Saints Medical Center

What type of procedures are performed at your lab? We perform elective heart caths, angioplasty, stent implants, pacemaker implants, trans-esophageal echos (TEE) and cardioversions. We perform approximately 20 cases per week and recently have started to perform peripheral cases as well, including renal, femoral, and iliac percutaneous transluminal angioplasty (PTA) and peripheral interventions. How did you begin performing peripheral cases? The hospital administration realized that this is a continuing paradigm shift and that the cath labs, special procedure labs, neuro-interventional labs and vascular surgery all need to work together. The decision was made to ready the cath lab to accommodate peripheral procedures. We also met with the finance and coding departments to ensure we had the proper charges in place, and compared them with the special procedure department to make sure they were in line with their coding. What training was instituted so staff could be competent and skilled in performing peripheral procedures? We sent some of our staff to the special procedures department to observe and orient. We also hired two RNs and 2 CVTs from a large tertiary center with a great deal of peripheral experience. Do interventional radiologists, vascular surgeons and cardiologists perform procedures in the same area? Not currently, but we welcome the interventional radiologists to utilize our cath lab space when needed. Vascular surgeons do not use the cath lab as they do their endovascular work in the special procedures area. However, we would also welcome them to use our cath lab when available. What procedures do you perform on an outpatient basis? Diagnostic cardiac caths, TEEs, cardioversions, and generator changes. We also do our own pre-admission testing. What percentage of your patients are female? Forty-five percent of our patients are female. What percentage of your cases are normal and what percentage of diagnostic cath patients go on to have an interventional procedure? Three percent of our cases are normal and 18% convert to percutaneous transluminal coronary intervention (PTCI). Does your cath lab perform primary angioplasty without surgical backup? Yes. We are currently enrolled in two studies looking at this issue. MASS COMM, run by the state of Massachusetts, is a study to compare (elective) percutaneous coronary interventions (PCIs) performed in our facility, which does not offer surgical backup, as compared to a hospital that does. Patients must meet certain criteria prior to enrollment. If an intervention is needed, they are then randomized to one of the two hospitals. Three of every four patients are done at Saints Medical Center (without surgical backup), and one will go to our collaborating facility which offers surgical backup. Since August 2004, we have also been enrolled in the Atlantic Cardiovascular Patient Outcomes Research Team (C- PORT) trial, which allows patients in the community setting to have primary PCI for ST-elevation myocardial infarction (MI) in the community hospital rather than being transferred to another tertiary facility. Our median door-to-balloon time since its inception is 79 minutes. We have been able to achieve this benchmark through a continuum of care, beginning with our paramedics, who have been serving the greater Lowell, Massachusetts area since 1983. The sequence begins with either early recognition and field activation by our paramedics or by the emergency department (ED) staff upon diagnosis of acute MI. Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? Since we began our PCI studies, we have not needed to send any of our patients out emergently for cardiac surgery due to a cath lab-related complications. Who manages your cath lab? We have a Nurse Manager, Erin Boutin, RN, ASN, who manages day-to-day operations and a Director of Cardiovascular Services, Jennifer McCarthy, RN, MS. Do you have cross-training? Who scrubs, who circulates and who monitors? The RNs, RTs and CVTs cross-train into all roles, including circulating, monitoring, and scrubbing, but medication is only given by the RN. Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab? Yes. 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 physician or the RT. Can you describe the system(s) you utilize and how they work in cath lab daily life? We have the Coroskop angiographic and monitoring system by Siemens (Malvern, PA). The x-ray component has peripheral capabilities which allows us to perform basic peripherals. We are currently looking to upgrade our hemodynamic system, to either GE Healthcare’s Mac-Lab (Waukesha, WI) or to Philips Medical’s Witt Calysto (Bothell, WA). Updating our hemodynamic system will help facilitate portions of our data input for the American College of Cardiology’s National Cardiovascular Data Registry (ACC-NCDR) database and other reporting/querying. Did your facility need to make any changes to the imaging equipment to accommodate peripheral procedures? No, we continue to use our Siemens Coroskop/HiCor system. It allows us to do digital subtraction and angio acquisitions appropriate for peripheral procedures. What are some of the new equipment, devices and products introduced at your lab lately? We just added the Fetch Aspiration catheter (Possis Medical, Inc., Minneapolis, MN) to our inventory. We are in the process of purchasing intravascular ultrasound (IVUS). In addition, we are now performing cardiac cath via the radial approach and have added some different sheaths and wires to optimize this technique. How does your lab handle hemostasis? We currently stock Perclose (Abbott Vascular, Redwood City, CA), Angio-Seal (St. Jude Medical, Minnetonka, MN), D-Stat Radial hemostat bands (Vascular Solutions, Inc., Minneapolis, MN), FemoStop® (Radi Medical Systems, Inc., Wilmington, MA) and the D-Stat Dry (Vascular Solutions) patch. Approximately 95% of our patient population receives an Angio-Seal, 2% receive a Perclose, 2% receive manual pressure alone, and 1% receive a combination of either manual pressure with hemostasis patches, D-Stat radial band and FemoStop. Patients go to our 4-bed holding area if they are being discharged or waiting for a bed. If they are being admitted they most often go to the IMC unit (Intermediate Care) or if needed, the ICU. Does your lab have a hematoma management policy? Yes we do. It is both a departmental and hospital-wide policy. How is coding and coding education handled in your lab? We do our own interdepartmental billing and coding. We work with finance and our supply chain department for pricing and procedural coding. Our coding is updated yearly or as new procedures are instrumented in our lab. How is inventory managed at your cath lab? Currently we do not have an automated inventory system. All inventory, consignment and non-consignment, is managed by all staff but, with one staff member (an RT) overseeing ordering and par levels. We order through our Materials Management department. For our peripheral equipment, the RT who manages equipment and products met with the interventional physicians to review desired equipment. She then met with a special procedure technologist to review common equipment so as to not over order, and set par levels. We brought in consignment product for almost all of our needs but still have some direct purchases. Has your cath lab recently expanded in size and patient volume? Our interventional volume has increased exponentially since our elective angioplasty program began in July 2006, under the MASS COMM study. In the near future, we are expanding to a full cardiovascular center offering peripheral angiography and intervention including renal, subclavian, and iliac stenting. We are also considering adding an electrophysiology (EP) program, but will start by offering implantable cardioverter defibrillators (ICDs). We also presently perform cardioversions and TEEs, along with single and dual chamber pacemakers. What other modalities do you use to verify stenosis? Are you using physiology for lesion assessment? We are currently in the process of purchasing IVUS from Boston Scientific (the iLab system). We do not use physiological assessment. What measures has your cath lab implemented in order to cut or contain costs? Due to the size of our lab, we are able to contain costs by having the majority of our most costly products on consignment, i.e, pacers, stents, balloons, guides, guide wires, and peripheral equipment. We are also a member of the Premier Buying group and Yankee Alliance. What type of quality control/quality assurance measures are practiced in your cath lab? A few of the quality indicators we monitor are the door-to-balloon times, bleeding, groin complications and patient satisfaction. We also flag our patient population through admitting, so if any patient is readmitted, our staff can follow them for any potential adverse outcomes. All PCI study patients are followed internally and externally with the state for quality. We meet monthly with our hospital Quality Nurse and the Medical Director of the Cath Lab to review any peri-procedural outcomes. Does your lab utilize any alternative therapies (such as guided imagery, etc.)? We offer a wide selection of music to be played during the procedure to help relax patients and we are awaiting the arrival of decorative ceiling tiles to replace the florescent light ceiling panels. Does your cath lab do electives on weekends and or holidays? Currently we only perform primary angioplasty on weekends and holidays with our on-call staff. Occasionally we have come in for electives on minor holidays. How does your cath lab compete for patients? Has your institution formed an alliance with others in the area? To compete for patients we advertise by a variety of media outlets (newspaper, television commercials, hospital newsletters). We also offer free educational seminars to our community, which have been extremely well-received and appreciated, as evidenced by enrollment and turnout. We have received many letters from participants asking for additional programs to be offered. The hospital also meets with our cardiologists to receive input about their needs so we can try to accommodate them. We have an alliance with the Lahey Clinic (Burlington, MA) which is our tertiary oversight hospital for the C-PORT Trial. We attend and sponsor joint educational programs with both Lahey Clinic and Lowell General Hospital (Lowell, MA). How are new employees oriented and trained at your facility? What licensure is required for all professionals who work in your lab? All new employees go through hospital orientation. New staff are also assigned a preceptor for 12 weeks (unless experienced). The length of time varies based on previous clinical experience and education. Staff are also sent to Lahey Clinic, our tertiary center, for angioplasty training. All staff are ACLS- and BLS-certified and licensed in their respective profession(s): RN, Registered Cardiovascular Invasive Specialist (RCIS), RT(R), etc. Multiple staff members are also ACLS and BLS instructors. Does your lab have a clinical ladder? The hospital is working on obtaining Magnet status from the American Nurses’ Credentialing Center (an affiliate of the American Nurses Association). With the Magnet status designation comes clinical ladders. The ladder steps require staff to obtain certifications, participate in quality-driven projects and other participation focusing on shared governance and research to move up the ladder and obtain financial rewards. This happens in tiers. We also strongly encourage the staff to obtain RCIS certification. This is one of the goals our educator is pursuing with the staff. What type of continuing education opportunities are provided to staff members? Saints Medical Center presently offers an on-site RN-BSN program. Seventy-five percent of the tuition is paid for students in this program. We are currently negotiating a BSN-MSN program to be offered at the hospital. We also offer a loan forgiveness program for new RNs and tuition reimbursement for all staff. Our educator is working with all staff to help them obtain their RCIS licensure. We also provide in-house as well as vendor inservices related to our field. How is staff competency evaluated? Competency evaluation is ongoing due to the constant changes and updates in technology. We have 10 unit-based competencies completed annually. Due to the study programs, we also have monthly in-services on our research and equipment such as the intra-aortic balloon pump (IABP). How does your lab handle call time for staff members? Our cath lab call team consists of 3 people: a scrub, circulator, and a monitor. Since we are not a teaching hospital, one of the team members is second assistant during all cases. The team is multi-disciplinary, but must have one RN and one RT present at all times. If called in overnight, staff is offered compensated sleep time. Our workday shifts are self-scheduled and staff works either 8-, 9-, 10-, or 12-hour blocks of time, depending on their scheduling needs. How do you handle vendor visits to your lab? Vendors must call ahead to obtain an appointment and book time within the lab. When they arrive to the hospital, they report to the front desk, are verified and registered with a visitor pass, then brought to the lab. Our vendors are very proactive about offering in-services and updates for staff on new equipment as well as any time there is a request from the educator and/or manager. What trends do you see emerging in the practice of invasive cardiology? Increased peripheral interventions, computed tomography (CT) and magnetic resonance (MR) imaging, congestive heart failure clinics and the expansion of electrophysiology programs within cardiology divisions. We also anticipate increased IVUS use for appropriate apposition and sizing of stents. Has your lab has undergone a Joint Commission on Accreditation of Healthcare Organizations (JCAHO) inspection in the past three years? We are presently preparing for a JCAHO inspection within the year. We are focusing on new JCAHO guidelines for labeling of fluids, pre-procedure note with ASA (American Society of Anesthesia) classification, airway assessments, and fall risk, as well as all patient safety goals for 2007 and 2008. Can you share the physical layout of your cath labs? We have one procedure room which unlike most, has 5 beautiful sealed windows with automatic blinds which can be closed during the procedure. Our lab is connected to the intensive care unit (ICU), and two floors above the radiology and emergency departments, which can be somewhat geographically challenging. We also have a 4-bed pre/post holding unit located directly across from the procedure room. Please tell the readers what you consider unique or innovative about your cath lab and staff. Our lab is unique in that our staff does pre-admission testing/interviews on all patients. We also do same-day admit to our unit and recovery post procedure. The staff are very dedicated to patients. They try to follow patients from pre-admission testing to procedure, recovery and then to discharge/admission. Beyond discharge, staff personally make follow-up calls to each outpatient. All PCI patients are followed on the floors each hospital day for post procedure teaching and discharge instructions. After discharge, staff call each patient at 24 hours, 30 days, and one year. If the patient is readmitted, they will go see the patient during subsequent hospitalizations. Our staff is also very involved with community services and programs. Is there a problem or challenge your lab has faced? As a small community hospital-based lab, it is hard to keep up with the larger institutions as far as the latest and greatest equipment. It is also an ongoing process to educate the community that a smaller institution can deliver state-of-the-art care. We maintain a high level of patient care and continue to surpass benchmarks like door-to-balloon times, maintaining and monitoring low complication rates, and overall patient satisfaction. What’s special about your city or general regional area in comparison to the rest of the U.S.? We are in a very culturally diverse community. We have a large Asian population (Cambodian/Laotian), so it is critical that we are educated in regards to their cultural practices (coining*, cupping**). These practices may seem unusual to some, but they can give clues as to what is going on with the patient despite language barriers (for example, coining over chest or scapular region can alert you upon physical exam that the patient has been having chest pains even before you utilize an interpreter). We are located in Lowell, Massachusetts and we have a very experienced 911-EMS/paramedic system. Our ER physicians are very supportive and proactive about field activations for STEMI. This has dramatically dropped our door-to-balloon times and enabled us to offer optimal revascularization to our patient population. We are also located about 30 minutes from Boston, which gives our patients many options to choose other specialty care if needed.

The Society of Invasive Cardiovascular Professionals (SICP) has added two questions to our spotlight:

1. Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? Do staff receive an incentive bonus or raise upon passing the exam? The RCIS is not a requirement in our lab, but we strongly encourage this exam. The staff has begun the process of preparing to study and take the exam as a group. At this point, until our clinical ladder is in place, there is not a bonus upon passing the exam, but with our annual merit evaluations, it would certainly weigh heavily upon their evaluation, which is tied to their merit raise. 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, Alliance of Cardiovascular Professionals (ACVP), or regional organizations? Our entire cath lab has become members of the SICP. Some also have been members of the American Heart Association. Jennifer McCarthy can be contacted at: jmccarthy@saintsmedicalcenter.com * Coining, is a method of using a copper coin dipped in tiger balm to apply pressure to acupuncture points of the body, which leaves bruise marks. (Source: Accessed September 12, 2007 at https://www.everyculture.com/multi/ Bu-Dr/Cambodian-Americans.html) ** Cupping is performed by fixing a piece of cotton in the bottom of a glass, lighting the cotton on fire, and placing the open mouth of the glass on the sick person’s back. This creates a vacuum (and contusion) and thus draws the wind (that may be causing the illness) from the body. In one session, the procedure is carried out three to four times bilaterally down the back on either side of the spine with six to eight circular contusions resulting. (Source: Accessed September 12, 2007 at https://www3.baylor.edu/Charles_Kemp/ laotian_summary.html)

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