Center for Cardiovascular Medicine (CCVM)

What is the size of your cath lab facility and number of staff members? Currently, the Center for Cardiovascular Medicine (CCVM) is operating with five cath labs, one of which is a dedicated electrophysiology (EP) lab. Our cath lab staff mix is 1 registered cardiovascular invasive specialist (RCIS), 6 registered radiologic technologists [RT(R)s], and 9 registered nurses (RNs). Two nurses are dedicated EP personnel. Our pre/post holding area has 12 beds and is staffed daily by 4 RNs, 2 CVAs, volunteers and a unit secretary. This is where cardioversions, transesophageal echocardiograms (TEE), and tilt table tests are performed. Eight invasive cardiologists and one vascular surgeon utilize our labs. The cath lab services our four-hospital system and also other hospitals within Westmoreland, and part of Fayette and Indiana County. The CCVM is located at Westmoreland Regional Hospital in Greensburg, Pennsylvania. Westmoreland Regional Hospital in Greensburg, Pennsylvania. What type of procedures are performed at your facility? Coronary procedures include diagnostic cardiac catheterization, acute angioplasty and stenting for myocardial infarction (MI), atherectomy, thrombectomy and intravascular ultrasound (IVUS). Peripheral procedures include peripheral angiograms and interventions, including arteriovenous (AV) fistulae, and renal, iliac, subclavian, carotid and limb salvage procedures. Does your cath lab perform primary angioplasty with surgical backup onsite? Surgical backup is available at all times. If backup is needed during off hours, there is an OR team on call that will arrive within 30 minutes. What procedures do you perform on an outpatient basis? Diagnostic catheterization, staged stent procedures, peripheral angiograms, cardioversion, generator change, TEE, tilt table and EP studies. What percentage of your patients is female? Approximately 49.8%. What percentage of your diagnostic cath patients go on to have an interventional procedure? Approximately 58%. Who manages your cath lab? Leslie Boltey, BSN, MBA, is Director of Cardiac Services, Ted Mertz, RT(R)(CV) is Lead in Cath Lab, Robin Weyandt, RN, BSN, is Lead in the CCVM Pre/Post holding area. Do you have cross-training? Who scrubs, who circulates and who monitors? The RNs scrub, circulate, and monitor. RTs scrub and monitor. Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab? Yes. 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? Each staff member is oriented and achieves proficiency in the scrub position. The scrub position controls the table, II and pans during the angiogram. In accordance with Pennsylvania law, only the physician and radiologic technologist may operate the fluoro. How does your cath lab handle radiation protection for the physicians and staff that are in the lab day after day? We currently utilize a 2-badge system to evaluate radiation exposure. Maximum shielding and table skirting is provided, staff rotates scrub duties and EP uses rad pads for pacer/ ICD insertion. If your lab performs peripheral interventions, what disciplines (physician and non-physician) are involved? Interventional cardiologists and vascular surgeons perform peripheral interventions in our lab. Dr. Chahin, cath lab director, started the peripheral program with renal artery stenting approximately 7 years ago. We utilize equipment from ev3 (Plymouth, MN), FoxHollow (Redwood City, CA), Cordis Corp. (Miami, FL) and Spectranetics (Colorado Springs, CO). Does your lab have a clinical ladder? The cath lab does not have a clinical ladder. There is a hospital-based clinical ladder called the Career Advancement Program (CAP) through the nursing department. A professional ladder is under consideration for non-nursing personnel as well. What are some of the new equipment, devices and products introduced at your lab lately? We recently purchased two new Philips (Bothell, WA) labs with coronary and peripheral provisions, the Spectranetics laser for peripheral and coronary procedures, and have iLab (Boston Scientific, Natick, MA) installed into each lab for IVUS use. Can you describe the system(s) you utilize and how they work in cath lab daily life? All procedures done in the CCVM are charted and able to be viewed on the Philips Witt system. This includes all invasive/non-invasive procedures and physician transcription. All inpatients and outpatients are entered into the Witt system, usually by the holding area unless there is an emergency. The patient enters the cath lab and charting continues in the same program. When the procedure is finished, the cine runs are available for all staff, physicians and patients to review. Continuity is maintained with the ability to review a previous cath or nuclear stress test, for example. Does your cath lab do electives on weekends and or holidays? Very rarely are elective procedures done during off hours, leaving the call team available for acute MIs. How is coding and coding education handled in your lab? Currently, the person responsible for monitoring the procedure applies the correct charge on a pre-printed charge sheet. This sheet is given to our cath lab secretary, who enters the charges originating in the lab and sends them to billing. Soon we will be able to pull our charges from the Witt program, eliminating the charge sheet. How does your lab handle hemostasis? Hemostasis is managed by our two cardiovascular technologists (CVTs). They are responsible for pulling a majority of the sheaths. During off hours, the on-call nurse is responsible for sheath removal. Angio-Seal™ (St. Jude Medical, Minnetonka, MN) is used by most physicians following diagnostic catheterization. The SyvekPatch® (Marine Polymer Technologies, Inc., Danvers, MA) is used after an intervention if requested by the physician. Every staff member in the cath lab/holding area is responsible for sheath removal. Does your lab have a hematoma management policy? No. There is a hospital protocol for every procedure done by nursing/CVT, but hematoma management is left to the discretion of the physician. How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies? Two RTs perform all the ordering of equipment, both coronary and peripheral. During each procedure, the equipment used is charted through the Witt system and the outside packaging is kept for specific equipment until ordered. Large equipment is decided upon by the physicians and directors. Has your cath lab recently expanded in size and patient volume, or will it be in the near future? In January 2007, we expanded from two cath labs and one EP lab, located within the surgi-center, to three cath labs and one EP lab with cath ability, located within the CCVM. Catheterization, PCI, peripheral vascular and EP procedures have all increased significantly, as demonstrated by our market share increase of 15 points within the past 2 years. Is your lab involved in clinical research? Currently, the cath lab is involved in the following American College of Cardiology (ACC) registry studies: • National Cardiovascular Data Registry (NCDR) ACTION Registry • NCDR ICD™ Registry • Funded by Datascope Corporation, the Benchmark 2™ Registry is currently being conducted by Chantal Trice, RN. • Chantal Trice and Dr. Juan Chahin recently completed the MAINTAIN trial in September 2007. This trial focused on acute coronary syndrome and lipid therapy. In the past, the cath lab was involved in the PAMI-Senior trial (patients with primary angioplasty versus thrombolytic therapy for acute MI in the elderly), OAT Trial (Occluded Artery Trial), COMPLY (complement inhibition in myocardial infarction treated with thrombolytics), and EXTRACT-TIMI 25 (Enoxaparin and Thrombolysis Reperfusion for Acute Myocardial Infarction). • SAPPHIRE WW (Stenting and Angioplasty with Protection in Patients at High-Risk for Endarterectomy World Wide) Registry for Carotid Stenting. The principal investigator is Ehab Morcos, MD and Study Coordinator is Robin Weyandt, RN. Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? Yes, but nothing unexpected or out of the ordinary. Our benchmark data demonstrates our complication levels are below or within ACC database findings. What other modalities do you use to verify stenosis? We use IVUS, WaveWire (Volcano Corp., Rancho Cordova, CA), and quantitative analysis on the Philips equipment. While these procedures create add-on costs to fixed DRG payments, patient needs come first. What measures has your cath lab implemented in order to cut or contain costs? We utilize primary vendor agreements, increased consignment and negotiating deals with suppliers to try and contain costs. What type of quality control/quality assurance measures are practiced in your cath lab? Each coronary and EP patient is entered into the ACC-NCDR database. A complication information sheet is attached to the chart of each patient we care for in the CCVM. Robin Weyant, RN, collects all the ACC and complication information for the CCVM. Door-to-balloon time remains a focal quality initiative with the ER and cath lab structure. Key tools used are the ST-elevation MI (STEMI) control tracking sheet and STEMI alert. How does your cath lab compete for patients? Has your institution formed an alliance with others in the area? In July 2005, Frick Hospital, Latrobe Area Hospital and Westmoreland Regional Hospital combined to form Excela Health. On May 1, 2008, Westmoreland Regional acquired Mercy Jeanette, now named Westmoreland Regional Hospital at Jeanette. Patients are referred within the hospital system and Excela Health demonstrates strong relationships within our referral physicians. Target-focused marketing and community outreach programs are conducted monthly to bi-monthly. How are new employees oriented and trained at your facility? What licensure is required for all professionals who work in your lab? All RNs must have two years of critical care experience and RT(R) is the preferred cardiac experience. New employees are assigned a preceptor and given an intense orientation until able to perform the duties of the job created by the hospital, signed off on by the preceptor and cardiologists. What type of continuing education opportunities are provided to staff? Most often, inservices are offered during lunch with different vendor representatives. If any questions arise regarding a medication or piece of equipment, the representative is notified and offers education to the staff. How do you handle vendor visits to your lab? All vendors must sign in through the hospital security department and wear a badge. Most vendors are not permitted in the cath lab unless educating staff/physician about new equipment. How is staff competency evaluated? Staff competency is evaluated during the preceptorship process and yearly thereafter with the director. Does your lab utilize any alternative therapies (such as guided imagery, etc.)? No. How does your lab handle call time for staff members? Our four call teams consist of three staff. One staff member must be an RT(R) and one must be an RN. Call is required one day per week and every fourth weekend. Throughout the week, an extra team will occasionally volunteer to stay and finish cases. What trends do you see emerging in the practice of invasive cardiology? We see increased multi-vessel stenting with drug-eluting stents versus coronary artery bypass grafting (CABG), percutaneous aortic valve replacement and coronary stenting for failed CABG. Has your lab has undergone a Joint Commission inspection in the past three years? The cath lab was last evaluated in 2005. Suggestions that we received and implemented: • Label fluids used on the table; • Medication reconciliation on both inpatients and outpatients; • Proven adherence or benchmarking of performance around the National Safety Goals. Where is your cath lab located in relation to the OR department and ER? The CCVM is located in the BB of the hospital with a separate entrance. The OR is found on the 7th floor and the ER is located on B. We have keyed elevator access to all these areas. What do you consider unique or innovative about the CCVM? The noninvasive [including echo, nuclear cardiology, magnetic resonance imaging (MRI), computed tomography (CT), cardiac rehab and pacing clinic] and invasive cardiology departments are connected, allowing the patient to complete all cardiac testing in the same center. Is there a problem or challenge your lab has faced? The integration of the four hospitals into one system is still in its infancy stage. As we continue to grow, we strive for excellence and to achieve our mission: “To improve the health and well-being of every life we touch.” 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”? Currently, we provide care for patients on the Westmoreland/ Allegheny county line. Westmoreland was once considered a community hospital; now we have become a tertiary care center. Our patients, who live in rural areas, no longer have to drive to the city for their needs. 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)? Do staff receive an incentive bonus or raise upon passing the exam? No. However, exams fees are reimbursed upon completion. 2. Are your clinical and/or managerial team members involved with any professional organizations, such as the SICP, ACVP, or regional organizations? Not at this time. n Not pictured: Richard Ciccarelli, RT(R), Brad Hornick, RN, and Terri Ciglar, RN. The author can be contacted at melissamcneely@msn.com

NULL