Condell Medical Center

Our prep/recovery area staffs four full-time registered nurses, three full-time patient care techs, three part-time registered nurses and one part-time patient care tech. Residences of all our staff members in the cath lab and prep/recovery area range from two months to 12 years. Fifteen cardiologists perform procedures in our labs, seven of which are interventional cardiologists. What type of procedures are performed at your facility? A vast array of procedures are performed at our facility, including: Bilateral cardiac catheterizations Primary angioplasty and stenting Coronary thrombectomies Intravascular ultrasound (IVUS) Fractional flow reserve (FFR) Intra-aortic balloon pump (IABP) insertions Temporary and permanent pacemakers Pericardiocentesis Electrophysiology studies Radiofrequecy ablations Automatic implantable cardioverter defibrillators (AICDs) Biventricular pacemakers and defibrillators AICD threshold testing Peripheral artery angiograms and interventions, including stenting of carotids, renals, and extremeties Peripheral and coronary Atherectomies Patent foramen ovale closures Cardioversions, as well as an occasional transesophageal echocardiogram, as needed. We perform approximately 40-50 cardiac caths/interventions per week and approximately 20-30 peripheral vascular studies per month, as well as approximately 20-25 implantable devices and 10-15 electrophysiology studies per month. When did you begin performing peripheral procedures? We began performing peripheral vascular studies approximately four years ago. When we expanded our facility, we purchased larger II C-arms to accommodate the need for performing peripheral vascular studies. Our physicians had to prove credentialing or performed supervised procedures (approximately 10 assisting and 10 supervised). Five of our cardiologists perform peripheral interventions. Only cardiologists work in the peripheral and cath labs. (Radiologists perform procedures in the special procedures department.) Currently we have two labs stocked with all necessary supplies to perform peripheral cases, including peripheral stents, balloons, atherectomy supplies, peripheral guide catheters, and carotid distal protection devices and stents. Training of staff for peripheral studies was primarily achieved with the help of the various clinical specialists from the product companies and through the our physician expertise. Does your cath lab perform primary angioplasty with surgical backup? Our facility provides primary angioplasty with surgical backup. The open-heart team is in-house during working hours and is on call 24-7 on off-hours. They have a thirty-minute response time. What procedures do you perform on an outpatient basis? We can perform cardiac caths, cardioversions, AICD threshold testing, peripheral artery studies, and IVUS and FFR procedures on an outpatient basis. What percentage of your patients is female? Females make up an estimated 40 to 50 percent of our patient population. What percentage of your diagnostic cath patients go on to have an interventional procedure? Approximately 40-50 percent of our cath patients go on to an interventional procedure, either coronary artery bypass grafting (CABG), valve replacement, percutaneous coronary intervention (PCI) or another invasive diagnostic modality. Who manages your cath lab? We currently are managed by our cardiology director, Maggi Griffin, Jim Russo, RN, supervisor and our medical director, Dr. Timothy Alikakos. Do you have cross-training? Who scrubs, who circulates and who monitors? All our techs scrub and monitor cases. Two nurses are proficient in all three areas in the lab and the remaining nurses function in the roles of circulating and monitoring. Does an RT (radiological technologist) have to be present in the room for all fluoroscopic procedures in your cath lab? In our facility, an RT must be present in the area, not necessarily in the room. Only the physician or a RT can run the fluoroscopy pedal, but the scrub tech can pan the table, position the II and angle the camera. What are some of the new equipment, devices and products introduced at your lab lately? Some of the new equipment introduced into our lab recently includes the StarClose Vascular Closure System (Abbott Vascular Devices, Redwood City, CA) and an upgraded ESI electrophysiology mapping system (St. Jude Medical, Minnetonka, MN). Our new cath lab, which was just finished, has a new C-arm from GE Medical (Waukesha, WI). We have Philips C-arms in our other labs (Bothell, WA). Can you describe the systems you utilize and how they work in cath lab daily life? One system we use daily to provide optimal safe care to our patients is simply teamwork and dedication. The one system we had in place from the beginning of the lab is the quality people we have hired. How is coding and coding education handled in your lab? Because of the vital importance of coding procedures correctly in order to maximize reimbursement, we currently have a team member, Lorraine Gopp, a registered coder by trade, overseeing our cath lab charges, physician documentation and dictation. Lorraine is a wonderful resource, but as staff members we are all responsible for learning proper documentation and working with the physicians to maximize this system. How does your lab handle hemostasis? Primarily, our patients' arterial accesses are closed with one of three vascular closure devices: Angio-Seal by St. Jude Medical, StarClose or Perclose (Abbott Vascular). In the event that one of our patients does not receive a closure device, we are responsible for pulling the sheath(s) and obtaining hemostasis prior to discharge home or to the appropriate nursing floor. Does your lab have a hematoma management policy? Every morning, a staff member is assigned to check the procedure sites on our inpatients from the previous day, as part of our continuing performance improvement benchmarks. Hematoma management, like hemostasis, is our job hospital-wide. We tend to use the FemoStop® compression device (Radi Medical Systems, Wilmington, MA) as an adjunct to stabilize hematomas. How is inventory managed at your cath lab? Two senior members of our cath lab team, Steve Baraboo, RN, RT and Mike Mays, CVT have maintained our stock of diagnostic and intervention supplies. In addition, Rick Soto, CVT has taken on the task of maintaining our central stockroom and central supply par levels for our labs. Has your cath lab recently expanded in size and patient volume? With the ever-expanding patient population and growth of our hospital, we needed to expand from our three current labs to four. We have just taken occupancy in our new lab and brand-new 12-bed prep/recovery unit. Is your lab involved in clinical research? Our lab has been part of the carotid artery stenting study, CAPTURE, for the last year, under the guidance of cardiologist Dr. William Benge and neurologist Dr. Mitchell Grobman. Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? Fortunately, we have not had a complication in our cath lab requiring emergent cardiac surgery in the past year. What other modalities do you use to verify stenosis? Currently, our physicians utilize fractional flow reserve (WaveMap, Volcano Corp., Rancho Cordova, CA) and IVUS (Volcano Corporation) to assist in assessing severity, morphology and vessel size. I have been witness to many cases with the use of one of these modalities, and for certain cases, without these tools, I am certain that the patient would not have received the right treatment pathway. What measures has your cath lab implemented in order to cut or contain costs? With our challenging patient population and the constantly evolving product and service market, this is a never-ending challenge. A few of the measures we have implemented recently include: 1) Utilizing primarily 150ml bottles of contrast for each case instead of opening a 100ml for the coronaries and a 50ml bottle for LV/aortogram injections. 2) To reduce supply waste, we attempt to open only necessary supplies pre-procedure as we prepare the sterile table. If the physician changes sheath size or guidewire choice, these supplies will not be wasted. 3) We maximize our consignment products, such as balloons and stents. We do not partake in bundle contracts and purchases on any of our supplies or products. 4) Unnecessary overtime is monitored. On low-volume days, staff will offer to leave early. 5) We have developed a value analysis team to monitor and evaluate inventory, cost and the ordering of any new products. 6) We consistently renegotiate contracts with vendors and insist on paying fair market prices for our products in order to provide the patients with fair and prudent care. Does your cath lab do electives on weekends and or holidays? Currently, we do not perform elective procedures on weekends, but we are moving towards performing electives to reduce the length of stay for patients who come in Friday night or early Saturday. This process will decrease patient waiting and facilitate lowering hospital costs for unnecessary lengths of stay. We have an emergency team on call for after-hour emergent cases. What type of quality control/quality assurance measures are practiced in your cath lab? The medical director of performance improvement monitors performance improvement and quality assurance measures. Measures in the cath lab consist of groin complications, conscious sedation outcomes and PCI door-to-balloon time, which is continuously tracked and monitored by myself and the emergency department (for the last four months, we have attained under 90 minutes > 90% of the time). How does your cath lab compete for patients? We really do not have to compete for patients. Our hospital is centrally located in the county and fortunately was the first to expand. We have continued to grow. How are new employees oriented and trained at your facility? New employees have approximately a 3-month orientation, consisting of shadowing a preceptor and then moving into autonomous practice. In our facility, I stress that learning is ongoing and we can learn something from anyone on any given day or presented situation. We require all RNs to be BLS- and ACLS-certified with at least 1-2 years critical care experience. Our CVT group is unique in that all our technologists were trained on-the-job and via educational seminars/lectures. All our technologists had some form of medical background prior to working in the cath lab. They all are encouraged to sit for the RCIS exam after two years of cath lab experience. We require them to be BLS-certified and encourage ACLS certification as well. Radiology technologists are required to be licensed in this state, as well as BLS- and ACLS-certified. Does your lab have a clinical ladder? Our hospital is in the midst of developing a hospital-wide clinical ladder, but I foresee us developing our own ladder to accommodate the specialty field in which we work. What type of continuing education opportunities are provided to staff members? Continuing education is a large part of our practice. I have instituted monthly mandatory staff education lectures. Our clinical specs from the various product companies are always a good source from which to draw education. Annual competencies are completed as well. I developed a program where each staff member picks a topic or modality relative to the cath lab. They must lecture and develop a written test for that topic or modality. I have found this to be helpful in fostering group cohesiveness and it allows for creative teaching ideas. A written competency exam is also given, covering all aspects of cardiac care in the cath lab. Staff is encouraged to attend seminars to broaden their clinical practices. How is staff competency evaluated? Staff competency is evaluated annually with annual reviews and competency testing throughout the year. How does your lab handle call time for staff members? We have five call teams, consisting of two RNs and a RT or CVT. Each team takes one night a week and every fifth weekend starting at 6pm on Friday until 6:30am Monday. Our daily operating shift is 6:30am to 6pm, Monday through Friday, with the first cases starting at 7:30am. Most of the staff work ten-hour shifts. A few work eight hour shifts and are fit into the schedule to accommodate the busier times. Within what time period are call team members expected to arrive to the lab after being paged? Is an attending cardiologist always on-site? Call members are to remain within 30 min. of the facility and respond to the facility within that timeframe. An interventional cardiologist is always on call (24/7) for STEMI cases. How do you handle vendor visits to your lab? Vendor visits are by appointment only. We have policy of only two vendors per day. They cannot be from competing companies. The vendors are asked to stay out of the control rooms during cases, but if the vendor is asked into the case by the physician he or she must be in the procedure rooms, not the control rooms. Vendors are required to register with REPTRAKS and are to check in as they enter our facility. Does your lab utilize any alternative therapies (such as guided imagery, etc.)? Currently we have not implemented any alternative therapies. What trends do you see emerging in the practice of invasive cardiology? First, the growth of peripheral vascular studies and interventions, particularly carotid interventions. Second, I see the growth of multiple stent deployments in multiple-vessel disease versus sending patients for CABG. This may be due to the quality and reliability of the drug-eluting stent and the high acuity of the patient population with multiple system diseases. Has your lab has undergone a JCAHO inspection in the past three years? Our facility underwent JCAHO accreditation approximately 3 years ago, and is expected to undergo another within the next few months. As of April of this year, we have not undergone an accreditation. The only advice I have for labs or institutions about to undergo an inspection is to clinically practice daily as if your inspection is tomorrow. Where is your cath lab located in relation to the OR department, ER, and radiology departments? Our cath lab is situated on the first floor in the northwest corner of a four-floor medical center. The emergency room is located two hallways away and on the same floor. The surgery department is located next to the ICU on the third floor, above the cath lab. Please tell the readers what you consider unique or innovative about your cath lab and its staff. Our cath lab is much like any other growing cath lab service. We have all the same growing issues and everyday problems, good and bad, that most facilities undergo. In our prep and recovery areas, we have begun to take cardiac rule-out patients from the ER and monitor them in our unit as they go through their diagnostic tests. If they are ruled out, they are discharged from our unit to home. Is there a problem or challenge your lab has faced? Approximately three years ago, we were faced with a large but common challenge, staff burnout. Our director at the time, developed a plan to stagger shifts, with two teams arriving by 7:30am and a second shift of two teams arriving at 11:00am. At that time, we only had the swing lab and one other lab and we were performing anywhere from 12 to 19 procedures a day. She also suggested the call schedule be changed to one night a week and every fifth weekend. The staff was very receptive to the change and honestly, it provided rest and relief to a very tired staff. What's special about your city or general regional area in comparison to the rest of the U.S.? Our lab developed into a much-needed program for the area and surrounding suburbs. We are located in one of the northern suburbs of Chicago, and prior to an interventional and open-heart surgery program, all our patients had to be transferred approximately 30 minutes south (near the city) or 30 minutes north to the Milwaukee, Wisconsin area for advanced cardiac care. We are now establishing ourselves as a top program in northern Illinois. 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? We encourage our CVTs to take the RCIS registry exam after two years of cath lab experience. They all receive a raise after achieving that goal. 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? Currently our staff is not involved with any professional organizations related to invasive cardiology, but we are all avid readers of Cath Lab Digest! Jim Russo can be contacted at jrusso (at) condell. org.

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