Sunrise Hospital & Medical Center

What types of procedures are performed at your facility? We perform a multitude of procedures in our cath lab, servicing neonates through geriatric age groups. Procedures include: Diagnostic left and right heart catheterizations Percutaneous coronary interventions (PCI) EP studies (pediatric and adult) Intravascular ultrasound (IVUS) Fractional flow reserve analysis Ablations (radiofrequency and cryoablations) Rotablator® (Boston Scientific Corp., Maple Grove, MN) Bi-ventricular and pacemaker implants AngioJet® (Possis Medical, Inc., Minneapolis, MN) Automatic implantable cardioverter defibrillators (AICDs) Laser 3-D mapping Intra-aortic balloon pump (IABP) insertions Loop recorders Atrial septal defect (ASD), ventricular septal defect (VSD), and patent foramen ovale (PFO) closures Many congenital heart anomaly interventions Valvuloplasties Alcohol septal ablations We perform approximately 310 billable procedures per week. In addition, we perform peripheral interventions, with an estimated annual procedural volume of 1,092. Does your cath lab perform primary angioplasty with surgical backup? Our cath lab performs primary angioplasty and all our patients are routinely consented for emergent surgical backup. We have cardiovascular (CV) surgeons in-house 24/7 and our critically-ill children will often have CV surgeons and pediatric perfusionists on standby during their procedure. At Sunrise Hospital, we are equipped with three open-heart surgical suites, which can accommodate any need that may arise in the cath lab. Risk stratifications are performed on CV surgical patients as needed. What procedures do you perform on an outpatient basis? Our outpatient procedures consist of diagnostic heart caths, myocardial biopsies, cardioversions, renal stents, percutaneous transluminal angioplasty (PTA) (depending on complexity), generator changes, some congenital closures, and loop recorders. What percentage of your patients are female? Approximately 47% of our patients are female. What percentage of your diagnostic cath patients go on to have an interventional procedure? Approximately 50% of our diagnostic cath patients go on to have an interventional procedure. Who manages your cath lab? Our cath lab is managed by Rob Williams, RN, RCIS, and Pam Leslie, RN, BSN is the administrative director of the CV service line. She reports directly to Steve Otto, Chief Operating Officer. Do you have cross-training? Who scrubs, who circulates and who monitors? We are in the planning stages of preparing a didactic and hands-on learning module for RNs who are interested in learning how to scrub. We currently have four RNs who scrub. Our coronary labs are set up with two RNs and two technical personnel. One RN circulates, one RN monitors, one tech scrubs and one tech assists with playbacks, monitors and gathers supplies that are needed during a case. In our EP labs, one RN circulates, one tech scrubs, and one tech assists with monitoring equipment. Anesthesia is present on all pediatric cases and EP cases. Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab? RTs are not required to be present in the room for all fluoroscopic procedures. However, we distribute our RTs throughout the lab so their expertise is available to all procedure rooms. 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? All RTs, CVTs, and RCISs are trained to operate all aspects of the x-ray equipment under direct supervision of the physician. RTs are always available if there is a need to troubleshoot x-ray equipment for functionality issues. RTs are a vital component of our lab. Since your lab performs peripheral interventions, what disciplines (physician and non-physician) are involved in these cases? Peripheral interventions that are done in the cath lab are performed by cardiologists who have appropriate delineation of privileges in accordance with medical staff. Interventional radiologists perform peripheral work in special procedures, which falls under the diagnostic imaging service line. Both follow the same policies and protocols but practice in different areas of the hospital. Both are supported by our surgical and neurological medical staff. The cardiologists consult with vascular surgeons and/or interventional radiologists if necessary during procedures. At times, we may have a vendor representative present during cases to assist with clinical support. How did you begin performing peripheral cases? Our cardiologists wanted to expand the services that they could provide to patients suffering from cardiovascular disease processes. The process of peripheral interventions in the cath lab entailed appropriate credentialing, education and training, delineation of privileges, establishing policies and procedures, and support from the ancillary areas such as radiology, vascular surgery, and internal medicine. What specific equipment was instituted and/or dedicated towards peripheral cases above and beyond what is used for coronary cases? Approximately seven years ago, we purchased a vascular suite for the cath lab with a 16 intensifier with digital subtraction capabilities. This is pertinent for visualization of larger areas utilized for abdominal angiograms and extremity runoffs. This is the same equipment/room that we utilize for carotid stent procedures. How is inventory management handled for the peripheral equipment? Consignment, consignment, consignment! Developing partnerships with your vendor community is key to minimizing costs. What training was instituted so staff could be competent and skilled, particularly for your carotid stenting program? A select group of cath lab nurses and techs were trained in the National Institute of Health (NIH) assessment and scoring. In addition, this select group has been trained on the proper deployment and use of the carotid stenting delivery systems and distal protection devices. An in-depth review of carotid and cerebral anatomy and physiology was conducted by one of the interventional cardiologists. Medical staff peer review is required on 100% of carotid stent procedures performed. What other modalities do you use to verify stenosis? Are you using physiology for lesion assessment? Fractional flow reserve analysis with the PressureWire® (Radi Medical Systems, Inc., Wilmington, MA) is utilized to verify stenosis physiologically and IVUS is still used for three-dimensional intravascular analysis. Does your lab have a clinical ladder? Our laboratory does not utilize clinical ladders. All CVTs who successfully pass their RCIS examination are automatically moved into an RCIS position with an adjustment to their salary to reflect the credentialing. What are some of the new equipment, devices and products introduced at your lab lately? In the last year, we have introduced new stimulators, a radio-frequency (RF) perforation system (Baylis Medical Company, Inc., Montreal, Quebec, Canada), upgrades to our generators, mapping systems, upgrades to our intravascular ultrasound technology, the Radi PressureWire, congenital closure systems (i.e., CardioSeal [NMT Medical, Boston, MA] and Amplatzer [AGA Medical Corp., Golden Valley, MN]), and cryoablation. We are the first facility in the state of Nevada to offer this new ablation technology. Our GE Marquette system has been upgraded from NT to IT platform and our facility has recently installed a picture archiving and communication system (PACS). Can you describe the system(s) you utilize and how they work in cath lab daily life? Currently we are running a completely digital lab that is integrated into the GEMnet archiving system by GE. This allows us to have reviewing stations in separate areas of the department as well as in surgery for the CV surgeons. Recently our hospital installed a PACS that will eventually allow our labs to be linked throughout the hospital. We are able to maintain an efficient flow by immediately archiving each case after the procedure is complete, enabling access for physician review. How is coding and coding education handled in your lab? We coordinate all coding issues with the Revenue Integrity and Utilization Review departments at our hospital to ensure accuracy and compliance with our billing. The cath lab charges are processed daily by cath lab personnel and Revenue Integrity reviews for accuracy. How does your lab handle hemostasis? For many years, the cath lab staff managed hemostasis in the procedure rooms for both manual and vascular devices. We recently completed a pilot study on having sheaths removed in our recovery area on all manual holds. This process has been beneficial and we will be moving towards removal of all sheaths/manual holds in the recovery area by a member of the cath lab team. By maintaining a smaller group of staff members responsible for hemostasis, we can minimize our complication rates. However, all staff members in the cath lab and cath lab recovery room are skilled in sheath removal. Closure devices will continue to be deployed in the cath lab procedure rooms by physicians. Does your lab have a hematoma management policy? Our hematoma management policy includes tracking and reporting of all hematomas. We track for trends and handle appropriately in coordination with our Quality Management Department. How is inventory managed at your cath lab? Managing inventory has always been a struggle for our cath lab due to our size and complexity of procedures. Specialized equipment is utilized for our pediatric patients and like many cath labs, we struggle for shelf space. We are in the process of evaluating a computerized inventory system that will assist with cost containment and analysis, ordering, and management of expired products. It is our goal to have an inventory system in place by 2007. We are working with our IS and materials management department to ensure that both systems will interface. We have two inventory specialists that are responsible for ordering, stocking, and managing our cath lab supplies as well as managing our implantable devices. Has your cath lab recently expanded in size and patient volume, or will it be doing so in the near future? In March 2005, we added one additional coronary interventional lab. We have plans to consolidate our recovery area to 30 beds. Our pediatric interventional volume has increased by 135% since last year, and our EP volume has grown exponentially as well. Is your lab involved in clinical research? Our cath lab is involved in approximately twelve clinical research studies presently. We are an active participant in cardiology research in our community. Studies that we are currently involved in pertain to congestive heart failure (CHF), the PFO CardioSeal closure study, post-market device studies, drug studies such as the ACUITY Trial a randomized comparison of bivalirudin versus heparin in patients undergoing early invasive management for acute coronary syndrome (ACS) without ST-segment elevation, and radiofrequency ablation of atrial flutter. We were involved with the Taxus peri-approval registry in January 2004. Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? Yes, however, this number is relatively small (What measures has your cath lab implemented in order to cut or contain costs? We have entered into a contract with two major suppliers for implantable devices. This contract encompasses the entire Far West Division of HCA facilities, done in order to negotiate improved pricing based on utilization. The contract has provided our division with substantial savings. In addition, we regularly review our CV contracts with vendors to explore shifting market share and obtain better pricing on products based on sole- and dual-source vendors, etc. It is a fine balance between containing costs, maintaining a superior product line, and physician satisfaction. We have moved all of our higher-priced items (balloons, stents, specialty catheters) over to consignment to minimize our expenditures on expired products. What type of quality control/quality assurance measures are practiced in your cath lab? We perform chart audits to ensure compliance with required documentation, contrast usage on pediatric patients, pre-procedure assessments, screening for glycoprotein IIb/IIIa contraindications, activated clotting time (ACT) results and sheath removals. We report monthly to the Quality Care Committee and trend our results. How does your cath lab compete for patients? Has your institution formed an alliance with others in the area? Las Vegas has become a competitive market in adult interventional cardiology. Quality of imaging, available technology, and efficiency of cath lab turnover time have played a major role in our competition for market share. It is an area that we never take for granted. We take a proactive approach with educational opportunities to maintain staff competency, and to improve job satisfaction and staff retention. How are new employees oriented and trained at your facility? What licensure is required for all professionals who work in your lab? RNs are required to have a valid nursing license, ACLS, and a critical care background. RTs and RCISs are required to have proper credentialing. CVTs are provided with on-the-job training if needed, but generally must have a cardiology background and/or acute hospital experience (i.e., paramedic, OR tech, etc.). New employees are paired with a preceptor who they shadow during training. Depending on a particular employee’s background, orientation can last between 2 and 16 weeks. ICU classes are available to assist with deficiencies if needed. All licensed staff working with pediatric patients must be pediatric advanced life support (PALS)-certified within one year. What type of continuing education opportunities are provided to staff members? Various continuing education opportunities are available through our clinical educator, our education department, and through vendor-sponsored events and various cardiology seminars. We also have an educational fund available to employees which allows staff to attend various cardiovascular conferences. How do you handle vendor visits to your lab? We currently have a closed lab to vendors. Vendors are allowed in the cath lab by appointment only in order to provide inservices for new products, changes to existing products and annual in-services on equipment (IVUS, AngioJet, etc.). All vendors must check in with our medical staff office and are issued an identification badge before entrance into any areas of the hospital. Our pacemaker representatives have allied health privileges and have a hospital-issued ID badge. Vendors who have consigned product in our lab are given one day per month to check their inventory levels and remove expired product. How is staff competency evaluated? Staff competency is evaluated annually by performance evaluation and skill days. Our high-risk, low-volume procedures are inserviced and evaluated a couple of times per year. IABP certification is required of all RN staff, and they are re-certified every twelve months. Does your lab utilize any alternative therapies (such as guided imagery, etc.)? We have music available in all procedure rooms. If patients have a special request for music, we try to accommodate them, especially our teenage patients. Child Life Specialists (who work to minimize stress and anxiety) are utilized for all pediatric patients. How does your lab handle call time for staff members? Our call team consists of four staff members (2 RNs and 2 technologists). Our tech mix generally includes at least one licensed tech (RT or RCIS) with a CVT. Staff takes call one night per week and one weekend every 5“6 weeks. Generally, the staff that work in EP are exempt from call in the cath lab since their workday varies so greatly. The majority of our staff work 4/10-hour days and have the day off following their call night. We have a separate team that stays after hours to complete pediatric cases that may run over, allowing our call team to be available for emergencies. We do not have multiple shifts. Operational hours are from 6:30 am - 5:00 pm Monday through Friday, and we are closed on all major holidays. What trends do you see emerging in the practice of invasive cardiology? We have seen more aggressive interventional treatment of coronary artery disease since the introduction of drug-eluting stents and non-surgical repair of cardiac anomalies with new implantable devices. I would suspect that we will see some new peripheral practices emerging. Has your lab undergone a JCAHO inspection in the past three years? We have, and my recommendation to any cath lab expecting a regulatory inspection would be to ensure that you have a process in place that labels all medications on your sterile field, including heparin flush bowls and all syringes. Labeling should identify the medication and concentration. Where is your cath lab located in relation to the OR department, ER, and radiology departments? Our cath lab suites are located in very close proximity to the ED, OR, and radiology. The cath lab is actually sandwiched between the ED and OR, with radiology directly across the hall. This configuration works very well with patient flow during critical situations. Please tell the readers what you consider unique or innovative about your cath lab and its staff. We are fortunate to have a staff comprised of many backgrounds, which contributes to the skill mix of the cath lab. Many of our nurses have come from the ED or ICU and bring their own critical thinking skills with them. Our technical staff have varied backgrounds as well, coming from interventional radiology, cardiology, and the ED. Our department is fortunate to have an elite group of cardiologists that provide valuable input to the functionality of the department. We are currently in the process of implementing a Cardiac Alert© Program, which would allow EMS personnel to activate the cath lab call team for an acute myocardial infarction (AMI) from the field. The objective of this new program is to reduce the door-to-balloon time and improve patient outcomes. Is there a problem or challenge your lab has faced? Every department is faced with challenges, and our cath lab is no exception. Two challenges that we struggle with are control of inventory and throughput of patients. Like many hospitals, we are tight on available beds, with many departments competing for the same bed. Our recovery room gets bogged down with hold patients, preventing us from moving patients through our area in an efficient manner. In addition to cath lab patients, our recovery area also pre-processes and recovers radiology patients. 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? Las Vegas is a unique area of the western U.S. We have a multitude of visitors who visit our city on business and/or vacation, and become ill while they are away from home. In addition, we have an influx in our population in the winter months due to seasonal residents, which impacts our volumes. There are several rural areas around Las Vegas that do not offer interventional cardiology services. Often these patients are air-lifted to our facility for a higher level of care. At Sunrise Hospital, we also do a large number of pediatric interventional procedures, which are long, labor-intensive cases. At times it is a challenge to staff after-hour adult call cases, EP, and pediatric cases simultaneously. Questions from the Society of Invasive Cardiovascular Professionals (SICP): Do you require your clinical staff members to take the registry exam for the Registered Cardiovascular Invasive Specialist (RCIS)? Do staff receive an incentive bonus or raise upon passing the exam? We do not currently require clinical staff members to take the RCIS examination. They are highly encouraged to obtain their RCIS and upon completion, the technical staff have an immediate change in job classification, resulting in a substantial pay increase. Two of our staff RNs currently possesses RCIS credentialing. 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? Our managerial team members are involved with CCMN (Clinical Cardiovascular Management Network), an HCA group that supports the invasive cardiology service line. There are over 1,000 participants and we meet annually, with approximately 500 attendees. Pamella Leslie can be contacted at Pamella.Leslie@hcahealthcare.com

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