Syracuse VA Medical Center

What is the size of your cath lab facility and number of staff members? The Syracuse VA Medical Center’s cardiac catheterization laboratory (CCL) consists of a 4-room suite with one diagnostic laboratory. We presently have a GE Advantage system (Milwaukee, Wis.). The CCL is staffed by 2 cardiologists, 2 RNs, 1 special instrument technician and 1 radiology technologist. The Syracuse VA’s Cardiovascular Interventional Radiology (CVIR) suite is a 5-room suite with a Siemens Multistar system. This is considered by many local physicians as a state-of-the-art laboratory. The CVIR staff serves 3 interventional radiologists, 4 neuroradiologists, and is staffed by 2 RNs and 2 radiology technologists. Since the Syracuse VA is a teaching hospital, cardiology and radiology fellows assist in both areas. What is unique about the CCL and CVIR labs is that the RNs and radiology technologists cross-train to each area. This provides the staffing we need to manage our patients and provide them with the best possible care. Can you talk a little more about your special instrument technician? We have one full-time special instrument technician. Two other techs from the cardiology department are cross-trained to fill in when needed. Their role in our cath lab is much like the CVT’s role in other labs; they have a wide variety of duties, from setting up sterile trays to keeping statistical data. The techs’ main role is to monitor and manage hemodynamic pressure during cardiac caths. They are also responsible for ordering sterile supplies and restocking the cardiac cath lab. When not in the cath lab, these valuable people cover in the cardiology department by assisting with stress tests, performing EKGs and a variety of other duties. They are flexible and experienced members of the cath lab team and are indispensable, respected colleagues. What type of procedures are performed at your facility? The CCL performs diagnostic left and right heart catheterizations, including heart and lung transplant workups. We also implant temporary and permanent pacemakers, and perform tilt table studies. Approximately 500 cases were performed in 2000. The CVIR lab performs many different procedures, including endografts, aortograms, runoffs, peripheral angioplasties and stenting, ultrasound and CT-guided biopsies, tube placements (G-J, chole and nephrostomy tubes), and PICC lines. The CVIR lab performed approximately 100 angioplasties/stents last year, including endografts. Approximately 1457 cases were performed in 2000. The radiology technologists also assist the neurosurgery department with trigeminal nerve decompressions in the CVIR lab. Does your cath lab perform primary angioplasty? No. What is your cath lab’s management system? The Cath Lab Director is Prabhakara Heggunje, MD, Assistant Professor of Cardiology, SUNY Upstate Medical Center, VAMC-Syracuse. Administrative management of the cath lab is encompassed by the cardiology department. The RNs are aligned with the hospital’s outpatient nurse manager. The RTs are managed by the imaging department. The CVIR Director is Kenneth Murphy, MD, CAQ-IR, Associate Professor of Radiology, Division Director-Cardiovascular and Interventional Radiology, also at SUNY Upstate Medical Center, VAMC-Syracuse. Administrative management of the CVIR lab is through the imaging department. Both the cath lab and CVIR are integrated by a collage of multi-disciplinary managerial styles and departments. Therefore, the directors and managers of the two labs depend heavily on RN and tech input for patient management. This patient management encompasses all aspects of our patients’ care, including pre- and post-procedure care, teaching, and scheduling. New procedures or equipment are usually thoroughly discussed, and the physicians require input from the staff as to the best approach for implementation. We recently completed an eight-month study of patient satisfaction. Staff were rated as superior, and patients indicated they were satisfied with their care. Does your lab have a clinical ladder? Our lab does not have a clinical ladder. You mentioned that you have cross-training. To what extent? In the cath lab, the RNs, with the assistance of the special instrument technician, prep the room and the patient. The RNs circulate and administer medications and are responsible for patient monitoring and IV conscious sedation. The RNs are also responsible for pre- and post-procedure teaching. The special instrument technician records the case events, including pressure measurements and maintaining data collection. The RTs are responsible for the imaging equipment. In CVIR, RNs are responsible for pre- and post procedure teaching and administering medications, IV conscious sedation and monitoring hemodynamics. The RTs prep the patients, circulate during the procedure and at times, procedural scrub. The RTs are responsible for the imaging equipment. All of the RNs are ACLS-certified. One RN is an ACLS instructor and one RN is a CPR instructor. All employees are required to be CPR-certified. What are some of the new equipment, devices and products introduced at your lab lately? The cath lab proposal to update the equipment to digital is pending approval. We have successfully implemented the radial approach, utilized vascular closure device Angio-Seal (St. Jude Medical, Minnetonka, Minn.) and the SyvekPatch® (Marine Polymer Technologies, Danvers, Mass.). CVIR has a Siemens Multistar T.O.P. angiography system (South Iselin, New Jersey) and a state-of-the-art angiography lab. New procedures being performed include endografts for AAA repairs, hepatic chemoembolizations, and possibly in the future, percutaneous vertebroplasty. New products include Fibrinotherm® (Baxter Healthcare Corp., Deerfield, IL), Arrow-Trerotola PTD Percutaneous Thrombolytic Device, (A.M.I. Technologies Ltd, Hod Hasharon, Israel), Angio-Seal, and the SyvekPatch. Is your cath lab filmless? Our cath lab uses 35mm cine film at the present time. CVIR is digital, but hard copies are made of every case. This provides images for different parts of the hospital who do not have access to digital equipment. What process does your lab use for pulling sheaths post diagnostic and interventional procedures? In the cath lab, the cardiology fellows are responsible for pulling the sheaths and obtaining hemostasis with nursing support. In CVIR, post diagnostic procedures are managed by the attending and/or fellow. Depending on the interventional procedure, the sheath is pulled or left in place with a heparinized saline drip. How does your lab handle hemostasis? In the cath lab and CVIR, both manual pressure and vascular closure devices are used, depending on the patient’s clinical situation. If Angio-Seal is used, the patient is observed in the cath lab’s or CVIR’s holding room until the stitch is clipped. The outpatients return to Same Day Procedure (SDP) floor after they are monitored in the cath lab or CVIR, per cath lab and CVIR discharge guidelines. The inpatients return to their floor after the discharge guidelines are met. The RNs are responsible for monitoring the patients until they leave the labs. In the CVIR, the recovery time varies, depending on the patient and procedure performed. How is inventory handled? In the cath lab, inventory control is a shared responsibility. The special instrument technician is responsible for ordering the majority of supplies (catheters, wires, sterile and non-sterile supplies). The RNs are responsible for ordering medications and contrast. In CVIR, the RTs are responsible for inventory of the majority of the supplies (catheters, wires, sterile supplies). The RNs are responsible for ordering medications, contrast, and sterile and non-sterile nursing supplies. Has your cath lab recently expanded in size? Last year, the patient volume in the cath lab has increased 25%. We anticipate continued growth. CVIR has also seen a tremendous increase in patient volume. These cases are also more complex and time-consuming. Over 1450 cases were done last year. CVIR has also physically expanded in size. The suite is now more than 2000 square feet. This provides room for interventional procedures. How has managed care affected your cath lab and its patients? Managed care has affected our VA patient population mostly indirectly by affecting the private sector. The VA patient population has grown significantly in the past few years. What measures has your cath lab implemented to cut or maintain costs? Both the cath lab and CVIR utilize Same Day Procedure unit for outpatient care. In the past, procedures required a three-day hospital stay. Now some procedures are performed on an outpatient basis, reducing the number of inpatient hospital days. This has saved a significant amount of money. Both labs also evaluate different vendors and products to determine the best quality and price. We recently collaborated on changing some products so our buying power is greater. CVIR orders more often and keeps less stock on hand to avoid overstocking and the chance of outdated supplies. How does your cath lab compete for patients? In the cath lab and CVIR, our patients are aligned with the military, either as veterans, active duty or family of active duty. The Syracuse VA presently has 7 outpatient clinics and serves a wide area in central and upstate New York. The Syracuse VA is part of the VISN 2 Network in New York state. If patients need coronary interventions and the patient is stable, some are sent to the Buffalo VA Medical Center in Buffalo, New York. Buffalo VA is part of the VISN 2 Network. The Syracuse VA has an alliance with the Upstate Medical University, also in Syracuse. The cardiology fellows participate with Upstate’s Cardiology Fellowship Program. The CVIR attendings are also based at Upstate, but are contracted to work at the VA. At times, some patients needing emergency procedures are transferred to Upstate. Can you tell us more about your outpatient program? We work very closely with the Same Day Procedures unit, which is located within the facility. The nurses on the SDP floor are very competent and flexible concerning the pre and post procedure care of our patients. Outpatients are pre-bedded ideally 5-7 days pre-procedure. This provides implementation of pre-procedure teaching and preparation of the patient for their test (i.e., labwork, EKG, CXR). Outpatients then return to the SDP floor for post care after the monitoring is completed in the cath lab or CVIR. The patient must meet standardized criteria according to American Society of Anesthesiologists (ASA) in order for the procedure to be done on an outpatient basis. CVIR patients are so varied that they are done as outpatients, inpatients and can be recovered in the CVIR suite. How are new employees oriented and trained at your facility? All new employees receive a hospital-based orientation which includes classes on infection control, safety, emergency codes, information management, quality improvement, customer service, communication, and training. In the cath lab and CVIR, the RNs are precepted by a senior RN until fully oriented. Functional statements are used as guidelines to write core competencies which are individualized to the specific position. The orientation is individualized to meet the needs of the orientee and the standards of our quality care. The RTs are precepted by a senior RT until orientation is completed. There are also opportunities for tuition reimbursement for seminars and special training. What type of CE opportunities are provided to staff members? The hospital provides frequent teaching days to allow employees to complete mandatory training. Opportunities exist that provide remitted tuition reimbursements for seminars. The cath lab staff attends weekly cath lab conferences. The cath conferences consist of pertinent cases and research presented by attending cardiologists. Every attempt is made for all of the cath lab staff to attend these very informative meetings. The CVIR staff also has the opportunity to attend weekly vascular and interventional conferences. These also provide discussion of pertinent patient cases. How is staff competency evaluated? Staff competency in the cath lab and CVIR is evaluated on a yearly basis. This evaluation is a collaberative effort between management and peers. A competency checklist is developed for each position. The employees are also required to complete hospital education guidelines annually, which includes mandatory reviews in infection control, safety, emergency codes, information management, quality improvement/customer service, communication, and training. Does your lab utilize any alternative therapies? We don’t use any alternative therapies. How does your lab handle call time? At the present time, the cath lab does not require call, although, if the cases run late, the staff will stay until finished. CVIR requires call. One RN and one RT are on call at all times after regular hours. The call is split evenly, but the staff is flexible in covering call. Only the RNs and RTs assume the call role; the special instrument technicians do not do call. What type of quality control/assurance measures are practiced in your lab? Performance improvement initiatives that have been measured include: Overall customer satisfaction and follow-up phone calls The radiation time involved with the femoral vs. the radial approach (5.7 minutes vs. 6.5 minutes) Percentage of normal coronary angiograms (8%) Patient satisfaction and efficiency of Angio-Seal vascular closure device Follow up of patients seen in CVIR Each patient, and if applicable, complication, is tracked by nursing services. We use an IVC sedation data sheet to track all of our patients. As our nurses and techs work as a team, each of our patients receive quality care. We work very hard and keep our standard of patient care very high. What measures has your cath lab employed to improve efficiencies in patient throughput? Since half our patients are done as outpatient procedures, we work very closely with the Same Day Procedure (SDP) unit. Without them, the timeliness of our procedures would be seriously compromised. Our nurses keep an open line of communication with the inpatient units as well, so staff are up-to-date on new procedures. Last year, the radiology department sponsored an open house for the employees. Part of this open house spotlighted the different procedures and technologies used in the cath lab and CVIR. This helped educate our fellow employees on what we do and how we operate. This was a team effort and helps to encourage new learning and understanding of procedures. The result is better patient care and throughput in our labs. Can you describe your lab’s physical layout? The main cath lab room’s dimensions are 23.5 x 16 ft. The holding room, control room and clean utility room are all about the same size (7 x 14.5 ft.). The CCL area is small. The need for more space, including another holding room for pre-procedures is being addressed by the hospital administration. The main CVIR lab is 40 x 24 ft. The control room/reading room is 28 x 18 ft. The holding room and sterile supply room are both about the same size (14 x 14 ft.). The CVIR lab is large and open. This room was updated in 1997 and is spacious enough to perform various types of cases, including endografts with full surgery support. What new trends do you see emerging in the practice of invasive cardiology? Some trends we see as emerging include biventricular pacing, and more procedures being done on an outpatient basis. Has your lab undergone a JCAHO inspection in the last 3 years? We underwent an inspection in 2000 and there were no deficiencies in the cath lab. What do you consider unique or innovative about your cath lab and its staff? The cath lab/CVIR staff work as a team no matter what type of case we are doing. Even though we are managed by different departments, we know we have to work together for the patients’ well-being. Even though we are considered small by the number of cases we perform, we are poised to accept more patients as our hospital has expanded. Is there a problem or challenge your lab has faced? One problem we faced was lack of RNs, as we only had two RNs for both the cath lab and CVIR. As our volume of cases increased, we documented the need for more RNs and the hospital responded by allowing us 2 more FTEs. Also, the need for more updated equipment and space was addressed in the angio area with a new digital state-of-the-art lab in 1997. Plans for the cath lab to update their equipment and space are slated for 2003. What services does the VA Medical Center offer veterans? The Syracuse VA Medical Center is located in central New York near Syracuse University. The Syracuse VA also has seven outlying clinics to make health care easy and close to home for many veterans. These outpatient clinics are in Auburn, Binghamton, Cortland, Massena, Oswego, Rome and Watertown, NY. Because the clinics do not offer some services (ie, cardiac caths and CVIR procedures), the veterans are referred to the Syracuse VA Medical Center. Some patients travel from as far away as Canada and Pennsylvania. We do offer a service called the Valor Inn. The Valor Inn is located within the hospital and provides short-term lodging for veterans who travel long distances or have a need to stay overnight for an early morning procedure. The Valor Inn can also sometimes accommodate family members of hospitalized veterans. The DAV (Disabled American Veterans) Transport Network is also a valuable resource for our patients. This volunteer organization provides transportation to clinic visits in an eight-county area. Without them, many patients would be unable to get to their appointments.

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