Email Discussion Group
November 2004
Group Members Respond to...Defining a "normal" cath
Creating in-house criteria a goal
Re: Your question 1. A lack of any significant coronary vascular disease (lesions of
Re: question 2. I've no idea on the generally accepted numbers of ‘normal’ caths…assuming one exists.
a. 20-25% is our percentage
b. I think the percentage level should be a bit lower than what I stated above. There needs to be a standardized set of criteria for patients to have cardiac caths done. I believe the criteria varies quite a bit between physicians (depending on where the physician did his/her fellowship). But, as we all can attest, we’ll more than likely never see standardization, unless of course those criteria are developed by the health insurance carriers (and there’s already enough friction between insurance and some physician groups).
A more realistic approach (and one that wouldn’t be quite so regulatory in nature) would be for a cardiology group to develop the criteria in-house and have a senior member of the group proctor any new cardiologists, thus passing along the same criteria to all members in the group.
The second option, in my opinion, is the more realistic one and is one that, I believe, would have the greater chance of success.
T. Revell
trev_7777@hotmail.com
25% fair, but in low risk, difficult
The state of New Jersey permitted a number of hospitals to open up low-risk cath labs in 1997. One of their rules was that hospitals with these low risk labs needed to maintain a normal cath rate of 25% or less. Normal was defined by the state as a less than 50% lesion in any of the coronary arteries. Valvular disease was excluded from the normal category, and I believe that cardiomyopathy is now excluded, although this is a recent change.
The normal rate at the hospital where I am the manager is about 20% at this time. I do think that 25% is fair, but in a low risk situation that can often be difficult to achieve. There must be strict guidelines for pre-cath workup, and the doctors MUST adhere to those guidelines.
Valerie Donnelly
Manager, Cardiopulmonary Services
Christ Hospital, Jersey City, NJ
Vrangr94@aol.com
Check American College of Cardiology
The ACC-NCDR Insignificant CAD is 28.1%.
carletta@weirtonmedical.com
There must be strict guidelines for pre-cath workup, and the doctors MUST adhere to those guidelines
Generally 18-20%. I keep track of all my physicians’ normals to make sure they are less than 20% per year. My percentage for each physician usually runs less than 16%. I have one physician that is 20%.
Larry Sneed, BS, RCP
Coordinator, Cath Lab
Alamance Regional Medical Center
sneelarr@armc.com
Use ACC Guidelines
We use the ACC guidelines This does not include ventricular motion or valvular disease. Normal coronaries are usually at about 15%.
Bill Colditz, RCIS
Manager Cardiac Cath Lab
Mercy San Juan Medical Center
wcolditz@chw.edu
Get facts from peer-reviewed journal
According to ACC/SCA&I Expert Consensus Document on Cath Lab Standards (JACC Vol. 37, No. 8, 2001, p. 2183):
For purposes of definition, ‘normal’ coronaries are defined as those with no or physiologically insignificant diameter stenosis by visual inspection in patients studied specifically to assess coronary anatomy.
...the RAND Corporation study group found rates of normal diagnostic cardiac catheterization studies ranging from 9% to 36% (average 21%).
More recent data from the SCA&I indicate that the frequency of normal angiograms is 20% to 27%, which appears to vary little over a reporting period of several years.
If you don’t have a copy of this document, get one!! It is a MUST read!!!!
As a percentage of total number of diagnostic caths, normals should be as low as possible. A low percentage of normals speaks to good pre-screening.
It also lets third party payors know that you are not over-utilizing your lab. If you can say that your rate of normal is less than that published in a reputable, peer-reviewed journal, then no one can argue with you.
Mark E. Davis, RN
Cath Lab Manager
The Heart Center
Huntsville, AL
MDavis@theheartcenter.md
Suggest peer review of staff cardiologists
It has been our experience that cath patients break down into three major groups: Normal, Medical Treatment and Intervention (Surgical and Catheter Based). These categories usually break down into roughly 30% each. Any significant variation on the Normal group should be addressed by a peer review of staff cardiologists (say one representative from each cardiology group, with normal standards set up by the peer review group). Cases should be presented with no name, and emergent caths should also be reviewed for appropriateness each month. This prevents docs from abusing the Emergent status to get a patient on the table, then the case is a Steve Gressmire RT(R)(CV) ARRT, ACCA
Cardiology Services Manager
Northwest Mississippi Regional Medical Center
Clarksdale, MS
Steve.Gressmire@nwmrmc.hma-corp.com
ACC a Source
The American College of Cardiology defines the % normal cath right now the threshold is 27%. Ours runs at 20% or below.
KStair@wmhs.com
Second Email Discussion Topic: Pregnancy in the Cath Lab Staff
How do you handle a pregnant staff member?
Pregnant staffer shares her experience
I am currently 37 weeks pregnant and still working. However, I’ve been on light duty for about 3 weeks due to some pre-term labor issues. Otherwise, in our lab, we all continue in cases and take call up until 1 month before our due date. Then we still work, but do not have to take call. We do have an extra little apron that some women wear under their regular lead. Our radiation is monitored by a medical physicist. He has shown that we have very little exposure under our lead and states that flight attendents get more exposure to radiation than we do.
Liz, UWHC Cath Lab, Madison, WI
ea.levi@hosp.wisc.edu
Radiation Safety Team
Once a woman formally declares her pregnancy, she is sent to the radiation medical physicist, who is part of the radiation safety team. The physicist discusses the importance of being away from radiation, especially during the first trimester and how to protect herself properly. The physicist makes sure she is issued a fetal monitoring badge, and explains that she can enter the room after the first trimester if she wears maternity lead. She is then required to complete a form to formally declare her pregnancy. Copies are kept by the manager, the physicist, and with the radiation safety committee.
The decision is completely hers if she wants to enter the procedure room during her last two trimesters. If she decides she wants to remain out of the room, then she has the right to do so. She can monitor procedures or work in the post care holding area (recovery room).
I have always respected women and their pregnancies. I have always recommended that they monitor or work in the holding areas for the entire gestational period.
Also, the woman is the only person who can undeclare her pregnancy once she has declared it. If she miscarries or has a spontaneous abortion in early gestation, she has to undeclare her pregnancy in writing.
Chuck Williams BS, RPA, RCIS
Cardiac Cath Lab, Emory University Hospital
CharlesWilliams@mail.weber.edu
State has parameter for fetal doses
In regards to pregnancy within the department, I work under Illinois state regulation (some of the strictest laws). The associate has the right to work within fluoroscopy, she is just requiring an abdominal badge for monitoring. It is only suggested she sustain if possible for the first trimester. Pregnant women continue to work in radiation areas. This is why the state has parameter for fetal doses, to allow for their safety while functioning at work. Our pregnant associates wear long, double-shielding leads and then assist in EP, where the cases require lower dose fluoro.
Stacey.Prentis@advocatehealth.com
Extra film badge assigned
We have had several nurses/techs pregnant in the lab. All were allowed to work as they wished, as we use full radiation protection for all employees. What we DID do, however, was to assign an extra film badge to be worn over the fetus. This was recorded as usual in the monthly log. A TLD would be better suited for this purpose, as the results are immediately available. I believe there are state and federal guidelines regarding this matter.
Alex.Holmes@tenethealth.com
Visit NRC website
Below is a link to the Nuclear Regulatory Commission on radiation dose limits to an embryo/fetus. According to this standard, an employer must provide a fetal monitoring device as soon as it is determined that the employee is actually pregnant, then follow these guidelines. Anything else would be up to the Radiation Safety Officer for the institution (usually a radiologist): https://www.nrc.gov/reading-rm/doc-collections/reg-guides/occupational-health/active/8-36/
Steve Gressmire RT(R)(CV) ARRT, ACCA
Cardiology Services Manager
Northwest Mississippi Regional Medical Center, Clarksdale, MS
Steve.Gressmire@nwmrmc.hma-corp.com
Teamwork helps
Currently we have a staff member who is in her 3rd trimester in the lab. She has worked throughout her whole pregnancy. She wears a second badge for the fetus monitoring but does the same work as the other staff members. As a group, we watch where she is during the case and remind her to be at least 6 feet away while fluoroing and for EP make sure that she has the lead screen between her and the tube.
Connie
No fluoroscopy
We have a policy that you cannot work in fluoroscopy while pregnant BUT we will utilize this person in a different role (i.e. monitoring, pre/post op or supplies). I have managed 3 different programs for 19 years, with numerous pregnant employees.
Thomas Gaylets, t9261@epix.net
Take break from the table
I have worked with very expectant technologists and interventional physicians in my career. They obviously don’t take mechanical risks with lifting and pulling patients or machinery. They do take extra care to cover up abdomen, neck and pelvis with appropriately fitting lead gear.
In addition, many hospitals have now implemented pre-cath standing orders for BHCG test for female patients who are menstruating to rule out pregnancy, even 50+ year olds. We are still a litigious society and a hospital has a right to protect itself from future lawsuits from your family should your wife or future child suffer a work-related injury.
I would also consider swapping roles with a lab colleague who monitors cases vs scrubs. That is, give yourself a much needed break from the table and monitor cases for a couple of months or pull-sheath duty only. The same cases and physician personalities will be there when you return from FEMLA.
DG, CVT, dlgils@innercitymedicine.com
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