Email Discussion Group

(Thank you to Defib Baptist Health, for last month’s discussion group question, below). Is your lab FULLY cross-trained, so everyone does every role, including giving meds? Which state do you live in? We all do some things. The meds are for RNs only. The scrubbing is shared by both techs and RNs. It depends on when you went to work in the CCL if you scrub or if you even want to scrub. All new employees are taught to scrub and scribe. Springfield, Missouri mikejerierin@alltel.net When the low-risk lab that I supervise was first opened, the goal was for all staff to cross-train for all duties, with the exception of giving meds, which in the state of New Jersey, only a nurse or physician can do. When I had a full staff in the beginning, we were all cross-trained. Now, because of my desperate staffing situation, it is not possible. This poses a severe problem when there is a vacation or sick call, because there is no one else to jump in if necessary. I have been relying on agency nurses to supplement the lack of staff, but obviously this is not an ideal or cost-effective situation. Vrangr94@aol.com I live in southern Texas and as far as cross-training goes, there is very little to none. I have worked in a wide demographic of areas in this country and have found this part of the country to have the least amount of cross-training. As an RCIS/EMTP, I can monitor and scrub cases, but circulating is out of the question. RNs circulate and sometimes monitor, but usually just circulate. The idea of a team concept is not fully exploited and the quality, as well as the quantity, of care is compromised because of it. Anonymous No, our lab is not fully cross-trained. In our lab, the RTs and CVTs scrub. Some of the RTs can also monitor, but not all. All the CVTs are trained on the monitor. Only one or two RNs can scrub, and then only diagnostic cases. RNs are cross-trained to monitor, but mostly they circulate. We try to cross-train everyone, but the problem is that they don’t get enough time to monitor or scrub (RN) once they have been trained, so they never get to improve their skills. I am from San Diego, CA Annie.Ruppert@sharp.com I live and work under the laws of California. In our state only those with a fluoro license can pan. How do other cath labs do it? How many people do you have on call? The laws in California prevent anyone except for licensed personnel (in our lab it would be physicians and RNs) from giving medications. Areas that do not require licensure but do require competencies are monitoring, data collecting, stocking, etc. mhannafo@5.stjoe.org CVTs scrub and monitor; RTs: image, scrub, and monitor; RNs: circ/meds, scrub, and monitor. Orange County, California JNelson1@memorialcare.org Our lab is fully cross-trained so that all staff members may administer medications. The staff is comprised of RNs, RT(R)s, Respiratory Therapists, RCIS, and Paramedics. All staff members are required to maintain ACLS certification. Any non-RN is also required to complete a skills checklist, take a written exam on medication administration, and complete an intense orientation with a senior staff member. Our lab is in North Carolina, and we performed approximately 10,000 exams last year. SDebastiani@wakemed.org I wish we were [cross-trained], but are not. The RTs are very territorial, making it difficult. Anonymous Having relocated from the Phoenix Metropolitan area (Arizona) to the Portland (Oregon) area recently, I can provide at least two perspectives. In my former lab in Arizona, each suite was staffed by three persons: 1 RN, 1 RT, and a third, either an RN or RT (CVTs were basically unheard of in this region of the U.S.). Each were trained to scrub. Only the RN administered medications while only the RT panned. If the lab had two RNs, they would take turns monitoring, recording, and circulating, and scrubbing every other case, while the RT panned each case. If two RTs were assigned to the suite, they would take turns scrubbing every other case while the sole RN would always monitor, record and circulate. All non-scrubbed personnel would circulate as they were available, with the emphasis on the RTs for actual procedural equipment. In contrast, the lab in Portland, Oregon employs RNs, RTs and CVTs. Each suite is staffed by four persons: two CVTs, one RN and one RT. The CVT would either scrub the case or monitor and document the case. Only the RN administered medications and only the RT would operate the x-ray equipment (the doctors would do the actual panning). All non-scrubbed individuals would circulate as available with the emphasis on the unscrubbed CVT and RT for procedural equipment. Two RNs had the capacity to scrub as well (and would routinely be placed into the CVT’s position) while two RTs could scrub all cases and two other RTs could scrub pacemakers only (incomplete cross- training). The RTs, however, were not routinely utilized for scrubbing due to staffing constraints. In general, this lab did not exercise cross-training; a new-hire is only oriented to fulfill a different lab role if they previously served in that role at another facility and had experience. Anonymous In our lab we have three RNs, two RTs (one as a manager) and one RCIS. We only allow the RNs to push the medications. The EMTs only participate during on call hours and must come in for 8 hrs per month to maintain their circulator skills (usually during a busy day). The RN is always the monitor technician, both during on-call and normal hours. The RNs also sometimes rotate as a circulator. The RTs and RCIS staff are the scrub and circulator technicians. These roles can be swapped between RT and RCIS staff during regular hours. During on-call hours, the RTs and RCIS are always the scrub tech. During a normal day, the RNs are utilized throughout the cardiology department for stress tests, holter hook-ups, EKGs and any other duties in cardiology that might need assistance. All staff are trained to start IVs. All staff help out the cardiology department for all kinds of duties, from starting IVs to editing EKGs. It is one of the few labs I know of that are very universal. The state of New Hampshire and our hospital policy does not allow technicians to give medications. However, this is being investigated by the hospital and has the possibility of being changed with proper education and documentation for the staff. r_a_siering@hotmail.com Our lab is in the process of cross-training to a certain extent. CV techs and x-ray techs will be fully interchangeable, but that will not include giving meds at this time. Electrophysiology is excluded from this cross-training. Our lab is in Washington state. Londo56@aol.com The cath lab staff in our hospital is cross-trained in all areas of practice, except for the administration of medications. The RNs are the only staff besides the physician to administer meds. Rebecca J.Jellison, Cath Lab Manager Elkhart, Indiana RJellison@egh.org We have 3 RNs and 3 scrub techs. We cross-train between scrub and monitor/RN and monitor. Only 1 of the nurses is cross-trained to scrub also. This makes up our 2 teams. STEPHSPENCER1@aol.com Yes, our lab is fully cross-trained. Everyone, including RNs, RTs and RRTs, shares in the scrub, monitor and circulate roles. Only the RNs are allowed to hang blood. All staff is required to be ACLS as well as CPR trained and all non RN staff must be educated on meds, with a post test and skills assessment.We also have CVTs that are PRN. They help out with our late shifts, and they primarily scrub. We are in Memphis, Tennessee. scoggint@methodisthealth.org For many years, we have been cross-trained, but not fully. We are just now implementing the intensive training and education necessary to FULLY cross-train the cath lab staff. I would like to know if your lab is FULLY cross-trained, so that we can use you for future salary market surveys. Also, I would like to know if everyone who has FULLY cross-trained staff makes it mandatory and if so, within what time frame? Is cath lab experience required? Is the salary tied to RN or RT market? Judy Parham Cath Lab Manager Athens Regional Medical Center Athens, Georgia jparham@armc.org I used to work in a cath lab in southern Connecticut. We do approximately 3000 cases per year (diagnostic and interventional) with two operating labs and one designated EP lab. Our staff at present consists of 4 full-time RNs, two part-time RNs, and two full-time radiology techs. I worked there for five years. I recently left because the hours were so sporadic. There were never any weeks that we worked less than 45 hours and we were on call at least one night a week. The only people cross-trained were myself and another full-time RN. This mean that when one of the techs was out sick or on vacation, we covered their position. Now with my absence, that leaves one RN cross-trained. I am not sure if the other RNs really want to cross-train or not. One of the full-time and one of the part-timers are relatively new and are still on orientation. The burnout rate in our lab is very high. CathLabDigest@aol.com No, our lab is not fully cross-trained. Only RNs give meds and run the control room. Only RTs pan the table. The role of scrub is shared by all. As a Surgical Technologist with 25 years of experience, I jumped the fence into the cath lab a year ago. Our lab does over 6000 cardiac procedures a year, which has enabled me to develop a level of competency in the role of scrub within our team structure. Cross-training is a sensitive issue in any setting. However, over the past 5-10 years the healthcare landscape has become increasingly fragmented and professionally divisive! Although most agree that competency should dictate one’s practice in healthcare, that’s lost in the translation. Breaking this cycle is difficult. Should this be addressed at a local level or statewide? Which comes first? The chicken or the egg? Herbert P. Underwood Jr., CIS Huntsville, Alabama hunderwo@HiWAAY.net No cross-training. RNs circulate, give meds, scrub, computer, recover (i.e., hold pressure.) X-ray techs scrub, computer only. Our equipment is Phillips (digital films). Maggie Lewis, Staff RN, Hardin Memorial Hospital Elizabethtown, Kentucky mlew88@earthlink.net We run a busy lab in Wisconsin and are currently adding a third room. It has been a divided lab here FOREVER, with techs only monitoring (scrub seldom) and nurses circulating, giving meds, stocking ,pulling sheaths, running the holding area and prepping, etc. I’ve suggested we try to cross-train somewhat because it seems a logical way to run things more efficiently, but the most senior techs will have nothing to do with it and they have the say here. Some of us are willing to learn more but are held back by others. From most of what I read about other places, the labs are cross-trained and work as teams (by room) on a daily/weekly basis.We can’t seem to try anything different here even if new/travellers suggest it might work better. Anonymous Our lab in Denver, Colorado is almost fully cross-trained. It is our long-term goal. With turnover, it has been challenging. All staff are licensed as RT, RCIS, or RN. Non-RNs must have a pharmacology course followed by 6 weeks of one-on-one training with an RN. Continuing education is encouraged, and medication errors and complications are monitored. A conscious sedation competency is also required, as well as air-way management. Everyone is ACLS-certified. LorraineWatkins@Centura.Org Our staff is not fully cross-trained, but we are close. The nurses administer drugs, start IVs, and do PATs (pre-administration testing) with our patients. The technologists take care of all imaging (fluoro, panning table, acquiring images, burning CDs to be sent to cardiologist and cardiac surgeon offices, and to open heart surgery), and all dealings with injector and contrast. Everyone scrubs cases and pulls sheaths. If you pull, the patient is yours post-care until discharge, return to their room or when waiting for a bed, until such bed is assigned. I work in northern Kentucky, just across the river from Cincinnati. Becki Fischer RT(R)(M)(CV) The St. Luke Hospitals/ The Health Alliance of Greater Cincinnati bfmargaritaville@hotmail.com Our lab is not fully cross-trained. The nurses are able to run the hemodynamic monitor and and techs scrub and monitor on a routine basis. The nurses are 150% and then some at what they do. The techs did not go to nursing school. The nurses did not go to tech school. If a lab is staffed correctly and efficiently, nurses and techs should be able to continue what they are trained and educated for. If I wanted to be a nurse, I’d go back to school and get my RN. If nurses want to do tech functions, then the RCIS is available to them as well. If cross-training persists, then testing for qualifications should as well. If a case goes to court, what’s your answer if something went wrong? I learned it from Sam or Sherri on the job, I didn’t know… R. Nilsson, Missoula, Montana Nelsongo24@aol.com Our cath lab is in Florida. It is a single room, doing pacemakers and diagnostic caths only (interventional is coming next summer with an open heart program). My staff is fully cross-trained. If there is only 1 nurse in the lab, they circulate; if there are 2 nurses, the other scrubs or records. I am a working manager with an x-ray background and have 1 other x-ray tech on staff, who scrubs and records. We all can administer medications if needed and are covered by the physician’s license. Under Florida law, non x-ray personnel can operate the equipment under direction of a physician, in their presence. Tracijo Capua Flagler Hospital, St. Augustine, Florida cathlab@flaglerhospital.org All personnel in our cath lab system are cross-trained. All are ACLS certified. I am in Georgia. codywms@msn.com I have RNs and RCISs (CVTs). All staff are cross-trained and can scrub any diagnostic, interventional or pacemaker procedure. In California, only RNs are allowed to give medications while circulating the case. All medications on the table are given by the MD. I have 1 RN who is also RCIS-certified and can do all jobs (circulate, monitor and scrub). I am a RCIS(CVT) and can scrub/monitor all cases for call coverage, lunches and sick call. Bill Colditz, Manager Cath Lab Mercy San Juan Medical Center Wcolditz@chw.edu Our cath lab is fully cross-trained. We employ nurses, x-ray techs, and paramedics. They all have obtained their RCIS credential, even though the state of Illinois does not recognize this licensure yet. We perform 4,500 procedures per year. We are cross-trained not only in invasive procedures, but also in EPS. We are located 40 miles west of Chicago. The state of Illinois implemented an addendum to the problem of who can pan, and recognizes the physician as the responsible party. Medication administration is governed by the hospital and supported by job description, licensure and JCAHO competency testing. Roberta Sparks, Coordinator, Cardiac Cath/EPS Labs In our cath lab, the CVT is able to scrub and monitor. The RN usually circulates and gives meds, or does the monitor. There are a couple of RNs that are able to scrub, but the CVTs are not allowed to administer medications. I am from UMC in Las Vegas, Nevada. Jo Ann Fisher, joann@skylink.net Michigan: the lab is cross-trained to the point of giving meds. Only RNs give meds. jfilthau@mcgh.org Here’s what we are doing in our diagnostic lab in Virginia. We have limited cross-training within the lab. We have 5 nurses, one rad tech and two respiratory therapists. Our rad tech and one of our therapists function as scrub assistants. One nurse is able to fill any role in the lab, and a second nurse is able to scrub in a pinch, but does not do this on any regular basis. Only heparin and nitro SL are given by non-nursing personnel. All staff circulate, but only nurses perform hemodynamic monitoring and do cath teachings. We have dreamed of fully cross-training everyone, but with our case volumes around 500/year and some staff part-time and prn, we have found that competency is an issue. It is a challenge when someone is sick or off on vacation usually the full-time people get slammed. I trained in a lab that was fully cross-trained, but it was started that way. Our lab began with staff roles being designated based on credentials and I think it is tough to come into an existing situation and change. If anyone has experience in this area or advice, I would be glad to hear from you. Thanks everyone, Natalie D. Beiler RMH Cardiac Cath Lab Supervisor nbeiler@rhcc.com