Behind the Scenes: The Genesis Medical Center Cardiac Cath Lab

Genesis Medical Center Cath Lab, located in Davenport, Iowa, is well-known to most large research networks in the country, including the Duke Clinical Research Institute, Harvard Clinical Research Institute and the Cleveland Clinic Cardiovascular Coordinating Center. Research has been conducted through Genesis Medical Center since 1990, with a formal department formed in 1997 by Dr. Michael Giudici (Electrophysiology and Chairman of the Genesis Heart Institute Research Committee) and Dr. Nicolas Shammas (coronary and peripheral) and Steve Fish, former executive director of the Genesis Heart Institute. Several other clinical investigators have since joined the laboratory, including Drs. Blair Foreman, Kent VanWhy, Eric Dippel, and Peter Sharis. Over 30 clinical trials are currently being conducted in the lab, with patients recruited from over 8000 procedures performed yearly by 16 cardiologists. Some of the currently ongoing trials include: TITAN, JUMBO, XaNADU, SYNERGY, SPIDER, INFLAME, ELECT, COURAGE, CHARISMA, ADVANCE MI, FINESSE, PREVENT and others. The Genesis Heart Institute web page is a resource to ongoing activities in the medical center and the cath lab (www.genesisheart.com). The success of the research program in the cath lab is largely attributed to its relentless and dedicated staff, and to our team of experienced research coordinators. The Basics: Staff & Procedures The Genesis Medical Center cath lab has six procedure rooms. Four are designated for cardiac diagnostic and interventional procedures, including peripheral cases, and two are designated for electrophysiology procedures. We also have a 6-bed holding area for pre and post procedure use. Our staff includes: 1 Nurse Manager Our CCL nurse manager oversees all aspects of the cath lab, including budget management, supply management, staffing levels and scheduling. 24 registered nurses (equaling 19.9 FTE) with position posted for growth. 15 radiology technologists, registered (equaling 13.4 FTE) with position posted for growth. 1 unit secretary 2 unit helpers We perform in the range of 600 to 900 procedures each month, with an average of 746 cases. The cath lab performs the following procedures: Diagnostic coronary angiography Right heart studies Percutaneous coronary interventional procedures, including: drug-eluting stents (DES), Rotablator® (Boston Scientific, Maple Grove, MN), AngioJet® (Possis Medical, Inc., Minneapolis, MN), atherectomy, and the Cutting Balloon (Boston Scientific). Coronary intravascular ultrasound studies (IVUS) Brachytherapy (gamma) Intra-aortic balloon pump (IABP) insertion Pericardiocentesis Valvuloplasty Patent Foramen Ovale (PFO) closure Diagnostic peripheral angiography Percutaneous transluminal interventional procedures (peripheral) Renal angiography with intervention Electrophysiology studies (EPS) Intra-cardiac defibrillator (ICD) insertion (including bi-ventricular) Permanent pacemaker (PPM) insertion (including bi-ventricular) Lead extraction for both ICD and PPM. Radiofrequency ablation (RFA) Tilt tables Temporary pacemaker insertion (TPM) With the comprehensive services provided by Genesis Medical Center, all angioplasties are performed with surgical backup. We have 5 cardiovascular surgeons to cover all unscheduled cases. Staff Functions & Development The CCL department is staffed from 0600 to 2330, Monday through Friday. After that time, we rely on the on-call staff. Staff has staggered shifts, starting at 0600, 0630, 0700, 0830, 1300, and 1500. The staff works 8, 10 and 12-hour shifts in order to keep labs open until 2330. Our nursing staff and RT(R)s are cross-trained. The RN is responsible for the patient care as the nurse in the lab, and the RT(R) is responsible for the x-ray role in the lab. Each procedure has 5 job positions. During the procedure, we have 3 to 4 staff members responsible for the patient’s care while in their single or dual role, with teamwork the top priority for patient care. During the course of the week, staff is rotated through each role, offering continued competency. This also provides staff with versatility in their day. Our on-call teams consist of 2 RNs and 2 RT(R)s. We have a team on call every weekday with a rotation on weekends. On-call staff begins call after the last procedure is completed until 0630 the next morning. For registered nurses, Genesis has a Professional Development program: Clinical Nurse Level I - designated as the registered nurse beginning orientation at Genesis Medical Center. Clinical Nurse Level II - a registered nurse who has completed orientation and validated the competencies required for his/her patient care area. Clinical Nurse Level III - a registered nurse who has at least two years clinical experience and certification in his/her area of specialty or a baccalaureate degree in nursing. This level of clinical nurse, demonstrating leadership and coordinated care for patients, is seen as a resource for new staff. Clinical Nurse Level IV - has a baccalaureate degree in nursing as well as a master’s degree (or is in active pursuit of master’s degree). The CN IV is accountable for additional role responsibilities in research, quality and education not only with his/her patient care area, but also within the hospital. Continuing Education. The hospital also provides a wide variety of continuing education. The Genesis Heart Institute cardiologists conduct four annual conferences, focusing on acute myocardial infarction, peripheral vascular intervention, cardiac nursing and general cardiology all available to the cath lab staff. In addition, the cath lab vendors offer education for new products and devices. The Cath Lab Practice Council organizes a day-long Cardiovascular Interventional Symposium dealing with a wide range of cardiac educational issues. New Staff Members. We have an 8-week preceptor orientation for new staff. The first two weeks are dedicated to the RN or x-ray circulator. This is followed by two weeks at scrub and two weeks at the recorder positions. The last two weeks are used for follow up and cross-training to the electrophysiology or the interventional side, depending on the new staff person’s main focus. After the new staff has completed orientation, a resource person is available for questions. Unit-specific competencies are completed within 6 months and continuing education is offered for low frequency competencies, new devices and research items. The Nuts & Bolts: CCL Equipment The Genesis cath lab recently completed a renovation, and we now have 3 GE Innova (Waukesha, WI) flat panel labs, a Philips Lab (Andover, MA), 1 biplane lab for complex EP procedures and one lab strictly for EP procedures. The cath lab went from cine film storage to CD storage, and we have currently signed a contract with Agfa (Ridgefield Park, NJ) for a Picture Archiving and Communications System (PACS) for short and long-term storage. We received the Cypher sirolimus-eluting stent in April 2003 (Cordis Corporation, Miami Lakes, FL). Currently, our patient demand outnumbers our supply. Since December 2001, we have also utilized: WaveWire (Jomed, Rancho Cordova, CA); Carto EP Navigation System (BioSense Webster, Diamond Bar, CA); Chili catheters (Cardiac Pathways, Sunnyvale, CA); Brachytherapy [Cordis Checkmate system (gamma)]. Cardiologists also have a choice of closure devices. Both collagen plug and suturing devices are available, along with the new Clo-Sur Pad from Medtronic (Santa Rosa, CA). At this time, we use the Perclose Closer S (Abbott Vascular Devices, Redwood City, CA) in almost 90% of our cases. Vendors are scheduled in advance through the manager or contract specialist. Business partners are allowed to come in once a month. Other vendors visit once every other month by appointment only. Inventory Management The cath lab has a dedicated Contract Specialist and a Distribution Tech. The Contract Specialist negotiates all supply contracts and capital budget acquisitions. The Distribution Tech stocks supplies in designated supply rooms. The Contract Specialist determines supply levels based on utilization. We have a Cost Task Force (comprised of physicians, CCL Administration and the Contract Specialist) that meets monthly to evaluate new products. The majority of the inventory in the department is consigned. This allows our physicians freedom of choice. Occasional bulk purchases are negotiated (especially on ICDs & pacemakers), which allow us additional savings. All inventory is managed on a just-in-time basis through an integration between our Witt hemodynamics system (Melbourne, FL) and the hospital’s Lawson accounting/inventory system (St. Paul, MN). (This also serves as our patient charge interface.) Pre-set levels in Lawson (done by the contract specialist) eliminate the need for daily manual ordering. All ordering is automatic. The Witt system also has bar code scanning that allows us real-time inventory management. Minor equipment and capital purchases are handled via the hospital’s protocols and are based off a pre-approved budget.

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