North Shore Medical Center–Salem
What is the size of your cath lab facility and number of staff members?
The North Shore Medical Center (NSMC)-Salem cardiac catheterization laboratory is located in Salem, Massachusetts. The NSMC-Salem is a diverse community teaching hospital that is a member of Partners HealthCare, an integrated healthcare delivery system. Salem is a historical city approximately 30 minutes north of Boston. The cardiac cath lab is one clinical area of the NSMC’s full-spectrum cardiac service line, which includes the NSMC Wellness Program, cardiac rehabilitation, inpatient/outpatient heart failure disease management, external counterpulsation, diagnostic cardiology, a pacemaker and implantable cardioverter-defibrillator (ICD) clinic, and a cardiothoracic surgery program.
We are a combined lab, performing interventional cardiology, peripheral vascular and electrophysiology (EP) procedures. The NSMC-Salem had one dedicated diagnostic cath-special procedure room dating back to 1964 and was one of the first community hospitals to offer this level of cardiology care in the community. Patients needing interventional procedures or cardiothoracic surgery were transferred to the academic tertiary centers in Boston.
In 1994, the lab moved to a new wing and expanded to two procedure rooms, which allowed for pacemaker implants and battery changes to be performed in the lab. The suite includes two procedure rooms, one holding room for pre and post procedure care, a staff workroom, a family waiting area, patient changing rooms, a reading room, conference room, administrative office and two supply rooms. One procedure room is dedicated to coronary angiography and percutaneous coronary intervention (PCI). The second procedure room is equipped for both EP procedures and peripheral procedures, with digital subtraction technology.
In 2002, NSMC was one of three community hospitals awarded approval to perform cardiothoracic (CT) surgery and percutaneous coronary intervention (PCI). The CT program began in March of 2003 and the PCI program began in November 2003.
To prepare for implementation of the PCI program, the staff of five expanded to a staff of eighteen. The staffing mix includes:
• 1 secretary
• 1 nurses’ aide
• 2 certified physician assistants (PA-Cs)
• 2 registered radiologic technologists (RT[R]s)
• 9 registered nurses (RNs)
• 1 cardiovascular technologist (CVT)
• 2 registered cardiovascular invasive specialists (RCIS)
• 1 RCIS who is the lead technologist
• 1 nurse manager
The tenure in our lab ranges from 2 years to 25 years. NSMC has three interventional cardiologists.
Massachusetts General Hospital (MGH)’s cardiac catheterization lab, under the direction of Susan Cronin-Jenkins, RN, provided PCI preceptorships to train the NSMC staff. We are grateful to the MGH cath lab staff for their guidance and education.
What type of procedures are performed at your facility?
We perform diagnostic catheterizations (right and left heart cath); vasoreactivity studies to diagnose pulmonary artery hypertension; percutaneous coronary intervention (balloon angioplasty, stenting, and Rotoblator [Boston Scientific, Maple Grove, MN]), and intravascular ultrasound.
In August of 2005, under the leadership of Briain MacNeill, MD, we began performing renal and iliac angiograms and interventions. Dr. MacNeill was on the Vascular Steering Committee, working collaboratively with his colleagues in interventional radiology and vascular surgery to develop the NSMC Vascular Center and design a carotid artery stenting (CAS) program. Dr. MacNeill has since returned to his native Ireland to raise his young family. The work initiated by Dr. MacNeill is continued by Dr. David Slovut, who joined the NSMC staff as an endovascular cardiologist in August 2007. Working with Dr Slovut, the cardiac cath lab performed our first CAS procedure.
Do interventional radiologists and cardiologists perform procedures in the same area?
At this time, the cardiologist who performs peripheral procedures performs some cases in the interventional radiology (IR) suite and some in the cardiac cath lab. With the advent of the Vascular Center, we anticipate interventional radiologists will soon be performing procedures in the cardiac cath lab.
What specific equipment was instituted and/or dedicated towards peripheral cases above and beyond what is used for coronary cases?
The Toshiba imaging system (Tustin, CA) used in the second procedure room is capable of performing both cardiac and peripheral studies. This capability allows for a greater degree of flexibility to meet scheduling needs.
We have a strong materials management (MM) department that works closely with the Partners HealthCare system MM department to secure inventory contracts. The peripheral inventory is handled similar to the coronary program. We consign as much as possible and purchased a nominal amount of inventory. On occasion, we borrow inventory from IR and they do likewise. Depending on the growth of peripheral procedures in the cath lab, I would like to see a stronger relationship with the IR department in terms of inventory management. We are currently evaluating inventory management systems.
What training was instituted so staff could be competent and skilled in peripheral procedures?
Staff attended peripheral vascular intervention inservices, including CAS, to prepare for this patient group. To prepare for CAS specifically, staff completed the Boston Scientific online CAS tutorial and have observed CAS procedures at MGH.
Does your cath lab perform primary angioplasty with surgical backup on-site?
The NSMC-Salem cardiac cath lab is the only lab on the north shore, between Portsmouth, New Hampshire and Boston, Massachusetts, to perform primary angioplasty services. Our lab provides 24/7 primary angioplasty services with notification to the CT surgery service. After hours, CT surgical backup is notification to the CT service that the cardiac cath lab team is in-house performing primary PCI.
What percentage of your patients are female?
Thirty-three percent of our patients are female.
What percentage of your diagnostic cath patients go on to have an interventional procedure?
Approximately one-third of our diagnostic cath patients will undergo an interventional procedure.
Who manages your cath lab?
Debra Pelletier, BSN, RN, the Cardiac Cath-EP Lab Nurse Manager, is responsible for the management of the department. Howard M. Waldman, MD, PhD is the medical director for interventional cardiology. The chief of cardiology, David J. Roberts, MD, FACC, manages the entire cardiac service line. On a daily basis, the lab utilizes the charge nurse role to facilitate the daily schedule.
Can you describe the roles of the PA-Cs working in your cath lab?
Michael Cothern, PA-C, is our Interventional Cardiology PA and Megan Salm, PA-C, is our Arrhythmia Service PA. Though each PA works for a different cardiology sub-specialty, the role is similar and is a supportive role for both the physicians and the cardiac cath lab staff. As a mid-level provider, the PA will consult on patients pre-procedure, may scrub the procedure with the physician and will follow the patient post-procedure to prepare the patient/family for discharge. Both of our PA staff maintain the state-mandated data collection (American College of Cardiology) for their sub-specialty and represent the cardiac cath lab on performance improvement committees (for example, door-to-balloon times). Our PA participates in the orientation of new staff, provides ongoing educational opportunities for department staff and guest-lectures at external education seminars. The PA role enhances patient care and we are very fortunate to be working collaboratively with the PA staff.
Do you have cross-training? Who scrubs, who circulates and who monitors?
All staff are cross-trained to staff interventional and peripheral cases, as well as EP. Registered nurses are also trained to staff the holding area. Each patient has a dedicated RN for the procedure. Every employee has the opportunity and the expectation to learn to monitor cases. At present, only the RT(R) and RCIS staff scrub cases. Some of our registered nurses have scrubbed cases in the past, but this is not our current standard. Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab? Yes. The state of Massachusetts, DPH-Radiation Control, sets the fluoroscopy guidelines standards for all cardiac cath labs.
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 physician and RT(R) may position the II, pan the table, and change angles. The physician steps on the fluoro pedal.
Does your lab have a clinical ladder?
At this time, we do not have a cath lab-specific clinical ladder. A clinical ladder for technical staff is under consideration as an upcoming annual goal.
What are some of the new equipment, devices and products introduced at your lab lately?
New products in the lab include the StarClose device (Abbott Vascular Devices, Redwood City, CA), Venture guidewire (St. Jude Medical, Minnetonka, MN), Pronto extraction catheter (Vascular Solutions, Minneapolis, MN), and the D-Stat Dry dressing (Vascular Solutions).
Can you describe the system(s) you utilize and how they work in cath lab daily life?
We use the Witt Biomedical system (Philips Medical Systems, Bothell, WA) for hemodynamic monitoring and documentation. Toshiba is the fluoro system used in both procedure rooms. Heartlab (an Agfa Company, Westerly, RI) is the digital archiving system used for all of cardiology, except 12-lead EKGs. It allows our cardiologists to view images from remote locations.
How is coding and coding education handled in your lab?
The staff member who monitors the case is responsible for documenting it in the Witt Biomedical system. If it is a PCI case, the billing slip for supplies and equipment used during the case is completed. The lead technologist uses this documentation to bill in the computerized billing system as well as for inventory management. The hospital is responsible for coding. Our department works closely with the revenue and the coding teams to insure compliance with practice and to provide shared educational opportunities. Any problem areas are addressed at monthly staff meetings.
How does your lab handle hemostasis?
All patients are evaluated for closure of femoral arterial sticks with either Angio-Seal (St. Jude Medical) or the Starclose device. If we are unable to use a closure device, we use manual pressure. Femostop (Radi Medical Systems, Wilmington, MA) is available when indicated.
The majority of our arterial access sites are closed with a closure device. Patients may transfer to the intensive care unit or the cardiac step-down unit with vascular sheaths in situ. If it is simply a diagnostic case, the sheath will be pulled in either the procedure room or the holding area. Outpatients are discharged later in the day.
The expectation is that all staff can pull sheaths and hold manual pressure after passing the unit-based competency.
Does your lab have a hematoma management policy?
Hematoma management is managed on a case-by-case basis with either manual or mechanical pressure. Hematoma management is incorporated into the diagnostic cath/PCI patient care protocol.
How is inventory managed at your cath lab?
Inventory management is a crucial component to insure smooth operations in the cardiac cath lab and is a shared responsibility with the MM department. The bulk of our everyday supplies are managed (ordered and stocked) by the hospital’s par levelers, who are employed by the MM department. Specialty items such as balloons, stents, implants, guidewires, etc., are purchased by the lead technologist and/or nurses’ aide. Purchasing is via the Peoplesoft system (Oracle Corp., Redwood Shores, CA). An advantage of being a member of the Partners Healthcare system is that pricing for supplies and equipment is standardized across all Partners affiliates. All new products must be approved by the Value Analysis Committee.
Has your cath lab recently expanded in size and patient volume, or will it be in the near future?
The physical space of the department has not changed, though we have experienced volume growth with the inception of the PCI program. We continue to experience an increase in complex cases, as well as a number of different procedures that we perform, allowing residents of the north shore to have their cardiology care at NSMC and preventing a trip into Boston. We are the region’s only full-service cardiology center.
Is your lab involved in clinical research?
At this time we do not participate in clinical research. We made the conscious decision not to enter into clinical trials while expanding the scope of our services and hiring new staff. With two years of PCI experience under our belts and stable staffing, we are now prepared for clinical research and look forward to this opportunity. Several of cardiologists participate in clinical research studies at MGH.
Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery?
In the past year, NSMC has had one STEMI case requiring emergent cardiac surgery.
What other modalities do you use to verify stenosis?
At this time, we utilize the Boston Scientific intravascular ultrasound system to assess stenosis. We added the Radi PressureWire to our inventory.
What measures has your cath lab implemented in order to cut or contain costs?
During program development of both PCI and peripheral vascular interventions, we worked closely with the vendors to arrange for consignment of products. This was an enormous upfront cost savings.
We meet weekly with our MM representative to address supplies and equipment issues. When physicians or staff requests a new product be introduced into the lab, a value analysis process requires completing supporting documentation with an evaluation of the cost impact. As members of the Partners healthcare system, all vendor contracts are approved at the corporate level, allowing NSMC to realize supply and equipment cost savings.
What type of quality control/quality assurance measures are practiced in your cath lab?
We participate in the American College of Cardiology-National Cardiovascular Data Registry (NCDR) as a benchmarking opportunity for our PCI patients. As a new PCI center, we meet with our tertiary hospital partner, MGH, on a quarterly basis to review our PCI data.
There is a joint Emergency Department and Cardiac Cath Lab Door-to-Balloon Quality Improvement (QI) Committee that meets monthly to review all primary PCI cases.
We recently instituted a monthly morbidity and mortality (M&M) interdisciplinary meeting that is chaired by the medical directors. This is a rich forum where cath lab staff and the physicians meet to perform collaborative case reviews. Prior to this, M&M was exclusionary and for physicians only.
We’ve instituted patient satisfaction surveys for our PCI patients and our outpatients discharged to home.
QI initiatives are reviewed at staff meetings, reported quarterly to the NSMC Cardiac QI Committee and then presented at the NSMC QI meeting.
How does your cath lab compete for patients?
We are the only hospital between Portsmouth, NH and Boston, MA that performs primary PCI. We are the only hospital on the north shore to offer comprehensive cardiology services. Our successful PCI program is marketed in the local community.
We’ve worked collaboratively with the EMS providers to design and implement a STEMI point-of-entry waiver that allows for field identification and triage of STEMI patients to our facility. When minutes matter, this collaborative relationship benefits all residents of the north shore. We compete by providing excellent patient-focused care with superb patient outcomes.
How are new employees oriented and trained at your facility?
This past year, we have hired three registered nurses without cardiac cath lab experience and two new RT grads. The clinical nurses had telemetry experience. All employees participate in the hospital-wide orientation program completing the required competencies.
All orientees are assigned a single preceptor and the orientation program is tailored to the needs of the orientee, based on their level of experience and past clinical experiences. In addition to working with the preceptor, staff spends time orienting with other staff (i.e., clinical RNs orient with the RCIS staff to monitor cases; the RTs spend time with the clinical RNs). Orientation is hands-on, competency-based and for staff new to the lab, is approximately 4 months in duration. New staff “buddy” with experienced staff for on-call responsibilities before taking call independently. The RTs are undergoing an extensive orientation program that involves classroom and hands-on experiences.
Registered nurses are licensed by the State of Massachusetts, Board of Registration in Nursing, and the RTs are licensed by the Massachusetts Department of Public Health.
In February, the cardiac cath lab reached consensus on the annual goals for the upcoming year and specialty certification is one goal for this department. Certification can be critical care registered nurse (CCRN), RCIS, or RT(R)(CV). All staff must be ACLS-certified.
What type of continuing education opportunities are provided to staff?
Continuing education is supported by the leadership team and takes many forms in the cardiac cath lab. We are all life-long learners and as professionals, must take responsibility for our own professional growth and development.
Staff can attend the CEU events sponsored by the hospital education department. The topics tend to be generic and not specifically cardiology-focused. The NSMC holds an annual Cardiovascular Nursing Conference each February that is open to all health care professionals. We take advantage of any vendor-supported (pharmaceutical and supplies and equipment) educational opportunities. We attend the monthly Combined Cardiac Surgery-Cath Lab Conference.
The cardiac cath lab has also initiated Cath Lab Rounds, a monthly forum where staff presents a topic of choice to their peers. The topic of choice is of clinical significance for the lab and can be a journal article, a device, a medication review, a challenging case, etc. The beauty of this educational forum is that staff are educating each other and developing their own comfort with group presentations.
Staff is encouraged to attend regional and national conferences with the caveat that the “pearls of wisdom” be shared with the staff upon their return. Attendance at regional/national conferences is rotated on an annual basis.
How do you handle vendor visits to your lab?
All vendors must meet with our MM representative who performs an orientation for the vendors. NSMC policies are reviewed and the vendors receive a NSMC ID badge that must be worn at all times. Vendors must schedule their time in the cardiac cath lab with our secretary to assure we will not have competing vendors in the lab at the same time. Vendors maintain a presence in the wing, not the control room, and are encouraged to offer education sessions.
How is staff competency evaluated?
Competency evaluation is a dynamic process. For low-volume, high-risk procedures, regularly schedule in-services are held and staff must complete a competency test (i.e., moderate sedation/intra-aortic balloon pump) and/or skill return demonstration.
Does your lab utilize any alternative therapies (such as guided imagery, etc.)?
The NSMC has a Wellness and Integrative Medicine department with a full range of services, including reiki, hypnotherapy and therapeutic massage, to name a few. At this time, we do not offer any integrative therapies, but have started initial discussions with the Integrative Medicine Center to discuss the potential of a research study.
The staff works diligently to promote a comfortable environment that will allay anxiety and discomfort.
How does your lab handle call time for staff members?
The cardiac cath lab has an on-call team 24 hours per day, 365 days per year, including holidays. Staff performs their own self-scheduling, including the call team. The call team has a minimum of three staff, two of whom are RNs and one staff who is a PA, RCIS or RT.
The on-call staff plus the interventionalist must be on-site within 30 minutes of activation.
Does your cath lab do electives on weekends or holidays?
On a very rare occasion we will schedule an elective/urgent case on the weekend to meet the patient’s need. The call team would be utilized in this case and the interventional cardiologist would have to “allow” the use of the call team in this instance. We try not to burden the call team.
Do you average any overtime per pay period?
We are able to manage our staffing needs, without any true overtime, through flexible scheduling and a 24-hour call team.
What trends do you see emerging in the practice of invasive cardiology?
Invasive cardiology is an ever-expanding field, with more complex procedures being performed in a less invasive manner. The decline in cardiothoracic surgical volume is but one example. In our lab, we’ve seen a growing complexity of cases that originally would have been treated surgically or managed medically (i.e., unprotected left main disease, bifurcation lesions). Additionally, centers are now managing valvular disease percutaneously.
Multidisciplinary collaboration among cardiologists, interventional radiologists, and vascular surgeons in the cardiac cath lab to improve upon the patient’s vascular care is an expanding venture.
Has your lab has undergone a Joint Commission inspection in the past three years?
The NSMC cardiac cath lab underwent a successful scheduled Joint Commission inspection and performed very well. The Joint Commission used the tracer methodology during their visit. The Joint Commission RN visited the lab and viewed part of a primary PCI case.
She assembled a team of 3-4 staff and questioned them about the delivery of care with regard to the National Patient Safety Goals (NPSG). Our motto in the lab is that a Joint Commission visit is not any different than a usual day in the lab because we follow prescribed guidelines and safe practice. We simply needed to articulate our practice. Because of this, the survey was painless.
I will say that we did have the Joint Commission on our monthly staff meeting agenda and tried to make the topics enjoyable. We created summary sheets of the National Patient Safety Goals (NPSGs), flashcards and placed posters in heavily trafficked areas.
Where is your cath lab located in relation to the cardiac surgical department, emergency department and radiology departments?
The cardiac cath lab is located on the fifth floor, in close proximity to the cardiac surgical wing and the critical care units. The emergency department (ED) is on the 3rd floor, one building away. The ED maintains a key that provides quick access to intercept an elevator for our STEMI or hemodynamically unstable patients.
The hospital is instituting a major overhaul and construction program to be completed in 2008 and we anticipate relocating.
Please tell the readers what you consider unique or innovative about your cath lab and its staff.
Despite growth in volume, new staff, new physicians, 24/7 STEMI PCI call, inexperienced staff, and new, more complex procedures, the NSMC cardiac cath lab staff and physicians who practice here are unique. The clinical staff are excellent practitioners who are compassionate, motivated and committed not only to their patient but to each other. Everyone works together to achieve the same goal: outstanding patient outcomes. The patient always comes first. The staff loves what they do and it shines through in their practice. We have a great collaborative relationship with the physicians as well. There is no hierarchy — we are one team. Travel staff have commented on the collegiality of the team.
Is there a problem or challenge your lab has faced? How was it addressed?
Our greatest challenge was transforming from a low-volume diagnostic lab into a full cardiology interventional service with a 24/7 call team. Prior to full-service cardiology services at NSMC (PCI, EPS, and cardiovascular and thoracic surgery [CTS]), the cardiology leadership made a decision to transfer all diagnostic cath patients with a potential for PCI or CTS to the MGH. This resulted in a low-volume cath lab with less critically ill patients being admitted to the inpatient units.
With the advent of PCI, we saw a greater number of complex cardiology patients and our staffing needs were accelerated. We worked collaboratively with the MGH to educate and precept clinical staff. The interventional cardiologists and MGH clinical nurse specialists held frequent education sessions for all clinical staff. We hired experienced registered nurses from the MGH and St. Elizabeth’s Medical Center, and experienced physician assistants. Additionally, we contracted with travel staff, both RN and RT(R), to fill in the gaps of experienced staff. The cardiac cath lab staff were very experienced, clinically expert diagnostic practitioners simply needing interventional experience. The new hires and the travel staff were able to precept the existing cardiac cath lab staff. Looking back, it was a tumultuous time, but the staff weathered it well and now, we are proud to have a delightful, professional, dedicated clinical staff that surpasses all expectations. We have covering MGH PCI MDs and travel staff who comment that they are amazed at the complexity of patients in the community and the skill set of the clinical staff.
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”?
Salem, Massachusetts is considered the beautiful north shore region of Massachusetts, with close proximity to the ocean, lakes, mountains and cultural events. Salem is a historic city with many offerings. Salem is located 20 minutes north of Boston, a center of world-class medical and cardiology care from which we also benefit. Our RT(R) and RCIS staff are fortunate to practice in a community setting, scrubbing cases that would be reserved for fellows at tertiary medical centers. Our experience with various travel staff was very educational and what we learned is that the care of the cardiovascular patient is regionally diverse. The approach to a lesion and even pharmacology used is different in various regions of the country. The travel staff experiences across the U.S. allowed us to learn from their experiences and incorporate some of their suggestions into the “Boston approach” to care.
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)? Do staff receive an incentive bonus or raise upon passing the exam?
In February 2006, the cardiac cath lab reached consensus of the annual goals for the upcoming year and specialty certification is one goal for this department. Certification can be CCRN, RCIS, or RT(CV). Though not required, certification is strongly recommended and suggested on annual performance evaluations. Staff will be compensated for the expense of the exam. Consideration is underway for a clinical ladder for the technical staff, as well as a bonus when they pass the exam.
2. Are your 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, but the nurse manager is a member of the American Association of Critical Care Nurses (AACN), American Heart Association (AHA), and the Massachusetts Organization of Nurse Executives (MONE).
Missing from photos: Theresa Munroe, RN, BSN, David Slovut, MD, FACC, Colleen Lima, RN, BSN, CCRN.
Debra Pelletier, BSN, RN, can be contacted at dpelletier@partners.org
