Maimonides Medical Center

What is the size of your cath lab facility and number of staff members? Maimonides Medical Center, located in the Boro Park section of Brooklyn, is a 705-bed not-for-profit hospital with very active cardiac services. The cardiac cath lab consists of: 2 GE Inova cath labs 1 Philips swing lab 1 GE EPS lab 24-bed ambulatory short stay TEE lab Staffing for these areas is provided by: 1 RN manager 3 physician assistants 4 nurse practitioners 39 RNs 4 cardiovascular technologists one special procedure radiology technologist 2 cardiopulmonary technologists 7 patient care technologists 8 support service workers 5 clerical staff 1 admitting clerk 1 systems analyst The most senior RN has been employed in the cardiac cath lab since 1986. Most cath lab personnel are long-term, with an average of 10 years in the cath lab. What types of procedures are performed at your facility? In 2003, the cardiac cath lab/EP lab performed 5,324 procedures. Thirty-nine percent of these cases were female. Procedures performed in the labs include: Right and left heart cath, PTCA/stents, drug-eluting stents and brachytherapy, percutaneous transluminal coronary rotational atherectomy (PTCRA), directional coronary atherectomy (DCA), PressureWire (Radi Medical Systems), intravascular ultrasound (IVUS), AngioJet (Possis Medical, Inc.), intraortic balloon pump insertions (IABP), peripheral angiograms/angioplasty (30-40 cases per year), renal angiograms/angioplasty, electrophysiology studies, ablations, pacemaker implants, automatic implantable cardioverter defibrillator (AICD) implants, bi-ventricular pacemaker implants, generator change and lead wire changes, and loop recorder insertion and removals. In our Advanced Cardiac Care unit, we perform cardioversions electrical and chemical, transesophageal echocardiogram (TEE), tilt table tests, and cardiac infusions [abciximab (ReoPro, Eli Lilly and Co.), nesiritide (Natrecor, Scios) and milrinone lactate (Primacor, Sanofi-Synthelabo Inc.)]. Does your cath lab perform primary angioplasty with surgical backup? Our facility has 3 designated open-heart OR suites. Primary angioplasty is performed during routine hours with a designated OR scheduled for surgical backup. When emergent cases arise off-hours, there is a designated on-call surgical staff. Stents and graft stents have significantly decreased the need for emergent OR intervention. What procedures do you perform on an outpatient basis? Angiograms, peripheral angiograms and angioplasties, TEE, cardioversion, cardiac infusion therapy, tilt table tests, generator changes, and EP studies are all done on an outpatient basis, unless otherwise indicated. What percentage of your diagnostic cath patients goes on to have an interventional procedure? 40% Who manages your cath lab? The Executive Director of Cardiac Services, Louise Valerio, RN, MS, in conjunction with the Director of Invasive Cardiology, Dr. Jacob Shani, has the overall responsibility of managing the cath lab. Team leaders for the cath lab and the ambulatory unit run the day-to-day operations with the Assistant Director of nursing, Peggy Healey, overseeing the units. Do you have cross training? Who scrubs, who circulates and who monitors? The nursing staff is cross-trained to circulate and monitor. The nurses are also cross-trained to circulate and monitor in EP, work in pre-admission testing (PAT), chest pain unit, ambulatory cardiology and TEE. Since we are a teaching hospital, we have 2 interventional fellowship programs (our own and a neighboring, non-interventional hospital) that provide cardiology fellows and physician assistants that scrub in the cath and EP labs. Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab? No. 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? The physicians and the cardiovascular technologists can position the II, pan the table and change angles according to the physicians’ directions. The physician is the only one to step on the fluoro pedal in the labs. Does your lab have a clinical ladder? The clinical ladder consists of senior staff nurse level I and II. An application process is necessary. Two letters of recommendation must be submitted with the application and the nurse must have a satisfactory attendance record. There are several additional pathways that the nurse may choose to meet the other requirements. These include: moderate a journal club, initiate and implement a staff teaching project, formal patient teaching classes, develop a patient teaching tool and specialty certification. Senior staff nurse level I and II must be re-certified annually. Each level constitutes a salary increase. What are some of the new equipment, devices and products introduced at your lab lately? We have the new GE Mac-Lab for hemodynamic monitoring, GE Flat Plate, the Galileo brachytherapy system (Guidant Corporation), AngioJet, Cypher (Cordis Corporation) and Taxus (Boston Scientific) drug-eluting stents, and the Galaxy IVUS (Boston Scientific). Is your cath lab filmless? Yes. We use OptiMed digital recording, which also records our patients’ echocardiograms. The recordings can be retrieved in several locations besides the cath labs, including the cardiac intensive care and telemetry units, offices of the Director of the Cath Lab and the Director of Clinical Cardiology, and in the cardio-thoracic OR. How does your lab handle hemostasis? Hemostasis is handled with mechanical compression utilizing a C-clamp device. The fellow, using the C-clamp, removes 97% of the sheaths in the holding area. Post-interventional patients are often given protomine, based on ACT results, and sheaths are removed. The remainder of the patient’s sheaths are sutured and removed by the fellow in patients’ rooms when they are stable or when the ACT is within normal limits, using manual or C-clamp devices. Cath lab RNs are also trained to remove C-clamp devices. Does your lab have a hematoma management policy? Yes. All hematomas are tracked. An outcome sheet is completed for each hematoma, listing the procedure, the person who pulled the sheath, anti-platelet therapy, etc. These patients are followed until discharge. If there is an increase in hematomas noted, it is examined for cause. The C-clamp clinician is scheduled for inservices twice a year (one inservice is scheduled when the new fellows start in July). A RN from the cath lab checks the groins of all patients who are in-house the day following their procedure. A follow-up phone call is made 24 hours after discharge on our ambulatory patients, with specific questions regarding procedure site. If there is any question of an adverse outcome affecting the site, the patient is asked to return to our ambulatory area so that the area can be checked. How is inventory managed at your cath lab? Our Lumedx data management and inventory system manages inventory. Staff runs queries for supply usage. Our Materials Management Coordinator (MMC), Mike Vega, coordinates the purchase of inventory as recommended by the Director of Invasive Cardiology. Our materials management coordinator utilizes contracts, consignments and negotiates prices based on market shares. How is coding and coding education handled in your lab? The nurse or CVT enter the demographics (including the procedure, which populates the ICD 9 code) into the mainframe hemodynamic monitoring system (GE MAC Lab). Through an electronic coding system, that information is sent over to the finance department. Has your cath lab recently expanded in size and patient volume, or will it be in the near future? In the last decade, there has been a 265% increase in volume in our cardiac cath labs. As our lab volume has been growing steadily, our lab has grown in size to accommodate this volume growth. With the current proposal to become a 24/7 cath lab and the anticipated increase due to drug-eluting stents, we currently have started construction of a fourth cath lab. The recent renovations in our EP labs will help accommodate our expanding volume in this area, together with the anticipated growth due to bi-ventricular pacing. Is your lab involved in clinical research? Yes. Both the cath lab and EP labs are involved in research. A full-time cardiology research RN assists the physicians with their research. We are currently participating in several multi-center studies, including the FINESSE AMI, TAXUS IV, RESOTRE, BOSS and BAST trials. There is also independent research conducted by the attending and cardiology fellows. Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? We had one patient who had a discrete LAD lesion, who after the balloon inflation developed a dissection mid-LAD back up to the left main and down the LCX. The doctor stented from the mid-LAD to the LM. The patient went to the OR hemodynamically stable with no chest pain and was subsequently discharged home. What other modalities do you use to verify stenosis? For moderate stenosis we use intravascular sonography (IVUS) or a PressureWire to assist in determining if stenoses are significant. This has a minimal effect on our operating cash flow. What measures has your cath lab implemented in order to cut or contain costs? We use consignment, contracts, Premier (group purchasing), and market share pricing, and all contribute toward containing costs. Redefining our uses of anti-platelet medication helped to cut costs in the last year. While we had been giving abciximab predominantly post stent, currently due to cost constraints abciximab (ReoPro) is only given to those patients who are high-risk, diabetic, or who have a large thrombus burden. In the majority of the cases, eptifibatide (Integrilin) is now given. What types of quality control/quality assurance measures are practiced in your cath lab? The nursing staff tracks all adverse outcomes (i.e., hematomas). Causative factors are identified and in-services are done for MDs and RNs. We completed a study in 2003 where we attempted to decrease length-of-stay (LOS) after cardiac catheterization. One large area of disparity was the point in time that the nurses started clocking time to chair, ambulation, etc. Some staff started timing from the point that the patient returned to his bed, where others started the clock from time of hemostasis. This was resolved by instituting a green sticker in the nursing notes that states the time hemostasis was achieved. This, combined with reinforcement of education of post cath standards and improved communication with the MDs, helped to decrease LOS by 20% for this patient group. How does your cath lab compete for patients? At the present, we are one of two hospitals in the county that performs invasive procedures. We get patients from area hospitals that do not have these services. We also have an alliance with several area hospitals for diagnostic and interventional procedures. Our cardiology group accepts most insurance, which in these days of managed care brings in a multitude of patients. We also get international patients from Italy and Israel due to the reputation of the Director of Invasive Cardiology, Dr. Jacob Shani. The Cardiac Institute at Maimonides Medical Center does lectures at community centers as well as in the medical center. We also sponsor health fairs in the community. Our hospital’s satellite clinics are another source of patient referrals, as is our cardiology group. The Medical Center has recently done extensive advertising, including radio, TV, newspapers and posters on buses. How are new employees oriented and trained at your facility? All employees get a hospital orientation and a specific cath lab/EP lab orientation. In-lab training lasts a minimum of 4 weeks for critical care trained nurses or experienced techs. During this 4-week period, the RN or tech is assigned to work side-by-side with one preceptor. After this time period, the new employee is evaluated and orientation is extended as needed. All RNs and LPNs require a current New York State Nursing License. Techs are required to become certified by passing the cardiovascular exam within one year of hire. What types of continuing education opportunities are provided to staff members? Continuing education is ongoing in our cath lab. In addition to the weekly cath conferences, monthly grand rounds, inservices within the department on a weekly basis, and launches of new products, there are also opportunities from vendors who sponsor lectures after work hours. The staff is also encouraged to attend cath lab seminars sponsored by vendors as well as national conventions such as TCT, AHA, or ACC. Nurses are given 2 conference days per year for outside conferences. How do you handle vendor visits to your lab? Vendors may schedule up to two visits per month, except during launch of new devices or products (they will be allowed more visits during that time). The vendors are allowed in the cath control rooms, but not usually into the procedure rooms during cases. All vendors must have vendor ID badges from hospital security. How is staff competency evaluated? There is an annual competency for all employees. Clinicians from various companies (for products such as IABP and IVUS) provide annual reviews to insure competence with equipment. Does your lab utilize any alternative therapies (such as guided imagery)? Music is provided in the labs. The patients are asked what type of music they prefer and the staff tries to accommodate them. We are currently working towards setting up a program with guided imagery. One of our nurses is currently working towards her NP in holistic medicine. How does your lab handle call time for staff members? There are 2 RNs and 1 tech on call for emergencies. The cath lab works 7 am-7 pm shifts. What trends do you see emerging in the practice of invasive cardiology? We are performing interventions on much more complicated lesions and multiple lesions as well as unprotected left main stenting. We also have a marked decreased use of the OR due to stents and the graft-coated stents as well as drug-eluting stents. Has your lab undergone a JCAHO inspection in the past 3 years? Yes. Our lab underwent a JCAHO inspection in 2002. The lab scored 100% at that time. The inspectors particularly liked the flow of the patients and how we do our own pre-admission testing (PAT), a.m. admission, procedure, post care and discharge. We don’t like how the cath labs are spread out. However, as we are expanding, we utilized the space that was available. The holding area is too small to accommodate our volume of cases. Plans are in progress to relocate the entire cardiology division to a location where all areas are connected. The staff likes having the option of the swing lab to facilitate cases. Where is your cath lab located in relation to the OR, ER, and radiology departments? The two main cath labs (including the swing lab) and the new lab currently under construction are located around the corner from the ED, providing easy access for acute MIs. The radiology department is located on the third floor, the same floor as our secondary lab. The operating room is located on the 4th floor. Please tell the readers what you consider unique or innovative about your cath lab and its staff. We have a team that is unique in our interactions. If you work in our department, you become part of a family. This has been proven recently with several staff members’ personal tragedies. The staff all came together and took care of their own, donating days to extend time off. There is a very low turnover rate in the department, despite the hard work and the long hours that personnel often encounter. The staff that stays in the department is open to new ideas, and is willing to try original techniques and ideas. The continuity of the care that the staff gives to its patients, seeing them from PAT to discharge, has contributed to the high satisfaction rate of our patients. The paramedic team, which provides inter-hospital transfers of patients for cath lab procedures, starts our patient education while in transit. They show a video of the cath and PCI procedure in the ambulance, helping to alleviate some of the patient’s anxiety. Is there a problem or challenge your lab has faced? Budget is a major challenge to all hospital facilities in today's society. Hospitals are faced with lower reimbursements, rising equipment costs and rising salaries. This is being addressed by the primary physicians expanding their referral base, and thereby increasing capital. The lab as a whole is working together to meet budgetary constraints. One way that demonstrates the staff cohesiveness is when sick calls are received, existing staff adjusts their workloads to facilitate maximum functioning of the unit without utilizing replacement staff. What’s special about your city or general regional area in comparison to the rest of the U.S.? Our patient population is older when compared to populations based on the Center for Disease control data. New York state has the highest age-adjusted death rate related to heart attacks in the United States. It is ranked 41st in overall cardiac and vascular deaths. Many factors contribute to this high mortality rate; socioeconomic, educational, and cultural factors, and the fact that there is restricted access to care in New York. Brooklyn has an overall crude mortality cardiovascular disease rate that is slightly higher than the New York state average, and is approximately 10% higher than the U.S. average. Maimonides’s service area is an older, diverse, yet very stable population of approximately 915,000. Maimonides was originally established to serve the Orthodox Jewish community. This influence is still strong and a vital part of MMC. As Brooklyn has grown, the population surrounding Maimonides reflects the influx of immigrants that arrived in New York, including Italians, Polish, Russians, Asians, Puerto Rican, and other Caribbean nations, as well as Middle Easterners and many other nationalities. Many of these ethnic groups have a very high risk of heart and vascular disease. Maimonides Medical Center (MMC) serves a highly acute patient population. The coronary artery disease rate is significantly higher than the New York and United States average, as evidenced by the market data. While the culture of populations served enter into this equation, the higher acuity is further evidenced by the facts that a majority of the patients arrive through the Emergency Department rather than as an elective admission. Approximately 50% of the population arrives at MMC by ambulance. Of the approximately 50,000 adult acute visits to the Emergency Department, the majority has some type of cardiac or vascular disease. The American Heart Association (AHA) estimates that 50% of the population over age 45 has some level of heart and vascular disease approximately 357,000 persons, or 39.1% of the population in the MMC area over 45, can be compared to the New York State average of 36.7%. Peggy Healey can be contacted at PHealey@maimonidesmed.org

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