Carolina Medical Center Union

The credentials of our staff are made up of: 4 RNs 2 RNs, BSNs 1 BS, RT(R), RCIS 1 RT(R), RCIS 1 RT(R)(CV)(CT), BS 1 RT(R)(CV), RCVT/RCIS* 2 RCISs 1 certified respiratory therapist (CRT) 1 certified nursing assistant (CNA) II * RCVT (Registered Cardiovascular Technologist) is the original version of the current RCIS credential (Registered Cardiovascular Invasive Specialist). What types of procedures are performed at your facility? We have two labs, one designated primarily for cardiac procedures and the other room designated for peripheral vascular and interventional procedures. Our cardiac room is for diagnostic-only heart caths, permanent pacemaker placements, cardioversion and intra-aortic balloon pump (IABP) placements. Our vascular room performs a variety of procedures including, but not limited, to: cerebral, thoracic, abdominal, and lower/upper extremity arterial angiograms, venograms, inferior vena cava (IVC) filter placements, peripheral angioplasty/stent procedures, embolectomy and therapy infusion procedures, fistulograms and fistulaplasty procedures, transjugular intrahepatic portosystemic shunt (TIPS), uterine fibroid procedures, peripherally inserted central catheter (PICC) line insertions, abdominal aortic aneurysm (AAA) stent/graft procedures, and port and perm-a-cath placements. We perform approximately 50 procedures each week, which includes a mix of cardiac, peripheral, and interventional cases. Does your cath lab perform primary angioplasty with/without surgical backup? We currently perform only peripheral vascular interventions (no cardiac interventional cases). We have an active surgical department that participates with us in AAA stent/graft cases performed in our lab, and so our surgery department is prepared to accept interventional patients from us should the need arise. What procedures do you perform on an outpatient basis? Most of our procedures are performed on an outpatient basis except for AAA stenting/grafting, and any emergent patients, such as a cold extremity, etc. Approximately 50% of our patients are outpatients. What percentage of your patients are female? 47.6% of our total cases for the past year were female patients. What percentage of your diagnostic cath patients go on to have an interventional procedure? Approximately 41% of our cardiac cath patients require some interventional procedure. Who manages your cath lab? Steven Dence, RT(R), RCIS, is the Director of Cardiology Services and has been directing the cardiovascular center for over six years. Kim Trotter, RN, BSN is our nurse manager. Do you have cross-training? Who scrubs, who circulates and who monitors? The technologists always scrub and monitor each case by rotating with their teammate, and they will also assist the nurses with circulating duties. Only the nurses can push meds, so an RN is always assigned to circulate each case. Also, all of our nurses are cross-trained in cardiac services (i.e., echo, transesophageal echocardiogram (TEE), stress tests, and cardiac rehab) and rotate through patient holding/recovery. All of our nurses have a critical care background and at least one nurse is present in every case that we perform. Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab? North Carolina has no state or local laws requiring licensing for operation of x-ray equipment. However, we strongly support efforts that would be instrumental in working to create laws requiring licensure for operating radiation-emitting equipment, such as the Consumer Assurance of Radiologic Excellence (Care) Bill. 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? We currently have only registered radiology technologists assigned to our peripheral vascular lab and working with our radiologists. Therefore, positioning, panning, setting up views and utilizing the fluoro pedal in our vascular room are performed by the physician or the RT(R). Since we have no state licensing laws, our cath lab technologists perform these duties in the cardiac suite. What disciplines (physician and non-physician) are involved in performing peripheral interventions? As noted, we have only registered radiology technologists assigned to our peripheral intervention room. All of our radiologists are licensed interventional physicians, many of them specializing in specific areas. All of our physicians work extremely well with each other and our cardiologists will often refer their patients needing interventional procedures to our radiologists. How did you begin performing peripheral cases? Our cardiovascular center was created in 1994 with one procedure room functioning as a dual procedure room for both cardiac and peripheral vascular cases. Although we performed only diagnostic procedures in the beginning, we soon moved into interventional cases after securing an interventional radiologist. Today, we perform diagnostic-only cardiac procedures, and diagnostic/interventional peripheral vascular cases. We also perform AAA stent/graft cases in our vascular suite, with a surgery team participating alongside our vascular lab team. What specific equipment was instituted and/or dedicated towards peripheral cases? To satisfy the needs and requirements of our interventional radiologist, and to provide our patients with the highest level of technology, our hospital committed itself to the massive task of creating a dedicated peripheral vascular suite that could function independently of our cardiac room. In late 2003, we completed the construction and installation of a Shimadzu digital MH-200S (Kyoto, Japan) with the Digitex Premier Digital System. It has a 16 II with rotational/3D angiography capabilities. This Shimadzu system gives us the opportunity for future growth, since it is upgradeable to the Shimadzu Direct Capture Flat Imaging Receptor. We also designed this procedure room to be large enough to accommodate both a surgical staff as well as interventional radiologists, together with our own CV team, to perform AAA stent/graft procedures. How is inventory management handled for the peripheral equipment, particularly with the varying lengths and sizes of the stents? First of all, we have separated and distinguished our inventory between our cardiac and vascular rooms. Each room has a designated technologist assigned to the responsibility of maintaining that room’s equipment supply and par levels. Next, we have developed our own unique inventory control program (initially created by Tom Leighow, RT(R)(CV), RCVT/RCIS, while working in an Arizona cath lab in 1999) that we have set up in Microsoft Excel. This program sorts our supplies into pre-selected, easy to find groups, gives us an on-demand tracking of current balances, comparison to par levels, red-flags time to order supplies, reflects date ordered, and lists earliest expiration dates of supplies. Stent and balloon sizes are indexed in groups of sizes based on diameter, then length, but are also arranged in sub-groups of self-expanding and balloon-expandable. What training was instituted so staff could be competent and skilled? Along with our annual competency evaluations, which cover the procedures that we perform, we also give attention to high-risk (e.g., AAA graft/stent) and infrequent procedures (e.g., IABP) by assigning proctors to less-experienced staff and using our educational trainers for regular in-service classes. All clinical staff members are required to have current BLS and ACLS. Can interventional radiologists and cardiologists perform procedures in the same area? Our two rooms are in close proximity to each other, so our cardiologists and radiologists do share some common ground, such as our patient holding area. The cardiologists and radiologists each have their own separate and designated physician’s room for reading and dictating. Although each lab is designated for specific purposes, all studies that we perform here can be done in either of our two rooms. Our cardiologists and our interventional radiologists work extremely well together, and their areas of expertise compliment each other to benefit our patients with complete and comprehensive cardio/vascular services. Does your lab have a clinical ladder? We are currently in the process of assessing the benefits of a clinical ladder. What are some of the new equipment, devices and products recently introduced at your lab? Our newest equipment is our vascular room’s digital imaging system, a Shimadzu MH-200S with Digitex Premier Digital System. It has a 1024 x 1024 12-bit imaging resolution at 30fps, and includes 3-D rotational imaging as well as a patented RSM-DSA compensation for motion artifact during acquisition mode. With the Shimadzu system, we can perform high speed C-arm rotation acquisition at a range of 60 degrees/sec. Since this system is so multi-functional (i.e., digital cine, continuous DSA, pulse DSA, and serial DSA), it works particularly well for our dual-purpose lab, such as when we bring cardiac cases into our peripheral room. What system is utilized in the cardiac suite? Our two labs utilize different imaging systems, each set up for specific needs for their respective rooms. Our cardiac suite uses a Toshiba DFP - 2000A coupled with an Infinix DP digital system with a 9 II (Toshiba America Medical Systems, Tustin, CA). Our Toshiba imaging system also has the capability of performing all peripheral radiology procedures with its dual image intensifiers (9 inch and 16 inch). Thus, we have no problem in accommodating our cardiologists in the cardiac room who may need to include some peripheral cases along with their heart cath. Our angio suite, utilizing the Shimadzu MH-200S, is specifically designed and set up for our peripheral vascular procedures. We schedule all of our primary radiology peripheral vascular cases in this room, although it can easily handle the overflow of any cardiac procedures. Additionally, each room is monitored utilizing a Witt hemodynamic monitoring system (Philips Medical Systems, Bothell, WA). How is coding and coding education handled in your lab? How is coding communication handled with the billing department? We have one dedicated staff member to do all of our coding and billing. This person is an RT(R), RCIS, who has received additional training for coding. Our director acts as back-up for the billing/coding duties. Coding is done directly from physician’s dictation and the codes are entered into our Witt system, which is then submitted directly to our hospital billing system. On the day following initial billing, all charges are reconciled between the Witt system and hospital-wide system for accuracy. How does your lab handle hemostasis? Our physicians make the call as to the use of any vascular closure device versus manual hold. We currently have the Perclose® ProGlide (Abbott Vascular Devices, Redwood City, CA), Angio-Seal (St. Jude Medical, Minnetonka, MN), VasoSeal® (Datascope Corp., Mahwah, NJ) and Chito-Seal (Abbott) available for physicians, but most often our interventional radiologists will opt for us to pull and hold manual pressure. Our patients will generally go to our clinical decision unit post-procedure or, depending on bed availability, patients may remain in our cath lab recovery unit and then be discharged from there. Does your lab have a hematoma management policy? We actually have a nurse assigned to do daily follow-ups on all of our patients to assess any patient issues and post-procedure complications. Has your cath lab recently expanded in size and patient volume, or will it be in the near future? We completed construction of our new vascular suite in 2003, and this has provided us with a second lab, enabling us to accommodate the prodigious growth that we are experiencing in Union County. Is your lab involved in clinical research? Not at the present time; however, we are one of the very few vascular labs in our area that perform AAA graft/stent procedures right in our own lab. Additionally, this lab serves as a training ground to other interventional radiologists for these types of procedures. We have OR sterility protocols that are easily managed in our CV lab, which makes it idea for OR procedures to be performed in this large room. How does the surgical team work with the invasive team? We correspond directly with the OR technical staff, the surgeon and anesthesia from the very moment a case is about to be scheduled. The case is scheduled only after direct communication with these teams is made. Equipment setup is generally done the evening before the case, and the interventional radiologists have previously communicated at length with the OR surgeons. The case is rehearsed between the physicians and staff prior to the day of the case. Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? No. What other modalities do you use to verify stenosis? No other modalities at the present. What measures has your cath lab implemented in order to cut or contain costs? We have worked with many of our vendors to put some of our interventional equipment on a consignment basis. Additionally, with the creation of our Microsoft Excel inventory system, we have a much better, on-demand overview of all equipment that we carry in our lab. We are part of the Carolina Healthcare System, which allows us greater ability to obtain competitive pricing for equipment and supplies. What type of quality control/quality assurance measures are practiced in your cath lab? We perform daily quality controls on our ACT, glucose, oxicom and temperature-controlled equipment, as well as our crash-cart, defibrillator and IABP pump. Additionally, we perform quality assurance protocols on the moderate sedation given to our patients. How does your cath lab compete for patients? Has your institution formed an alliance with others in the area? This hospital facility is actually leased by Carolina Healthcare System (CHS). We are, therefore, part of CHS, which is the largest healthcare system in the Carolinas. Our county, Union County, is currently rated as one of the fastest-growing counties in the United States, so, as you can imagine, we compete with multiple facilities in the surrounding area. Right now we have approximately 7 other medical facilities offering cardiac and vascular services, all within a 25-mile radius of our facility. How are new employees oriented and trained at your facility? All of our staff technologists and nurses must be ACLS/BLS-certified. Our nurses are all registered nurses (RNs) and all have critical care experience. Additionally, all of our technologists must be registered as an RCVT/RCIS or CV. We prefer our technologists to hold an RT(R); however, this is currently not a requirement in our lab. What type of continuing education opportunities are provided to staff members? We try to provide opportunities for our staff to attend various seminars, workshops and lectures, and all of our staff are offered membership in the Society of Invasive Cardiovascular Professionals (SICP). How do you handle vendor visits to your lab? Suzie Farley, certified respiratory therapist (CRT), handles and directs a multitude of functions for our lab, among which includes: coordinating vendor visitations to our daily case schedule for both labs, assuring security procedures are met by vendors and controlling the number of vendors to our lab each day. How is staff competency evaluated? Our staff is required to complete various competency evaluation tests during the course of each year. These competencies are designed to help maintain and strengthen our staff’s proficiency in the multi-functional modalities in which we engage on a day-to-day basis. Does your lab utilize any alternative therapies (such as guided imagery, etc.)? Presently we are not utilizing any alternative therapy in the cardiovascular center. How does your lab handle call time for staff members? Currently, there is no on-call or weekend/holiday scheduling at this facility. What trends do you see emerging in the practice of invasive cardiology? There are three areas in which we see probable emerging changes in current procedures and practices. One is the trend for interventional procedures to be performed at facilities which have no direct surgical back-up. This is a practice that is becoming more prevalent across the nation and with this should come more strict and uniform standards. Second, technology advancements in computed tomography (CT) are moving quickly, and so we envision the time coming when CT scanners will gradually replace the typical diagnostic heart cath procedure as we know it today. Finally, we believe that statistical data gathering will be a primary necessity to fulfill the requirements for hospital insurance reimbursement. Has your lab undergone a Joint Commission on Accreditation of Healthcare Organizations (JCAHO) inspection in the past three years? We just completed two JCAHO surveys during this past year. One was the laboratory point of care assessment, which was done in July 2005, and the JCAHO hospital facility survey was done in March 2005. We passed all areas without exception to any segment. Where is your cath lab located in relation to the OR, ER, and radiology departments? Our lab is on the bottom floor of our hospital facility and our radiology department is directly above our lab on the next floor up. We have direct access to radiology via stairs within our department. Our ER is also one floor above us and down the corridor, and our OR is also one floor above us, accessed by way of elevators outside the doors to our lab. Please tell the readers what you consider unique or innovative about your cath lab and its staff. This cath lab is, indeed, unique in many respects. First, it is quite rare to find a lab that performs such a variety of cardiac, and peripheral vascular/ interventional procedures while offering to its staff the benefit of no on-call, no weekend work, or no holiday work. Secondly, the cath lab director has established a very sincere, highest-priority standard of FAMILY FIRST policy for our staff. This means that the entire staff is prepared to do whatever is necessary to cover for any team member who needs to be off, leave early, or just needs extra time on the phone due to family or personal issues. Everyone here consistently jumps in to help each other out, and there is a real sense of a caring family atmosphere throughout this department. In the past four years, this lab has experienced a less-than 1% turnover rate among staff. This is an astounding and remarkable number for a cath lab setting, given the typical staff turnover rate in most labs, and we feel that this is a direct result of the qualities mentioned above. Is there a problem or challenge your lab has faced? Perhaps our biggest challenge during the past couple of years was the planning, developing and opening of our peripheral vascular lab to accommodate both cardiologists and radiologists. Additionally, with Union County being one of the fastest-growing counties in the nation right now, planning and budgeting for our expected growth has been a challenge. What is 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? Our location places us central to North Carolina’s largest city, Charlotte, and all of the mega cultural, sports, and shopping which is unequaled anywhere in the United States. We are located just three hours from Myrtle Beach, and two hours from the Smoky Mountains and the Blue Ridge Parkway.

The Society of Invasive Cardiovascular Professionals (SICP) has added two questions to our spotlight:

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 salary increase upon passing the exam? Yes, we require that all of our staff technologist hold the RCIS, RCVT or RT(R)(CV) credentials. The incentive for having these credentials is simply this: it completes the first requirement for being considered as a viable candidate for a position in this lab. Is 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? All of our nurses and technologists are members of the SICP, and in fact, we are probably one of a few cardiac/vascular facilities in which every one of our clinical staff is a member of SICP. Additionally, several of our staff members belong to, and participate in, the American Society of Radiologic Technologists (ASRT) and the Association of Vascular and Interventional Radiographers (AVIR). Tom Leighow can be contacted at tomandbecky@carolina.rr.com

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