Raigmore Hospital is located in Inverness, a rapidly growing city in northern Scotland. Located 254km north of Edinburgh, and 903km north of London, the city is situated at the mouth of the River Ness, which flows from the nearby Loch Ness. The population is approximately 57,000, with two languages spoken, being English and Scottish Gaelic, and is ranked fifth out of 189 British cities for quality of life.
Interview
What are the sizes of your Cardiology Department and Hospital?
Raigmore Hospital is the 600 bedded regional centre for the Highlands of Scotland. Within the Cardiac Unit there is a 6 bedded CCU and 16 bedded step down ward. There is also a dedicated cardiac rehab unit. (The Highland Heartbeat Centre)
What is the geographical intake area and population served by your hospital?
NHS Highland covers 41% of the land mass of Scotland, same size as Wales! 300,000 people live in the area but there is a large tourist influx. The dispersed population makes this one of the least densely populated areas in Europe with some of the most remote patients and many island communities.
How many staff? Roles?
We have recently expanded to 4 consultants (2 PCI trained) as well as a fully staffed CCU, Cath Lab and Cardiac Investigations unit. Cardiac rehab teams are present throughout the area and there are good links with our local district and community hospitals.
Types of procedures?
Other than EP, there is a full range of cardiac services available including diagnostic angiograms, PCI, bradycardiac pacing, ICD, TTE, TOE, cardiac CT, cardiac MRI, and MPS.
Types of equipment used?
The current lab used is a Philips modular lab but in March 2011 our new lab complex will be opened with GE cath labs, integrated Volcano for IVUS and pressure wire.
How do you believe the integrated Volcano Multi-modality system will benefit your new Catheter Lab?
The Volcano integrated system provides a unified platform including FFR and IVUS and is integrated with the DICOM System, meaning that all our FFR & IVUS reports are consolidated with the angiograms. This integration assists our Cath Lab Staff as it ensures the workflow in the lab is much smoother and importantly time saving, without the need to bring in different pieces of kit for each procedure. The other advantage means they only need to be trained on one system for all modalities. Having this integrated system will also allow us to take advantage of the future technologies that Volcano are currently developing, including Forward Looking IVUS (FLIVUS) & OCT.
How many procedures are performed a year?
Our lab is projected to undertake approximately 1000 angiograms this year. Over 150 PCI’s were performed in the first 4 months since starting PCI in May 2010, thus we predict we will undertake around 350 in the first year. IVUS and pressure wire are important tools – we performed 19 IVUS and 7 pressure wire studies in the first few months.
What is the approximate percentage of cath lab cases performed radially compared with femorally?
85 percent are radial.
Does your department offer a Primary Angioplasty Service? If yes, what have been some of the challenges setting it up? If not, is this planned for the future?
Due to the dispersed nature of our population and the presence of only 2 PCI cardiologists, the development of a PPCI service will be a challenge for the cath lab and the ambulance service. Currently we operate a mandated ECG telemetry service to the ambulance service - where ECGs are telemetered for prehospital thrombolysis. At present over 90% receive thrombolysis. Overall our PHT rate is 60%. Discussions are under way to offer PPCI to the 60% of the population who live within 1 hour drive time of the lab.
Are any of your staff cross-trained (generic workers)? Future?
No, but this is something we are actively looking at to overcome the smaller number of staff in each discipline. This should allows us greater flexibility when opening the lab out of hours.
What new procedures / techniques have you implemented into the department recently? Future?
PCI has been the main focus this year but we have been lucky to attract an established consultant (Peter Clarkson) who is proficient in CRT, and we hope to start this service soon.
What are the benefits to patients attending your facility?
The development of on-site PCI has had an enormous benefit to patients. While we have not developed a PPCI service yet, several patients have had rescue or primary PCI within the cath lab operating times. The treatment of NSTEMI patients has been greatly improved and the turn-over of patients on our cardiac step down ward has quadrupled since the start of the PCI service.
How is your inventory managed?
Stock at present is a paper system with Excel spread sheet support, and a dedicated store person. We are looking into costing and implementing a bar code system that will have set levels, max/min, and can re-order with a link to automatic ordering when these levels are at a minimum.
How does the lab handle haemostasis?
As the majority of our cases are radial the TR band is our main method. For those patient requiring femoral puncture we use either angioseal or exoseal depending on the patient situation.
What measures has the department implemented to cut costs?
We are continually seeking for competitively price products. Furthermore approximately 50% of our PCI cases will be undertaken as day case procedures and this has a cost saving.
What kind of training can new employees expect to receive?
Staff new to the cardiology DCU/Cath Lab can expect to be supernumery initially and have an appointed member of staff as their mentor to support them in the early stages of learning. They assist with new procedures, guidelines and protocols for the safe delivery of high standards of care. A training pack is given to each member of staff covering anatomy and physiology of the heart plus cardiac interventions, angiograms, pacing, PCI, ETT, MPS and cardiac rehab. Once familiarised with daycase procedures, and protocols, staff are integrated into cath lab working, observing initially, followed by scrubbing in with a senior member of staff. Consultant input in the cath lab also contributes in training staff as scrub nurses, particularly as second operators for PCI, with cath lab manager support.
What kinds of continuing education programs are available to staff?
We are fortunate at Raigmore to have Charlie Bloe from CB training as our CCU ward manager. Training programs for nurses include, online education programmes for ACS, drug calculations, IABP, ECG recognition and thrombolysis training days. We have an annual conference, Heart of the Matter which is well attended by those interested in cardiac care in the Highlands. Isobel Adams, our cath lab sister joined us this year and brings great experience from James Cook Hospital in Middlesbrough, which has been extremely valuable when setting up the service.
What kinds of competency checks do staff have to undergo once employed?
Competencies for staff have been developed and implemented as a means to assess the knowledge gained by staff during training, where extra support is needed, and to deem a member competent in a particular area. For example, the following are assessed by the cath lab manager/clinical educator: patient safety and risk, through check lists, orientation (to know where equipment is and what it’s for), procedures, theoretical and practical knowledge. A new competency being developed is a log for staff covering scrub and second operator in the cath lab, flooring (scout nursing), and FFR/IVUS. This will be assessed every 3 months.
How do you deal with late finishing of cases?
Currently PCI is limited to morning working only – however as predicted this is insufficient capacity, and discussions are ongoing to create an oncall staff to allow PCI in the afternoons.
What is your policy for company reps within the labs?
Reps are encouraged to visit BUT in line with BCIS recommendations are only allowed in the lab when specific staff training is required.
Reducing radiation dose is a high priority in the cath labs. What techniques are employed by your radiographers to ensure dosage during cases is kept to a minimum? Also what is the maximum dose limit a patient can receive in your labs before it is recorded in their notes, and what is the follow-up process?
Slick PCI operators is clearly the key to reducing radiation dose! Low dose screening and aquisition techniques are used with low screening and aquisition times, and collimation where possible.
We also ensure we use appropriately trained specialist radiographers.
All staff must wear correct lead equivalent personal protection and radiation monitoring badges. Use of lead shielding on equipment and the numbers of staff in the lab are kept to a minimum when using radation. Radiographers notify cardiologists when skin dose is 2 Grays (200 DGS). Cardiologists consider staged procedures or where possible change the angle of the tube. The medical physics department is informed when a high dose occurs, and the Cardiologist is responsible for the medical follow up.
What are the advantages for SpR’s training at your facility?
We provide a truly consultant delivered service (due to lack of SpRs) thus a trainee at Raigmore will be ensured of excellent supervision during their training and exposure to a range of cardiac patients.
What is the best part of working at your facility?
The team effort to establish PCI has been a great bonding experience. The enthusiasm and skills of the cath lab staff have been particularly uplifting, and the transformation of the patient flow in the CCU and cardiology ward has only been achievable due to the huge effort of the nurses and support staff in these areas.
