Scripps Memorial Hospital La Jolla

What is the size of your cath lab facility and number of staff? The Cardiovascular Center at Scripps Memorial Hospital La Jolla has three cath labs, one electrophysiology lab, and a six-bed recovery area. Our department has 43 staff members: six CRTs, 14 CVTs, 18 RNs, two schedulers, one senior buyer, an investigational clinician, and one RN manager. We also have openings currently for two CRTs. Our most senior cath lab staff member has been with Scripps La Jolla for 25 years and our most recent addition to the cath lab staff joined our team four months ago. The majority of our cath lab staff members have been with Scripps La Jolla for more than 10 years. Scripps Memorial Hospital La Jolla has 372 acute-care licensed beds and more than 1,700 employees. It is part of Scripps Health, a not-for-profit, community-based health care system that includes more than 2,600 affiliated physicians, five acute care hospitals, an ambulatory care network, and home health care services. Scripps employs about 10,500 people in San Diego County and treats 525,000 patients annually. What type of procedures are performed at your facility? We perform both diagnostic and interventional procedures. Diagnostic procedures include: right and left heart catheterizations, EP studies, tilt table studies, and cardioversions. Interventional procedures include: PTCA, stents, valvuloplasty, PFO/ASD closures, brachytherapy, peripheral PTA and stent placement, pacemaker and ICD implants, and ablations. Each week approximately 180 procedures are performed. Approximately five peripheral interventions are performed each week. Does your cath lab perform primary angioplasty with surgical backup? Yes. This is scheduled through a surgical stand-by team that is located in-house 12 hours a day with an on-call team the remainder of the time. What procedures do you perform on an outpatient basis? EP studies, ablations, diagnostic angiograms and a rare single vessel PTCA with a groin closure are performed on an outpatient basis. What percentage of your patients are female? Approximately 40 percent of our patient population is female. What percentage of your diagnostic cath patients go on to have an interventional procedure? Approximately 60 percent of our diagnostic cath patients go on to have an interventional procedure. In 2003 we performed 2,000 interventions. Who manages your cath lab? Brenda Boone, RN, BSN, is the manager of the Cardiovascular Center. The Center also encompasses ECHO and EKG. Brenda reports to the Director of Imaging Services, Michael E. Sykes, RN. Brenda is responsible for the overall day-to-day operations of the Cardiovascular Center. She works collaboratively with other hospital services, medical staff and administration to ensure that quality patient care is delivered. Duties include hiring, evaluating and counseling personnel, setting standards for patient care, developing a safe, professional environment, allocating and managing department resources, and providing direct patient care as needed. Do you have cross-training? Who scrubs, who circulates and who monitors? Yes, we cross-train to scrub and circulate. The RNs are responsible for the moderate sedation and all medication administration. We alternate between CVTs and CRTs for the scrub positions. All team members can circulate. Each case has one CRT assigned, one or two CVTs and at least one RN. We have 4 staff assigned for all cases. When we do carotid stenting and valvuloplasty, we will add an additional RN and CVT. We have an excellent and cohesive team approach to our cases. Does your lab have a clinical ladder? Scripps Health replaced its clinical ladder program with the Nursing Practice Recognition Program in 2002. This program is designed to recognize those nurses who demonstrate excellence in clinical practice as determined by selection criteria based on the four domains of nursing which embody the Scripps Philosophy of Nursing.

Patient/family relationship: Treat each patient with compassion. Foster trust with patients and family members. Provide respect for diversity and rights of patients. Collaboration with physicians and team: Coordinate all levels of a patient’s care, provide an individualized and comprehensive plan of care, and serve as the patient’s advocate. Critical thinking and clinical judgment: Ability to see the whole picture in regard to the patient’s clinical situation and make quick and accurate decisions that impact the patient outcome. Clinical outcomes leadership: Make a significant and lasting impact on nursing practice through the professional development of others, the application of new nursing knowledge or impacting the health of the community.

Nurses recognized through the program receive a cash bonus and special acknowledgement throughout the Scripps system. In 2004, we are looking at implementing an incentive program for CVTs once registered with their RCIS. What are some of the new equipment, devices and products introduced at your lab lately? New technology recently adopted at Scripps La Jolla includes: PFO/ASD closures, drug-eluting stents, ICD and pacemaker implants, a 100 watt RF generator with Circucool pump, and the Thrombex PMT System (Edwards Lifesciences, LLC, Irvine, CA). In early 2004, we will be installing a new GE Innova system (Waukesha, WI). Is your cath lab filmless? Our cath lab has been filmless since August 2003 and we have a web-based server for referring physicians to remotely access images. How does your lab handle hemostasis? Manual pressure is rarely used. We try to have all diagnostic cases closed with a closure device so that these patients can go home directly from our recovery room. A core group of CVTs is certified in groin closure using Angio-Seal (St. Jude Medical, Minnetonka, MN) and Perclose (Abbott Laboratories, Redwood City, CA) devices. Sheaths are not routinely removed from post interventional patients. These patients are transferred to a post-intervention care unit. This unit utilizes a FemoStop® (RADI Medical Systems, Inc., Reading, MA) for all sheath removal. Our intervention patients routinely stay overnight and are discharged the following morning. Does your lab have a hematoma management policy? We have a process for sheath removal and evaluation of hematomas. Also, as part of our ongoing quality assurance, all hematomas are trended. How is inventory managed at your cath lab? The senior buyer for the cath lab is responsible for handling all of the purchasing and supplies. We also have a Lawson purchasing system (Lawson Software, St. Paul, MN) for Scripps Health. We do all our ordering through this system to track utilization and inventory. Has your cath lab recently expanded in size and patient volume, or will it be in the near future? Our patient volume has steadily increased with each passing year and we have outgrown our current facility. Plans are underway to add two cath labs and one EP lab within the next two years. We will also be expanding to a 12-bed recovery area. Is your lab involved in clinical research? We are currently participating in the following trials: Deliver, Inhibit, Captive, Sirius 4, Decode, BOSS, Rescue and Contak Renewal. We have a very active research program, with four main investigators: Drs. Maurice Buchbinder, Richard Fortuna, Steven Higgins and David Meyer. We are involved in research in cardiovascular devices and medications, and also with electrophysiology devices. We were one of the sites for the first Sirius trial. We were also one of the sites for MADIT I and MADIT II trials. Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? Approximately 2,000 cardiac interventions are performed per year at Scripps La Jolla. Of this volume, approximately six cases require emergent cardiac surgery. As a tertiary receiving center, we anticipate more complex cases and are proud of our low complication rate. We are always prepared for any emergency. What measures has your cath lab implemented in order to cut or contain costs? Scripps Health has a system-wide PAT (product assessment team) that looks at the standardization of consumables and some physician preference items. To help maintain inventory and introduction of new products, the Cardiovascular Center at Scripps La Jolla added a senior buyer position. Through a partnership with physicians, we have improved our pricing on several physician preference items. What type of quality control/quality assurance measures are practiced in your cath lab? Fluoro times are monitored for prevalence of radiation burns. In addition, we monitor all technologists’ insertion of closure devices. Scripps Memorial Hospital is also involved with the NRMI (National Registry Myocardial Infarction) database and the American Heart Association’s Get with the Guidelines database. How does your cath lab compete for patients? Has your institution formed an alliance with others in the area? There are a dozen cath labs in the greater San Diego area Scripps La Jolla has the highest volume of this group and is one of the highest in Southern California. Both our hospital marketing department and our corporate marketing department assist us in promoting our services. In addition, Scripps La Jolla recently added the position of a physician liaison to help promote hospital services directly to our 900 affiliated physicians. We have formed an alliance with Kaiser Permanente to perform all of their cardiac procedures for San Diego county. We are also a tertiary receiving facility for Scripps Encinitas and five other hospitals in San Diego and Imperial counties. How are new employees oriented and trained at your facility? What licensure is required for all professionals who work in your lab? All new employees are required to attend a mandatory hospital orientation followed by a departmental orientation. After this is completed, they are assigned a preceptor and spend several weeks undergoing training. A competency checklist must be completed. Each staff member is then checked off annually on competencies. In addition, all RNs and CRTs must be licensed and all RNs must be ACLS-certified. What type of continuing education opportunities are provided to staff members? Scripps La Jolla has a Continuing Education Department within the hospital that has multiple offerings for all staff. Within the cath lab, we have a cardiac education presentation once a month and each year monies are designated within the budget for staff to apply for reimbursed conferences. Scripps Health offers all of its employees $1,000 per year tuition reimbursement. President Scholarships of $1,000 are also available to those that apply. RNs have 10 CEUs paid for by the hospital each year. How do you handle vendor visits to your lab? All vendor visits are scheduled and vendors are required to obtain a visitor’s pass. We also require our vendors to hold annual in-services and privacy training. Prior to initial entry into the cath lab, vendors are required to show proof of vaccinations and TB status. How is staff competency evaluated? We have a yearly competency evaluation that includes an assessment of high-risk, low-frequency procedures. Does your lab utilize any alternative therapies (such as guided imagery, etc.)? No. How does your lab handle call time for staff members? The cath lab has multiple shifts, with a late shift being the call team that stays until the end of the day. The call team consists of four team members (two CVTs, one RN and one CRT) who remain on call after hours until 7 a.m. and 24 hours on weekends. What trends do you see emerging in the practice of invasive cardiology? We anticipate continuing use of drug-eluting stents and a decrease in the use of brachytherapy, as well as an increase of peripheral procedures in the cath lab. Has your lab has undergone a JCAHO inspection in the past three years? Scripps Memorial Hospital La Jolla underwent a JCAHO survey in February 2003 and earned a 96 percent out of 100 possible points. Where is your cath lab located in relation to the OR department, ER, and radiology departments? The Cardiovascular Center is located directly beneath the OR, ER and ICU. A designated large elevator is readily available to transfer patients right up to these departments. Radiology is upstairs and down the hall; however, we are self-contained and rarely utilize this department.. Please tell the readers what you consider unique or innovative about your cath lab and its staff. We have a supervisory committee for the cath lab that consists of the two medical directors, Drs. Richard Fortuna and Maurice Buchbinder, the Director of Imaging Services, Michael E. Sykes, RN, and the Cath Lab Manager, Brenda Boone, RN. This committee is responsible for addressing the operations and quality issues of the Cardiovascular Center. We have developed a partnership approach to management of the Cardiovascular Center. We have a highly motivated team dedicated to addressing process changes to benefit patients, staff and physicians. The majority of our staff have been with the hospital for more than 10 years and welcome the opportunity to mentor new members. We are also proud of the fact that our department has a very low turnover rate. Dr. Maurice Buchbinder is one of the medical directors of our lab. In conjunction with his foundation’s conferences, we have live case presentations quarterly. This is quite informative for the staff and frankly a lot of fun. We even did four live cases through a satellite feed to Korea a few years ago. The year 2003 has been a very eventful one for us. In August, Scripps Memorial Hospital La Jolla was recognized by U.S. News & World Report as one of America’s 50 Best Hospitals for cardiac care. We were one of the select hospitals to participate in the Cypher stent study and also one of the first in the nation to utilize the stents once they had received FDA approval. Additionally, we marked our 50,000th cath lab patient on August 14, 2003. In July, we also played host to the Surgeon General, FDA Commissioner, NIH Director and CDC Director during their cross-country campaign to promote Medicare reform and pharmacy legislation. Is there a problem or challenge your lab has faced? How was it addressed? A study by the Tiber Group earlier this year showed that we were well over capacity for our current labs. Plans are in the works to expand in the next two years. As a stopgap measure, we are renovating two cath labs, which necessitates the closure of one lab at a time for a total of six months. We have finalized a plan to maintain our current volume in two labs instead of three by using staff and physician collaboration for guidelines in scheduling cases, turnover time and addressing case delays. 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? Scripps Memorial Hospital is located in the town of La Jolla, an incorporated city of San Diego, California. California’s second largest city and the United States’ seventh largest, San Diego boasts a citywide population of nearly 1.3 million residents and more than 2.8 million residents county-wide. Known for a near-idyllic climate, 70 miles of pristine beaches and dazzling array of world-class family attractions, including the world-famous San Diego Zoo and Wild Animal Park, SeaWorld San Diego and LEGOLAND California, San Diego offers a wide variety of things to see and do, appealing to guests from around the world. Because of the ideal climate, our volume stays constant year-round. Given the attraction to the area and the competitive nature of a large city, our staff and physicians tend to be leaders in their fields and are more in demand due to their knowledge of the latest in cardiac technology.

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The Society of Invasive Cardiovascular Professionals (SICP) has contributed 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? We do not require our clinical staff members to take the registry exam for RCIS. However, a bonus program is currently under consideration for 2004 for those that do successfully complete the exam. Cardiac sonographers are required to take the registry exam for Registered Diagnostic Cardiovascular Sonographer (RDCS). All 5 of our cardiac sonographers are registered. 2. Are your clinical and/or managerial team members involved with any professional organizations that support the invasive cardiology service line, such as the SICP, ACVP, or regional organizations? Some of our staff are members of various organizations and all are encouraged to join at the expense of the hospital.

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