Citrus Memorial Hospital

What is the size of your cath lab facility and number of staff members? We have two cath suites, and a six-bed pre/post unit with a total of 18 FTEs and 2 PRNs. Staff consists of 6 CVTs/RTs, 11 RNs, 1 Manager (RCIS), and 1 unit secretary. What type of procedures are performed at your facility? Does your lab perform peripheral interventions? We currently offer diagnostic catheterization, balloon angioplasty, stenting, rotational atherectomy, AngioJet® (Possis Medical, Inc., Minneapolis, MN), pacemaker insertion, automatic implantable cardioverter defibrillator (AICD) insertion, intra-aortic balloon pump (IABP), as well as peripheral studies and interventions to include angioplasty and stenting of renal arteries, leg arteries, filter placements and plaque excision. Peripheral volume is approximately 10 interventions per month but is beginning to pick up. Our previous volume as a diagnostic-only lab was at 700 patients per year. In our first year as an interventional lab, beginning in January 2004 with the opening of our new Open Heart Center, we saw 1885 patients. Currently we are on track for 2400 patients this year. If your lab performs peripheral interventions, what disciplines (physician and non-physician) are involved? Currently, peripheral interventions are performed by interventional cardiologists who have received additional training in the peripheral vascular procedures. The radiologists perform similar procedures in diagnostic imaging and we have two vascular surgeons on staff who utilize the OR and radiology suites. Do you average any overtime per pay period (if so, how many hours)? We do have overtime throughout the pay-period, primarily throughout the winter months in Florida. However, our overtime has been well controlled through scheduling adjustments and proper staffing levels. Do interventional radiologists and cardiologists perform procedures in the same area? Currently interventional radiologists utilize a separate area to perform their studies and the cath suites are only used by cardiologists. Did your facility need to make any changes to the imaging equipment to accommodate peripheral procedures? In the start-up phase of our Heart Center, we purchased one unit that is capable of both cardiac and peripheral modalities in anticipation of peripheral procedures being performed. There was no need for any additional equipment purchases to implement the peripheral program. Does your cath lab perform primary angioplasty with/without surgical backup? The CVOR has a team ready at all times during operating hours and a team can be available within 30 minutes on weekends or after hours. What procedures do you perform on an outpatient basis? Outpatient procedures consist of diagnostic catheterization and peripheral studies. What percentage of your patients are female? We fluctuate between 35 and 45%. Our organization will be kicking off a women’s heart health program on May 1st. What percentage of your diagnostic cath patients go on to have an interventional procedure? Currently 30-40% of our diagnostic patients convert to PCI. Who manages your cath lab? Eric Shiffer, RCIS. His training is through the U.S. Army Cardiovascular school. While in the military, he held many leadership roles in various capacities. Citrus Memorial Hospital is his first organization outside of the military and Eric has managed this cath lab through its start-up and beyond. Eric reports to the Director of Cardiovascular Services, Isabelle Garibaldi RN, MSN, CCRN, who joined the team in April 2004. She has been a great asset to the organization and has played a critical role in our continued success. Does your lab have cross-training? Who scrubs, who circulates and who monitors? Staff is cross-trained to work in both the hold area as well as in the lab. RNs can circulate, monitor and scrub, while our CVT/RTs currently only scrub and monitor. Does a RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab? No. 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? Physicians control the flouro pedal, and any staff scrubbed can operate the table if needed. Does your lab have a clinical ladder? Currently we do not have a clinical ladder. What are some of the new equipment, devices and products introduced at your lab lately? All of our interventional equipment and supplies are relatively new, since the program is new. Our GE Innova flat panel system (Waukesha, WI) was purchased in October of 2003, and we added a Witt hemodynamic system (Melbourne, FL) with imaging and DVD archival in October 2003 as well. We also use a Philips Allura 15 II (Bothell, WA). What other modalities do you use to verify stenosis? We are not currently using any alternative modalities. How is coding and coding education handled in your lab? Cath lab staff only enters the charges, while the coding department attaches the codes. Communication on complicated cases or in the case of errors is with the manager, who also educates the staff PRN. Shortly we will have a coding professional working on location within the cath lab department to better facilitate communication. How does your lab handle hemostasis? All hemostasis is performed in either the cath lab or the hold unit prior to transfer to another nursing unit. We use a combination of manual, Perclose® (Abbott Vascular Devices, Redwood City, CA), and Angio-Seal (St. Jude Medical, Minnetonka, MN). Does your lab have a hematoma management policy? We have protocols established for the management of hematomas, as well as a tracking method established to identify potential problems. We utilize a tracking sheet for each patient with several checkbox items and space to write in comments. In doing so, we can track the operating physician, method of site closure, the person who obtained hemostasis, and the anti-coagulation status of every patient we see. This data is compiled and reported through the Cardiovascular Quality Improvement committee as well as the hospital CQI department. We also report this data to the physicians and provide a report card with several pertinent indicators for each physician to compare their practices with each other on a monthly basis (We are more than willing to share the format with anyone interested). How is inventory managed at your cath lab? Inventory is managed by one CVT who is responsible for maintaining par levels and ordering supplies. All new equipment purchases are handled by the manager and go through the capital request process as needed. Has your cath lab recently expanded in size and patient volume, or will it be in the near future? Yes, we recently added an Open Heart Center in January 2004, consisting of two cath lab suites, a six-bed pre/post hold unit, two CVORs, a six-bed surgical recovery unit, and a 15-bed cardiovascular step-down unit. In the cath lab, we increased our volume from an average of 700 patients per year to approximately 1800 patients in our first year of operation, with no signs of slowing down. In our second year of operations, we are on track to see 2400 patients. Is your lab involved in clinical research? No. Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? Since the opening of our Heart Center in January 2004, we have sent two patients to surgery as a result of complications in lab. Both patients are doing fine. What measures has your cath lab implemented in order to cut or contain costs? We have aggressively negotiated with our vendors in every aspect of our supplies and have consolidated supplies where applicable. We are also associated with VHA and Novation (Irving, TX). What type of quality control/quality assurance measures are practiced in your cath lab? Currently our quality control measures include access site complications and percent normal catheterizations. The access site complications have remained low throughout the previous 18 months of tracking. We just began monitoring our percent normal procedures in January 2005, and through March 2005, our average is right at 30%. We are planning on subscribing to the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR®) in the fall and expect to utilize the benchmarking data for future improvements. We also administer the Acute Myocardial Infarction (AMI) Core Measures. How does your cath lab compete for patients? Has your institution formed an alliance with others in the area? We are the only full service heart center in our primary service area. How are new employees oriented and trained at your facility? What licensure is required for all professionals who work in your lab? All new employees go through the hospital orientation classes and then begin a rotation within the cath lab department. This department orientation can last up to three months, depending upon experience. Each new hire is required to rotate through scrub, monitor, and circulating positions in the lab as well as through the hold area. All patient care staff is RCIS, RT(R), or RN. What type of continuing education opportunities are provided to staff members? We will be hosting a one-day cath seminar this spring/summer, which will provide CEUs for the staff free of charge. Our staff development department provides a variety of self-study and classroom education as well. How do you handle vendor visits to your lab? All vendors schedule their time in the lab through the CVT assigned to inventory management. Upon arrival, they are required to get a visitor badge through purchasing. How is staff competency evaluated? We have an extensive competency-based training protocol, which new hires must go through, and then all staff are evaluated annually thereafter. Does your lab utilize any alternative therapies (such as guided imagery, etc.)? No. How does your lab handle call time for staff members? Is there a particular mix of credentials needed for each call team? Do you have flex time or multiple shifts? Call teams consist of three people with at least one RN on the team. Call is one day per week and one weekend of four. We will have two primary shifts when fully staffed; the cath labs will be on 10-hour shifts four days per week, and the hold area will be on 12-hour shifts three days per week. What trends do you see emerging in the practice of invasive cardiology? Many advances in medication knowledge are changing the current medication protocols. The AMI core measure is working to standardize response nationwide. Multi-slice CT scanners (MSCT) are here and will significantly impact the way in which we practice. I expect magnetic resonance (MR) technology to make great strides over the next 8-10 years as well. Has your lab has undergone a JCAHO inspection in the past three years? Our JCAHO evaluation was in August 2004, and we did great. Where is your cath lab located in relation to the OR department, ER, and radiology departments? Our cath lab is next door to the CVOR suites, and directly above the ER, and radiology departments. Is there a problem or challenge your lab has faced? How it was addressed? With the opening of the new open-heart center, our volume nearly doubled within weeks and has continued to increase. Staffing was our greatest challenge. We split our shifts to cover for the long hours and added personnel to support the rapid volume expansion. What’s special about your city or general regional area in comparison to the rest of the U.S.? How does it affect your cath lab culture? Citrus County is located 70 miles north of Tampa and 60 miles northwest of Orlando. We are centrally located to major cities, airports and other metropolitan amenities. Few counties in Florida enjoy a year-round climate more supportive of health and well-being than Citrus. Summer days average 82 degrees, moderated by constant breezes from the lakes and the Gulf of Mexico, while winter lows average 62 degrees (Source: Citrus County Chamber of Commerce). We are a very close-knit team that works hard and has the opportunity to relax and enjoy life in Florida. Questions from the Society of Invasive Cardiovascular Professionals (SICP): 1. 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? Currently there is no requirement to attain the RCIS credential for our facility. We are in the process of adding an incentive to complete attaining the RCIS credential. 2. 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? The cath lab manager is a member of SICP, ACCA, and ACHE, as well as active with the local American Heart Association. Eric Shiffer can be contacted at Eshiffer@citrusmh.org

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