The current Royal Brisbane and Women’s Hospital is located in Brisbane, Queensland, Australia. It is a 942 bed general, tertiary referral teaching hospital. The Royal Brisbane and Women’s Hospital is the largest tertiary referral hospital in Queensland and provides services to patients throughout the State, Northern New South Wales, the Northern Territory and from neighbouring countries in the South West Pacific.

The Cardiology Department is currently in a state of expansion. It comprises a 12 bed Coronary Care Unit, and a 14 bed Cardiology Ward. The Cardiac Cath Lab (CCL) is comprised of 2 labs. One is a bi-plane angiography suite, and the other an EP Lab. Non-invasive Investigations are performed in the Cardiac Investigations Unit (CIU), and a decentralised Cardiology out-patients department is located within the department. Procedures and investigations performed in the CIU include Trans-oesophageal Echo’s, Trans-thoracic Echo’s, ECGs, 24 hour Holter and blood pressure monitoring, Stress Echo, Exercise Stress testing, and Pre Admission clinic for the CCL.

Interview

1. Cath Lab size
We have 2 Toshiba labs, a Bi-plane and an EP Lab. The EP Lab will be commissioned by the beginning of 2007. This lab has been funded for half EP and half angiography/intervention. We have a GE haemodynamic monitoring system. The 10 bed recovery bay is due to open with the increased activity. Currently the day cases are prepared and recovered in a 4 bed bay in the Cardiology Ward.

2. Staff numbers and their roles
We currently have 9 nursing staff of which 1 RN and 1 AIN staffs the CIU. With the increased activity proposed for 2007, a further 9 nurses will be required. The nurses in the CCL are responsible for completing preparation of patients for their procedure. A scrub and a scout nurse are required for each procedure, with sheath removal being performed in the recovery area either by digital pressure or the CompressAR device. This is usually conducted by the scrub nurse to ensure continuity of patient care. All nurses are required to be Advanced Cardiac Life Support (ACLS) competent. 1.5 FTE radiographers is allocated, with the senior radiographer based in the CCL and the further 0.5 FTE filled by a rotation of angiography trained radiographers from the Department of Medical Imaging. 1 FTE Cardiac Scientist is allocated to the CCL on a rostered basis, and they are responsible for the haemodynamic monitoring throughout the procedures. We have 2 FTE Staff Interventionalists, 1.6 FTE Cardiologists and 3 VMO’s.

3. Number and Types of procedures
We perform approximately 1700 procedures per year, 350 of which are PCI’s, 1250 diagnostic angio’s, 60 PPM’s and the remainder a mixture of PFO and ASD Closures, Percutaneous Balloon Mitral and Aortic Valvotomies, Pericardiocentesis and IABP insertions. With the increased funding, we will be performing a further 560 diagnostic angiograms, 240 PCI’s and 200 EPS’s.

4. Day cases
All elective diagnostic angiograms and PPM insertions are performed as day cases. When the CCL Recovery is open in January 2007, all day cases will be prepared and recovered by the CCL nursing staff. Elective PCI’s will be prepared in CCL and recovered either in the Cardiology Ward or the CCU.

5. Cross training of staff
We currently don’t cross-train staff between disciplines. We do offer a nursing rotational position between CCU, Cardiology Ward and the Cath Lab which allows for the department to have a core group of multi-skilled nursing staff. There are 3 nurses at a time on the rotation, and they each spend 6 months in each area. If at the end of the rotation there is a position in the field of their preference, they may apply for a position there.

6. Surgical backup
Currently we don’t have cardiothoracic surgery on site at the RBWH. If the patient requires urgent surgery, they are transferred to The Prince Charles Hospital, which is a 10 minute ambulance journey.

7. Inventory Management
All of our interventional catheters, balloons and stents are on consignment. We pay as we use on the same day, and the replacements are delivered via urgent courier directly to the Cath Lab the next working day. This system works very well, but requires meticulous management from all nursing staff. The consumable costings are also entered on a database called ‘Cath Lab Manager’, and this is downloaded at the end of every month and fed back to the Cardiology Management Advisory Group. Case time, recovery time, set-up times and complications are also recorded in this database.

8. Haemostasis
Digital pressure is the preferred mode of sheath removal as it is the ‘gold standard’. We do however have the CompressAR device, and utilise this when we are short staffed as it doesn’t require 2 nurses. The Femostop is not routinely used for primary sheath removal, but is utilised for haematoma management. Angioseals and Starclose are used in selected patients who are anticoagulated or are unable to lie flat for an extended length of time.

9. Private Cases
As the RBWH is a public hospital, few private cases are performed.

10. Measures implemented to cut costs
We recently introduced a 9 day fortnight for full-time nursing staff. This has a two-fold benefit. The longer shifts have reduced the over-time claimed as the shifts finish later in the evening, and staff morale has increased as a day off is rostered every fortnight. To achieve this, staff work 8 x 8 ½ hour and 1 x 8 hour shift every fortnight.

11. Alliances with other hospitals
We have an alliance with hospitals in Queensland that don’t have a Cath Lab. Patients with ACS are referred for angiography and are accommodated in the CCU in 3 quarantined beds for Inter-hospital Transfers.

12. Training for new employees
New employees have a comprehensive orientation program. In short, they are completely ‘off-line’ for the first 2 weeks, and work with their preceptor during this time. By the end of the off-line time they are expected to be able to scrub for an angiogram alone. Once comfortable with angiography, they then learn to scrub for angioplasty. Staff must be supervised to scout by an ACLS competent nurse, until they have achieved their ACLS competency. This can take up to 6 months if the nurse has no prior Cardiology experience. IABP, Temporary Pacing Wire and Sheath removal competencies are also included in the program.

13. Continuing education programs
The Cardiology Nursing Group has a weekly in-service program provided by staff who work in Cardiology. It is delivered on a rotational basis. All staff are expected to participate in the in-service program. The RBWH has a decentralised in-service program which staff are given the opportunity to attend. Every Friday morning there is a multi-disciplinary education forum where different members of the multi-disciplinary team present on Cardiology topics.

14. Competency checks for staff once employed
Annual competencies are assessed once per year and they include
ACLS
Manual Handling
Fire
Performance Management

15. Training facility for Cardiac Registrars
The RBWH is a major teaching hospital. We currently have 3 Advanced Cardiology Registrars, and from next year we will have 4. The Registrars are supervised by the Cardiologist whilst performing Coronary Angiography. They also perform Transthoracic and Trans-oesophageal Echo’s and attend out-patient Clinics as well as attending to the in-patients in CCU and Cardiology Ward.

16. Best part of working at RBWH Cath Lab
The best part of working at the RBWH Cath Lab is being an integral part of the multi-disciplinary team.