Spotlight: Norman Heart Hospital at the HealthPlex

The cath lab at Norman Regional Hospital was opened in 1991, at the Porter campus location. In 2009, the HealthPlex campus opened its doors and houses the Chest Pain Center and the Norman Heart Hospital, which is comprised of the cardiac cath lab (CCL), cardiovascular intensive care unit (CVICU), and post coronary care unit (PCCU). Adjacent to the Norman Heart Hospital is the Heart Plaza. It consists of cardiology and cardiothoracic surgery offices, outpatient diagnostic testing, and cardiopulmonary rehab.  With the expansion of our cardiovascular service line, the Norman Heart Hospital has placed tremendous emphasis on creating an entire campus where accessible cardiovascular services are provided to our patients. 

Tell us about your cath lab.

 At Norman Heart Hospital, part of Norman Regional Health Systems, we currently have two cath labs and two shelled-out areas for expansion. Our cath lab is staffed by a mixture of registered nurses (RNs), registered radiologic technologists (RT[R]s), cardiovascular technologists (CVTs), and registered cardiovascular invasive specialists (RCISs). 

We have 20 dedicated cath lab employees, as well as eight cardiologists and two cardiothoracic surgeons. Several physicians and staff have been with the hospital since the opening of the lab over 20 years ago.  

What procedures does your cath lab perform?

 Our lab performs approximately 200-250 procedures each month that include: 

• Diagnostic coronary angiograms, coronary intervention, and insertion of the Impella left ventricular assist device (Abiomed).
• Diagnostic peripheral angiograms and peripheral interventions, including chronic total occlusions, laser atherectomy, orbital atherectomy, and thrombolytic infusion.
• Atrial septal defect (ASD) and patent foramen ovale (PFO) closures.
• Carotid and cerebral angiography and stenting.
• Pacemaker and implantable cardioverter-defibrillator (ICD) implants.

Our hospital has a dedicated cardio-thoracic surgeon either on site or available twenty-four hours a day.

What percentage of your patients is female? 

Fifty-one percent (51%) of our patient population is female (by American College of Cardiology National Cardiovascular Registry data).

What percentage of your diagnostic cath patients goes on to have an interventional procedure?

Approximately 40% of our diagnostic catheterizations go on to have an interventional procedure.

Who manages your cath lab? 

The cath lab is managed by:

• Sara McMillan, BSMI, RT(R), Cath Lab Supervisor
• Amy Baden, RN, BSN, CVICU/PCCU/and Cath Lab Manager
• Phil Regas, MSM, RRT, RCIS, FSICP, Cardiovascular Service Line Director

Do you have cross-training? Who scrubs, who circulates and who monitors?

Extensive cross-training is conducted at the Norman Heart Hospital. Not only is the cath lab staff capable of performing various roles, but our cardiovascular ICU staff is also cross-trained to the cath lab. This is beneficial, specifically in the event of treating more than one ST-elevation myocardial infarction (STEMI) patient at a time. The primary role of the cath lab RN is to administer and document medications and perform patient assessments. However, many are cross-trained to circulate, monitor cases, and scrub. Our RTs and CVTs routinely scrub and drive or monitor and circulate cases. The cath lab supervisor determines the daily staffing assignments based on case mix.

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? 

The cath lab staff member who is responsible for scrubbing also positions the II and manipulates the table. The cardiologist delivers ionizing radiation.

How does your cath lab handle radiation protection for the physicians and staff?

Radiation safety is of utmost importance and certainly a priority of the Norman Heart Hospital. Standard protection includes lead aprons and leaded glasses. All visitors and observers are held to the same standards. The cath lab supervisor is the radiation safety lead and attends the hospital radiation safety meetings. Dosimeter badges and dosimetry reports are managed.  

What are some of the new equipment, devices and products recently introduced at your lab? 

Our lab was chosen to be the first lab in the region to utilize the Zilver PTX drug-eluting stents (Cook Medical).

We are currently upgrading our PACS/cardiovascular information system (CVIS). This will allow for all cardiovascular imaging services to be compiled into one database. It will increase the efficiency of reporting and physician dictation. It will also allow for physicians to access the system remotely.

How does your lab communicate information to staff and physicians to stay organized and on top of change?

Norman Regional Health System has various means to communicate with physicians and its service line staff. The cardiologists are a part of a co-management shared governance arrangement with the hospital to make decisions.

Our Chest Pain Council and other quality meetings occur monthly. All NCDR and Society of Thoracic Surgeons (STS) quality monitoring elements are used and results are communicated at cardiology, emergency department, OR and department meetings.

The Norman Heart Hospital is fortunate to have the same manager over the cardiovascular ICU, progressive care unit, and cath lab. This allows our staff to all be communicated with in the same manner. It also ensures that the same quality and consistency is provided to all of our patients in their continuum of care.

How is coding and coding education handled in your lab? 

Our lab has a dedicated coding and billing specialist that is responsible for auditing and reviewing all patient charges. Education has been established to allow for the staff to submit procedural and supply charges.

Where are patients prepped and recovered? 

Our lab has eight same-day surgery rooms, located next door to the cath lab. Our own RNs prep and recover outpatients in this area. These specialized cardiovascular nurses improve patient outcomes and reduce possible complications.  

The physician will specify how hemostasis is to be obtained. We currently have the options of the Thrombix patch (Vascular Solutions) for manual compression and also closure devices, including Angio-Seal (Kensey Nash Corp.), MynxGrip (AccessClosure), or Perclose (Abbott Vascular).

Post intervention inpatients are taken to the cardiovascular ICU, where the RN removes the sheath and manages hemostasis. For solely diagnostic inpatients, the sheath is pulled in the lab, prior to patient transport to the unit.

All cath lab staff is trained and proficient at pulling sheaths. Technologists usually assist the RN while they document and stand by for potential complications.

What is your lab’s hematoma management policy?

Our hospital uses a universal house-wide policy for hematoma management. Amy Baden, the cath lab and CVICU manager, oversees the “Hematoma Hot Line”, where any hematomas are reported and tracked.

How is inventory managed at your cath lab? 

The cath lab supervisor is responsible for managing the cath lab inventory, using the GE DMS software (GE Healthcare) and the Meditech electronic medical record. Purchasing is done in combination with the materials management department, which has allowed for great saving and standardization for our facility.

Has your cath lab recently expanded in size and patient volume, or will it be doing so in the near future?

The Norman Heart Hospital has plans to grow by adding another lab. These plans are for a hybrid lab, which will allow for further expansion of services. 

Is your lab involved in clinical research?

Our lab has participated in the CHOICE study for carotid stenting and would like to participate in others in the future.

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?  

Norman Heart Hospital has developed our own quality improvement process. This process is continually reviewed by the Chest Pain Council, which is led by our Chest Pain Coordinator and is comprised of members from the ED, cath lab, cardiovascular ICU, administration, and department-specific medical directors. Currently Norman Heart Hospital has a median D2B time of 59 minutes. An emphasis has been placed on community education, referral centers, and surrounding emergency medical services (EMS), in order to achieve improvements in the areas of D2B, door-to-EKG, and transfer times. Our facility is an active participant in the ACTION Registry - GWTG  and Mission: Lifeline as a percutaneous coronary intervention (PCI)-capable receiving facility. This data has been the driving force for change in continued quality improvements. The Norman Heart Hospital has applied for Chest Pain Certification through the Society of Cardiovascular Patient Care and is currently awaiting its site visit.

What measures has your cath lab implemented in order to cut or contain costs?

Our hospital focuses on cost reduction and savings with staffing and supplies. We have recently engaged with EHS, the consulting firm, for cost-saving suggestions with staffing and productivity. Currently, we are working with VHA to improve cost containment with supplies.

What quality control/quality assurance measures are practiced in your cath lab?

Quality control/quality assurance measures for our lab consist of chart audits, and the monitoring of infection rates, core measures, HCAHPS (patient satisfaction), medication administration, and bleeding rates. 

We are affiliated with the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR). Our Chest Pain Coordinator collects, abstracts, reports, and presents this information regularly. This data is used to enhance process improvement measures. 

How does your cath lab compete for patients? 

Norman Heart Hospital is conveniently located off of Interstate 35, which allows for prime access to our facility. It is the southernmost PCI facility in the Oklahoma City metro area. Our health system has a unique benefit of being co-owner with the city’s emergency medical service providers. Our Chest Pain Coordinator, Brittni McGill, conducts site visits with referring facilities, and promotes rural and surrounding community outreach. This outreach has been extended to the surrounding emergency service providers to attend our Chest Pain Council meetings. This promotes a collaborative and cohesive relationship with other agencies and organizations that transport patients to our facility.

How are new employees oriented and trained at your facility? 

New staff orientation is based on previous experience. Our hospital has an education center that offers a wide variety of classes. Many of these classes are part of the standard orientation process. RN, RT(R), and RCIS are all accepted as valid credentials for cath lab staff. We have a wide range of backgrounds and experience levels in our department.  Many of our RNs have cardiovascular ICU or ED experience. We also have a variety of staff members with a surgical background. Several of our staff members have worked in a cath lab for over 25 years.  

What continuing education opportunities are provided to staff members?

Norman Regional Health System has an internal education department with service line educators. In September of this year, we hosted our first Heart of a Sooner Cardiovascular Symposium. This highlighted many of our own cardiologists as speakers and provided education to not only our own staff, but employees and physicians from surrounding area hospitals. In November, we also offered the Heart of a Sooner Registered Cardiovascular Invasive Specialist Review and Exam Prep Course.

How do you handle vendor visits to your lab? 

Vendors are restricted from the cath lab, unless they are either invited to the hospital for specific cases or make appointments with the lab supervisor. Reptrax is utilized by the vendors to sign in and out. When representatives are invited for inservices or education, their access is restricted to the department break room.

How is staff competency evaluated? 

Yearly skills fairs are offered and various competencies are evaluated by the cath lab supervisor. Employees are encouraged to attend continuing education classes. Inservices are also scheduled for products and devices, based on need.

Does your lab have a clinical ladder? 

Our cath lab has clinical ladders used to encourage and reward staff excellence. These ladders are specific to job description. 

How does your lab handle call time for staff members? 

Staff members are on a call rotation, their coverage averaging one night a week and one weekend a month. The team usually consists of an RN and two cardiovascular specialists. The unit-specific on-call policy states that the employee, as well as the cardiologist, must be on site within 30 minutes.

Do you have flextime or multiple shifts? 

Our shifts are staggered to meet productivity targets. Some of our staff works five eight-hour shifts, while others work four ten-hour shifts. 

Where is your cath lab located in relation to the operating room (OR) and emergency department (ED)? 

Our lab is located on the second floor, directly above the Emergency Chest Pain Center, which has an express elevator connecting the two. The OR is located next to the cath lab and the dedicated cardiothoracic surgery suite is easily accessible through a set of double doors.

What is unique or innovative about your cath lab and staff?

Norman Heart Hospital has been awarded as one of the “Most Wired” in technology. Due to our technological capabilities, we have been able to institute an electronic patient board in the department as well as the waiting room. These boards can be updated from various PCs within the unit. The color-coordinated scheduling board enhances communication among the cath lab team. Patient and family member satisfaction has been increased with the addition of the procedure board in the waiting room. This board updates family members with the status of their loved one’s procedure.  

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”? 

Oklahoma is ranked sixth in the nation for heart disease and about one-third of its population is obese. With our new cardiovascular service line, our hospital is working to expand the cardiovascular services provided to our patients. Due to the large number of smokers and prevalence of obesity and diabetes, we have experienced an increase in the number of peripheral vascular disease cases. Oklahoma’s patient base is more rural and demands for more outreach activities for patient access.

Two questions from the Society of Invasive Cardiovascular Professionals (SICP):

1. Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? Does staff receive an incentive bonus or raise upon passing the exam?

RCIS certification is not currently required, but is encouraged.

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?

Various members of our cardiovascular leadership belong to the following organizations:

• American Academy of Medical Administrators 
• American Association of Colleges of Nursing
• American Association of Critical Care Nurses
• American Association of Radiologic Technologists
• American College of Cardiology
• American College of Healthcare Executives
• American Heart Association
• American Heart Association State Advisory Committee
• Fellow, Society of Invasive Cardiovascular Professionals
• Oklahoma Association of Nurse Executives
• Oklahoma Code STEMI Committee 
• Society of Cardiovascular Patient Care
• South Central Oklahoma Association of Critical Care Nurses 

The authors can be contacted via Phil Regas, MSM, RRT, RCIS, FSICP, Cardiovascular Service Line Director, at pregas@nrh-ok.com.

A question from the American College of Cardiology’s National Cardiovascular Data Registry:

How do you use the NCDR Outcome Reports to drive QI initiatives at your facility?

We use NCDR data in all of our cardiovascular management meetings as well as system QA reports. ACTION allows us to participate in Mission: Lifeline. Lastly, the NCDR reports are sent to Blue Cross Blue Shield and United Healthcare for levels of quality distinction.