles and do one-on-one training with the different vendors and devices. This year we have a separate management track as well. It will be on Tuesday, and focuses on management’s responsibility to the patient. I’m teaching positive management techniques, a topic that is common sense and based in good manners. I’ve been a part of the CRT faculty for a few years. And all joking aside, this is a team of stars. I am just happy they asked me to be a part of the team.

More information is available about the CRT meeting at www.crtonline.org

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