Albert Einstein Medical Center

What is the size of your cath lab facility and number of staff members? Albert Einstein Medical Center (AEMC) is located in the city of Philadelphia. The AEMC cath lab consists of 3 cardiac laboratories capable of performing a wide range of diagnostic and interventional cardiology procedures. One lab is equipped with a Philips Allura Xper FD20 (Bothell, WA) to perform various peripheral, diagnostic and interventional procedures. Our cath lab staff consists of 1 nurse manager, 6 staff nurses, 6 cardiovascular technologists (CVTs) and 1 inventory coordinator. We also have 2 electrophysiology labs with their own dedicated staff of 8 registered nurses (RNs). Employee experience varies from 20 years to 1 year. Two of our CVTs recently retired after 25 years. What types of procedures are performed at your facility? We perform diagnostic catherizations (right and left heart), percutaneous coronary interventions (PCIs) including stenting, angioplasty, AngioJet (Possis Medical Inc., Minneapolis, MN), and Rotoblator (Boston Scientific Corp., Natick, MA). We also perform intravascular ultrasound (IVUS) and use the PressureWire (Radi Medical Systems, Wilmington, MA) to evaluate the physiologic severity and the degree of stenosis. Other procedures include intra-aortic balloon pump insertion, temporary pacemakers, pericardicentesis, aortic and mitral balloon valvuloplasties, and myocardial biopsies. In the last two years, we have included peripheral diagnostic and interventional procedures. Since 2007, AEMC has been inserting the percutaneous external ventricular assist device TandemHeart (Cardiac Assist, Inc., Pittsburgh, PA). It provides extracorporeal circulatory support for patients with acute myocardial infarctions, decompensated heart failure and cardiac arrest. Does your cath lab perform primary angioplasty with surgical backup on-site? Yes. AEMC is a teaching hospital with 24-hour cardiothoracic surgery back up. For procedures that are considered high risk, cardiothoracic surgery is present during the catheterization and intervention. What procedures do you perform on an outpatient basis? We perform transesophageal echos, cardioversions and diagnostic cardiac catheterizations as outptatient procedures. Who manages your cath lab? Our cath lab is managed by Lisa Tomlinson RN, BS, who has been employed for over 20 years at AEMC. D. Lynn Morris, MD, is the Chairman of Cardiovascular Diseases and Director of The Heart and Vascular Center. Shahziar Yazdanfar, MD, is the director of the cardiac catheterization laboratory. We have a total of 5 full-time physicians that perform catherizations, one of whom also does peripherals. Do you have cross-training? Who scrubs, who circulates and who monitors? All staff have the opportunity to monitor cases, but it is not a primary nursing function. At this time, only the CVTs scrub in during cases. Our registered nurses circulate during procedures, provide ongoing clinical assessment and assume responsibility for the overall care of the patient. The nurses manage all medication administration and provide moderate sedation. RNs also staff the recovery unit. Since we are a teaching hospital, fellows scrub in along with the CVT and cathing physician. How does your cath lab handle radiation protection for the physicians and staff that are in the lab day after day? All staff members are required to wear their radiation badges, have monthly dosimeter readings and have monitoring performed by the radiation safety department. All staff must wear protective lead at all times during the procedures. Our leads are annually inspected under fluoroscopy as mandated by radiation safety guidelines. The physicians use a protective shield at the head of the table during the procedure. Can you describe your lab systems? We use the Series IV (Witt/Philips Medical Systems) for documentation, patient monitoring, and billing. Our digital archiving system is McKesson (San Francisco, CA) and is used to store all imaging and reports. We upgraded to McKesson in 2006. All our radiographic equipment is manufactured by Philips. What percentage of your patients is female? Approximately forty-five percent of our patient population was female in 2008. What percentage of your diagnostic cath patients go on to have an interventional procedure? Approximately 50% of our cath patients require an interventional procedure. Can you share some of the ways your facility works to keep door-to-balloon (D2B) times under the mandated 90 minutes? We are constantly working to maintain the American Heart Association and American College of Cardiology standard of 90 minutes D2B. This has been a challenge, but we have achieved considerable improvement with the implementation of preferred staff parking and increased cooperation among departments: protective services, the cath lab and emergency department. Is your lab involved in clinical research? Yes, we are in the process of completing the Taxus ARRIVE registry for Boston Scientific. We have been monitoring patients that have had Taxus stents implanted over a 2-year period. We are collecting data on any complication related to the stent or its implantation. How does your lab handle hemostasis? We use the 6 French and 8 French Angio-Seal closure devices (St. Jude Medical, Minnetonka, MN) as our primary hemostasis tool for the femoral artery. For brachial access, radial access below the femoral bifurcation or if a patient has peripheral vascular disease, we use manual compression. All venous access sites are controlled by manual compression. Outpatients undergoing diagnostic procedures are recovered in the patient holding area and monitored for four to six hours until discharge. In-patients undergoing diagnostic procedures are monitored for a brief time in the holding area in the cath lab and then returned to their room. All post intervention patients are also monitored for a brief time post procedure in the cath lab. These patients are admitted to the cardiac care unit (CCU) or cardiac intermediate care (CICU) unit depending on clinical condition. What are some of the new equipment, devices and products introduced at your lab lately? At AEMC, we recently received new Datascope intra-aortic balloon pumps (Mahwah, NJ) and we have introduced the new Datascope balloons, the Linear and the Sensation. Our most recent addition is the Promus stent from Boston Scientific. We are constantly evaluating and upgrading new products to improve patient care. How is inventory managed at your at your cath lab? Who handles the purchasing of equipment and supplies? We have a dedicated inventory coordinator that handles daily ordering of equipment and supplies. We have par levels that we maintain of interventional balloons and stents. What is your lab’s hematoma management policy? We have implemented groin site checklists that are placed in the progress section of the patient’s chart. Cath lab staff document access site, closure device used, groin dressing type, any medications given in cath lab, vital signs and pulses on this sheet. The accepting nurse must document that they agree with the assessment. Cath lab staff provide inservice education for telemetry, CICU, CCU nurses and assistants on groin care and management of complications. Groin management is an annual skill competency that must be completed. What other modalities do you use to verify stenosis? At this time, we use the PressureWire to assess the patient’s fractional flow reserve (FFR) and IVUS. Both of these procedures are used to verify physiologic severity and degree of stenosis. We also have quantitative angiography capabilities through the McKesson system. How are new employees oriented and trained at your facility? New employees undergo a twelve-week orientation period that is designed to fit the educational needs of the individual employee. Both RNs and CVTs are assigned a preceptor who guides them through the orientation process. We currently have no staff members with less than one year’s experience. All of our CVTs are graduates of accredited CVT programs and are RCIS-certified or eligible for certification. The nurses have either critical care or emergency experience. All lab personnel are ACLS certified. How do you handle vendor visits to your lab? Vendors must call ahead and schedule time through our inventory coordinator. Only one vendor is permitted to visit the lab at one time and must wear a visitor’s badge. How is staff competency evaluated? All staff members must attend one skills day per year and complete the required competencies. CVTs complete those skill stations and competencies applicable to the cath lab, while RNs must also complete competencies for critical care. All staff members must maintain ACLS certification. Does you lab have a clinical ladder? At this time, AEMC does not have a clinical ladder program. However, RNs are eligible to apply for the nursing excellence award, a monetary award that reflects activities and responsibilities above the normal nursing role such as teaching, precepting, publishing and leadership. Does your lab utilize any alternative therapies? In an effort to maximize patient comfort and ease, we have music piped into all labs. The choice of music is up to the patient. We also utilize Bair Huggers (Arizant, Eden Prairie, MN) in an effort to keep patients warm and comfortable during the procedure. How does your lab handle call time for staff members? There is one call team available during off-hours, weekends and holidays to maintain 24-hour availability. We do not do elective cases on weekends and holidays. The team consists of 1 attending interventional cardiologist, 1 interventional fellow, 1 RN and 2 CVTs. We are alerted by page and have 30 minutes to arrive. The attending interventional cardiologist has the same response time frame as other staff members. However in the event of a cath alert (an acute ST-elevation myocardial infarction), the attending interventional cardiologist is in contact with the emergency department attending and or the cath lab RN. Do you have flex time or multiple shifts? We do not currently utilize flex time or multiple shifts. The cath lab day is from 6:30 am to 5:00 pm. All staff members work ten-hour shifts, except one RN who works 8 hours a day. Has your lab undergone a Joint Commission inspection in the past three years? Yes, we successfully passed a Joint Commission inspection in 2007. The inspectors were particularly impressed with our department and mentioned this specifically in the roundtable discussions. The best advice we can give is to conduct your lab as if a Joint Commission inspection is always imminent. Review policies and procedures for accuracy and relevance frequently, store supplies in the accepted manner, and routinely inspect medications, IV fluids and supplies for expiration and replacement. We do this monthly. Remind staff members of the importance of current national patient safety goals so that they are incorporated into daily practice and become second nature. Where is your cath lab located in relation to the OR and ED? The operating room is located two floors above the cath lab and is accessed by an elevator just outside the cath lab doors. The emergency department is located one floor down. How do you see your cardiac catheterization lab changing over the next decade? We continue to see an increase in interventional procedures compared to coronary artery bypass graft surgery (CABG). As equipment and technology evolve, we expect this growth to continue. We also expect to see an increase in the amount of peripheral procedures. What is unique or innovative about your cath lab and staff? We consider ourselves a team consisting of highly dedicated, caring, and compassionate individuals with a commitment to provide the best of care to our patients. We are a uniquely cohesive group where each team member is valued for his or her contribution. What is special about your city or general area in comparison to the rest of the U.S. and how does it affect your “cath lab culture”? Philadelphia and the surrounding area are rich in historical tradition. Our colonial and revolutionary history echo in every street and neighborhood. Our institution, once known as the Jewish Hospital, has a long tradition of providing care for the underserved, and that mission continues today. Our patient population is typical of the urban environment, often facing financial hardship and multiple co-morbidities. The Society of Invasive Cardiovascular Professionals (SICP) has added a question to our spotlight: Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? Do staff receive an incentive bonus or raise upon passing the exam? RCIS certification is not required, but is encouraged. Several of our CVTs have acquired the certification and others plan to take it in the future. Upon successful completion of the exam, the candidate is reimbursed for the exam and receives an annual monetary bonus to maintain the certification. RNs are encouraged to attain and maintain specialty certification as well, and are renumerated in the same fashion. The authors can be contacted at viscojoan@yahoo.com

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