Houston Northwest Medical Center’s Ed Roberson Heart Center

What is the size of your cath lab facility and number of staff members?   Ed Roberson Heart Center cath lab includes three cath rooms, an interventional radiology room and a 12-bed pre/post chest pain unit. Staff consists of: • 12 full-time registered nurses (RNs) • 1 PRN (pro re nata, or as-needed) RN • 5 full-time radiologic technologists (RTs) • 2 PRN radiologic technologists • 1 American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) database coordinator • 1 picture archiving and communication systems (PACS) administrator Physicians have a high level of confidence in our staff, as we have several employees which have been in the cath lab for more than 16 years. What type of procedures are performed at your facility? Diagnostics heart caths, percutaneous coronary interventions (PCIs), electrophysiology procedures (EP), peripheral cases, transesophageal echocardiograms (TEEs), tilt table testing, and stent grafts for abdominal aortic aneurysms (AAAs) and cardiac rhythm management devices (CRMs). Approximately how many procedures are performed each week? On average, we perform 40 cath procedures and 15 interventional radiology procedures each week. We perform about 50 peripheral procedures each year. Does your lab perform primary angioplasty with surgical backup on site? Yes. Our Class 3 patients are done with surgical backup (the OR has a room prepped, and surgical staff and a perfusionist are on site and ready if needed). These are scheduled with the OR by our staff and only for very complex procedures. What procedures do you perform on an outpatient basis? Diagnostic catheterizations, peripheral interventions, generator change-outs, diagnostic EP without ablations, arterio-venous graft declots, TEEs and tilt table testing are all done as outpatient procedures. Do any of your physicians regularly gain access via the radial artery? Yes. We have protocols in place for radial artery access and also use special catheters and sheaths. What percentage of your patients is female? Forty percent of our patients are female. What percentage of your diagnostic cath patients go on to have an interventional procedure? About thirty percent go on to have a PCI. What percentage of your diagnostic caths are normal? Normal rate for 2009 is 9.5%. Who manages your cath lab? Pam Egan, RN, is director of the heart center with four charge staff, a mixture of RTs and RNs. Bruce Lachterman, MD, is medical director of the cath lab. Who scrubs, who circulates and who monitors? RNs scrub, monitor or circulate, and RTs pan, scrub or circulate. Does an RT 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? Our RTs handle and monitor all of our x-ray equipment. How does your cath lab handle radiation protection for the physicians and staff that are in the lab day after day? Everyone has a radiation badge they are required to wear on a daily basis. Radiation exposures are posted for staff and physicians to view on a monthly basis. We provide lead aprons and glasses for staff and members of the medical staff. We also have lead shields attached to the table for additional protection. What are some of the new equipment, devices and products introduced at your lab lately? McKesson Horizon Cardiology PACS (San Francisco, CA) was purchased for the Ed Roberson Heart Center and is an all-inclusive system for nurses’ notes, image archives and physician dictation. We are currently using cool ablation technology and 3D mapping in our EP area. We utilize the Crosser (FlowCardia, Inc., Sunnyvale, CA) for chronic total occlusions and the Jetstream atherectomy device (Pathway Medical Technologies, Inc., Kirkland, WA) for peripheral interventions. Can you describe the system(s) you utilize and how they work in cath lab daily life? The McKesson Horizon cardiology system has several advantages for the physician. The system gives them the ability to view all of the devices used during the procedure, review balloon inflation times and pre-op history. The physicians can then review, modify the report if needed, sign, and send the report to our electronic medical record (EMR). The report can also be sent to the referring physicians. These reports can also be done via the web. We use GE flat-panel technology for our units in the cath suites. We have two GE Innova 2000 cardiovascular imaging systems and one Innova 3100 (Waukesha, WI). Interventional radiology uses Siemens Axiom (Malvern, PA), which has 3D capabilities. How is coding and coding education handled in your lab? Management keeps abreast of all new codes coming from CMS. Inservices are given to staff when new codes or revisions take place. A computer in the cath lab interfaces with patient billing and uploads all charges for supplies and procedures into the patient’s account. How does your lab handle hemostasis? We do use closure devices, mainly Angio-Seal (St. Jude Medical, Min-netonka, MN), Mynx (AccessClosure, Inc., Mountain View, CA) and some Perclose (Abbott Vascular, Redwood City, CA). The Mynx device is technologist-deployed and all of the staff are authorized to perform the closure device. Angio-Seal and Perclose are physician-deployed. All of the staff RNs and technologists are competent to perform manual holds. If the patient is a manual hold, the recovery room staff pull the sheath unless it is an unstable patient or a ST-elevation myocardial infarction (STEMI). What is your lab’s hematoma management policy? We take prudent steps to prevent hematomas by mandating extensive staff training. We frequently monitor post-op patients. When we do have a hematoma, the physician is notified and the patient is treated per physician’s orders. Staff on all cardiology floors are trained in hematoma identification and management. How is inventory managed at your cath lab? We use the par level system. Most of the more expensive inventory, including stents, guides, balloons, and some EP catheters, are on consignment. Materials management stocks the department with some necessary supplies and the charge staff is responsible for assuring the rooms are adequately stocked. Who handles the purchasing of equipment and supplies? The director/manager handles all of the equipment purchases through the capital budget. Consignment supplies are ordered by the charge staff. On a daily basis, supplies are scanned into the McKesson cardiology system and a report is run to identify needed supplies. Is your lab involved in clinical research? Yes, we perform a limited amount of drug studies. Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? Yes, one patient. This was a patient with a ventricular aneurysm that was undergoing an ablation. Can you share your lab’s average door-to-balloon (D2B) times and some of the ways employees at your facility have worked together to keep D2B times under the mandated 90 minutes? We have a team of ER nurses, cath lab staff, ER physicians and cardiologists that meet to assure our times remain below 90 minutes. Houston Northwest Medical Center has a protocol-driven STEMI activation system and partners with Cypress Creek EMS to reduce response time. Paramedics and ER nurses rotated through the cath lab to learn how to set up a patient for a procedure. These steps help reduce times by fast-tracking the patients directly to the lab, with only two cath lab members in-house. It is unique in that the paramedic alerts the cath lab team and cardiologist for a STEMI from the field by interpretation of the 12-lead EKG. Patients enter the ER and the ER physician reviews the EKG to confirm a STEMI. First quarter 2009 D2B time average was 64 minutes and ETB (time from 911 call) was 91 minutes. What measures has your cath lab implemented in order to cut or contain costs? We have incorporated measures such as our inventory management system, performing bulk buys for CRMs and getting aggressive pricing from our vendors on high-dollar items. In an effort to reduce costs and be more eco-friendly, the department reprocesses non-biohazard supplies. What type of quality control/quality assurance measures are practiced in your cath lab? The STEMI program is the most aggressive quality initiative. The department also participates in core measures throughout the hospital. Houston Northwest Medical Center has been awarded the Gold Performance Achievement Award for heart failure and coronary artery disease by the American Heart Association (AHA). How does your cath lab compete for patients? The marketing department works closely with the director on the marketing tools used for the heart center. The hospital is active in the community and offers several complimentary heart healthy preventative screenings throughout the year. Staff members are involved in awareness campaigns and participate in lecture series, the AHA Heart Walk, and other community activities. Other communications vehicles used to market cardiac services include quarterly community newsletters, monthly electronic newsletters, print ads, the website, etc. How are new employees oriented and trained at your facility? There is a three-month orientation period. The first month is spent learning to scrub, getting used to identifying the vessels, learning the workflow and knowing the physicians. The next month is used for panning or monitoring, depending on the employee’s licensure. In the last month of training, the new employee functions as a regular staff member with their preceptor in the room as a resource. What type of continuing education opportunities are provided to staff members? We have a computer program for education and inservices, which are chosen by the staff on a monthly basis, are available on a variety of topics. These are given by physicians, staff or outside sources. How do you handle vendor visits to your lab? Vendors are required to have an appointment with either the supervisor or the director. They are required to sign in and out in our materials management department. How is staff competency evaluated? We have a yearly critical care skills fair in which staff are checked off on certain skills. How does your lab handle call time for staff members? Call time is on a rotational basis. Is there a particular mix of credentials needed for each call team? We have three staff members on call, one RN and one RT. The third call team member can be either credential. Within what time period are call team members expected to arrive to the lab after being paged? Within 30 minutes, the call team and cardiologist must be on site. Do you have flex time or multiple shifts? We have flex time on slow days. Our recovery room has a late evening shift from 12pm-8:30 pm. Has your lab has undergone a Joint Commission inspection in the past three years? Yes, in March 2009. The inspector who came through our lab was very interested in our moderate sedation policy, time outs, medication reconciliation and discharge of patients from our recovery area. How do you see your cardiac catheterization laboratory changing over the next few years? We think cardiologists will become more aggressive with stenting multiple vessels at one time and will start to perform more peripheral interventions on an outpatient basis. With the downturn in the economy, we could potentially see more acute MIs as patients put off medical care. What do you consider unique or innovative about your cath lab and staff? Our cath lab staff has an average of six years of experience, giving us the ability to truly work as team members with physicians. Cardiologists bring the difficult cases to Houston Northwest because they are very confident and comfortable that the staff can handle any event which might occur. In addition, we have non-interventional, recovery and the CPU all on the same floor. Physicians can perform their stress test, see their CPU patients and perform caths without leaving the unit. Houston Northwest Medical Center is among an elite group of hospitals nationwide — and among only two in Texas — named by the Institute for Healthcare Improvement (IHI) as a Mentor Hospital for Acute Myocardial Infarction. The hospital is also the recipient of the American Heart Association’s Get with the Guidelines Gold Performance Achievement Award for both heart failure and coronary artery disease. Houston Northwest is one of two hospitals in the United States to become a beta site for the McKesson Horizon Cardiology PACS system. This will give us a voice in how the application will work before it is released to the general public. Is there a problem or challenge your lab has faced? We are challenged to remain competitive as an area leader as more and more cath labs continue to open in our region. We built a new cardiology floor which contains invasive, non-invasive and CPU. We try to accommodate our physicians with the latest technology and schedule procedures in a timeframe acceptable to them. What’s special about your city or general regional area in comparison to the rest of the U.S.? Houston is the fourth-largest city in the United States, with a very diverse culture, allowing the city to have a wide range of cultural activities, from the rodeo to the theater district. Houston is also well known for its cutting-edge medical care. Being located in such a diverse city has allowed staff to learn from and about other cultures. 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. 2. Are your team members involved with any professional organizations that support the invasive cardiology service line, such as the SICP, ACVP, or regional organizations? Our director is involved in the SICP. The authors can be contacted at pam.egan@tenethealth.com.

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