Central DuPage Hospital’s Interventional Laboratory Department

What is the size of your interventional lab and number of staff?   Our interventional laboratory department is made up of six interventional labs that service cardiac cath, electrophysiology, interventional radiology, interventional neuro-radiology and overflow electrophysiology (EP has a separate, dedicated bi-plane lab). Each clinical specialty has identified a primary lab that can flex to meet other clinical needs as necessary. Patient preparation and recovery for these six labs is provided in our 13-bed holding area, located within the interventional lab department. We have 35 staff members who support the labs and holding area. Our cardiac cath and interventional radiology labs are staffed with registered nurses (RNs) and radiologic technologists (RTs) that work in both specialties. The interventional neuro and electrophysiology teams have core clinical teams supplemented with interventional lab RN staff to provide patient assessment and medication administration. Our neuro team is comprised of RTs, advanced practice nurses (APNs) and physician assistants (PAs). Our core electrophysiology team’s charge nurse is NASPE-certified and oversees RN and cardiovascular technologist (CVT) staff. We have 35 staff members who support the labs and holding area. Our cardiac cath and interventional radiology labs are staffed with registered nurses (RNs) and radiologic technologists (RTs) that work in both specialties. The interventional neuro and electrophysiology teams have core clinical teams supplemented with interventional lab RN staff to provide patient assessment and medication administration. Our neuro team is comprised of RTs, advanced practice nurses (APNs) and physician assistants (PAs). Our core electrophysiology team’s charge nurse is NASPE-certified and oversees RN and cardiovascular technologist (CVT) staff. The lab holding area is staffed by 12-hour critical care RNs and patient care technicians (PCTs) who are supplemented with interventional lab RNs that rotate into holding. This lab/holding RN staffing model allows for more lab-trained RN staff to dilute on-call coverage responsibilities. Eighty-eight percent of our RNs have or are obtaining their BSN degree. The majority of our staff have five to twenty years of experience in their clinical areas. Staff new to the interventional labs have at least five years of critical care or emergency room experience. What procedures are performed in your labs? Our cardiologists perform approximately 1,900 coronary angiograms and interventions annually. In our open lab model, interventional radiologists, cardiologists and vascular surgeons all can perform peripheral vascular procedures. These physicians perform approximately 1,000 peripheral angiograms and interventions on an annual basis. Other labs do approximately 1,800 interventional radiology non-peripheral vascular procedures, 1,000 interventional neuro-radiology procedures and 800 electrophysiology procedures annually. When we moved into our current facilities in June 2005, we integrated the existing cardiac cath and interventional radiology labs. Previously, cardiologists performed peripheral vascular procedures in the cath lab, while the interventional radiologists and vascular surgeons utilized the interventional radiology lab. With our lab integration model, all physicians have access to the same technology and imaging for peripheral vascular work. In addition to integrating the cath and interventional radiology labs, we also established an interventional neuroradiology program. Our neuro team performs diagnostic cerebral angiograms and multiple neuro intervention procedures, such as cerebral aneurysm coiling, carotid stenting, acute stroke intervention and spinal procedures. To provide these services, advance practice nurses and physician assistants are employed to assist in procedures, coordinate a transfer program and consults, and also coordinate significant education and research initiatives now underway. To optimize lab utilization, we have implemented a modified block schedule in our labs. This allows physicians with interventional lab procedural priviledges access to the lab. What procedures do you perform on an outpatient basis? All of our scheduled patients are registered as outpatients for their procedure. Our labs are located in a hospital-based ambulatory services building attached to the hospital. Our hallway is adjacent to the critical care unit to promote efficient patient care. Our holding department recovers patients post procedure. Post-procedure patients are either discharged to home or hospital admission is arranged, dependent on the patient’s status. In addition to patient preparation and recovery, our interventional holding department staff also perform conscious sedation procedures such as cardioversions, transesophageal echos and tilt table testing for both inpatients and outpatients. Does your lab perform primary angioplasty with surgical backup on site? Our laboratory performs primary coronary angiography. Surgical backup is available on site during the day and readily available after-hours if needed. Our on-call list for cardiovascular surgery is maintained in the cardiac cath lab and on our hospital’s intranet, viewable from anywhere in the hospital. What percentage of your patients are female? Forty percent of our patients are female, with 50% of their ages being between 50 and 69. What percentage of your diagnostic cath patients go on to have an interventional procedure? Approximately 33% of our cardiac patients go on to receive percutaneous coronary intervention (PCI). Who manages your cath lab? Julie Nelson, RN, MBA, is the director of interventional labs and non-invasive cardiology. Daily operations are coordinated by our manager, Pat Brown, RN, BSN, and interventional labs supervisor, Bob Burch, RT(R)(CV). Michael Schmidt, MD, FACC, FSCAI is our cath lab medical director. Do you have cross-training? Who scrubs, who circulates and who monitors? Our cardiac and interventional radiology labs consist of all licensed staff, so we are able to maximize staff cross-training. We are currently training all lab RNs to scrub cardiac cath procedures. All staff who pass electrocardiogram (EKG) rhythm competency testing are cross-trained to the hemodynamic monitor role. Only the circulating RN role, which is responsible for patient assessment and medication administration, is performed solely by RN staff. Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab? Radiologic technologists (RT) are present in the department during fluoroscopy procedures. 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? In our lab, both nurses and RTs act as scrub assistants. In this role, they position the II, pan the table and change angles. Dynamic fluoroscopy is performed by the physician in cardiac cath procedures. What are some of the new equipment, devices and products introduced at your lab lately? We are always looking for the newest products to bring in and trial. We were one of the first hospitals in our area to trial St. Jude Medical’s Proxis embolic protection system (St. Paul, MN). We recently brought in Volcano’s intravascular ultrasound (IVUS) (San Diego, CA) for use in both cardiac and interventional radiology applications. IVUS is used in our lab in conjuction with CTO (chronic total occlusion) devices for increased success in peripheral vascular cases. The Virtual Histology and ChromaFlow options in the Volcano system also lead to increased usage for pre and post lesion analysis. Within the last year, we launched Xience V, Abbott Vascular’s everolimus-eluting stent (Redwood City, CA) and AngioScore’s Angiosculpt scoring balloon (Fremont, CA). Most recently, we upgraded our AngioJet (Possis Medical, Inc., Minneapolis, MN) to the AngioJet Ultra platform, which can be used in both cardiac and interventional radiology applications. Our interventional radiology and neuroradiology labs participate in numerous trials, and we have used multiple new devices such as the Jetstream (Pathway Medical Technologies, Kirkland, WA), Cool Tip Radiofrequency Ablation (Covidien Valleylab, Boulder, CO), Acculink Carotid Stent system (Abbott Vascular), Merci Retrieval System (Concentric Medical, Mountain View, CA) and Penumbra System (Penumbra, Alameda, CA). Can you describe the system(s) you utilize and how they work in cath lab daily life? We use the Witt/Philips system (Bothell, WA) to document cardiac cath procedures and Vericis (Emageon Inc., Birmingham, AL) for digital archiving. Peripheral vascular and interventional radiology/neuroradiology procedure images are archived in the McKesson PACs system (San Francisco, CA). Our hospital was ranked as one of the “most wired” and “most wireless” hospitals in the nation. All EKGs, PACs/Vericis images are available via our intranet within the hospital and via remote access from outside the hospital. How is coding and coding education handled in your lab? The department chargemaster and charge requisition sheets are updated quarterly as Medicare changes occur. The interventional lab supervisor, manager and director are responsible for this process. Procedural billing is performed by front-line staff and bill batching/reconciliation is performed by department leadership daily to ensure charge accuracy. We have established a monthly revenue cycle meeting to review coding and research reimbursement. How does your lab handle hemostasis? For the majority of our procedures, hemostasis is achieved using a vascular closure device. The device most often used in our laboratory is St. Jude’s Angio-Seal. We also use Perclose by Abbott Vascular. For manual pulls, we use the FemoStop (Radi Medical Systems, Wilmington, MA) device as needed. Hemostasis recovery is performed in our holding department. Our physician order sets have standardized recovery and we use an early ambulation protocol to expedite care. For stable vascular closure device patients, we maintain bed rest for 1 hour and discharge after 2 hours in most cases. Does your lab have a hematoma management policy? To ensure high quality of care, we centralized vascular access management to the interventional lab holding department. When we opened the interventional holding department in 2005, we partnered with St. Jude clinical representatives to enhance staff training and maximize the benefit of vascular closure devices. Because of our holding staff competency levels, we made the decision to perform all inpatient groin recoveries in the holding department before transferring back to their room. Our interventional holding area is open 6:30am to 7:30pm. After-hours groin management is provided in the critical care units, where the staffing ratios and monitoring promotes safe arterial site recovery. Is your lab involved in clinical research? Currently, CDH has approximately 20 active research studies in our interventional labs. Our cardiac lab was involved in the e-CYPHER trial. Our EP lab was recently involved in the Medtronic Chronicle CHF study and the St. Jude Quickflex study. We are involved in the Cordis carotid stent registry and our interventional neuro program is involved in multiple other studies. How is inventory managed at your lab? We have a central supply area where general supplies are kept. Inventory is managed by several of our senior staff. In each room, we use a barcode system for the majority of our specialized inventory. For supplies not bar-coded, we have par levels set and our interventional lab supervisor is notified when levels fall below par. We have implemented a product review process in which all physicians can provide input into inventory purchase decisions. Has your interventional lab recently expanded in size and patient volume, or will it be in the near future? In 2005, our focus was on integrating multiple interventional lab specialties and establishing an interventional neuro program. In 2007, with assistance from a hospital foundation grant, we opened a state-of-the-art bi-plane EP lab with 3D mapping and CT image merge technology. Because of increasing patient volumes and physician recruitment, we expanded in 2008 with the addition of two more labs. These labs will service interventional neuro radiology, interventional radiology and cardiac cath procedures. During construction, a temporary C-arm room was made available. In addition to lab expansion, our holding area increased to 15 bays. What measures have you implemented in order to cut or contain costs? Integrating the interventional labs (cath, EP, radiology and neuroradiology) has allowed for more effective inventory management. With the constantly evolving inventory products, reducing cost is a never-ending challenge. A few of the measures we have implemented to maximize inventory management include: • Implementation of an inventory management system (we utilize the Witt/Philips bar code inventory management system). • Monitoring contrast utilization and developing a patient selection criteria for Visipaque (GE Medical, Waukesha, WI) use. • Development of a product evaluation process to assess new products. • Maximization and continued “right-sizing” inventory consignment agreements. • Continued vendor inventory pricing negotiations. We have taken advantage of our integrated lab model and negotiated corporate level pricing agreements for different product lines in all clinical specialties. These inventory expense reductions resulted in approximately $800K savings last year. After inventory expense management, maximizing the staffing model and reducing overtime promotes cost reduction, but more importantly, a satisfied staff. We are continually looking at staggered shifts and revised call team models to match current clinical needs. What type of quality control/quality assurance measures are practiced in your lab? • All outpatients receive a follow-up discharge call from our holding area RNs to check on their recovery status and ensure that they understood discharge instructions. • The interventional lab staff perform post-procedure rounds on inpatients to assess groin recovery and to provide an opportunity to interact with the patients. • Multiple QA monitors are performed by the staff. They include ST-elevation myocardial infarction response time, contrast utilization, digital image archive management and conscious sedation. • In addition to the multiple internal QA projects, the labs also participate in American College of Cardiology (ACC)-Cath, ACC-PCI, ACC-Defibrillator and Hi-IQ peripheral vascular databases, and the CMS carotid stent registry. How does your interventional lab compete for patients? Has your institution formed an alliance with others in the area? Central DuPage Hospital is a 313-bed not-for-profit hospital with 8 “Convenient Care” centers and a retirement community. We are fortunate to have an outstanding medical staff comprised of both hospital-based and private practice groups who admit and refer patients to our service. Our focus on quality has been very successful in increasing hospital census and procedural volumes. Over the past few years, we have earned multiple awards related to the care provided in our labs — they include, but are not limited, to: • The Joint Commission Gold Seal of Approval and Special Award: 2005, 2008 • US News and World Report Best Hospitals: since 2007, 2008, 2009 • Thompson Reuters 100 Top Hospitals: 2006, 2007, 2008 • Health Grades Clinical Excellence: 2007, 2008 • Health Grades Coronary Intervention: 2008 • Health Grades Critical Care: 2007, 2008 • Health Grades Patient Safety: 2006, 2007, 2008 • Health Grades Stoke Care: 2006, 2007, 2008, 2009 • PRC 5-star outpatient award • Most Wired/Wireless: 2008, 2009 Our hospital is a recognized Medicare Carotid Stent Facility and we provide neuro-interventional services for 14 referring hospitals. In cardiology, we partner with hospitals without open heart programs to provide surgical backup and receive transfers for high-risk coronary interventions. How are new employees oriented and trained at your facility? Everyone in the interventional labs is licensed — we staff our labs with only RNs and RTs. All staff are BLS-certified and our RNs are required to maintain ACLS certification. We have a competency-based orientation. We tailor the orientation program to meet the individual’s needs. In general, our orientation spans 3-6 months. Orientees are assigned a preceptor who provides hands-on teaching and multiple education resources are used. Before new staff begin call, they shadow the call team to provide adequate orientation. We are currently cross-training the RNs to the scrub role. We assess staff members’ competencies and develop a staff training plan to ensure adequate training resources. What type of continuous education opportunities are provided to staff members? We develop an annual education plan based on staff and physician input. Last year, we established a lecture series with CEU hours for the staff. Because of our multi-specialty labs, our educational offerings cover all lab clinical areas. Some of the resources used include vendor-provided CEU programs, hospital-based online Heathstream courses and department-based journal clubs. In 2008, we initiated clinical conferences dedicated to all specialties. Does your lab have a clinical ladder? Our hospital has a clinical ladder for nursing staff. This clinical ladder recognizes nurses for their leadership and teaching strengths. RN I staff are recognized with higher salaries to compensate for their leadership roles within their departments. We recently implemented a clinical ladder for RTs to recognize advanced image processing skill sets. Our interventional lab supervisor oversees radiation safety and interventional radiology inventory and coding. How is staff competency evaluated? We provide a competency-based orientation. Staff are signed off as “independent” on specific roles after their preceptor has documented competency. We develop an annual education plan with CEUs and competency assessment for new technology, low-volume and/or high-risk procedures. Does your cath lab do electives on weekends and/or holidays? At this time, our cath lab does not routinely perform elective procedures on weekends or holidays. With continued high hospital census, we routinely perform interventional neuro and radiology procedures on weekends to reduce patient hospital stays. We continually review this model and balance the benefit to patient care with the interventional lab staffing needs. At this time, an integrated call team provides on-call coverage for urgent/emergent cardiac cath, interventional radiology and neuroradiology procedures. How does your lab handle call time for staff members? We have an integrated call team that provides primary and secondary clinical call coverage. Our cath call team consists of two nurses and one RT. Our interventional radiology call team consists of one nurse and two RTs. Our neuro call team consists of one RN and 2-3 RTs. Our department hours span 7am – 5pm, with staggered shifts. Call coverage starts at 5pm and continues through 8am. As our volume continues to increase, we are looking into increasing the number of staggered shifts to allow for longer hours of service. How do you handle vendor visits to your lab? We have a strict vendor policy. Vendor visits must be approved and scheduled on a “vendor calendar.” All vendors must check into security and have the appropriate paperwork on an electronic RepTrax (Lewisville, TX) file before they are allowed to come to a patient care area. We usually schedule vendors for specific procedures or for a limited time (3-4 hours). We have found that scheduling vendors is one of our biggest challenges with our multiple disciplines and multiple rooms. Does your lab utilize any alternative therapies (such as guided imagery, etc.)? Music is available in the labs during procedures per patient request. What trends do you see emerging in the practice of invasive cardiology? Our hospital has two 64-slice CT scanners in which we perform cardiac CT angiography. Our interventional lab RNs provide nursing coverage due to the beta blocker therapy required. Use of the Volcano IVUS, with its cardiac and vascular applications, is also an emerging practice. Has your lab undergone a Joint Commission inspection in the past 3 years? We achieved re-accreditation in 2008. There was a large focus on conscious sedation, medication reconciliation and timeout processes. Our most recent projects include standardizing patient “hand-off” reports for ancillary departments throughout the hospital. Tell us about your department layout. We have a designated corridor for the interventional labs. Integrating these lab areas gives us supply and staffing efficiencies not previously possible. Recent changes made to the lab design include a larger combined control room and additional conference room space, and more prep and recovery bays. Recently, we centralized procedural flow to mirror a surgery inner-core model which gives us the opportunity to further maximize patient flow. Where are your interventional labs located in relation to the OR and ER? Our interventional labs are all located on one floor in an outpatient ambulatory building attached to the main hospital. Our labs are located on the same floor as the CCU. We have a dedicated 13-bed holding department adjacent to the 6 interventional labs. The emergency department is on the ground floor. A single elevator provides immediate access from the emergency department to the interventional laboratories. What is unique or innovative about your lab and staff? The integration of cardiac cath, electrophysiology, interventional radiology and interventional neuroradiology has offered significant opportunities to provide efficiencies. We have also transitioned prep/recovery of these patients to our dedicated 13-bed holding department staffed by all critical care RNs. To improve inpatient bed utilization during full census days, the holding department accepts cardiac patients from the ER that require cardiac caths. This process allows patients to undergo a full cardiac workup without being admitted to an inpatient bed. In 2007, the CDH Foundation funded 12-lead EKG technology for in-the-field transmission for the EMS departments that service our hospital. By providing this technology to the paramedics in the field, the EMS staff are able to call the cath lab team in before the patient arrives at the emergency room. By utilizing these technologies, we have been able to achieve and sustain an average door-to-balloon time in the low 60-minute range. We recently developed a cardiac transfer program for hospitals without cardiac surgery programs for high-risk angioplasty. Is there a problem or challenge your lab has faced? Successful integration of several clinical labs requires significant management of staffing, capacity, technology and cultures. We spent a lot of time with the physicians and staff to ensure that all clinical needs were met. We also spent a lot of time with the staff reviewing call team and lab staffing integration. We continually assess clinical coverage needs and break out subspecialty core teams as needed. What’s special about your city or general regional area in comparison with the rest of the U.S.? How does it affect your “interventional lab culture?” Our hospital is located in the western suburbs of Chicago, with easy access to multiple highways. This ease of access is great for staff, whose interests range from metropolitan to rural activities. While this location has great benefits, significant growth in the western suburbs has impacted transportation times and has provided some challenges in hiring staff who are able to respond within 30 minutes. Patricia Brown can be contacted at patricia_brown@cdh.org

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