Advanced Cardiovascular Institute Ltd.

What is the size of your cath lab facility and number of staff members? The cath lab facility is a mobile unit, integrated as a fixed unit, adherent to the clinical centre. The staff includes a cardiovascular technician, a radiographer, two scrub technicians, a dedicated registered nurse, and a lab and procurement coordinator. There are three house officers on staff as well as an interventional cardiologist. The Clinical Director is a board-certified cardiologist with 17 years experience post fellowship training. Other visiting physicians include two additional interventional cardiologists and four radiologists. The lab has been operational since December 1998. What type of procedures are performed at your facility? Coronary angiography Percutaneous transluminal coronary angioplasty (PTCA) and stenting; both elective, facilitated and primary Peripheral angiography and PTA Carotid artery stenting Cerebral 4-vessel digital subtraction angiography Ureteric stenting Aortic stent grafting, both elective and emergent (total of 12 procedures; 3 patients were emergent and 9 patients were elective.) Device implantation: Permanent pacemakers, biventricular resynchronisation pacemakers Renal artery angiography and stenting Vena cava filter insertion Uterine fibroid embolization Approximately 900 procedures are performed annually, the bulk of the work being diagnostic coronary angiography. About 110 coronary interventions are performed annually. Between 5 and 10% of the remaining procedures are peripheral vascular procedures. Does your cath lab perform primary angioplasty with surgical backup? The majority of angioplasty, including primary PTCA, is done without surgical backup. We have a domestic 7-year experience of PTCA without mandatory surgical backup. During this time, no case has ever required surgical rescue. What procedures do you perform on an outpatient basis? All diagnostic procedures listed above are performed on an outpatient basis. The coronary angioplasty patients are kept overnight, and the aortic stent graft insertions require additional hospitalization. What percentage of your patients are female? What percentage of all patients are obese? About 26% of our patients are female. Average BMI for all patients equals 25.8. Eighteen (18)% are obese (BMI > 30). Therefore, it is possible that obesity may not be as important a driver of coronary disease in the Caribbean as in North America. Other risk factors may be more active. Who manages your cath lab? A lay cath lab coordinator/manager. She began her experience as transcriptionist at the cath lab in 1994 and became adept at our cath lab jargon and protocols. She next progressed to inventory clerk and procurement officer, before being cross-trained in hemodynamics. She has participated in numerous industry-sponsored training programmes and is hence now competent in all non-nursing cath lab functions. She is the primary supervisor of cath lab activities. What percentage of your diagnostic cath patients go on to have an interventional procedure? Seventeen percent of our diagnostic cath patients go on to have an interventional procedure. Do you have cross-training? Who scrubs, who circulates and who monitors? There is no official cross-training program. Due to the size of the facility and the intimate interaction among all staff, usually everyone becomes familiar with some aspects of the roles of the different staff. There are two dedicated scrub technicians, circulation is exclusively by RNs and there is a cardiovascular technician and radiographer, who monitor. Our policy is to actively promote the breaking down of barriers which define turf. In our cath lab, it is not unusual, for example, for a doctor or nurse to help mop the floor between cases to expedite turnover times. Does your lab have a clinical ladder? No. What are some of the new equipment, devices and products introduced at your cath lab lately? In November 2003, we introduced drug-eluting stents (DES). Now our current ratio of DES to bare metal stents is 5:1, mainly driven by demands of informed patients. The X-Sizer thrombectomy device (EndiCOR Medical Inc., San Clemente, CA) is used for ectatic vessels with high thrombus burden. Covered stents are used for the rare vessel rupture. In 2005, we began use of distal protection devices for vein graft PCI and we generally reserve the SyvekPatch® (Marine Polymer Technologies, Inc., Danvers, MA) for PCI procedures and brachial punctures. Radial artery access is not performed at our cath lab. Is your cath lab filmless? What systems does your lab utilize, and how do they impact your cath lab daily life? Our lab is fully digital, utilizing the DICOM standard. It is a modular lab which has been incorporated into the external wall of an existing small community hospital. Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab? An RT is present for elective cases. Which personnel can operate the x-ray equipment (position the II, pan the table, change angles, step on the fluoro pedal) in your cath lab? Only the doctor or RT can step on the fluoro pedal. All other functions can be performed by any team member with coaching from the RT. Your lab performs peripheral interventions. What disciplines (physician and non-physician) are involved in the various procedures? Radiologist and cardiologists perform peripheral interventions. In the case of aortic stent grafts, a team approach is used, consisting of an anesthesiologist, vascular surgeon, cardiologist and two scrub nurses. How did you begin performing peripheral cases? This occurred in response to local needs. Threatened limb loss cases were appropriate initial subjects. Later, as confidence grew, elective interventions were added. In 2000, the Cath Lab Director attended a peripheral training program, which greatly facilitated the introduction of new procedures. How is inventory management handled for the peripheral equipment? Cardiologists performing peripheral cases were encouraged to cross-utilize coronary equipment whenever possible. User preference determines inventory on a case by case basis. Do you average any overtime per pay period? Yes, approximately 6 hours per week. Do interventional radiologists and cardiologists perform procedures in the same area? Yes, cardiology cases are block-scheduled. When a peripheral case is requested, the radiologists are given first preference for performing the case; however, experienced cardiologists are not excluded. Did your facility need to make any changes to the imaging equipment to accommodate peripheral procedures? Not yet. However, we are planning to install a new flat panel combo lab by year’s end. How does your lab handle hemostasis? For diagnostic angiography, hemostasis is managed by manual compression. For coronary intervention, hemostasis is primarily managed by a vascular C-clamp device with or without the SyvekPatch. Since the inception of the lab, intravenous enoxaparin has been routinely used as the primary anticoagulant during coronary intervention. For the past two years, sheaths have been removed at 6 hours post administration, without adverse incident of bleeding or hematoma. The SyvekPatch is primarily used in patients with difficult hemostasis as in brachial access, or in renal failure patients. How is coding and coding education handled in your lab? How is coding communication handled with the billing dept.? Coding is not required in Trinidad and Tobago. Does your lab have a hematoma management policy? Management is individualized, but if hematoma does develop, all patients get vascular duplex ultrasound evaluation of the affected site with further management determined by these results. How is inventory managed at your cath lab? The cath lab coordinator is chiefly involved in manual inventory control, sourcing and purchasing of supplies. Has your cath lab recently expanded in size and patient volume, or will it be in the near future? Patient volume has increased, as the lab handles all of the domestic work at present and receives a lot of referrals from the eastern Caribbean. The physical boundaries of the lab itself are fixed, but the facility has recently expanded to include an admissions office, patient and relative waiting area, and more equipment storage areas. Still space is a critical problem. As a result, the lab soon be forced to relocate to another hospital with more available space. Is your lab involved in clinical research? Yes, we have presented data in many local and regional cardiology symposia. There has also been international research interest and collaboration. We are a site for the Taxus OLYMPIA Registry. Does your lab perform elective cardiac interventions? Yes. Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery? No. What measures has your cath lab implemented in order to cut or contain costs? Shared recovery room with the operating rooms. Use of consignment for interventional equipment and stents. Outsourcing for gas sterilization and laundry. Direct international equipment sourcing rather than through third party distributors in most cases. Selective Ethylene Oxide (EtO) re-sterilization. RNs seldom used for scrub assist; rather, cross-trained scrub technicians are shared with the OR. What type of quality control/quality assurance measures are practiced in your cath lab? Clinical review by the medical director. External review of in-house CDs is encouraged. What other modalities do you use to verify stenosis? We do not currently perform physiologic measurement of the lesion in the lab. QCA is randomly performed. How does your cath lab compete for patients? Has your institution formed an alliance with others in the area? There are two cath labs in Trinidad, the other being non-operational. Competition is therefore not an issue at present. This will soon change, however, since new labs are in the process of being commissioned both domestically and in neighboring islands. How are new employees oriented and trained at your facility? What licensure is required for all professionals who work in your lab? Lab policy is observing 10 procedures before becoming hands-on. We also follow standard national criteria for state licensure, plus two independent referrals are required. What type of continuing education opportunities are provided to staff members? At present, fortnightly cath-conferences and journal club meetings presented by the house officers are the mainstay of educational commitment. Physicians are responsible for their own professional development. Invited international experts are on-hand for the introduction of new clinical services. How do you handle vendor visits to your lab? Vendors are not allowed at the lab. Exceptions include at the introduction of new devices with first clinical use, and at these times, their presence is limited to non-clinical areas. How is staff competency evaluated? Staff are usually under the direct supervision and work with the cath lab director at most times. There are no formal appraisals or evaluation committees. Does your lab utilize any alternative therapies (such as guided imagery, etc.)? No. How does your lab handle call time for staff members? Is there a particular mix of credentials needed for each call team? Do you have flex time or multiple shifts? Basically the team operates 24/7. Call outs operate on a rotating basis for the RNs, house officer doctors and tech support. It must include one interventionalist, one junior doctor, one registered nurse, one scrub technician, and one cardiovascular technician. What trends do you see emerging in the practice of invasive cardiology? The emerging widespread use of drug-eluting stents may lead multi-vessel stenting to surpass CABG surgery as the choice method of revascularization in Trinidad. At present, most multi-vessel disease is treated with CABG rather than intervention. Where is your cath lab located in relation to the OR department, ER, and radiology departments? If you could choose one department to be adjacent to, which would it be? The OR is adjacent to the lab, and shares its recovery room. The ER and radiology departments are on the same floor, just down the hall. The setup is pretty neat; we have already had door (ER)-to-balloon times in primary PTCA of 55 minutes. Please tell readers what you consider unique or innovative about your cath lab and its staff. Intravenous enoxaparin has been used exclusively for interventional work for the past 4 years. At least half of all interventional procedures are performed without onsite back-up cardiothoracic surgery. Is there a problem or challenge your lab has faced? How it was addressed? Due to our small volume and location, ordering of supplies directly from large distributors overseas has led to either neglect or long delivery times. Sometimes this is circumvented by the use of alternate sources in Latin America. Performance of primary PCI without backup onsite cardiac surgery sometimes influences choice of cath or technique. We do not perform unprotected left main PCI. We try to avoid stiff wire approaches for chronic total occlusions (CTOs) and have discontinued rotablation. What’s special about your city or general regional area in composition to the rest of the U.S.? How does it affect your cath lab culture? We are remote from other interventional cath/surgical/support services. Open Heart Surgery backup is available only one week per month. The lab is situated in the metropolitan area of Trinidad’s capital city, Port of Spain. The location is opposite the stadium, where international cricket tournaments are held and a mere 20-minute drive from nearby popular beaches. The hospital is also in the midst of the activity at Carnival time, and this tends to slow things down at the lab a bit, since all access is blocked by streets full of music trucks and thousands of revellers. SICP Questions: Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RICS)? Do staff receive an incentive bonus or raise upon passing the exam? No. Are your clinical and/or managerial team members involved with any professional organisations that support the invasive cardiology service line? The Cath Lab Director is a Fellow of the Society for Cardiovascular Angiography and Interventions. Dr. Ronald E. Henry can be contacted at rhenry@trinidad.net

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