Spotlight: Swedish Medical Center

The authors can be contacted via Jeff Mercer, RCIS, at jeff.mercer@swedish.org.

Founded in 1910, Swedish Medical Center is the largest non-profit healthcare provider in the greater Seattle area. Swedish is consistently named the area’s best hospital, including the best physicians, nurses, and care in a variety of specialties, and is comprised of seven facilities and approximately 1,200 inpatient beds.

The Swedish Cherry Hill campus, located downtown Seattle, provides specialized and highly acute treatment for our cardiovascular and neuroscience patients.

The Swedish Heart and Vascular Institute includes three state-of-the-art cardiac catheterization labs, one of which is specialized for peripheral endovascular intervention and 3-dimensional (3D) vessel reconstruction imaging. We also utilize a hybrid operating room, shared with interventional radiology (IR) and surgery, and a Stereotaxis-equipped room, shared with electrophysiology (EP).

Our cardiac cath lab was recently awarded the MVP (Making Values a Priority) award for the Swedish system. The award was given in recognition of the hard work behind our ST-elevation myocardial infarction (STEMI) program and our continuous efforts to not only maintain our low door-to-balloon times, but to improve our practice. 

Recently, in a very exciting announcement for our cardiac surgery colleagues, Consumer Reports named Swedish as the only hospital in the state ranked among the best 15 in the country, in both bypass and valve repair or replacement surgeries.

Where is your catheterization lab located in relation to the operating room (OR) and emergency department (ED)?

Our catheterization lab is across from the OR and directly below the ED and ICU.

What procedures are performed in your catheterization lab?

Regularly scheduled cases include the following:

• Left/right cardiac diagnostics;
• Coronary intervention, including chronic total occlusions (CTOs) and rotational atherectomy;
• Device implants (pacemaker, implantable cardioverter defibrillator [ICD], intra-aortic balloon pump [IABP] or Impella [Abiomed]);
• Peripheral diagnostic and interventional cases;
• Aortic angio and carotid angio and intervention;
• Structural heart (patent foramen ovale [PFO]/atrial septal defect [ASD] repair, transcatheter aortic valve replacement [TAVR], left atrial appendage [LAA] ligation or occlusion, percutaneous mitral valve repair, and alcohol ablation).

Approximately how many procedures are performed each week? 

Currently, we average about 60 cases a week, with approximately 48% diagnostic, either coronary or peripheral.

Can you share your experience with TAVR?

We performed our first TAVR in June 2012 and opened our first hybrid OR in December 2012. The hybrid OR is equipped with a Siemens Artis Zeego with Syngo DynaCT, allowing for 3D vessel reconstruction.

Our TAVR team is a collaboration between CVOR and the cardiac cath lab, and consists of the following groups: anesthesia, interventional cardiology, vascular surgery, cardiac surgery, perfusion, echocardiography, nursing from both the cardiac cath lab and surgery, and technologists from both cardiac surgery and the cardiac cath lab.

We were successful in establishing a cohesive, collaborative team by adapting to each department’s culture, and utilizing each other’s strengths and skills to provide high-quality patient care.

What trends have you seen in your procedures and/or patient population?

We have seen an increase in structural heart patients and are excited to be innovative leaders in cardiology. Our TAVR cases, emerging mitral valve treatments, and the increasing complexity in our percutaneous coronary intervention (PCI) population consistently push our staff to be learning and collaborating with physicians to develop safe, beneficial, evidenced-based, patient protocols. 

Do any of your physicians regularly gain access via the radial artery?

Many of our physicians regularly perform angiography and intervention through the radial artery. Currently, about 30% of our cases are done via a radial approach.

Swedish Medical Center partners with the Seattle Science Foundation (SSF), a local and national training facility for physicians and vendors, to provide courses in the transradial approach to angiography.

What are some of the new equipment, devices and products recently introduced at your lab?

In the last few years, we have seen a big growth in structural heart with the addition of TAVR, percutaneous mitral valve repair, left atrial appendage ligation and occlusion procedures. We are utilizing the new paclitaxel drug-eluting stent in peripheral cases and are participating in the ABSORB III trial (with the Abbott Bioresorbable Vascular Scaffold).

Has your cath lab recently expanded in size and patient volume, or will it be in the near future?

We expanded our catheterization lab in 2012 with the hybrid OR, which is shared with the cath lab, EP, IR, and OR as case need arises.

How does your catheterization lab handle radiation protection for the physicians and staff?

Swedish Medical Center provides personalized lead aprons for all catheterization lab employees. Shields are available at the image intensifier (II) for the physician and scrub technologist, as well as lap shields, which hang or project up from the table. Portable shields are also available for circulating and visiting staff. Lead aprons are inspected thoroughly for defects upon purchase and annually.

Where are patients are prepped and recovered (post sheath removal)? Who pulls the sheaths post procedure, both post intervention and diagnostic?

Our surgical procedures admissions unit (SPAU) handles most admission and recovery of diagnostic cases. In these cases, femoral sheaths are pulled in the lab by the scrub tech and radial cases are finished with application of a compression bracelet.

How does your lab handle hemostasis? 

Post intervention, our physicians may employ a closure device or leave the sheath sutured in place. If the sheaths are left in, they are pulled by nurses in the interventional cardiovascular recovery unit (ICVU), cardiac ICU, or telemetry units.

What kind of training is mandated before someone can pull sheaths?

In the lab, technologists must demonstrate competency with sheath removal before the end of their orientation period. The ICVU, cardiac ICU, and the telemetry units maintain their own competency, and each registered nurse (RN) must attend an orientation class and demonstrate proficiency prior to being considered qualified to pull sheaths.

Can you share your cath lab’s average door-to-balloon (D2B) times?

Swedish Medical Center has the lowest D2B time within the Providence Healthcare System and is consistently within the top 10% statewide, with a median D2B of 47 minutes. Our excellent collaboration with our admitting department, ED staff, critical care nurses, nursing supervisors, and physicians assist in maintaining our D2B times.

Swedish partners with our local emergency medical services (EMS) through the Washington State Emergency Cardiac and Stroke System (ECS) and is recognized by Washington State as a Level 1 Cardiac Center. 

Who transports the STEMI patient to the catheterization lab during regular and off hours? 

STEMIs are frequently initiated by EMS in the field. The ED communicates with incoming EMS and pages the cardiac cath lab staff as soon as possible. Upon arrival to the ED, an overhead page, “Code STEMI,” goes out. All stable STEMI patients are greeted by the rapid response team, but kept under the care of EMS and bypass the ED for direct admission to the catheterization lab. Unstable patients are held and evaluated by the ED physician until they can be safely transported to the cath lab.

When the call team is not on site, the rapid response team greets the patient in the ED. Stable patients are transported directly to the cath lab by EMS and the rapid response team, which then assumes care of the patient in the lab until the team arrives. Unstable patients are held under the care of the ED physician until the cath lab team is on site or the patient is stable enough for transfer.

What do you do when the call team is already busy doing a procedure and a STEMI comes into the ED?

Despite our double call coverage, a rare STEMI may occur in when the teams are occupied. If a team is unavailable, the rapid response team retains care of the STEMI patient in one of the available cath labs. Once cath lab staff is available to assume care of the new STEMI, the rapid response team then assumes care of our previous patient and transports them to the appropriate unit.

What measures has your catheterization lab implemented in order to cut or contain costs?

During the challenging economic climate of the past few years, cost containment has been a major focus of our organization. We have revised our vendor contracts and pricing as well as utilized consignment inventory. Our merger into the Providence Healthcare system a few years ago has provided access to a very large contracting base that has helped to leverage cost. In addition, new devices and supplies are reviewed and approved by the Product Committee or Value Assessment Team before purchase. During cases, we try to reduce the amount of discarded supplies by refraining from opening equipment unless verified by the physician. We are also currently looking use of bivalirudin versus heparin during PCI in a cost-benefit analysis.

How is inventory managed at your catheterization lab? Who handles the purchasing of equipment and supplies?

Our lab employs an inventory control coordinator (Vincent Carbonell) who oversees the supplies for the cath Lab, EP lab, IR lab and OR. He collaborates with the supervisor for equipment and supply purchases. In addition, we utilize Pyxis cabinets (CareFusion) for supply storage and to aid in billing.

Who manages your catheterization lab?

Our lab is managed by a collaborative group. The following people oversee daily operations:

• Manager CCL/EP Seattle Campus, Steve Rowell, RCIS, RDCS, BA
• Supervisor, Jeff Mercer, RCIS
• Lead Tech, Steven Swenson, RCIS, BS
• Charge Nurse, Diane Bogstie, RN, BSN

We are supported by Elizabeth J. Flett, RN, MNPL, Executive Director of Surgical Services & Swedish Heart and Vascular Institute Clinical Services, and R. Jeffrey Westcott, MD, Medical Director of Invasive Cardiology.

How does your lab communicate information to staff and physicians to stay organized and on top of change?

System-wide, Swedish has several communication channels and publications that are electronically and physically disseminated throughout the facility. Email is an essential communication tool and team members are encouraged to read their inboxes frequently to stay abreast of changes in policy, personnel, and equipment, as well as educational opportunities and in-services both within and outside the department.

Staff meetings are held monthly, and are structured to include safety briefings, system and hospital-wide updates, discussion on happenings in the lab, as well as educational segments featuring our physicians or vendors.

Are your physicians dictating their cath procedure reports, or do they use a structured reporting tool?

Physicians enter procedure notes in the EMR (we use EPIC) immediately with a full post-operative note entered within 24 hours. Some of our physicians take advantage of the features in EPIC which standardize and streamline entering information through a structured note.  However, many still dictate full notes through the transcription service that are relatively uniform.

How is coding and coding education handled in your lab?

The monitor tech is responsible for entering all procedure charges into the electronic record at the end of each case. Part of lead tech and charge RN duties include reconciling the procedure and supply charges for all cases within 3 days.

We work closely with our coding specialist (Eileen Torres, RHIA, CCS-P) who keeps us apprised of CPT changes and interpretations. The information is organized and distributed to the staff via group education.

Are you recording fluoroscopy times/dosages?

Fluoroscopy time and dose are recorded for every case in our hemodynamic monitoring system, as well as in the patient’s electronic chart.

What is the mix of credentials at your lab, and how long have staff members been “in residence”?

Average work experience in the lab equals 17 years and our most senior member has been in the lab 43 years! The lab is currently staffed by eight RNs, eleven registered cardiovascular invasive specialist (RCIS)-credentialed technologists, and four registered radiologic technologists (RT[R]s).

Who scrubs, who circulates and who monitors, and who documents medication administration during the case?

Our teams are organized into an RN, a scrub tech and a monitor tech. Each technologist must hold an RT(R) or RCIS. We require all staff to be able to perform at least two of these roles. The monitor tech records the procedure in real time, documents all compliance data, logs all equipment exchanges, and must maintain vigilance on patient rhythm and hemodynamics. The RN/circulator is responsible for dispensing and administering all medication, conscious sedation, and patient monitoring, in addition to obtaining supplies and operating ancillary equipment (intravascular ultrasound, Ekosonic endovascular system [EKOS Corp], fractional flow reserve, laser, Diamondback atherectomy device [CSI), Impella, IABP, optical coherence tomography [OCT], etc.)

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 scrub tech can either be an RCIS or RT(R). In addition to setting up the sterile field and managing the equipment for the procedure, the scrub tech is responsible for positioning the II, changing angles, and panning the table. The physician typically steps on the fluoro pedal and handles contrast injection.

How does your lab handle call time for staff members? Is there a particular mix of credentials needed for each call team?

Each call team consists of an RN and two techs. We have two call teams: a primary team and a secondary team. Double coverage is provided on weekday evenings and Saturdays, which allows for case overflow during the week. It also enables us to serve our inpatient population’s needs on the weekends, while frequently maintaining a free STEMI team.

When are call team members expected to arrive at the lab after being paged?

All team members are expected to arrive at the hospital within 30 minutes of a STEMI page.

How are new employees oriented and trained at your facility?

RNs and techs train one-on-one with a preceptor for a two- to three-month period, depending on experience level. During orientation, we ensure the new employee is directly involved with a variety of procedures and interventions involving coronary, peripheral, structural, and device placement before completing orientation. All new staff is required to shadow call teams prior to the end of their orientation to become acquainted with call back procedures.

How is staff competency evaluated?

Annual staff performance evaluations are completed by the supervisor or manager per hospital policy. Procedural competency and proficiency with equipment is each employee’s responsibility and is self-reviewed monthly. Vendors are frequently in the lab for more detailed in-service as requested by staff or leads.

Do you have flextime or multiple shifts?

We have varied shifts to cover our 13-hour workday, which include eight hour early, eight hour late, 10-hour, and 12-hour shifts. The lab opens at 6:15 am, with the first case scheduled at 7:00 am, and the last case scheduled at 5:00 pm.

What continuing education opportunities are provided to staff members?

We partner with both our physicians and vendors to provide opportunities on site for education at staff meetings or brown bag lunches. Swedish Medical Center provides required certifications classes (basic life support and advanced cardiac life support) on site, as well as free online opportunities. Our contract also provides a fixed annual reimbursement for continuing education completed outside of the hospital.

Does your lab have a clinical ladder?

Swedish Medical Center does not have a clinical ladder. However, our employees are encouraged to obtain and maintain certifications in their specialty areas (i.e., critical care RN [CCRN] or RCIS).

Is your lab involved in clinical research?

Swedish Medical Center’s cardiac catheterization lab participates in many national trials. Our research department has nurses that primarily concentrate on cardiac trials and are present for research cases.

Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) or any other outside data collection registry?

Data is reported to various agencies such as the ACC, Clinical Outcomes Assessment Program (COAP, Washington State), and the Providence Collective. Data collection is initiated by the monitor tech that enters patient and specific case information into our monitoring and recording system. In addition, cardiovascular data architect Bob Fletcher and cardiovascular data coordinator Debbie Bridge accrue and manage data for the ACC-NCDR.

How does your catheterization lab compete for patients? Has your institution formed an alliance with others in the area?

SMC is allied with Providence Health and Services, one of the largest providers on the West Coast. Swedish is the largest organization in the greater Seattle area and serves a diverse patient population that ranges from northwest Washington to southeast Alaska.

Due to our top-level Washington state categorization in cardiac care, many patients arrive in the ED via the Emergency Cardiac and Stroke System (ECS). The ECS is a statewide, coordinated effort to increase access to quality emergency cardiac and stroke care for Washington state residents.

Swedish also contracts with several rural hospitals within Washington’s Olympic Peninsula to provide specialized cardiac care. Swedish Heart and Vascular Institute (SHVI) physicians have practices located across northwest Washington, requiring travel several times a month to outlying clinics.

How do you handle vendor visits to your lab? 

Physicians schedule vendor visits for specific cases, or vendors are scheduled by the leads for days in the lab for staff education. Upon arrival, vendors are registered with Reptrax and only allowed in the room by physician invitation.

Has your lab recently undergone a national accrediting agency inspection? 

Our cardiac catheterization lab had a recent visit from the Joint Commission that focused on procedural safety pauses and medication labeling, both on and off the table.

Is there a problem or challenge your lab has faced? 

In 2012, Swedish experienced a hiring freeze, as well as hospital cutbacks. Decreased resources combined with increasing inpatient volumes created problematic staffing scenarios that made it difficult to complete scheduled cases. However, our director was able to hire a few full-time and per diem RNs and technologists that allowed us to maximize our three labs for a thirteen-hour workday.

What is unique or innovative about your catheterization lab and staff?

Our cath lab is especially focused on maintaining and improving our door-to-balloon time and we continually seek opportunity to improve our teamwork. We are persistently collaborating with medics, ED physicians, admitting, and our rapid response team to better our door-to-balloon times.

In addition, our lab collaborates with the Seattle Science Foundation (SSF) to transmit live cases for training programs. The SSF is a non-profit organization located onsite that offers professional training and educational resources for healthcare practitioners and the medical industry.

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”?

Seattle is known as one of the nation’s most livable cities, as well as the nation’s most educated city, with the highest percentage of college graduates. Our city is number four in Bicycling Magazine’s “Top 50 Bicycle-Friendly Cities”. Biking is a common mode of transportation for many Swedish employees.

Seattle also offers a thriving food, restaurant, art, and music scene. From its position on the Pacific Rim, Seattle’s views of Puget Sound and the Olympic Mountain Range are truly breathtaking.

In Seattle, CPR training is widespread, and EMS response and time to defibrillation is short. Seattle has the highest rate of cardiac arrest survival in the country, estimated at around 30% of all witnessed events. According to the present study, that would be an overall survival rate of around 16%, better than twice the average. (Circulation: Quality and Outcomes, 2009)

A QUESTION FROM THE AMERICAN COLLEGE OF CARDIOLOGY’S NATIONAL CARDIOVASCULAR DATA REGISTRY:

How do you use the NCDR Outcome Reports to drive quality improvement initiatives at your facility?

Outcome reports are regularly reported to the department of cardiology for quality improvement projects both within the department of cardiology and the cath lab. This information has been essential in building, streamlining, and main- taining excellence in our STEMI program.

Two questions from the Society of Invasive Cardiovascular Professionals:

1) Does your hospital require that cath lab staff obtain the registered cardiovascular invasive specialist (RCIS) credential? Does staff receive an incentive bonus or raise upon passing the exam?

As of June 2012, Washington State requires all catheterization lab personnel to be licensed (previously RCIS were “registered” with the state) and implemented a license for certified cardiovascular invasive specialists. However, Swedish employees who are RT(R) licensed are not required to take the exam. There is an incentive for certification per our contract, which offers an hourly bonus for those with certifications in their specialty areas.

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?

Our manager, Steve Rowell, RCIS, RDCS, BA, is a member of the SICP.