Winter Haven Hospital Cardiac Catheterization Laboratory

Tell us about your cath lab.

Winter Haven Hospital is a 527-bed facility located in central Florida. We are the only Magnet-accredited hospital in Polk County. We currently have three labs utilized for coronary, peripheral, and electrophysiology (EP) procedures. In addition to serving the local community, we conduct a number of training courses for physicians, including a hands-on radial course, laser atherectomy, rotational atherectomy and orbital atherectomy. We also participate in a number of clinical trials.

Our department consists of 26 total staff members, with an average of six years of experience in cardiac catheterization. Among them are eight registered nurses (RNs); all are eligible to have their critical care registered nurse (CCRN) certification. Four of our RNs have bachelor of science in nursing (BSN)-level educations. We have 12 technologists of varying backgrounds, including radiology, respiratory, and cardiovascular, 100% of whom are registered cardiovascular invasive specialist (RCIS)-certified. The additional six staff members are support staff: our secretary, financial coding analyst, licensed practical nurse (LPN), transporter, and tech assistants. This staff works among three procedure rooms and one three-bay holding area.

What procedures are performed in your cath lab?  

We are a fully invasive cardiac catheterization lab, capable of performing essentially all procedures, with the exception of transcatheter aortic valve replacement (TAVR); however, there are plans to incorporate TAVR in the near future. We perform approximately 80 procedures per week. Since 2008, we have transitioned to a “radial-first” mentality and now perform approximately 75% of our coronary procedures via the radial approach. We perform the following procedures:

• Invasive cardiac procedures:  Left and right heart catheterization, percutaneous coronary intervention (PCI) including Impella (Abiomed)-supported procedures and chronic total occlusions (CTOs), rotational and orbital atherectomy, laser atherectomy, AngioJet thrombectomy, aortic balloon valvuloplasty, pericardiocentesis, and intra-aortic balloon pump.  
• Rhythm therapy procedures:  Bi-ventricular automatic internal cardiac defibrillators (AICDs), pacemaker and loop recorder devices. We also have a budding EP program in which we perform EP studies and atrioventricular  node/atrial flutter ablations.
• Non-invasive cardiac procedures:  Transesophageal echocardiogram, tilt table testing, cardioversions and non-invasive programmed stimulation procedures.
• Peripheral procedures: Abdominal angiography, peripheral digital subtraction angiography, percutaneous transluminal angioplasty of the peripheral vessels utilizing laser, orbital and rotational atherectomy, and including lesions considered to be CTOs, critical limb ischemia, limb salvage procedures, carotid angiography and stenting, and inferior vena cava filter insertions/removals.

Can you share more about your planning for TAVR procedures?

We are currently budgeted for a new hybrid procedure room to facilitate the performance of TAVR as well as other structural heart procedures, aortic endografts, etc. Construction should begin in early 2013.

Does your cath lab perform primary angioplasty without surgical backup on site? 

Winter Haven Hospital has cardiovascular surgeons on call at all times, providing our facility with full surgical backup. We also serve as an emergency backup site for a few nearby facilities without surgical backup.

What percentage of your diagnostic caths is normal?

Over half of our diagnostic procedures yield positive results that may warrant some form of revascularization therapy (PCI or bypass). Our lab practice is largely evidence-based; therefore, we utilize a good deal of intravascular ultrasound (IVUS, Boston Scientific and Volcano) and fractional flow reserve (FFR) (Volcano, Inc.), particularly with intermediate angiographic lesions. We also try to utilize a heart team approach when choosing a revascularization strategy in complex anatomy.

Winter Haven has a strong radial access program. Can you tell us more?

We have a total of seven cathing physicians that work in our lab, four of whom are interventionalists. Six are competent in and regularly utilize the radial artery access site.  Zaheed Tai, DO, is the course director for our Terumo transradial course, conducted on a monthly basis. This is a “hands on” training course for physicians seeking initial or additional training in transradial procedures. Our facility is also featured regularly in Cath Lab Digest in a column presenting transradial catheterization cases (Ask the Transradial Expert, with Dr. Tai and Orlando Marrero, RCIS).

Who manages your cath lab? 

Donald Whatley, RN, CCRN is our acting manager. He oversees the day-to-day operation of the department in addition to balancing the administrative duties that come with the job. Danny Lopez, registered respiratory therapist (RRT), RCIS, is second in command and is in charge of the daily room scheduling for staff members, as well as the flow and efficiency of the department.

Do you have cross-training? Who scrubs, who circulates and who monitors? 

We have a very eager and ambitious staff that is in the process of achieving 100% cross training. Currently, only RNs are able to administer medications. Technologists have the primary responsibility of scrubbing, but most of our RNs are currently in the training stages of scrubbing procedures. Both RNs and techs are capable of monitoring all procedures, as well as being well-versed on all of the support equipment we use.

Does an RT have to be present in the room for all fluoroscopic procedures in your cath lab?

An RT is not required as long as a physician is present in the room during fluoroscopic procedures. However, we do have four RTs on staff and available.

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? 

All staff members are capable of positioning the II, panning the table, and changing angles. However, only physicians and RTs may step on the fluoro pedal to produce images.

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

All staff is encouraged to practice the time, distance, and shielding method for radiation safety. In addition, we also do monthly film badge monitoring to check radiation levels for each staff member and physician.

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

As a lab, we constantly embrace the latest technology and products. Some of our new equipment utilized on a regular basis includes: the Impella left ventricular assist device, FFR, IVUS, the Stealth 360° Orbital PAD system (CSI), ClearWay OTW Local Therapeutic Infusion catheter (Atrium Medical), and Wildcat CTO catheter (Avinger). We are often one of the first sites chosen for product launches for many different companies. For example, we were one of the initial sites chosen for the  Coyote peripheral balloon (Boston Scientific), Emerge coronary balloon (Boston Scientific), Promus Element drug-eluting stent (DES) (Boston Scientific), Resolute DES (Medtronic), GuideLiner catheter (Vascular Solutions), and AngioSculpt scoring balloon catheter (AngioScore), among others.

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

We have staff meetings on a monthly basis, as well as a weekly cath conference for physicians which all staff members are encouraged to attend. We also send several staff members to various conferences throughout the year to keep up with recent trends.

How is coding and coding education handled in your lab? 

We recently hired a financial coding analyst to achieve optimal charge capture.

Who pulls the sheaths post procedure, both post intervention and diagnostic? 

Due to our radial-first approach, most sheaths are pulled on the table by the scrub tech using a TR Band (Terumo) immediately after the procedure, regardless whether it is diagnostic or PCI. On the occasions in which we use the femoral approach, diagnostic sheaths are pulled in the holding area when a closure device is not utilized. Interventional sheaths are pulled in the Cardiac Intensive Care Unit (CICU) by CICU nurses at the appropriate time. Staff members in both the cath lab and CICU are trained in sheath pulls and site maintenance, and are signed off as competent after ten successful pulls under experienced supervision.  

Where are patients prepped and recovered (post sheath removal)? 

Outpatients are prepped in our Ambulatory Care Unit and return there following diagnostic procedures. Inpatients are prepped throughout the hospital, depending on where they are prior to cath. Since the majority of our cases are performed via the radial approach, hemostasis is achieved in the lab by the scrub tech. Our closure devices of choice are the Perclose (Abbott) and Angio-Seal (St. Jude Medical) for our femoral cases.

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

We currently have one staff member in charge of ordering and managing supplies. The purchase of equipment and supplies is approved by management prior to being ordered.

Has your cath lab recently expanded in size and patient volume?

We have noticed a steady increase in volume over the past several years, culminating in our busiest year to date. Also, due to our location in central Florida, we notice seasonal increases in volume during the winter months. 

Is your lab involved in clinical research? 

We are currently involved in a number of clinical trials, such as:

• PROTECT: Patient Related OuTcomes With Endeavor Versus Cypher Stenting Trial
• ORBIT II: Evaluating the safety and efficacy of an orbital atherectomy system (Diamondback 360, CSI) in treating severely calcified coronary lesions.
• SAPPHIRE Worldwide: Stenting and angioplasty with protection in patients at high-risk for endarterectomy. At Winter Haven, the SAPPHIRE trial is solely being headed up by one of our interventionalists, Dr. Boris Nunez.
• TRANSLATE-ACS: Treatment with adenosine diphosphate (ADP) receptor inhibitors: longitudinal assessment of treatment patterns and events after acute coronary syndrome
• SAFE-PCI for Women: Comparing the efficacy and feasibility of the transradial approach to percutaneous coronary intervention (PCI) in women compared with the transfemoral approach.

Can you share your lab’s average door-to-balloon (D2B) times and some of the ways employees at your facility have worked together to keep D2B times under the mandated 90 minutes?  

Our average D2B time has been 62.4 minutes over the last few months and has been consistently in that range. We continue to examine ways to see if we can improve on this time. We are currently registered with the American College of Cardiology’s D2BAlliance.   

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

A cath lab RN is required to transport critical patients at all hours. In addition to RNs, we have RRTs on staff and available to provide airway support and management when necessary. 

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

We utilize one call team. In cases where two STEMIs present in close proximity to each other, we work in conjunction with the emergency department and CICU to provide immediate pre and post procedure care, while the call team readies the available lab and performs the procedure. Ultimately, the decision falls on the ACS physician to determine the best course of action (administration of thrombolytics or other anticoagulation). 

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

Our priority has always been on providing top-quality care to the patient, regardless of cost, but staff has a good understanding of what products should be pulled and when, and they try to limit the amount by avoiding the use of unnecessary items. Also, we have hired a financial coding analyst to review the physicians’ directions of the procedures and work closely with staff in order to optimize charge capture.  

What quality control measures are practiced in your cath lab?

We have an independent committee made up of invasive and non-invasive cardiologists to review cases and discuss issues. This committee works closely with other review committees throughout the hospital. In addition, we work with the program director from a nearby teaching facility to render an independent opinion if there are controversial cases. This eliminates concerns regarding peer bias.

Are you recording fluoroscopy times and dosages? 

We record the fluoroscopy time and dosages per case on our documentation for each patient and also in the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) database. 

Who documents medication administration during the case?

The staff member that is documenting for the case will document the medication given and the nurse giving that medication. Then, after the case, the nurse will go over the medication administration to make sure that the correct medications, amounts, and times are documented. 

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

As a community hospital and relatively small cath lab, we believe that if you keep the patient as the central focus, you do not have to compete for patients. We follow evidence-based practices to give our patients the most efficient and best care possible, so that customers choose to have their procedures at Winter Haven Hospital. 

How are new employees oriented and trained at your facility? 

New employees go through a three-month orientation process. We pair them with a preceptor who shows them the “ins and outs” of the cath lab. We assess  their progress on a weekly basis, and regularly evaluate strengths and weaknesses. At the end of the three-month period, we do a final evaluation. We do not expect the new employee to master everything at that point, but they need to be a productive member of the cath lab team.  We will teach them to be an expert over time.   

What continuing education opportunities are provided to staff members?

As a cath lab and as a profession, we believe that you should never stop learning and challenging yourself. We send staff members to as many open education opportunities as possible, including the TCT (Transcatheter Cardiovascular Therapeutics) conference, C3 (Complex Cardiovascular Catheter Therapeutics) conference, etc. Staff members also have a close working relationship with cardiologists in the cath lab. Physicians like Dr. Kenneth Gibbs, who has over 30 years of experience, are a valued resource and someone that staff can go to with questions.  

How do you handle vendor visits to your lab? 

Vendors have to go through a credentialing process and get a hospital badge with photo identification. Vendors are required to call ahead and schedule a time if they have a case or in-service.   

How is staff competency evaluated? 

New staff competency is evaluated in the three-month probationary period as discussed above. After that, employees are to maintain licenses and certifications through CEUs. In addition, the staff is peer reviewed on their annual evaluation and the staff does a self evaluation that they go over with management. Staff is also in-serviced on all new products before they come out by the company. The staff must demonstrate proficiency and be checked off by a super-user for each new product.        

Does your lab have a clinical ladder? 

Currently, we only have a nursing clinical ladder, but are in the planning stages to develop a tech clinical ladder as well. 

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

We use a four-member call team that has at least one RN and three other members from other disciplines. Our preference is one RN, one RRT, one cardiovascular technologist (CVT), and one other member, but that does not always work. Call team members are all proficient cath lab staff members that have been approved on all competencies. Staff is required to take at least one call shift each week and one weekend a month. 

Within what time period are call team members expected to arrive to the lab after being paged? 

Call team members maintain a 30-minute response time.  

Do you have flextime or multiple shifts? 

Currently, we have several different shift differentials for which the cath lab qualifies. We only have one shift per day and staff member work four ten-hour shifts, with alternating days off. With the ever-growing increase in volume, we do see the need for having multiple shifts in the near future.    

Has your lab recently undergone a national accrediting agency inspection? 

We recently underwent an inspection by the Joint Commission, and staff and physicians did extremely well. We are also a Magnet-recognized hospital and are currently going through re-designation at this time.  

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

Our cath lab is located on the fourth floor in the main building of the hospital and our OR is directly below us on the second floor. The emergency room is on the first floor. All areas can be reached very quickly via a badge access-only elevator for quick patient transport.  

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

As with every cath lab across the country, we have seen trends focused around appropriate use criteria, but we have also seen our patient volume and acuity increase as well. We see more patients come to us because they know that we use the radial approach. Patients are more informed and now shop around for the facility that best suits their needs. 

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

The cath lab staff at Winter Haven Hospital believes we are leading the way into the future, not just at our hospital, but in our industry. We have a 100% certification standard. A large majority of staff is completing their bachelor’s-level education. Seventy-five percent of cases are done via the radial approach, with no compromise of patient care while adding safety and comfort for the patient. 

Any problem or challenge that we have faced we have addressed as a cohesive unit, more like a family at times than co-workers. 

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 are located in central Florida, halfway between Tampa and Orlando. We see some seasonal increases in patient volume, but this is an area that is still growing, so there has also been a steady increase in overall volume. Winter Haven is a relatively small community, with an aging population that has a lot of heart and vascular disease. The community feel of the hospital allows us to give more personal care.  

The Society of Invasive Cardiovascular Professionals (SICP) has added two questions to our spotlight:

1. 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?

Yes, we do require RCIS certification for all our cath lab technologists, and we have 100% certified that are eligible to take the exam. Additionally, all of our nurses are required to have at least two years experience with critical care background and have obtained their CCRN. The staff, upon completion of these certifications, receives a bonus certification raise added on to their base hourly rate, as long as they keep the certification and membership in the professional organization current. We believe that this practice raises the level of professionalism in our lab and shows that we are committed to giving the best and most efficient care possible to the community that we serve.        

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?

Most members of our cath lab belong to at least one professional organization, with some belonging to multiple organizations. The two biggest organizations staff at Winter Haven Hospital cath lab belongs to are the American Association of Critical-Care Nurses (AACN) and the Society of Invasive Cardiovascular Professionals (SICP). 

Donald Whatley, RN, CCRN, Cardiac Catheterization Laboratory Manager, can be contacted at Donald.Whatley@WinterHavenHospital.org.