Cath Lab Digest - December 2007 - (Page 21) 21 Overall, we maintain very realistic par levels that keep cost down and ensure no product waste. Has your lab recently expanded in size and patient volume, or will it be in the near future? Our cath lab is located in the Coachella Valley of Riverside County, California. This area is one of the fastest-growing populations in the nation. We have seen a steady increase in patient volume that covers the calendar year, not just the winter months. We are a resort community with a season lasting six to eight months of the year that sees an influx of visitors from all over the world. Each year, increasing numbers of people are becoming full-time residents. Eisenhower Medical Center is currently constructing a new building to open in the summer of 2009 to increase the current 289-bed count to approximately 400 beds. The building is a result of generous gifts from our benefactors. After it is complete, our cath lab will be relocated into the current existing ICU, which will be remodeled for our use. We will have three suites. One suite will be designated as peripheral. This move will consolidate all of Cardiac Services. It is an exciting future of change and growth for the entire hospital. We do expect an increase in acute coronary patients based on our recent designation as one of the ST-elevation MI (STEMI) receiving centers in Riverside County. This designation requires ambulance services to deliver STEMI patients to Eisenhower Medical Center if it is within 30 minutes or less from another receiving center. Based on clinical evidence, patient outcomes are better when paramedics identify and take patients to an advanced cardiac treatment center. Our Emergency Department is currently under major reconstruction and expansion from 27 to 44 beds (to open in winter of 2008) to accommodate our growing patient population. We also expect a large increase in peripheral patients. Dr. Khanna has started an outreach to physician offices to teach diagnostic screening to physicians (i.e., podiatrists and primary care physicians) and their staff. An ankle brachial index (ABI) screening program is an excellent tool to identify frequently missed PVD patients. Have you had any cath lab related complications in the past year requiring emergent cardiac surgery? Our lab sees a high percentage of complex coronary disease due to the older age of our patient population. We do very challenging interventional procedures on patients who have multiple health issues, previous open-heart surgeries, physical inability to have open-heart surgery, age older than seventy-five years, and, in general, have more co-morbidity. Statistically, even though our patient population is one of higher risk, we have excellent outcomes. An emergent surgical call is rare from our lab; we are fortunate to have a highly skilled open-heart team who can respond to the infrequent necessity for surgical intervention. What other modalities do you use to verify stenosis? Cardiologists will first make an educated visual lesion judgment based on coronary angiography. We do have intravascular ultrasound (IVUS) available for use, but do not use it on every interventional case. We do take advantage of IVUS when there is a question of apposition of a stent, to better evaluate an in-stent restenosis concern, to better define a left main stenosis, and whenever a physician has any quandary or concern with respect to a lesion determination. Using IVUS requires opening basic interventional supplies onto the sterile field. Top row: Dixie Sargent, RCIS, Kathy Stevens, RN, Mary Jacobs, RN, Sue Salimaki, RN. Bottom row: Cheli Shea, RN, Maureen Lochridge, RT, Cindy Olson, RN. Gus Hernandez (Central Supply Tech). We have an excellent hemostasis record that is a result of multidepartmental teamwork. What is your hematoma management policy? Hematomas are charted at the onset. Appropriate compression and hemostasis management is immediately applied. A patient is not transferred out of the cath lab without control of the access site. Continuous monitoring of the site and patient hemodynamics are charted. When a patient is transferred, the recovery RN is given a detailed report in order for him/her to continue observation of the site. Hemostasis begins at the moment of access. Meticulous attention is given to groin management from access to discharge. Patient education is reinforced all along the path of patient stay. We have a few cardiologists that prefer a 4Fr sheath for the diagnostic angiogram. These patients will get a manual hold. Most manual holds will also include a D-Stat Dry (Vascular Solutions) pad to enhance the speed of hemostasis. The scrub tech generally does the manual hold. The majority of our patients will have a 6Fr sheath and receive a closure device. Techs or physicians deploy the closures. We usually use Angio-Seal (St. Jude Medical, St. Paul, MN) or Mynx. If there is any oozing at the site, a Safe-Guard dressing (Datascope, Mahwah, NJ) is applied. A sheath left in post procedure is secured with suture, an obturator placed in the shaft of the sheath and a flush device connected. The majority of our patients are transferred to the Cardiac Diagnostic Interventional Unit (CDIU) for recovery and/or transfer to an inpatient room. The RNs in this area monitor groins for hemostasis, do sheath pulls, and reinforce post procedure teaching. How is inventory managed at your cath lab? Who handles the purchasing of equipment and supplies? Our sterile processing department (SPD) conducts a computerized daily inventory via the McKesson system. Appropriate supply is restocked and rotated for outdates by the SPD tech (Gus Hernandez) in the early morning, prior to cases. This per-item barcode scanning system is used hospital-wide. Clinical staff requests special order items on a per use basis. Our clerical support (Monica Turner and Frank Zazueta) follows through with an order. This includes stents and special interventional products for both coronary and peripheral procedures. This system allows us to maintain a realistic par level of expensive items on the shelf. It also prevents costly waste of expired items. Our director must approve capital equipment, special orders, and/or new product requests prior to purchase. The hospital new product committee must approve all new product requests before product can be stocked in the lab. A physician, with approval from the director, can initiate specific product/equipment trials. This would include our product research and development items. We do very challenging interventional procedures on patients who have multiple health issues, previous open-heart surgeries, physical inability to have openheart surgery, age older than seventy-five years, and, in general, have more co-morbidity.
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