Opening the Bethesda Heart Institute: Challenges and Goals

The Bethesda Heart Institute opened on February 4, 2008, adding an entire cardiovascular service line to Bethesda Memorial Hospital. This article from Cath Lab Digest features an interview with Barbara J. Dale, Executive Director, and Tracy Justice, Assistant Nurse Manager of the Cath/EP lab at Bethesda Heart Institute in Boynton Beach, Florida. Barbara, in addition to your position as executive director of Bethesda Heart Institute (BHI), what other management is in place? Barbara: Right now BHI has an assistant nurse manager for the admission/recovery area (ARU), and Tracy Justice is the assistant nurse manager for the cath lab and electrophysiology procedures (EP) area. Prior to the opening of the Heart Institute, the hospital did not have open-heart services or an interventional laboratory. Bethesda Memorial Hospital originally had a 300-procedure diagnostic catheterization laboratory (cath lab). The hospital actually began the Certificate of Need (CON) process for open-heart facilities and an interventional lab in 1996. Florida is a CON state, and as a result of a litigation process over the last ten years instigated by two area competitors, we did not receive a CON until early 2006. We then began construction on the Heart Institute immediately, and opened in February 2008. BHI has four stories and is attached to the main hospital, but has its own separate entrance. All cardiovascular services are consolidated into one area for ease of doing business for both the physicians and patients. Patients come directly into BHI’s lobby; we have our own registrars and our own scheduler. On the second floor, we consolidated the noninvasive cardiology services, and have echocardiography (echo), electrocardiography (ECG) and respiratory therapy. On the third floor, which holds the main operations of the building, there is a ten-bed admission and recovery area for the cath and EP labs. BHI has two cath labs and one EP lab, as well as a shell lab for future growth. We also have two dedicated cardiovascular operating rooms (CVORs) on the same floor, located in the next hallway adjacent to the cath lab. We also have an eight-bed cardiovascular intensive care unit (CVICU) and administrative offices on the third floor. On the fourth floor, there are eight additional critical care beds and 23 step-down beds. We had originally discussed putting an endovascular suite in the shell lab area of the cath lab, but then decided against it because we were fearful that if our cath or EP labs grew, we would have no place to expand. Instead, the new endovascular suite was placed in the main operating room (OR) as a new OR suite. What is BHI doing at present in terms of cath lab procedure volume? Barbara: In the seven months since we’ve been open, our facility has performed 900 interventional and diagnostic procedures. How many cath lab staff members do you have? Tracy: We have nine cath lab staff members, three EP staff, and five admission and recovery staff members. How many cardiologists are using your cath labs? Tracy: We have approximately 15 cardiologists with privileges in our lab, of which three are invasive and the other 12 are interventionists. Barbara, you oversaw the construction of BHI. Was this your first building project? Barbara: Before coming to Bethesda Heart Institute, I was the executive director of heart services at Holy Cross Hospital in Ft. Lauderdale, Florida. For part of my last five years of tenure at Holy Cross, I was involved in a construction project at their heart institute, focusing on the cath labs and the admission and recovery area. It was not quite the magnitude of this building, though. What were some of the challenges you faced? Barbara: Construction challenges! When I came to Bethesda, the Heart Institute was already under construction, and I was asked, “Can you live with the design and make it work?” The answer was yes, although I did think the admission and recovery area, with the size and anticipated growth we were planning, needed improvement. Ten beds can get a little tight at times, especially since we also now use that area for transesophageal echos (TEEs) and cardioversions in order to facilitate things for the cardiologists. We like to keep everything in one general location for them. Once BHI was up and running, how did you work on changing local referring practices? Barbara: Bethesda Memorial Hospital is a not-for-profit community hospital that is surrounded by three competitors: JFK Medical Center, an HCA hospital, is located ten miles northwest; Delray Medical Center, a Tenet hospital, is located about ten miles southwest; and Boca Raton Community Hospital, another for-profit community hospital, is about ten miles due south. The physicians on our staff have also been working at those hospitals for many years. We focused on getting them to buy into the fact that BHI was capable of providing high-quality services with experienced staff. Our medical director, Dr. Louis Snyder, is also an interventional cardiologist. He helped ensure that the standards we set were very high. However, we did have several interventionists who said they’d wait and see how we did before they came over. Now they are slowly starting to come over to BHI, because the staff has done such an outstanding job. Tracy, as assistant nurse manager of the cath lab, can you share your involvement in starting up the BHI? Tracy: I actually came to Bethesda in November 2007. My role was to get the supplies and training on board to facilitate the conversion to an interventional lab. New policies and procedures, new order sets, and development of cardiac alert procedures were needed. We began the interventional program in February, so I came at the beginning of November to help with the transition. How many of the original staff from the diagnostic lab were trained for interventional procedures? Tracy: Only one person came with me from Bethesda Memorial who already had interventional experience; everyone else was hired and brought in as part of the team to initiate the interventional program. Barbara: Since we were moving to an interventional lab, we felt that we did not have the luxury of training someone from a diagnostic lab to become an interventional staff member, because we knew we were going to hit the ground running. Staff from the original diagnostic lab relocated to different positions within the organization. For example, one of the nurses became our database manager. Two of our staff members transferred to the interventional radiology lab, and then, as Tracy noted, we actually had to recruit all other experienced interventional staff from outside the hospital. You wanted to avoid “silos” for staff at BHI. How was this accomplished? Barbara: We actually had the luxury of hiring all staff and bringing them on board six weeks before BHI opened. All staff were trained off-site as a group, so whether you were a respiratory therapist, a cath lab professional, a critical care nurse or a step-down nurse, everybody learned together and bonded as a team. In hiring, we sought to avoid the critical care nurse, for example, who says, “I only do critical care, I don’t do anything else.” We hired staff who were willing and able to fulfill different roles, as needed, such that a critical care nurse could float to the admission/recovery area and help if volume was high, or likewise, could come over if help was needed on the cardiovascular stepdown floor. Everyone is able to maneuver within the organization. If candidates who were interviewed and informed of our vision raised an eyebrow, made a funny noise, or displayed discomfort through body language, they were not selected to be part of our team. As a result, our teamwork is very, very strong. The organization truly put together a service-line model in which the hierarchy, under my position actually, holds the responsibility for everything within BHI, and we all report to one vice president, Geralyn Lunsford, RN, CNO. This means we don’t have to go to nursing and/or to operations to get things done. Everything is managed under one large umbrella. How has BHI worked with EMS to improve ST-elevation myocardial infarction (STEMI) patient care? Tracy: We had to prove ourselves to EMS and gain their trust, so we did a lot of mock calls with the ER and the cath lab, working on our door-to-balloon (DTB) times with fake patients. Like anything else, it took time to gain that trust. Once we were able to prove ourselves and were within the DTB time window, EMS felt comfortable. We are also providing education, not only for the staff in-house, but also for EMS professionals. It is important to keep them involved with our program as it evolves. Have you started doing ECGs from the field with EMS? Tracy: Yes, Cardiac Alert is being called in the field, which is currently a work in progress. You had a three-year-old Siemens lab that you brought over from Bethesda Memorial. Barbara: Yes, we decided to stay with one vendor for all the new equipment we needed because of the consistency it offered. The vendor within the hospital financial system was already Siemens, the radiology and the radiology PACS system was Siemens, and with the first cath lab being Siemens, it was an easier transition to continue with the same, both from the standpoint of maintenance and equipment pricing. Better negotiating power is offered when considering a comprehensive system from one vendor. The new cath lab is ceiling-mounted. Is that something the physicians specifically asked for? Barbara: Yes, that is the newest, latest and greatest type of installation. We have one of the most upgraded platforms as far as our angiography system is concerned, so our images are very crisp, very high quality, and the physicians are extremely satisfied with it. The system is the Artis zee. Ergonomically, it works very well, particularly with use of the table-mounted controls. We have amazing and outstanding support from Siemens, because they are involved with the whole organization and within the hospital. There is always someone around if assistance is ever needed. Siemens has been very good about educating us about their system and its many capabilities. BHI also transitioned to computer documentation versus the old paper charting system. Barbara: The critical care on the hospital side and then all of BHI moved to Sunrise Clinical Records (Eclipsys Corporation, Atlanta, GA), which is a computerized tool. The physicians initially had difficulty maneuvering through the system, so we actually went back to the old paper flow sheets until we could recreate a very comprehensive flow sheet with the Sunrise system. The physicians now only have to select one tab to see all the patient’s vital signs, all the Is and Os, the latest chemistry and laboratory results, as well as the patient’s listed medications. It has made it much easier for the physicians to maneuver through the charting. What did Siemens offer in terms of image storage and patient records Barbara: We chose the Siemens cardiac PACS system, so everything is integrated. The physicians can pull up catheterization reports, echos, computed tomographic scans, etc., so it is a wonderfully integrated system. The reports feed into that system as well. Syngo Dynamics allows the reports and images to be pulled together. Tell us about the block scheduling that your center offers. Barbara: Well, it’s been interesting. Even though we offer it, none of our physicians have yet taken us up on it. What they do now is call, and if we can, we accommodate their preference. We have done fairly well in that about half of our physicians like to come in the morning and the other half like to come in the afternoon. We have not had a major issue with scheduling as of yet. As the assistant nurse manager of the cath/EP lab area, Tracy carries a phone until 9:00 pm each evening for scheduling. Tracy: Yes, I carry the phone all day when I am at work and also carry it at night. We have trained our physicians to call me if they would like to add a procedure, need to change their time, or have questions, concerns or comments about cases. All the physicians have my phone number and can call me throughout the day to deal with anything regarding that day’s schedule. Then, once I leave the hospital, I take the phone and a copy of the schedule home with me. Many of our physicians prefer to do their rounds after the cath lab staff and the scheduler have gone, so they will call me at 8:00 pm, for example, and say, “What do you have available? I need to do this patient.” We do not have a nursing supervisor handle our schedule. I take care of it myself so that I can ensure cases don’t get double-booked. I have the schedule and will call the lab and leave a message so the person who gets into the lab at 6:00 am the next morning can immediately write it into the schedule. This system has been working very well thus far. Not all of the physicians take advantage of it, but I have noticed lately that an increasing number of physicians are calling, even on the weekends. If a physician sees a patient on the weekend, he/she will call me and say, “I want to perform the procedure on so-and-so at 7:30 in the morning.” I think our physicians are feeling more comfortable with this setup, because they know that they can reach me nearly anytime. It helps them and us plan for the next day, since a lot of our physicians perform procedures at several hospitals. Barbara: This way, our lab does not receive multiple phone calls in the morning, requiring us to figure out who is going where and when. Our physicians can basically say, anytime, to Tracy, “I want to come to Bethesda tomorrow morning to perform three cases; what do you have to give me if I want to add on?” You performed 126 procedures in your first month of opening, when BHI only had one lab available. When was the second lab scheduled to be installed? Barbara: We had to scramble to move up the installation date of the second laboratory. We opened with only one lab and kept the other one operational downstairs, just in case there were any equipment malfunctions in the new lab. However, when we saw how busy our one lab was, our CEO, Robert Hill, asked Siemens to get the second lab up as soon as possible. It was mid-March when the second lab was up and running. What are your plans for the future? Barbara: I think we will continue to get busier. The reputation that our surgeons and interventionalists have established in the community, along with the quality of our staff, just add to the overall reputation for quality of our program. The patients love us, so we are experiencing growth as a result of word-of-mouth. We have tried to create an environment that is hotel-like, not institutional-like. Patients like the concept of all-private rooms. They are very comfortable while they are here. We also plan to work with EMS through our Bethesda Hospital Foundation. We have raised funds with the goal of equipping our local EMS with modems so they can telefax in the ECGs from the field, allowing us to continue to improve our door-to-balloon times. We are working toward getting our emergency department accredited as a chest pain center. In addition, one of our interventional cardiologists is performing patent foramen ovale (PFO) procedures in the cath lab. Two of our interventionalists also perform peripheral procedures, and one interventionalist is considering possibly performing valvuloplasties in the cath lab. The physicians are very involved in the growth of the lab. Our staff is exceptional. We “stole” from the local hospitals and took what I like to say are “the best”. They work together extremely well as a team. It’s much like a symphony — everyone knows his or her “instrument,” and Tracy is there orchestrating the “flow of the day.” This article was reprinted with permission from Cath Lab Digest 2008;16:60-63.