Cath Lab Digest Email Discussion Group

LAST MONTH’s QUESTION: If you have two or more cath labs running: 1. Are you running 8, 10, or 12-hour shifts? 2. Start time of first case in each room. 3. Length of time slots, i.e., 90 min-120 min. 4. Are all diagnostic caths possible interventions in the same setting, or do patients return to their room with sheath in until later in the day? 5. RN to CVT ratio to start each room. 6. Can all staff scrub on all types of cases? 7. If you stagger shifts, when does the second shift arrive? 8. How many staff on call? 9. RN to CVT ratio on call? 10. Number of scheduled time slots in each room per day. 11. Average number of cases done each day in each room? 12. Do you close one room down after a certain hour and run the other room with call team until cases are done? 13. Do you insert permanent pacers in your labs? HAVE A SUGGESTION FOR NEXT MONTH’S QUESTION? Email us at cathlabdigest@aol.com Responses to last month’s question: We have 2 labs and do most interventions in the primary room (it’s newer). 2. First case start time: We start cases at 8am if not in-house. 3. Length of time slots: 1 hour per case. 4. Diagnostic caths possible interventions in the same setting? Interventions may be done at the same time as the finding, depending on a variety of factors, i.e., time schedule of MD. 8. No. of staff on call: 4 staff members 9. On-call staff ratio: One RN, one scrub tech, and 2 ray persons From: MelodyBelaire@aol.com 1. 8, 10, or 12-hour shifts: We have 8- and 12-hour shifts. 2. 1st case start time: 0730 each room 3. Length of slots: 1 hour, 15 min. 4. Dx caths possible interventions, same setting? All caths are possible PTCAs. 5. RN to CVT ratio to start each room: 1 rad tech, 1 scrub tech, & at least 1 RN. 6. Can all staff scrub? All rad techs can scrub and most of the RNs 7. Second shift arrival time? We do not stagger shifts. 8. No. of staff on call: Three. One rad tech, 1 scrub tech, and at least 1 RN. 9. No. of scheduled time slots: 13 time slots in each room per day 10. Average no. of cases done daily in each room? 10 in one room and 6 in the other. 11. Close one room down after a certain hour? One room has a dedicated evening shift; the other room has on-call personnel after 1930. 12. Insert permanent pacers? Yes. From: DougCDIC@aol.com (Doug, Supervisor) 1. 8, 10, or 12-hour shifts: 8-hr shifts 2. First case start time: Cath lab 1 starts their schedule at 0700. Cath lab 2 starts at 0800. 3. Length of time slots: Time slots are every hour, but realistically, only straightforward, uncomplicated cases get bumped back as needed. Physicians are given a 30-minute "heads up" throughout the day that their case time is approaching. This does cause some problems with schedules at the clinic and other diagnostic areas that require their presence, but it is what we are used to. 4. Diagnostic caths possible interventions in the same setting? It is rare that patients return to their rooms with sheaths in. We generally move right into intervention if needed. One situation which would necessitate the patient returning to their room and coming back to us later is in the event that we need standby from the OR and they have both their heart teams in the middle of procedures. We do occasionally wait for them to finish. 5. RN to CVT ratio to start each room: We run either 1 RN and 2 RT/CVT staff per case or 2 RN and 1 RT/CVT, depending on what staff is here. All on-call emergency cases are 2 RN, 1 RT/CVT. 6. Can all staff scrub? All RT/CVTs scrub all cases. Nurses do not scrub. 7. Second shift arrival time? First shift 0630, then staff filter in at 0700, 0730, and on-call staff at 0800. 8. No. of staff on call: 3 staff members 9. On-call staff ratio: 2 RNs and 1 RT/CVT 10. No. of scheduled time slots: Cath lab 1 has 10 and Cath lab 2 has 9 11. Average no. of cases done daily in each room? Average of 6 per room 12. Close one room down after a certain hour? After the 1600 cases we close down to one room and the on-call staff finishes whatever is left to do. 13. Permanent pacers? All implants are done in our OR room, which is staffed by the Electrophysiology group. They are cross-trained to the cath lab, but have their own schedule and staff assigned to them daily. From: JJenisch@rcrh.org 1. 8, 10, or 12-hour shifts: We have four labs. Not enough staff to run all four. Only three full time. We all work 10-hour shifts four days a week (7:30 am-6pm). Many personnel work their day off to keep the rooms running with as much staff as possible. 2. First case start time: Our start times are 8am except for Wednesdays due to conferences from 7:30-8:30am. 3. Length of time slots: 60 minutes 4. Diagnostic caths possible interventions in the same setting? Diagnostic cases are ad hoc PCIs. 5. RN to CVT ratio to start each room: RN-CVT ratio can be 2:1 or 1:2. 6. Can all staff scrub? All staff are fully cross-trained. All are ACLS-certified. All have been trained in conscious sedation through anesthesia services. 7. Second shift arrival time? We haven’t staggered shifts in over a year due to manpower shortages. 8. No. of staff on call: Three team members are on call at all times. Four when we begin to precept a new employee. 9. On-call staff ratio: RN to CVT ratio on call: Can be 2:1 or 1:2 10. No. of scheduled time slots: We have 8 time slots per room per day. 11. Average no. of cases done daily in each room? 7-8 12. Close one room down after a certain hour? The last elective cases for the rooms other than the one going to be used for the on-call staff is not put on the table after 5pm. The call team uses the room that has the fastest CD-ROM system to download the case. 13. Permanent pacers? PPM and ICDs are done in a separate EP lab. They have 2 rooms. From: codywms@msn.com (Chuck Williams, Emory University Hospital) 1. 8, 10, or 12-hour shifts: We have 8 and 10 hour shifts, staff preference. 2. First case start time: Four labs, we start 2 at 8am and 2 at 8:30am. 3. Length of time slots: No real length of time slots. 4. Diagnostic caths possible interventions in the same setting? Same setting majority of time. 5. RN to CVT ratio to start each room: 1 RN, 1 CVT, 1 Cardio-Invasive assistant (scrub tech). 6. Can all staff scrub? Our intent is to train all staff to scrub on all cases. Due to recent staffing shortages, RNs have not been trained to scrub. 7. Second shift arrival time? Staff start at 7:30, 8am and the call team works 11am-7:30pm. 8. No. of staff on call: 3 staff members 9. On-call staff ratio: One RN, 2 other call folks can be a CVT or one may be a scrub tech. 10. No. of scheduled time slots: No slots schedule as many cases as need to be done within reason. 11. Average no. of cases done daily in each room? 5 12. Close one room down after a certain hour? We also have a late team that stays to finish cases if more than one cardiologist is working; if only one, the call team stays and other rooms are shut down. 13. Permanent pacers? No permanent pacers are done in the cath lab; ep labs are separate physically from the cath lab. From: Ccole@carilion.com 1. 8, 10, or 12-hour shifts: We run 4 10-hour shifts. Days off rotate. When a person is off on Friday, they are also off Monday of the next week. Therefore, every 5th weekend is a four-day weekend. This has worked out very well for us, and is an attractive incentive when hiring new staff. 2. First case start time: 0700 in the first room and 0800 in the second room. 3. Length of time slots: Diagnostic Heart Cath: 60 minutes Pacemakers: 90 minutes Special procedures: 60 minutes PTCAs: 90 minutes 4. Diagnostic caths possible interventions in the same setting, or do patients return to their room with sheath in until later in the day? Both. 5. RN to CVT ratio to start each room: One RN, one RT, and the third person is either discipline. 6. Can all staff scrub? Yes. 7. Second shift arrival time? 7:30am. The first shift runs 6:00am to 4:30pm. The second shift runs 7:30am to 6:00pm. The second shift is the call team and stays late if needed. We all try very hard to get the first team out at 4:30. It helps everyone’s mindset to be able to count on getting out on time at least part of the time. 8. No. of staff on call: 3 staff members 9. On-call staff ratio: One RN, One RT, and the third person is either discipline. 10. No. of scheduled time slots: Room one: 7-8 slots, and Room two: 7-10 slots. 11. Average no. of cases done daily in each room? 6 12. Close one room down after a certain hour? Yes, room two closes down at 4:30. 13. Permanent pacers? Yes. From: mpierski@baxterregional.org (Michele Pierski, Baxter Regional Medical Center, Mtn Home, AR) 1. 8, 10, or 12-hour shifts: We run 8 hour shifts. 2. First case start time: 7:00am for both rooms 3. Length of time slots: No scheduling policy. Some cases are scheduled at half hour intervals. This causes huge delays and lots of problems. The lab supervisor will not set a scheduling policy, even though the staff have repeatedly asked for it. We are trying to convince the docs to do something about it, but they all abuse scheduling and thus don’t want to restrict it. Catch-22. 4. Diagnostic caths possible interventions in the same setting? All diagnostic cases have permission to proceed with intervention in the same setting as long as the patient has been informed and consented. 5. RN to CVT ratio to start each room: It’s a mix. We use three per case depending on acuity. Nurse must circulate, other positions filled with available staff. Most nurses don’t do complex R+L heart caths yet, as they haven’t mastered the calculations that are sometimes required. 6. Can all staff scrub? All staff scrub all cases. 7. Second shift arrival time? The call team for any given day arrives at 9:00am. 8. No. of staff on call: Three people are on call at any given time. 9. On-call staff ratio: Must have one nurse. 10. No. of scheduled time slots: As many as needed. 11. Average no. of cases done daily in each room? Average was around 6, but we may have as many as 11. 12. Close one room down after a certain hour? Most days, non-call people are out by 5pm, sometimes earlier. Call team stays until the work is done. 13. Permanent pacers? Yes. We do PMs and ICDs. Most of our EPs are done at our sister facility. 1. 8, 10, or 12-hour shifts: We have four labs but currently only three are being used. We are on 10-hour shifts. Our first shift, which is 0700-1730, starts the first case at 0800. Our second shift starts the second room at 0900; their shift is 0800-1830. Three days a week we run three rooms. The third room case starts at 10am and the shift is 0900-1930. 2. First case start time: Our first shift, which is 0700-1730, starts the first case at 0800. Our second shift starts the second room at 0900; their shift is 0800-1830. Three days a week we run three rooms. The third room case starts at 10am and the shift is 0900-1930. 3. Length of time slots: Our time slots are usually like this: LHCC: 1 hour RLHC/RLHC with BX: 2 hours LHC/possible PCI: 2 hours AICD: 2 hours Perm Pacemaker: 2 hours Biopsy: 1 hour EPS and RFAs are usually allotted more time: 2-3 hours 4. Diagnostic caths possible interventions in the same setting? Our interventions are done at the same time as the diagnostic cath unless there is not an OR available for backup or there is a problem with the interventionalist being unavailable. 5. RN to CVT ratio to start each room: We have four staff in each room: 1 RN, 1 RT, 1 CVT, and the fourth person can be any of the 3 disciplines. 6. Can all staff scrub? No. Some of the RNs are trained to scrub but usually on the diagnostic cases and combos, biopsy. Our CVTs and RTs do all the scrubbing. We would love to cross-train, but do not seem to have enough RNs to do it. It is required to have an RN as well as a RT in each procedure. 8. No. of staff on call: We have four people on call with the same RN, CVT, RT ratio as in #5. 10. No. of scheduled time slots: 5 slots are in each room per day. 11. Average no. of cases done daily in each room? Our lab varies with the number of cases done per day. Sometimes we run two rooms and have only 8“10 cases. Other times we have 3 rooms, filled with cases scheduled up to 9-10pm at night. 12. Close one room down after a certain hour? We have the last case in the day in the start room at 1600, and then that room goes home at 1730. Depending if it is a three-room day or not, and depending on the cases left, we either have the late crew (start time 0900-1930) or the call team (0800-1830) stay and finish. If at 1730, there are two cases left, both the call and late team stay and finish. If there is only one case left, the late crew stays and does it, since they are on ST until 1930. If there are several cases left, call and late crew stay (until 1930). After 1930, all the remaining cases are finished by the call team (0800-1830). Last case in the call room is at 1700, and last case in the late room is at 1800. However, cases are frequently scheduled after these times. 13. Permanent pacers? We do insert permanent pacemakers in our lab and have been doing so for many years. I started in the lab in 1989 and they were putting in pacers at that time. We do not have a surgeon assist. The cardiologist does the whole procedure. We also placed AICDs in our lab, also done by cardiologists without a surgeon. We have one room which is for EPS, RFA, AICD and pacemakers. When none of these type cases are scheduled we use the room for dx and PCI cases. From: Annie.Ruppert@sharp.com (Annie Ruppert, RN, Sharp Memorial Hospital, San Diego, CA) Currently we are running two labs with expansion of a third lab projected by May 2001. This will also expand our prep/recovery area from 8 beds to 16 beds. Our volumes remain high, with approximately 2900 diagnostic and interventional cases (coronary and peripheral) out of the two labs. We also implant pacemakers, AICDs and do diagnostic EP studies. With these cases added in, it brings our caseload to approximately 3200 per year out of the two labs. It appears by the time we have a third lab in place, we will hopefully be on our way with the addition of a fourth lab, as we have enough CON equivalents out of the current two labs. Here is how we currently are running: 1. 8, 10, or 12-hour shifts: Each lab runs a 10-hour shift, 0630-1700, with the first case scheduled to start at 0700. The biggest problem is trying to get the three MDs who drive 60% or more of my business to arrive on time for cases. They are consistently late, which makes the day run late. Staff have been concerned with the late hours to finish up add-ons. This may improve some with the third lab, but with more cardiologists receiving peripheral privileges and the possible addition of an ablation program, the third lab will probably not help for long. 2. First case start time: Our prep area runs 0600-1630, recovery 0800-1830 and non-invasive 0700-1730. With the added recovery space coming, we will add a 1500-2330 shift for recovery and have the third lab run 0730-1800, with the start time in this lab for 0800. 4. Diagnostic caths possible interventions in the same setting? A bigger share of the cases are scheduled for possible intervention, especially with MDs who cath one day per week. If not scheduled for possible PTCA, if a lesion is found and family is available for consent, we will usually then proceed. 5. RN to CVT ratio to start each room: We run one RN and two techs daily in each lab. 6. Can all staff scrub? Techs scrub. We do have one RN who is also an RT who scrubs. 8. No. of staff on call: 3 staff members 9. On-call staff ratio: One RN and two techs, unless vacations come into play. Then we can go with two RNs and one tech. Call staff work their 10 hour day and then finish up any add-ons that have come through the day. This can make for some long days. Currently call rotates approximately 7 days per month among the staff (one weekend and a rotating day throughout the week). 11. Average no. of cases done daily in each room? We can usually do 14 cases per day (7 per room), if all MDs show up on time, and not past 1700. 12. Close one room down after a certain hour? After 1700, one cath lab goes down, and the call team finishes up the day of add-on cases. 13. Permanent pacers? We have gotten around the anesthesia coverage issue by having the implanting AICD MD trained in conscious sedation and airway management by the anesthesiologists. We give Brevital IV when it is time to check the AICD and have a respiratory therapist in the room to monitor the airway. The respiratory therapist is also trained in intubation if needed. Five minutes later the patient is awake and the cardiologist is almost done closing the pocket. From: BEES9909@aol.com (Bart RN, RT(R)) 2. First case start time: 8:30am 3. Length of time slots: 90 minutes 4. Diagnostic caths possible interventions in the same setting? Unless an emergency occurs or equipment fails, all cases are possible intervention at the same setting. 5. RN to CVT ratio to start each room: 1 RN, 1 scrub tech and 1 tech to monitor. 6. Can all staff scrub? All scrub staff scrub interventions, diagnostic, pacemakers, ICDs, etc. 7. Second shift arrival time? 7:00 first shift, room setup 7:30 2nd shift, assists with room readiness 8:00 3rd shift, call team, stays late for cases 8. No. of staff on call: 3 staff members 9. On-call staff ratio: 1 RN, 1 scrub, 1 monitor 10. No. of scheduled time slots: As needed for the day, occasionally a 7:00 case as doctors’ schedules dictate. Otherwise, cases are 90 minutes apart. 11. Average no. of cases done daily in each room? 6 12. Close one room down after a certain hour? If we have no staff willing to stay, yes; otherwise we will run two rooms. 13. Permanent pacers? Yes. From: Wcolditz@chw.edu (Bill Colditz, Manager Cath Lab, Mercy San Juan Medical Center) 1. 8, 10, or 12-hour shifts: We have two cath labs. We have one eight and one ten hour shift, three staff each shift, alternating weeks with one lab starting at 0630 and the other starting at 0830 (these people cover call). 3. Length of time slots: We do not have allotted slotted times. Knowing the level of talent determines the approximate time of lab usage per doctor. It sounds unbelievable but it works. We have 11 cardiologists but all do not work everyday. 4. Diagnostic caths possible interventions in the same setting? All caths are possible interventions in the same setting. 6. Can all staff scrub? Either RN, or CVT, or RT all personnel are cross-trained. 8. No. of staff on call: 3 staff members 9. On-call staff ratio: We try for an RN, RT and paramedic. 11. Average no. of cases done daily in each room? We do not have an average, but with the two rooms, if someone has an exceptionally long case, then the other room takes up the extra cases. We average between 14 and 20 cases per day, and we are finished usually by 4:00pm. 12. Close one room down after a certain hour? If there is a late case, yes, the call team stays, but only after all cases are close to being finished. 13. Permanent pacers? Our third room is an EP lab where most of the pacers and ICDs are inserted. We can do a pacer or ICD in one of the other rooms if the cath schedule is completed. From: Roberta.Sparks@advocatehealth.com (Roberta Sparks, Good Samaritan Hospital, Downers Grove, IL) 1. 8, 10, or 12-hour shifts: We are currently running scheduled 8 hour days with the call crew picking up end of shift. We’ve explored 10- and 12-hour shifts, but have found that we need another cardiologist to make this consistently work. 2. First case start time: The start times vary in our lab, with 9:30 each Monday, 9:00 every other Wednesday, and 9:00 every Thursday. Tuesdays and Thursdays are at 6:15. If there are less than 2 scheduled cases for the day, then we start at 7:00. 3. Length of time slots: Dependent on the procedure scheduled. Diagnostics are typically 60 minutes and planned angioplasties are 2 hours. 4. Diagnostic caths possible interventions in the same setting, or do patients return to their room with sheath in until later in the day? Currently, we have 2 interventionalists that do the angioplasty immediately following the diagnostic, if appropriate. We have one other interventionalist who refuses to do the intervention following the diagnostic unless they become unstable during the case. 5. RN to CVT ratio to start each room: 1 RN to 2 technologists to start each room, unless it is a known diagnostic only, in which case 3 technologists can do the case. 6. Can all staff scrub? No, currently only the technologists are scrubbing and panning the table with the exception of 1 RN, who came to us with 10 years of scrub experience. In addition, we have a mix of technologists that can monitor and a few RNs who can pan the table. 7. Second shift arrival time? The second shift comes 1 hour after the first shift, and the third start time is at 9:00am, which is our call crew. 8. No. of staff on call: 3 staff members 9. On-call staff ratio: One RN and 2 technologists. 10. No. of scheduled time slots: Currently only the radiologists in Special Procedures limit the amount of scheduled cases to 2 cases per day. We do not have a limit on scheduled cases done by cardiologists, whether they are cardiac or peripheral cases. 11. Average no. of cases done daily in each room? 4 12. Close one room down after a certain hour? Yes. We run the cardiac/peripheral room until 4:30 and the cardiac room goes with the call crew until finished. 13. Permanent pacers? Yes, ICDs also. From: MRupert@providence.org (P.J. at Providence Yakima Cath Lab) 1. 8, 10, or 12-hour shifts: We currently have 8-10-12-16-hour shifts. These shifts have been in place for a couple of years now, and are very effective. 2. First case start time: We staff 1 room to open at 6:30am and if more than 1 physician requests the time slot, we make staffing arrangements to accommodate. 3. Length of time slots: Dependent on the procedures and physician. 60 minutes for caths and 90-120 minutes for angioplasty. 4. Diagnostic caths possible interventions in same setting, or do patients return to their room with sheath in until later? Cases are booked as L&Cor, L&Cor possible PTCA, or PTCA. If a physician has a case booked as a L&Cor and it needs intervention, they may choose to proceed with the fact that they will be bumping all other physicians behind them on the schedule. Because of this, our physicians very rarely exercise this unless it is deemed an emergency. 5. RN to CVT ratio to start each room: We have RNs, RT(R)s, RRTs, CVTs, LPNs, and ORTs in our lab. In the cath rooms, we have at least one RN and RT(R) to each room and dependent on staffing, one RRT (we currently have 3) in each of the cath rooms. In our EP rooms, we staff ORT, RT(R), RN and LPNs. 6. Can all staff scrub? Yes, our staff is completely cross-trained (or in the process of being trained). This includes EP staff cross-trained to cath and vice versa. 7. Second shift arrival time? The administrative director and nurse manager our lab are both progressive in their staffing views. It is their belief that if you set your own hours and days, you will not only reduce tardiness but work the hours that best suit you and/or your family, thus creating a happier associate. Our first shift comes in at 6:00am, then some arrive at 6:30am, 7:00am, 9:00am, 10:30am, 1:00pm, and 3:00pm. Our PRN/Supplemental associates call on the day they are able to work to see if they might be needed. 8. No. of staff on call: 3 associates, Monday-Thursday and 4 on Friday-Sunday. 9. On-call staff ratio: At least one RN and RT(R) per call team. We also like to have an RRT on each team, but that is not always possible (3 on staff). 10. No. of scheduled time slots: No limit. 11. Average no. of cases done daily in each room? 6-8 in the angioplasty rooms, 8 in the diagnostic room, and 5 in each of the EP labs. 12. Close one room down after a certain hour? EP staff does not take call, therefore, they stay until their work is done. On the cath side, we run two rooms until 11pm, unless the schedule is finished. If there is not enough staff to cover until 11pm, then the call team covers. 13. Permanent pacers? Yes, along with other implants. From: Escoggin@midsouth.rr.com 1. 8, 10, or 12-hour shifts: We have 8 hour shifts. 2. First case start time: 0800 and 0830 3. Length of time slots: 120 minutes unless specified otherwise. 4. Diagnostic caths possible interventions in the same setting? All caths are possible interventions. 5. RN to CVT ratio to start each room: 1 CVT, 1 RN, 1 RT (if a fourth person is needed, any one of the three is okay). 6. Can all staff scrub? Yes, including peripheral vascular, EP, and pacemakers. 7. Second shift arrival time? 0800 arrival. 8. No. of staff on call: Four for hearts and interventions. Three for peripheral procedures and permanent pacemakers. 9. On-call staff ratio: 1 RN, 1 RT, 2 additional positions vary between RN, RT, or CVT. 10. No. of scheduled time slots: 4 each (08, 10, 12, 14) and (0830, 1030, 1230, 1420) 11. Average no. of cases done daily in each room? 4 to 6. When the schedule is heavy, we often run a third room and adjust staffing 3 to a room. 12. Close one room down after a certain hour? Yes, although our employees who are not on call will frequently stay and help finish procedures. 13. Permanent pacers? Yes. From: JNelson1@memorialcare.org (Jan Nelson, RN, CCRN, Program Coordinator - Cardiovascular Labs, Saddleback Memorial Hospital, Laguna Hills, California) 1. 8, 10, or 12-hour shifts: 90%of the staff works 10-hour shifts. The shift is 8-6:30 (until we are done). There are 3 people who come in at 6:30 to open. We have 4 MDs and usually try to only have 3 here at a time. We have 3 rooms and are a closed lab. 2. 1st case start time: We try to make it 8am (sometimes earlier). 3. Dx caths possible interventions in the same setting? We do the procedures in one setting. Nobody is ever scheduled to return the same day. If the patient requires multiple coronary as well as peripheral procedures, they may come back days or weeks later for further intervention. 4. RN to CVT ratio to start each room: All people are cross-trained. WE have Rad Techs, RCISs, and RNs. We have 3 people per room (occasionally 4 per room) and prefer 2 drug-givers per room. The techs who have passed the RCIS exam and the cath lab pharmacology test, and who have been precepted in medication administration may give drugs. 5. Can all staff scrub? Yes. 6. Second shift arrival time? We do not stagger shifts other than mentioned above. 7. No. of staff on call: Three M-F. Four are on call on the weekend with one additional employee scheduled for weekends only. 8. On-call staff ratio: One drug-giver during the week. At least one RN on the weekend. 9. No. of scheduled time slots: Generally a doctor gets a room to himself all day and will work at his own pace. 10. Average no. of cases done daily in each room? 8“10 per room per day. 11. Close one room down after a certain hour? As one room finishes, 3 staff members who have accrued the most hours during the current pay period are given the option to go home. I just go down the list and there are always 3 people willing to go home. This will leave 3 people in each of the two rooms and 2-3 in the observation room. The call team can be called in for those cases which are added on after 6:30 pm. 12. Permanent pacers? No. From: jamessaine@mrhs.org (James Saine, RN, CCRN, RCIS, Education Coordinator, Cath Lab)

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