Cath Lab Spotlight: Hendricks Regional Health
Tell us about your cath lab.
Hendricks Regional Health is a non-profit Magnet® hospital located in Danville, Indiana, serving the western suburban area of Indianapolis. In response to the demands of our growing community, we expanded cardiovascular services in 2005 to include a cath lab. Currently, we have one lab with ten pre- and post-procedure rooms. We have seven registered nurses (RNs) and two registered radiologic technologists [RT(R)]s. Our staff has an average of ten years experience in cardiovascular patient care.
What procedures are performed in your lab?
The majority of our work is cardiac diagnostic and interventional procedures. We also perform diagnostic and interventional peripheral vascular studies, thrombectomy devices, intra-aortic balloon pumps, temporary pacemakers and pericardiocentesis. We perform interventional radiology procedures, including vertebroplasty and kyphoplasty. Sandeep Joshi, MD, FACC, provides electrophysiology services, including implantable devices (generator changes, permanent pacemakers). Additional procedures include transesophageal echocardiograms (TEEs), and cardioversions. We perform approximately 22 procedures per week.
Does your cardiac cath lab perform primary angioplasty without surgical backup on site?
Yes. Our physicians are world-renowned interventionalists who also support St. Vincent’s Heart Center in Indianapolis. Our agreement with the St. Vincent’s Heart Center includes acceptance of patients for emergency transfer. Also, as part of planning for patient safety, we have advanced life support (ALS) emergency transport available on site. There is also a helicopter service on site for emergency transfers. Our team practices emergency processes with both services.
What percentage of your patients is female?
Approximately 40% of the patients we see in our cath lab are female.
What percentage of your diagnostic cath patients goes on to have an interventional procedure?
On average, 59% of our diagnostic cath patients go on to have interventional procedures.
Do any of your physicians regularly gain access via the radial artery?
Yes. One of our physicians led our team to develop a radial artery access program. After educating all members of our cath team and inpatient nursing staff, we have had a very successful implementation. Last review, about 11% of our patients received radial access procedures.
Who manages your cath lab?
Donna Haggard, RN, BSM, MSN, is the Clinical Director. The Medical Director of Cardiovascular Services is Robert D. Glassman, MD, FACC, and the Director of Interventional Cardiology is James B. Hermiller, MD, FACC, FSCAI.
Do you have cross-training? Who scrubs, who circulates and who monitors?
All staff is cross-trained to scrub and monitor cases. Only nurses circulate and administer medications, and RTs are responsible for the radiology equipment and radiation safety.
Does an RT have to be present in the room for all fluoroscopic procedures in your cath lab?
Yes, with the exception of the presence of individuals holding the limited state radiology license, held by two of our nurses.
How does your cath lab handle radiation protection for the physicians and staff that are in the lab day after day?
Lead glass, aprons, collars, and lead screens are used in the cath lab. Radiation levels are monitored on a monthly basis through our radiology department.
What are some of the new equipment, devices and products introduced at your lab lately?
We introduced a fractional flow reserve (FFR) wireless system (St. Jude Medical) in the last year. We are also currently evaluating new hemodynamic and archiving systems.
Can you describe the systems you utilize to organize staff and communicate necessary information?
The staff utilizes a hands-free communication system (Vocera) to communicate during and between procedures, texting to cell numbers (our small size allows a close relationship between staff and physicians), and email for regular correspondence.
How is coding and coding education handled?
We have a dedicated person in our health information management department that collaborates with cath lab staff for coding cases.
Where are patients prepped and recovered? How does your lab handle hemostasis?
Patients are prepped and recover in our pre and post care observation rooms housed in the cath lab area. Manual pull by the cath lab team is our gold standard and occurs 80% of the time. We are proud of our 0% complication rate related to site management. Our closure device use rate is 20%.
What is your lab’s hematoma management policy?
The cath lab staff manages all access sites throughout the hospital.
How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies?
We have an RT and nurse working together to ensure our par levels meet the needs of demand. We utilize the hospital’s online purchase requisition and just-in-time inventory.
Has your cath lab recently expanded in size and patient volume, or will it be in the near future?
Our patient volumes have consistently increased since opening in 2005. To meet the needs of the community, we tripled the square footage of our cath lab area in 2010. We increased to 10 pre and post observation rooms, and added a non-invasive testing/procedure room, several restrooms, staff lounge, patient consult room, and shell space for future expansion.
Is your lab involved in clinical research?
We participate in the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR), but are involved in no clinical research at this time.
Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery?
No.
Can you share your lab’s average door-to-balloon (D2B) times and how employees at your facility have worked together to keep D2B times under the mandated 90 minutes?
Our D2B time average was below the 90-minute benchmark at 77 minutes. We recently received Chest Pain Center Accreditation and as part of that process, we have refined our procedures to include a pre-hospital notification alert that has dropped our average D2B time to 61 minutes.
What other modalities do you use to verify stenosis?
We use intravascular ultrasound (Boston Scientific) and fractional flow reserve (FFR).
What measures has your cath lab implemented in order to cut or contain costs?
We are constantly looking for ways to contain costs. We recently negotiated new prices with our vendors and realized significant savings, particularly for interventional equipment.
What type of quality control/quality assurance measures are practiced in your cath lab?
Quality indicators include, but are not limited to, D2B times, acute care transfers, critical drips, patient satisfaction, and value-based purchasing parameters. Nurse-sensitive indicators have included items such as current weight on patient, pain reassessment and patient safety time-outs prior to start of case.
How does your cath lab compete for patients?
We use advertising, earned media, and social media. We have an alliance with St. Vincent Health in Indianapolis.
How are new employees oriented and trained at your facility?
Currently, all of our staff has more than five years of experience. St. Vincent Heart Center of Indianapolis helps provide training for staff. All staff holds an Indiana state RN or RT license.
What continuing education opportunities are provided to staff members?
We provide CEU programs, vendor seminars, etc. For RTs, 30 hours of continuing education per year are required.
How do you handle vendor visits to your lab?
Visits are scheduled, and we use Vendormate where representatives sign in, get a badge and are accompanied at all times. Pharmaceutical representative visits must be requested by a physician.
How is staff competency evaluated?
We do quarterly evaluation for high-risk, low-volume procedures (such as balloon pump), but other evaluations take place annually.
Does your lab have a clinical ladder?
Nurses can participate in a house-wide clinical nursing ladder.
How does your lab handle call time for staff members?
We are not taking call at this time. After-hours emergencies are transferred to the St. Vincent Heart Center of Indianapolis.
Do you have flex time or multiple shifts?
With our lab being relatively new, the staff has been flexible with their schedules since we opened.
Has your lab recently undergone a national accrediting agency inspection?
We are accredited by the Healthcare Facilities Accreditation Program (HFAP). We also worked closely with our emergency department to pursue Chest Pain Center Accreditation and received that honor in the fall of 2011.
Where is your cath lab located in relation to the operating room and emergency department?
We are fortunate to be directly behind the emergency department and next to the operating rooms.
What trends have you seen in your procedures and/or patient population?
We have seen an increase in radial access and patients requesting that method. We feel this is due to patients researching and becoming more knowledgeable about this technique.
What is unique about your cath lab and staff?
Patients can have continuity of care, with the same nurse before, during and sometimes after the procedure. Because of this set up, we have very low complication rates in our patients and we have consistently maintained extremely high patient satisfaction scores.
Is there a problem or challenge your lab has faced?
Starting a new cath lab from the ground up had growing pains associated with it that were challenging. We went from having an interventional cardiologist one day a week to now five days per week.
What’s special about your city or general regional area in comparison to the rest of the U.S.?
Hendricks Regional Health is located in an area that is growing. Our county is the second-fastest growing county in Indiana. We have a high percentage of obesity and a high number of heart hospitals per capita for our metro area. Our county is also fairly affluent and we face intense competition for well-insured patients.
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 discuss data quarterly at the cardiovascular council meetings, attend- ed by cardiologists, emergency department physicians, and vice presi- dent of medical affairs, as well as the chief nursing officer and nursing directors. Decisions are made based on patient outcomes.
The Society of Invasive Cardiovascular Professionals (SICP) has added two questions to our spotlight:
Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)?
It is not required, but encouraged.
Are your clinical and/or managerial team members involved with any professional organizations that support the invasive cardiology service line, such as the SICP, ACVP, or regional organizations?
Cath lab director Donna Haggard is a member of the SICP and an associate member of the ACC.
The authors can be contacted at DKHagga@Hendricks.org.
