Author Response

The Process of Developing Competencies for Cath Lab Skills is highly relevant from the notion of a need for practice standards, staff training and staff certification. However, though it is intriguing to think of a workplace where the docs are so busy they don™t have time to perc a groin, I suspect in reality this was one institution™s method of dealing with tardy physicians and patients waiting on the table. Our four interventionalists are certainly open to more staff participation: for example, staff members often inflate the balloon or deploy the stent, particularly when tandem stents are placed. Jackson Thatcher, MD About me and our lab: I am very new to the cath lab. It™s been two and a half years now. I originated from (strictly) CCU and then ICU. Because of my education and CCU experience, I know some things that a 14-year experienced RCIS staff member may not (patient care issues and certain medications). No name provided (RN,BSN) Our four interventionalists are certainly open to more staff participation: for example, the first question is if there is assessment performing this type of activity (perc stick). If not, it is a technical skill and can be taught to anyone. Our nursing administrator felt this was only a technical skill, but the physicians and I disagree. Nurses are trained in assessment in a formal setting. You would have to have proof of this if the staff performing this does not have formal training. I commend him for being so bold. It may not be in the gene pool like he says, but it is much easier to use a nurse because of their credentials and assessment skills. Please sign me ˜Anonymous™ I feel that after reading Dr. Thatcher™s, No Name BSN/RN™s and Anonymous™s comments that I must say something about my own and my institution™s background. I™ve been in the cath lab a little more than 25 years. I graduated from an accredited CPT program in 1976 (Grossmont College). I scrubbed my first interventional procedure in 1978 at Borgess Medical Center. This was the hospital™s first attempt at an interventional procedure (we were the fifth hospital in the nation to start performing this procedure). There were no books around at that time on this subject it was done by the seat of the pants. You can™t imagine the feeling of assisting in a case where nobody knew if the patient was going to live or die, except for Dr. Enrique Leguizamon. There were a lot of people in the control room. Chief among them were the surgeon, anesthetist, and surgical crew (who just knew we were going to kill the patient). Dr. Leguizamon was the physician who started the staff at Borgess doing perc sticks in 1982 (it was not started by our institution, as Dr. Thatcher suggested). He himself was trained by Dr. Mason Sones. Dr. Leguizamon™s been retired for ten years, but this year received an achievement award from the American Heart Association for his lifetime commitment and achievements to cardiology. I was fortunate enough to work with and be trained by Dr. Leguizamon for over 15 years. I™m also a Level-4 Senior Technologist at Borgess Medical Center in Kalamazoo, Michigan. To reach this level, I had to be evaluated by several different groups. 1. I was evaluated by physicians on my scrubbing ability and cath lab presence (ability to perform appropriately in an emergency). 2. I was evaluated by all the techs on my knowledge and abilities as a resource person. 3. I was evaluated by administration on my effectiveness as a staff person. 4. I was finally evaluated by a committee made up of an administrator, a representative from Human Resources, a nurse and several techs. The committee also evaluated me on proficiencies covering knowledge of all procedures and research trials being performed, x-ray equipment, physiologic monitoring equipment, all cath lab devices in the department, cardiac anatomy and physiology, patient assessment, perc sticks and even under the section for team player, the ability to interpret non-verbal communication (i.e., hand, eye or body language during a procedure). I™ve taught classes to nurses, techs and EMTs. I™ve trained many nurses and techs in the cath lab, and that includes teaching cath lab patient assessment. I work in a lab that last year saw over 6000 patients with a staff of less than 20 nurses and techs (about half nurses and half techs) while having 90% of the staff going home on time 99% of the time. Of these 20 staff members, we have 4 staff members who have greater than 20 years apiece in the cath lab and only two are Level-4 techs. All staff work with 16 interventionalists, 2 interventional fellows and 6 diagnosticians (who are on time as a rule rather than an exception) and are trained to assess all their patients. It™s part of the job description. All staff are ACLS certified, and are expected to overlap each other in paying attention to the patient. Now we come to the point where I disagree with the comments of Dr. Thatcher, No Name, and Anonymous. Let me repeat Dr Bernard Meier™s comment from Invasive Cardiology: A Manual for Cath Lab Personnel: It has been shown conclusively that low-volume operators produce inferior results with interventional cardiology compared to high-volume operators. It has also been shown conclusively that this deficiency is annihilated when low volume operators work in the realm of experienced catheterization laboratory, i.e., with the help of experienced catheterization personnel. I wanted to repeat this to underscore a logical end to Dr. Meier™s comment, i.e.: 1) A high-volume operator working in the realm of experienced cath lab personnel can perform the impossible. 2) An operator with a less than experienced staff may not be as successful as he may wish. In our area of southwestern Michigan, we have four labs in a thirty-mile area that perform diagnostic procedures. Two perform interventional and surgical procedures, and have been in operation the same amount of time. Our cardiologists and surgeons have privileges at both of these hospitals, yet the Borgess cath lab performs three times the number of cases. You can™t blame this discrepancy on the physicians they™re at both hospitals. I have to conclude that it has to do with the cardiac care that the patient has come to expect from one hospital over the other. I™ve seen patients leave a particular physician because of questions of quality of care, yet keep coming to Borgess because of the level of care they™ve come to expect from our institution. Dr. Thatcher states that there is a verbal contract between himself and the patient and he™s absolutely correct. However, there is also a contract between the hospital and staff with the patient that we will give him the best level of care possible. That includes good levels of communication between staff who are sending and receiving the patient, and cath lab staff whose duties overlap, to keep some important piece of data from falling thru the gaps. This lack of standard stirs GREAT CONCERN within me. Luckily, our lab works very well together everyone does everything (from x-ray to medication administration). Perhaps it is that everyone respects each other™s origins and background and freely consults each other. Perhaps it is that everyone respects each others origins and background and freely consults each other. Because of my education and CCU experience, I know some things that a 14-year experienced RCIS staff member may not (patient care issues and certain medications). In the same regard, that same staff member (who also has radiology experience) knows MUCH more about how a cath lab flows and information related to x-ray. Nursing does have a standard of care. I don™t know what the other disciplines (RRT/RCIS/Rad Techs) teach. With this mix of disciplines coming together to perform a function (the cath lab) it is alarming to me (coming from a standard of care mindset) that there hasn™t been progression in this area. No name provided (RN, BSN) I used perc sticks as my article topic, but it could have been any subject related to cath lab standards. You don™t consult someone to get the job done you ask, you get training, and you learn, so that all staff gradually start working on the same page in regard to patient care. In the last ten years, our hospital has made a big effort to acquire experienced staff when an opening became available. We acquired RNs, x-ray techs and RCISs. We acquired one nurse from Texas who is great. She can scrub, monitor and has a great background in teaching. One x-ray tech with 17 years in x-ray and 9 years in a cath lab couldn™t tell v-fib from NSR. When asked why he didn™t see the v-fib, he stated that he™d been trained to scrub and didn™t care what happened on the other monitor (he™s no longer with us). One x-ray tech came to us with two years cath lab experience. We found out when she got to us that all her cath lab time had been spent setting up trays, and she didn™t know an EKG rhythm from a pressure tracing. We also just welcomed an RCIS with seven years cath lab experience. He was the senior tech in his lab in knowledge and age (37). He is good but discovered that he still wasn™t up to our standards (but is getting there very quickly because of his desire to learn). He also discovered he was now our most junior staff member in knowledge and age (he™s still 3 years younger than our next youngest staff member). People who work in a cath lab and state it as a definer of their job skills must be able to pass competencies for those particular jobs listed in a cath lab. For example, the position of a monitoring person should be able to pass competencies in EKG, coronary anatomy, cardiac hemodynamics, x-ray operation, medications, data analysis (EF, valve areas, stenosis analysis, digital subtraction, etc.), and procedural supplies (being able to look at a monitor and be able to tell the difference between an AR-1 and a JR-4 makes for less need of communication and delay of a procedure). There are distinct responsibilities applied to all three primary cath lab positions (scrub, circulate and monitor) and all labs should be able to break these responsibilities into specific responsibilities to that position. DNA and the Medical Profession: Being trained in school is recognized in our society as an accomplishment. With this accomplishment comes responsibility and the privilege of performing certain tasks. No one is dismissing experience in a particular field. No name provided (RN, BSN) Dr. Judkins was a trained radiologist and is considered one of the fathers of modern cardiology. No name, you are dismissing experience and knowledge acquired outside of school, and that is one of the main reasons for the degree of disharmony seen in many cath labs. Outside of certified RCIS schools (and maybe a few RT programs developed to train people into cardiology), there are no schools to prepare individuals to work in the cath lab. When an RN, x-ray tech or a new RCIS come into the cath lab, they are exposed to a totally new field where the skills of many separate professions are melded into a new skill, called a cath lab professional. As long as people keep wishing to stay only a nurse or only a tech, and are unwilling to learn and develop new skills, then you™re going to have a less than experienced staff. If all staff can develop competencies agreed to by physicians, administration and staff as gold standards for specific job positions (scrub, circulator and monitor), and are all allowed to perform those assigned skills, then you are on your way to an experienced staff that can annihilate inferior results.

NULL