Botsford Hospital

What is the size of your cath lab facility and number of staff members? We currently have one cath lab with a nurse manager, five registered nurses (RNs), one cardiovascular technologist (CVT)/registered cardiovascular invasive specialist (RCIS) and one special procedure room (SPR) technologist. Staff experience ranges from less than 1 year to just over 20 years. Our cath lab is utilized by approximately 10 cardiologists, four interventional radiologists and two vascular surgeons. In addition, we have a four-bay holding area where patients are both prepped and recovered. The cath lab became functional in 1987 and was the first cath lab at Botsford Hospital. It was instrumental in bringing cardiology to the hospital and, eventually, the emergent angioplasty program. What types of procedures are performed at your facility? We perform cardiac catheterizations, pacemaker implants, internal cardiac defibrillator implantation, cardioversions, primary (emergency) angioplasty and radiology services including angiograms, vascular surgeries, filter placements, long-term catheter placements, and peripheral angioplasties for a variety of patient diagnoses and syndromes. We perform approximately 25 to 30 different procedures per week, but that number can vary greatly. We have often done nine or 10 cases in a single day. Does your cath lab perform primary angioplasty with surgical backup? We perform primary angioplasty without surgical backup. We contacted the State of Michigan for the necessary Certificate of Need and received it in the fall of 2005. Our staff was sent to our sponsor hospital for necessary training and experience. We opened officially in November of 2005 for emergent cardiac angioplasty. What procedures do you perform on an outpatient basis? We perform many procedures on both an inpatient and outpatient basis. We perform diagnostic cardiac catheterization, heart biopsy, some radiology procedures, cardioversions, and transesophageal echocardiograms (TEEs). Some of our procedures, like permanent pacemaker implantation, require an extended recovery period and patients may get transferred to one of our nursing units for a few hours. They would then be discharged from there. Due to the high volume of patients in our hospital, the cath lab will try to recover as many short-term recovery patients as possible, and then discharge them from the cath lab. There is an exit from the hospital a short distance from the cath lab, so it is very convenient for friends, families, or EMS services to pick up the patients for transport after discharge. What percentage of your patients is female? Forty-seven to forty-eight percent of our patients are female, so generally speaking, half of our patients. We try to spend time teaching them and their families to understand that cardiac disease is not just a ‘man’s disease.’ What percentage of your diagnostic cath patients go on to have an interventional procedure and what percentage of your diagnostic caths are normal? We track these monthly for quality assurance/quality improvement statistics. Our ‘normal’ rate is below 20%, which is the benchmark we try to achieve. We send about 30% of our patients from diagnostic procedure out for interventional procedures to our sponsor hospital because we are unable to perform elective angioplasties due to state guidelines. The number of cases sent out for intervention varies from month to month. Who manages your cath lab? We have a nurse manager, Heather Glover, RN, who serves as the manager of cardiology services. At Botsford Hospital, cardiology services includes the EKG, non-invasive cardiology (cardiac stress testing), cardiac rehabilitation, cardiac catheterization and echocardiography. Glover has a Bachelor’s of Science in Nursing from Madonna University in Livonia, Michigan, and has worked at Botsford for approximately 18 years, primarily in the critical care and cardiology departments. Do you have cross-training? Who scrubs, who circulates and who monitors? The staff, both RN and technical, cross-train for the documentation role and for the circulating role. Since we are a teaching hospital, fellows and residents act as the first assistants and scrub during the cases. Often, there is one fellow assisting and a second fellow, medical student or intern observing the case. At Botsford Hospital, medications are primarily given by RNs. The only instances where the cath lab RNs do not provide sedation is during defibrillator implants. Anesthesia personnel dose sedation for ICD (internal cardiac defibrillator implants) upon specific request. At Botsford, the patient monitoring role is specifically given to an RN. A technologist can help observe the patient while circulating the room, but the RN is ultimately in charge of the patient. Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab? Not necessarily an RT, but a cath lab staff member must be in attendance if there is a case going on in the procedure room. We prefer to have someone to assist with the equipment or to help troubleshoot in case any issues or questions arise. It’s both a safety and customer service practice. 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? The attending physician or fellows will utilize the fluoroscopy foot pedal and guide the positioning of the table and the angle of the flat detector. The CVT or the SPR technologist can lend an extra set of hands to perform the positioning of the equipment or the patient. The technologist, especially the SPR technologist, can also assist newer physicians with ideas and tips to secure the best images and help troubleshoot during difficult cases due to the amount of prior experience she has in both cardiology and radiology. If your lab performs peripheral interventions, what disciplines are involved? Our lab does perform peripheral interventions on any given day. The procedures are generally performed by vascular surgery attendings with input from the interventional radiology group. The attendings are often assisted by the fellows and residents within the same discipline. In addition, the cath lab RNs and the SPR tech are involved in and can provide ancillary support during peripheral intervention cases. Interventional radiologists, vascular surgeons, and cardiologists all share the space in the cath lab and perform procedures in the area. What are some of the new equipment, devices and products introduced at your lab lately? In 2005, we purchased a Philips FD20 Allura Imaging system and the Witt (now owned by Philips Medical, Bothell, WA) Calysto Hemodynamic system. Previously, we had a Philips Integris 3000 Imaging system and a GE MacLab hemodynamic system (Waukesha, WI). Also in 2005, we began performing emergent cardiac angioplasty procedures without surgical back up. In 2007, we began inserting primarily Medtronic internal defibrillators and in 2008 we began performing biventricular pacemaker implants also using Medtronic as our primary vendor (Santa Rosa, CA). How is coding and coding education handled in your lab? How is coding communication handled with the billing dept.? Currently, we do our own interdepartmental billing and charging. All of the RNs have been trained to put in their own charges for the cases with which they assist. We work with management support, finance, and medical records for updates and coding. Communication with the various departments is handled via phone, email and face-to-face. Since we are a smaller-sized hospital, contacting the right people and resolving issues is done very quickly. Interdepartmental teams work very closely with each other and have a mutual respect for one another. It makes life much easier! How does your lab handle hemostasis? To provide hemostasis, the physicians have a choice of using Angio-Seal (St. Jude Medical, Minnetonka, MN), the Mynx device (AccessClosure, Mountain View, CA) and/or manual compression. Patients have hemostasis achieved by the physician in the procedure room with closure devices directly after the case is completed. The nurses or technologists can pull the sheath in the holding area and perform manual pressure when needed. What is your lab’s hematoma management policy? Hematomas are rare for us, but any are reviewed on a case-by-case basis with the medical director and involved staff (i.e. physicians, fellows, RNs, etc.). They fall under the heading of UPO (‘Unexpected Patient Occurrence’). We work with our quality assurance staff for medical record review and to see if any process changes or re-education is needed. How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies? At this time, we do not have an automated inventory system. During each case, all supplies used are documented and the packaging for certain supplies are saved until verified that they have been charted. All inventory, consignment and non-consignment, is handled by specific staff, primarily the SPR tech. We work very closely with our materiel management department for supplies, template updates, pricing, vendor visits, usage reports and contracts. Has your cath lab recently expanded in size and patient volume, or will it be in the near future? We have not increased in size or volume, but we have increased in product line and patient acuity. We perform many more types of cases than we have in the past and we offer more services than in previous years. Our physician base has also grown recently which has increased the variety of our cases. Recently, with the addition of the echocardiography department under cardiology services, the cath lab RNs have increased their practice to include sedation and monitoring during TEEs. Is your lab involved in clinical research? No, we are not involved in clinical research. Have you had any cath lab related complications in the past year requiring emergent cardiac surgery? No. Can you share your lab’s average door-to-balloon (DTB) times and some of the ways employees at your facility have worked together to keep DTB times under the mandated 90 minutes? Our average DTB time is about 87 minutes. Through a central activation system, our emergency department makes the STEMI diagnosis and activates the system by a one-touch icon on the computer desktop. There is a required five-minute callback time for the two cath lab RNs, a cath lab technologist, a fellow, the interventionalist and our EMS standby team. There is also a 30-minute response time for the staff to arrive into the cath lab. Hospital administration involvement, support and feedback are achieved by receiving the timing information for each primary percutaneous coronary intervention (PPCI) case 24-48 hours after the procedure. We are striving to maintain DTB times under the mandated 90 minutes for 75+% of our cases and have made significant improvements. We also work closely and maintain a strong relationship with our EMS, police and fire departments in our local and surrounding municipalities. Last year, we had an award recognition event for police staff, fire personnel and paramedics who contributed to a cardiac rescue event. It was televised locally and was a great event for the hospital and for the award recipients. We are also involved in the Blue Cross Cardiovascular Consortium (BMC2), a project that studies angioplasty care at Michigan hospitals. This is a data repository and networking group that builds relationships with other hospitals and shares strategies to improve door-to-balloon times. They meet regularly to discuss those strategies, communicate any state information that may impact the PPCI process and audit our current practice of performing PPCIs. What measures has your cath lab implemented in order to cut or contain costs? To contain, cut and control costs, we go through a standardization of supplies process almost annually. We also use consignment and specific buying groups to get the best pricing available. We utilize a steering committee to analyze the benefit and cost of any potential new products coming into the cath lab. Our medical director, Dr. Mark Rasak, is also very involved in this process of supply selection. What type of quality control/quality assurance measures are practiced in your cath lab? For the PPCI process, we closely monitor door-to-EKG time, emergency department time, cath lab time, and door-to-balloon time. We have specific benchmarks for those times and analyze each case in detail. If a certain area is out of range for the time allotted, we review the chart to find out the cause and make any changes and/or re-educate as needed. Also measured as quality control indicators are normal vs. abnormal catheterizations and complication rates. All PCI and implantable cardioverter defibrillator (ICD) patients are monitored through state requirements. We have monthly nursing quality indicator meetings, monthly chest pain center meeting reviews with the medical director of both the emergency department and the cardiac cath lab on any cases needing analysis, and quarterly meetings with our surgical back up sponsor hospital for angioplasties. How does your cath lab compete for patients? Has your institution formed an alliance with others in the area? We maintain strong relationships with community municipalities and emergency medical services. We also advertise by a variety of media outlets (newspaper, television commercials, and hospital publications). We have an alliance with our surgical back-up hospital. How are new employees oriented and trained at your facility? All new employees go through hospital orientation and nurses go through nursing orientation as well. New staff members are assigned a preceptor and are given an individualized orientation based on their needs. All team members are BLS- and ACLS-certified and licensed in their respective profession. Two staff members are BLS instructors. One person has less than one year of experience in the cath lab. Three of the four nurses came from our critical care; our newest team member came from emergency. Our CVT graduated from Carnegie Institute and has been working at Botsford ever since. The SPR tech transferred from radiology several years ago. What type of continuing education opportunities are provided to staff members? We offer monthly nurse education opportunities, tuition reimbursement for certification, and in-house and vendor in-services. How do you handle vendor visits to your lab? Vendors must check-in with the materiel management department and wear a badge. They are generally not allowed in the lab unless they are there for a specific procedure. In-services must be scheduled. ‘Walk-ins’ are discouraged, but handled politely; we make strong efforts to protect patient privacy. How is staff competency evaluated? Every fall there is a nursing department ‘mandatory marathon’ that tests staff on nursing knowledge, fire, safety, OSHA, HIPAA, patient rights, etc. In the spring/summer, there are specific competencies based on various nursing departments and the focus of those departments. All tests (excluding CPR certifications and re-certifications) are performed online, and it is required that all nursing staff pass. Performance feedback reviews are administered annually. Vendor in-services and training on new equipment and supplies are also offered throughout the year. Does your lab have a clinical ladder? Currently we do not have a clinical ladder. Does your lab utilize any alternative therapies (such as guided imagery, etc.)? We have played music during procedures to help relax patients, if that is something they would like. How does your lab handle call time for staff members? Is there a particular mix of credentials needed for each call team? We have a separate call time schedule for the radiology team and for the heart team; however, both teams are multi-disciplinary. For radiology procedures, the call team consists of one nurse and one tech. For cardiology procedures (PPCI), the call team includes two nurses, one tech and a cardiac fellow. Both also have an attending physician included. Since we are a one-lab department, the staff is smaller in number. There is a regularly rotating schedule, but staff trade and flex time with each other to maintain the work-personal life balance. Within what time period are call team members expected to arrive to the lab after being paged? For emergency cardiac angioplasties, the team members are expected to arrive within 30 minutes after receiving and calling back after the notification page. This includes the interventionalist and fellow. Team members are expected to arrive within 60 minutes for emergent radiology cases. The cardiology attending is not always on-site but has the same callback and arrival requirements as the rest of the cath lab staff. Do you have flextime or multiple shifts? We have staggered start times and encourage staff to flex their schedules as much as needed to maintain their life balance. Currently we do not have multiple shifts (just very dedicated staff)! Does your cath lab do electives on weekends and or holidays? At this time, we do not offer elective cases on weekends and/or holidays. Has your lab undergone American Osteopathic Association or Joint Commission inspection in the past three years? We did undergo an AOA inspection in 2007 with no citations. How do you see your cardiac catheterization laboratory changing over the next decade? We see the level of procedures becoming more in-depth and more technological. We also see (and have seen) the patient acuity level increase. There will be an increase in non-invasive imaging as well, and currently we are reviewing our needs for that type of modality. Please tell the readers what you consider unique or innovative about your cath lab and its staff. Our lab is unique in that we are small, but self-sufficient. We do billing, charging, supply inventory, QI, and charting, but expert, compassionate patient care and service excellence are our specialties. The staff is very dedicated to our patients and they personally make all discharge phone calls within 48 to 72 hours of procedure completion. The staff works very closely with physicians and house staff. Our staff is extremely loyal to the hospital and has a real interest in continuing to improve the cath lab. 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?” Botsford Hospital is located in Farmington Hills, a culturally diverse community in metropolitan Detroit. Detroit is known for being the home of the “Big Three” American automakers and bordering Canada. The largest employer in Farmington Hills, we take pride in working with and for the community, providing services ranging from charity care, subsidies for hospital care and community health improvement services, to education and community-building activities. The Society of Invasive Cardiovascular Professionals (SICP) has added a question to our spotlight: Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialists (RCIS)? Currently, the registry exam is not required; however, our CVT did take and pass the exam. There is no monetary bonus upon passing the exam, but it is highly encouraged. The author can be contacted via Stacy Brand at sbrand@botsford.org

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