The Emory Healthcare Cath Lab Teams
Pioneers in nurse-led sedation during TAVR, they are the only clinical site in the US for the NIH’s structural heart group.
Emory Healthcare has a rich history of innovation in interventional cardiology, having been home to world-renowned experts such as Andreas Gruentzig, Spencer King III, and John S. Douglas Jr. Across the Emory system, multiple cath lab teams are known for having high levels of technical and clinical ability. Notably, Emory’s Structural Heart & Valve Center is the only clinical site in the United States for the National Institutes of Health (NIH) Structural Heart Group, overseeing groundbreaking pharmacologic and device research.
According to their nominator, these cath lab professionals have “some of the best outcomes and highest volumes in the country for coronary and structural procedures, and are especially well known for nurse-led sedation and the minimalist approach for TAVR.”
Cath Lab Forum spoke with Patricia Keegan DNP, NP-C, AACC, Director of Strategic and Programmatic Initiatives and Lead NP for the Structural Heart & Valve Center, as well as Cecilia Mortorano, MSN, RN, NEA-BC, Director of Cardiology Services at Emory University Hospital Midtown.
Each of you work at different locations within Emory Healthcare. What are some of the things that make your particular cath lab team stand out?
Keegan: We really do take nursing buy-in very, very seriously. For many of the procedures that we do, it’s understood that there is considerable effort that goes into training the provider. But at the same time, we pride ourselves on making sure that all of our staff are prepared and knowledgeable in their own training as well. We have to know how to recover the patient and understand what everyone is expecting. I think one thing that's really made our program excel is having that approach where everybody is invested: everyone understands the plan and has a say.
Mortorano: Our team is highly skilled, highly motivated, and they work very well with each other. Staff engagement has been a big secret to our success. For example, in all of our PCI quality metrics such as risk-adjusted bleeding and acute kidney injury, we have a team member who is dedicated to collecting data on that information, as well as implementing interventions that keep those rates below the threshold that we consider acceptable. We have started to really try to include our team members in each of those quality metrics so that they can have an active role in helping to drive improvement. This allows the team to have ownership over the work that they do and know that they are the drivers of quality. We have seen a lot of success from involving them in this way and empowering them to make decisions and suggestions to improve upon the day-to-day work we do.
Emory has been instrumental in leading the way for nurse-led sedation as part of minimalist TAVR procedures. Can you tell us more about that?
Keegan: We started our nurse-led sedation program in May 2012. There is some confusion that surrounds this topic because there are no definitions that describe exactly what ‘moderate sedation’ or ‘conscious sedation’ is in the TAVR experience. Often people will say conscious sedation when they’re actually delivering monitored anesthesia care (MAC) with an anesthesiologist present. That makes it difficult to know how widespread the practice of true nurse-led sedation is because it isn’t tracked in the TVT Registry. Nonetheless, we began our program when TAVR was about to be approved for high-surgical-risk patients. We are a high-volume center and we were limited in anesthesia resources and in room availability, which impacted our ability to meet the needs of patients and turnaround time needs. Our goal was to match the sedation with the case. This required significant prep work, including working with the cath lab teams, the floor nurses, and the ICU nurses to make sure we had buy-in with the development pathway that we had worked out with anesthesia. In our early conscious sedation cases, we still had everybody in the room, but the nurses were the ones delivering the sedation. It took about 3 months before we were able to transition to a fully nurse-delivered sedation protocol, meaning that we didn't have perfusion or anesthesia in the room. This was accomplished with the aid of a number of safety metrics, including a code to call for anesthesia and a balloon pump in the room to ensure the patient was adequately protected. In October of 2012, we were able to start sending patients directly to our cardiac telemetry unit, bypassing any kind of recovery unit or ICU. Members of our team wrote about our experience in a paper published in 2014. Since then, there have been a number of studies showing that moderate sedation or minimalist pathways in TAVR decrease length of stay, are safe, and are associated with lower cost.
Has your staff had to overcome any challenges recently with respect to staffing issues, availability of space, etc?
Mortorano: Yes, one thing that we have struggled with has been team members who joined us to learn the cath lab skill set, but then departed after 6 months to a year once they had enough of the skill set to be hired by a travel company. We taught them the skills, and then before they could become highly functional members of the team, they left and we were faced with rehiring for those positions and starting over again with new people. I'm sure our situation is not unique and that other cath labs are dealing with this as well. One way that we have tried to prevent this is by being very selective in our hiring process to ensure that the team members that we're bringing on board want to be ‘owners’ as opposed to ‘renters.’ We are forthcoming with prospective hires during interviews and make it clear that we are looking for people who are going to be with us for the long term.
Do you have tips on things that you have found to be effective in retaining quality staff?
Mortorano: First and foremost, we try to be flexible. If a nurse or any team member has gone back to school, for example, we want to know so that we can accommodate their work/school schedule. Another thing that we introduced this year is a standardized shift start time to ensure that we are all beginning the day at the same time, with the goal of everyone starting and ending at the same time. Working in the cath lab is taxing both physically and emotionally. We want to support the work-life balance of our team.
Do you have working groups for different types of procedures?
Keegan: We don’t, but what we do have is nurse champion programs. Nurses who feel a little bit more invested in structural heart disease, for example, spend a little bit more time getting to know the technology and the procedures, and what happens is they become our ‘go-to’ people and our resident experts. It’s invaluable to have staff in those roles.
How do you handle training and familiarization with new technology being introduced in your labs?
Mortorano: Our cath lab team members have an education session every Friday morning. If we know that we will have a new piece of equipment on the horizon, we will train on that equipment during those sessions. Because we are always using new equipment or new approaches, it has been very vital to our success to have that time dedicated weekly for a touch base. Additionally, when physicians have decided upon a procedural plan, they'll communicate that to the team at that point prior to the procedure.
Keegan: As part of our NIH collaboration, we were involved in the development of the LAMPOON and BASILICA procedures for TAVR. Whenever we have early feasibility or first-in-human trials, we'll have additional team meetings specific to the technology and the patient. As a team we want to ensure that everyone involved understands where the procedure is going to be done, who's going to do it, and what the goals are for recovery. Some of the cutting-edge trials that we are involved in at the moment include SUMMIT, CLASP TR EFS, AccuCinch, and ALTERRA, a congenital pulmonary valve dysfunction trial. It's been really rewarding for us to be the only clinical site for the NIH’s Structural Heart Group in the United States. It shows not only that they have trust in our practitioners, but also that they have trust in our entire team to provide care for these patients. I believe that where we really excel with our nursing in this regard is in the development of specialized care protocols, which comes from our experience and knowledge of advanced interventions.
Mortorano: I think It’s very gratifying for our teams when we're able to see the ultimate impact of those cutting-edge studies and know that we had such an early role in bringing that research forward.