Kresge Cardiovascular Catheterization Laboratory, Frederik Meijer Heart & Vascular Institute, Spectrum Health

Tell us about your cath lab.

The Kresge Cardiovascular Catheterization Laboratory at the Frederik Meijer Heart & Vascular Institute has six adult catheterization labs and three electrophysiology (EP) labs. Our 56 staff members have varying credentials, including cardiovascular technologist (CVT), three of which have obtained their registered cardiovascular invasive specialist (RCIS) credential, registered nurse (RN), and radiologic technologist (RT). Staff averages 12 years of experience in the cath lab.

What procedures are performed at your cath lab?

We perform diagnostic catheterizations, percutaneous coronary intervention (PCI) (elective, primary, and high-risk interventions), biopsies, peripheral diagnostics and interventions, and advanced circulatory support procedures. We perform 6,061 cardiac and peripheral procedures per year.

Does your cath lab perform primary angioplasty without surgical backup on site?

No, we have open-heart surgery available on site.

Is your cath lab performing transcatheter aortic valve replacement (TAVR)?

We are involved in the Medtronic CoreValve trial here at Spectrum Health. The procedures are done in a hybrid OR room with a combined team of cath lab and OR staff.  We do recognize the need to develop more space for hybrid procedures and are working together as a system to determine if that will be in the OR, cath lab, or both.

Do any of your physicians regularly gain access via the radial artery?

Yes, some operators use the radial approach for all cases, even ST-elevation myocardial infarction (STEMI) work. Overall, we see about 30 percent of our coronary work done via radial access.

What percentage of your diagnostic caths are normal? 

Thirty-seven percent of our diagnostic caths are normal.

Does your lab have cross-training? 

Yes, staff works in other specialized teams such as pediatrics, peripheral, TAVR and EP. Most staff members seem to like the variety of performing all the roles. 

In the cath lab, one RN will be circulating and sometimes a second circulator will be a technologist. The majority of RNs scrub diagnostic and interventions, but a few do not scrub interventions.

Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab?

No, it is not a requirement at our facility.

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 perform all these activities in our lab.

How does your cath lab handle radiation protection for the physicians and staff?

We provide the basic protection such as lead aprons. We also have ZeroGravity systems (CFI Medical Solutions), generally worn by the operator. The cath lab is represented by a staff member in the hospital-wide radiation safety committee. This committee reviews staff and patient dose exposure. It also reviews policy related to radiation and helps educate on best practice.

What are some of the new equipment, devices and products introduced at your lab lately?

We continue to see growth in advanced intracoronary imaging devices for coronary work.  Fractional flow reserve (FFR), intravascular ultrasound (IVUS), optical coherence tomography (OCT), and near-infrared spectroscopy are common tools used in the rooms. Another area of considerable growth has been the technology around advanced circulatory support. We have considerable experience with Impella (Abiomed), TandemHeart (CardiacAssist), and CentriMag (Thoratec) for patients in cardiogenic shock and for supporting high-risk coronary interventions. We also provide cooling protocols for patients presenting to the lab after cardiac arrest.

How does your lab communicate information to staff and physicians to stay organized and on top of change?

We have several ways to communicate to the team. One of the most effective groups has been an interventional sub committee that meets monthly. This has been a very effective way to involve physicians in both clinical and business decisions. We also hold a weekly case conference, monthly blinded review of routine work done in the lab, quality meetings for acute MI, and division and staff meetings monthly.  If we are implementing a focused change, this is often handled with in-lab education for staff and physicians.

How is coding and coding education handled in your lab?

We do not offer coding education for the staff, but do get documentation feedback from the coders and adjust our documentation tools accordingly.

Where are patients prepped and recovered?

Patients are prepped in our prep and recovery unit. This unit has 24 private rooms and is staffed by nurses and technologists. Once the sheath is removed, manual pressure is the most common way we manage the site. We do see closure devices, but they are more commonly used with interventional cases.

Who pulls sheaths post procedure, both post intervention and diagnostic cases?

All radial sheaths are pulled in the room. Other lines are removed in the 24-bed pre and recovery area, or on the inpatient cardiac unit. Generally, our sheaths are pulled by technologists. Staff receives an eight-hour class on sheath removal and then must be signed off on a minimum of 10 pulls to be independent.

How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies?

Our inventory is managed with Pyxis machines (CareFusion). The machines are able to track pars, product turns, expiration dates, drop charges directly to our charge master, and create purchasing requests. The system is managed by our equipment coordinator, Kathy Flynn, and she is assisted by Bob Karam from the supply chain team.

Has your cath lab recently expanded in size and patient volume, or will it be in the near future?

Our coronary work has declined. However, that decline has been offset by growing needs in EP.

Can you share your lab’s average door-to-balloon (D2B) times and some of the ways employees at your facility have worked together to keep D2B times under the mandated 90 minutes? Are you registered with the American Heart Association’s Mission: Lifeline or the American College of Cardiology’s D2B Alliance?

Our average D2B time is 53 minutes. We are doing several things to continue to reduce these times. We currently staff the cath lab 24/7 Monday am to Friday pm. We then staff an on-call system for the weekends. We use logs so staff can clearly see any step that exceeds our time goal. We also have staff members on our acute MI quality team, so we can continue to coordinate our efforts with the emergency room (ER). We currently participate in AHA’s Mission: Lifeline. Denise Busman is the clinical nurse specialist for the lab, participates in the National Science Advisory Task Force, and is on the Michigan Lifeline Steering Committee.

How does your lab handle call time for staff members? Is there a particular mix of credentials needed for each call team?

We staff the cath lab Monday from 6 am to Friday 8 pm with an in-house team. The remaining weekend hours are staffed by an on-call team. The team consists of two RNs and two CVTs.  

How long has your 24-hour coverage during the week been in place?

We have had it for the past five years. The staff loves it. The reduced call time and reduction of staff shortages after a busy night have been tremendous positives for everyone. We saw benefits in safety for the staff from reduced fatigue, reduced turnover of staff, elimination of next-day schedule disruptions and increased staff satisfaction for the day team. Other benefits the night shift adds are well stocked and organized rooms, reviewing of documents for quality and charging, equipment checks, and support for other floors in the hospital with site or sheath questions during the off shifts.

Within what time period are call team members expected to arrive to the lab after being paged?

Thirty minutes.

Who transports the STEMI patient to the cath lab during regular and off hours?

The ER and emergency medical services (EMS) transport the patient to the cath lab during both regular and off hours.

What do you do when the call team is already busy doing a procedure and a STEMI comes into the ER?

We have four staff on call, so one person will go and open up another room. We use the in-patient areas to help with transport. We are actively working on creating a second back-up STEMI team. Even though the volume of STEMI is stable, the length and complexity of STEMI cases is creating greater risk of a competing need.

Do you have flextime or multiple shifts?

Yes, we offer 8-, 10-, and 12-hour shifts.

What measures has your cath lab implemented in order to cut or contain costs?

With the growth of radials, we saw an increase in table resets. We redesigned the process of opening equipment, requiring a confirmation regarding access site from the proceduralist prior to opening product, and have created a savings of about 38K per year. We also implemented a product review at the end of the case to validate accurate charges. This double check is new, so we are not sure of the results yet.

What quality control/quality assurance measures are practiced in your cath lab?

Like other labs, we follow many quality control tasks to ensure the equipment is current and ready to use. For quality assurance, we focus on activities that are shown to enhance safety. Examples are audits of labeling on the sterile table, procedural time outs, handoffs between departments, and practicing safety behaviors such as double checks. Although these actions seem simple, consistent monitoring, in our experience, is the only way to hardwire the behavior.

How are you recording fluoroscopy times/dosages?  

We record time and dose in the procedure log. We also record mGy to help provide more dose information than just minutes.

Who documents medication administration during the case?

The monitor person documents all medications given during the case in the XIM procedure log (Philips). The XIM creates a time-stamped procedure log while incorporating hemodynamics. To help increase transparency with the inpatient units, the circulating nurse also documents all anticoagulation and any IV meds that will continue outside of the procedure room.  

Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) or any other outside data collection registry?

Yes, we participate in the NCDR as well as the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) database.

How does your cath lab compete for patients? Has your institution formed an alliance with others in the area?

We do have competition for patients and we do partner with outlying hospitals. We work with the outlying hospitals to make access easy and to give input into policy around STEMI transfers.  

How are new employees oriented and trained at your facility?

All staff attends required classes, depending on their role. We also take advantage of critical care classes for hemodynamic/shock education.  

What continuing education opportunities are provided to staff members?

We generally send one or two staff members to the large, national conferences. Spectrum Health also offers a cath lab conference and a cardiovascular conference. Our next cath lab conference will take place January 19, 2013 (email Anne Beekman at anne.beekman@spectrumhealth.org for more information). Staff members are offered reimbursement for obtaining credentials such RCIS.

How is staff competency evaluated?

We do annual competencies for the staff. More of the work is now done online; however, we still offer hands-on time to review low-frequency, high-risk equipment such as TandemHeart.

Does your lab have a clinical ladder?

Yes, just for the technologists at this time. The clinical ladder program has two steps.  The program separates the CVT role into two categories: CVTs without specialized registration or licensure from CVTs with a specialized registration or license.

Has your lab recently undergone a national accrediting agency inspection? Do you have any recommendations or advice for labs about to undergo this inspection?  

We just completed our Accreditation for Cardiovascular Excellence (ACE) accreditation.¹ The process was very informative and we felt it was very valuable. In our experience, the review focused heavily on our quality data and physician performance. The quality of the review and summary of the action plan was very thorough, with clearly defined action items.

How do you handle vendor visits to your lab? 

Vendors must schedule an appointment or have a physician request. We also use Reptrax to monitor traffic.  

Where is your cath lab located in relation to the OR and ER?

The cath lab is located on the third floor of the Frederik Meijer Heart & Vascular Institute. The ER /Chest Pain Center are on the first floor and the OR is on the second floor. These key departments are well connected with an oversized elevator.

What trends have you seen in your procedures and/or patient population?

We see PCI work declining and a growth in EP and diagnostic work that supports ventricular assist device (VAD) and transplant patient needs. Overall, we continue to experience a higher acuity in the STEMI population. We have also seen an increase in intracoronary diagnostics using FFR, near-infrared spectroscopy, IVUS, or OCT.

What is unique or innovative about your cath lab and staff?

This team is unique in their involvement with the “business” of healthcare. The staff is involved and participating in our VSA (value stream analysis). This is an opportunity to look at waste in the work environment. Clinically, the team has embraced the very sick STEMI population. Their growth and knowledge in cooling and advanced cardiac support devices is impressive.

Is there a problem or challenge your lab has faced?

We had a problem with vascular site complications. We developed a multi-disciplinary team to look at our process for these patients. With the right people at the table, it was incredible to see the dramatic reduction in complications.  

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”?  

We are a certificate of need (CON) state, so we routinely coordinate care with our community hospitals. We also live in a community we feel has a strong culture of philanthropy. Many of our clinical areas are funded by donors of all levels.

The Society of Invasive Cardiovascular Professionals (SICP) has added two questions to our spotlight:

1. Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? Does staff receive an incentive bonus or raise upon passing the exam? 

We do not require the RCIS, but certification such as the RCIS allows our CVTs to move up the clinical ladder.

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? 

Not at this time.

Anne Beekman, BSN, RN, Manager Cath Lab, can be contacted at Anne.Beekman@spectrumhealth.org. 

Ryan Madder, MD, can be contacted at Ryan.Madder@spectrumhealth.org.

Reference

1. Beekman A. Getting ahead of the curve in providing appropriate care: why ACE accreditation must be included in your 2013 cath lab budget. Cath Lab Digest. 2012 Oct; 20(10): 46-50. Available online at https://www.cathlabdigest.com/articles/Getting-Ahead-Curve-Providing-Appropriate-Care-Why-ACE-Accreditation-Must-Be-Included-Your-. Accessed December 14, 2012.