Inside Duke Medicine

DRH’s Cath Lab makes a difference, time Is muscle

The Cath Lab achieved the highest level of employee satisfaction in the 2009 Work Culture Survey with a Work Culture Index score of 99 percent. In addition, the team consistently scores high in patient satisfaction.

Pictured above, left to right: Emily DuBray, RN; Rachael Cantalupo, cardiovascular technologist (CVT); Amy Waddell, RN; Robert Vandrick, RN; Gwen Sherrill, CVT; Neal Compton, RN, former manager; Richard Sykes, CVT; Joanne Carey, RN; and Louise Saladino, RN, interim director Emergency Department & Critical Care services. Not pictured: Reheem Jordan, CVT, and part-time employees: Todd Carey, RN; Jason DuBray, Radiology technologist; Judy Markham, RN; and Cathy Oakley, RN.

Ms. Smith is experiencing what appears to be a heart attack in the middle of the night and calls 911, who calls Durham Emergency Management Services (EMS). EMS performs an electrocardiograph (EKG) enroute to Durham Regional that shows Ms. Smith has experienced an ST Elevation Myocardial Infarction (STEMI), or a heart attack. EMS notifies the Emergency Department (ED) physician and charge nurse of a heart attack enroute to the hospital. The ED physician immediately activates the STEMI team, which includes a cardiologist, two nurses and two technologists.

“Time Is Muscle”
According to the American Heart Association, every 26 seconds someone in the U.S. has a coronary event (almost 400,000 a year), and every minute someone dies from one. When caring for a patient who is having a heart attack, every second counts. As Ms. Smith is being cared for in the ED, the on-call Cath Lab staff will have 30 minutes to reach the hospital to prepare for life-saving procedures.

The Cath Lab team of specialized cardiologists, nurses and invasive cardiovascular technologists is available seven days a week, 24 hours a day to treat any cardiac emergency.

The Cath Lab team also performs many diagnostic procedures that are scheduled during operating hours. These procedures include ultrasounds, heart catheterizations, intravascular ultrasound, transeophogeal echo and cardioversions, balloon angioplasties, placing stents, and implanting permanent pacemakers and Automated Impantable Cardioverter-Defibrillator (AICDs). In addition, the Cath Lab was recently upgraded to include enhanced capability for vascular stenting, cardiac eblations and electrophysiology (EP) studies. There is also a new cardiovascular x-ray system.

With heart attacks, the ED physician can usually tell what is happening from the EKG. But, the Cath Lab is where the direction of care is determined. The diagnostic procedures completed in the lab reveal the insides of the heart and arteries, enabling the cardiologist to determine the proper course of treatment for each patient.

It is 2 am, and Gwen Sherrill is the first on-call member to arrive in the Cath Lab to care for Ms. Smith. Gwen, a cardiovascular technologist (CVT), begins preparations for an emergency cardiac catheterization. This is a procedure in which a catheter is placed in Ms. Smith’s coronary arteries that feed the heart muscle. A cardiologist injects dye through the catheter to determine if there is a blockage in the arteries and where it is located. The angiographic pictures from the process help determine what procedure needs to be done for the heart.

Since she’s first in the Lab, Gwen prepares the room for the procedure, including preparing the Catheterization instrument tray and necessary supplies. By this time, the on-call intervention cardiologist—who is Dr. Stewart Jones this morning—has arrived in the ED and is checking Ms. Smith’s medical history.

Emily DuBray, RN, arrives at the Cath Lab. She calls the ED to make sure the patient is ready. She also helps Gwen complete the room set-up. Richard Sykes, CVT, and Amy Waddell, RN, arrive in the Cath Lab.

Ms. Smith is brought to the Cath Lab. She is placed on the EKG monitor and connected to oxygen. Defibrillation pads are also placed. Emily checks Ms. Smith’s medical record sent by the ED.

Gwen is now entering patient information into the Hemodynamic system and will record the procedure and Ms. Smith’s response to treatment. Richard, who will be at the table as the scrub tech, scrubs in.

He prepares the procedure site. Before the procedure begins, a time-out is completed while the doctors, nurses and technologists confirm the right patient, right equipment and right procedure and supplies are checked. The patient’s condition, including any allergies, is noted.

Ms. Smith is placed under procedural sedation (medicine for anxiety and discomfort). Dr. Jones numbs the area the catheter will enter before beginning the procedure.

Dr. Jones gains access to the heart through an artery in the groin and injects dye to determine if and where there are blockages and if a stent is necessary. He numbs the groin and then places a sheath (used for access to the arteries that go to the heart and to monitor arterial arteries and pressure).

He decides to open the artery with a balloon and place a stent (a steel coil or wire mesh) in the artery to keep it open.

During stent placement, Dr. Jones continues to take angiographic pictures to confirm the location of the stent as it is placed. Richard actively assists Dr. Jones during this process.

Amy monitors Ms. Smith’s airway and overall condition, giving her any medications for comfort.

Emily is now the circulator, providing what is necessary for the procedure.

The team talks to Ms. Smith while she is under sedation to see how she is doing throughout the procedure.

The time Ms. Smith entered the ED to the time her artery was opened with the balloon was approximately 73 minutes–a result of the great teamwork within the Cath Lab and between the EMS, ED and Cath Lab departments.

When Ms. Smith was having a heart attack, her heart muscle was not getting the oxygen it needed to work. Heart muscle will die without oxygen, so every second that passes during a heart attack matters. In fact, the American College of Cardiology suggests that heart arteries should be opened within 90 minutes to avoid permanent heart damage—Time is Muscle!

In 2007, Durham Regional joined an American College of Cardiology initiative to reduce the time that lapsed from patient arrival at the hospital to the restoration of circulation.

The target time was 90 minutes. In order to reach this goal, Durham Regional implemented an interdisciplinary team that developed and implemented a plan of action that emphasized teamwork and communication between multiple departments and professionals in the hospital. Last year, Durham Regional’s average time improved to 71 minutes.

“The process changes implemented by the team required a great deal of collaboration and cooperation between the Emergency Department, Cardiac Cath Lab, Emergency Physicians, Cardiologists, Cardiac Interventionists, Communications, Pharmacy and Special Services,” says Regina Woody, Strategic Services associate and chair of the DRH AMI Team. “The processes implemented have been successful in helping us to consistently provide quality care to all patients treated for heart attacks at DRH.”

Durham Regional Receives National Award from American College of Cardiology
Durham Regional Hospital is one of 36 hospitals nationally to receive the American College of Cardiology Foundation’s NCDR ACTION Registry–GWTG Silver Performance Achievement Award for 2009. The award recognizes Durham Regional’s commitment and success in implementing a higher standard of care for heart attack patients, and signifies that the hospital has reached an aggressive goal of treating coronary artery disease patients with 85 percent compliance to core standard levels of care outlined by the American College of Cardiology/American Heart Association clinical guidelines and recommendations.

“We’re honored to be recognized by the American College of Cardiology for the work our physicians and staff have done to improve the quality of cardiovascular care for our patients,” says Kerry Watson, CEO, Durham Regional Hospital.

To receive the award, Durham Regional consistently followed designated treatment guidelines for 12 consecutive months. These guidelines include aggressive use of medications like cholesterol lowering drugs, beta-blockers, ACE inhibitors, aspirin and anticoagulants in the hospital.