Holy Family Memorial

The staff includes:  Dan, a RN with broad CCU experience;  Anita, a RN with extensive ER background;  Terry, a RT(R) with former cath lab management experience. We also utilize Debbie, a LPN from the physicians Heart Center Clinic, and Kim, a RN who is cross-trained from OR. We are among the OR suites and this situation allows us the possibility of extra staff on short notice. What type of procedures are performed at your facility? The lab is responsible for all cardiac caths, balloon pumps, pericardiocentesis, tilt table studies and pacemaker insertions. We are currently reviewing the appropriateness of EP for our lab. The cost of capital equipment, training of staff and equipment expense is being reviewed against the actual need for services in our community in the past year. We are also evaluating the possibility of leasing the EP equipment with payments made on a per-case basis. In August, the first of several new cardiologists will be joining our network. We will closely monitor the new cath volumes in the lab. Being a single room lab, we may not have the time available in the lab for EP procedures. The lab completes 45 pacemakers and is currently on pace to complete over 400 diagnostic and interventional caths yearly. We have done iliacs in our lab, but no other peripheral interventions to date. We currently focus our attention more towards the cardiac area due to time constraints on our single cardiologist. With the coming arrival of another cardiologist, this may change. What procedures do you perform on an outpatient basis? Diagnostic caths and tilt table testing. Does your cath lab perform primary angioplasty in acute MI? What about surgical backup? Our lab performs select angioplasties on patients considered lower risk. Holy Family Memorial cath lab has a Scope of Service policy which addresses the angioplasties that will be completed in the lab (see Figure 1). The cardiologist carefully reviews each patient and makes a decision after reviewing the patient™s condition and the available options. This is done without surgical back-up at the present time. An open-heart room has already been shelled in as part of construction and our future expansion into complete cardiac care. Is your cath lab nursing- or radiology-managed? Our cath lab is nursing-based. I report to the Director of Cardiac Services, who is an RN. Nursing-based management has led to our lab™s utilization of the nursing process (assessment, planning, implementation and evaluation). Do you have cross-training in the cath lab? Who scrubs, who circulates and who monitors? Our limited number of staff makes it essential that all staff are cross-trained. To remain proficient, we rotate roles on a case-by-case basis. The RT(R) and LPN have restrictions on what medications they can administer, so they never act as the lone person in the circulating role. In our institution, a RT(R) is not allowed to administer any medications other than contrast and oxygen. The LPN is allowed to give medications but is not allowed to administer narcotics or blood products. These restrictions eliminate the possibility that the RT(R) or LPN could function appropriately as the sole circulator without any other staff support. For this reason, they are trained so they can function as a support person to any circulator, but will not function by themselves. Their main staff functions are directed towards the scrub and monitoring roles. What are some of the new equipment, devices and products introduced at your lab lately? Our lab was one of the first to use the new GE Mac-Lab® 7000 (Milwaukee, WI) for hemodynamic monitoring. The Mac-Lab 7000 is interfaced with Catalyst (also from GE) to provide assisted automated dictated cath reports, report routing and inventory control of department supplies. We are using a Philips Integris X-ray system for our imaging. We are very happy with the system and have experienced zero patient downtime. Images are archived onto CDs and stored with a copy of the patient™s medical record. With our current limited volume, this has proved to be the most cost-effective storage method. Other options will be considered when our case volumes increase substantially. How does your lab handle hemostasis? Our physician™s closure device of choice is the Angio-Seal 6F (St. Jude Medical, Minnetonka, MN). It has also proven to be the staff choice due to its highly effective method of sealing and achieving hemostasis. We have had good luck with Angio-Seal both on diagnostic and interventional cases. When Angio-Seal is not appropriate, manual holds or the C-clamp are used. Patients usually go to same-day surgery if they are diagnostic only. Interventional cases go to CCU. The nurses in these units are responsible for the patients. However, any sheath pulling is done by personnel from the cath lab. How is inventory managed at your cath lab? Being a small lab has advantages as well as disadvantages. One advantage is the ease of handling our inventory. Most commonly used items are stocked in our purchasing department and ordered by staff at the end of the day. Special order items are ordered by the cath lab supervisor as needed. The lab has two software programs, LMT (Lab Management Tools) and Catalyst, (both GE products) to track inventory items used during cases. Has your cath lab recently expanded in size and patient volume, or will it be in the near future? Our fixed base lab was completed in September of 2000. Prior to this time, we performed cardiac caths in a mobile Med-Cath truck parked outside the Emergency Department. With the lab advancing to interventional cases, our volume has already increased. We will be adding more cardiologists to our staff, which again will greatly increase our volumes currently limited by physician availability. Our current volume may make us a small lab, but our physical size makes us one of the biggest around. Staff love the spacious 23™ x 34™ lab. An open-heart room was shelled in at the same time our lab was built. We will begin construction on the final pieces of our cardiac network in 2002. Is your lab involved in clinical research? We are not involved in any clinical research at this time. Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? We are happy to report that we have not experienced any complications requiring emergent cardiac surgery. What measures has your cath lab implemented in order to cut or contain costs? Consignment inventories and agreements to take back stock if not used or replaced by new technology. We also educated our vendors on our future expansion plans to help obtain low prices on these agreements. Training staff to function in areas outside the cath lab addressed staffing cost. RNs assist with patient care in the Heart Center Clinic, which is also based in the hospital. One RN also works in cardiac rehab. These departments often have hours available when the cath lab is quiet. How does your cath lab compete for patients? Has your institution formed an alliance with others in the area? Two hospitals serve our county of 82,000. Our hospital has the only full-time local cardiologist. Other cardiologist not in our network visit the community and see patients, but all other cardiologist send their patients out of our community for cardiac caths. These patients must drive 40 to 90 miles for services. It is our goal to develop a heart center program and a network of physicians that will eliminate the need for anyone in our community to leave for cardiac care at any level. How are new employees oriented and trained at your facility? When the lab opened a year ago, we had application specialists train everyone on the equipment. Associations were also set up with two other hospitals, Froedtert in Milwaukee and St. Mary™s Hospital Medical Center in Green Bay. These hospitals accepted our staff members and provided some of the necessary training. Any new employees hired now are trained in the lab. We utilize a mannequin and simulator to generate a somewhat realistic experience prior to moving to the next step of hands-on. Competencies in each area must be met before the individual is allowed to function on their own. What type of continuing education opportunities are provided to staff members? Staff can attend national seminars in our general area if appropriate. Staff members also provide education to other staff members by preparing an in-service on related subject matter during slow periods or downtime. This has worked well with the staff™s diversified backgrounds and interests. We also utilize our sales reps to provide education on assorted topics throughout the year. Our lab has also developed a Lunch & Learn program. We have developed relationships with several non-competing cath labs. Once every three months, we will meet for a Lunch & Learn, rotating the meeting site among labs. The hosting cath lab presents education on the topic of their choice. Lunch is provided for those in attendance. The education session is followed by a general round table discussion. This discussion gives all the labs a chance to ask other labs what and how they do things. It has been a great resource for the smaller labs, and we have experienced great vendor support in education. Our most recent Lunch & Learn was Hemodynamic Monitoring A Closer Look at Wave Forms, presented by Nancy Staszak, RN, from Froedtert Hospital in Milwaukee. Nancy™s presentation was focused on the understanding of normal versus abnormal wave forms, and what makes a wave form abnormal. The evening included the usual round table discussion on various topics that the attending cath labs brought up. St. Jude Medical, Daig Division, sponsored this month™s presentation and meal. Representatives also provided a short demonstration on the new version of Angio-Seal, which no longer requires a spring. The upcoming Lunch & Learn in June is tentatively scheduled to include a presentation on Meeting Joint Commission Requirements on Conscious Sedation. How is staff competency evaluated? Competencies are evaluated during mock procedures in the lab during training and continue as they work in each of the staff roles. ACLS certification is also required for those administering medications. Does your lab utilize any alternative therapies (such as guided imagery, etc.)? Not at this time. How does your lab handle call time for staff members? Our lab is operational Monday through Thursday. Call is only utilized on Fridays for a 5-hour window. All primary cath lab staff rotate on-call. We only have 4 regular cath lab members, making any other type of call almost impossible if we want to maintain staff. With the development of the heart program and additional physicians, the staffing will increase and on-call will develop. What type of quality control/quality assurance measures are practiced in your cath lab? Our computer systems automatically monitor and report average case times and fluoro and contrast amounts as well as findings. We also do follow-up phone calls with patients and have found them to be greatly satisfied. Prior to staff leaving at the end of any day, one member makes a quick visit to all prior cath patients for the day. This visit is to check the site as well as answer any last-minute questions the patient or family might have before we leave for the day. What measures has your cath lab employed to improve efficiencies? Having staff cross-trained to improve efficiency. What trends do you see emerging in the practice of invasive cardiology? With continuing developments in stents (drug-coated, etc.) and innovations such as brachytherapy, CABG will become less frequent. As the population becomes older, the average age of our patients is also increasing. Has your lab has undergone a JCAHO inspection in the past three years? Yes, we passed the inspection but did get cited for recording temperatures of our medication refrigerator. With the lab closed over the weekends, no one was around to record the temperatures. We addressed the recommendation by purchasing a $100 continuous record thermometer with chart paper for the refrigerator. The unit records the temperature on weekends and holidays when staff are not in the lab. Please tell the readers what you consider unique or innovative about your cath lab and its staff. We are located in an OR environment and must follow procedures and practices that pertain to OR rooms. Another unique feature is that several of our staff members are able to see patients prior to their cath and in follow-up. Since we only have one cardiologist at the present time, some of our staff also work part of the day in the clinic or cardiac rehab. This is a unique opportunity for continuity of care, which makes it possible for a nurse to see the patient in the clinic pre-cath, later assist with the cath procedure for that patient, and possibly even see them again in cardiac rehab. One practice that developed as a result of the limited volume has proved highly beneficial for our lab. Before leaving at the end of the day, one staff member involved in the case visits the patient and any family. During the visit, the groin is examined and any questions that the patient or family has are addressed. Many times we will also take samples of wires, catheters and stents for the family, to help them visualize what they have heard about the procedure that day. The response has been fantastic and the staff enjoy this follow-up. As a marketing tool, we also leave the patient a highly compressed cath lab t-shirt in the shape of a heart. This has been well received by the patients and their families. Our physician, Dr. Diaz, frequently gives patients a CD of their cardiac cath if they have a computer at home. The patient is then able to take the CD home and review the images. Many of our community members are also snow birds and leave for warmer weather in Florida or Arizona when our winters arrive. They are encouraged to take a copy of the CD images with them. Is there a problem or challenge your lab has faced? Staffing and education are the biggest challenges for our lab. It is either feast or famine. We are staffed Monday-Thursday with in-house staff. On these days we can go from zero to as many as 6 cardiac caths or interventions. Until we add to our number of cardiologists, whenever our cardiologist goes on vacation the staff is forced to either take vacation, low census or pick up hours in other departments. Continuing education is the other challenge. In response, we set up associations with two other labs: Froedtert Hospital in Milwaukee and St. Mary™s Hospital in Green Bay. These two hospitals allowed our staff to train in their labs while our fixed unit was being built. We were pleased to return the favor when their labs were updated and their staff members came to our lab to train on our new equipment. We use our down time to constantly improve our lab. Staff members use down time to educate themselves in related areas. They will prepare educational in-services which, when time permits, are presented to other staff members. What™s special about your city as compared to the rest of the U.S.? How does it affect your cath lab culture? Manitowoc, Wisconsin is located on the western shore of Lake Michigan. We™re just 35 miles south of Green Bay (Go Packers) and 90 miles north of Milwaukee. Our seasonal temperatures range from the high 90s to lows around -20 degrees. We see an increase in cardiac cases after large heavy snowstorms. We are prone to heavy snowfalls due to warmer air coming off Lake Michigan. The folks here enjoy their brats and beer. Butter, cheese (deep fried cheese curds and mushrooms), summer sausage, and deep fried fish are other popular items that will provide job security for the cath lab staff long into the future. The Manitowoc area has an older population base and a problem with obesity. We cringe when we get a call asking, What™s the weight limit on your table? Our county population is 84,000, and our institution has the only full-time cardiologist and the only cardiac cath lab in the county. Competing hospitals in our county ship their patients to Green Bay or Milwaukee for cardiac caths. What are some anticipated changes for your lab? We have effectively recruited a new cardiologist to our team. He will begin his services at Holy Family Memorial in August of 2002. He is interventionally trained and will complete cardiac caths in the afternoon when Dr. Diaz is seeing patients in his clinic. Construction will also begin this fall on a new Heart Center from which the physicians will practice. The clinic will be located in a newly created section of the hospital. If things go as planned, the clinic will be staffed with several additional cardiologists, a pulmonologist and a thoracic surgeon. We hope to have our open-heart program functional within the next 3-5 years.