Cath Lab Spotlight
St. Clair Hospital
Shawn Balaschak, RN, BSN, Manager
Pittsburgh, Pennsylvania

What is the size of your cath lab facility and number of staff members?
Currently, we have two rooms equipped with Siemens digital imaging systems (South Iselin, N.J.). Each lab has its own control room equipped with a nurses' station, monitoring system, and imaging monitor. Our lab also has its own 7-bed holding/recovery unit. Each holding bed is equipped with full hemodynamic monitoring and critical care capabilities. We are staffed with 4 full-time RNs, 3 part-time RNs, 3 full-time RTs, 1 part-time RT, 1 CNA, 2 part-time secretaries, and 1 manager. We have 13 cardiologists that perform cases (12 of which are interventionalists).

What types of procedures are performed at your facility?
We perform diagnostic right and left caths, PTCAs, coronary stent insertions, DCA, Rotablator® (Boston Scientific Scimed, Inc., Maple Grove, Mn.), Cutting Balloon™ procedures (Boston Scientific Scimed, Inc.), permanent pacemaker insertions, intra-aortic balloon insertions, peripheral diagnostics, peripheral PTAs and stent insertions, PercuSurge procedures (Medtronic, Inc., Santa Rosa, Ca.) intravascular ultrasound, and pericardiocentesis cases. We currently perform over 1700 procedures per year.

Randi Whaley, RN and Jay Randolph, RT in the control room.

Does your lab perform peripheral interventions?
We perform diagnostic and interventional peripheral cases. We have two physicians that perform interventions on renals, iliacs, femorals and popliteals. At this time, we are doing carotids on a diagnostic basis only. We normally do about 15 peripheral cases per month. We are excited to be doing peripheral procedures and look forward to the program growing in years to come.

Does your cath lab perform primary angioplasty in acute MI without surgical backup?
St. Clair Hospital utilizes a primary angioplasty program, which is available 24 hours a day. All myocardial infarction patients are brought to the cath lab. We are a large 300+ bed community hospital which receives emergency MI patients via air and ground emergency services from hospitals in the area that do not have a program. These patients are directly admitted to the cath lab. We are extremely fortunate to have a tremendous group of surgeons at our facility. Our primary cardio-thoracic surgeon, Dr. Fred Woelfel, has incredible outcomes and provides us with backup that makes us feel very comfortable. The cardiovascular operating team is also very efficient and reliable in providing the cath lab with surgical backup. We would not want it any other way.

Do you have cross-training in the cath lab? What are the regulations in your state?
We have cross training to a degree in our facility. Both nurses and RTs scrub procedures. Both nurses and RTs circulate procedures. However, RNs administer all medications, perform all patient documentation and do 95 percent of all patient monitoring. RTs do 100 percent of the panning on cases.

Is your cath lab filmless?
We have a totally filmless lab. Both of our suites are digital. Personally, I have been using digital systems since 1996. However, I have worked in a lab that had one remaining film system and there is no comparison. The RTs in our lab handle all of the responsibilities regarding imaging. They love using the digital systems.

What process does your lab use for pulling sheaths post diagnostic and interventional procedures?
We follow a process for diagnostics in which the ACT needs to be below 150. From that point, the scrub individual will pull either in the room or in the holding area. If we are very busy and in need of the room, we will transport the patient into the holding/recovery area where the sheath will be pulled. Otherwise, the sheath will be pulled in the procedure room. We hold for at least 10 minutes while the patient is being hemodynamically monitored. Once hemostasis has been reached, we apply betadine ointment and a clear tegaderm dressing over the site. The patient will then be transferred to the recovery unit. We hold our patients in the recovery unit for 30–45 minutes to ensure that there is no problem with the access site. We also want to be sure that the patient is alert and stable before we transport them back to their rooms. We hold manual pressure for 70 percent of our cases. The remaining 30 percent we use closure devices. For post-intervention situations with an ACT above 150, our coronary care unit is responsible for pulling the sheaths. Currently, all of our post-interventions go to our coronary care unit. The staff is fully trained and equipped to pull all of the post intervention sheaths.

How is inventory managed at your cath lab?
Our inventory is very closely monitored. We use a team approach to ensure that our supplies will be available when needed. For interventional supplies, one person who worked the case will record all supplies used for that particular case. That record will be submitted to me. Upon the end of the working day, I will place orders for all supplies used. All orders are on an overnight shipping pattern. This ensures that if a product was used, it will be back on the shelf as soon as the very next day. One day a week, I will manually eyeball the shelves and make sure that something did not get missed during the week. I rely on staff to help me by doing the same thing. They will inform me if the par level is low on something.

Each member in the lab is responsible for a different area of diagnostic and general supplies. They keep their own par levels and monitor the levels accordingly. When they need replenishment, staff will reorder as they feel necessary.

How does your lab compete for patients?
Our institution is committed to providing the most personalized, friendly, courteous, competent patient care. We approach each patient with a smile and feel that no request is too big or small to accommodate.

We also advertise in a sort of "grass roots" method. We rely on word of mouth as well as presence in the community. We participate in health fairs and provide programs for the community. We have a commitment to be a part of any special event in the community. This allows us to reach our community in a manner other than an in-patient setting. We feel that our patients are the best advertisement for the hospital. If we provide a friendly, welcome, and safe hospital stay for them, they will share their feelings about that experience with the rest of the community.

Our institution does participate in newspaper and periodical advertising. However, we put a much heavier emphasis on directly approaching the patient. It has been very successful for us. We happen to be located in an area of Pennsylvania that is heavily saturated with hospitals. Many have had to merge in order to meet operational needs. We have been very fortunate and have not had to merge with anyone. Recently, St. Clair Hospital was named as one of the Top 100 Regional Hospitals for benchmark success, and one of the top 100 community hospitals for stroke and ICU.

Chris Primero, RT and Val Scalise, RN prepare for a case.

Who handles your procedure scheduling?
We use a team approach to scheduling procedures. Everyone in the department is oriented for and has experience in scheduling cases. This is an area of the department that is extremely important, as with any cath lab. Therefore, all employees understand the importance of properly scheduling cases. Physicians and offices call the lab directly and schedule with whom ever takes the call. All staff members have the authority to schedule. We allow a 1-hour spot for all cases. Physicians are given 30 minutes to respond to their scheduled time. We have a policy of not putting the patient on the table until the physician arrives. If they have not arrived in 30 minutes, the following physician will be allowed to proceed. This rarely happens in our lab. Our physicians are usually conscious of their case times and do a good job of getting the case off on time.

How is your cath lab managed?
I manage the cath lab at St. Clair Hospital. I am a Registered Nurse with a Bachelors of Science in Nursing, and I am currently pursuing a Masters in Business Administration.

I give staff as much autonomy as they want. The Heart Center in our institution falls under a service line approach. I report directly to the Director of the Heart Center, Cynthia Loughman, RN, MLLS. I have no charge personnel or supervisor, so I handle the clinical and administrative tasks of the department. Having an autonomous staff helps me tremendously. Many times, I may be doing payroll or budgets, or be in meetings when cases are in progress. The staff functions very well when I am absent from the department. I try my best to provide a flexible and worker-friendly environment. Other than a few staff members that have left to pursue careers with their families, we have had almost a zero percent turnover rate. I think that this is a reflection of the flexible work environment in our department.

Has your lab been involved in any recent studies?
The most recent study that we participated in was the AMISTAD II Study. This study evaluated the efficacy and safety of Adenosine as an adjunct to reperfusion therapy in the treatment of acute anterolateral myocardial infarction.

Have any new devices or equipment been implemented in your lab recently?
The newest device or procedure that we have been doing is biventricular pacemaker implants. We started implanting them in October. From a staff standpoint, it is very similar to implanting a regular pacemaker. The SyvekPatch® (Marine Polymer Technologies, Inc., Danvers, Ma.) is another new device that we have started using in the past two months

Does your lab utilize brachytherapy?
At the moment, we do not perform brachytherapy cases. It is something that we have discussed and continue to discuss. Our institution and physicians are still in the process of determining the practicality of it for our patient population. It is an area that we have considered in terms of spatial planning for the future.

Does your lab have an outpatient program?
We have a very dedicated and efficient outpatient program. The outpatient unit is separate from the cath lab. However, both work very closely together on a daily basis. The outpatient unit is responsible for receiving the patient in the morning and preparing them for the cath lab. When they have completed their orders, we will bring the patient to the cath lab and assume responsibility.

If the patient does not need to be admitted after the cath, we will transport them back to the outpatient unit. There they will complete their bedrest order and be cared for until discharged.

What measures has your cath lab implemented in order to cut or contain costs, and improve efficiencies in-patient throughput?
Some of our biggest cost savings have come through bundle purchasing. Essentially, this is pre-pricing the procedure in exchange for a certain level of commitment to a specific vendor. Our primary vendor charges us one price per case if we use a certain amount of their products for the case. Each item in the "one price" is lower priced than it would be if we used each item individually and sporadically.

Another way that we have saved a considerable amount of money is through bulk purchasing. The larger the purchase, the larger the discount. This has been very beneficial to us in terms of pacemakers and selective catheters.

Also, we only accept new products on consignment. Our entire interventional inventory is consignment. This includes stents, wires, guides, balloons, and inflation kits.

Capitalizing on any vendor rebate programs is another way that we have saved considerable amounts of money. Many rebate programs exist and it is important to stay informed of them and inquire if you are eligible to benefit from the programs.

We keep our physicians informed of all of our cost containment efforts and ask that they participate, comply, and give advice on any new ways to help provide the latest technology to patients while reducing costs. We are fortunate to have physicians that pay attention to cost containment.

Mary Janet Johnson, RN, Barb Cahill, CNA, Debbie Hepler, Secretary.

Has your cath lab recently expanded in size and patient volume?
We have existed as a full service heart program for just over three years. Before that, our institution had a one-suite cath lab. In 1997, we had an entirely new cath lab built. It consists of two new suites, a 7-bed holding unit, staff locker rooms, staff lounge, physician dictation area, and supply rooms. In 1998, we opened for cases. Since then, our volume has grown each year. Being a newer program, we expect continued growth for quite some time.

How does your lab handle call time for staff members?
We ensure that all staff members receive an equal amount of call. Each staff member has at least three requests per month in which they can request a day to not be on call. We make every effort for a staff member to have at least two weekends off in a row. Our lab has three staff members on a call team. We cover day to day instead of week to week. Monday through Thursday, each member may have one or two days. If they have weekend call, the same three staff members will cover Friday through Sunday.

How often is each staff member on call?
Each staff member is on call from 8-11 days per month. This number depends on how many days are in the particular month and if anyone is on vacation.

We average about 15 call-ins per month. If the staff is needed, they know they will have to work a full schedule the next day. I do everything possible to let staff go home if they are not needed. I will let them start late if the cases start late or leave early if the cases end early. If we are slow, they have the option of not coming in that day.

Is there a particular mix of credentials needed for each call team?
The mix of credentials that we have for each call team is one RT and two RNs.

What type of quality control/quality assurance measures are practiced in your lab?
We closely study our intra-procedure stroke, MI, emergent CABG, death, vascular access site complications, and contrast agent complications. Our current complication and procedure success rates are well below the ACC recommendations.

We also measure physician response time, call team response time, conscious sedation monitoring, point of care testing documentation, door to balloon time, and pre cath requirements.

Does your cath lab utilize any alternative therapies?
The only thing that we do other than conscious sedation is use music. We have speakers built into the ceilings of each lab. We play music at the request of patients or physicians. Some patients find it comforting and relaxing. Some physicians find it relaxing as well.

What trends do you see emerging in the practice of invasive cardiology?
I think drug-covered stents will bring an enormous change to interventional cardiology. When all of the drug-coated stents are on the market, it will be very much like 1995–1997, when the advancements in stent technology had affected interventional cardiology. That was an exciting time.

Primary stenting seems to be becoming very regular on a national level at this point.

Of course, brachytherapy will be affecting interventional cardiology.

If biventricular pacing becomes a true and proven treatment for CHF, many labs may find themselves quite busy implanting biventricular pacers.

What type of continuing education opportunities are provided to staff members?
The Heart Center has an education committee (which I co-chair) that provides at least one continuing education program per month. Usually, it numbers around two or three per month. We cover subjects such as acute myocardial infarctions, rhythm interpretation, cardiac enzymes, coronary artery disease, and other subjects that pertain to the cardiac/cardiovascular system. Many times we bring in doctors or guest speakers to lecture in the programs. These programs are for the whole Heart Center or anyone in the hospital that wants to attend.

We try to have one cath lab-specific program per month. Clinical specialists frequently will inservice or do programs which provide continuing education units for the staff. In total, each staff member has the opportunity to attend 2–4 continuing education programs per month.

One of our most informational and educational opportunities each week occurs Thursday mornings from 7:30–8:30. Cardiologists as well as staff meet to discuss interesting or complicated cases from the previous week or weeks. As a department, with the cooperation of the physicians, we have committed to set aside this hour each week for education. It has worked very well for both staff and physicians.

How does your lab handle hemostasis -- where do patients go, and who is responsible?
Currently, we are holding manual pressure on 70 percent of our patients. We are using closure devices on the remaining 30 percent. We use VasoSeal® (Datascope Corp., Mahwah, N.J.), Angio-Seal™ (St. Jude Medical, Minnetonka, Mn.), Perclose (Redwood City, Ca.), the SyvekPatch, and Duett™ (Vascular Solutions, Inc., Minneapolis, Mn.) devices. We are using mostly Angio-Seal and VasoSeal at this point.

The cath lab is responsible for achieving hemostasis on all diagnostic caths or any of the interventions in which the patient's ACT falls below 150 before they leave the lab. Patients that have an ACT of above 150 are sent to CCU with the sheath in place. The CCU staff will assume responsibility for achieving hemostasis on that particular patient. Occasionally, we will keep a patient in the recovery unit until the ACT has reached 150. At that time, we will achieve hemostasis on the patient.

What is unique or innovative about your cath lab and its staff?
Our heart program has existed for almost four years. However, the staff in the cath lab has vast years of experience. The hospital recruited experienced individuals to ensure that this program would have a qualified staff who could provide optimal care to patients and comfort to the physician staff.

We have staff members that have worked many years in other large heart programs. There are individuals that have 15 years of cath lab experience working in this department. What makes this a unique situation is that all of these very experienced individuals from different cath labs came together and contributed what they felt was the best things about their previous labs. So, it is kind of an all-star team. We have several vastly seasoned perspectives on which to rely.

Sometimes, labs get into the habit of thinking there is only one way to do things. Fortunately, with all of these different perspectives, we have been able to be open-minded and flexible in regards to how things are done in the lab. We have a highly diverse group of professionals.