Mercy Health Partners Mercy Hospital

Our staff includes 16 members total. Nine are registered radiology technologists, five of which hold the Registered Cardiovascular Invasive Professional (RCIS) credential. Two techs work in both EP and cath. Our lab also includes 7 registered nurses, including our nurse manager. In addition, three of the nurses hold an RCIS credential and act as our main cath lab nurses. Two nurses are designated EP and the other is a pre-op/post-op nurse for our five-bed holding area. All staff are trained in ACLS and balloon pump insertion. We also have a wonderful secretary who handles all the scheduling, films, old reports, etc. We are a well-seasoned staff. I say this because we have all been at our positions for an average of 16 years! We have been lucky enough to see and experience the tremendous growth in interventional cardiology over the past decade. What type of procedures are performed at your facility? We performed 2,385 cases last year, totaling over 7,300 procedures, including 848 interventions. We offer percutaneous transluminal angioplasty, stenting, Rotoblator (Boston Scientific, Maple Grove, MN), intracoronary ultrasound (Volcano Therapeutics, Rancho Cordova, CA), Wavewire® (Volcano Therapeutics), PercuSurge (Medtronic Inc., Santa Rosa, CA) and the FilterWire Ex (Boston Scientific). In the past we have used laser and beta radiation therapy for our patients. Our EP lab supervisor is Joseph J. Healey, RN, BSN. Dr. John Lundin is our electrophysiologist. The EP laboratory provides a full spectrum of electrophysiology services, from simple tilt-table testing to radiofrequency ablations. The majority of our EP business is device implants. In 2005, we implanted over 250 devices and expect to see a large increase in 2006 due to expanded coverage guidelines for implantable cardioverter-defibrillators (ICDs). Medtronic has an 80% market share for our devices, but we also utilize Guidant, St. Jude, and Biotronik. The area where our facility is located is in northeastern Pennsylvania. We have a huge number of elderly people in our population. For this reason, there is a great need for not only cardiac work, but also peripheral work. Our hospital offers peripheral studies along with interventions. We have two highly trained interventional cardiologists, Dr. Stylianos Galanakis and Dr. Sun-Tak Han, who have been trained in peripheral work. Our volume is steadily increasing and we expect it to grow rapidly with our new lab. We are looking forward to doing carotid stenting and helping a whole new realm of patients. Along with our physicians, our nurses and technologists are preparing to become a highly skilled and dedicated carotid vascular team. Does your cath lab perform primary angioplasty in acute myocardial infarction (MI) with surgical backup? At our facility we do 66% of our interventions ad hoc, always with surgical backup available. As primary angioplasty is now the gold standard for the treatment of MI, we bring our MI patients directly to the cath lab when they are brought into the hospital. In support of the CMS Core Measures Initiative, we strive to achieve the most rapid door-to-open-vessel time (within 90 minutes). Is your cath lab nursing-or radiology managed? Currently our lab is managed by a nurse manager, Janet Zelna, RN, BSN, CCRN. James C. Craven, BS, MS, is the Director of Cardiovascular Services at Mercy. He answers directly to the Chief Administrative Officer, C. J. Urlaub. Our Chief of Cardiology is Christopher J. Dressel MD, FACC, FSCAI. We are designated as part of the cardiovascular service line (not directly under radiology or nursing). Do you have cross-training in the cath lab? In our institution, only RNs can administer medications. Our nurses are dedicated to monitoring the patient’s condition during conscious sedation, while the techs scrub and circulate. In all other aspects, we are seamless in our cross-training. The way we perform has not changed much over the years. We continue to grow and have worked extremely hard to blend the seams to the best of our ability. We are very team-oriented, realizing that to survive in this stressful job, we must be on the same team. What are some of the new equipment, devices and products introduced at your lab lately? In September 2005, we opened our newest room with a Philips Integris FD20 with vascular essentials. It features a new flat detector, 3D imaging and bolus chase. One of the many nice features is image grab, which enables the operator to save fluoro shots and not have to use cine all the time. This will enable us to use less contrast on every patient and reduce radiation exposure to the patient and staff, improving safety for everyone. We have also taped out a three-foot square from the center of the x-ray tube, called the jewel box. This enables the staff to stay a safe distance from the radiation (a tip we found in Cath Lab Digest many years ago). Safety is a very high priority in our organization. Our hospital recently received a Distinguished Hospital Award for Patient Safety from an independent healthcare quality rating organization (1 of only 88 in the country). We are confident that our new equipment has increased excellence at our hospital. Better visibility means better outcomes. As far as new products are concerned, we offer the drug-eluting Taxus (Boston Scientific) and Cypher® (Cordis Corporation, Miami Lakes, FL) as our front-line stents. The Filterwire has been newly introduced for distal protection of vein grafts and possibly, in the future, carotid protection. Guidant’s new balloon, Voyager (Santa Clara, CA) has become our front-line workhorse balloon and we also use Guidant’s Pilot® guide wire. We also have a new wire from Boston Scientific, the IQ guide wire, with and without markers. We are mainly a rail lab, but offer over-the-wire balloons as needed. We also keep a supply of Jostents (Abbott Vascular, Redwood City, CA) for those rare cases when they are needed (but always appreciated!). New to our peripheral program is the MS SilverHawk (FoxHollow Technologies, Redwood City, CA). It offers precise plaque excision from both de novo and restenotic lesions. Another new technology that we offer to our patients is use of the radial approach. We have two cardiologists dedicated to this new technique, Dr. Sun-Tak Han and Dr. Samir Pancholy. We are fortunate that we can offer this new choice to our patients. For those with bad backs, etc., there is no longer any post-procedure bedrest required. We perform right heart, left heart and interventions from the radial artery and vein. We even offer left radial approach for left internal mammary artery (LIMA)-access PCI. In addition, Dr. Han and Dr. Pancholy specialize in chronic total occlusions (CTOs). To date, we have had very few complications. Our lab is very lucky to have had world-famous operators visit our hospital to help with some tricks of the trade and demonstrate the newest techniques in radial access catheterization. They include Dr. Shigeru Saito from Kamakura, Japan; Dr. Tejas Patel from Almedad, India; and Dr. Ian Gilchrist from Penn State’s Cardiovascular Center in Hershey, Pennsylvania. With their help we have strengthened our program. Can you describe your cath lab imaging system? We have been filmless for 8 years and love it. We have recently switched over from digital CD storage to digital mass storage using the recently installed Siemens Acom Network. It has proven to be far better than the use of CDs, which we no longer have to worry about storing. Physicians can always quickly find their films by themselves! This has also cut down on radiation exposure to the patients and the staff by reducing procedure capture from 30 frames to 15 frames per second. Our physicians have also reduced the amount of cine and fluoro time spent in the left anterior oblique (LAO) position. We have a viewing station in our cardiovascular OR, allowing surgeons to immediately recall their patient’s cath films. We are now working to expand access via the web to enable our physicians to view studies from anywhere in the hospital, their office or even their home. How does your lab handle hemostasis? We have tried many closure devices. Newest to our lab is StarClose (Abbott Vascular). We are about to trial this product for several weeks. We have seen a fair amount of complications with closure devices and, as far as perfect hemostasis is concerned, the jury is still out. Currently most interventions are closed with a closure device deployed by the physician, with Angio-Seal (St. Jude Medical, Minnetonka, MN) being the product of choice at this time. About 30% of our cases are done using transradial access. In these cases, a HemoBand (AccuMed Systems, Ann Arbor, MI) is placed on the wrist for a few hours with little to no discomfort to the patient. The patients who are not candidates for a closure device get the sheath sutured in place. It is later pulled on the floor by our team using a Clo-Sur Pad (Medtronic Inc.). One of our performance improvement (PI) projects is to expand the use of the less expensive closure pads while insuring no compromise in the quality of patient care (monitoring hematoma rates). We felt that this was an easy and safe way to save money. We are continuing to switch to hemostasis pads, when appropriate, and expect to realize thousands of dollars in savings annually. These patients are on bedrest for 2 hours with their head at 20 degrees and then ambulated and fed. They are then discharged from our holding room at hour 3 or to the short stay unit for an additional 1-2 hours. As we all know, every physician is different, including discharge, but so far this process has worked very well for us. All patients are followed and telephoned the next day to document any complications, including hematoma. If the patient had an intervention, they will be admitted to our telemetry floor and will stay overnight. The cath lab transports all their own patients on monitors back to the floors. How is inventory managed? One of our techs, Mark Mileski, RT, RCIS, is assigned to inventory management. He has done a wonderful job getting all of our balloons, wires and stents on consignment in order to reduce cash flow. He works very closely with our vendor representatives to ensure that our contracts are followed and rebates realized in order to save money for the institution. All of our other supplies and drugs have moved to a Pyxis Supply System (Cardinal Health, San Diego, CA). In this system, the patient’s ID number is inserted and each item is charged and reordered in one easy step. Access to the Pyxis storage unit is based on the use of your fingerprint. This makes it safe and efficient, especially for drugs. Has your cath lab recently expanded in size and patient volume, or will it be in the near future? Yes, our patient volume has increased over 45% during last three years and we expect it to continue to grow with the installation of our new lab. We also credit this to the fact that we have tried very hard to be a physician- and patient-friendly lab. We have pursued physicians from other groups and have tried very hard to meet their ever-changing needs for new technology and equipment. A happy physician makes for a great day for all! Is your lab involved in clinical research? Yes, we recently have become involved with a new project. The radial artery is becoming an increasingly popular site for accessing the arterial circulation for diagnostic and therapeutic purposes. In view of the fact that the radial artery is a muscular artery with a large component of vasomotion, it is prone to spasm. Spasm is the Achilles heel of transradial access. It could limit the progress of the procedure and frequently leads to local pain. We first used nitro mixed with our local lidocaine for numbing and to prevent spasm at the radial site, but several spasmolytic cocktails are used by operators, with ingredients selected based on pharmacologic properties. There is no data testing the relative utility of these different components such as nitrates and calcium channel blockers. We are planning a study for the purpose of comparing the utility of nitroglycerin (NTG) versus a combination of diltiazem (Dilt) and nitroglycerin for the prevention of spasm. Another arm of the study will compare the utility of intra-arterial versus intravenous administration of Dilt for the prevention of spasm. This study is pending approval of our Institutional Review Board. Does your lab perform elective cardiac interventions? Yes, we do perform scheduled elective interventions, especially if the patient has been staged and is returning for another vessel to be fixed. Regardless, of whether the intervention is scheduled or emergent, 66% of our interventions are done as same-day procedures. Have you had any cath lab complications in the past year requiring emergent cardiovascular (CV) surgery? Well, as we say, The more you do, the more you see. Emergencies have come up, and thankfully, with stent technology always improving, we have seen a decline in patients that must be sent to the OR. Now, with the JoStent, even a perforation can be saved from the bright lights and cold steel! Of course, we always verify surgical backup before initiating PCI, and have had an excellent response from CV surgery and perfusion services. Our average for complications is well below the national American College of Cardiology standard. What measures has your cath lab implemented in order to cut or contain costs? We are always looking for a safe and efficient way to cut and contain costs. We worked with our pharmacy to look at drug costs, namely GP IIb/IIIa inhibitors, and have saved thousands of dollars through the utilization of rebates. We’re continuing to reduce the use and cost of expensive closure devices. We utilize national contracts (Premier Inc.) to take advantage of cost savings for high usage/high cost products. We negotiate with vendors for their best price on items where national purchasing groups have not identified effective contracts. We have cut back on the waste of hospital lunches for patients and have replaced them with new heart healthy lunches and snacks. We have standardized contrast in the hospital to Optiray®(Mallinckrodt Inc., Hazelwood, MO) We have customized our left heart packs (Boston Scientific) to include contrast-saving tubing and use a large multi-dosing bottle of contrast. All these things have saved significant dollars. How does your cath lab compete for patients? With a competing lab about 8 blocks away, we strive on a daily basis to ensure that we deliver the highest quality care in an environment that satisfies both our physicians and patients. A tribute to this is our recent recognition by Solucient as one of the Nation’s Top 100 Heart Hospitals for the past 2 years. We are very proud of this recognition, since it reflects our total commitment to providing the best cardiovascular care available. Since receiving the award, our case volumes have been very strong. From a patient standpoint, we have designed our program to be extremely patient-centered. Patients, along with their families, report directly to the cath lab, bypassing the admissions, lab, x-ray, and EKG departments. We can perform all pre-op testing from the cath lab at this time. The fewer the stops for the patient, the more convenient it is for both them and their family. Administration has allowed us to provide the newest in equipment and procedures modalities. We now have a fully computerized operation which permits mass storage of our studies and ready access by our physicians through available computer workstations. This system will soon be part of the hospital’s PACS (picture archival and retrieval system) to extend the physicians’ access to studies from virtually anywhere (office or even their home). Making things convenient for the physicians is one of the best ways to ensure that they choose to practice in our hospital. Our cardiologists also provide us with patients through small clinics that have been set up in outlying area hospitals. Patients have easier access to cardiology consults where otherwise they would need to travel a great distance. Many patients have been referred to us in this way and it really has helped to build our business, both here and in the outlying communities. Finally, we now offer transradial access for both diagnostic and interventional procedures. This approach has some benefits in terms of getting the patient up and around significantly sooner. As a result, a number of patients now seek us out. What a great feeling! Does your lab have an outpatient program? Yes, we have an outpatient program in place. We do diagnostic catheterizations, tilt tests, select pacemakers, and some ICD/pacemaker generator changes. We are also considering a dedicated outpatient cath lab to perform both cardiac and peripheral procedures. How are new employees trained at your facility? We have one-on-one preceptorship for cath staff training. Staff are oriented to each role in the lab as part of a competency-based program. All staff are then sent to several mandatory hospital-based classes which include hemodynamics, an intra-aortic balloon pumping class, and BLS and ACLS certification. Licenses are kept current and RCIS credentials must be maintained. What type of continuing education opportunities are provided to staff members? Our staff has initiated a self-directed education program. This has proved very successful. We held classes to prepare and successfully pass the RCIS certification. We do continuing education credits together on a regular basis. Laura Carpenter, RT, RCIS, is currently in charge of seeking out opportunities for ARRT and RCIS credits. Our sales representatives and clinical specialists also provide us with educational in-services and credits. How is staff competency evaluated? Competency is evaluated as part of the employee’s annual performance appraisal. They are also required to review fire safety, radiation safety, blood-borne pathogens, etc., via a computer-based learning program. Staff and physicians are kept current on the newest equipment with frequent vendor in-services. In addition, we have had a number of highly acclaimed speakers visit Mercy to lecture. This past year we had several world-renowned physicians visit Mercy to speak on transradial catheterization, including Dr. Shigeru Saito and Dr. Tejas Patel. We also hosted an International Conference on Transradial Catheterization. The program, entitled TRIP 2006 (TransRadial Interventional Program), was held on July 8, 2006. The objective was to provide a comprehensive demonstration and didactic discussion of transradial techniques for femoral operators. One of our physicians, Samir B. Pancholy, MD, FACC, FSCAI, a member of the Transradial Working Group of the Society for Cardiovascular Angiography and Interventions (SCAI), put the program together and served as program director. Live cases were transmitted from our new cath lab to the conference, which was held at a local hotel. Faculty members included world-renowned physicians including J. Tift Mann, Wake Heart and Vascular Associates, Raleigh, North Carolina; Shigeru Saito, Shonan Kamakura General Hospital, Kanagawa, Japan; Tejas Patel, Sterling Hospital, Ahmedabad, India; John Coppolla, St. Vincent’s Hospital, Manhattan, New York, NY; and Ian Gilchrist, Penn State’s Cardiovascular Center, Hershey, PA. For more information, see our website at: www.gotransradial.com. Plans are currently underway to host TRIP 2007! How does your lab handle call time for staff members? Our team consists of 1 RN to monitor conscious sedation, 1 technologist to circulate in the procedure room and either an RN or RT to perform the hemodynamic monitoring role. Weekday call starts at 4:30 pm Monday, continues through the week and includes the entire weekend. Our call rotation is about 1 week per month. During call week we are required to be within 30 minutes of the hospital at all times. We are just about to try a new idea of starting call Friday through Thursday instead. We feel we will get through the hard part the weekend first, and then coast through the rest of the week. We hope it works, at least mentally. What type of quality control (QC)/quality assurance (QA) measures are practiced in your lab? Equipment QC includes ACT, Accu-Check, crash carts and defibrillator checks. This is in addition to any required PM or safety checks by our Bio-Med Department. Patient satisfaction is measured by a survey sent out by an outside company (NRC-Picker, Lincoln, NE). We also follow-up with the patient one day post-procedure to insure clinical quality. Quarterly cardiovascular section meetings are conducted to provide a forum for physicians to receive program information and discuss, among other things, opportunities to improve our quality. These also include an interesting case of the quarter for educational purposes. The meeting is well-attended by our cardiologists, cardiac surgical team and administration. The Cardiovascular Services Morbidity and Mortality Committee meets quarterly to review cases and insure physicians maintain high standards of quality. A broad range of quality data is collected on a regular basis to monitor our clinical performance. Indicators also include CMS Core Measures. In order to benchmark our performance nationally, we recently implemented the ACC-NCDR® CathPCI registry and the ACC-NCDR ICD registry. What measures has your cath lab employed to improve efficiencies in patient throughput? About three years ago, a committee was established to look at patient flow. It was decided that the patient should report directly to the cath lab to decrease patient anxiety and activity the day of the procedure. Patients are much happier with direct report to the cath lab, bypassing the admitting and registration department. Any additional blood work is obtained as IV access is established in the pre-procedure area. Our nurse manager was a member of the patient flow committee, which studied patient flow issues involving the ED, telemetry, cardiac cath lab and ICU areas. The primary focus was on patient safety and satisfaction. Our nurse manager also participates on a committee to improve scheduling of cases and organizing pre-admission work-ups. This committee is mainly focused on operational efficiencies prior to patient arrival, thus making evaluations of abnormal labs and their treatment less stressful on procedure day. It also helps lessen cancellations due to abnormal lab results. What trends do you see emerging in the practice of invasive cardiology? We see a reduction in length-of-stay for our ad hoc and elective PCI/stent patients. We see more diagnostic cases being done by the radial approach and being discharged in as little as 60 minutes post-procedure. We see increasing numbers of peripheral procedures being done by our cardiologists. We see a technological revolution as a result of increasingly sophisticated computerization. Has your lab undergone a JCAHO inspection in the past three years? Yes, we were inspected in 2005 and all went very well. Based on the new process of unannounced inspections, we expect to maintain our level of readiness at all times. Are there any texts or websites that your lab/staff uses and would recommend to others? Yes, two great CME sites: www.freecme.com and www.medscape.com. [Editor’s note: www.naccme.com also has many free CME programs.] A great text is The Cardiac Catheterization Handbook (Third Edition), Morton J. Kern, MD, Professor of Medicine. Please share with readers what you consider unique or innovative about your lab and its staff. Well, as I indicated previously, we are very proud of being selected by Solucient as one the Top 100 Cardiovascular Hospitals in the Nation for the past 2 years. In addition, our cardiovascular program has received several national recognitions from other healthcare quality rating organizations over the past 3 years. Also, I know our staff is unique in terms of their experience as a team. We have been working together for quite some time. In fact, there is very little turnover in our lab. Our combined cath lab experience adds up to over 173 years. We believe this is a key to our success! Is there a problem or challenge your lab faced? How was it addressed? I think cost containment will always be a challenge. One of the difficulties in growing is that we are experiencing a lot of overtime. While we stagger our start times, we only have one shift. Therefore, the call people stay until the day’s work is completed. This runs into some very late nights. Some solutions are on the horizon: First, we completed construction of an additional procedure room and expect to use it to more efficiently process our patients. Second, we are working closely with the physicians to try to accommodate them and at the same time, work with their offices to efficiently schedule their patients. We are currently trying block scheduling. It’s a good plan and has seemed to pan out so far. Each physician picks a block of four hours to work around his office time. They can perform as many cases as they can complete in that timeframe. They also get the privilege of working in the "new" room, which is important to them. Lastly, we are in the transition of putting in a later shift of 9:30 am to 6 pm. This is designed to help with the overflow of the day and free up the call team for emergencies. We expect that all these changes will cut down on some overtime. Another financial pressure which all cath labs are trying to address is the use of expensive drug-eluting stents. We have very good contracts as well as reasonable usage. We expect that as more companies enter the marketplace, the cost will decline. We can be contacted at jzelna @ health-partners. org.

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