®
Tom Lassar, MD: Platelet Function
Testing at University Hospitals page 32
Clinical Editor’s Corner – Morton Kern, MD Serial Lesion FFR Made Simple
page 4
www.cathlabdigest.com
®
CASE REPORT & INTERVIEW
Cath Lab Spotlight
Treatment of Severe
Coronary Artery Disease in
a Diabetic Patient Using the
Resolute Integrity Stent:
A Case Study
Ronald P. Caputo, MD, FACC, FSCAI, Director of Cardiac Services,
St. Joseph’s Hospital, Syracuse, New York
Lorissa Plis DNP, RN with the cath lab team.
Crouse Hospital
Lorissa Plis, DNP, RN, CNS, CCNS, CCPC, Manager Cardiac
Care Center & Chest Pain Center Coordinator, Crouse Hospital,
Syracuse, New York
Tell us about your cath lab.
Crouse Hospital is a 563-bed not-for-profit hospital located in
Syracuse, New York. Within the Cardiac Care Center, there are
three cath labs and a nine-bed admission/recovery area. Crouse
is an Accredited Chest Pain Center and Heart Failure Center by
the Society of Chest Pain Centers and is the site of the region’s
only pediatric cath lab. We have twelve registered nurses (RNs),
one licensed practical nurse (LPN) and one interventional radiologic technologist. Several nurses working in the cath lab are currently working on either a bachelor’s or master’s degree in nursing. Together, our staff has an average of 15+ years experience in
cardiovascular nursing.
What procedures are performed in your cath lab?
We perform diagnostic and interventional cardiac catheterizations, patent foramen ovale (PFO) closures, temporary and permanent pacemaker insertions, implantable cardioverter-defibrillator
(ICD) insertions, pediatric catheterizations and ablations, emergency balloon septostomies on newborns, and diagnostic and
interventional peripheral vascular studies. We also have the capability for intra-aortic balloon pumps, pericardiocentesis and
thrombectomies. We perform approximately 35 scheduled procedures a week, and provide 24/7 emergency call for adult and
pediatric emergencies.
continued on page 24
September 2012
vol. 20, no. 9
Intro/Abstract
The Resolute Integrity drug-eluting stent (DES) (Medtronic) was approved for use in
the U.S. in February 2012. The first stent to have an indication for the treatment of
coronary artery disease in diabetic patients, the stent has enjoyed rapid adoption in
the clinical arena. The following case study illustrates the effective use of this stent in
a diabetic patient.
continued on page 14
THE TRANSRADIALISTS
Iliac Artery Intervention
via Radial Access
Matthew Evans, DO, Kintur Sanghvi, MD,
Deborah Heart & Lung Institute
Browns Mills, New Jersey
continued on page 10
CATH LAB MANAGEMENT
Community-Based
Collaborative Vascular
Disease Detection
How one center utilized the PADnet
Disease Management System to grow its service line
Cath Lab Digest talks with Jane Bower, CV Service Line Director of
Development, West Georgia Medical Center, LaGrange, Georgia.
continued on page 16
24
Cath Lab Spotlight
september 2012
Continued from cover
Crouse Hospital
Lorissa Plis, DNP, RN, CNS, CCNS, CCPC, Manager Cardiac
Care Center & Chest Pain Center Coordinator, Crouse Hospital,
Syracuse, New York
Does your cath lab perform primary
angioplasty without surgical backup
on site?
Yes. We have an agreement with
SUNY University Hospital, which is
adjacent to Crouse Hospital. In the
event of an emergency surgical intervention, patients are transported via a
connecting tunnel directly to the University Hospital OR.
What percentage of your patients is
female?
Forty-five percent of the patients we
see are female.
What percentage of your diagnostic
caths is normal?
On average, 74.16% of our patients
need an intervention at the time of
their catheterization. Only 25.82%
are normal.
Do any of your physicians regularly
gain access via the radial artery?
Yes, almost exclusively. We have
been using the radial approach since
1997. We only utilize a femoral artery or a brachial cut-down approach
when absolutely clinically necessary.
The radial artery is even the site used
with emergency ST-elevation myocardial infarction (STEMI) patients.
Femoral arteries are reserved for right
heart caths and for patients who absolutely cannot be accessed through
the radial artery.
Who manages your cath lab?
Lorissa Plis DNP, RN, CNS, CCNS,
CCPC, is the Cardiac Care Center
manager and Chest Pain Center coordinator, Robert Pikarsky is the
administrative director and Joseph
Battaglia, MD, FACC, FSCAI, is the
medical director.
Do you have cross-training? Who
scrubs, who circulates and who
monitors?
All RNs in the department rotate
scrub, circulator and monitor roles.
The LPN and the RT cannot push intravenous medications, so they only
scrub and monitor cases. The RT is
responsible for the radiology equipment and radiation safety.
Does an RT (radiologic technologist)
have to be present in the room for all
fluoroscopic procedures in your cath
lab?
No, but we have a RT on staff in the
cath lab. She is present and available
for all cases, but is not assigned to
each case. The physicians initiate and
operate fluoro in all the cases.
Which personnel can operate the xray equipment (position the II, pan
the table, change angles, step on the
fluoro pedal) in your cath lab?
Only trained physicians and the interventional radiological technologist can operate the x-ray equipment.
The physicians in our lab typically
operate the fluoro pedal and pan the
table during cases; however, the RT
can assist with positioning the II,
panning the table, and changing the
angles or operating the fluoro pedal
as needed. Nurses have no involvement in any of these duties.
How does your cath lab handle radiation protection for the physicians
and staff?
Radiation safety is very important
to us. Our RT and the inventory and
equipment support specialist sit on
the Radiation Safety Committee. We
monitor and disclose radiation levels monthly to staff and are always
looking for strategies to reduce radiation exposure.
Quality Cardiac Care is a team approach; we are happy to partner with our
EMS and Emergency Department to provide the best in patient care and
promote community health. Pictured are Susie Barnett AEMT-P, Dr.
Richard Steinmann (Emergency Department), Dr. Anil George (interventional cardiologist), and Crystal Barus MS, RN.
Cath lab staff and physicians
with director Robert Pikarsky.
The pediatric lab.
What are some of the new equipment,
devices and products recently introduced at your lab?
Because safety is our priority, we
have instituted the use of the RadPad for our fluoro cases (Worldwide
Innovations & Technologies, Inc.).
The RadPad is a disposable, lead-free
pad that reduces scatter radiation exposure to medical personnel during
fluoroscopy procedures by 95%. We
are also implementing the LUMEDX
Cardiovascular Information System
for real-time scheduling, and cardiac
catheterization and echocardiography
physician documentation. We have a
dedicated cardiovascular information
system (CVIS)/picture archiving and
communications system (PACS) manager, Justin Pratt, AEMT-P.
How does your lab communicate information to staff and physicians to
stay organized and on top of change?
We utilize email, bulletin boards,
staff huddles and a communication
book. We have Vocera for day-today communication and group pager systems.
daily communication with Janice
Jorgensen, our inventory and equipment support specialist. Janice was a
LPN in the cath lab, but now oversees
equipment and supplies, and coordinates with coding to assure our service codes and billing sheets are up to
date and compliant.
artery sheaths. We use closure devices
on any patient who can be closed.
When a manual press is required, all
the cath lab staff is trained to perform
it. During the orientation period,
staff must perform five manual press
sheath removals with their preceptors
before performing independently.
How is coding and coding education
handled in your lab?
The coder is located outside of the
Cardiac Care Center, but she is in
Who pulls the sheaths post procedure,
both post intervention and diagnostic?
Since we primarily do the radial approach, we do not have many femoral
Where are patients prepped and recovered (post sheath removal)?
Patients are prepped and recovered
in our pre and post care observation
26
Cath Lab Spotlight
september 2012
Dr. Joseph Battaglia
and Dr. Anil George.
Dr. Joseph Battaglia and the cath lab team.
area, housed in the cath lab area.
Sheaths are typically pulled while the
patient is still on the cath lab table.
Patients in whom activated clotting
times (ACTs) are high, where sheaths
cannot be pulled immediately, are
moved to the recovery area, where
sheaths are pulled by a staff member when appropriate. We utilize a
closure device (Angio-Seal, St. Jude
Medical) whenever possible to avoid
manual pressing.
What is your lab’s hematoma management policy?
The cath lab staff manages all access
sites throughout the hospital.
How is inventory managed at your
cath lab? Who handles the purchasing of equipment and supplies?
Inventory is ordered and managed
by the inventory and equipment specialist. We perform daily reconciliation of critical supplies, stents and
balloons. Each room has designated
par levels of supplies, and the rooms
are assigned daily for restocking. The
inventory and equipment specialist is
in charge of all ordering and maintenance of supplies. New products are
introduced through our Cardiac Value Analysis Team (VAT) for approval.
Has your cath lab recently expanded
in size and patient volume?
We recently transitioned all ICD
implants from the main OR to the
Cardiac Care Center. We are in the
process of expanding our hours of
operation to accommodate early admissions and late discharges directly
from the Center, rather than utilizing the Recovery Care Center. This
expansion will allow for later scheduling of procedures and allow for increased volume.
Do you have a hybrid cath lab, or are
you planning to build one?
Yes, one of our labs is a hybrid lab.
We have the Mac-Lab as our hemodynamic system (GE Healthcare) and
Siemens medical imaging equipment.
Is your lab involved in clinical research?
Yes, we are active in many clinical studies, in coordination with our
cardiologists. We are also active in
research with our emergency medical
services (EMS) community. We also
participate in the American College
of Cardiology National Cardiovascular Data Registry (ACC-NCDR) and
the NCDR-ICD Registry.
Can you share your lab’s average
door-to-balloon (D2B) times and
how employees at your facility have
worked together to keep D2B times
under the mandated 90 minutes?
We are incredibly proud of our D2B
times. In 2010, our mean D2B was
45.25 minutes and in 2011, it was
39.25 minutes. We achieve over 81%
of our cases in less than 60 minutes, and
100% were achieved within 90 minutes
in 2011. We do participate in the AHA
Mission Lifeline and the American College of Cardiology’s D2B Alliance
A look at lab layout: The Cardiac Cath and EP rooms were designed and
built in 2000 under standards that allowed for smaller rooms. We would
definitely like larger labs. The EP lab is very small and difficult to do device work in. The cath labs become very congested with equipment. Ideally, our labs would be larger, with more cabinet space and our admission/
recovery area would be larger to accommodate reclining chairs at each
bedside for recovery from the radial procedures.
Who transports the STEMI patient to
the cath lab during regular and during
off hours?
STEMI patients are transported by a
combination of ED nurses, paramedics, physicians and cath lab staff. The
minute the cath lab is ready, we roll,
so whoever is at the bedside at the
time transports. This is the case with
both on and off hours.
What do you do when the call team is
already busy doing a procedure and a
STEMI comes into the ED?
We utilize a group page system. If the
team is already in the middle of case,
a second page goes out. Because only
one physician is on call for the cath
lab at a time, the case on the table is
finished while the STEMI is prepped
in another lab.
What other modalities do you use to
verify stenosis?
We use intravascular ultrasound
(IVUS, Volcano Corporation) and
fractional flow reserve (FFR).
What measures has your cath lab
implemented in order to cut or contain costs?
We have a Value Analysis Team
(VAT) that is constantly looking for
expense reduction and operational efficiency savings. We re-evaluate contracts, custom packs and supplies on
a continuous basis, and are very aggressive in empowering staff and physicians to look for cost containment
and expense reduction ideas.
What quality control/quality assurance measures are practiced in your
cath lab?
Crouse Hospital is both an Accredited Chest Pain Center as well as an
Accredited Heart Failure Center, so
we are measuring many clinical indicators, including, but not limited
to D2B times, transmission rate for
EKGs from EMS, readmission rates,
and turnaround times for troponins.
We also measure multiple value-based
purchasing indicators as well as patient satisfaction, employee satisfaction, physician satisfaction, and Hospital Consumer Assessment of Health
Providers and Systems (HCAPS).
Are you recording fluoroscopy times/
dosages?
Yes, we document our fluoro times
and doses in the Mac-Lab electronic
clinical event logs and in our logbooks. We have protocols in place for
high fluoro exposures for long-term
28
Cath Lab Spotlight
september 2012
The cath lab staff is trained
in adult cath, pediatric
cath, and electrophysiology
procedures, as well as
device work. This training
really sets them apart from
other labs in the region.
Lorissa Plis, DNP, RN, chest pain
center coordinator and manager
of cardiac care, and Dr. Joseph
Battaglia, medical director.
follow-up of patients. We evaluate
fluoro procedures and doses on a bimonthly basis, and have a strong focus
radiation reduction. This information
is also reviewed at the monthly Radiation Safety Committee Meetings.
Who documents medication administration during the case?
The nurse monitoring the case documents all medications in the MacLab. The nurse and physician both
sign this report before it is placed in
the patient’s chart.
How does your cath lab compete for
patients? Has your institution formed
an alliance with others in the area?
Within the city of Syracuse, there are
four hospitals with cath labs. We are
physically connected to SUNY University Hospital, which also has one,
although not affiliated. There is a lot
of competition for market share. We
utilize radio, TV, billboards, community forums and other media sources
for advertisement.
How do you handle vendor visits to
your lab?
We utilize VeriREP for vendor tracking. Vendors must make an appointment in the lab. No more than one
vendor is allowed at one time unless there is a specific request from a
physician.
How are new employees oriented and
trained at your facility?
Orientation to the lab is staged. We
begin with circulating, then the scrub
role, then, finally, monitoring. We
then transition their orientation to
pacemaker/ICDs and lastly, the pediatric cath lab. We utilize a team approach, so each new nurse is assigned
two preceptors for the duration of
their orientation.
What continuing education opportunities are provided to staff members?
We have a weekly cardiac cath conference with presentations from the
cardiologists and staff is strongly encouraged to attend. We also look for
local and national conferences for
staff when funding is available.
We have a strong focus on staff returning to school for advanced degrees and allow for flexible scheduling to accommodate school.
How is staff competency evaluated?
We have yearly competencies that
include computer-based learning,
hands-on return demonstration, as
well as skills labs that are set up in collaboration with our vendors for validating competency with equipment.
Where is your cath lab located in relation to the emergency department (ED)?
The cath lab is below the ED and
there is a dedicated transport elevator for patients to be brought down
to the cath lab.
Does your lab have a clinical ladder?
No. Currently there is a clinical ladder being developed for the organization. We do have an informal clinical
ladder that allows staff to transition
to charge nurse and orientor roles.
What is unique or innovative about
your cath lab and staff?
We are almost exclusively a radial
approach lab (for adults only). Patients have learned of this option
and often come in requesting this approach. We are also the only pediatric
cath lab in the region. The cath lab
staff is trained in adult cath, pediatric cath, and electrophysiology procedures, as well as device work. This
training really sets them apart from
other labs in the region.
How does your lab handle call time
for staff members?
We utilize self-scheduling for call.
The only requirement is that there
are two RNs on each team (which is
always made up of three staff members). We do pay special attention to
skill mix so that new nurses are not
together when they come off orientation, until they gain more confidence
and experience with emergencies.
Within what time period are call team
members expected to arrive to the lab
after being paged?
Staff has 20 minutes to arrive.
Do you have flextime or multiple
shifts?
We do have some flexibility with
shift scheduling. We currently have
0645, 0730 and 0830 start times.
This will soon be expanded to include
0600-1830 shifts.
Has your lab recently undergone a national accrediting agency inspection?
We received Chest Pain Center Designation in 2010 and Heart Failure
Center Designation in 2011. The
best advice we have is start looking
at your gaps, and build strong relationships and processes to support
providing the best patient care. These
designations really solidified the fact
that our processes were resulting in
the best patient care.
What trends have you seen in your
procedures and/or patient population?
We are seeing a very disturbing trend
of acute myocardial infarctions (AMIs)
in our 30- to 50-year-old population.
Is there a problem or challenge your
lab has faced?
Our greatest struggle is with consistency of scheduling. Given the nature of the cath lab, it is often hard
to predict volumes. We work closely
with our cardiology practices to try
for consistency in scheduling elective
caths, but inpatient and emergency
cases are far less predictable. Worklife balance for the staff is very important, so we work hard at trying to
help them achieve this.
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”?
Syracuse University is adjacent to
our hospital. Syracuse University
football and basketball draw very big
crowds to the “hill” where the university and Crouse Hospital are located.
This creates large traffic jams and reduces accessibility to the hospital. As
a result, we require on-call staff to
stay in-house 2-3 hours before game
time until the start of the game in order to ensure there are no delays in
D2B times.
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)?
At this time, it is not required. We
do encourage it and several staff
members are in the process of obtaining their RCIS credential. They will
receive an additional hourly stipend
per union contract upon obtaining
the RCIS.
2. Are your team members involved with
any professional organizations that support the invasive cardiology service line?
Members of the cath lab leadership have joined SCPC, AACN,
SICP, and ACC. n
Lorissa Pils, DNP, RN, can be contacted at LorissaPlis@crouse.org.
A question from the American
College of Cardiology’s National
Cardiovascular Data Registry:
How do you use the NCDR Outcome Reports to drive QI initiatives at
your facility?
We compare the reports with current QI initiatives and develop yearly QI
initiatives driven by this data.