Stanford Hospital & Clinics Cath Angio Lab

What is the size of your cath lab facility and the number of staff?   Stanford Hospital & Clinics is located on the beautiful campus of Stanford University in Palo Alto, California. It is about 20 miles north of San Jose and 40 miles south of San Francisco. Stanford Hospital & Clinics is a 479-bed Level I trauma center, a ST-elevation myocardial infarction (STEMI) Receiving Center for the county of San Mateo, and a Joint Commission-certified Stroke Center. We achieved Magnet Status in 2007. Stanford Hospital & Clinics Cath Angio Lab has 12 procedure rooms: 3 biplane rooms, 8 single plane rooms and 1 hybrid room. The Cath Angio lab is a multidisciplinary department, with specialties including adult cardiology, adult electrophysiology, pediatric electrophysiology, pediatric cardiology, interventional radiology, interventional neuroradiology, and vascular surgery. We have a dedicated 9-bed pre-admission unit and 20-bed post-recovery unit. We have a combination of registered nurses (RNs), radiologic technologists (RTs) and registered cardiac invasive specialists (RCISs), and have a total of 121 staff: • 69 RNs • 27RTs • 5 RCISs • 5 lab assistants • 7 office assistants/schedulers • 1 clinical nurse specialist • 2 assistant nurse managers • 1 business manager • 1 technical manager • 1 assistant technical manager • 1 nurse manager • 1 director • 1 medical director. Our program supports fellowship training in all the cath angio specialties. What type of procedures are performed at your facility? Cardiac/adult: Radial and femoral right and left diagnostic cardiac procedures, percutaneous coronary interventions (balloon/stent), rotational atherectomy, intravascular ultrasound (IVUS), optical coherence tomography (OCT), coronary flow reserve, endomyocardial biopsy, pericardiocentesis, atrial septal defect (ASD) closure, patent foramen ovale (PFO) closures, septal ablations, valvuloplasty, intracardiac echo (ICE), renal artery stenting, peripheral vascular stenting, intra-aortic balloon pumps, percutaneous ventricular assist devices, ethanol septal myomectomy, percutaneous valve replacement. Cardiac/pediatric: Right and left diagnostic cardiac procedures, ASD/ventricular septal defect (VSD)/ PFO/patent ductus arteriosus (PDA) closures, septostomy, endomyocardial biopsy, valvuloplasty, pulmonary hypertension studies, aortic and pulmonary angioplasty/stenting, perivalvular leaks and vascular coilings. Electrophysiology/adult: Diagnostic mapping and ablations, pulmonary vein ablations, ventricular-tachycardia (VT) ablations, cardioversions, pacemaker implants, biventricular ICD implants, laser lead extractions, generator changes, loop recorder implants, 3D mapping using Navix (Navix Diagnostix, Inc., Taunton, MA), Carto (Biosense Webster, Diamond Bar, CA), CartoSound, ICE and Hansen (Hansen Medical, Mountain View, CA) robotic-assisted ablations. Electophysiology/pediatric: Diagnostic mapping and ablations, pacemaker implants, ICD implants, loop recorder implants, epinephrine QT stress test. Neuroradiology (adult/pediatric): Diagnostic angiograms, vertebroplasty, aneurysm coiling, arteriovenous malformation (AVM) embolizations, acute stroke interventions, Wada studies, extracranial and intracranial angioplasty and stenting, brain and spine tumor embolization. Vascular surgery: Carotid stenting, peripheral vascular stenting, inferior vena cava (IVC) filter placements and retrievals, thoracic and abdominal stent grafts. Interventional radiology: Diagnostic and interventional vascular/nonvascular procedures (drains, tubes, lines), transjugular intrahepatic portosystemic shunts (TIPPS), chemo embolizations/SIR-Spheres (Sirtex Medical Inc., Wilmington, MA)/ TheraSpheres (MDS Nordion, Ottawa, ON, Canada), uterine fibroid embolizations, thoracic stent graft, abdominal stent grafts, filter retrieval, deep vein thrombosis (DVT) treatment and jugular venous stenting. What procedures do you perform on an outpatient basis? The majority of our scheduled procedures are outpatient. During 2008, we performed approximately 9,500 procedures. What percentage of patients are female? Approximately 45% of our patients are female. What percentage of your diagnostic cath patients go on to have an interventional procedure? Approximately 30% of our diagnostic cardiac cath patients go on to intervention. A large number of our patients also undergo diagnostic workup for pre-transplantation, pulmonary hypertension, percutaneous aortic valve replacement and cardiomyopathy. Who manages your cath lab? Donna Keith, RN, CRN, is the director of interventional services. Robert Tallerico, RT, is the technical manager and Chris Buzzard, RT, is the assistant technical manager. Susan McKay, RN, is the nurse manager. Jodi Blanchard is the business manager. Laura Morris, RN, is the assistant patient care manager for the pre/post unit, Jacque Kixmiller, RN, CRN, is the assistant patient care manager for the Cath Angio Lab, and Lisa Curtis, RN, CNS, is the clinical nurse specialist for the region. Do you have cross-training? Who scrubs, who circulates and who monitors? Yes, we do have cross-training. We have a three-person team per room. The RN’s primary role is moderate sedation and/or circulating; however, RNs do have the opportunity to scrub. RTs and RCISs scrub and/or circulate. The monitor role is performed by RNs, RCISs or some RTs that have been cross-trained. Does an RT have to be present in your room for all fluoroscopic exams? Yes. All physicians in the Cath Angio lab have a California fluoroscopic license as well. How does your cath lab handle radiation protection for your physicians and staff that are in the lab day after day? Lead aprons, protective eyewear and mobile shields are provided for physicians and staff. Radiation badges are utilized and monitored by the health physics department. Radiation safety training is conducted annually. Radiation exposure is also monitored for the patients as well. If a patient receives 100 minutes or greater of fluoro, or 7000 mGys, those numbers are reported to the health physics department. Health physics will follow up with the attending physician or patient as deemed necessary. How is coding handled in your lab? Simple cardiology coding is done in-house. All complex coding is outsourced to the Coding Network, LLC (Los Angeles, CA). How does your lab handle hemostasis? Hemostasis is achieved by the use of vascular closure devices or manual compression. Vascular closure devices [Starclose, Perclose (Abbott Vascular, Redwood City, CA) or Angio-Seal (St. Jude Medical, Minnetonka, MN)] are deployed by a physician. Manual compression is performed by trained staff in the cath lab or post procedural area. All pediatric patients have manual compression in the procedure room to ensure hemostasis and optimal safety before transport back to the Lucile-Packard Children’s Hospital at Stanford. We also perform radial and brachial access. For hemostasis after a radial procedure, we utilize the TR Band (Terumo Medical Corporation, Somerset, NJ). Can you describe the systems you utilize to organize staff and communicate necessary information? Communication is key to running a successful lab. It seems we cannot communicate enough in this day and age where the cases are very complex, the technology continually changes and the economic climate lends itself to constant resource challenges. We have found that predictable meeting times and consistent communication helps to maintain a cohesive working environment. Each morning, we start off with a 5-minute “huddle.” During this time, the Cath Angio management team shares pertinent information including general hospital announcements and departmental news. The staff is also given the opportunity to share concerns or questions from the previous day. This forum for communication handles issues in real-time. Monday mornings of each month are designated for 1-hour meetings. The topics vary according to which Monday of the month the meeting falls on. General staff meetings are the first Monday of every month, educational meetings are the second Monday of the month, resource staff meetings are the third Monday of every month, and the unit council meeting is the last Monday. Email is utilized with a departmental distribution list for those who may have missed a meeting, are on leave or on vacation. We also have informational boards near the staff lounge. We have a new employee board, featuring a picture and brief bio of each new employee or traveler working in the lab. Information about CE classes, Magnet news, patient safety, Joint Commission and hospital councils are also posted. Staff meeting minutes are posted for everyone to read. The Cath Angio Lab has an interventional medical director meeting once a month with Dr. Michael Dake, the medical director. This is the forum at which the director of the lab, business manager and technical manager bring forward topics for discussion. There is a physician representative from each specialty in the lab in attendance, along with Jerry Maki, VP, and a representative from the department of anesthesia. Ad hoc members such as pharmacy, quality and compliance are invited to attend as necessary. There is a monthly cardio-vascular oversight committee meeting that the director attends as well. This is where the service line departments come together with the medical directors to discuss volumes, quality, finances, key drivers or performance. How is inventory managed in the Cath Angio Lab? We have a large number of products in our lab. In order to handle the diverse inventory needs of all our specialties, we have an automated inventory system called QSight (Owens and Minor, Mechanicsville, VA). We have 2 full-time employees of Owens & Minor on-site to handle all inventories. Staff scans the bar code on the inventory during the case. Par levels are pre-set, and the system deducts and orders according to the set par. This is just-in-time ordering and most products show up the next day. Some of our custom items take longer to arrive. Lead technologists are responsible in the rooms for keeping track of inventory issues. There is a weekly QSight meeting between the lead techs, technical manager and the business manger to discuss inventory issues. We also have a value analysis committee hospital-wide. The Cath Angio lab participates in this committee. We are continually evaluating and looking for new ways to keep our costs down. What are some of the new equipment, devices and products recently introduced at the Cath Angio Lab? In the last three years, we have undergone a large remodel and upgrade of our imaging equipment. This upgrade allows us to offer our physicians and patients the latest technology to address their complex medical needs. We have multi-modality software in all new rooms which allows us to utilize cardiac and vascular imaging. In 2008, our pediatric room was upgraded to a Siemens Artis zee platform, offering bi-plane angiography and with a large detector on the frontal plane. Our new interventional cardiology/ peripheral room is a GE Innova 3100 (GE Medical, Waukesha, WI). Our primary EP room is currently under construction in the main Cath Angio Lab. It will be a Siemens Artis zee, bi-plane EP, large detector on the frontal plane, with a Hansen Robotic Ablation System. We are about to begin construction on our new Siemens Artis zee bi-plane hybrid neuro- interventional/OR room. This room will be used by the Cath Angio Lab and the OR to perform combination neurointerventional/surgical cases. In 2007, we installed 3 Siemens dTA single-plane rooms in the hospital’s outpatient advanced medicine center. These rooms are primarily used for interventional radiology. Two of these rooms have syngo DynaCT (Siemens) capability. We are currently embarking on upgrading our hemodynamic/PACS systems (GE Medical). We have ICE, iLab (Boston Scientific, Natick, MA), Galaxy IVUS (Boston Scientific Corp.), and new Volcano Corporation technology (San Diego, CA). We have a large number of products in our lab to handle diverse specialty needs, including the Impella Proforma (Abiomed, Danvers, MA), the Ekos system (Ekos Corp., Bothell, WA), CartoSound (Biosense Webster), and Penumbra aspiration system (Penumbra, Inc., Alameda, CA). What type of quality control/quality assurance measures are practiced in the Cath Angio Lab? We work closely with the quality department on performance improvement and patient safety initiatives. Utilizing PDCA (Plan, Do, Check, Act) and Learn Six Sigma DMAIC (Define, Measure, Analyze, Improve, Control), Stanford Hospital & Clinics participates in initiatives that measure key organizational performance priorities, as identified in the strategic imperatives. The performance measurement effort is systematic, scientific and interdisciplinary. Managers in the department attend the hospital-wide BEST (Bringing Excellence in Safety and Quality Together) meeting. This is a monthly meeting where quality dashboards and core measures are reviewed. One of our biggest process improvement projects has been our door-to-balloon time project. We developed a STEMI steering committee that consists of members from the emergency department (ED), cath lab, telecommunications and quality. We meet once a month to discuss ALL code STEMI cases. This committee developed an algorithm in 2007 to streamline the process for all physicians, ED and cath lab staff. There is a STEMI board in the hallway where all cases are reported, so staff can see the numbers. We have STEMI pizza parties after every 10 cases reported to be What measures have you implemented in order to cut or contain costs? The cath lab participates in a hospital-wide value analysis program. We have managed to save 1.6 million dollars this past fiscal year. We are also a member of Premier, for group purchasing. Our business manager works very closely with the staff to constantly find cost-saving opportunities. How does your lab compete for patients? Stanford Hospital & Clinics has a large communications and marketing department that develops ongoing campaigns for the Centers of Excellence. There is also dedicated staff working on physician outreach and education, as well as patient education. Our physicians attend conferences, speaking engagements and Grand Rounds at other healthcare facilities. We have outreach programs at many of the local hospitals. How are new employees oriented and trained at your facility? All staff attend a general hospital orientation. RNs also attend a one-week general nursing orientation. Each specialty has an RN educator and a lead technologist. New employees are paired up with a preceptor who works in tandem with the educator and lead technologist to get new staff through their specialty. The level of experience determines the type and length of orientation new staff receives. If a new employee has never worked in the cath lab, a 3- to 6-month orientation in each specialty is required. Stanford Hospital & Clinics is home to the Goodman Simulation Center, a training center offering virtual reality and simulation-based training models. This past year, the Cath Angio staff had the opportunity to participate in training scenarios at the Goodman Center. Scenarios specific to the cath lab were developed and staff were given the opportunity to work within a simulated environment where they were free to learn, make mistakes and ask questions. We are about to embark on a research project regarding manual assist closure devices, the FemoStop (Radi Medical Systems, Wilmington, MA) versus Safeguard (Maquet Cardiovascular, Montvale, NJ). There is also another research project underway that is investigating heparin use in the cath lab and the incidence of heparin-induced thrombocytopenia (HIT). What type of continuing educational opportunities are provided to the staff members? Stanford Hospital & Clinics provides an educational stipend for all staff of up to $1,000/year to be utilized for educational and conference fees. The hospital has a Center for Education that provides diverse educational opportunities for all staff throughout the year. Within the Cath Angio department, twelve educational scholarships are given out yearly for exceptional staff to attend both local and national conferences. Staff who attend conferences are required to give a short overview on what they learned at the conference. We encourage staff to obtain certifications in their specialty areas. In September, we participated in live case demonstrations for the TCT (Transcatheter Cardiovascular Theraputics) meeting hosted in San Francisco. How do you handle vendor visits in your lab? Vendor visits are strictly controlled. All vendors must sign up on a calendar that is controlled by the business manager. All visits are pre-arranged and rotated. Vendors are able to provide ad hoc training for new products, but there are no vendor-sponsored educational activities within the lab. How is staff competency evaluated? The CNS, as well as the nurse educators/lead technologists, must sign off on staff competencies. Some competencies are annual. Staff must also maintain basic life support (BLS), advanced cardiac life support (ACLS) and pediatric advanced life support (PALS). Healthstream is the hospital-wide tool used for annual competencies that all staff must maintain, such as disaster preparedness, back safety and fire safety. How does your lab handle call time for employees? There are three call teams: neurointerventional, cardiology, and interventional radiology. The call teams consist of 3 members, an RN/RT and monitor (RN/RT or CVT), consistent with daytime staffing for cases. We also have an RT on call for the OR. The OR tech covers all trauma/vascular cases. Staff sign up for call and seniority is taken into consideration. Within what time period are the call team members expected to arrive to the lab after being paged? The call teams are expected to arrive within 30 minutes. The attending cardiologist must call back within 10 minutes and arrive in 30 minutes. Do you have flex time or multiple shifts? The cath lab has 8- and 10-hour shifts. The pre/post procedural unit has a combination of 8-, 10- and 12-hour shifts. Where is the cath lab located in relation to the OR and ED? The main cath lab is located on the second floor of the hospital. The OR is adjacent to the main cath lab on the second floor. The ED is on the first floor directly below the main labs. Directly across the hall from the front of the main cath lab is the neuro/trauma intensive care unit and directly across the hall behind the main lab is the CV intensive care unit. The heliopad is on the third floor, directly above the main lab. The clinical decision unit is on the first floor. This is where the chest pain observation patients go. How do you see your cath lab changing over the next decade? We hope to see our volumes grow across all service lines. As open procedures continue to transition into the interventional arena, we are experiencing a shift in where cases are done. We now work closely with vascular and cardiothoracic surgery. Multidisciplinary teams bring expertise to the table from both the OR and interventional environments to treat complex disease. We currently participate in the PARTNER clinical trial, replacing aortic valves percutaneously. The OR and the cath lab staff have developed a great working relationship, learning from each other. This cross-pollination of skills has raised the bar for the Cath Angio staff. We grow as clinicians while working with our surgical colleagues. We are in the process of designing a new hospital. The new Cath Angio Labs are being designed with flexibility in mind and will be built in an area combined with the OR. Can you describe the systems(s) you utilize daily? Our cath lab uses the Mac-Lab hemodynamic system (GE Medical) for hemodynamic measurements and procedural documentation. RISC is utilized for exam scheduling. GE PACS is utilized for radiology image archiving and GE Centricity PACS is utilized for cardiac image archiving. Apollo (Lumedx Corp., Oakland, CA) is utilized for cardiology physician reporting and American College of Cardiology database reporting. OpTime (Epic Systems, Verona, WI) is our hospital’s procedure scheduling/ electronic medical record system. What’s special about your city or general area in comparison to the rest of the U.S? The San Francisco Bay area is one of the top destinations in the U.S. The climate, culture and diversity attract many people to this part of the country. There are numerous sights to see and activities to enjoy in the Bay area. We are home to many professional sports teams, museums and musical venues. If you enjoy outdoor activities, you can find a multitude of options. There are a number of great wineries to visit as well. The Stanford University Campus is a residential community with 8,000 acres of surrounding foothills and plains. The campus offers the students, faculty and community rich opportunities. Stanford has a strong tradition of supporting the performing arts. These venues are open to the public. The campus has state-of-the-art recreational facilities that support 35 varsity athletic programs, as well as club sports. The authors can be contacted at JKixmiller@stanfordmed.org

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