Staffing in the Lab

Lately, I’ve been observing cath and EP labs who have questions about staffing. They’re good labs, but they’re not living up to their potential. The biggest question to ask is, “Do you see the lab as a nursing unit where nurses perform procedures assisted by non-nurses, or do you see the lab as a multi-disciplinary procedure area where nurses and non-nursing professionals assist physicians to perform procedures? These issues seem to arise in labs where nurses have moved from the floor or an intensive care unit to manage the cath lab without ever working or observing in the lab. With no one to ask, they do their best, and they create good labs…where there could and should be great labs.
The biggest problem with seeing the cath lab as a nursing unit is that it turns all other lab staff into sub-professionals. It is vital that a cath lab manager understand who is qualified to work in the lab. Here they are:
• RN (Registered Nurse)
RNs bring general patient care knowledge into the lab. They are the ones who are trained in pharmacology, physiology of the entire body, and medication administration. RNs can be BS or ADN trained. There is a Cardiac Vascular Nursing Certification (RN-BC) for RNs, but it is not specific to the cath lab. Many RNs come from the ICU and have a CCRN certification. However, the RNs I have spoken with have told me that ICU and CCRN certification do not adequately prepare a nurse for the cath lab. Many RNs choose to earn their RCIS certification, as it is cath lab specific.
NOTE: LPNs are welcome in the lab, but usually function as techs due to their inability to administer narcotics.
• RT (Registered Technologist – Radiography)
RTs bring strong anatomy knowledge, as well as experience working with radiation and radiation-producing equipment. They tend to be more “techie” than most nurses. Cath and IR Lab is included in the RT training. RTs can be BS or Associates degrees. There is an advanced certification for RTs in the cath lab: The Cardiovascular interventional (CI) credential. This is an exam taken by RTs after working in the lab for some time.
See for details
NOTE: The CI and VI were combined into the CV credential until the early 2000s, when they divided into the CI and VI.
• RCIS (Registered Cardiovascular Interventional Specialist)
The RCIS brings cardiac-specific knowledge to the lab. The requirements to challenge the RCIS exam are found on the CCI website,
• Other professionals are also welcomed into the lab:
 LPN (functions as tech)
 Respiratory Therapist
A fourth professional is found in the EP lab. This is the RCES (Registered Cardiac Electrophysiology Specialist). The requirements are found on the CCI website:
And so, it is important for a cath lab manager to understand who is available to work in the lab and what their strengths and weaknesses are.
Then what’s the solution? First, ask some questions.
1. Do you staff according to credentials?
Do you put the nurses into the cases and then look to see what holes are there to be filled?
2. Do you staff according to roles?
Have you defined the roles and what is required for each?
If you are staffing according to credentials; if you put the nurses into the case and “fill in” to assist them, how do you decide what your nurses can and can’t do? Are your nurses expected to scrub? Are they expected to monitor? Have they been trained to do these things? Do the nurses sedate the patients? Do they do anything else while they are sedating the patients? Are your other lab staff BLS certified? ACLS certified? What do they do in emergencies? How many staff are in each procedure? How many are nurses? How many are not nurses?
And the big question:
If you are staffing according to roles, what are the roles? Do you have only nurses filling some of the roles and only techs filling some? As you have seen from the definitions above, there are some roles that can be filled with either nurse or tech. So…let’s define the roles and who should fill them.
But before we can define the roles, we should probably define the tasks to be performed.
In the cath lab:
• Write/Scribe/Document
• Sedate and monitor patient
• Gather equipment for procedure
• Scrub
• Pan/Drive table
• Set up extraneous equipment (Impella, IABP, Atherectomy (Rotational, Directional), Thermodilution CO, Thrombolysis, Thrombectomy, Laser)
Can any of these be combined? According to new guidelines, the sedater should not do anything other than sedate the patient. Therefore, they should not gather or set up equipment. The scrub will be busy at the procedure table. They can pan or drive the table. So, we can call it scrub/pan. That makes the roles in the Cath Lab:
• Sedater
• Write/scribe/documenter
• Scrub/Pan
• Circulator
So what credential is necessary for these roles?
The Sedater, with a few exceptions, can only be an RN, as moderate/conscious sedation involves administration of narcotics. I’ve been in facilities where they called it “Sedation Nurse”.
The Writer/Scribe/Documenter (we call it “Monitor”) needs to be educated and informed, but could be either an RN, an RT or an RCIS.
The Scrub/Pan, with a few exceptions, can be any of the above. In a few states, only an RT can pan the table. They become the driver, with anyone else scrubbing. The RT can pull equipment if they are available to pan for the case. In that instance, the RT pan would be called the “Circulator”.
The Circulator pulls and sets up equipment. In rare cases, they may be called upon to assist the sedater in case of emergency. Therefore, the circulator should probably be an RN, although it could be any of the above.
The conclusion? In the cath lab, in order to have the roles filled, there should be, at the least, 2 RNs, 1 RT, 1 RT or RCIS. 4-man teams. I have worked with 3-man teams where the sedation nurse is also the circulator. A good cath nurse can do this.
The 2 RN/2Tech model works well in most labs simply because it provides expertise from all three professionals.
In the EP lab:
• Write/Scribe/Document
• Sedate and monitor patient
• Gather and open equipment for procedure
• Connect cables to pin blocks/PIU
• Set up irrigation lines to catheters
• Scrub
• Pan/Drive Table
• Run ablator (Cryo or RF)
• Run Stimulator/pacing/mapping
The EP Lab is a little different.
• The sedater should watch the patient exclusively. However, in the EP lab, anesthesia is usually present for ablation cases. This frees up a nurse for another role. If there is no anesthesia, the sedating nurse must be free to do nothing other than watch and sedate. With a few exceptions, this must be an RN.
• The Writer/Scribe/Documenter (Monitor) can pull equipment, set up irrigation lines and pin cables. This team member can be RN, RT or RCIS/RCES (EP specialist)
• The scrub will break when the catheters are in place; they are then available to run the ablator. There is very little panning done during an EP procedure, and it is typically done by the physician. This team member can be RN, RT or RCIS/RCES
• The person running the stimulator/pacing/mapping should not leave their position. It can be either RN, RT or RCIS/RCES.
Therefore, the mix in the EP Lab is:
1 RN for sedation if anesthesia is not present.
3 RN/RT/RCIS/RCES for the other roles if anesthesia is present. As always, it is good to have a mix of credentials, in order to have all knowledge bases represented. A 3-man team is all that is necessary. For implants, a 4th may or may not be present, again, if there is no anesthesia for sedation management.
This should be a 1 RN, 1 Tech, one either RN or Tech.
The conclusion, then, is to ask the big question: Are you running a nursing unit that does procedures with nurses and their assistants or are you running a procedure unit with a multi-disciplinary team?
The best labs are a procedure unit first, utilizing a multi-disciplinary team (with the emphasis on “TEAM”). Everyone should be equal. Except where necessary (narcotics, radiation), credentials should be left at the door. This approach creates an atmosphere, where everyone feels like a valuable member of the team. It creates an atmosphere where everyone has incentive to earn an extra credential and become even more valuable to the facility.
If you run a nursing unit, you will have nurses and assistants. If you run a procedure unit, you will have a team. Which do you want?