Vascular Conference: a Multi-discipline Approach to Improved Communication and Patient Outcomes

Imagine a meeting of cardiologists, radiologists, surgeons and internal medicine physicians engaged in conversation about their patients and treatment options, with occasional input from nurses, radiology, ultrasound, echo, and cath lab technologists. At Bon Secours Venice Hospital (BSVH), this type of collaboration is a reality, and is known as the Vascular Conference. Over the years, technological advances and escalating health care costs have triggered the need to cap expenditures. The increasing cost of health care has given rise to new practice models and payment schemes by the government and health care insurance companies. Reimbursement for this care has been reduced, causing physicians to become more competitive. The skills and expertise of cardiologists, radiologists and surgeons overlap each other’s specialties, resulting in physicians everywhere crossing each other’s boundaries, which triggers competition and turf battles. The Beginning The vascular conference at Bon Secours Venice Hospital is the vision of a vascular surgeon, Dr. Sidney Holec. When asked what prompted him to begin the conference, Dr. Holec responded, While in training, we had a mortality and morbidity conference with multiple disciplines. It was an open forum. I felt this could be applied to Bon Secours Venice Hospital. It is a way to discuss complex cases, exchange ideas and involve nurses and technologists.

"I find the conference very informative. We see one patient case presentation and three perspectives (surgical, radiology and cardiology). I am able to get to know the physicians. It also keeps me informed about new modalities and treatment options." Maria Falbo, RT, RDMS, RDCS, RVT

Planning for the vascular conference began with a discussion between Dr. Holec, his surgical group and Dr. Sergio Luis Selva, an interventional radiologist. Their goals were to improve communication between physicians; share information about their specialties; and to develop plans to provide better treatment and options to patients. With the help of Linda Meunier RN, BSN, a certified radiology nurse, the vision became reality. The initial conference was held in April 2000 with surgeons, interventional radiologists, nurses and several technologists. After several conferences, cardiologists were invited to participate, since cardiologists were crossing the boundaries as well. Interest in the conference grew as surgeons, cardiologists and radiologists shared expertise, knowledge and skills. They began working together, discussing difficult and complex cases, seeking their peer’s opinions, and assisting each other. Staff also began looking forward to the conferences. The Vascular Conference The meetings take place in the hospital auditorium on the first and third Wednesday of each month. Linda Meunier, the conference coordinator, schedules cases for presentation and obtains and coordinates the data necessary for radiology and ultrasound cases. Sharon Haines RN, RCIS, coordinates cardiac cath lab data. Various media modalities are utilized. The cardiac cath lab is equipped with the GE Innova 2000 (Waukesha, WI). Procedures are transferred to CD-ROM and projected on a large screen for viewing. The cardiovascular ultrasound department utilizes GE and Philips ultrasound machines for recording transesophageal echocardiograms (TEE), echocardiograms and vascular studies via VHS tapes. The interventional radiology department enhances cut film with digital subtraction during their angiography and intervention cases. Digital subtraction enhances the images and provides excellent visualization of the vessels. MR angiography and CT angiography provides another dimension in diagnosis. The vascular conference also informs the staff of advances in technology at BSVH which have improved and enhanced patient diagnosis and treatment. The vascular conference begins with the primary or attending physician presenting a patient’s history. As each physician becomes involved in a case, they discuss the role each has had in diagnosis and testing. The dialog and results presented provide the audience a complete picture. A physician may ask peers for their expert opinion or discuss what procedure he performed and why. Questions and suggestions are welcome and encouraged. The discussions result in a sharing of knowledge and expertise, enhanced working relationships and, most importantly, improved patient care with more positive outcomes. Presently we have one interventional cardiologist who performs peripheral intervention. It is interesting to observe him interact with the surgeons and interventional radiologists. Expression of opinions and approaches are highly encouraged. Laughter occasionally ensues as opinions vary according to the physician’s field of expertise. Nurses and technologists are also encouraged to participate. Gary Dennis RN, who works in the cardiac cath lab, recently provided information assuring patients without financial resources a means to obtain their prescription for Plavix.

"A conference such as this helps to improve communication between disciplines, decrease turf battles and most importantly, improve quality of care for patients. The conference has increased awareness among all of us about the value of non- invasive diagnostic tests for patients with vascular disease. The improvement of MR angiography and the 16-channels CT scanner is superb and raises the level of noninvasive diagnoses." Cardiologist Dr. William J. Corin

Communication Increases The conference has opened many doors of communication. Several years ago during a radiology staffing shortage, the cardiac cath lab staff assisted during radiology procedures. Each staff member was able to learn from each other and had a greater appreciation and perspective regarding the other’s skills and equipment. Also during this time, as the cardiac cath lab manager, I observed an opportunity to reduce expenses and supplies. Three departments (radiology, cardiology and surgery) were stocking many of the same sheaths, wires, catheters and stents. A consignment agreement with Cordis was achieved. These three areas now profit from a shared stock, decreased cost and duplication of supplies, efforts and manpower. The conference has also allowed coders to gain a better understanding of dictated cases, thus allowing for proper coding and reimbursement. The conference allows a discussion of complex cases, making it easier for coding and helping us (the hospital) receive proper reimbursement, notes Nilda Clark, LPN, coding manager. The first implanted AAA stent was a joint venture between surgeons and interventional radiologists in the operating room. Nilda was able to provide data about reimbursement for this venture.

"The conferences allow us to come to the table with different skills, thus allowing one to integrate skills into options and to see the broader picture." Dr. Michael A. Basnight, an interventional cardiologist who also performs peripheral interventions. Dr. Basnight has been involved in the vascular conferences from the very beginning.

New and Emerging Technologies Our vascular conference also provides a forum for discussing new and emerging technologies. These technologies better evaluate vascular disease in the least invasive way and use the newest technology available, including recent developments such as MR angiography and CT angiography. The conference also showcases new endovascular solutions to complex problems. The radiologists have recently acquired the Toshiba 16-channel CT scanner that provides instantaneous sagittal and coronal reconstruction at 1mm intervals. It allows greater imagery in vessels from head to lower extremity. Attendees were quite impressed and awed when Dr. Selva presented these new modality images. The cardiovascular ultrasound department showcased their newest technology with the purchase of the Philips Sonos 7500. Echos will be done via 3D Live. The detail with these newest modalities is just unbelievable. Diagnosis has been taken to another level. On July 7, 2003, BSVH launched our Regional Heart Center. The cardiovascular surgeons and interventional cardiologists were welcomed into the conference group. We now perform percutaneous coronary intervention (PCI) in the cardiac cath lab. Recently, an interventional cardiologist new to our hospital was encouraged to present a case in which he was involved. Fellow cardiologists and cardiovascular surgeons offered their expert opinion. The interventional cardiologist, Dr. James J. Fox, said, I didn’t know this conference was so well-received or I would have been here sooner. Dr. Fox sees the conference as a unique, well-suited program to facilitate an interdisciplinary approach of patient care. It provides a source of teamwork and leadership which is important to develop. Patients, Physicians and Staff Members Benefit Recently a vascular surgeon presented a case in which he was involved. He asked his colleagues how they would approach the case, which probably would need a cardiac evaluation and intervention. A cardiologist and cardiovascular surgeon each offered their expert opinion. The surgeon stated the patient had an appointment with him that afternoon and now he felt he could offer her options. Respect for a fellow physician was evident during a recent conference. Dr. Michael J. Carmichael, cardiovascular surgeon, acknowledged and thanked an interventional radiologist because he approaches his cases from the opposite side when possible. This allows for a clean case in the event the patient needs surgery. Another result of discussing cases is that surgeons and radiologists now incorporate Lovenox, Plavix and low-dose heparin infusions in their treatment. Rachel Chambers, RD, LD, a hospital employee, was a particularly unique beneficiary of our vascular conference. Rachel was training for a triathlon when she developed swelling in her right upper arm. Her attending physician presented her history, diagnosis and initial treatments at the conference. Her vascular ultrasound was viewed and a discussion followed. Causes for the thrombosis and treatment options were discussed. It was a unique conference where the patient was actually present. We were able to obtain input from her and she in turn asked questions. Rachel commented, I appreciated the multi-discipline input and the high-tech view of the scan on the large screen. It was nice to have the technologists there who performed my scan offer their input. Rachel was able to compete in a triathlon in Spain several months later, placing fourth in her age category. She has had a repeat scan, which showed no evidence of the thrombosis, and she continues to train. (Permission for disclosure provided by Rachel Chambers)

"It is not unusual to have a patient with a difficult case presented by one section and another section has a solution. This ensures the best overall patient care and the patient benefits from many doctors’ ideas and a variety of perspectives. It is like having multiple second opinions in one setting." Interventional radiologist Dr. Sergio Luis Selva

Educational Benefit Recognized It was recommended that CMEs and CEUs be awarded for attending the conferences. Since August 2001, Linda Meunier has submitted paperwork for awarding CMEs and CEUs to physicians, nurses, ultrasound and radiology technologists. From a nursing perspective, the conference helps keep us abreast of new technology, and new approaches to treatment. It keeps communication open between all disciplines, allows a sharing of ideas and improved patient care and outcomes, which is our ultimate goal. As a result of collegiality and good communication, our annual Legs for Life is a huge success every year. Legs For Life® is national screening program for peripheral vascular disease (PVD) dedicated to improving the cardiovascular health of the community. This year, a cardiovascular surgeon joined the team of radiologists and surgeons working side-by-side to ensure the results were evaluated and patients advised of problems if any were discovered. Despite being a small community hospital, we feel BSVH has accomplished great things as a result of our vascular conference. Our ultimate goal continues to be improved patient care and outcomes.

"In a time of increased competition among specialties, our conference breaks down barriers of perceived mistrust, to the ultimate benefit of the patients we treat." Interventional radiologist Dr. Chuck S. Gordon

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