Frederick Memorial Hospital Cardiac Catheterization Lab

What is the size of your cath lab staff and facility? The cath lab at Frederick Memorial Healthcare System is a new department, approved by the Maryland Healthcare Commission to perform primary percutaneous coronary intervention (pPCI) as of March 14, 2008. Until a permanent structure is built, we are currently renting a modular catheterization lab through Modular Devices Inc. (MDI) of Indianapolis, Indiana, which is giving the hospital time to make crucial long-term decisions regarding the construction and design of the new, permanent cath lab within the next two years. We currently have 9 full-time and 2 part-time staff members: • 4 full-time registered nurses (RNs); • 1 part-time RN; • 4 full-time radiologic registered technologists (RTs); • 1 part-time RT; • We also have 1 full-time RN who is dedicated to the task of data collection. We do acknowledge the registered cardiovascular invasive specialist (RCIS) credential and have staff members who hold a dual registry and license. Our manager is Bridget Plummer, RN, and our director is Nancy Bruce, RN. What types of procedures are performed at your facility? We perform left-heart catheterizations, right-heart and left-heart combination catheterizations, permanent and temporary pacemaker insertions, pericardiocentesis, transesophageal echocardiography (TEE), pPCI, intravascular ultrasound (IVUS), intra-aortic balloon pump (IABP) insertion and various peripheral procedures. Since opening on March 14, 2008, we have performed approximately 12 pPCI procedures monthly, as well as a significant volume of diagnostic cardiac catheterizations. Our modular lab is equipped to perform diagnostic heart catheterizations as well as pPCIs. A holding bay in the modular lab area is utilized for TEEs as well as cardioversions. We utilize a hybrid OR in the operating room that is shared by interventionalists and vascular surgeons, with the appropriate equipment for peripheral procedures. Does your cath lab perform primary angioplasty with surgical backup on-site? We were given approval through the Maryland Health Care Commission to perform pPCI with a tertiary hospital as support. Washington Adventist Hospital is our designated tertiary hospital, which provides surgical backup for any cases that arise. What percentage of your patients is female? On average, about 40 percent of our patients are female. What percentages of your diagnostic catheterizations are normal? We average approximately 15 percent normal procedures. Who manages your cardiac catheterization laboratory? Bridget Plummer, RN is the manager of the cardiac cath lab, echocardiography, electrocardiography and vascular departments. She possesses over 20 years of cath lab and electrophysiology experience. Do you provide cross-training? Cross-training is offered at our facility in various areas. All staff are cross-trained within the scope of practice relating to their specific credentials. All staff perform three roles, with the exception that only RNs administer medications and the registered radiologic technologists and physicians handle the imaging equipment. Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab? The radiologic technologists are always required to be present for exams involving fluoroscopy. Which personnel can operate the X-ray equipment (position the image intensifier, pan the table, change angles, step on the fluoro pedal) in your cath lab? Both the physicians and the RTs can perform these duties. How does your cath lab handle radiation protection for the physicians and staff who are in the lab day after day? All staff interacting with radiation in any form must wear radiation monitoring badges and a full lead apron. We also use the rules of time, distance and shielding to reduce exposure to staff. The radiologic technologists are in charge of ordering, supplying, returning and monitoring the use of radiation badges in the lab. How is staff competency evaluated? Competency is evaluated annually by the clinical leaders who test employees according to a list of skills for all equipment and procedures. Does your lab have a clinical ladder? At this time we have a clinical ladder for the RNs and will be developing a clinical ladder for our RT and RCIS staff members. How do you handle vendor visits to your lab? Vendor visits are scheduled with our vendor liaison who coordinates appropriate times so as to not distract our staff during cases. When vendors are needed for a specific procedure, if they do not have a radiation badge provided by their company, we provide a visitor badge for them. We avoid having vendors entering the lab without an appointment as much as possible, unless they are needed to provide a specific service for a case in order to protect patient privacy. How does your cath lab handle call-time for staff members? At this time, our staff is on call for a week at a time, every other week. Our call-team consists of four staff members: two RNs and two RTs. Within what time period are call team members expected to arrive to the lab after being paged? All call team members are required to arrive to the lab within 30 minutes of being paged. An attending cardiologist is not always on site; however, we have technology that allows the initial electrocardiogram (ECG) to be transmitted via fax or phone. A cardiology consultation is performed within 10 minutes of ECG arrival. If necessary, a “Code Heart” is activated (meaning the patient has a ST-elevation myocardial infarction, or STEMI), and the call-team is activated with a one-page system. Our center has also initiated a Lifenet system involving the emergency medical services (EMS). Lifenet is a 12-lead ECG transmission system allowing Code Hearts to be called prior to patient arrival, with the coordination of the ED physician. To save valuable time, this pertinent system allows us to move patients directly to the cath lab, bypassing the ED. Do you have flextime or multiple shifts? Yes, we have both an early and late shift. These hours are flexed for the staff when on call. Does your cath lab perform elective procedures on weekends and/or holidays? No. The call-team is only available for emergencies. Has your lab undergone a Joint Commission inspection in the past three years? Frederick Memorial Hospital has undergone several Joint Commission surveys, the most recent of which was very successful, as no recommendations were made. Where is your cath lab located in relation to the operating room and the emergency room? Our modular lab is located next to the emergency department, which is very convenient for emergency cases. We are also located in close proximity to the operating room. Have you had any cath lab-related complications requiring emergent cardiac surgery? No. What other modalities do you use to verify stenosis? We use intravascular ultrasound (IVUS) imaging. Does your lab utilize any alternative therapies (such as guided imagery, etc.)? No, not at this time. What measures has your cath lab implemented in order to cut or contain costs? The medical director and manager, along with the materials management department, cooperate to ensure contracts and inventory management. For example, we utilize buying groups and maintain tight control of inventory. Supply additions or changes are handled through a process that evaluates necessity and costs. What types of quality control/quality assurance measures are practiced in your cath lab? We have a dedicated data collection nurse who maintains all of our STEMI data. This includes door-to-balloon (DTB) times and patient follow up. In addition, we conduct monthly cath lab operations and case review meetings. How does your cath lab compete for patients? Has your institution formed an alliance with others in the area? Our hospital is fortunate, since we are the only one in the area and do not have much direct competition. Now that patients can receive services nearby instead of having to drive a long distance, our competition has been further reduced. We do have an alliance with Washington Adventist Hospital in Takoma Park, Maryland, and Johns Hopkins Hospital in Baltimore, Maryland. How are new employees oriented and trained at your facility? We have a formal orientation packet/process in place for all new employees that is specifically designed for the individual role the new employee will play in the lab. None of our staff members has less than a year’s experience. Our staff members come from many different facilities in the Washington, D.C. and Baltimore areas. In order to work in the cath lab, candidates must be at least a registered nurse or a registered radiologic technologist. What types of continuing education opportunities are provided for staff members? We have frequent vendor visits for inservices on their products, equipment and pharmaceuticals, so that the staff are well-trained in all aspects of the cath lab. What are some of the new equipment, devices and products introduced at your lab lately? Our facility just purchased the AngioJet Ultra (Possis Medical, Minneapolis, Minnesota) and an iLab ultrasound system (Boston Scientific Corp., Natick, Massachusetts). Can you describe the system(s) you utilize in your cath lab? We have Philips X-ray equipment (Bothell, Washington) and a GE CardioLab (Waukesha, Wisconsin). Our cath lab is very well equipped. How is coding and coding education handled in your lab? The coding department at our hospital handles this process. Patient charging is done for procedures, along with the supplies used in our hospital-wide computer software by our cardiac cath lab staff, which is then sent to our billing department. How does your lab handle hemostasis? If possible, closure devices such as the Angio-Seal (St. Jude Medical, Minnetonka, Minnesota) or Perclose (Abbott Vascular, Abbott Park, Illinois) are used to increase patient comfort. When we are unable to use a closure device, generally the staff member who scrubbed with the physician holds pressure on the access site and achieves hemostasis. In the case of an intervention, when we have administered heparin or a glycoprotein IIb/IIIa inhibitor, we measure the activated clotting time (ACT). If it is not appropriate to pull the sheath immediately post procedure, the patient is sent to the intensive care unit, usually with a FemoStop (Radi Medical Systems, Wilmington, Massachusetts), and an ACT is repeated until it is appropriate sheath removal. What is your lab’s hematoma management policy? In cases of a hematoma, a cath lab staff member is alerted and we hold pressure to reduce the size and avoid spreading of the hematoma. FemoStop, c-clamp or hemostatic pads are utilized. How is inventory managed at your cath lab? At this time, we have a team who handles maintaining par levels and ordering equipment and supplies. One person orders diagnostic supplies, another orders interventional products, and a third person is in charge of electrophysiologic supplies. We do utilize an inventory management system for the modular lab, but plan to implement such a system for the permanent structure. Has your cath lab recently expanded in size and patient volume, or will it in the near future? Yes. Our facility used to perform diagnostic catheterization procedures in a room that was shared with interventional radiology/special procedures, so the number of examinations was very limited. Today, we have a full-service, dedicated cath lab, which allows us to perform a large number of procedures on a daily basis. The cath lab staff members have many years of cardiac interventional experience. Future new hires who do not have these skills will go to our tertiary center for additional training. We also hope to see an even bigger increase in patient volume when we move into our permanent area with more labs. Is your lab involved in clinical research? No, not at this time. Can you share your lab’s average door-to-balloon (DTB) times? Currently, we have an average DTB time of 69 minutes. One of the ways we have worked to keep our DTB times low is to work on maintaining a great relationship with the entire emergency department staff. They have shown us tremendous support and are all on board to consistently meet the required DTB times. This is not seen as a cath lab effort, but rather a hospital-wide effort. In addition, each of our cath lab staff members takes personal ownership of his/her role in contributing to the shortest possible DTB time. We take great pride in celebrating the cases with short DTB times and great care in examining cases that were further out on the spectrum so as to eliminate any possible causes of future delays. How do you see your cardiac cath lab changing over the next few years? We are in the process of planning our permanent cath lab area and would like to have two or three rooms for procedures. There are ongoing meetings with the architects to designate a permanent cath lab location. We would also like to add a full-service electrophysiology program. Is there a problem or challenge your lab has faced? The modular lab has very limited storage space, which causes difficulties with storing supplies. Since we are in the process of drawing up plans for a permanent facility with several labs, we are making sure to leave ample room for storage and supplies. Please tell the readers what you consider unique or innovative about your cath lab and its staff. So far, we have been able to achieve phenomenal DTB times. Ours is a collaborative effort that results from being able to alert the cath lab team from the field, staying within a 30-minute response time from all cath lab team members, and receiving tremendous support from our emergency department staff. 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 hospital is the only one in the area for the population it serves. As a result of our new cath lab, there is a huge geographical area that now has access to diagnostic, and more importantly, interventional procedures, that previously would have had to be performd at a center located at least 45 minutes away from most patients’ homes. This is a huge relief for patients and their families, as it is often a burden for family to be able to travel back-and-forth to larger facilities. The Society of Invasive Cardiovascular Professionals (SICP) has added two questions to our spotlight interview: 1. Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? Do staff members receive an incentive bonus or raise upon passing the exam? No, not at this time. However, all of our staff members must be either a registered nurse or a registered radiologic technologist. 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, the ACVP or regional organizations? Not at this time, but we look forward to this in the future. The author can be contacted at bplummer@fmh.org

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