South Austin Hospital

What is the size of your cath lab facility and number of staff members? We currently have two labs at South Austin Hospital, which is a 200-bed facility. Adjacent to one of the labs is a small 2-bed holding area for pre and post procedure. We have just started an expansion project to increase our capacity. The hospital is adding additional beds, a new ICU, a new CVRU, an expanded ED, two new CVORs, and other expanded ancillary services. Included will be the addition of two more labs for a total of four labs. Our two existing labs will be moved to the new area, where we will also have an expanded patient prep area. The construction has already begun, and expected completion time is 18-24 months. There are 12 full-time positions in the lab. Our staff mix includes: RNs RTs RCISs CVTs Patient Care Techs Materials Coordinator/Buyer We also supplement our staffing with PRN and contract labor as needed. Many of our staff have transferred into the department from other areas of the hospital. Tenure starts at six years and varies from there. Several staff members have been at our facility for more than 10 years. What type of procedures are performed at your facility? A typical week in the lab will include diagnostic heart caths, peripheral diagnostic and interventional procedures, pacemakers, and PCI. The PCI cases range from POBA to rotational atherectomy, stenting, brachytherapy, and distal protection PCI. Recently, we started do AAA stent graft procedures. We average around 70 cases a week and we will do close to 1000 interventions this year. Our peripheral volume has grown each year and physicians are working to increase their referral for this patient population. Does your cath lab perform primary angioplasty with/without surgical backup? About twelve years ago, our CV surgical group in Austin looked at the number of patients undergoing an intervention that converts to an emergent bypass or repair. It ended up being such a low volume that formal surgical backup was discontinued in all labs in the community at the same time. This was a significant move if you consider that the decision to halt formal surgical backup was made prior to stenting. We moved to this new way of thinking in several steps. Initially, we would still call the coordinator for the CV surgeons and just give them a heads up that we were doing an intervention. Then they could plan accordingly in case something came up, based on where the surgeons were operating. Simultaneously, we would call surgery so they could consider their schedule and when room would be coming up if a problem occurred. After following this procedure for a while, we eventually moved to our current process, completing a PCI as we would any other routine procedure. A cardiologist can still request some type of backup on a high-risk case if he would like, but this rarely happens anymore. Who manages your cath lab? I am the director of the cath lab at South Austin Hospital. I am an RT and have been working in the cath lab setting for the last 18 years. I came to South Austin to start the program in March of 1992. My responsibilities have become more and more administrative over the last couple of years. Supervisor Johnnie Farris, RT, is responsible for the daily operation of the department and Denise Brookshire, RN, is the Charge Nurse. Denise has the responsibility of driving changes in nursing practice and implementing changes to meet regulatory requirements. My boss is the Director of Nursing and I participate in all meetings that pertain to the cath lab and to nursing practice and policy changes at our facility. Do you have cross-training in your cath lab? We have consistently had some level of cross-training in our lab. Everyone learns to monitor cases. RNs will also circulate and scrub. RTs and CVTs will scrub and monitor as well. This adds to the flexibility of daily staffing and call coverage. Techs do not currently circulate because of considerations in the State Nurse Practice Act. We try to consider all options as we go forward and our staffing needs continue to offer many challenges. We are also developing a career path and an education process to help non-registered staff prepare for the RCIS registry exam. This is another effort to plan for future staffing needs in the department. Does your lab have a clinical ladder? We do not have a clinical ladder at this time. We have considered several options, but the financial piece is the most difficult to define. We are always considering ways to retain our staff, so we would consider a good working model if other labs have one they would like to share. What are some of the new equipment, devices and products introduced at your lab lately? Within the last year, we installed the GE Innova® (Waukesha, WI), which has improved our imaging capabilities. Going filmless has also been an exciting move. (There are many labs that have been doing this for years, but it just takes a little longer for some of us, I guess.) Some of our newer devices have been the Medtronic Guardwire for distal protection and the AneuRx® Stent Graft (Medtronic, Santa Rosa, CA). We always evaluate new technology as it comes out. It’s important to get physician input, outcome information and cost feasibility. Once we start new procedures, we collect as much data as we can to evaluate the quality outcomes. We also follow the cost and reimbursement information to allow us to continue adding new procedures and services. Is your cath lab filmless? Yes, we finally got out of the dark ages a little over a year ago. Boy, that was an instant staff satisfier! Finding the capital for this technology was a long process. There seemed to always be other priorities, but we were able to include it in a room upgrade last year. We installed the Heartlab Encompass system (Westerly, RI). When we came online, we also added echo to the digital realm. The transition went very well with the cath and echo images. The new system has also allowed us to begin the evaluation of remote access function for the physicians. We put workstations in several areas in the facility, including CVOR, Consulting, Telemetry, Echo, and in each lab. We also installed network drops in our high-volume units upstairs to download echo images. This allows for quicker access by the medical staff, who then don’t have to wait for the tech to come back downstairs. How does your lab handle hemostasis? We use both manual compression and vascular closure devices. It was important to us to be able get patients through the system as quickly as possible. Like many other facilities, bed availability can be a major bottleneck. In an attempt to move patients through, we will use closure devices with many of our outpatients, some interventional patients, and patients who have difficulty laying on their back or are non-compliant with keeping their leg still. We use: Duett (Vascular Solutions, Inc., Minneapolis, MN); Perclose (Abbot Vascular, Redwood City, CA); and some VasoSeal® (Datascope Corporation, Mahwah, NJ). Manual compression is used on all patients that leave the cath lab with a sheath in place. These patients will go to a critical care unit if their condition requires that level of care. Otherwise, the patients that leave the cath lab with a sheath will go to our tele unit, which has a pod designed for post interventions and groin management. Staff calls this area the Continued Cardiac Care Pod. On either unit, staff pulls sheaths per physician orders or more often based on ACT. The nursing staff from the Pod will spend part of their orientation to the unit in the cath lab, pulling sheaths and learning how to run ACTs. We continue to evaluate the quality and cost effectiveness of both manual compression and closure devices. How is inventory managed at your cath lab? Good inventory management is essential to the success of the cath lab. It is not only important to have the supplies you need, when you need them, but to be able to do it as efficiently and cost-effectively as possible. Pam Moser is our Materials Coordinator and is dedicated to both of these principles. We use the inventory module in our Witt Series IV Hemodynamic System (Melbourne, FL) for real-time usage. When a supply item is documented at the point of use, the system also takes it out of inventory. We also use the Witt system to run utilization reports, which allow us to make adjustments in our par level and develop contract strategies. The cath lab and surgery are generally the highest cost centers in the hospital. That means we get a lot of attention from administration regarding cost management. The hospital materials department receives our supplies and equipment, but does not maintain or stock any of our cath lab inventory items. All ordering and inventory management is done at the department level. Pam (our Materials Coordinator) works very closely with the physicians, staff, and cath lab director to perform a role that is truly customer-focused. She is involved in contract negotiations and as we continue to grow, so do her responsibilities. Has your cath lab recently expanded in size and patient volume, or will it be in the near future? Growth continues each year in the cardiovascular program at South Austin Hospital. We have seen significant growth each year, and this year has been no different. With the addition of several cardiologists, our volume has increased quite a bit in the past 12 months. Is your lab involved in clinical research? A little over a year ago, Samuel DeMaio, MD joined the medical staff at South Austin Hospital. He has brought to our facility both his experience and the opportunity to engage in clinical research. We have recently participated in the Boston Scientific TAXUS IV-SR trial and CREST (Cilostazol for REStenosis Trial). It has been exciting to participate in these trials, and we will soon be involved in the EMERALD (Enhanced Myocardial Efficacy and Recovery by Aspiration of Liberalized Debris) trial as well as TAXUS V. Does your lab perform elective cardiac interventions? We offer cath lab coverage 24/7. Therefore, we will perform emergent or elective interventions. Most of the time, we will perform the intervention immediately following the diagnostic procedure. Patients really prefer to have everything done at the same time. The most common question that I hear is, "If you find something that needs fixing, can you do it right then?" We also want to support primary PCI for AMI patients. Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? In previous years, complications such as dissection or a perforation may have forced an immediate trip to the OR. Nowadays, with stents, covered or bare, there isn’t the same urgency to send anyone to surgery as the result of a complication. What measures has your cath lab implemented in order to cut or contain costs? The most significant opportunities have been through contracting. If we can do a good job with the medical staff preferences and drive compliance for our contracts, we can save money. Good inventory management is also key to successful cost containment. Occasionally, we will buy products such as stents or pacers in bulk to save additional dollars. However, you can’t talk about cost savings without having an effective process in place for capturing all charges. Obviously, it’s important to get paid for what you use. What types of quality control/quality assurance measures are practiced in your cath lab? Quality control starts every day when the staff walks in the door. The simple day-to-day checks of crash carts, defibrillator, etc., are the first steps toward patient safety. Medication safety has been a huge focus in the media over the last year. Ensuring that processes are in place to reduce the risk of error continues to be important in the lab as well. The cath lab also monitors a number of complication rates, including: Mortality; Hematoma; CVA; Contrast reactions; MI; Unplanned CABG; Vascular complications; Success of vascular closure devices; Interventional outcomes. Also, we had several ORYX indicators that have now become the Core Measures.* We have chosen to look at AMI and CHF. Payors and employers continue to talk about quality expectations, and most states are putting more and more data out for public access. We must be able to show that we provide quality patient care at our facility by always looking for ways to improve. *In 1997, JCAHO announced the ORYX initiative, which requires accredited hospitals to continuously track and submit to JCAHO clinical performance measures as part of the accreditation process. Each Core Measure Set is a group of performance measures in a particular clinical or therapeutic area. Hospitals began tracking Core Measure Set data beginning with patients discharged on July 1, 2002. (From www.nrmi.org) How does your cath lab compete for patients? We feel that one way to attract patients is through physician satisfaction. Physicians are important customers that contribute to our volume. If they enjoy coming to our hospital and they can do their work with a minimal effort, everyone benefits. On the other hand, if physicians feel there are barriers increasing their workload and decreasing their overall satisfaction, they will go where they can get the kind of service they want. Obviously, ensuring satisfaction throughout the continuum has to be a hospital-wide effort. Similarly, since insurance companies decide where a patient can go, we must do an effective job of contract negotiations with them as well. Another important factor in competition is our reputation. We focus on quality and market good outcomes when applicable. The increase of clinical research at South Austin Hospital has also allowed us to increase public awareness about our work in the community. We have also introduced several marketing campaigns to allow for higher visibility in the city. Despite everything, most important is patient satisfaction. Patients’ experiences will stay with them forever. We have to keep the patient first and when we don’t meet their expectations, do everything possible to rectify the problem. There’s nothing better than getting feedback from a patient that describes a positive experience in the lab and names the staff that made a difference in their hospitalization. Can you discuss your outpatient program? About 45% of our patients start as an outpatient. All the diagnostic patients will go back to the outpatient short stay if no intervention is done. They will be discharged home according to the physician orders. Even in this area, accelerated throughput is important, so many of these patients will have their arteriotomy closed or sealed. How are new employees oriented and trained at your facility? What licensure is required for all professionals who work in your lab? When a new employee is hired, a preceptor is assigned to him/her and will be the new employee’s main resource for the first 90 days of employment. The preceptor will work out a calendar as a guide to plan for the orientation period. Through self-assessment and interview by the preceptor, additional educational needs are identified. During the orientation period, a competency skills checklist will be completed. The new employee will go through facility orientation and be checked off on department-specific equipment. For licensure, we require an RN, RT, or registry-eligible CVT. Registry-eligible means they have graduated from and approved school or they have sat for the basic science exam and are eligible to sit for the RCIS registry. What types of continuing education opportunities are provided to staff members? Vendors continue to provide inservices when appropriate and are good resources for what is going on in the field. Staff also has the opportunity to attend some of the meetings sponsored by Cath Lab Digest and the Society of Invasive Cardiovascular Professionals (SICP) in neighboring cities. In addition, we belong to a multi-facility partnership that offers many courses for continuing education. A course schedule comes out every quarter and most courses are free to employees. We have also purchased some educational material that the staff can utilize to increase their knowledge in the field. We have several copies of Wes Todd’s study tools (www.westodd.com), Virtual Cath Lab (Lawrence Educational Media, Gainesville, FL) and Procedure Skills for the Cardiac Catheterization Team by Morton Kern (Mosby, ). How is staff competency evaluated? An initial competency assessment is performed as part of the new employee orientation. The new employee will complete a self-assessment that will be checked off by the preceptor once demonstrated. Our facility also puts on competency fairs and Octoberfest, which provide opportunities to evaluate additional annual competencies. This would include defibrillation, EKG interpretation, medication safety, pain management, and much more. We also have annual department competencies for our low-volume, high-risk procedures. A mock code is done annually. If new procedures or products are added, we have the vendor representatives assist with education and training. Does your lab utilize any alternative therapies (such as guided imagery, etc.)? No. How does your lab handle call time for staff members? Call time is split as evenly as possible and if anyone wants additional call, there is always someone looking to give it up. A three-person team covers the call. At least one RN is on the team. The remaining two team members will be a combination of RN, RT, or CVT. Over the last couple of years, as our caseload has increased, it has been important to look at how we staff the lab. In the last 12 months, we have made many changes to our staff mix and total FTEs. With the addition of contract labor, we have been able to relieve some of the workload. Having experienced PRN personnel can also add to department flexibility. We are in the process of designing and implementing creative ways to cover the changing caseload. The need to do elective cases on the weekend also requires us to be more sensitive to our staffing pattern. What trends do you see emerging in the practice of invasive cardiology? All the talk now is about the financial and clinical impact that drug-eluting stents are going to have in the field. There are many different estimates on the impact it will also have on CABG volume, depending on whom you talk to. Many facilities will consider starting new programs and they may even consider coronary intervention without surgery programs. Many cities are also seeing niche players in the market who will build freestanding facilities. Another thing to watch will be the potential impact that the emerging non-invasive technologies may have on our programs. They may not there yet, but development is ongoing, and they will be here before we know it. There will continue to be an increasing need for cardiac services as the population continues to age. Facilities of all types will be competing for these patients. Consumer demand for quality and how we respond to that will also drive how our programs do in the future. Has your lab undergone a JCAHO inspection in the past three years? We successfully completed our JCAHO survey in August of 2002. There were no recommendations in the lab, and our facility did very well. The process was different than our previous surveys. Surveyors spent more time on the units and talking to the staff. In the lab, they were very focused on the medical staff and asked our Medical Director, Dr. Paul Tucker, many questions about quality improvements in the cardiology department. There was a brief tour of the lab and the staff was questioned on medication safety, patient monitoring and the daily QC. CAP (College of American Pathologists) also surveys the cath lab for our ACT waive testing. That survey took place in September 2002. ACTs are done throughout the hospital and managed through our department. Again, there were no recommendations and we did very well. Please tell the readers what you consider unique or innovative about your cath lab and its staff. You can never overemphasize the impact that good people have in the workplace. People who are passionate about what they do and demonstrate quality patient care can truly make a difference. No job is perfect every day, but our staff maintains a positive attitude no matter what. This attitude can be contagious and nothing can relieve stress like someone that wears a smile and has a positive outlook. I am privileged to work with people who have this attitude. Here are some of the comments made by the staff when asked about the lab as a place to work: It is filled with good workers who are friendly and work great together; Competent staff, who are pleasant and fun to work with. Responsive and accessible management, modern equipment, and all-around good hospital to work in; We have a great group of people! Everyone is competent and works very hard. We support each other the best we can. On whole, we work with a great group of doctors; Overall, the people here are great to work with. Everyone usually maintains a very positive attitude in what can be a very stressful and tiring job. I enjoy working here because of whom I work with. The people here give 110% to their jobs and there is never a ˜slacker’ attitude; It is a good place to work as long as you do your job. No pressure on a person, no one looking over your shoulder. Very nice people in the lab, everyone is willing to help. Is there a problem or challenge your lab has faced? As with many other units, we had to develop ways to staff the lab effectively when we had vacant positions or an increase in volumes. The St. David’s Partnership in Austin, which includes three other hospitals, created its own agency. In 2002, this agency become part of a company called All About Staffing. Working with the director of that program, we found nurses that were interested in learning more about the cath lab and would be willing to train. Over the last couple of years, we have taken some really good nurses and cross-trained them to be competent in the cath lab. This has helped tremendously and we continue to use them when needed. What’s special about your city or general regional area in comparison to the rest of the U.S.? Austin is a great city to live and work in. With its beautiful hill country and lakes, Austin doesn’t fit the pre-conceived image that many people have when they think of Texas. One of the challenges continues to be the cost of living and the relative income. This is not limited to just healthcare, but many other industries in the area. We work to be competitive in a market that changes on a regular basis. Matt Anderson can be contacted at: Matt.Anderson@stdavids.com

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