We’re in the Spotlight!
Catherization Lab Spotlight: University Health System
By Debbie Gruendler RN
Have you seen the latest issue of Catherization Lab Digest? University Hospitals’ Cardiac Catherization Lab was featured in the Cardiac Cath Lab Spotlight in the June 2007 issue. The article included various procedures performed, treatment modalities, latest in research and the current trends in Cardiology. See the complete story below.
- An Interview with Franklin D. Espanto, BSC, RCIS, Clinical Director, UHS Cardiac Catheterization Services, San Antonio, Texas and featured in Cath Lab Digest online.
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What is the size of your cath lab facility and number of staff members? University Health System (UHS) Cath Labs have 3 lab suites supported by 29 staff members, consisting of full-time and part-time clinical and non-clinical personnel. We have 14 registered nurses (RNs), 5 cardiovascular technologists (CVTs, 2 of whom carry the Registered Cardiovascular Invasive Specialist [RCIS] certification), 2 of whom carry the Registered Cardiovascular Invasive Specialist [RCIS] certification), 2 case manager RNs, 1 critical care technician, 1 administrative assistant, 1 operations manager, 1 inventory specialist, 1 data entry specialist and 1 data systems coordinator. University Hospital CCL staff range from 3 to 20-plus years of employment.
What type of procedures are performed at your facility?
UHS Cath Labs perform about 15,686 procedures annually, approximately 300 procedures per week. We perform various cardiac and peripheral interventions, including adult diagnostic heart studies, electrophysiology (EP) studies, device implantations, percutaneous transluminal coronary angioplasty (PTCA), cardiac stenting, alcohol (ETOH) ablations, chronic total occlusions (CTOs), atrial septal defect (ASD), patent foramen ovale (PFO) and ventricular septal defect (VSD) closures, intravascular ultrasound (IVUS), rheolytic thrombectomy, atherectomy, renovascular stenting, peripheral atherectomy, thrombectomy and peripheral stenting. Our carotid intervention volume has been increasing, according to Stephanie Hyde, CCL Data Systems Coordinator.
Does your cath lab perform primary angioplasty with surgical backup?
UHS Cath Labs have arrangements with our cardiothoracic surgery staff on a 24/7 basis.
Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery?
I can recall we had one right coronary artery (RCA) perforation that required emergent cardiac surgery.
Has your cath lab expanded in size and patient volume?
With the recent addition of peripheral procedures performed in the cath lab, new cardiologists and a new electrophysiologist (Dr. Manoj Panday), we have indeed seen a patient increase. At this pace, we will be experiencing more volume and may have to add another lab suite or a computed tomography angiography (CTA) suite.
How does your cath lab compete for patients?
UHS is the only county facility that has referrals from most of south central Texas due to its trauma Level I status. In addition, from our cardiology group, we receive referred patients with critical needs from nearby communities.
What procedures do you perform on an outpatient basis?
We perform diagnostic heart studies as well as certain peripheral interventions.
What percentage of your patients are female?
Fifty-seven percent of our patients are female.
What percentage of your diagnostic cath patients go on to have an interventional procedure?
Anywhere from 50 to 60 percent of our diagnostic cases become interventions.
Who manages your cath lab?
The cath lab is under Patient Care Services, of which Nancy Ray RN, MA is the Chief Nursing Officer (CNO)/Associate Administrator. The cath lab is managed primarily by a clinical director (Franklin D. Espanto, BSC, RCIS) with a medical director (Marc Feldman, MD). What is unique about this setup is the very close bond between these entities. With the support of the CNO, clinical decisions are made by both the medical and clinical directors. In addition, every staff members is a part of this management process. We collect, review and discuss issues to further “raise the bar†in delivering patient care.
Do you have cross-training? Who scrubs, who circulates and who monitors?
Currently, we do not have cross-trained staff. It has been a focus since I arrived at University Hospital two years ago. We have been working towards this goal through simple educational sessions and protocol reviews. Since University Hospital is affiliated with the University of Texas Health Science Center of San Antonio (UTHSCSA), the staff attending cardiologist scrubs with the fellow. We have a CVT that monitors, an RN that circulates and an RN that charts. On occasion, we have our CVTs or RCISs scrub cardiac and peripheral procedures. We do have our trained technologists assist on all device implantations.
Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab?
Not necessarily, since the cardiac fellow and the staff attending cardiologist operate the x-ray equipment. The physicians primarily control the positioning of the II, table panning and stepping on fluoro.
How did you begin performing peripheral cases?
Initially, the cardiologists were performing simple peripheral renovascular, carotid and lower extremity procedures. After upgrading one of our radiological units to improved imaging technology, vascular surgery joined in to use our lab. We became aggressive in our supply capabilities and have exposed our staff, particularly the CVTs, to scrubbing in on these procedures.
What specific equipment was instituted and/or dedicated towards peripheral cases?
Since most of peripheral supplies are “macro†compared to the cardiac side, it was important to have a process to introduce these supplies. With our own supply section, we had very close communications with the primary peripheral operators on what was needed. Operations manager David Parks, Jr., arranged with the various peripheral vendors to consign supplies. A “peripheral cart†with the supplies essential for these procedures was created. Some of the specific equipment requested was the Silverhawk catheter (FoxHollow Technologies, Inc., Redwood City, CA), Frontrunner® XP CTO catheter (Cordis Corporation, Miami, FL) and the Angio-Jet® system (Possis Medical, Inc., Minneapolis, MN).
How is inventory management handled for the peripheral equipment?
With the help of our hemodynamic system, which has a bar code feature, the operations manager can see and forecast peripheral supplies that are routinely used and must be re-ordered before we have no replacements available on the shelves. This process also requires the personal effort of double-checking the “cart†once in a while, which is done by inventory specialist David Schmid.
What peripheral procedure training was instituted so staff could be competent and skilled?
During the transition of peripheral procedures into the cardiac lab, we initiated educational in-services targeting peripheral anatomy, procedures, and supply and equipment use. We also attended peripheral coding seminars to learn accurate peripheral charging and coding.
Do different disciplines perform procedures in the same area?
Our cardiologists and vascular surgeons perform these procedures in the cath lab. However, vascular surgery uses one of the lab suites on a certain day of the week.
Did your facility need to make any changes to the imaging equipment to accommodate peripheral procedures?
No. We already had a lab suite that has the desired features like DSA, imaging grab, stent boosting, enhanced digital imagery and table stepping.
What are some of the new equipment, devices and products introduced at your lab lately?
About a year ago, UHS was the first site to have the integrated IVUS unit with our x-ray system (by Philips Medical Systems and Volcano Corporation). We were a beta site before release of the “S-I†series a few months ago. We have the Pioneer Catheter (Medtronic Inc., Santa Rosa, CA), which is combination of an Outback catheter (Cordis Corp.) and an IVUS catheter used in CTOs. We also use steerable wires.
Can you describe the system(s) you utilize?
Our main system that we interact with on a daily basis would be the physio-hemodynamic unit. It is the Witt system (Philips Medical, Bothell, WA), which has been in use at University Hospital for over 4 years. We have experienced ease of use with the system and found it has a great database to query information. The staff likes it because it is customizable to the various practice changes that occur in a growing lab.
How do you handle vendor visits to your lab?
Vendor visits are not totally restricted. We allow one or two non-competing vendors at a time. Since the vendors are a good source of education, we welcome them to help us with hands-on training on their equipment and in-services. They are also sources of CEUs or contact hours for our staff. Vendors must still follow our hospital guidelines. They sign in and are issued badges while on the premises. They are not allowed to deliver patient care; however, they are invited to work with our physicians and staff on individual basis.
How is coding and coding education handled in your lab?
Coding education is handled by management through intra-departmental in-services. The staff are educated on the different procedural codes. The hospital charge master informs the CCL of any updates and/or changes regarding cardiac and peripheral codings. We have invited the coders to observe procedures performed in the cath lab to understand what we do and relate to the codes they see everyday.
How does your lab handle hemostasis?
The majority of our patients receive an invasive closure device. We currently use StarClose (Abbott Vascular, Redwood City, CA), Angio-Seal (St. Jude Medical, Minnetonka, MN), Perclose (Abbott Vascular) and manual compression. Patients that get a closure device go straight to the recovery wards and follow routine post-procedure care. However, patients that undergo manual compression will be pulled in our holding area by a physician, RN, technologist or CCT. Kriss Jones RN notes that patients are observed by our nurses, then sent to the recovery ward or discharged from the holding area.
What is your lab’s hematoma management policy?
It includes proper procedure to obtain hemostasis, expressing the hematoma and the use of the FemoStop (Radi Medical Systems, Inc., Wilmington, MA).
How is inventory managed at your cath lab?
Supply inventory is the responsibility of every staff member. Staff work together to handle and identify supplies that are used routinely. Periodically, staff performs a inventory of all supplies to identify any expirations as well as product rotations. Purchasing of supplies and equipment, however, is another story. I believe this is the most challenging job of all. It requires thorough attention and skill acquired through the daily routine to keep up with the pace. One thing we don’t want is an empty shelf. David Parks Jr, our operation manager and David Schmid, our inventory specialist, do an excellent job.
Is your lab involved in clinical research?
Yes! Being affiliated with UTHSCSA, we are always involved in one or two new research studies every six months. We are currently involved in:
• CORAL: Cardiovascular Outcomes in Renal Atherosclerotic Lesions
• Closure I: a prospective, multi-center, randomized controlled trial to evaluate the safety and efficacy of the STARFlex® septal closure system versus best medical therapy in patients with a stroke and/or transient ischemic attack due to presumed paradoxical embolism through a PFO.
• EARLY-ACS: Early Glycoprotein IIb/IIIa Inhibition in Non ST segment Elevation Acute Coronary Syndrome: A Randomized, Placebo-Controlled Trial Evaluating the
Clinical Benefits of Early Front-loaded Eptifibatide in the Treatment of Patients with Non-ST segment Elevation Acute Coronary Syndrome
• CURRENT/OASIS7: Clopidogrel Optimal Loading Dose Usage to Reduce Recurrent EveNTs/ Optimal Antiplatelet Strategy for InterventionS
What other modalities do you use to verify stenosis?
Use of IVUS (Volcano Corp. and Boston Scientific) and the FloWire (Volcano Corp.) are some of our methods of verifying stenosis and lesion physiology. University Hospital Cath Lab has also been involved in Virtual Histologyâ„¢ IVUS (Volcano Corp.).
What measures has your cath lab implemented in order to cut or contain costs?
Since first starting with UHS, this has been an issue that operation manager David Parks, Jr. and I have taken very seriously. We discussed plans and processes to streamline expenditures and maximize reimbursement. We concentrated on consignment of new and old supplies, discontinued stocking “slow†high-value items, analyzed routine supply trend usage and appropriately adjusted par levels. The most important and crucial aspect was working with the operators to make such a drastic change.
What type of quality control/quality assurance measures are practiced in your cath lab?
We have our point-of-care quality control, which is performed daily and validated by the pathology department. We perform our documentation quality assurance by random monthly audits. Annually, we target one patient satisfaction project. Kimberly Medellin RN, PCC, notes that we also monitor pain scale documentation with appropriate intervention and follow-up.
How are new employees oriented and trained at your facility?
New employees are placed with senior RNs for 3 months of orientation. The best experiences are given to the new staff to meet the competency requirements. All nurses are registered nurses. The technologists are encouraged to obtain the RCIS certification. In addition, BCLS and ACLS certifications are mandatory for UHS cath labs.
What type of continuing education opportunities are provided to staff members?
In-services are offered monthly by staff or company representatives. I have been trying to send each staff member to a out-of-town conference annually, but this is based on the funds available and department coverage.
How is staff competency evaluated?
Staff competency is evaluated annually. It is evaluated by the designated “super users†in the various competencies. The “super-user†can be a nurse or a technologist. Ultimately, the director ensures that the evaluation process is completed in a fair and thorough manner.
Does your lab have a clinical ladder?
Yes, for the nurses. UHS have different staff nurse levels ranging from staff nurse I – III. There are different criteria each level has to accomplish to advance to the next level. In cases like the CCL, nurses rotate as charge nurse. They have to demonstrate supervisory skills, critical thinking, and clinical judgment. Some nurses have secondary duties (i.e. infection control, safety, pharmacy, education, quality initiative [QI], quality control [QC], etc.) that are evaluated by the director.
How does your lab handle call time for staff members?
Call schedule is controlled by the staff. They select their call days during the week based on their days off and other staff member’s vacation times. The director designates which staff member has rotation to pull on holidays or which staff member may have to do two-weekend (Friday, Saturday, Sunday) call. Other than that, staff control the schedules. The director will then review, balance, finalize and post the call schedule. Our call team consists of 1 CVT, and 2 RNs. Currently we have multiple shifts to cover open-ended hours: 7am-5:30pm, 7:30am-4pm, 8:30am-5pm, and 10am-6pm.
Within what time period are call team members expected to arrive to the lab after being paged? Is an attending cardiologist always on-site?
Like other cath labs in the area, a 30-minute response time is expected from each call team member. The EC contacts the cardiology staff who may be in-house and gets the process started.
Does your cath lab do electives on weekends and or holidays?
Our staff does not routinely work on weekends or holidays. Our call team (1 CVT and 2 RNs) responds to cases that need to be performed on weekends and holidays.
What trends do you see emerging in the practice of invasive cardiology?
It seems that the trend is moving more towards devices that aid in revascularization. As vascular devices become more “slick,†operators are attempting more complex interventions like CTOs, thrombectomies, percutaneous valve repairs, ASD/PFO closures, etc. Also, there have been many advancements that are going percutaneous rather than open-incision, according to Dr. Jorge Alvarez, interventional fellow.
Has your lab has undergone a JCAHO inspection in the past three years?
Yes, we underwent a JCAHO inspection last year. In preparation for this event, we developed a task force to attend informational meetings provided by the hospital and applied them to the lab. We took the main points that applied to us and tweaked them. We developed behaviors that made the processes part of our normal, daily routine. It was a complete team effort to JCAHO-proof our department, recalls Sabrina Harris RN, case manager. One issue that came up was a secured area for contrast media. Some CCLs have contrast heaters, so as long as the contrast is secured, that will usually fix the issue.
Where is your cath lab located in relation to the OR department, ER, and radiology departments?
The cath labs are almost adjunction to the ER on the sublevel of the hospital. The OR is on the 11th floor and radiology is two floors above us. However, our trauma elevators are large enough to accommodate all emergent transfers to the OR.
Please tell readers what you consider unique or innovative about your cath lab and staff.
There are a few things that make our cath lab unique. One is the existing mutual trust in decision-making between the lab staff and the physicians. It goes a long way in working in this lab. Since the operators know the staff are experts in their field, they give them autonomy and ownership to perform the job. UHS also gets the latest in technology, constantly raising the bar for our staff skill levels.
Is there a problem or challenge your lab has faced?
During the time I arrived at University Hospital, there were attitude problems that were affecting teamwork and patient care. Drastic measures were implemented and resolved that problem. However, from time to time, residual events come up and they have to be dealt with on an individual basis. A challenge we have is to cross-train the staff. Since we are dealing with an educational and cultural change, simplified approaches and gradual skill training are vital.
What’s special about your city or general regional area in comparison to the rest of the U.S.?
Being in Texas, we have seen a diverse population of various diseases, especially in the Hispanic population. Diabetes, hypertension and PVD are very prevalent. Our Tex-Mex food is great!
The following questions are courtesy of the Society of Invasive Cardiovascular Professionals (SICP):
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?
Presently, it is not a requirement for our technologists to be registered; however, they are encouraged to pass and obtain an RCIS certification for self-accomplishment along with an incentive bonus.
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, ACVP, or regional organizations?
Not yet; still working on this one!
Franklin Espanto can be contacted at franklin.espanto (at) uhs-sa.com
Is there a question you’d like to see answered by our spotlighted labs?
Email us at: rkapur (at) hmpcommunications.com
Click the link below to review the article online in the Cath Lab Digest.
After consulting with Nurse Advisory, we opted for using the Practice Environment Scale developed by Lake (2002). Lake defines nursing practice environment as the “organizational characteristics of a work setting that facilitate or constrain professional nursing practice”. The Subscales of this include Nurse Participation in Hospital Affairs; Nursing Foundations for Quality Care; Nurse Manager Ability; Leadership, and Support of Nurses; Staffing and Resource Adequacy; and Collegial Nurse-Physician Relations. 
Bonnie has not only stuck it out, she’s been an invaluable asset. She makes all the nurses feel that she is concerned for their personal, as well as professional well-being. When things don’t seem to be going right, Bonnie can be counted on to find a solution. Although Bonnie’s first calling was in Labor and Delivery, she came to the 7th floor when Learning Resources down-sized their department. Technically, she still works part-time in Learning Resources and part-time for us. Grace noted that one of her most successful contributions is the Nurse Re-entry Program. Through this program, not only has nursing in general, benefited by having nurses return to the bedside, but the hospital benefits specifically – we’ve hired over 40 nurses since the program began. She’s served in many roles, including applying for CEUs, not only in the area of nursing but social work and even Certified Public Accountants. This entails writing 600 page applications to the various boards for accreditation of CEUs. Bonnie oversees every detail of presentation from booking rooms to making sure equipment is there on time to arranging lunch breaks to assuring payment and registration of CEUs. Bonnie is also an inspiration at all the Magnet events, and you can see her in her many disguises as Sherlock Holmes, a pirate or cheerleader. Bonnie is a wonderful nurse and individual.
Shirley joined University Hospital in 1991 as a unit clerk with desi-Stars on the 12th floor and then, went full-time in Stars for eight years floating to various floors. Shirley joined the 8th floor one year prior to it’s amalgamation with 7th floor and says that very few of those original 8th floor employees are left. Prior to Sunrise, the new electronic medical record system, Shirley was indispensable to new RNs learning about numerous forms and how to complete them. In addition, she helped RNs locate these forms. She also knows those special phone numbers and persons to contact for various reasons like getting a room cleaned or helping a new patient. During “Code Blue,” Shirley quickly calls in the crisis management team by directing staff to the room and getting everything ready! She’s also a very organized person. She keeps her desk spic and span. Shirley continues to do a great job. We love her!
Rick can proudly say that his marriage has lasted well past 15 years, so he understands that any relationship, whether at work or home, requires time, work, effort, patience and lots of understanding. Thus, he also celebrates his 15th year at University Hospital as a medical surgical technician. Initially, Rick began at BAMC in 1982, the old Fort Sam, later arriving at UH in March 1991 as an attendant. He returned to St. Philips College to achieve his Tech Medical Surgical degree and began work on Grace Cookson’s oncology floor. They both go back many moons. When that area was being reorganized, Rick went to the 12th floor, and then later, to the 7th floor. He remembers when techs used to change the patient’s dressings and the continuous breaking down and setting up of orthopedic equipment. Although techs no longer perform dressing changes, the fast turnover of patients, (admissions and discharges) and the significant increase of heavy care have added to the heavy demands placed on techs. Rick appreciates the additional supplies he works with now in comparison to the “olden days.” He’s excited about getting new and improved equipment and sharing more effective communication among staff members. Rick is an important member of our team.
Paula works on the 7th floor as a service aide. She received her ten-year pin from her supervisor Grace. Paula began her career in housekeeping at UH in 1996. Grace took the time to express her sincere appreciation of all the work Paula does for the floor. It is not an easy task to keep a 52-bed unit continuously stocked with patient supplies – this includes lots of pillows. All of these supplies are required by nurses and techs, in order to meet the medical and personal needs of all patients. Paula also has a tough task of making sure all the equipment is accounted for and in good condition. The floor staff is constantly trying to find missing SCD pumps, or having equipment repaired. Paula is very much appreciated!
