Cath Lab Spotlight: Carlyle Fraser Heart Center Emory University Hospital Midtown

Tell us about your facility and cath lab.

Our history dates back to 1908, when two physicians, Dr. Edward Campbell Davis and a former student of his, Dr. Luther C. Fischer, opened the 26-bed Davis-Fischer Sanatorium on Crew Street, near present-day Turner Field in Atlanta, Georia. With just 26 beds, the hospital quickly outgrew its capacity and by 1911, Davis and Fischer moved the hospital to its present site, opening an 85-bed Davis-Fischer Sanatorium on Linden Avenue. Emory Crawford Long Hospital was renamed “Emory University Hospital Midtown,” effective February 13, 2009. Emory University Hospital Midtown (EUHM) is part of Emory Healthcare and is located near downtown Atlanta. Emory Healthcare is the largest and most comprehensive health care system in Georgia, comprised of seven hospitals and 200 provider locations, with over 1800 physicians in more than 70 specialties. EUHM is part of the Emory healthcare’s rich history of research, modernism, and brilliance. Emory is the considered the birthplace of modern interventional cardiology.

What is the size of your cath lab facility and number of staff members?

Our cath lab consists of 2 cath labs and 2 hybrid OR/cath labs. We currently have 20 clinical staff members, and about half of our team are registered nurses (RNs) and half are cardiovascular technologists. The majority of the staff has less than 5 years of experience in the lab, but we have a registered cardiovascular invasive specialist (RCIS) with almost 15 years of experience and an RN with 35 years of nursing experience, 18 of which have been in the EUHM Cath Lab.

What procedures are performed in your cath lab?

We average 50-70 cases per week and perform a wide variety of procedures. Our services include right and left heart catheterizations, CardioMEMS (Abbott), pericardiocentesis, percutaneous coronary intervention (PCI), chronic total occlusion (CTO) PCI and other complex PCI procedures, balloon aortic valvuloplasty (BAV), transcatheter aortic valve replacement (TAVR), percutaneous transvenous mitral commissurotomy (PTMC), MitraClip (Abbott Vascular) transcatheter mitral valve replacement (TMVR), patent foramen ovale (PFO), atrial septal defect (ASD), and ventricular septal rupture (VSR) closures, catheter-directed tPA and thrombectomy for pulmonary embolism, as well as peripheral procedures.

Can you share your experience with TAVR?

The Cardiac Cath Lab at EUHM began performing TAVR procedures more than 10 years ago when we participated in the placement of aortic transcatheter valve trial (PARTNER). The PARTNER trial compared a transcatheter aortic valve to the standard surgical or medical treatment of patients who were high risk or not surgical candidates. At the time, all TAVR cases at EUHM were done in a hybrid room located in the OR. Due to the need to share the hybrid OR with other disciplines, we were only able to schedule TAVR cases on Tuesdays. Over the years, our structural heart program has evolved through several trials and commercial valve replacement and repair systems, and structural cases are now scheduled every day. In addition to TAVR, we perform mitral and tricuspid replacements and repairs, both commercial and investigational, along with aortic and mitral valve leaflet lacerations [Bioprosthetic Aortic Scallop Intentional Laceration to prevent Iatrogenic Coronary Artery obstruction (BASILICA) and Laceration of the Anterior Mitral valve leaflet to Prevent Outflow track ObstructioN (LAMPOON)]. All of our transcatheter interventions are now done in the cardiac cath lab, and most of these patients receive either moderate sedation administered by the cath lab RN or monitored anesthesia care (MAC) administered by a CRNA. The structural team has an algorithm they follow during the workup to determine whether each patient receives moderate sedation, MAC, or general anesthesia.

What is your percentage of normal diagnostic caths?

Around 25% of our diagnostic caths reveal normal coronaries.

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

Most of our physicians have a “radial first” preference, using femoral access only if the procedure requires a sheath larger than 7 French (Fr), the patient has both left internal mammary artery (LIMA) and right internal mammary artery (RIMA) grafts, or the patient does not have a radial pulse. In addition, many of our right heart catheterization procedures are performed via right brachial vein access using a 5 Fr pulmonary artery (PA) catheter.

If you are performing peripheral vascular procedures, do any operators utilize pedal artery access when appropriate?

We currently have 2 interventional cardiologists and 3 vascular surgeons who perform peripheral procedures in the cath lab. One of the vascular surgeons will occasionally use pedal access.

Who manages your cath lab?

Cecilia Mortorano, MSN, RN, NEA-BC is the new Director of Cardiology at EUHM. We are very excited and happy to have her as our new leader. Day-to-day operations of the lab are managed by our cath lab manager, Margaret Jones, who manages budget, schedule, quality metrics, and patient issues that arise. We also have clinical staff flow coordinators who run the board each day.

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

Each cath lab staff member is expected to perform at least two roles. Cardiovascular technologists in our lab scrub and monitor, and RNs circulate and monitor. RNs are not required to scrub but some of the RNs choose to do so. Each RN decides whether or not they wish to learn this role.

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?

Fluoroscopy is administered by a physician, whether it is the interventional cardiology attending or the cardiology fellow. Table positioning, panning of the table, and camera angles are all a shared responsibility, largely done by the scrub person, who is also responsible for teaching the cardiology fellows this skill.

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

On an annual basis, mandatory radiation safety courses are completed by all physicians and staff who are exposed to radiation. Physicians and staff are provided with custom-fit lead aprons and thyroid shields. Physicians and staff who scrub are provided with lead glasses. Radiation protection scrub caps are available for those who wish to use them.

Monthly exposure is monitored with radiation dosimeter badges for all staff, physicians, and any ancillary personnel who are present in the lab during cases. Individual exposure reports are available monthly and timely updates are received if anyone has had exposure above the standard limits. Our staff and physicians are  mindful of body shields, eco dose fluoroscopy equipment settings, and collimation during cases to help reduce scatter.

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

We recently began using the Shockwave lithotripsy balloon (Shockwave Medical) to treat heavily calcified peripheral arteries and will be participating in the research on the Shockwave coronary lithotripsy balloons. We also have begun using the NRG Transseptal Needle (Baylis Medical) to Bovie across the septum for some structure heart procedures.

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

Each staff member has an Emory healthcare email. We have a huddle at the beginning of each workday, and a staff meeting each Wednesday. The cardiologists have a weekly staff meeting and staff members are encouraged to attend. Educational in-services are held both on and off campus by vendors.

How is coding and coding education handled in your lab?

Emory employs certified medical coding and billing specialists to do all of the billing and coding. Their continuing education to maintain certification is paid for by Emory. One of our inventory RCIS staff members is also trained in billing and coding.

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

Cath lab, cardiac observation area (COA), coronary care unit (CCU) nurses and all RCIS staff members are trained to pull femoral sheaths. Cath lab staff is also trained to pull radial sheaths. During normal hours of operation, COA nurses will go to the telemetry floors if a femoral sheath needs to be pulled. During off hours, one of the cath lab call team will be called in to remove groin sheaths on telemetry floors. We are now in the process of developing and implementing a sheath pulling team for the telemetry floors. The cardiology fellows pull sheaths as part of their training.

What kind of training is mandated before someone can pull a sheath?

CCU, COA, and cath lab staff must pull 6 groin sheaths with a preceptor as a part of orientation training. Cath lab staff also must pull 6 radial sheaths.

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

Outpatients are prepped and recovered in the COA. Inpatients may go to COA post procedure or back to telemetry floor depending on their needs. All ICU patients go to ICU post procedure. The COA RNs pull groin sheaths both in the COA and on the telemetry floors. Only trained physicians deploy vascular closure devices.

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

Two of our RCISs manage the inventory, and purchase equipment and supplies. The manager will assist them as needed.

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

The EUHM Cath Lab recently added two hybrid OR labs, located in the cath lab, and three post anesthesia care unit (PACU) rooms, located in our COA recovery area. A restructuring of Emory Cardiology significantly increased our structural caseload by consolidating structural heart cases and resources at the Midtown campus. This expansion accommodates change, and provides the convenience of performing and recovering all of our transcatheter structural cases in the cath lab. We no longer need to compete for time in the OR hybrid lab or transport general anesthesia patients to PACU post-procedure.

Is your lab involved in clinical research?

We are currently involved in several research studies, including the PARTNER 3 trial to study the safety and effectiveness of the Edwards Lifesciences Sapien 3 transcatheter heart valve in low-risk patients. Other trials include:

• Early TAVR trial evaluating transcatheter aortic valve replacement compared to surveillance for patients with asymptomatic severe aortic stenosis,
• Early feasibility study of the AccuCinch Ventricular Repair System (Ancora Heart);
• Early feasibility study of  the Tendyne transcatheter mitral valve replacement system (Abbott).

Non-structural research trials we are involved in include:

• SPYRAL HTN-ON Med and SPYRAL HTN-OFF Med (both Medtronic), evaluating the effectiveness of renal denervation in treating hypertension;
• SAVI-PCI clinical trial, evaluating the efficacy of tirofiban using a high-dose bolus plus a shortened infusion duration versus label-dosing eptifibatide in patients undergoing PCI;
• HARMONEE clinical trial, assessment of a novel drug-eluting stent platform for PCI in patients with ischemic and non ST-elevation myocardial infarction (STEMI) coronary disease (OrbusNeich Combo).

Are you registered with the American Heart Association’s Mission:Lifeline?

We are a part of Mission:Lifeline, the American Heart Association’s initiative to reduce mortality, and in 2018 received the Mission:Lifeline Silver Receiving award and the NSTEMI Silver Award. Many of our patients initially present to non-PCI hospitals and are then transferred to us, so we have shifted our focus from door-to-balloon times to “first medical contact to device” time and are actively engaged in developing strategies to improve.

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

STEMI patients in the emergency department (ED) are transported to the cath lab by the ED nurse and inpatient STEMI patients are transported by cath lab staff.

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

We are able to handle this situation well, because we have a 4-person call team and we are a teaching hospital. If the call team is already in a procedure, they split into 2 teams of 2 to handle the STEMI. One RN and 1 RCIS continue with the ongoing case, and the others respond to the STEMI. An attending cardiologist and a cardiology fellow will scrub the case without a cath lab scrub person.

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

The vendors and inventory staff members meet monthly to check consigned stock. The inventory staff will mark short dated items as “USE FIRST”, and cath lab staff will check stock to ensure products are used before the expiration date. No cross stents are returned to the manufacturer for replacement according to each manufacturer’s crossing guarantee. When stocking supplies, they are rotated on a first in, first out basis to prevent expiration.

We recently split the pericardiocentesis standard order set into diagnostic and palliative to prevent doing expensive testing on pericardial fluid for those patients in whom the diagnosis is already known and where treatment will not be changed by the results.

What quality control measures are practiced in your cath lab?

X-ray, emergency equipment, and emergency medications in each lab are checked daily to ensure they are available and working properly. All Emory RNs are required to do a project each year. Recent quality projects have focused on reducing the radiation dose to the patient, ensuring that patients are pre-hydrated prior to coming to the cath lab in order to reduce contrast-induced nephropathy, reducing room turnover times, removing barriers to on-time first case starts, and reducing the risk of catheter-associated urinary tract infections (CAUTI) by not placing a Foley catheter in structural patients receiving moderate sedation or MAC.

How do you determine contrast dose delivered to the patient during an angiographic procedure?

Our standard formula for calculating maximum allowable contrast dose is estimated glomerular filtration rate (eGFR) x 3 = maximal allowable contrast dose (MACD). We have one physician who prefers a stricter control of contrast dose and he uses the formula eGFR x 2 = MACD.

Are you tracking the incidence of contrast-induced acute kidney injury in patients?

We are tracking patient renal function through pre-procedure and post-procedure lab work. Our nurse navigator reviews patient lab work and does follow-up calls three days post procedure.

How are you recording fluoroscopy times/dosages?

Fluoro time in minutes and radiation dose in mGy are documented in our CVNet (Cerner) documentation system on procedures done in the cath lab.

What is the process that occurs if a patient receives a higher than normal amount of radiation exposure?

When a patient receives >60 min of flouro time or >5000 mGy of radiation, a report is filled out and submitted to the radiation safety department for follow-up. The radiation safety officer communicates to the attending physician of the procedure, who is then responsible for patient notification and follow-up.

Who documents medication administration during the case?

During the case, the circulating RN communicates all medications administered to the monitor person for that case, who may be an RN or RCIS. The monitor person verbally confirms the medication with the RN and documents in the CVNet. At the end of the case, the circulating RN and the monitor person review and confirm given meds and doses to ensure accurate documentation.

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

EUHM cardiologists use a structured reporting tool application by Cerner for electronic health record.

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

Yes, we use the ACC-NCDR’s CathPCI registry and also participate in the Society for Thoracic Surgeons (STS)/ACC Transcatheter Valve Therapy (TVT) registry.

How are you populating the registry data records?

Emory employs a nurse who does the cardiovascular data entry.

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

As part of the Emory Healthcare Network with seven hospitals, 200 provider locations, and over 1,800 physicians in more than 70 specialties, Emory has patients from all over Georgia. There are also physicians in Florida, Alabama, Tennessee, and the Carolinas who routinely refer high-risk patients to Emory, expanding our referral network to the entire Southeast. We have even received pregnant women from South America who suffer from critical valve disease and require the availability of innovative structural heart care as well as high-risk neonatal care during and after a C-section. Emory Healthcare and Kaiser Permanente have an alliance.

How are new employees oriented and trained at your facility?

The nurses and RCIS technologists are placed with a preceptor for 90 days to 6 months, individualized depending on their needs and prior experience. They also have one to two weeks of general hospital orientation if they are new to Emory. Each preceptor/preceptee team meets with the nurse educator weekly to discuss their progress, goals, and needs.

The nurse educator, preceptor, and preceptee must all agree that a staff member is ready to function independently prior to ending orientation, and the preceptor is still available as a mentor once the formal orientation period is over. Since we are hiring nurses without a critical care background, we are partnering with the CCU for these nurses’ orientation. Our new nurse educator works with vendors to provide both on and off campus training.

What continuing education opportunities are provided to staff members?

Emory sponsors many annual conferences that are free to Emory employees, including the Women and Heart Disease Conference, Emory Practical Intervention Conference, Southeastern Pulmonary Embolism Conference, and Emory Symposium on Coronary Atherosclerosis Prevention. The cath lab also has a generous education budget and pays for staff to attend out-of-town conferences such as the Transcatheter Cardiovascular Therapeutics (TCT) conference, Transcatheter Valve Therapies (TVT) Structural Heart Summit, and the Society for Cardiovascular Angiography and Interventions (SCAI) Scientific Sessions.

Are your clinical and/or managerial team members involved with any professional organizations that support the invasive cardiology service line, such as the Alliance for Cardiovascular Professionals (ACVP) or regional organizations?

Some of our RCIS staff are members of ACVP and many of our nurses are members of the American Association of Critical Care Nurses (AACN). One of our RNs serves on the board of directors for the Atlanta Area Chapter of AACN.

How do you handle vendor visits to your lab?

The vendors schedule lab days with the clinical nurse educator. Vendors are allowed in the cath procedure room only with the attending cardiologists’ permission. Each vendor representative pre-registers with Emory, and provides their credentials and documentation of a TB test and flu shot updated annually. Each time they visit the lab, they check at a vendor kiosk and print a picture ID badge with the date, vendor’s name, and name of the physician they are here to see if applicable, then check in at the cardiology reception desk. The vendors provide valuable resources to physicians and staff.

How is staff competency evaluated?

Our new clinical educator is in the process of reviewing how we handle competency check-offs. In the past, staff competency check-offs were done on a Saturday with vendors educating staff on their equipment. The nurse educator is planning on competency evaluations being performed throughout the year, utilizing staff trained as super users to educate their peers and perform check-offs focusing on a different competency each month.

Does your lab have a clinical ladder?

Emory has a system-wide nursing multi-tiered lattice system (called the PLAN). Nurses are able to advance in the PLAN by submitting a portfolio with projects, CEUs, and elective activities to the PLAN council. The clinical ladder for the cardiovascular Technologists is cath lab-specific, and has 3 levels based on degrees held and years of experience.   

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?

All of our cardiovascular technologists are required to be RCIS certified and do not receive a bonus for certification. RNs are not required to be RCIS certified, but some of them choose to. RNs are eligible for one certification bonus annually that is not specific as to type of certification. Currently, four of our RNs are RCIS certified and two of our RNs are CCRN certified.

Does your lab have any physical (layout) challenges?

The Cath Lab at EUHM has an efficient layout with no physical barriers. COA, which is our pre and post area, is next door to the labs and includes 3 PACU rooms. The ED is four floors below the cath lab and the helipad is on the roof above the lab. The ED, cath lab, and helipad are connected by an emergency elevator that requires badge access. The CCU and cardiology floor are on the same floor as the cath lab.

What do you like about your department’s physical space?

The labs at EUHM are large and travelers often comment that they are larger than other labs in which they have worked. In the Philips Azurion hybrid labs, we have screen savers that can be changed to different scenery with sound to promote a calm atmosphere.

Is there a particular mix of credentials needed for each call team? Are staff permitted to leave early or start later after a night of on-call?

We have a 4-person call team. The team is made up of 2 RNs and 2 RCISs (an RN who is RCIS-trained may fill this spot if needed). If the team is called in after midnight they have the option to come in as late as 11am the next day. Staff are allowed to leave early as well, schedule permitting.

How does your lab schedule team members for call?

The cath lab manager generates the schedule every month. Each staff member is given a blank schedule to fill out their preferences. It includes requests for days off each week and call days. The senior nurse manager then makes the schedule, accommodating as many requests as possible.

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

Three staff members are required to arrive for a callback within 30 minutes. The team member who is listed as “backup” is allowed 45 minutes to arrive. This “backup” allows some of our team members to spend an extra night or two at home each month.

Do you have flextime or multiple shifts? How do you handle slow periods?

We have shifts starting at 06:30, 07:00, and 07:30, and ending at 16:00, 17:30, and 18:00.  If we do not have many cases, staff who volunteer to flex off have the choice of either using their paid time off or not.

Do staff members have any little perks that you might like to share?

Staff who stay late to finish scheduled cases are given a free meal voucher for the hospital cafeteria. On “fun day Mondays” there are food trucks outside the hospital and twice a week there is a farmer’s market in the hospital lobby offering fresh vegetables.

Our minimum callback is 4 hours, so even if you are not here long, you get paid 4 hours at time and ½. The department provides private, on-site on-call rooms with a queen size bed, large refrigerator, flat-screen TV, microwave, coffeemaker, large bathroom, and shower.

Has your lab recently undergone a national accrediting agency inspection? Do you have any recommendations or advice?

EUHM just went through a Joint Commission inspection in September 2018. Joint Commission focused on:

• TIME OUT: Make sure no one is moving or talking during the TIME OUT.
• Ensure that narcotics are counted and wasted as dictated by your policy.
• Make sure every staff member’s orientation, educational records, and proof of licensure are maintained.

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

We are doing more structural heart procedures and high-risk PCI with ventricular support. Extracorporeal membrane oxygenation (ECMO) procedures are becoming more common in the cath lab rather than going to OR.

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

Our cath lab staff is innovative because we hire RCIS team members right out of school. We have partnered with Gwinnett Tech Invasive Cardiovascular program to provide preceptorship for their students to enhance their learning and educational experiences. Our lab is willing to take nurses without ICU or CCU experience, and new graduate RNs. We will provide them critical care courses and partnership with a CCU nurse for hands-on critical care experience.   

Is there a problem or challenge your lab has faced?

The ongoing challenge that we face, like many cath labs, is finding qualified staff members. It is very challenging finding nurses with cath lab experience or finding nurses willing to be on call. We addressed the problem by hiring staff with no experience and training them on the job. The cath lab manager, electrophysiology lab manager, COA manager, and nurse educator have a weekly meeting with the recruiter to  go over new applications and place the applicants with the correct manager for an interview.   

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”?

Atlanta (ATL) is the birth place of Martin Luther King, Jr. ATL is also the only city in the nation where you can view two Nobel Peace Prizes: one in the Martin Luther King Center and the other in the Jimmy Carter Center. EUHM is within walking distance of the Fabulous Fox Theatre (where Prince did his last performance), the Georgia World Congress Center, State Farm Arena, and Mercedes Benz Stadium. We are the home of the Atlanta United Major League Soccer (MLS) 2018 Champion, and host to the 2019 Super Bowl LIII, The World of Coca-Cola, and Georgia Aquarium. The “HOT ATL” is a sophisticated, cultural, exciting (and pricey) place to live.

A question from the American College of Cardiology’s National Cardiovascular Data Registry:

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

We use data from the NCDR CathPCI registry to provide patient-level data to our interventional cardiologists. These data are reviewed at our monthly cath lab quality meetings and guide decisions regarding processes for quality improvement. The quarterly outcomes reports are used to track the effects of these changes, particularly the risk-adjusted metrics. The quarterly outcomes reports are shared with hospital leadership and all of our interventional cardiologists. 

The authors can be contacted via Anthony Renrick at anthony.renrick@emoryhealthcare.org.