Geisinger Medical Center

Geisinger Medical Center is a 410-bed, level 1 trauma center in central Pennsylvania. We have been designated as an Accredited Chest Pain Center with PCI by the Society of Chest Pain Centers and have been voted, for the 4th time, one of the nation’s top 100 cardiovascular hospitals by Thomson Reuters. We recently obtained Magnet designation by the American Nurses Credentialing Center. Our hospital was founded in 1915 and is one of the largest rural healthcare facilities in the United States. Our care spans through 40 counties, reaching 2.5 million residents of central and northeast Pennsylvania. What is the size of your cath lab facility and number of staff members? Included within our department are 3 cardiac cath labs, 1 electrophysiology (EP) lab, 1 minor procedure room and a 16-bed cardiac recovery suite. Staffing the cath lab and EP labs are 20 registered cardiovascular invasive specialist (RCIS)-credentialed technologists, 1 cardiovascular technologist (CVT) and 1 EP registered nurse (RN). The experience of our techs ranges from 1 to 25 years, with over half employed for more than 10 years. We have 6 interventional cardiologists, 3 electrophysiologists, 1 invasive cardiologist and 1 pediatric interventional cardiologist. Because we are a teaching hospital, our staffing also includes 1 interventional fellow and 1 EP fellow who work full-time in the labs, and 12 general cardiology fellows in our 3-year fellowship program who rotate through the labs. Ten RNs, with LPN assistance, run the cardiac recovery suite, which transitioned into a 24-hour unit this year. Our department is further supported by 3 secretaries and 3 research coordinators. What types of procedures are performed at your facility? We provide to our adult patients both diagnostic (2,800/year) and interventional (1,100/year) cardiac procedures. These also include intravascular ultrasound (IVUS), fractional flow reserve measurements, intra-aortic balloon pump (IABP) insertion, coronary thrombectomy, rheolytic and aspiration thrombectomy, pericardiocentesis, patent foramen ovale (PFO) and atrial septal defect (ASD) closures, rotational atherectomy, biopsies, TandemHeart (CardiacAssist, Inc., Pittsburgh, PA) and Impella (Abiomed, Inc., Danvers, MA) left ventricular assist support for high-risk interventions, valvuloplasty, left atrial appendage occlusion (in research trials) and laser atherectomy. Robert Mangano, MD, runs a very successful pediatric cardiology service at Geisinger. Approximately 2-3 children per week are scheduled for both diagnostic and interventional cases in the care of congenital anomalies. Procedures include right and left heart evaluations, ASD/PFO/ventricular septal defect (VSD) closures, valvuloplasties, patent ductus arteriosus (PDA) coiling, biopsies, and ballooning and stenting of various stenosed vessels. Our peripheral program began in 2003 and continues to grow. Our program includes endovascular revascularization of lower and upper extremity, carotid, renal, and mesenteric arteries. About 75 interventions and 150 diagnostic procedures were performed in 2008. These volumes are increasing with referrals and from our involvement in research trials. Our EP lab performs ablations, pacer and defibrillator implantations and changes, lead extractions with and without the use of laser, lead revisions, cardioversions, and tilt table testing. Does your cath lab perform primary angioplasty with surgical backup on site? Geisinger has a fine team of cardiovascular surgeons available for emergent and urgent surgery for our patients, but are not on standby for our procedures. If the occasion arises, we will contact one of our surgeons who is assigned each day to emergent cases. When there is an indication for surgery, arrangements are made to move the patient to a surgical suite as soon as a team is available. Emergency surgery for complications of percutaneous coronary intervention (PCI) at Geisinger, as at most institutions, is needed in only about 0.1% of elective cases and in about 0.2% of emergency cases. What procedures do you perform on an outpatient basis? All of our patients undergoing a diagnostic procedure are recovered and evaluated post procedure through the cardiac recovery suite before they are sent home. We are currently piloting a program for same-day discharge for elective, uncomplicated PCI patients. This may eventually include most of our outpatient PCI patients. What percentage of your patients are female? Approximately 41% of our patients are female. What percentage of your diagnostic cath patients go on to have an interventional procedure? All diagnostic patients undergo full informed consent for interventional procedures prior to their procedure. About 1/3 of diagnostic catheterization patients also undergo PCI. Of these, 93% are done directly after the diagnostic procedure. Due to patient-centered or medical reasons, some PCIs are scheduled for a later session. Who manages your cath lab? Our entire invasive department is managed by our operations manager, Donna Myers, RCIS, MHSA. She has 22 years of experience with the Geisinger cath lab, first as a technologist, then as director of the Geisinger School of Cardiovascular Technology. After obtaining her masters degree in health services administration, she began managing the department in 2005. Do you have cross-training? Who scrubs, circulates and monitors? Our cath lab is unique in that it is staffed entirely with RCIS technologists who are fully trained to work in all roles of the cath lab, thanks in part to our school, the Geisinger School of Cardiovascular Technology. The school is accredited until 2017 by the Commission on Accreditation of Allied Health Education Programs. Stephanie Ranck, BS, RCIS, who began as director of the school in January 2006, is one of about 80% of our techs who have been educated through this school since the first class in 1991. Students work closely with preceptors to learn and understand all aspects of patient care in each of the 3 roles. The students study cardiac anatomy and physiology, cardiovascular disease and assessment, pharmacology, hemodynamics, electrocardiography, radiation physics and safety, electrophysiology, pediatric cardiology, respiratory care, and patient care, among other subjects. Multiple rotations through the lab roles give the students the competence needed to perform all duties. The school is a 1-year program that is fully integrated with our entire cardiology department. Because of this training, and the additional experience after hire, all of our techs are skilled in all positions and are able to do any part of a procedure, offering a good team approach to the care of our patients. What are some of the new equipment, devices and products introduced at your lab lately? Our initial use of some new devices comes through research trials. We were the second lab in the country to place the Parachute, a left ventricle apical partitioning device (CardioKinetix, Inc., Menlo Park, CA) and we have performed left atrial appendage occlusion. We have used the TandemHeart for support in high-risk coronary interventions and have recently started using the Impella left ventricular assist device. Introduced last year for use in our lab was the Excimer Laser System (Spectranetics, Colorado Springs, CO), used for both coronary and peripheral chronic total occlusion (CTO) cases and EP procedures. We have stocked the new Medtronic Endeavor (Minneapolis, MN) and the Xience V (Abbott Vascular, Redwood City, CA) and have added the Starclose (Abbott Vascular) to our supply of closure devices. We have increased our use of Volcano Corp.’s Eagle Eye Gold IVUS and Prime Wire (Rancho Cordova, CA) to assess lesion severity, with Volcano systems installed in all cath lab rooms. Can you describe the systems you utilize and how they work in cath lab daily life? Our pediatric room is equipped with Siemens (Malvern, PA) bi-plane flat screen equipment. This allows lower radiation and contrast exposure for our babies and for our adult patients who have renal insufficiency, for example, and require less contrast exposure. We have 2 rooms that have been equipped with Philips (Bothell, WA) systems, including the use of digital subtraction and a 12-inch intensifier in our peripheral room. Images are archived immediately onto our Philips Xcelera PAC system. This allows doctors to view the images on any Xcelera station in the hospital. Images from echocardiology can also be viewed on the system, allowing for an integrated approach to cardiac diagnostics. How is coding and coding education handled in your lab? The certified professional coder (CPC) from the billing department coding the cath and EP labs has an office within the cath lab and works closely with our operations manager on billing each day. They verify preliminary coding done by the techs for each procedure and submit a daily report of charges for review to the billing department for accurate reimbursement. Attendance at national coding conferences and in-services are available to our CPC for yearly updates. Changes that have come in the past few years have required some revising of forms to include codes for additional procedures. All staff is educated on the changes in codes and coding policy. How does your lab handle hemostasis? Sheath removal and groin management are handled differently for each interventionalist. Prior to sheath removal in PCI cases, femoral angiography is done to determine potential issues with hemostasis. In most of our interventional cases, hemostasis is managed by closure devices. We primarily use Angio-Seal (St. Jude Medical, Minnetonka, MN) but also use Perclose and Starclose (Abbott Vascular) devices or use manual compression following guidelines for clotting time. Technologists who have performed 25 successful vascular closures procedures under supervision are approved as independent operators. At the interventionalist’s discretion, the tech can take responsibility for performing vascular closure independently. In all of our radial cases, we use the TR Band (Terumo Medical, Somerset, NJ), or D-Stat Dry (Vascular Solutions, Inc., Maple Grove, MN) devices. Hemostasis after diagnostic catheterizations is often managed by manual compression. The scrub tech in the case is responsible for hemostasis at the end of the case. Sheath removal after diagnostic procedures is done in the cardiac recovery suite. Does your lab have a hematoma management policy? We do not have a formal policy for management of hematomas. For patients in the cardiac recovery suite or on patient floors, assessing groin management issues is usually the responsibility of the technologist. Hematomas are pressed out at the first sign, whether during or post procedure. Manual pressure is used and devices such as the FemoStop (Radi Medical Systems, Wilmington, MA) are considered when necessary. Part of the doctors’ post-procedure protocol is to do a groin check of each patient who has undergone an intervention later that day and on the following day, and groin complications are recorded. Complications are presented at monthly conferences. Has your cath lab recently expanded in size and patient volume, or will it be in the near future? Construction is currently underway to build a 9-story hospital dedicated mostly to cardiac care. The Hospital for Advanced Medicine will consist of cardiac intensive care units, telemetry rooms, and non-invasive procedure units as well as the EP and cardiac cath labs. This will expand our suites to 2 EP rooms and 3 catheterization labs, and a minor procedure room, as well as space for future growth. The cardiac recovery suite will be expanded to accommodate a projected increase in outpatients. The hospital is expected to open in 2010. Despite national trends toward fewer interventional procedures, our cath lab volumes have remained stable at a time of expansion in diagnostic and interventional labs within our service area. In contrast, our EP lab volumes have increased by over 40%, which has demanded increases in lab time and staffing. Is your lab involved in clinical research? Since 1993, the Geisinger cath lab has participated in over 45 research studies, bringing in well over $2 million to Geisinger. At present, clinical research is a daily part of the cath lab. We currently participate in 28 sponsor-supported clinical trials and 4 investigator-led, “home-grown” studies. There are 3 full-time research coordinators for interventional cardiology along with an administrative research liaison. This staffing supports the interventionalists, who are all active in clinical research. Recently our lab was the top-enrolling site in the country for the AMIHOT II trial of aqueous-oxygen intra-coronary infusion after myocardial infarction (MI), and for the ERASE-MI study. We have participated in studies that involve IVUS analysis of lesion progression, left atrial appendage occlusion, distal protection devices and a ventricular partitioning device placement. We have also been part of various stent and pharmaceutical trials. Funds remaining after trial closure have been used to endow a visiting professorship that brings world-famous cardiologists to speak at Geisinger. These residual funds have also been used to purchase cath lab equipment and cover participation in unfunded trials, both home grown and multicenter. We were able to fund the start-up of our Level 1 Heart Attack program, a program that offers our emergent patients the shortest time to PCI, starting with first responders. What other modalities do you use to verify stenosis? The x-ray systems in all of our rooms allow for quantitative analysis at tableside. Since the publication of the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial, we have increased our use of IVUS and intra-coronary fractional flow reserve to determine when PCI of lesions is appropriate. We have recently experienced a 5% drop in interventional volumes with a corresponding increase in fractional flow wire procedures. We think this reflects a more evidence-based approach to decision-making for PCI of intermediate lesions. How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies? Inventory ordering and management is handled by our own techs. Our primary ordering manager is Jesse Weaver, RCIS, who works through our purchasing department to order necessary supplies and equipment, and to control inventory. Three other techs take a secondary role in specific inventory control, in the areas of pediatrics, peripheral and diagnostic supplies, to better manage our large inventory. With the new hospital expansion, an inventory system is being implemented to help manage our expected increase in supply needs. We have begun to work with QSight Materials Management Systems (Owens & Minor, Mechanicsville, VA) to control inventory more efficiently. Our medications inventory is managed by Joyce Roberts, BS, RCIS. Joyce works with pharmacy staff in maintaining stock, monitoring outdates and managing adherence to guidelines for medication safety and preparation. What measures has your cath lab implemented in order to cut or contain costs? We are working on increasing consignment stock as well as maintaining par levels to avoid overstock. It became evident in the past few years that much of the loss was tied up in purchased inventory that was outdating for lack of use. Having techs responsible for checking outdates assists in cutting costs from waste. Once implemented, we believe the QSight system will also assist us in controlling costs. To control inventory matters, a Cardiology Clinical Use Committee was formed. This committee approves the purchase of devices and equipment of interest to the lab, and also renegotiates contracts. This controls costs in several ways. First, it ensures that all orders are placed through the supply chain services department, which negotiates for the best possible price. Second, it requires the interventional physician group to reach consensus on which devices to use, instead of random decisions that lead to overstock and unused merchandise. Third, it ensures that physicians are sensitive to the financial impact of their selection of equipment and encourages them to be fiscally responsible. The committee saves several hundred thousand dollars annually and the idea has been copied throughout the health system. What type of quality control/quality assurance measures are practiced in your cath lab? Each of our techs has assigned monthly quality control tasks for equipment or processes within the cath lab. These include radiation reports, calibration and function of our equipment, pharmacy reports, inventory control with monitoring of expiration dates, Joint Commission compliance, and procedure protocols. We also participate in the American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR). Starting in 2008, we initiated our ProvenPCI program to improve quality of PCI procedures. A team consisting of cath lab techs, mid-level providers, interventional cardiologists and clinical effectiveness experts identified 40 evidence-based aspects of the “perfect” PCI procedure. Examples of these include bicarbonate infusions for patients with renal insufficiency and performing femoral angiography before PCI is undertaken to identify unsafe access situations. Now the team is working to ensure that every interventional patient receives all 40 aspects of ProvenPCI. The goal is 100% compliance for 100% of patients. How does your cath lab compete for patients? Has your institution formed an alliance with others in the area? Geisinger has formed an informal alliance with community hospitals and instituted a program to manage care for patients in need of emergent PCI. The Level 1 Heart Attack Program of Central and Northeastern Pennsylvania is based from Geisinger Medical Center and involves a coordinated effort with 15 referring community hospitals, 5 Life Flight helicopters, and participating emergency medical units from 10 counties. The Level 1 Heart Attack Program, under the direction of James C. Blankenship, MD, director of the cardiac catheterization laboratory, and Karen Tompkins-Weber, RN, helped us reach a median door-to-balloon time of 89 minutes for all transferred STEMIs. For patients entering our institution, door-to-balloon time for 2007 was 42 minutes. A year ago we instituted the CathDirect program to simplify access to catheterization services for our patients and referring physicians. Prior to this, patients often waited weeks for an appointment. Under the CathDirect program, a referring physician can schedule a diagnostic catheterization, usually within a week, directly through a hotline number and an additional cardiology consult is not required. Mid-level providers are able to obtain information from referring physicians and patients, and upon arrival to the cath lab, can complete all necessary exams and obtain consent. This program has worked very well and has been received enthusiastically by both referring physicians and patients. About half of our outpatient catheterizations are currently scheduled by CathDirect. What type of continuing education opportunities are provided to staff members? We have many inservices from our drug, equipment and device representatives offering information on the latest developments in cardiology and cardiac care, and also making credits available toward our credentials. Our fellows and doctors have also lectured for the technologist staff on specific cardiac diseases and treatments. All techs are given opportunities to attend national conferences and are made aware of lectures through SICP or other professional organizations. The Geisinger cardiology department offers a yearly conference and many well-known speakers come to the campus throughout the year to speak on cardiac care topics. How do you handle vendor visits to your lab? Geisinger has begun to use Vendor Credentialing Service (Spring, TX) for vendors who wish to visit our hospital. VCS credentials vendors, installs badge scanners for security and assures vendor compliance to healthcare organization guidelines. Beyond the requirements of the hospital, vendors who do visit the cath lab are welcome with a few restrictions. Scheduled through our secretary, we usually limit to one or two non-competing representatives per day unless particular vendors are invited by the interventionalists for a specific procedure. All of our vendors are asked to keep their product and material in our conference room and all must ask permission of the doctor if they wish to be in the patient areas of the lab. No pharmaceutical representatives are allowed without an appointment with a physician. How is staff competency evaluated? At this time, annual written evaluations are provided. Jim Roberts, BS, RCIS, has designed competency evaluations for all staff members for equipment, medications and procedures. With some new employees joining our staff in the past 5 years and the continuous introduction of new devices and technology, we want to assure ourselves that we can remain competent with the growth of the cath lab. How does your lab handle call time for staff members? The call schedule is made by our operations manager. Three techs will be on call and are usually scheduled one night per week and one weekend per month. Weekend and holiday teams are consistent, whereas weekday teams rotate throughout staff. Holidays are rotated through the group in a 4-year rotation. There is one tech per day on a staggered schedule. This person is primarily responsible for patient care on the floor, such as post-procedure sheath removal or with special procedures such as pericardiocentesis and IABP insertions. Has your lab undergone a Joint Commission inspection in the past three years? Our last inspection was in 2007 and we did very well. We hope to maintain the progress that we’ve made and assigned one of our techs to monitor our Joint Commission status. Lead tech Dennis Neamand, BS, RCIS, keeps up to date with Joint Commission requirements and alerts staff to practices that are not compliant. This is part of our environmental surveys, which also include patient tracers done by the operations manager, and quality assurance tracers, which all monitor performance for areas of improvement. We also have mock surveys performed by a senior executive leadership team. This will keep our lab within guidelines from year to year. Where is your cath lab located in relation to the OR department, ER and radiology departments? The cardiac cath lab is found on the first floor directly behind the Emergency Department and next to the helicopter/emergency elevator. The operating room is on the second floor just off of that elevator. Transfers between these departments are uncomplicated. 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”? This part of central Pennsylvania is a rural region, with communities primarily started by our coal mining and farming industries. It tends to be an area with generations of families living in close proximity for all of their lives. Strong family ties are important to the people of this area. Most of our techs were raised locally and will often find familiarity with their patients in the things they do or knowing the same people and places. The thought that a neighbor is taking care of them gives our patients a sense of trust and puts them at ease. This regional trait translates to the cath lab family as well. Family is how we describe our cath lab staff. Staff will frequently spend time together outside of the lab for personal events or just social times. We have, almost in entirety, attended each others’ bridal and baby showers and weddings, attended family funerals and graduation parties. We celebrate each others’ birthdays. We designed and sewed a quilt with inspirational and personal messages for a coworker with cancer. We offered up our sick days to those who were more in need of paid time off. One tech, with definite plans to move away, instead decided to stay because of the unique environment that we have at Geisinger. We have our own community amongst ourselves and the bond we have is what gets us through the illnesses, grief and joys of our brothers and sisters. It is apparent to the staff throughout the hospital, and to our patients as well, that this lab is quite special and sincerely considers ourselves a family. 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? All of our tech staff are expected to obtain an RCIS certification within 2 years of the start of their employment. All of our students in the CVT school have the opportunity to take the test at the end of the program to be ready for hire as an RCIS. There is no bonus in place for passing the exam. 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? Many of our techs are members of SICP and we are currently attempting to start a chapter for this area of Pennsylvania with other hospitals in the northeast region. Some of our techs are also members of the American Heart Association. Acknowledgments. We are grateful to James Blankenship, MD, Karen Tompkins-Weber, RN, Donna Myers, BS, MHSA and Susan Frye, MBA, for their review of and contributions to this article. The author can be contacted at pashoup@geisinger.edu.

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