North Ridge Medical Center

What is the size of your cath lab and number of staff members? Overall, there are a total of six rooms and one pre-op/recovery area. We have three fully dedicated cath labs utilizing the Siemens Coroskop Hi-P and HICOR (Iselin, NJ) with a Witt monitoring system (Melbourne, FL). Our fourth invasive room is a swing lab with the Toshiba CAS-10A (Tustin, CA), using a dual head. Not only is this room used for caths, it often hosts invasive neurology cases and overflow from the OR. This room can also be converted for electrophysiology cases, since our EP lab often has an overflow of cases. There is also another invasive and one non-invasive room specifically for the electrophysiology lab. North Ridge staffs 13 registered nurses, 7 RCISs, 1 transporter, 2 secretaries and 1 LPN. We have one director and one assistant nurse manager for the cath lab and for the EP lab. Among our EP staff, there are 2 CVTs and 4 RNs. What type of procedures are performed at your facility? We perform everything from diagnostic cardiac catheterizations to coronary interventions, including coronary angioplasty (PTCA) and/or intracoronary stent implantation. We also perform Rotablator® (PTCRA) (Boston Scientific, Maple Grove, MN), intravascular ultrasound (IVUS) and AngioJet® (Possis Medical, Inc., Minneapolis, MN) procedures. In January 2001, our cath lab became certified to perform brachytherapy, and as of December 2001, we began performing PercuSurge procedures (PercuSurge, Inc., a division of Medtronic AVE, Sunnyvale, CA). In May 2002, which is one of our slowest months, we performed a total of: 331 diagnostic caths; 92 PTCAs (PCIs); 153 stent implantations; 6 ultrasounds (IVUS). We also had 4 balloon pump insertions (IABP); 0 Rotablator procedures; 0 AngioJet interventions; 3 successful brachytherapy procedures; 3 PercuSurge procedures. We also had 6 in-house patients having persistent chest pain return for an additional angiogram. Out of the total number of patients (598), 109 were inpatients, 170 were outpatients, and 84 were transferred from other facilities. For the fiscal year of 2002, we performed 6,428 total cases. Do you have cross-training in the cath lab? We have three positions: one staff member monitors, one circulates, and one scrubs. Technologists record, operate the x-ray equipment and perform daily fluoro checks on the equipment. Nurses circulate (only RNs are licensed to give meds in this hospital). Both techs and nurses scrub. Can you briefly describe how you staff your labs for diagnostic and interventional procedures? We have four rooms and basically staff three per room: either one RN and two techs, or two RNs and one tech. On an especially difficult case, for example, a Rotablator case, we might use 2 RNs and 2 techs. The pre-op area has one LPN. In post-op holding, we usually have one charge nurse and one RN, along with a transporter. Can you share a little about your brachytherapy experience? After seeing both the Cordis Checkmate (gamma radiation) (Miami, FL) and Novoste systems, we chose the Novoste Beta-Cath (radiation) system (Norcross, GA). We solved scheduling issues by performing the therapy two times per week. If they are not previously booked, the radiation physician and the physicist can often come immediately. How is inventory managed at your cath lab? Prior to our implementation of an inventory management system late last year, inventory management was divided up between four staff members. One tech handled and ordered all interventional equipment, one tech ordered only interventional guides, and one tech ordered only diagnostic catheters. All other supplies were ordered by one of our RNs, including sheaths and face shields. However, since the implementation of our Inventory Maintenance Management System (IMMS) in November 2001, we now have a full-time employee, Kris Kerrigan, who is our Inventory Controller and does all the ordering of supplies. What measures has your cath lab implemented in order to cut or contain costs? We already have the majority of our interventional supplies, such as balloons, stents and wires, on consignment, which has helped a lot, and just this year we’ve been asking vendors to help us on our diagnostic products. As a result, our diagnostic catheters are also now on consignment. We asked various vendors to come in, tried their products, and had them come down on the pricing. We now have our diagnostic catheters and all diagnostic wires and sheaths on consignment. How are new employees oriented and trained at your facility? New employees are interviewed by a peer review process, which includes anyone in our department, RNs, and RCISs, that aren’t in cases at the time. Our manager, Nancy Pierce, RN, receives staff feedback on the possible new hire. A new person will not be hired unless they pass the peer review process. We do have a team of preceptors in the North Ridge Medical Center cath lab. To be a preceptor, staff must take the preceptor classes, already possess expertise in the area, and have teaching abilities. New team members are paired with a preceptor, learn to circulate and spend anywhere from 3-6 weeks with a preceptor, depending on their skill level. After learning to circulate, a nurse learns to scrub, but only after they feel comfortable circulating and taking call. Only at this point will the nurse learn to scrub. New techs tend to come in to North Ridge right after school. They start off with a tech preceptor on the monitor. Techs right out of school may learn to record, and they stay in that position up to one year, until they are determined ready to advance to a scrub position. Does your lab have clinical ladders? Yes, we currently have RN 1, RN II, and RN III. To rise from level I to level II, we require current CPR, ACLS, PALS, and/or NRP. Also, the staff member must have successfully oriented to the charge nurse role. We provide clinical goals and objectives, and require their most recent evaluation to be 85% or higher. For RN II to RN III, the staff member must have been employed at North Ridge for at least 24 months and have 4 years of clinical experience. They must have certification in a clinical specialty or a BSN degree. We ask that there be a submission of three successful peer evaluations, plus two Director evaluations. Applicants must type a list of ten clinical and/or professional goals, and reasons for their advancement. They must also provide proof of CEU programs attended and proof of completion of North Ridge Medical Center’s mentor program and competencies. Of course, they must not have had any counseling or disciplinary actions, etc. How are staff members supported by continuing education? North Ridge holds a cardiology conference once a month for staff and physicians. Cases are presented for educational purposes with the approval of our medical director, Dr. Ghahramani. Also in conjunction with Dr. Ghahramani, North Ridge hosts an annual cardiology symposium for staff and regional physicians. World-renowned physicians are invited to lecture in their area of expertise and the latest advancements in cardiac care. The date of North Ridge’s next symposium is February 6-9, 2003. This year’s symposium (held each year in February) was a great success, with over 200 physicians, nurses, technologists and other allied health professionals attending. Attendees came from as far as Texas, Georgia, Alabama, and South Carolina. Does your cath lab perform primary angioplasty in acute MI with/without surgical backup? In emergency situations, we have a call team for the cath lab and a surgical team on standby at our facility. If it is a life-saving measure, our lab does perform primary angioplasty during an acute MI without a surgical team present in the hospital. Has your institution formed an alliance with others in the area? North Ridge Medical Center is part of Tenet Health Care Systems. We work with a number of sister hospitals in the area on a daily basis, as well as several non-Tenet facilities. Does your lab have an outpatient program? North Ridge has an exceptional outpatient program that starts by providing transportation to and from the facility on an as-needed basis, as well as a pre-op and post-op outpatient care center. Pre-caths are registered in admitting as a 23-hour patient, then come directly to the cath lab pre-op area. Our staff then prepares the patient, starting IVs and getting the patient’s history. Any patients not requiring further care after their procedure are recovered and discharged from outpatient services. Staff members aim to establish a strong rapport and continuity of care as early as possible. We take pride in our pre/post cath patient and family teaching. How does your cath lab handle hemostasis? At the present time, our cath lab utilizes a variety of closure devices along with manual pressure techniques. The scrub person is responsible for pulling sheaths and achieving hemostasis. In our facility, 95% of sheaths are removed with a closure device or manual pressure. The other 5% are sutured into place. Our lab is currently using: Perclose (Redwood City, CA); Duett (Vascular Solutions, Minneapolis, MN); VasoSeal® (Datascope Corp., Mahwah, NJ); SyvekPatch® (Marine Polymer Technologies, Inc., Danvers, MA); and The new 6F Angio-Seal (St. Jude Medical, Minnetonka, MN), which seems to be a favorite. We are also using the Clo-Sur P.A.D. (Scion Cardio-Vascular, Miami, FL) as an alternative when having to hold manual pressure. We are now using closure devices immediately following interventional procedures. Does your lab have a hematoma management policy? We have a competency for pulling lines, but not a management policy. New staff must be checked off the competency list and be able to manage a hematoma if one arises. Our policy involves what to do in the event of a hematoma. How does your lab handle call time for staff members? In the summer months, we routinely staff one call team for the cath lab. It consists of one tech and two RNs. Our busy season starts by November and lasts through May or June due to snowbird migration and tourism in the Sunshine State. When we begin to approach our busy season, we have two call teams, the second being a relief call team. The relief team can be staffed with either one technologist and two RNs, or two technologists and one RN. What are some of the new equipment, devices and products introduced at your lab lately? The Bx Velocity stent with Hepacoat (Cordis Corporation, Miami, Florida) is our newest stent and seems to be well-liked by our physicians. Is your lab involved in clinical research? Yes, we are involved in a few trials now. Dr. Ghahramani is doing the CAPTIVE trail using a filter device for vein grafts. He is also doing the MAGIC trial, using magnesium for MIs. Dr. Neiderman is doing numerous studies in the cath lab also. Is your cath lab filmless? Our cath lab has been filmless since April of 1999, when we implemented the WriteStar (ComView, a member of Electromed, Dublin, CA). Each room has its own acquisition station, and the images are immediately sent to the review stations. Each acquired case goes to the deep archive system, which contains enough storage for a 6-year period. All acquisition stations are equipped with CD burners to make copies of any studied case to be sent to other physicians for review or filing. Each case can also be uploaded onto a website whereas other physicians around the country can download and review the case. How is staff competency evaluated? The staff is inserviced and tested on an annual basis on competencies pertinent to the cath lab. Staff preceptors participate in the annual reviews. Do you require your clinical staff members to take the registry exam for the Registered Cardiovascular Invasive Specialist (RCIS)? The only staff required to take the RCIS (registry) are the CVTs. Within one year, they must receive their RCIS and there are no pay increases. Nurses are not required to participate in the registry exam. If an RN decides on his or her own that they want to take the RCIS exam, and pass, they will be allowed to monitor/record cases, but there is no pay increase. Right now in our cath lab, only our techs have the RCIS credential. Is there a challenge your lab has faced? Our biggest challenge was when our two separate labs were finally ready to merge as one. They both ran independently for five years and were two very different cath labs. They were so different that each side used different equipment and different techniques. One lab used power injecting and one lab hand injecting. Each lab was set in their own ways. (Currently, one of our physicians utilizes the Angiomat® Illumena® system [Mallinckrodt, St. Louis, MO], and the remaining physicians manually inject through the manifold.) In 1998, under the direction of a new manager, Nancy Pierce, RN, the two independent labs merged. Nancy chose to tackle the challenge by developing a rapport and communicating often with all staff members. She took the best of both cath labs and started to institute one lab. She began by evaluating each staff member personally. All complaints were taken into consideration and we formulated plans together, then implemented them on both sides. First, everyone was cross-trained to each cath lab before the merger. Nancy decreased burnout by offering 10 and 12 hour shifts, and enforcing the rule that per diems take their required one weekend of call per month. Over the course of one year, the labs became one unit, combining both staff and physicians. It wasn’t easy, but the end result proved to be well worth the effort. What is unique about your region or city that affects your cath lab culture? We are in Fort Lauderdale, Florida, and it is a highly multi-cultural city. We have patients from a wide variety of Latin cultures, and many do not speak English. We also have Creole and Haitian patients. In our lab, we have a few people who are fluent in Spanish and others who can speak it well enough to communicate on a medical level with patients. Tourism in the state of Florida is the second-largest industry next to healthcare, partially due to a very large elderly population.

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