Staying Ahead: Thoughts on Education in the Cath Lab

Dennis Holloway, MBA, CVT, Director of Diagnostic Cardiovascular Services

Dennis Holloway, MBA, CVT, Director of Diagnostic Cardiovascular Services

Training is probably one of the most vital aspects of cath lab excellence. Training, which eventually turns into what is called continuing education after an individual is more skilled, must be ongoing throughout every cath lab professional's career. There is no doubt that increased educational training in the performance of specific procedures and/or processes can make for a higher standard of care. Giving staff the tools to do their jobs enhances their performance. Increased education is certainly a tool, one that leads to increased skill levels, which in turn also increases physician confidence in staff. Education, in my opinion, cannot be overemphasized nor overdone. I have not yet met a cath lab specialist who does not want to learn more and more about the profession. This hunger for knowledge needs to be fed on a regular basis. The educational process can be accomplished in many ways: through inservices, whether by company representatives or by qualified departmental staffing, clinical educators, departmental training sessions, hospital training session, seminars, conferences and/or formal academic colleges or universities. No matter how long a person practices in their profession, education should never end. Medical technology advances at such a high rate of speed that what is used today could be (and is often) replaced by the next generation tomorrow. Our patients deserve the best care possible. Our staff deserves the best educational training possible. It's our duty to provide that service to all of them. Start Off Right with New Employees Educational training builds confidence, not only in oneself, but in the cath lab as a whole. Staff confident in what they are doing make this evident in their actions and manner, which is easily sensed by others (perhaps most importantly, by patients). Furthering a person's knowledge level also builds self-esteem and pride. This is a very important factor to remember when a person is new to the cath lab. Going through preceptorship can be a very nervous, overwhelming and intimidating time for many this is a trying time. Teaching should be at its peak during this time. Most preceptorships, in my experience, last about 3 months. This does not make a person qualified to be on their own, but generally means they are capable of being a functional member when paired with a qualified cath team. This same individual can also make a positive contribution to the call teams. After three months have passed, however, it does not mean training stops. Just the opposite it never stops. Training needs to be ongoing throughout each professional's career. It takes a year or even years to learn enough to be comfortable with one's own capabilities (or to be experienced enough to know what we don't know). Lest we forget, none of us were born working in the cath lab. Why make it difficult for new people because that was how some of us were brought into this business? Some places tend to eat their young, as the expression goes. Yet the better we train, the better the outcome. I have known individuals who would not share their knowledge or experiences out of fear that another person may take their place, become the go-to person or even the thought that they may lose their job. This is a feeling we need to change if an opportunity presents itself. Managers need to assure those with experience that sharing their talents or gifts make us all better, not only as individuals, but as a team. Teamwork is what working in the cath lab is truly all about. Use It or Lose It Just because an inservice or training session has educated individuals on a certain product or system does not mean attendees will later remember all aspects of that device. It's difficult to be expected to retain what has been learned and then not use that knowledge, except for perhaps once a month or even only a few times a year. In years past, and maybe even in some places today, designated staff specialized in certain devices. When that device was needed for a procedure, one of those specialized staff members was called to the room. Yet if that person was already functioning as a nurse or technologist in another room, he or she will have to be replaced so they can now go to a different room and operate the equipment for which they are being called. It is a difficult process to coordinate on a daily basis, not to mention time-consuming. Is there an alternative? Cross-training is essential; however, reoccurring in-services or refresher training should be highly stressed. If all staff, depending on the size of the lab, cannot be fully trained on a system, a core team could be the answer. Select five or six personnel to be the experts. This way it will not only be easier to concentrate the training sessions, it allows the lab to be more versatile by having specialists available on rapid notice. Use All Sources As important as it is to learn from our peers and/or educators, it is just as important to learn from our physicians. Their clinical and practical experience is almost an endless source of knowledge. Pick their brains! Ask questions! Most cardiologists, in my experience, are very willing to help train staff. Some will even hold training sessions or in-services, which are a tremendous help in bringing together the complete team. It's important for us to utilize every available tool we can. The Importance of Anatomy and Physiology A question that tends to crop up in control rooms is, What vessel are we working on? Those who have been in the cath lab profession for a long time will know this, but what about those who have only been in this environment for a year or even two? If trainees are not taught, it is very difficult to learn on your own. As a scrub person, it is even more important to know your way around the heart. Labs where nurses and techs pan the table (like our lab) need to have staff who understand exactly what they are looking for. It's not only important to know what RAO, LAO, cranial and caudal mean, but to know what these vessels look like on the screen. When a physician wants to review a procedure, they may have one of the staff move through the pictures and ask for the AP cranial, RAO caudal or spider shots. Will that person be able to know which pictures the physicians need? This is where knowledge of coronary vessel anatomy and physiology is crucial. Understanding the coronary vessels can be as confusing as a road map. Different angles can lead to a confusing identification of vessels. Looking at an RAO view of an LAD is different than seeing the same LAD in an LAO view. Sometimes little hints as to what to look for will make it easier to identify. For example: a. Look for the LAD first. It is the easiest to find, since it is typically large and extends down to and beyond the apex of the heart. b. Look to identify the diagonals or obtuse marginals. Typically a diagonal will extend off the LAD at a 90-degree angle, whereas the obtuse marginals will extend off the circumflex at a 45-degree angle. I have also used the following example in training (this sample is just one of many that exist): 1. RAO: - Spine/catheter will be on the left side of the screen - Ribs slant upper left down to lower right of screen 2. LAO: - Spine/catheter will be on the right side of the screen - Ribs slant from lower left to upper right of screen - If visible, sternum will be on the left of screen 3. Cranial: - Diaphragm visible along the bottom of screen - Proximal portions of vessels appear foreshortened, distal portions appear elongated. - Vessels appear to drop off from origin and catheter 4. Caudal: - Less diaphragm visible compared to cranial angulations - Proximal portions of vessels appear elongated, distal portions appear foreshortened - Vessels rise up from the guiding catheter before descending; fountain appearance; catheter tip lies under vessel origins This information was taught to me during an in-service back in the early 1990s by an ACS representative. (ACS was a well-established, highly profitable company that was bought out in the mid-to-late 1990s by Guidant Corporation. ACS is most famous for its interventional wires. Most of these wires are used as the workhorse of every lab today. With the recent buyout of Guidant, Abbott Laboratories is now the proud owner of these products.) It has been very useful in my career and I have passed this information on when I could a responsibility all experienced staff share. There are other tips and tricks to help identify views associated with left coronary systems, right coronary systems, vessel segments of each system, saphenous vein grafts and internal mammary grafts. I Want to Know Why? Another point I would like to stress is that we as nurses or techs not only want to know how to perform these procedures, and work the equipment, but we want to know the why! Anyone can be told just do this or do that. Cath lab staff are well-educated and extremely talented professionals. They want to know how things work, what can happen and what to do if something does happen. For example, when training a new person, don't just show them that when the physician begins putting the diagnostic catheter in the sheath, to start advancing the wire. Tell them the reason: a. Advance the wire ahead of the catheter before it exits the sheath end. This helps prevent the chance of the catheter of prolapsing and potentially causing a tear or other harm to the femoral artery or ascending aorta. b. When removing a catheter, reinserting the wire will help prevent the same potential harm. Final Note: Thoughts on education at nurse/technologist symposiums As a manager, I have had the opportunities to attend many of the nationally renowned seminars or conferences, the largest of which include the American Heart Association (AHA) Scientific Sessions, the American College of Cardiology (ACC) Scientific Session and the Transcatheter Cardiovascular Therapeutics (TCT) meeting. Dozens of smaller and equally important meetings throughout the year make up an incredible educational environment for our field. Often nurse/technologist symposiums are available as a part of these meetings. My first nurse/technologist symposium was at the 2000 TCT, coordinated and facilitated by nurses and techs from all over the nation. I was duly impressed. I was a new manager at a large facility and the symposium offered an opportunity I would not normally be given in my day-to-day work. I was able to network, discuss issues, learn new ideas or innovations, and to even pass along some of my ideas. I was even more impressed when during a mid-day period, the meeting broke off into a managers meeting in another room. This meeting went on for about two hours. A qualified and knowledgeable panel was in attendance. Managers from all across the country and even the world could ask questions for the panel and audience. The amount of knowledge, skills, experience and education mounted in this room was phenomenal. I walked away from this meeting with awe and excitement, feeling that each year I could find one of these meetings and learn more and more each time. Unfortunately, that wonderful process is now gone! Sadly, the nurse/technologist symposiums of today are increasingly physician-coordinated and facilitated. The panels that change throughout the day consist of mainly physicians with the occasional nurse or technologist. In 2006, I attended two nurse/technologist symposiums: the CRT in April, in Washington, D.C., and the October TCT, also in Washington, D.C. Having physician speakers is very important, but should not be the major focus of the nurse/technologist meeting. The information that is given at the symposium is usually already available during the main conference. At the most recent nurse/technologist symposium I attended, I noticed the audience as speakers presented. At the early morning, the house was full. Within a couple of hours, some people left, not to return. The after-lunch crowd had thinned as well. I talked to several who had left to take a break or just leave for the day, and asked them what they thought of the meeting and if they had attended one before. Surprisingly, most said this was their first meeting. The overall feeling I was able to gather was that the symposium was not what they expected. These attendees felt it should be more nurse/tech-oriented and focused on what occurs in their practices. Although there were indeed some amazing nurses and technologists who did present at this symposium, two presenters I happened to see and particularly admire were Thomas Maloney, MS, RCIS, and Chris Nelson, RN, RCIS. I listened to these two professionals and was amazed by their presentations, knowledge and expertise. Thomas and Chris showed the cardiovascular society that indeed nurses and technologists are knowledgeable in their work and can teach or present that knowledge. We need to take back the nurse/ technologist symposiums. Provide a panel of nurses and technologists who can share their experiences and knowledge by presenting and/or answering questions that many of us ask every day. Give the audience an opportunity to ask a panel or presenter questions. Attendees may find issues that exist in their labs but not in others. Why is that? What can they do to make a change or difference? There are so many thoughts and ideas active in cath labs everywhere. We need chances to share knowledge and experience. Cath lab professionals are in this profession because we love it. It is our life and most of us want to be the very best. After all, we are here to save lives. How many occupations arrive to their workplace each day only to find a human being in a life-threatening situation? Ours is a workplace where we come together as one, with a single, common goal to bring life back into a patient who needs our help. Finally, to those cath lab professionals who can teach, teach, and teach! I have not met a cath lab nurse or technologist who does not want to learn. They are hungry for more. The more we teach, the better the outcome, the happier the staff and the higher the morale. Acknowledgements I would like to thank all those who took their time and gave their knowledge to help educate me; this includes but is not limited to, nurses, techs, physicians, administrators, teachers, professors, friends and family. Without these individuals, I would not have the privilege of doing what I do today and hopefully being able to pass on some of that knowledge to others. Dedication I would like to dedicate this article to all of the cath lab staff and cardiologists at Bay Medical Center. They truly are role models and it is an honor to work with them. As managers, we are asked to measure the success of a process, plan, procedure or improvement. How do you measure the success of exceptionally trained and educated staff? In August 2006, our cath lab was awarded the Solucient Acute Myocardial Infarction (AMI) Center of Excellence and in October 2006 the Health Grades 5 Star Excellence Award for PCI. None of these national awards would be possible without staff dedication to their profession, department, hospital and each other. This excerpted article was reprinted with permission from Cath Lab Digest 2007;15:20 - 24.