Charlton Memorial Hospital

What is the size of your cath lab facility and number of staff members? Our cath lab facility consists of 2 cardiac cath labs, control room, reading room, a 5-bay holding area and support space. Within the next six months, we will be adding a third room for a comprehensive Electrophysiology Program. The lab is staffed by 26 FTEs with the following credentials: 14 RNs 2 CVTs 1 RT 2 CVT candidates. 4 PAs/NPs 2 cath lab assistants 1 per diem transporter Staff residence runs from 2 months to 7 years. What type of procedures are performed at your facility? We perform diagnostic cardiac catheterizations, elective, emergent and primary angioplasty. Interventional procedures include IABP insertion, PTCA, stents, intravascular ultrasound, Rotablator® (Boston Scientific, Maple Grove, MN), AngioJet® (Possis Medical, Inc., Minneapolis, MN) and the PressureWire (RADI Medical Systems, Reading, MA). We perform approximately 200 procedures per month, 60 of which are interventions. We do not perform peripheral interventions. What percentage of your patients are female? Approximately, 60% male and 40% female. Does your cath lab perform primary angioplasty with/without surgical backup? We perform primary and elective angioplasty with surgical backup. We have a new open-heart program that started in April 2002 and our elective angioplasty program started in November 2002. The surgeons and the CVOR are on call. What percentage of your diagnostic cath patients go on to have an interventional procedure? Greater than one third of our patients go onto to PCI. Who manages your cath lab? Richard Shulman, MD, Medical Coordinator, Cardiac Services Jonathan Bier, MD, Medical Director, Cardiac Interventional Services Laurie Mulgrew, RT(R)(CV)(M), Director, Cardiac Interventional Services Elizabeth Yokell, RN, Resource Nurse Do you have cross-training? Who scrubs, who circulates and who monitors? All staff members are cross-trained to the extent of their licenses. Scrub people include RNs and CVTs. RNs predominantly circulate and both RNs and CVTs monitor. Only RNs administer medications. All staff pull sheaths and recover patients. Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab? State regulations require an RT be involved in the cath lab for specific radiation safety issues. 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 physician is responsible for operating the x-ray equipment and is assisted by our scrub personnel. Does your cath lab have a clinical ladder? We do not have a clinical ladder in the cath lab. The only position that we do have within our hospital is called Clinical Recognition, where an experienced nurse may focus her practice on a particular specialty. We have not implemented that yet in our lab. Our plan is to implement a Clinical Recognition position with an education focus. What are some of the new equipment, devices and products introduced at your lab lately? With the advent of our elective angioplasty program in November 2002, we added IVUS, the PressureWire, AngioJet and Rotablator. We also added the new Cypher stents (Cordis Corporation, Miami Lakes, FL) and Multi-Link Vision stents (Guidant Corporation, Santa Clara, CA) to our equipment stock. Is your cath lab filmless? We have been filmless since 1998 and were the first cath lab in Massachusetts to be filmless. We have equipment from Siemens Medical (Malvern, PA) and HeartLab, Inc. (Westerly, RI) for image storage in both our cath labs. How does your lab handle hemostasis? The cath lab staff is responsible for pulling sheaths during normal business hours. We have a 24-hour PA/NP staff that pull sheaths after normal cath lab hours and oversee the post cath care of our patients. Sheaths are pulled in our holding area. Outpatients are then transported to our surgery center for recovery and discharge. Inpatients are returned to their rooms for post cath care. Patients requiring interventions are transferred to the CV Step Down Unit post PCI. Our primary angioplasty patients recover in CCU. In addition to manual pressure, we utilize: SyvekPatch® (Marine Polymer Technologies, Danvers, MA), FemoStop® (RADI Medical Systems) Angio-Seal (St. Jude Medical, Minnetonka, MN). Approximately 30 percent of the groins are sealed by the physician using Angio-Seal. Does your cath lab have a hematoma management policy? We follow the American College of Cardiology (ACC) criteria for hematoma management. How is inventory managed at your cath lab? We have two staff members who manage inventory. Most supplies are currently reordered through our hospital information system. We are currently working on an inventory management system within our department to automate at much as possible. Our staff members work with the purchasing department for purchasing and equipment orders and is very cognizant of equipment choices and costs. Has you cath lab recently expanded in size and patient volume, or will it be in the near future? Our cath lab has experienced steady growth in procedures and volume since we began performing diagnostic cardiac catheterizations in 1991. In 1998, we participated in the Cardiovascular Patient Outcomes Research Team (C-PORT) Trial. Conducted out of Johns Hopkins Hospital in Baltimore and through the Massachusetts Department of Public Health (DPH), the C-PORT trial was a randomization of treatment for heart patients within the community hospital setting. This study allowed us to perform primary angioplasty without surgical backup. In 2002, Massachusetts passed legislature to allow three new cardiac surgery programs in community hospitals statewide. Our community hospital was granted licensure for a comprehensive heart center. In April of that year, Southcoast Health System was the first of the three chosen entities to open a cardiac surgery program at our Charlton Memorial site in Fall River. In November of 2002, we opened an elective angioplasty program and our volume tripled. We began in November 2002 and have performed more than 600 interventions in 11 months. It was the first new interventional catheterization lab to open in Massachusetts in at least a decade. Is your lab involved in clinical research? No. What measures has your cath lab implemented in order to cut or contain costs? Our staff and physicians are very aware of costs and efficient use of equipment. In addition, we have negotiated with our vendors for the lowest possible price and 98% of our interventional supplies (stents, balloons, guides) are on consignment. What type of quality control/quality assurance measures are practiced in your cath lab? Quality control is performed on all of our equipment daily and we have a weekly multi-disciplinary cath conference for case review. In addition, we have an extensive Quality Assurance program that is predominantly produced through our ACC-NCDR database. Our lab was recognized by the DPH as the first cath lab in the state of Massachusetts to install the ACC database for collection of patient data and we have been recognized as the model for ACC data collection within our state. How does your cath lab compete for patients? Has your institution formed an alliance with others in the area? Southcoast Hospitals Group is a three-hospital system (Charlton Memorial in Fall River, St. Luke’s in New Bedford and Tobey in Wareham) with a large market share in Southeastern Massachusetts. The closest metropolitan areas are Providence, RI and Boston, MA. Both New Bedford and Wareham are one-hospital towns while Fall River has one smaller hospital that just recently opened a diagnostic cath lab with no cardiac surgery component. St. Luke’s and Tobey refer patients to the Charlton cath lab for diagnostic and interventional procedures. As yet, it is not determined what competition the other hospital in Fall River might prove to be. Our advantage is that, with our cardiac surgery program, we can offer comprehensive care to our patients. Does your cath lab have an outpatient program? We have no formal outpatient program, although we do perform outpatient cardiac catheterizations. How are new employees oriented and trained at your facility? We have a formal hospital orientation process, which every new employee completes. Within the cardiac cath lab, each person is assigned a preceptor and the orientation program is tailored to his or her need based on his or her prior experience. RNs and RTs are required to be licensed. CVTs are registered. CVT candidates are encouraged to take their registry exam within two years of employment. What type of continuing education opportunities are provided to staff members? Continuing education is an individual responsibility and staff are encouraged to participate in local educational conferences. In addition, vendors provide educational opportunities for the staff. How do you handle vendor visits to your lab? Vendors are allowed in the cath lab in a limited fashion and are required by hospital policy to check in with our purchasing department. How is staff competency evaluated? Competency is evaluated by direct observation, return demonstration and annual clinical competency evaluations. Does your lab utilize any alternative therapies (such as guided imagery, etc.)? Currently we do not use guided imagery or other alternative therapies. A former cath lab nurse who went on to be a nurse practitioner did a guided imagery study with lab staff and patients during her research for her capstone. We found patients very receptive to the technique. Southcoast currently has a complementary therapy committee that is exploring integrating such therapies into clinical practice, so there is a possibility of introducing them in the future. We do offer patients their choice of music during procedures and have CD players with headphones the patients can utilize. How does your lab handle call time for staff members? Each staff member currently is on call two days per week and one weekend per month. The call team consists of four staff members with a minimum of two RNs per call team. One person does the hemodynamic monitoring, one person scrubs and the two nurses circulate. We offer staff an option of 8- or 10-hour days, rotate our start times and are currently embracing a flex-time policy. Our hours of operation are 7 am to 6 pm, Monday through Friday. What trends do you see emerging in the practice of invasive cardiology? We recently started using the sirolimus-eluting Cypher stents. We look forward to emerging technologies to help provide more efficient quality care for our patients. Our experience with DES has been satisfactory so far. We look forward to Boston Scientific’s product. Our patients are interested in having DES. Has your lab undergone a JCAHO inspection in the past three years? We underwent an inspection in 2001 and were found to be deficiency free. With the start of the new state program to license community hospitals for open heart surgery/elective angioplasty, we have undergone many regulatory surveys by the DPH to insure the quality of the new program. Please tell readers what you consider unique or innovative about your cath lab and staff. Although we have a management structure with a Director and a Resource Nurse, we use a shared governance model. Every staff member, once oriented, takes on some outside responsibilities beyond patient cases. This really works well and lets people feel a sense of responsibility and accountability within the lab. We truly embrace the cross-training philosophy where everyone is able to share expertise. We also have a Witt hemodynamic monitoring system (Witt Biomedical, Melbourne, FL) which is located within the cath lab itself, allowing staff to participate in patient care. The Witt system has a transcription package where the physicians do their report generation, which is then forwarded to the hospital information system. We have two staff members who tirelessly keep our ACC database and reports pristine. Is there a problem or challenge your lab has faced? We experienced a rapid rise in volume since last November, with the start of our elective angioplasty program. While our volume in 2001 was approximately 680 procedures, for 2002/2003 we are at 2,200 procedures. This created a manpower and support services issue. We are happy to report that our administration was very supportive and quickly responded by increasing our FTEs to help meet our demand. What’s special about your city or general regional area in comparison to the rest of the U.S.? The prevalence of heart disease in Southeastern Massachusetts is 24% higher than the state average, which has a definite impact on the cardiac catheterization lab. More than 30% of our diagnostic caths go on to elective angioplasty and 15% to 20% of our patients go on to open heart surgery. Our patients benefit from the cultural initiative program Southcoast Hospitals Group embarked on more than 2 years ago. Each member of the cath lab is cognizant of our cultural elements quality and caring in the context of fiscal constraints; integrity, trust and openness across all departments, level and sites; and adaptiveness and flexibility while honoring our legacies. We see the rewards of cultural program in our congenial cath lab atmosphere and are sure that our patients benefit from it. For more information, please contact author Laurie Mulgrew at: MulgrewL@southcoast.org.

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The Society of Invasive Cardiovascular Professionals (SICP) has contributed 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? Clinical staff members are required to have certification. Exceptions are made based on experience “ as long as the registry is completed successfully within 1 year of employment. 2. Are 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? At this time, we have no one who is actively involved in their respective professional society.

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