Cardiovascular Associates, PC

Cardiovascular Associates (CVA) is a freestanding outpatient cardiac cath lab located in Kingsport, Tennessee. Our lab is one of only three outpatient cath labs in the state, and one of fewer than 60 in the entire country. The lab is owned and managed by Cardiovascular Associates, PC, a group of 21 cardiologists and 3 cardiothoracic surgeons. Founded in 1978 by Dr. Harrison Turner, the practice has grown from 1 physician to 24. Their physicians specialize in interventional cardiology, nuclear medicine, echocardiography, stress testing, electrophysiology and the latest in cardiac CT and MRA imaging. What is the size of your cath lab facility and number of staff members? Our facility has 5,100 square ft. of space allocated within the office building of CVA. The catheterization laboratory consists of 1 procedure suite that is equipped with a Siemens Coroskop TOP Hicor Digital System (Malvern, Pennsylvania), a 2-bed holding area and 5 patient rooms. Our 6-person staff consists of 3 RNs, 1 RT, 1 RCIS and 1 CVT. The RNs, RT and the CVT have been in-residence since the catheterization laboratory opened in May 2001. We added the full-time RCIS position in February 2004. We also have a PRN pool of RNs, RCISs, and CVTs. Our staff members have 62 years of combined catheterization laboratory experience. What types of procedures are performed at your facility? Our cath lab performs diagnostic right and left heart catheterizations with left ventriculogram (LV gram) and abdominal aortography. We average 25 cases per week. At present, we do not perform coronary or peripheral interventions. We have done 3,000 catheterizations since the lab opened in May 2001. As a freestanding cath lab, we are within a 10-minute drive to the nearest hospital and we have an agreement with EMS for patient transport if needed. Our cath lab is stocked with all of the necessary emergency equipment, including an intra-aortic balloon pump (IABP), defibrillator and temporary pacemaker. Who manages your cath lab? Cardiovascular Associates is the owner and operator of the cath lab. Our director is Kathy Lee, RN, RCIS; she has 14 years of experience in the cath lab. Kathy joined CVA in 1997 and is responsible for budgeting, daily operations and staffing the lab. The Medical Director, Greg Miller, MD, is a Kingsport native who joined the practice in 1997. Dr. Miller is responsible for strategic planning and ensuring that policies and procedures are followed. Do you implement cross training? Who scrubs, circulates and monitors? All RNs, RCISs and the RT are cross-trained to scrub, circulate and monitor. The CVTs also scrub, but only after completing an orientation checklist. What are some of the new equipment, devices and products that have been recently introduced at your lab? We have recently evaluated the Clo-Sur PAD (Medtronic, Inc., Santa Rosa, California) and 4-French (Fr) catheters. How does your lab handle hemostasis? Our staff members apply manual pressure by either hand or clamp (FAVC - Femoral Artery Vascular Clamp, Pressure Products, Palos Verdes, California) in the holding area. All RNs, RCISs, the RT and the CVTs are trained in sheath removal and hemostasis techniques. Has your lab insituted a hematoma management policy? Should the patient develop a hematoma, manual pressure is applied until the hematoma is resolved. The patient is then assessed every 15 minutes until stable, and then every hour thereafter until discharge. We phone the patient for follow-up the next day and thereafter as necessary. How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies? We utilize par levels for supplies. Our cath lab director is responsible for ordering supplies and equipment. Has your cath lab recently expanded in size and patient volume or are there plans for expansion in the future? We have seen our patient numbers steadily increase since opening in 2001. In the future, we envision performing low-risk PCI procedures once the American College of Cardiology approves interventional procedures without the requirement of surgical backup. Our Siemens equipment (Coroskop TOP Hicor Digital System) provides peripheral capabilities even though we do not handle peripheral procedures at this time. Office space is available at our facility for future expansion if needed. Is your lab involved in any clinical research projects at present? Cardiovascular Associates (CVA) is involved in a clinical research program to which we refer our patients. Our cardiologists are affiliated with numerous studies that have gained national recognition. CVA was ranked the number-one enroller internationally for the SYNERGY Trial. CVA was also ranked number-one for enrollment in the PRIDE distal protection trial, number-two in the ELECT Trial, number-two in the TAXUS Trial, and in the top 10% of enrolling sites for the REPLACE-2 Trial. In recent months, our research team has participated in the FLAME, LUNAR, X-traction (distal protection), C-STARR (distal protection), OASIS 5 and ARRIVE trials. The research team is currently enrolling patients in ACUITY, APEX, AMI, ASPIRE, TAXUS ATLAS (direct stent/long lesion/small vessel), EARLY ACS, DELTA MI, EVEREST, FINESSE, OAT, and SPIDER studies. The electrophysiologists at our center recently participated in MARQUIS VR, DEFINITE, EnPulse, PEGASUS, and are currently enrolling patients in the BLOCK HF study. Registries have become an exciting venture for our research staff, and we are currently participating in the STENT and the D.E.S.cover registries. With the addition of a peripheral vascular clinic at CVA, our research team was able to participate in the TALON PV Registry. CVA’s research team is looking forward to the future with the expectation of expanding our research program to include participation in a carotid stenting trial. What measures has your cath lab implemented to cut or contain costs? All staff members are very aware of cost containment and everyone helps out by using supplies wisely. In order to contain cost, we negotiate with vendors for the best pricing. We also have standardized supplies that the cardiologists have agreed to use. What types of QC/QA measures are practiced in your cath lab? We perform a daily checklist of the procedure room and all emergency equipment to make sure that all are working properly and that supplies are available. Each month, staff members check expiration dates on all sterile supplies and medications. We are also conducting an ongoing study with our Nuclear Medicine Department to correlate findings of the patient’s stress test with the catheterization report. In addition, monthly chart reviews are done on 25% of the total volume of patients treated. All patients are telephoned the next day post-catheterization for follow-up. If the patient reports anything other than the norm, we continue to call the patient daily until the issue is resolved. Our department also sends out patient satisfaction surveys quarterly. We collected data for a study in 2004 that tracked the time of the patient’s sheath removal to hemostasis, the time to sitting, and the time to ambulation, comparing cases where 6 French versus 5 Fr sheaths/catheters were used. The only exclusion criterion was BP > 180 systolic. The results of the study were: a. 20 minutes was the average time from sheath removal to hemostasis using manual pressure. b. The patient’s HOB was elevated 30 degrees immediately after hemostasis and 45 degrees 30 minutes post-hemostasis. c. The patient sat at the bedside 2 hours post-hemostasis and then ambulated in the hallway. d. The average length of stay post-hemostasis was 2.5 hours. There were no hematomas or groin complications and no difference in patient outcomes with 6 Fr versus 5 Fr sheaths/catheters. This continues to be our current practice for post-catheterization care. How does your cath lab compete for patients? Has your institution formed an alliance with others in the area? CVA physicians are the only ones allowed to order cardiac catheterizations that are performed at our facility. This is to ensure that a cardiology consultation has been done and that the patient’s condition is clinically appropriate to meet the inclusion and exclusion criteria that have been adopted by the physicians of CVA. Our exclusion criteria follow the American College of Cardiology (ACC) guidelines. Some of these include: unstable angina, valvular heart disease, acute myocardial infarction within the last 7 days, and suspected left main disease. Some of our inclusion criteria include age > 16 years, angina pectoris with or without coronary risk factors, suspicion of ASHD, and noninvasive testing (positive stress test, abnormal stress perfusion scan). If the patient has been examined and does not meet the inclusion criteria, the physician will perform the catheterization at one of two local hospitals with which we have an excellent working relationship. Only one of these hospitals provides services for percutaneous coronary interventions (PCI) and open-heart surgery (OHS), and recently, CVA contracted with this hospital to provide management services for their entire cardiology product line. Our cardiologists also operate outreach clinics for some hospitals in the region. This allows patients easier access to a cardiology consultation without having to travel long distances. Many of the patients who are seen in these clinics are then referred to our facility for cardiac catheterization. How are new employees oriented and trained at your facility? All employees complete an orientation and competency verification program in order to work in the cath lab. The length of orientation varies according to individual’s needs. All staff must maintain current licensure or certification, must be BLS-trained and all licensed staff must be ACLS-certified. What types of continuing education opportunities are provided to staff members? To accomplish our goal of providing superior patient care, CVA strongly believes that it is essential to have skilled staff. This need is recognized and opportunities are provided. Each month an on-site Lunch and Learn session is offered to employees, CVA sponsors an annual Heart Talk, and we also welcome vendor-sponsored in-service programs. The cath lab staff members are also given the opportunity to attend off-site seminars. How do you handle vendor visits to your lab? Vendor visits are scheduled so that only one representative is in our lab at one time. We do recognize the value of vendor representatives and try to accommodate them when possible. Their access is limited to the nurses’ station or the control room, unless the clinical specialist is needed in the cath lab suite. How is staff competency evaluated? Staff competency is evaluated by annual performance evaluations from the Cath Lab Director and the Medical Director. Does your lab utilize any alternative therapies (such as guided imagery, etc.)? No, although we try to relax the patient by playing his or her favorite type of music during the procedure. How does your lab handle call for staff members? CVA does not use call! All cases are elective and are scheduled during the hours of 7:00 am-4:30 pm. The staff is assigned in staggered shifts (6:45 am-3:15 pm, 7:00 am-3:30 pm, 7:30 am-4:00 pm, and 8:00 am-4:30 pm) to cover our hours of operation. What trends do you see emerging in the practice of invasive cardiology? There will continue to be more peripheral diagnostic and interventional procedures performed by cardiologists, with more invasive procedures being performed in an outpatient setting. Also, we foresee an increased utilization of MRI and CT scanning with the technological advances emerging in these fields. Has your lab undergone a JCAHO inspection in the past three years? We are not currently affiliated with JCAHO. However, our largest health network provider conducts annual on-site visits to our lab to retain their JCAHO accreditation. During our most recent survey, CVA was judged to be 100% compliant with their standards and was commended for our excellent performance. Please tell the readers what you consider unique or innovative about your cath lab and its staff. As one of only a handful of true, freestanding cath labs in the southeast, CVA is indeed a unique facility. When patients are scheduled for catheterization, they are directed to the cath lab for pre-catheterization teaching and a tour of the department during which they are introduced to the staff members who will care for them. Our lab is full-service in that the same staff members care for the patient from admission to discharge. This gives us the opportunity to really get to know the patient and the family or caregivers and their needs. We schedule patient arrival times at thirty-minute intervals (beginning at 7:00 am) and admit the patient to a private room. Patient catheterization procedures are performed in the order that they are scheduled. And because CVA only does scheduled procedures, patients do not get bumped due to emergencies. When the catheterization procedure is completed, the patient will be transported from the procedure suite to the holding area for sheath removal. Once hemostasis is achieved, the patient will return to his/her room for recovery. Discharge is usually 2 to 2.5 hours after hemostasis is achieved. Prior to discharging the patient, all arrangements will be made for a follow-up office visit, PCI, or surgical consultation, whichever is indicated. Extensive post-catheterization teaching is done with each patient and a follow-up phone call is made within 24 hours to assess the patient’s condition and to answer any questions he/she might have. The feedback from our patients and families has been overwhelmingly positive. Is there a problem or challenge your lab has faced? Due to the increasing patient load and outpatient waiting times at an area hospital, our physicians saw the need for a freestanding cath lab. A team of our physicians applied for a Certificate of Need (CON) at The Tennessee Health Facilities Commission in Nashville, Tennessee. When the CON was approved, the cath lab planning stages commenced. The biggest challenge we faced was in the planning phase prior to the opening of the cath lab. Since ours is a freestanding cath lab, we did not have the convenience of calling on ancillary hospital departments for help. As a result, it took much planning and organization to ensure that everything was in place from capital equipment, to sterile supplies, to linen services and dietary needs. This thorough planning paid off. The cath lab opened on May 9, 2001 and everything went as planned! What is special about your city and region compared to the rest of the U.S.? The Tri-Cities region is made up of Kingsport, Bristol and Johnson cities. Kingsport is nestled in the foothills of the Appalachian mountains in the northeast corner of Tennessee, just a few miles from the Virginia border and 45 minutes from North Carolina. We are privileged to enjoy all four seasons in our state. In 1999, the Tri-Cities region was named an All American City (one of only 10 in the country). Kingsport’s city limits population is 44,905. The Tri-Cities Standard Metropolitan Statistical Area has a population of 480,091. Cardiovascular Associates serves patients from northeast Tennessee and a large patient population from southwest Virginia. We feel that this is a great place to live and to work and we are very proud of the cardiac care that is provided by our center. Questions from the SICP Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? The RCIS registry is not required, but as cardiac professionals, we encourage staff members to take the exam. Kathy Lee can be contacted at klee@theheartcenter.net

NULL