Sutter Medical Center - Sacramento

Sutter is proud of our many cardiovascular firsts in the greater Sacramento region: First successful open heart surgery on adults and children, first heart transplant, first coronary angioplasty, first electrophysiology study, first transmyocardial laser revascularization, first minimally invasive coronary bypass surgery, first extracorporeal membrane oxygenation (ECMO) and treatment with nitric oxide to newborns with lung dysfunction, first coronary brachytherapy, first endoscopic vein harvesting in cardiac bypass surgery, and first sirolumus drug-eluting stent. Sutter Medical Center-Sacramento is the only hospital in the greater Sacramento Valley area that performs heart transplant operations and is rated one of the best in the country for long-term survival rates. What is the size of your cath lab facility and number of staff members? What is the mix of credentials at your lab, and how long have staff members been in residence? Sutter Medical Center-Sacramento has 4 cath suites and a 10-bed Holding Area. Our newest room opened early in 2003 and is primarily dedicated to electrophysiology procedures. We have over 50 staff members who include a talented mix of RNs, CVTs, RTs, and several support staff. In addition, we intermittently use traveling RNs and CVTs. Support staff, including nursing assistants and unit secretaries, provide invaluable assistance with patient care, clerical duties, transportation, and scheduling. We have hundreds of years of cath lab experience in our lab and have several staff members who have worked in the department more than 10 years. Our most 'seasoned' employee has been with the department for 28 years. Additional staff who assist the cath lab in various ways include a Materials Manager Coordinator, two Cardiovascular Clinical Nurse Specialists (adult and pediatric), and an IT Project Manager. What type of procedures are performed at your facility? Approximately how many are performed each week? Does your lab perform peripheral interventions? What is the approximate volume? We performed 5323 cases in 2003 and expect to perform more in 2004. In a busy week, we will do 40 diagnostic caths, 30 coronary interventions, 10 peripheral interventions, 10 EPS/Ablations, 10 pacemakers/ICDs, and 5 cardioversions and tilt table tests. In addition to our adult service, Sutter Medical Center-Sacramento is one of the two providers of invasive pediatric cardiology services in our area. We did about 150 pediatric diagnostic and interventional cases in 2003 and expect to see that number steadily increase, as we re-opened our pediatric cardiac surgery program in September 2003. Does your cath lab perform primary angioplasty with /without surgical backup? If with surgical backup, how is it scheduled? We have been providing coronary intervention since 1981, when the first PTCA in Sacramento was performed at our facility. Our surgical back-up procedures have evolved with time and with the sheer volume of both interventions and cardiac surgeries performed here. About 1,000 adult and pediatric cardiac surgery procedures will be performed in 2004 at SMCS Currently, in the very rare event that a patient would need to go emergently to surgery from the cath lab, we work on a 'next available OR room' basis. What procedures do you perform on an outpatient basis? Many of our procedures are performed on an outpatient basis, including many of our patients who have diagnostic cath procedures, EP studies, or right ventricular biopsies. We are fortunate to have a 10-bed Holding Area located adjacent to the procedure rooms. This area opens to outpatient admissions at 6 a.m. Patients are prepared for their procedures, then many return to the Holding Area for monitoring, recovery, and discharge home later the same day. This area is staffed from 6 am to 9 pm (Monday through Friday only) with 3-5 RNs, depending on the number of patients. Who manages your cath lab? Our cath lab is managed by Nursing Director, Carol Prinzo RN, who has been in the position since October 1998. She reports to Margaret Mette RN, Assistant Administrator of Sutter Medical Center-Sacramento. Day-to-day oversight is provided by the Assistant Nurse Manager, Joni Fletcher RN, and Rod Zumstein, Lead EP Tech. We have three medical directors for invasive cardiology services - David Roberts, MD, Cardiac Catheterization Services, Larry Wolff MD, Electrophysiology Services, and Andrew Juris, MD, Pediatric Cardiology. Do you have cross-training? Who scrubs, who circulates and who monitors? Currently, most of our staff are cross-trained to at least two roles. Our goal is to have as many people trained to as many different jobs as possible. Our circulators, who assess patients and administer medications are RNs, as required by California regulations. Our scrub person and monitor person may be an RN, CVT, or RRT/CVT, depending on their training, experience, and competency demonstration. Does your lab have a clinical ladder? Would you be willing to share it? Sutter Medical Center-Sacramento has a formal clinical ladder program that is available to the cath lab RNs. It is limited to regular full-time and part-time employees. All RNs in good standing are automatically placed at Level II of the Clinical Ladder. Advancement to Level III and Level IV are at the choice of the RN. A yearly bonus of $1700 is paid to Level III RNs and $2300 to Level IV RNs. Type of activities that qualify for the clinical ladder include participation in unit-based and hospital-wide committees, updating policies and procedures, overseeing quality improvement projects, teaching BLS, ACLS, PALS, or other types of educational opportunities, and publishing in professional journals. The cath lab is exploring a clinical ladder for our technologists. What are some of the new equipment, devices and products introduced at your lab lately? Our most recent technology addition is Guidant's Acculink/Accunet Carotid Stent system (Santa Clara, CA). We also have intra-cardiac echocardiography (ICE), which we are using with adult ASD/PFO closures and electrophysiology procedures and the Frontrunner CTO catheter (LuMend, Inc., Redwood City, CA). Additionally, we have IVUS, WaveWire (Volcano Therapeutics, Inc., Rancho Cordova, CA), AngioJet® (Possis Medical, Inc., Minneapolis, MN), and distal protection device capability. In EP, we use Carto (Biosense Webster, a Johnson & Johnson company, Diamond Bar, CA) and Localisa® (Medtronic, Inc., Santa Rosa, CA) for 3-D mapping, and cryoablation technology. Is your cath lab filmless? Yes, we have been filmless for 10 years. We were the first cath lab in the Sacramento area to go digital. Our x-ray vendor is Philips and our vendor for digital archiving is Heartlab. We are now placing viewing stations throughout various locations of the hospital, including medical records, CICU, telemetry, and the cardiac operating room. Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab? We do not have an RT (radiologic technologist) present during every procedure we perform. All of our physicians maintain their California fluoro license which allows them to operate the equipment. During complex procedures, peripheral procedures, and pediatric procedures, we do have an RT in the room. There is always at least one RT working in the department whenever open per California Department of Health Services Titles 17 & 22. After-hours and weekend on-call teams always include 1 RT in the mix. Which personnel can operate the x-ray equipment in your cath lab? All of the options below apply when fluoro is being performed. Per Title 17, with the exception of initiating x-ray when a patient is in the beam, anyone can position the table or change settings. - Positioning the image intensifier - Cardiologist, RT - Panning the table - Cardiologist, RT - Changing angles - Cardiologist, RT - Stepping on the fluoro pedal - Cardiologist, RT How does your lab handle hemostasis (i.e., manual or vascular closure devices, where do patients go, who is responsible?) We use vascular closure devices in 25% of our patients. Angio-Seal (St. Jude Medical, Minnetonka, MN) is the predominant device in use. We have trained four of our RN staff to deploy Angio-Seal and plan to work with the vendor to train more RNs and CVTs. Outcomes with RN deployment of Angio-Seal have been excellent. We also use the Neptune Disc (TZ Medical, Inc., Portland, OR) and have had good results, although we continue to primarily use the FemoStop (Radi Medical Systems, Inc., Reading, MA) and the CompressAR® (Advanced Vascular Dynamics, Portland, OR) for mechanical compression. Does your lab have a hematoma management policy? We have a hospital-wide management protocol for the patient who has undergone cardiac catheterization and/or a coronary/peripheral interventional procedures. These protocols provide guidelines for managing vasovagal episodes, chest pain, and bleeding/hematoma that may develop post-procedure. These concepts are taught on a regular basis by the nurse educators and clinical nurse specialists, and competency for groin management is assessed at least annually. Additionally, staff members are asked to report hematomas so that rates can be tracked by Integrated Quality Services. Additionally, vascular complication rates are captured in our ACC data, which is reported to our cath lab staff and medical staff committees on a regular basis. How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies? We are very fortunate to have a dedicated Materials Management Coordinator in the department who oversees our extensive inventory of supplies, catheters, and devices. Inventory is managed using a GE computerized tracking system and bar code scanning at the point of supply usage, which automatically modifies inventory and alerts the Materials Management Coordinator when the re-order threshold has been reached. The GE Marquette MacLab (Waukesha, WI) interfaces to the GE LMT system in the Materials Coordinator's office and supplies are ordered. A careful verification of all procedures and charges is done daily to eliminate lost charges and verify accuracy of charges. Has your cath lab recently expanded in size and patient volume, or will it be in the near future? Currently, we have an average of 18-22 scheduled cases each day, and then the unstable patients and the add-ons come in all day and evening. We opened our 4th room last year, which is predominately used for electrophysiology procedures and device implantation. This has helped our daily schedule tremendously. Sutter Medical Center also does some device implantation in the operating room, depending on physician preference for use of general anesthesia or schedule flexibility. We are also in the planning to move and expand our Holding Area from 10 beds to 16 beds. We anticipate beginning construction in early 2005. Is your lab involved in clinical research? Sutter Heart Institute participates in many device clinical trials and has three dedicated RNs who oversee the multiple clinical trials. We were the only Sacramento site for the sirolimus drug-eluting stent clinical trial. Some of the other clinical trials we are involved in include evaluating distal protection devices in saphenous vein grafts, drug eluting stents vs. radiation therapy for in-stent restenosis, IIb/IIIa inhibitor vs. direct thrombin inhibitors, CAD regression studies with statin medications, and several electrophysiology studies. Does your lab perform elective cardiac interventions? Yes, we perform elective cardiac interventions. As a tertiary referral center, many of our patients are referred to us from both Sutter and non-Sutter facilities throughout the greater Northern California, southern Oregon, and western Nevada areas. In addition to our Holding Area, Sutter Medical Center has an 11-bed cardiovascular interventional unit (CVIU), where the majority of our post-PCI patients are cared for. Having this specialized unit has helped our throughput for our interventional patients. On the CVIU, the nurse-to-patient ratio is 1:3, allowing these nurses to closely monitor for early complications, manage sheath removal, provide detailed patient and family teaching, while attending to other patient care needs. Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? Our rate of acute complications requiring emergent cardiac surgery is well below national benchmark. We attribute this to the expertise of our interventional cardiologists and the training and skills of our exceptional nursing and technical staff. What measures has your cath lab implemented in order to cut or contain costs? We have many initiatives in place to control costs. Ninety percent of our interventional devices are consigned, including all pacemakers, ICDs, stents, balloons, and guiding catheters. We also have a rigorous procedure in place for negotiating costs up-front, including establishing a one-price level for our stents (except drug-eluting), balloons, and guiding catheters for coronary and peripheral vascular products. Our Materials Management Coordinator carefully tracks the cost of daily supply orders in a spreadsheet, which is benchmarked against our monthly supply budget. This gives us a daily view of what we're spending and how it stacks up against our budget. We also have a rigorous process to ensure accurate, and appropriate, charge-capture, so supplies aren't missed. How is coding and coding education handled in your lab? How is coding communication handled with the billing dept.? Procedural coding information is built into our MacLab Hemodynamic System. During procedures, the procedures/codes are selected by the CVT and print out on the report. Procedural codes for each procedure are verified on a daily basis. This information is then sent to our Central Billing Office for processing. What type of quality control/quality assurance measures are practiced in your cath lab? In addition to the routine daily equipment quality control, review of turn-around times, compliance with current history and physicals and pre-sedation assessment regulations, we collect and submit data to ACC, STS, and NRMI. In 2005, we plan to begin submitting data to the CRUSADE database as well as implementing the American Heart Association's Get With the Guidelines. We routinely gather patient satisfaction information from our patients and share this information with staff and other departments as needed. How does your cath lab compete for patients? Has your institution formed an alliance with others in the area? Sutter Medical Center-Sacramento is an affiliate of Sutter Health. The Sacramento region is a unique market, in that it is predominately managed care. There are five hospitals within the Sutter Sacramento-Sierra region and our campus provides tertiary cardiac catheterization and open-heart surgery services for these hospitals, as well as several other smaller, non-affiliated hospitals in the region. Physicians and cardiologists who work with Sutter Health have outreach programs in the rural areas and refer patients in for services when necessary. Additionally, the Sutter Specialty Network markets our services to area physicians and hospitals. How are new employees oriented and trained at your facility? What licensure is required for all professionals who work in your lab? The SMCS cath lab hires RNs, CVTs, and RTs. The CVTs may have Radiological Technologist licensure, LVN licensure, or Respiratory Therapy licensure. All RNs and CVTs are required to have ACLS. Invasive RNs are also required to be PALS-certified. CVTs are also required to be RCIS-certified. The EP technologists and the EP RNs are required to be NASPE-certified. RCIS and NASPE certifications must be obtained within two years of hire. Some of our nurses are also CCRN-certified. In addition to hospital orientation and nursing orientation for RNs, newly hired staff are assigned a primary preceptor who guides their orientation experience. Our orientation plan is based on the 2002 recommendations from the Society of Invasive Cardiovascular Professionals (SICP). Each newly hired staff member is given a detailed orientation checklist to complete with their preceptor. Like many cath labs in California, we currently use traveling staff, both RNs and CVTs, and they complete the same checklist as our core staff members. Orientation is tailored and individualized, depending on the staff knowledge level and previous clinical experience. Ongoing conferences are held with the staff member, their preceptor, the clinical nurse specialist, and the director to review progress and provide feedback. During their orientation period, the newly hired staff person shadows their preceptor and works the same schedule, though they are not expected to be on-call or work after-hours until their orientation is complete. What type of continuing education opportunities are provided to staff members? Sutter Medical Center-Sacramento and Sutter Heart Institute provide ongoing educational opportunities appropriate for the cath lab professional. Sutter Heart Institute holds several meetings each year: Cardiovascular Medicine/Surgical Update, Arrhythmia Update, and Cardiovascular Nursing, which are open to all interested staff throughout the hospital and region. We also have access to the Continuing Education Consortium, a regionally-based education program which provides courses such as "Cath Lab and Beyond,” a 35-contact-hour program designed for the new cath lab professional, as well as arrhythmia interpretation, basic and advanced hemodynamics, and various critical care topics. BLS, ACLS, and PALS is provided by the hospital to all staff that are required to take it for their jobs. How do you handle vendor visits to your lab? (Are they allowed in the cath lab at any time? Badges? Limited times or areas? Etc.) Vendor visitation is coordinated by our Materials Management Coordinator and our current policy was developed by our System Procurement process. Vendors are permitted to visit once monthly, unless there are special circumstances, such as extended rollout of new products that required extensive physician/staff training. They are required to be badged and are set up in the cath lab hallway where they can interact with staff and physicians. They can be present in the procedure room only at the request of the physician. How is staff competency evaluated? Ongoing competency assessment is done and is reflected in annual performance reviews. New this year is the addition of quarterly skills labs, where hands-on training and competency assessment with various procedures, equipment and devices is assessed. Stations we have completed to date include AngioJet, ICE, WaveWire, intra-aortic balloon pumping, carotid stenting, and sterile technique. Future stations will include procedural sedation, IVUS, and Rotoblator® (Boston Scientific Corporation, Maple Grove, MN). Does your lab utilize any alternative therapies (such as guided imagery, etc.)? At this time, we do not use any of these techniques. How does your lab handle call time for staff members? Is there a particular mix of credentials needed for each call team? Do you have flex time or multiple shifts? On a typical workday, we will have 20-25 staff members working. Our routine hours for procedures are Monday through Friday, 0730 - 2130. We have overlapping 8-hour shifts, with staff arriving at 0600, 0700, 1200, and 1300. After hours, weekends, and holidays are covered by a 4 person 'on-call' crew. Currently, staff are on-call one week night per week and every 4th - 5th weekend. What trends do you see emerging in the practice of invasive cardiology? We see the volume of our interventional procedures increasing and expanding to include more peripheral work, including carotid stenting. We have also seen a tremendous growth in our electrophysiology/device volume. There are 7 electrophysiologists who have privileges in our lab, so we expect this trend to continue. Has your lab has undergone a JCAHO inspection in the past three years? We just successfully completed JCAHO review in late August/early September of this year. To prepare for this, we developed a core team of unit experts from our Holding Area and the procedure rooms who were key supporters for the process. Specific areas of interest to the surveyors were staff training and competency, sedation practices, and medication management. Where is your cath lab located in relation to the OR department, ED, and radiology departments? If you could choose one department to be adjacent to, which would it be? At our facility, all of these departments are located on the first floor and are within close proximity to one another, which is very convenient for patient flow. The clinical laboratory is in close proximity also. We are presently in the Master Planning phase of designing our new hospital, which will open in late 2009. Please tell the readers what you consider unique or innovative about your cath lab and its staff. The uniqueness of our lab centers around our mix of pediatrics and adults. We have four pediatric interventional cardiologists, 1 pediatric electrophysiologist, and more than 50 adult cardiologists and electrophysiologists. While this is challenging at times, it provides the staff with a wide range of experience. There's never a dull day in our busy lab, because of our mix of diagnostic, interventional, multiple clinical trials, EP, device implants, cardioversions, tilt tables, and pediatric cases. Is there a problem or challenge your lab has faced? How it was addressed? As with many labs in California, the shortage of RNs and cardiovascular technologists is one of our biggest issues. We are using some experienced traveling staff to supplement our teams while we continue to aggressively recruit RNs and CVTs into our lab. 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? For years, Sacramento had a reputation as a place one drives through on the way to somewhere else. Now, people all across the country are recognizing Sacramento as the place to be in California - one of the Golden State's fastest growing and most desirable places to live, work and raise a family. The region is now a prime place to be - and it's still close to recreational attractions, such as Lake Tahoe, ski resorts, the Mother Lode and Napa Valley, that make weekend getaways a breeze. Of course, Sacramento has always had its own attractions. Right here, we have enough natural delights and cultural events to keep your weekly planners filled year-round. There are a thousand miles of Delta and river waterways to play on, the American River Parkway bike trail to ride on, and annual events like the world-famous Sacramento Dixieland Jazz Jubilee. The River Cats AAA minor league baseball franchise built family-friendly Raley Field in West Sacramento and set attendance records, and Sacramento is home to one of today's hottest NBA teams, the Sacramento Kings! The location of the capital here, in a state whose economy is ranked the sixth largest in the world, gives the area a beat and throb that's unique. The economy of the region alone, at $58.1 billion, would rank 79 out of 172 if it were a nation. There's a sense of common ground among community leaders. Agriculture and commerce blend creatively. Over the years, high-tech companies have taken note of the area's amenities and moved here, and now the high-tech output of the region places Sacramento at 21st out of 100 other metro areas. And, now of course, Sacramento is the part-time home of Governor Arnold Schwarzenegger! (Thanks to the Sacramento Metro Chamber of Commerce for these details.) Sacramento is a great place to live. Sutter strives to be the preferred employer of area hospitals, so please check out our website to learn more about employment opportunities with Sutter Medical Center-Sacramento. Go to www.sutterhealth.org and learn how you can become part of the Sutter Difference!

NULL