How Many People Do You Need to Do a Cardiac Cath?

We changed the daily tour of duty for our cath lab team. Instead of 10-hour days with one shift to run 2 labs, we split overlapping 8-hour shifts. This brought up the question, “Exactly how many people (and what kind of training) should you have to do a cardiac cath?” The answer to this question depends on several factors. Decisions for more or less staff will mostly depend on what type of case, such as interventional vs. diagnostic cath, elective vs. emergency, and what type of practice (private vs. university training hospital) as well as state regulations for hospitals. Although I have worked in both private and university cath labs, the staffing issues never appeared to me to be such a problem until recently. Cath lab volumes dropped (in part due to the success of coronary interventions) and the national budget crisis emerged, changing hospital and lab resources. It is difficult to glean from reading the excellent profiles of the cardiac cath labs featured in Cath Lab Digest exactly what is the composition of most labs. To get a sense of the answer to this question, I asked 40 cath lab directors and interventionalists to share with us their answer to 2 simple questions: 1). What do you consider adequate compliment of staff for a cath case? 5 people: 2 RNs, RT, tech, fellow 4 people: 2 RNs, RT, tech 4 people: 1 RN, RT, tech, fellow 3 people: 1 RN, RT, tech Other mix_______________________________ 2). Why? 1. Plenty of staff 2. Plenty of money to hire 3. Old habits 4. State/regulatory requirements 5. Other_________________ Before I give you my opinion, I summarized the responses by city (see Table 1) and kept some of the comments (edited) from the cath physicians. I think you’ll find their answers informative as well as entertaining. From Temple, Texas: For daytime staffing, our usual is 1 RN (for documentation and meds), 1 CVT for monitoring and the variable participation of another CVT or RN. We have a fellow on every case. Most attendings will let third-year fellows do cases “on their own” with the attending in the control room observing. In that situation, a CVT or RN scrubs with the fellow (as it will be in private practice). For a rookie fellow, the attending always scrubs with the fellow (to slap hands and teach) and then at minimum, there is 1 CVT (monitoring and hemodynamics) and 1 RN (charting and drugs). However, during the day there is plenty of “recruitable” help for the sick patient. All RNs and CVTs are cross-trained to cover each others’ jobs (except for giving medications; Texas law says must be a RN or MD). Physicians do all of their own panning and camera set-up. If we happen to be short-staffed due to illness, or over the lunch hour, the attending usually scrubs in to help. For on-call staffing, as a teaching institution, we have the luxury of “recruitable” staff, which may include a CCU cardiology fellow and sometimes the CCU attending plus an ICU resident, all helpful when the patient is heading ‘south’ fast. Staffing reasons are a combination of regulatory requirements, money considerations and other factors. From Salt Lake City, Utah: We have 3 staff per lab. For each case, we also have 1-2 fellows (“rad blockers”) and an attending physician. On call we have 2 RNs and a third person (either an RN or tech). Last year, we increased our on-call staff from 2 RNs to 3 RNs. It works much better, particularly for the unstable patients. From Little Rock, Arkansas: For daytime staffing at the VA and university hospital, we have 2 nurses and a tech. It works well. For night call emergencies, clearly, a fourth person would be helpful, but three seems to be adequate. At the university hospital, there is one nurse, one tech, and one CCU nurse who “helps out.” We believe that this arrangement is not acceptable from the cath care standpoint, but are told by administration that they can’t afford a third cath lab person on call and that the current arrangement is “acceptable” for emergency procedures. From New York City, New York (and formerly Rochester, Minnesota): Until recently, we had 5 people: a fellow, circulator (opens sterile packages), RN, camera monitor (hemodynamics and data entry) and RT. We consolidated RT positions, so we got along with 1 RT for 2 rooms. We also had a handful of nurse anesthetists who handled very sick patients – they circulated between rooms. After moving to New York City, we have 3 people: fellow, circulator, camera operator. A tech will join for complex cases or substitute if a fellow is missing (you know how they are). No RTs here (don’t know why). As for training, in Rochester, camera monitors and circulators were high school grads (no longer). In NYC, the nurses’ union has muscled a hold on these positions. You need at least one RN to handle meds, but otherwise the circulator and monitor jobs can be done well by much less expensive talent. From St. Louis, Missouri: We have 1 nurse, 1 tech, 1 fellow, 1 attending. The ideal situation would be to have the ability to pull in an additional nurse for tough cases. The biggest problem we have had with staffing is high turnover — cath folks are in high demand and a lot like recently departed football coaches from the state of TN. We have been dependent on traveling nurses/ techs, although this is not as good as the “real thing” (sorry, sounds like a commercial). From Atlanta, Georgia: We have 4 people — 1 RN, 1 RT, 1 tech, 1 fellow. But it also depends on what is being done. A complex patient needing a balloon aortic valvotomy (BAV) and/or coronary PCI may need 5 (extra RN). [If you came into our lab during] a percutaneous valve implant procedure, it would look like “Coney Island at low tide”. From Gainesville, Florida: For elective cases, we use 1 RN to give conscious sedation and enter all of the nursing documentation in the computer, 1 CVT in the control room to record the case (sometimes circulate), and a second CVT who either scrubs or circulates. It is inconvenient for the recording tech to leave the monitoring and recording system, and retrieve equipment. If we have enough people, we sometimes use 3 techs: one to record, one to scrub, and one to circulate. For STEMI cases, 1 RN and 2 techs are on call. If a patient is unstable and requiring a lot of attention, we have “Stat nurses” in the hospital who can come help, or sometimes a CCU or ED nurse. The staffing is this way, because that is all administration wants to pay for and “that's the way we have always done it.” But, in reality, we often have another tech and sometimes another nurse present, because it works better that way. From Raleigh, North Carolina: During the day, we usually have 3 staff. Always 1 RN (to assess sedation, assess patient, give meds), 1 tech (for monitoring and scribing), and 1 circulator (could be an RN or a tech). We can ramp up quickly to put more hands on deck given the physical arrangement of the lab. Also, in our back-to-back rooms, we will do cases with 2.5 staff available when absolutely necessary. We also have a fellow for 97% of cases, but I wouldn't count them as being that useful. About half of cases are done by the fellow and the scrub person, with minimal hands-on contact by the attending. We do not have RTs in the lab, just “cath lab techs.” For STEMI call, we have 4 staff: at least 1 RN, usually 2, with the rest techs. Our estimate is that this reduces door-to-balloon time by ~3-5 minutes, and the extra pair of hands is quite useful in the 20% of unstable patients. For STEMI cases, both the attending and the fellow scrub, so there are 3 people in the case. The non-MD scrub person is primarily responsible for prepping equipment. We did try a model of bringing a CCU nurse over as the fourth person on STEMI calls (i.e., staffing only with 3), but that didn’t work. As well-intentioned as the CCU staff person was, performance level was worse than a first-year fellow. The reason for this arrangement is “within regulatory constraints, the system works, without compromising patient safety.” From Aalst, Belgium: We use “3.5” people/room: 1 fellow, 1 nurse at the table, 1 RN in the room, 1 nurse-tech for 2 rooms. All nurses are multi-functional and trained to do all technical recordings, QCA, IVUS measurements, etc. They are supported by one technician who is also an information technology (IT) person. We tried several other combinations to reduce these numbers. These changes were always followed by a decrease in efficiency (patient flow) and in quality. From New Orleans, Louisiana: We have 3 people: 1 RN for conscious sedation, 1 RT, 1 scrub tech (can also be RN or RT). P.S. In training programs, there are also fellows, but they are more work than help (and it doesn’t matter how many there are). From Atlanta, Georgia (#2): We generally have 3 staff (RT/RN combination-cross trained) and a fellow. The other night we had to divide the 3 staff to cover two rooms. I was in the middle of an urgent PCI with the call team when a young patient with an inferior STEMI presented to the ER. My partner was in the hospital, so he did the primary PCI with one cath lab RN, 1 “untrained” ER RN, and 1 diagnostic fellow. So with appropriate training of staff, I think one can get by with 2 staff and a fellow. From Philadelphia, Pennsylvania: In my opinion, 3 (people) is more than 50% better than two. In particular, for acute infarcts or other unstable patients, having one person behind the monitor and two people to help make up drips, get the disposables, IABP, whatever, is a real help. I’ve also had nurses only, mixed nurses/techs, and techs only. With the latter, medication administration is sometimes an issue, even with appropriate training. For critical cases, having someone who has experience and instincts for preparing and running multiple drips in critical care settings is really important. Of course, all this is limited by finances. Finally, from our lab in California: I agreed with our nurses, who stated they prefer 4 people: 2 RN, 1 tech, 1 RT. I believe that monitoring and documenting the patient (as is required by the Joint Commission during the administration of conscious sedation) is nearly a full-time job and when coupled with giving drugs and retrieving supplies, the nurse’s efficiency is stretched enough to slow down the procedure. A tech scrubbed at the table is most helpful in the absence of an experienced fellow, otherwise is a necessity. The RT is less a necessity when the operators/scub person can pan the table, but needed when a complex case requires complete operator and tech attention. During a crisis, any lab will take all the help it can get. Although I wanted 2 RNs and 2 techs, the administration preferred 1 RN and 2 techs. They won this battle and it’s not hard to guess why. Bottom line: As we now know from the myriad of staffing modes and the sampling of my colleagues’ responses, there is no one right answer to cath lab staffing, but rather an answer that satisfies your lab’s case mix, physician and non-MD talent, and the financial wherewithal of your institution. Disclosure: Dr. Kern reports that he is a speaker for Volcano Therapeutics and St. Jude Medical, and is a consultant for Merit Medical and InfraReDx, Inc. Dr. Morton Kern can be contacted at mortonkern005@hotmail.com

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