Rogue Valley Medical Center

Can you tell us about your cath lab?

Rogue Valley Medical Center in Medford, Oregon, is a 378-licensed bed regional medical center serving a nine-county area in southern Oregon and northern California. We offer a full array of cardiac and peripheral procedures, both diagnostic and interventional. Among these are carotid stenting, thoracic and abdominal endograft deployment, and atrial fibrillation ablations. Rogue Valley Medical Center has 5 rooms capable of performing angiography within the institution and 2 diagnostic angiography suites in our outpatient center. In the inpatient cath lab area, there are 3 cardiac procedure rooms, one of which is dedicated to electrophysiology studies. The fourth room is utilized for vascular procedures and overflow cardiac cases. We also have a hybrid angiography suite in the operating room that we use for general peripheral angiography, including endoluminal and thoracic graft cases, as well as our carotid stents and laser cases (both lead extraction and peripheral atherectomies). Vascular surgeons perform the majority of our peripheral interventions. Our institution has been a training site for abdominal aortic aneurysm endoluminal grafting procedures. One of our cardiologists and two of our vascular surgeons perform carotid stenting. We have 10 registered nurses (RNs), 9 radiologic technologists (RTs), and 2 registered cardiovascular invasive specialists (RCISs). Our staff has a combined 400 years of cardiac care experience. Our inpatient labs perform approximately 2,600 cardiac and electrophysiology procedures, and 600 peripheral procedures per year.

Does your cath lab perform primary angioplasty with surgical backup on site?
Rogue Valley Medical Center has a cardiothoracic surgical team available around the clock.

What procedures do you perform on an outpatient basis?
Some diagnostic catheterizations, select electrophysiology procedures, and device replacements that do not involve lead manipulation are performed on an outpatient basis.

What percentage of your patients is female?
Thirty-eight percent of our patient population is female.

What percentage of your diagnostic cath patients goes on to have an interventional procedure? Approximately 18 percent of our cardiac diagnostic cases have an intervention at the same sitting.

Who manages your cath lab?
Mic Bradshaw, RN, manages day-to-day operations and directly reports to the director of imaging services, John Mayben.

Do you have cross-training? Who scrubs, who circulates and who monitors?
We cross-train all entities within the confines of their scope of practice. All personnel can scrub, circulate, and monitor cases, although RTs are the only specialty that can operate x-ray equipment, by state law. RNs are responsible for conscious sedation. All other medications may be given by any licensed staff member who has obtained an advanced certification, proven competency, and been approved by the physician medical director.

What are some of the new equipment, devices and products introduced at your lab lately?
We introduced the EnSite EPS system (St. Jude Medical, Minnetonka, Minn.) to our arsenal of tools in the electrophysiology lab and have upgraded our Prucka system (GE Healthcare, Waukesha, Wisc.). We recently installed a GE Innova 2100 with integrated intravascular ultrasound (IVUS) (Volcano Therapeutics, Inc., Rancho Cordova, Ca.). We have started using the Jetstream catheter (Pathway Medical Technologies, Kirkland, Wash.) for both peripheral venous and arterial interventions. It has proven quite successful in treating deep vein thrombosis, acute arterial occlusions, and limb salvage.

Do any of your physicians regularly gain access via the radial artery?
We currently have one physician who regularly performs diagnostic and interventional angiography through the radial artery approach. He has performed approximately 125 cases and has had no major complications.

How does your lab handle hemostasis?
The majority of our patients are recovered in our vascular prep and recovery area. FemoStop (St. Jude Medical), manual pressure, and Angio-Seal (St. Jude Medical) are used, depending on patient condition and body habitus. We use the TR Band system (Terumo Medical Corp., Somerset, New Jersey) for our radial access patients. Our emergent or unstable percutaneous coronary intervention (PCI) patients are taken directly to the critical care unit.

What is your lab’s hematoma management policy?
Our vascular recovery unit handles most of our recovery procedures. Hematomas are managed at the time of occurrence by one of our trained recovery nurses.

How is inventory managed at your cath lab?
We use the Witt system (Philips Medical, Bothell, Wash.) for hemodynamic monitoring and archiving of images, and also use this system for electronic inventory management, charge capture, and charting. It automatically deducts from preset par levels in correlation with our point-of-care log entries. Our materials management department handles the ordering of our products electronically.

How is coding and coding education handled in your lab?
Coding is handled through accounts payable and any correspondence is routed through our charge capture specialist.

Has your cath lab recently expanded in size and patient volume?
Our cardiac angiography business has remained stable. We have seen an increase in endoluminal cases (both abdominal and thoracic), and in the electrophysiology realm.

Is your lab involved in clinical research?
We were involved with the DEScover Registry, and have been involved with peripheral and cardiac rhythm management (CRM) trials, such as MADIT CRT. We participated in the CAPTURE I and II (Carotid Acculink/Accunet Post-Approval Trial to Uncover Unanticipated or Rare Events) registries and CREST (Carotid Revascularization Endarterectomy versus Stent Trial) trial. We are currently participating in the CHOICE (Carotid stenting for High surgical-risk patients; evaluating Outcomes through the collectIon of Clinical Evidence) carotid stent registry.

Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? We have had rare complications, dissection, acute closure, etc., requiring emergent surgery. In 2009, our cath lab-related complications requiring emergent surgery rate was 0.56%.

What other modalities do you use to verify stenosis?
We utilize the Volcano pressure wire and IVUS system to assess lesions as needed.

How does your lab communicate information to staff and physicians to stay organized and on top of change?
Staff communication is performed through a variety of methods. Staff meetings and postings on department bulletin boards are used to communicate new or changing information to staff members. Weekly cath conferences also provide topics and/or guest speakers that help to keep our lab up to date with current practices. Also, all staff members are required to have an organizational email account so that any important organizational information may be received from our facility. Our cardiovascular laboratory medical director communicates necessary information to physicians.

What measures has your cath lab implemented in order to cut or contain costs?
We have contracted with device vendors to ensure competitive pricing on current technology. We have an agreement in place with a vendor to bundle multiple service lines, i.e., cardiac, peripheral, and CRM, and render savings based on each entity. These savings are compounded when multiple tiers are attained.

What quality control/quality assurance measures are practiced in your cath lab?
We monitor charts monthly for time-outs, patient identification, appropriate chart documentation, in-hospital outcomes, and door-to-balloon (D2B) times, to name a few. We monitor National Patient Safety Goals, such as time outs, hand hygiene, medication labeling, antibiotic administration, and two patient identifiers. We collect data for the National Cardiac Database Registry (NCDR) through the American College of Cardiology. Our hospital performance improvement department monitors major complications, such as hematomas requiring transfusion, deaths, strokes, etc.

How does your cath lab compete for patients?
We are in the unique situation of being the only facility that reliably offers emergency cardiac services 24 hours per day, seven days per week, 52 weeks per year in our area. We accomplish this by having a primary call team and physician group that is dedicated to quality care. Our leadership with the Acute ST-Segment Elevation Task Force (ASSET), a partnership with hospitals and EMS services in our region to route STEMI patients directly to our cath lab, has helped with our growth and our STEMI program. While we have performed interventions on STEMI patients for many years, the formal process and dedicated committee for this population has been in place since June of 2003. This committee is led by a dedicated physician, Brian Gross. The success of our STEMI program is multi-departmental, and workflow changes have been embraced and supported by staff, physicians, and hospital administration.

Can you tell us more about your lab’s door-to-balloon (D2B) times?
We are a STEMI regional center directly accepting patients from 52 miles away and secondary referral from 150 miles. We are currently enrolled in the D2B Alliance (www.d2balliance.com). We are also part of the American College of Cardiology Cath/PCI Registry and ACTION registry, along with the American Heart Association’s Mission: Lifeline. Participation in these various registries allows us to benchmark our performance with other facilities across the nation, allowing us to obtain useful information regarding best practices in achieving top performance. In 2009, we had a median hospital D2B time of 39 minutes, with an average time of 46.7 minutes. We have worked diligently with the local EMS service to educate and formulate algorithms that ensure the most efficient system possible. EMS activation of the team from the field and direct transport to the cath lab has further decreased our program’s D2B times. Our results have been nationally recognized.

How does your lab handle call time for staff members?
We have a variety of call formations. Each crew must have at least one RN and one RT. We have 4 team members on call at all times. We have found the 4-person rotations especially beneficial in our growing STEMI program. This improves efficiency and patient safety.

Within what time period are call team members expected to arrive to the lab after being paged?
The staff is required to be in the building within 30 minutes of being paged. The physicians are either on site or enroute to the cath lab when the patient arrives.

What continuing education opportunities are provided to staff?
Continuing education opportunities are elicited in the form of speakers, presentations, and new equipment training. We have a weekly cardiac conference where physicians discuss complex cases and on many occasions, include a guest speaker or specific topic related to the cardiac arena. We have purchased cath lab-specific programs online through Healthworks (Douglassville, Penn.) that allow staff members to complete cath lab-specific educational materials. Currently, we do not have any staff with less than one year of experience in the cath lab. The majority of RTs were hired locally and RNs were hired from specialty areas (CCU, ED, etc.). All employees are required to have current advanced cardiac life support (ACLS) and basic life support (BLS) certifications. Our RTs are required to have their advanced certification, either cardiac interventional (CI) or vascular interventional (VI).

How is staff competency evaluated?
Staff competencies are completed on a yearly basis, with specific competencies taught by staff members, which, in turn, are evaluated by return demonstration and/or physical testing by staff members. Unit-specific competencies are completed for high-risk, low-volume equipment, and procedural care.

Does your lab have a clinical ladder?
We do not have a clinical ladder system at this time.

Do you have flextime or multiple shifts?
We have shifts beginning at 0600, 0700 and 0900. We currently have 8- and 10-hour shifts. We schedule cases Monday through Friday 0700 to 1700.

Does your cath lab do electives on weekends and or holidays?
We serve patients as needed, either elective or emergent, at all hours, on any day. We have our call crew handle all cases on weekends, holidays and Monday through Friday after 1730. We average 3 cases on Saturdays and 2 on Sundays. These may be emergent or elective.

Has your lab recently undergone a Joint Commission inspection?
We have just passed our DNV inspection (DNV Healthcare, Inc. is a division of the Norwegian company Det Norske Veritas, and a national hospital accrediting agency). The focus in our area was on patient safety in regard to time outs and universal protocol.

How do you handle vendor visits to your lab?
Vendors are asked to make an appointment with our purchasing department. They are allowed in limited areas of the lab and only allowed in the procedure rooms if requested by a physician. They may come once per month by appointment only.

Where is your cath lab located in relation to the operating room (OR) and emergency department (ED)? Our hospital has undergone major renovation and at the current time, the cath lab is on the first floor with the ED and OR, but not within line of sight. Our layout has grown with the hospital. With the addition of our hybrid angiography suite in the OR, we have become a little spread out. This layout can present challenges with staffing, but our crew has met this challenge through scheduling flexibility.

What trends have you observed in your procedures and patient population?
The institution of our STEMI program and EMS diagnosing our patients in the field has led to our lab receiving patients that bypass our ED. Also, our physicians have made a concerted effort to increase the awareness of our community in regards to the signs and symptoms of a heart attack. We have seen an increase in our atrial fibrillation and supraventricular tachycardia ablation cases. We feel that these populations will continue to grow as technology increases. We have seen a trend in patients with higher levels of hemodynamic compromise. This may stem from patients putting off routine visits to physicians and not seeking care until they are in extremis.

What is unique or innovative about your cath lab and its staff?
One unique aspect of our lab is our experience. Twenty out of 21 of our professional staff members have >10 years of cardiac experience. We are proud that all our RTs have passed their advanced certification. We use our Witt log to electronically create charges and manage our inventory. We also have been very proactive regarding our STEMI program. Our EMS personnel diagnose patients in the field. It is not uncommon for them to bypass the ED and transport directly to the cath lab. We are working on having 12-lead ECGs transmitted to the ED. Our STEMI program has developed into an efficient method of providing state-of-the-art care to this population of patients.

Is there a problem or challenge your lab has faced?
In the past, we had difficulty reaching the goals in our STEMI program. Through community, interdepartmental, physician, and staff cooperation, we have been able to achieve 92% 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”? We have a large retirement population in southern Oregon. Approximately 70% of our cardiac patients are >60 years old. We also are the regional STEMI center, accepting patients within a 150-mile radius. Our large retirement population lends itself nicely to the “culture” within our lab, as most of our employees are very familiar with the area, some staff having lived in the Rogue Valley their entire lives.

A question from the Society of Invasive Cardiovascular Professionals (SICP):
Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? Does staff receive an incentive bonus or raise upon passing the exam?
RNs are encouraged to take the RCIS, and receive a bonus upon completion and recertification. The RTs are required to take their advanced certification and receive a 3% raise upon completion. All our staff is encouraged to take the RCIS for quality and service excellence.

Mic Bradshaw can be contacted at kbradshaw@asante.org