Baylor Jack and Jane Hamilton Heart and Vascular Hospital

What is the size of your cath lab facility and number of staff members? Baylor Hamilton Heart and Vascular Hospital is comprised of five cardiac suites, one cardiac/peripheral suite, and one endovascular suite. We are in the process of renovating one of the cath lab suites, which will function as a combo cardiac/peripheral suite. Baylor Hamilton Heart and Vascular Hospital’s cath lab has a combination of registered nurses (RNs), registered cardiac invasive specialists (RCISs), and radiologic technologists (RTs). We have a total of 38 staff: 21 RNs (12 full-time, 2 part-time and 1 PRN), 7 RCISs (5 full-time, 1 part-time and 1 PRN), and 10 RTs (8 full-time, 1 PRN and 1 team leader). Our team members have an array of length of experience, ranging from one to thirty years. Our electrophysiology (EP) department has a dedicated staff that operates independently from the cath lab. Our hospital consists of cardiologists and vascular surgeons. Each physician group has their own patient mix. They do consult with one another if assistance is needed from the other specialty. Baylor Hamilton Heart and Vascular Hospital is a teaching hospital with cardiac and vascular fellows participating in procedures. The cardiology fellowship duration is three years with two fellows accepted into the program each year. We do have a cardiology interventional fellowship, which consists of one fellow for an additional year. Our vascular surgical fellowship is two years, with two fellows accepted per year. What type of procedures are performed at your facility? Cardiac: Right and left diagnostic cardiac procedures, percutaneous coronary intervention (PCI) procedures (balloon/stent), rotational atherectomy, intravascular ultrasound (IVUS), endomyocardial biopsies, atrial septal defect (ASD) and patent foramen ovale (PFO) closures, septal ablations, valvuloplasty and intracardiac echocardiography (ICE). Peripheral: Diagnostic procedures, percutaneous transluminal angioplasty (PTA), stenting (including carotid stenting), atherectomy, endograft repair — both abdominal and thoracic, and inferior vena cava (IVC) filters, both bedside and in the department. During the 2008 fiscal year, we performed 5,749 cases, broken down as follows: • Cardiac diagnostic cases: 2,421 • Cardiac interventional cases: 1,450 • Diagnostic peripheral cases: 351 • Peripheral interventional cases: 610 • Peripheral diagnostic w/ cardiac procedures: 917 Does your cath lab perform primary angioplasty with surgical back up on site? Yes, we are connected to the main Baylor University Medical Center at Dallas campus. A room and team are available 24 hours a day, 7 days a week. What procedures do you perform on an outpatient basis? The majority of our scheduled procedures are on an outpatient basis. Endograft repair and carotid stenting remain on an in-patient basis. What percentage of your patients is female? Forty-two percent of our patients are female. What percentage of your diagnostic cath patients go on to have an interventional procedure? The total number of diagnostic coronary angiography cases having interventions in same visit to the lab was 39.1%. Who manages your cath lab? Andres Sisneros, RT(R), manages our lab. He has been the cath lab and imaging manager/team leader since October 2005. Prior to becoming our team leader, Andres was part of our staff, starting his career at Baylor in 2000. Andres has been in the cardiology field since 1993. He reports to Nancy Vish BSN, MSN, PhD, President and Chief Nursing Officer of Baylor Jack and Jane Hamilton Heart and Vascular Hospital. Do you have cross-training? Who scrubs, who circulates and who monitors? We operate with a three-person team per room. The RN circulates while the other two team members scrub and monitor. All RCISs and RTs will scrub and monitor. The RNs do have an opportunity to learn all three roles in the lab. Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab? Not necessarily in the room, but we have 9 full-time RTs in the cath lab. Texas does require an MD or an RT to administer ionizing radiation. The majority of our MDs prefer to operate the fluoro and panning of their images. We do have a couple of physicians that prefer the staff to pan. All of our personnel can operate the table (panning) and monitoring equipment. What are some of the new equipment, devices and products introduced at your lab lately? We upgraded both of our Volcano IVUS units (Rancho Cordova, CA) with Virtual Histology and fractional flow reserve. Our FoxHollow atherectomy devices (Redwood City, CA) now have new and improved sizes for distal vessels. We have the Diamondback, which is another type of atherectomy device used for distal vessels (Cardiovascular Systems, Inc., St. Paul, MN). We also began performing the TandemHeart (CardiacAssist, Inc., Pittsburgh, PA) procedure in 2008. This is a percutaneous ventricular assist device, which is an adjunct for patients needing heart transplants. Impella Proforma is a new product from Abiomed (Danvers, MA), which is a percutaneous cardiac assist device. Can you describe the system(s) you utilize and how they work in cath lab daily life? Our cath lab uses a hemodynamic system by Mennen Medical (Horsham, PA), used for recording pressures and documenting cath lab and vascular procedures. The TCS Symphony is our cardioPACS (picture archiving and communication system) system, a McKesson product (San Francisco, CA) that we use to store our DICOM (Digital Imaging and COmmunications in Medicine) images. The TCS is used to obtain digital images from the DICOM-enabled angiographic systems, and analog images from the legacy systems. Meditech (Westwood, MA) is an integrated healthcare information system allowing the hospital to interface clinical, administrative, and financial processes. Apollo is a Lumedx (Oakland, CA) product used in our cath lab, as well as across the entire healthcare system. It is a data repository for cardiovascular information. With Apollo, we are able to look up any previous procedures to see what equipment the physicians used during the case. We are also able to pull data for our American College of Cardiology (ACC) database reporting. Other statistical reports can be pulled to provide data on equipment utilization such as case, staff, and physician statistics. In addition, our department has 2 GE suites (Waukesha, WI), 3 Philips cardiac suites (Bothell, WA), 1 Philips cardiac/peripheral and 1 Philips endovascular suite. How is coding and coding education handled in your lab? One of our RTs, Leigh Ann Dibble, has become a certified interventional coder to aid with the changing world of peripheral procedures. We also have 3-4 hospital coders in our HIM (health information management) department. Different vendors offer in-services and updates once or twice each year. How does your lab handle hemostasis? We use vascular closure, manual compression and c-clamp. Our facility has two outstanding recovery rooms for post vascular procedures. We have dedicated recovery room staff that pull sheaths and recover the patients until time to transfer to their private patient room. This prevents any delays and allows the cath lab staff to continue with procedures. In October 2006, we changed our practice of sending all post-cardiac patients with closure devices to recovery. Instead, we began sending them directly from the cath lab suite to their room for discharge 2-3 hours later, depending on physician orders. What is your lab’s hematoma management policy? We call the physician and report the size of the hematoma. Bleeding is managed by holding pressure over the site until hemostasis is achieved, applying a HOLD (Hemostatic Occlusive Leverage Device, Pressure Products, Inc., San Pedro, CA) to the site. How is inventory managed at your cath lab? We have an inventory supply manager who manages all cath lab and EP inventory. Has your cath lab recently expanded in size and patient volume? We have recently renovated our endovascular suite and are now in the process of renovating one of the cath labs into a combo cardiac/ peripheral suite. Is your lab involved in clinical research? We are currently participating in several studies: CORAL is a renal stenting trial (a NHLBI-sponsored study to assess the benefits of renal artery stenting when added to medication therapy for patients with uncontrolled hypertension). EVALVE is a mitral valve clip trial which was recently completed. EVEREST II is a trial comparing surgical valve repair to percutaneous clip repair for patients with severe mitral regurgitation. The ACCESS/PFO registry is a study to close PFOs in patients with two or more cryptogenic strokes. ESCAPE is a study to determine if patients with a PFO and migraine headaches benefit from placement of an interatrial septal closure device. VIPER is a study of an endoprosthesis with a heparin bioactive surface for the treatment of peripheral arterial disease. ABCD is a study of same-day discharge for patients after having angioplasty or a coronary stent. GRAVITAS is a study comparing clopidogrel doses to limit late stent thrombosis. RECOVER II is a study in which patients diagnosed with acute myocardial infarction (AMI) are randomized to an intra-aortic balloon pump (IABP). PROTECT II is a study in which high-risk PCI patients are randomized to an IABP. All of the research and clinical trials performed at Baylor Hamilton Hospital can be found on our website: www.baylorhearthospital.com Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? In the past 12 months, we have had one complication that resulted in surgical intervention. What other modalities do you use to verify stenosis? We use the Volcano IVUS and FFR (pressure wire). It has not really affected our operating cash flow, because not every lesion requires the use of IVUS. What measures have been implemented to cut or contain costs? We have a multi-disciplinary Procurement Committee that negotiates with product vendors. This system-wide committee meets with vendors once a month for presentation of new products and equipment. After the procurement meeting, the committee meets with physicians and uses majority voting to decide on product approval. What type of quality control/quality assurance measures are practiced in your cath lab? We run daily controls on our Avox (Avox Systems, Inc., Fair Oaks Ranch, TX) and I-Stat machines (Abbott Laboratories, Abbott Park, IL), which we utilize for blood specimens. We have yearly skills check-offs on equipment such as IABPs, rotablator, IVUS, etc. Our nurses and technologists are required to take yearly written cognitive exams regarding moderate sedation, IABPs and catheterization lab emergency protocols. Our staff performs monthly audits on epidemiology, time-out verification and two-patient identifier. Several committees manage quality control and quality assurance: The Clinical Practice Committee is comprised of direct care clinicians and administrative personnel who discuss established and emerging clinical topics that affect patient care. The Standards and Measures Committee reviews the Press Ganey Scores obtained from patient surveys and discusses ways to help improve hospital survey outcomes. The AMI (Acute Myocardial Infarction) Committee is a house-wide committee to ensure the 90-minute door-to-reperfusion time is met. This committee also reviews processes for quality improvement for AMIs. The Professional Development (Education) Committee is a hospital-wide committee ensuring all employees are educated and updated on procedures, equipment and new hospital policies. STARRS (Service, Training, Accountability, Recruitment, Retention and Satisfaction) is comprised of medical as well as ancillary staff. How does your cath lab compete for patients? We became a Magnet facility in 2007. Also, the 75-plus research trials in which we are involved separates us from the other facilities within our metro area. We lead regional hospitals in outcome data and rank equally with nationally renowned organizations on quality measures. In Press Ganey, we rank 96% among inpatient and outpatient satisfaction. Baylor Hamilton Hospital has an arrangement with several outlying hospitals and two local flight services to bring all AMI patients directly to the cath lab. The outlying hospital activates the cath lab call team and the interventionalist on call. How are new employees oriented and trained at your facility? All staff members are required to have and maintain basic life support (BLS) and advanced cardiac life support (ACLS) certifications. Each new member is assigned a preceptor, receives an orientation manual and attends an 8-10 week critical care internship (this also includes the technologists). The training process takes anywhere from 6–12 weeks, depending on previous cath lab experience. We require all employees have one of the following licensures: RN, RCIS or ARRT. What type of continuing education opportunities are provided to staff members? We have a group education committee, which consists of an RN, RCIS and RT. These staff members arrange for CEU in-services on the fourth Tuesday and last Friday of each month. We also have staff meetings every Tuesday morning. In August of each year, our team leader, Andres Sisneros, organizes a cardiovascular symposium specifically aimed at cath lab professionals. In 2008, this symposium had just over 700 attendees. The volunteers consist of our staff members and the speakers are mostly physicians from Baylor Hamilton Hospital. This past August was our twelfth year for the symposium. It is quite an educational and entertaining event, definitely worth the trip to Dallas. The Cardiovascular Symposium 2009 will be held August 15th at Southfork Ranch, Plano, Texas. How do you handle vendor visits to your lab? Vendors must schedule their time in the lab with our inventory supply manager. Vendors are in the lab for 1-2 weeks for evaluation of new products. If a physician requests a vendor be present, the vendor must stay in the scheduled room until the case is finished. Consignment product vendors are given one scheduled day in the lab to inventory their product, and update staff and physicians as needed. During our annual cardiovascular symposium, we have a contest for vendor participation. The vendor who wins receives an extra day in the lab. How is staff competency evaluated? Annual skills are evaluated with an equipment skills check-off, done with our vendor representatives and staff members who are super trainers. Annual testing includes IABP testing and moderate sedation testing (required by both nursing and non nursing staff members). We also have bi-annual testing of mega code (ACLS skills). Does your lab have a clinical ladder? We do have a clinical ladder program, created to recognize our team members and their unique contributions to patient outcomes. The program distinguishes clinical practice as the integration of knowledge, skills, experience and attitudes, that when linked to patient needs and characteristics, creates a synergistic process resulting in safe passage and optimal outcomes. Bonuses are allocated to those who participate in this program. Does your lab utilize any alternative therapies (such as guided imagery, etc.)? Baylor Hamilton Hospital has a Healing Environment program, which offers video and audiotapes, a 24-hour relaxation TV channel, and aromatherapy. For any patient or family member who requests it, our chaplain will visit with them and provide spiritual guidance. How does your lab handle call time for staff members? We have 7 call teams with 4 people per team. Call is one day each week and one weekend every 7 weeks, leaving two weeks with no call. Within what time period are call team members expected to arrive to the lab after being paged? We have a 30-minute response time. The attending cardiologist is not always on site, so the nursing floor at Baylor Hamilton Hospital activates the cath lab and the interventionalist simultaneously. Do you have flex time or multiple shifts? We have a 7:00 am–5:30 pm shift in which we work four 10-hour days with one day off each week. Our staff also rotates through a 7:00 am–3:30 pm Monday-Friday shift with no call during that week. Does your cath lab do electives on weekends and or holidays? No elective cases are scheduled on the weekends. Emergent cases during the holiday are covered by on-call staff. Has your lab undergone a Joint Commission inspection in the past three years? We underwent our last inspection in January 2008. While in the cath lab, Joint Commission focused on time outs, clinician-to-clinician hand offs, continuum of care, signed orders and two patient identifiers. Where is your cath lab located in relation to the operating room (OR) and emergency department (ED)? The cath lab is located 3 floors up from the ED and 1 floor up from the OR. We have a dedicated elevator from the ED and a very close service elevator to the OR, with alternative access to the ED. What trends do you see emerging in the practice of invasive cardiology? Left main stenting, new technologies with cardiac assist devices and percutaneous mitral valve repair. What is unique about your cath lab and its staff? If you walked into our department, you would not be able to distinguish between nurses and technologists. Our department is founded on a shared governance model, which requires involvement by all team members and committees. Our facility has always operated as a Magnet facility, even before we achieved Magnet status. Is there a problem or challenge your lab has faced? Due to the dynamics of our cath lab and only having two peripheral labs, we have gone to block scheduling in conjunction with the OR to satisfy the needs of our physicians. We have also purchased an additional C arm so that we are able to accommodate more vascular procedures in our OR. 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”? Dallas is a major corridor for south Texas, Louisiana, Oklahoma and Mexico. This results in a wide range of cultural backgrounds among our patient population. We are also one of the largest volume cath labs in North Texas. 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? RCIS is not required. However, Baylor Hamilton Hospital will pay for staff members who would like to take the exam. Once staff members pass the exam, they can use it for their clinical ladder program. 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? We have some staff members who belong to the SICP. The authors can be contacted via Leigh Ann Dibble at: leighd@baylorhealth.edu.

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