The Wesley Hospital

What is the size of your cath lab facility and number of staff members? Our cath lab has two procedural rooms. We use both rooms for cardiac diagnostic and interventional procedures. One room has recently been upgraded to double as an electrophysiology (EP) lab. We also have a four-bay holding area that we use for patient check-in and for pulling sheaths post procedure under monitoring. Our staff numbers twenty-nine: Two part-time employed (PTE) and three full-time employed (FTE) radiographers; One clinical nurse manager (CNM); 19 registered nurses (equaling 18.4 FTE); One enrolled nurse (EN); Two PTE cardiac techs; An orderly. Many of our nursing staff have critical care and cardiac-related backgrounds. However, it is not our current practice to insist on these areas of experience. Our current staff have been in residence for a period ranging from two months to ten years. What types of procedures are performed at your facility? Our cath lab operates as a department within The Wesley Hospital (Brisbane, Australia), a facility with over 450 beds. The lab serves nine diagnostic cardiologists and seven interventionalists (including three electrophysiologists), who perform the following procedures: Diagnostic coronary angiography Right heart studies Angioplasty (PTCA) and stenting Rotablator® atherectomy (Boston Scientific, Maple Grove, MN) Coronary intravascular ultrasound studies (IVUS) Intra-aortic balloon pump (IABP) insertion Valvuloplasty Atrial Septal Defect (ASD) closure Temporary pacing wire insertion Permanent pacemaker (PPM) insertion (including bi-ventricular) Intra-cardiac defibrillator (ICD) insertion Electrophysiology studies (EPS) Radiofrequency ablation (RFA) Approximately 300 procedures are performed each month, making us one of the busiest private cath labs in the state of Queensland. Although we have accommodated vascular and peripheral interventions in the past, these procedures are now performed in a purpose-built area annexed to the radiography department of the hospital. Does your cath lab perform primary angioplasty with/without surgical backup? Due to our location within The Wesley Hospital and the comprehensive services it provides, all angioplasties are carried out with surgical cover. The cardiac theatre has a rostered on-call team (including one of three cardiac surgeons) to cover all unscheduled hours. The maximum period for assembly of the team is 30 minutes. On weekdays, there is a cardiac surgeon on campus. Naturally, all critical emergencies take precedence over elective surgical cases. Who manages your cath lab? Our clinical nurse manager (CNM, Level-3, RN) oversees: Budget management Stock supply Staffing levels Liaison with associate hospital departments Adherence to hospital policies and procedures. Within the hospital structure, we come under the umbrella of peri-operative services. In the event that the CNM needs a holiday away from it all, the lab can be managed by one of four level-2 RNs. Our chief radiographer is responsible for management of radiography staff and for maintenance of radiographic equipment and safety. We are also fortunate to have had a relatively new position, that of the medical director, filled. This has helped with facilitating negotiations and communications with our medical staff. When major issues arise, such as capital upgrades, session time changes and allocations, or facilitation of new procedures, all three personnel may be actively involved. Do you have cross-training? Who scrubs, scouts and who monitors? From orientation, our nursing staff are trained into all three roles. During the course of the day, we are rotated through each role. This helps to share the amount of time spent in leads, and to maintain continuity in the working team within each theatre. The cardiac techs also help with monitoring during angiograms and angioplasties, but their main focus is EPS. There is no issue as to who is able to acquire and pan shots. Both radiographers and MDs are permitted. Allocation of these tasks is purely dependent on the individual MD's preference (which pretty much reflects what they were taught in their original training). Does your lab have a clinical ladder? There are four levels of nursing staff within the unit: 1. Enrolled nurse (EN) 2. Level-1 RN 3. Level-2 RN (Clinical Nurse Specialist, holding a specialist qualification in a related area) 4. Level-3 RN (Clinical Nurse Manager). The level-2 nurses include our two education facilitators. What are some of the new equipment, devices and products introduced at your lab lately? We are happy to report we are using the sirolimus-eluting stent since August 2003. The CYPHER is used in approximately 90% of cases. This has had no financial impact on our facility as the cost is 100% rebatable from private health insurance funds. (Recent national insurance figures have revealed a rise in payouts for prosthetic devices of 24% in the last 12 months, of which 14% has occurred in the last quarter. This dramatic rise has been primarily attributed to the introduction of CYPHER.) We have utilised the Cutting Balloon (Boston Scientific, Maple Grove, MN), and have recently purchased an IVUS machine, which we also use to participate in an international drug research study. Our EP software is in the process of being upgraded with the GE Medical Systems’ Windows NT®-based CardioLab system (Milwaukee, WI) formerly known as the Prucka CardioLab® 7000. Is your cath lab filmless? The lab upgraded from cine film in 1999. Although we still have the capability if specifically requested, procedures are recorded digitally and stored on CD-ROM for archiving. How does your lab manage haemostasis? Cardiologists have a choice of three methods. Both collagen plug and closer suture are available, along with traditional digital pressure. Angio-Seal STS (St. Jude Medical, Minnetonka, MN) is used in approximately 35% of cases and the Perclose Closer S (Redwood City, CA) in Does your lab utilise any alternative therapies (such as guided imagery)? The alternative therapy we do use is aromatherapy on our warmed blankets. This is well received by clients, and lavender is a tried and true favourite. We also have a wide variety of music available to each lab, accommodating client requests (or staff!) when possible. How does your lab handle call time for staff members? The on-call team consists of three RNs and one radiographer. The nursing mix is based on experience. A junior nurse is partnered with senior RNs in order to gain confidence with and an understanding of call-in procedure. If a session is running past scheduled operational time, it will be staffed by the on-call team members, who will see the procedure through to its conclusion. The call period extends from 1930hrs to 0700hrs the following morning. FTEs cover a total of eight on-call shifts per rostered month, including two weekend days. It decreases proportionately for PTEs. Do you have flextime or multiple shifts? Scheduled session hours are from 0700hrs to 1930hrs, with open slots available from 0700-0800 and 1230-1330. Our rostered shifts are of six, eight or ten hours duration, and stagger start from 0630hrs to 1100hrs. For excess hours worked, we have the choice of being paid overtime or accruing TOIL (time off in lieu). TOIL may then be taken in quiet times or paid out later (as when going on holiday with a dire need of extra shopping money). How is inventory managed at your cath lab? Supply is managed in three major ways in our lab. Firstly, our standard stock (e.g. gloves, gowns, dressings and tapes) are barcoded and has minimum and maximum par levels set. These barcodes are utilised by the stores department to order imprest (i.e., in advance of payment) stock twice weekly. On a daily basis, our EN checks stents, wires and stock not on imprest. The CNM then orders twice weekly, depending on how busy we have been. Representatives from various companies check our consignments of catheters, stents and balloons. This consignment stock is rotated and updated as necessary. For the purchase of major equipment and assets, the request is sent through the executive committee of the hospital. How are vendor visits handled in your cath lab? If vendors wish to visit, it is understood that they must telephone and make an appointment in advance. We have a good relationship with most vendors. They generally have no reason to enter the OR itself unless for MD training with new devices, etc. Vendors are permitted to sit in the monitoring room where they can communicate with the MD if necessary. What measures has your cath lab implemented in order to cut or maintain costs? A major review of our operational hours and session allocation times has provided a marked reduction in overtime costs. Scheduled operating hours have been increased from 0800hrs-1830hrs to 0730hrs-1930hrs. How are new employees orientated and trained at your facility? The Wesley Hospital runs a general orientation for all new staff on commencement of employment. This is compulsory. For RNs, the cath lab then runs a preceptored orientation program of approximately six weeks, depending on previous experience. Usually within three months, new staff are autonomous and have completed basic procedural competencies. They are then required to complete an ALS program and attain subsequent yearly certification. The pleasures of on-call responsibilities then begin! What types of continuing education programs are offered to your staff members? Eighteen months ago, our lab was extended and underwent renovations. This included a newly allocated education room. A shared education facilitator role was also created. This has provided a much-needed boost to the organisation and development of our educational resources, upgrading of competencies, and facilitation of educational opportunities, both internally and externally. Each staff member is granted two paid educational leave days per year. Two of our junior staff members are currently undertaking a university-accredited cardiology course, specialising in cath lab procedures. (There is no widely recognised qualification equivalent to the RCIS currently available in Australia.) What licensure is required for all professionals who work at your lab? Radiographers must have a current Radiation Use License (under Australia’s Radiation Safety Act) with the Queensland Health Radiation Board. Each has qualified with a Dip.App.Sci or BSci in Diagnostic Radiography. Our EN and RNs (Dip. App. Sci or BSN) must have current licensure with the Queensland Nurses Registration Board. Our cardiac techs (officially employed as cardiac scientists) are again holders of either a Dip.App.Sci or BSci, specialising in cardiac physiology. What is innovative or unique about your cath lab staff? In 2001, one of our cardiologists paid a visit to the Shahid Gangalal National Heart Centre in Nepal and assessed the need for training of their resident physicians. The Centre began from an old shoe factory renovated and furbished largely with the aid of international foreign charity organizations and individuals. Since then, with the aid of sponsorship, their chief cardiologist has spent three months training here in Brisbane and has returned home to Nepal, where he has performed over 90 diagnostic cases. In February 2003, one of our RNs traveled to Nepal with the aim of assessing and assisting training of local nurses in cath lab procedures, and aiding implementation of administrative systems for smooth day-to-day operation; in particular, to help prepare for commencement of interventional procedures. This is being undertaken on a voluntary basis. Many thanks to all who have offered their support in this project. Finally, a unique and much appreciated characteristic of our staff is their ability to whip up an international gourmet spread at the slightest hint of a celebratory event then again, no event required! Cheers! From The Wes.

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