Mount Sinai Medical Center

What is the size of your cath lab facility and number of staff members? The Mount Sinai Medical Center’s cardiac catheterization laboratory in New York City consists of 3 adult labs, 1 pediatric lab,1 EP lab, 1 cardiac biopsy suite, 8 bed prep and recovery area along with a 15 bed ambulatory bed area. The staff consists of: 24 professional registered nurses 3 per diem professional registered nurses 10 cardiovascular support specialists 3 x-ray technologists 10 patient care associates 1 clinical nurse manager 3 nurse practitioners 1 operations manager 6 business associates & schedulers 5 interventional fellows/ 2 EP fellows 12 invasive cardiologists (7 perform PCIs) 3 electrophysiologists 1 pediatric interventional cardiologist Among the nursing staff, approximately 30% are credentialed in critical care nursing or medical surgical nursing. One hundred percent of nurses are bachelors degree nurses. The great news is that we are currently starting to do construction for 2 additional labs and increasing our prep/recovery area to 20 beds. What type of procedures are performed at your facility? We performed approximately 9,660 interventions in 2003. 4,655 diagnostic catheterizations 2,841 percutaneous coronary interventions: Approximately 10% of patients have multi-vessel interventions and 30% of patients have multi-lesion interventions. We also have private cardiologists at diagnostic-only facilities who bring their patients in for interventions. 563 biopsies 1,340 electrophysiology cases 260 pediatric procedures The wide range of adult services that we provide includes: Diagnostic cardiac catheterizations Coronary interventions Rotablators Stents PTCA Brachytherapy Complicated lesions such as unprotected left main disease, along with protected left main disease Septal alcohol ablation Aortic valvuloplasty Mitral valvuloplasty Electrophysiology studies Cardioversions Atrial flutter ablations Ventricular ablations Permanent pacemaker placements Automatic implantable defibrillator placement Bi-ventricular pacemaker implants Tilt table procedures Pre and post transplant work ups Pulmonary hypertension studies Some of pediatric procedures include: Congenital heart diseases Pre and post transplant work ups Line placements for the pediatric population We also do a small volume of peripheral interventions. Does your cath lab perform primary angioplasty with or without surgical backup? A cardiac surgical team is available at all times, either in-house or on call. Primary angioplasty is done without surgical backup. What procedures do you perform on an outpatient basis? We perform EP studies, cardioversions, pacemaker implants, battery change/generator changes for ICD/ pacemakers, pulmonary hypertension studies, and pre and post transplant workup on outpatient patients. We have been progressive in terms of moving towards ambulatory cardiac interventions. We are currently performing approximately 10% of our coronary interventions on an outpatient basis. Each patient must meet specific clinical indicators in order to qualify for an ambulatory coronary intervention. What percentage of your patients are female? Approximately 33% of our patients are female. What percentage of your diagnostic cath patients go on to have an interventional procedure? Approximately 60% of our diagnostic cases receive interventional procedures. Who manages your cath lab? The lab is managed by a clinical nurse manager. The nurse manager reports to the Clinical Director of Primary Care and Cardiac Services, Nancy Rodenhausen, who reports to the Vice President of Nursing, Tom Smith. There is an operations manager, Gregory Gojkovich, who manages the supplies and the scheduling office of the cath lab. Do you have cross-training? Who scrubs, who circulates and who monitors? All nurses and cardiovascular support specialists are cross-trained to perform any function. The nurses are the only ones who administer medications. Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab? No, a radiologic technologist does not have to be in the room during cases. 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? Nurse practitioners, cardiology fellows and the interventional cardiologists are the ones who operate the x-ray equipment. Does your lab have a clinical ladder? We do not currently have a clinical ladder in place. What are some of the new equipment, devices and products introduced at your lab lately? As one of the leaders in the world of interventional cardiology in the New York City area, we are often fortunate to be the pioneers in implementing new technology and new procedures. We recently implemented the Taxus® stents (Boston Scientific, Maple Grove, MN) and recently trialed new transeptal radiofrequency ablator catheters in adults. Some of the other devices that we have been using for a while include: Cypher sirolimus-eluting stents (Cordis, a Johnson and Johnson company, Miami Lakes, Florida) Distal protection devices: the FilterWire (Boston Scientific) and the PercuSurge device (Medtronic, Inc., Santa Rosa, CA) Cutting Balloons (Boston Scientific) Galaxy IVUS System (Boston Scientific) Brachytherapy (Beta-Cath system, Novoste, Norcross, GA). We also recently updated our hemodynamic system (GE Mac-Lab®, Waukesha, WI). In 2003, we developed and implemented the SoftLink® report generation system (Brooklyn, New York) in the cath lab. The company came and helped us to design, develop, implement and train staff with our own report generation program. This program allows for instant report generation, which is then automatically faxed to referring physicians. This is key to ensuring that we keep our referring physicians satisfied and in the loop of communication. It also allows us to track room time utilization, physician time utilization, and supply utilization. The system generates an immediate bill for services and supplies used per procedure for revenue capture. It also helps the material coordinator and operations manager to keep a close eye on supply and equipment usage, and assists in ordering supplies and following utilization trends. Is your cath lab filmless? The lab is completely digital and we use an OptiMed Technologies, Inc. (Fairfield, NJ) system. How does your lab handle hemostasis? Currently, if no closure devices are used, about 95% of all sheaths are being pulled in the prep/recovery bed area by nurse practitioners and the cardiology fellows. If closure devices are applied, they are done while the patient is on the lab table. The remaining sheaths are pulled either in the Coronary Care Unit or in our 8-bed dedicated procedure bed located on a progressive telemetry unit. We use closure devices on 80% of our patients. The following are being used: Perclose® (Abbott Vascular Devices, Redwood City, CA) Angio-Seal (St. Jude Medical, Minnetonka, MN) VasoSeal® (Datascope Corp., Mahwah, NJ) We use FemoStop® (RADI Medical Systems, Reading, MA) in approximately 30% of our patients. Does your lab have a hematoma management policy? We are very aggressive with hematomas. All patients are tracked and overall, the rate of hematomas is very low for the lab. How is inventory managed at your cath lab? We have a dedicated materials management coordinator in the lab. He orders supplies daily and is responsible for maintaining the par level of supplies in each room. The operations manager assesses the pricing, reviews contracts and negotiates with vendors. All new products must be trialed prior to setting up any contracts to purchase. How is coding and coding education handled in your lab? A billing department is responsible for coding and coding education. Has your cath lab recently expanded in size and patient volume, or will it be doing so in the near future? We have recently begun construction on two additional labs. The anticipated completion of the labs will be in 2005. In terms of patients, our patient volume continues to grow and grow. In the last year, our growth was approximately 10% and our anticipated growth will be 10% for the year 2004. Is your lab involved in clinical research? Yes, we are actively involved in many research protocols. We have four dedicated research associates who run the clinical trials. We are currently involved in the PREDICT, FORCE, MYOGENSIS, BARI2-D, COPE, PRIDE, TAXUS, and AMIGO clinical trials. Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? Approximately 0.3% of patients undergo emergent cardiac surgery. The Mount Sinai hospital has the best angioplasty outcomes of any major hospital in New York City, according to a recent report from the New York State Department of Health. What measures has your cath lab implemented in order to cut or contain costs? We are constantly looking for cost-saving measures, such as rebate programs along with bulk purchasing for high-cost inventory items. What type of quality control/quality assurance measures are practiced in your cath lab? Being part of a large academic medical facility, we have many quality control and quality assurance measures. The medical staff meet weekly to review cases, along with monthly meetings to discuss performance indicators. There are hospital-wide performance indicators that are monitored quarterly. We monitor such things as patient satisfaction, compliance with site-side verification policies, medication administration, sedation and hematomas. We also call every ambulatory patient the day after discharge to follow up on their care. How does your cath lab compete for patients? Has your institution formed an alliance with others in the area? We have many hospitals that are affiliated with Mount Sinai Hospital. Many are diagnostic-only facilities and patients are transferred to our facility for coronary interventions. We are also in the process of negotiating our own ambulance services to service-affiliated hospitals. How are new employees oriented and trained at your facility? All new hires must complete a hospital-based orientation. Unit-based orientation is coordinated by the nurse educator, along with the new staff member’s preceptors. All new staff are assigned preceptors and trained one-on-one for three months. A unique feature of our cardiovascular support specialist is a result of the limited programs in New York City for cardiovascular technologists. We must home grow our technologists, which means that we hire and train all our specialists with formal classroom training and hands-on training. What type of continuing education opportunities are provided to staff members? We start late on Tuesdays, which allow staff time for inservices and staff meetings. Our inservice calendar is usually booked one month ahead by vendors or by the nurse educator. Within the department itself, a lottery is done for two major conferences (ACC and TCT) and two staff members are chosen to attend. There are many learning opportunities in which staff can participate (medical grand rounds, nursing grand rounds, organizational development and learning programs such as Spanish, and computer programs). Nursing staff can also apply to attend nursing conferences through the Department of Nursing Education. Mount Sinai is also the proud host of our own annual symposium. This year, we will hold the 7th Symposium on Complex and Interventional Procedures, June 16-18, 2004. This three-day event has live case presentations with physician discussions about complex cases in the world of interventional cardiology. It draws medical experts from all over the world. The nurses and the techs are active participants in this symposium, either as presenters at the one-day nurse/tech symposium or as staff in the live case presentations. How do you handle vendor visits to your lab? Vendor visits are scheduled visits. Two vendors are allowed in the lab on limited days. How is staff competency evaluated? Staff competency is evaluated by direct observation, along with specific annual testing of staff members. Staff are tested for proficiencies in use of the: Hemochron® machine (International Technidyne Corp., Edison, NJ) ABG blood testing SAT machine, along with intra-aortic balloon pumps AngioJet® (Possis, Inc., Minneapolis, MN) FloWire (Volcano Therapeutics, Rancho Cordova, CA) along with competencies in BCLS, sedation and analgesia (nurses only). How does your lab handle call time for staff members? The lab’s normal hours of operations are from 6:30 in the morning to 10:00 at night. The nursing staff have flex-time with 11.5-hour shifts. The rest of the staff (cardiovascular support specialists, x-ray technicians and patient care associates) currently work 7.5-hour shifts. The nurse practitioners work 10-hour shifts. In November 2003, we expanded our call hours from weekends to 24 hour availability of the cath lab. The hours of call are 10 p.m. to 6:30 a.m. (Monday-Thursday) and on the weekends, the cath lab is available to be opened anytime. The on-call team consists of three members of the staff, including one nurse and 2 technologists. The sign up for on-call is voluntary, and the list is often completed within 30 minutes of releasing the sign up. The only requirement to taking call is that staff members must have worked in the lab for a minimum of one year because of the acuity of the patients. Does your lab utilize any alternative therapies (such as guided imagery, etc.)? Our nurse educator, along with one of the staff nurses in the cardiac cath lab, has an active research protocol with the use of guided imagery in the cardiac cath lab. What trends do you see emerging in the practice of invasive cardiology? While we are already leading the way in terms of ambulatory cardiac interventions, I see this becoming a huge trend in our field. I also see the trend moving towards percutaneous valve procedures, along with the additional uses of imaging tools such as MRA and PET scanners. Also, peripheral interventions such as renal and carotids are increasingly being done. Has your lab has undergone a JCAHO inspection in the past three years? Yes, we underwent a JCAHO inspection in 2003. We did remarkably well. Where is your cath lab located in relation to the OR department, ER, and radiology departments? The cath lab is located on the fifth floor, while the cardiac operating room is located on the third floor. The ER and the radiology department are located on the main corridor level of the hospital (five floors below). I think that we are ideally located, as the elevators are close to the lab, which allows for quick access to these departments. We are also located close to the Coronary Care Unit, which is perfect for us, because we can keep a close eye on the critically ill patients. Please tell readers what you consider unique or innovative about your cath lab and its staff. A unique feature of our cath lab is its use of advance practice nurses. We currently have three full-time nurse practitioners in the cath lab who see patients pre-procedure, perform diagnostic and coronary interventions (under the direct supervision of an attending cardiac interventionalist) and follow these patients upon discharge. With over 60 staff members, this large group of individuals are all unique. They bring a wide range of backgrounds and experiences to the cath lab, but their most amazing quality is the ability to function efficiently in an extremely busy lab, while always keeping the interest of the patient as a top priority. Another excellent quality held this group of individuals is that they are a highly motivated team, with loyalty and dedication to patient care. The camaraderie that exists is amazing. Since the implementation of 24/7 on-call and freedom of the lab to be opened, the staff actually sign up for on-call rather than management having to impose mandatory rotation and rules. Staff were and continue to be the key ingredients to the successful operation of the on-call program. Another great characteristic is the physician group’s support of the nursing staff. The physicians are often recognized for their ability to teach and guide new staff members, whether these new members are interventional fellows, new staff members, nursing students, physical therapy students or nutrition students. The staff (nurses, techs, patient care associates, business associate and the physician staff) are very cohesive and rise to all occasions. Is there a problem or challenge your lab has faced? Health care overall is now facing many new challenges. One is the nursing shortage. We are facing some challenges in recruiting new staff members. We are still trying different techniques to recruit new staff. Another challenge is expanding volume. While it is a paradox in that it is excellent news for hospital administrators, the cath lab staff are constantly faced with long and stressful shifts with overtime (often done by nursing personnel with dedication to patient care). The good news is that we are building two additional labs (to be completed in 2005) which will better serve our expanding volume. What’s special about your city in comparison to the rest of the U.S.? Mount Sinai Medical Center is located on the Upper East Side of Manhattan in New York City. What can be said about the Big Apple that has not already been said? It is a large urban area with an extremely diverse group of people. It is a fast paced city that abounds with energy and never sleeps at night, as so many have said. One of the most amazing things about the geographic location is that while it is a metropolitan area, it remains close enough to regularly visit beaches and mountains. There is truly something for everyone fine dining, arts, culture, sports, fashion and museums, and on and on. It truly is an amazing city. Questions from the Society of Invasive Cardiovascular Professionals (SICP): 1. Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? Do staff receive an incentive bonus or raise upon passing the exam? No, staff are not required to take the RCIS exam. 2. Are your clinical and/or managerial team members involved with any professional organizations that support the invasive cardiology service line? Not at the current time. Author Grace Su can be reached at Grace.Su@msnyuhealth.org

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