The Waikato Hospital as part of the Waikato District Health Board is a tertiary centre for the Midland region servicing a population of 980,000. The area covers the central North Island of New Zealand. It currently has 597 beds, 15 operating theatres, and employs more than 5800 staff. In 1999 the existing lab was refurbished and a new lab was opened.
The Cardio / Resp Investigation Unit (CRIU) has two areas within the department. Two Labs and outpatient clinics of respiratory, pacemaker and ambulatory monitoring, are run by Technologists. The ETT clinic is either Tech/Dr or Tech/ Nurse run. Tilt table testing is undertaken by nurses.
The organisation is currently in the planning stage of re-development and the department will undergo significant change. By 2011 there will be three labs (one dedicated for EP) with a shell for a fourth lab.
Interview
Cath Lab
The labs are almost 8 years old and are equipped with Toshiba KX100, supported with Marquette Maclabs haemodynamic monitoring system, Radiwire and Volcano IVUS. We are also currently moving towards PACS (Picture Archive system).
The labs carry out around 2150 procedures per year that include angiograms, angioplasties, pacemaker insertions, EP / ablation and ICD and bi-ventricular implants. Other procedures ( eg pericardial taps, temporary pacemakers) are also performed occasionally. Around 720 interventions are performed annually.
Based on UK Cardiac Society recommendations of procedures per million of population (1750 per million) the dept should be performing for the number of population 2150 per million which would mean a large increase of the volumes that the dept manages to achieve currently.
The cause of this is multi-factorial. Funding, staff resource, capital costs for equipment maintenance and the availability of staff to employ are just some.
Despite these figures the department works an 8 hour day frequently running into overtime, manages an after hours on call service for Primary Angioplasty for Myocardial Infarction (PAMI), and Pacemaker and ETT for the Chest pain unit.
EP
Whilst the department does not have a dedicated EP lab, two cardiologists specialise in this area in a lab which is equipped with EP Medsystems. The lab carries out around 75 EP / Ablations per year and 31 ICD implants. These numbers are somewhat limited due to the acute demand of inpatients and pressure from outlying feeder hospitals, that the EP lab is not a dedicated lab and the EP Cardiologists having other responsibilities in the department.
PAMI service
The department has been performing angioplasty in acute myocardial infarction since 1994 and to date has performed 768. (+/- 64 per year). It was the first lab in NZ and was so for several years to offer an 24 hour on-call service for the region. All staff who are on call are expected to be at the department within 20mins of been advised by pager.
Clinical Trials
The department is well recognised for its long history of active participation in international clinical trials. There are frequently several trials running at any one time.
Education and Training
Cardiologists working in the lab have their licence in Radiation Safety.
Ongoing in-service lectures for the professional groups and attendance at national and international conferences is an important part of the yearly calendar, however this can be difficult due to organisational policies and requirements.
1) How many staff? Roles?
The department has a staff of 28 FTEs comprised of Nurses, Technologists, Radiographers and Clerical staff. The Cardiologists have dedicated sessions in the Cath Lab each week.
2) Types of procedures?
Angiography / Angioplasty / EP / Ablation / ICD implants / pacemaker implants. PAMI ( Primary Angioplasty in Myocardial Infarction) 24hrs per day 7 days per week.
3) Are patients performed as day cases?
20% procedures through the Cath Lab are elective procedures. 80% are acute from the 48 bed Cardiology ward supporting 9 outlying hospitals from both within and outside the region.
Elective Angiogram / angioplasty / pacemaker implants / EP are all done as day stay patients. If the patient lives further than 20mins from the hospital they are required to stay in the hospital hotel accommodation. This has been the practice for a number of years without any adverse events.
4) Are any of your staff cross-trained?
Historically there has been no cross training of staff in our department. Each professional group has its own responsibility in both outpatient and Cath Lab procedures. It is understood that teamwork in the Cath Lab is imperative for an efficient service and there is teamwork however no official cross-skilling of the professional groups.
It is anticipated that in the future there will be some form of cross training within the Cath Lab. One MRT has been training and is utilised in the scrubbing role. This has proved very successful and is hoped this will be a pathway for future professional development of all Cath Lab staff.
5) Is their any surgical back-up in the cath lab?
Waikato Hospital has a Cardiac Surgery backup. PAMI procedure does not have backup.
6) How does the lab handle haemostasis?
Digital / manual pressure by scrub nurse. Occasional closure device.
7) What new procedures have you implemented into the department recently?
We recently trialled a 3D imaging system for EP / ablation. It would be on the wish list if the funding was available.
8) What are the main roles for the radiographer, nurses, tech?
The different professional groups tend to work as a team during the patient journey through the lab although they each have distinct responsibilities.
Nurses: All aspects of patient care.
Pre-admission clinic for patients on waiting list to prepare for procedure.
Preparation of elective list for Cath Lab week.
Scrub nurse who assists cardiologist with procedures.
Runner nurse who manages the care of the patient. And scouts for the scrub team.
Immediate post procedure care.
MRT: Imaging
Technologists: Haemodynamic monitoring.
Stimulating and analysis during EP.
Device selection and technical aspects of pacemaker / ICD insertions and temporary pacing.
The techs have speciality portfolios of responsibilities that ensure maintenance and effective service provision for each area within the department.
9) How is your inventory managed?
Regular and close collaboration with sponsoring companies. Equipment is managed both consignment and purchased outright. Interventional equipment is 100% consignment. Annual tendering for purchasing of pacemakers and ICD.
10) Do you perform Private cases?
No, athough we do have a close relationship with the private lab in the same city and have a “borrow and return” system for equipment (eg catheters) when stock levels have been depleted. Most of the Cardiologists and some nurses and technologists also work there in their own time. Due to difficulties in maintaining adequate elective patient throughput for a variety of reasons (eg bed crises) we have recently had a successful collaborative contract with the private hospital when 120 patients had Cardiac Catheterisation performed.
11) What measures has the lab implemented to cut costs?
Given the type of service delivered this is very difficult. Employing to budgeted FTEs, tender processes, seeking deals with the sponsoring companies for better pricing of equipment, legislative guidelines for use of Drug-eluting stents. Careful selection of appropriate pacemaker matching patient requirements.
12) Has the hospital formed an alliance with other hospitals for treating patients?
As we are the tertiary referral centre for the region, we maintain close relationships with the feeder hospitals and a yearly forum is held to discuss clinical practice, new trends and to ensure the ongoing establishment and re establishment of guidelines to ensure equity of treatment for patients throughout the region.
13) What kind of training can new employees expect to receive?
Depends on the professional group.
Nurses: All are registered nurses and they receive an extensive orientation of six weeks and an ongoing training programme until practice is to the required standard that will enable participation on the on-call roster.
Techs: New employees with an appropriate undergraduate degree enter a training programme which includes a 2 year post graduate diploma by distance with block courses. This group have the opportunity to specialise in various aspects of the work and as such participate in self-directed learning and on the job training to complete courses.
MRT:
Extensive orientation in the modality of Cardiology imaging. This continues until practice is at a level when the MRT is able to participate on the on call roster.
14) Kinds of continuing education programs are available to staff?
All groups as part of their annual registration have an expectation of proof of professional development which is written into Collective agreements.
Attendance at appropriate conferences with collegial feedback mechanisms. An organisational policy that only two per department attend conferences makes this form of ongoing education difficult to achieve.
The organisation offers many different day courses for many aspects of professional development. Eg. Powerful Presentation / Managing
Difficult Situations.
Nurses: The educational opportunities for nurses are varied. Undergraduate and post-graduate papers via tertiary institutions, collaborative organisational / universities clinical papers available.
MRT: Post grad papers are available via the universities.
Techs: Post grad papers diploma is the basic trainee technologist expectation of employment. Masters are available via universities for individual professional development and career progression. Individuals are encouraged to attain the NASPE qualifications.
15) What kinds of competency checks do staff have to undergo once employed?
This is done as part of the orientation for the Nurses. Following this period there is no formal department competency checks, however organisational requirements require generic competency checks for IV and ACLS. Technicians follow a trainee and advanced training manual of competencies, with a specified time-line. They must show competency in each procedure prior to working autonomously.
16) What have been some of the challenges in setting up the new department?
Difficulty in attracting staff due to the chronic national shortage of appropriately trained technologists.
17) Is the department used as a training facility for cardiac registrars?
We have had training registrars fellows who have supervised training in angiography and intervention. They have proved very effective in the increasing the throughput of acute patients through the labs.
18) What is the best part of working at your facility?
The teamwork. The ability to make a difference. The diversity of work. The weekend! The department boasts a nationally recognised service and strives for excellence.
