The Changing Face of the Cath Lab

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 Allura Xper from Philips Healthcare is in use at the brand new Seton Medical Center Williamson in Round Rock, Texas.

Digitized, streamlined information systems in the cardiac catheterization lab drive efficiency, healthcare quality and patient safety. At a time when more and more specialists are using cath lab facilities for a wider range of procedures, electronic data helps facilities get the most out of their equipment investment.


Managing competition



Seton Medical Center Williamson (SMCW) in Round Rock, Texas, just opened in February with technology no one else in town has, according to Julia Davis, RN, a cath lab manager. That includes the Allura Xper FD20/10, the Allura Xper FD10/10 with the Allura 3D-CA interventional tool and Allura 3D-RA interventional tool from Philips Healthcare. The equipment allows for a single contrast injection and rotational images. The ability to view all coronaries with one shot lets the clinicians use less contrast. “Contrast-induced nephropathy is held off greatly. That’s a tremendous aspect,” she says.

Another plus for the new facility is full electronic charting and an Xcelera archiving system that lets any physician pull up any study done within the network. The system is “a great electronic tool,” Davis says, that lets doctors review studies with patients. With ADT and HL7 interfaces, reports for registered patients can be autopopulated, reducing clerical errors and physician time spent creating the report. Those reports interface to the main registration center. Physicians can dictate or write reports on the fly and include images, all of which automatically go into the patient’s medical record.

More and more endovascular work is being performed in the cath lab, Davis says, so “the reality is that everything needs to be kept as one chart—the whole vasculature.” There is less distinction between cardiology and radiology, for example, if the peripheral arteries in the leg are examined. So, the latest systems serve as one big repository for patients’ vasculatory studies.


Integration for enhanced workflow


Stephen Green, MD, associate director of the cardiac catheterization lab at North Shore University Hospital (NSUH) in Manhasset, N.Y., has been using a digital cath lab for the past eight years. Over the years, the facility has continued to install new labs in addition to upgrading old labs with digital technology for a total of eight digital cath labs today. Green uses a selection of Inova large-format, flat-panel x-ray systems for angiographic imaging, Inova 3131 IQ Biplane imaging system and the OEC 9900 Elite, all from GE Healthcare.

Successful cath labs need more than digital imaging systems, he says. “The more you integrate your systems, the easier it is for workflow, and if workflow is enhanced, physicians are more likely to bring their patients.” NSUH performs about 14,000 cath lab procedures a year in the busy geographic area of Long Island, where 3 million residents have nine facilities to choose from. Competition is fierce.

Information systems let users pull demographic, insurance and other key patient and operational information into the labs and move it to report-generating systems. The EMR demographic data from the hospital system is interfaced with Mac-Lab, also from GE,  for the initial demographic data. Further data entry occurs in Mac-Lab throughout the case. The data are downloaded during and after the procedure to GE Centricity, which then has the demographic data from Invision, as well as cath lab data from Mac-Lab. The physician simply completes the final components of the study from pull-down menus. There is ample ability to text additional data in all segments of the report, but generally that is not required. “We can shift data from system to system effortlessly and in the background. It’s a very efficient way of doing things,” Green says.

With 15 hospitals in the NSUH system, each has a different grouping of information systems. The PACS currently are not integrated. “That is something we will be attempting with most of the system hospitals,” he says. All have Mac-Lab and all but one will eventually get Centricity. One community hospital, with their independent hospital IT group, elected to go with McKesson for all of their IS needs. The rest of the hospitals go through a VPN account to view their images.

“It’s harder to integrate 15 hospitals efficiently and cost-effectively. So, going to electronic medical records is our biggest goal right now.” Green anticipates that the six system hospitals that do cath lab procedures will be integrated and physicians will be able to view reports and images from any network hospital. “Integration just keeps getting better and better, which is great for patient safety. When someone comes into the hospital, you don’t have to guess about their history. You can look up a report which helps healthcare quality and improves efficiency. There’s a lot to be gained from that.” Green says that, in his experience, most hospitals do not have digitized, streamlined information and report-generating systems.


Stretching equipment


With cath lab procedures on the decline, “decision-makers might incorrectly decide ‘we don’t need a cath lab or we might delay upgrades,’” says Ronald P. Karlsberg, MD, clinical professor of Medicine at the David Geffen School of Medicine, University of California-Los Angeles and a cardiologist with Cardiovascular Medical Group of Southern California. “That’s the wrong question. The question is, ‘how do we purchase equipment that is multifunctional and still maintain the highest standards?’” The challenge is considering the resource requirements of the entire institution and blending them into a single unit. With special procedure rooms and other expanded capabilities, it’s a glass half-full, half-empty situation. “There’s potentially an expanded market,” he adds, providing one takes the higher view of the entire institution.

Karlsberg, who is also director of the of the Cardiac Diagnostic and Interventional Center at Brotman Medical Center in Los Angeles, has invested time and effort in enhancing equipment utilization. Cath lab procedure volume is on the decline in most areas of the country and while coronary angiography, angioplasty, and stenting are the mainstays of the cath lab, there is opportunity to expand. 

Vascular surgeons, interventional radiologists and other subspecialists have become more interested in looking at peripheral vascular disease, carotid disease, and other diseases, Green says. To that end, NSUH installed an initial large-format digital flat-panel, as well several small and medium-sized solutions. This equipment range provides greater flexibility since the smallest systems work well with cardiology procedures, larger systems accommodate peripheral work; and the intermediate sizes serve a multipurpose function, such as for neurological and carotid procedures, as well as leg, coronary, and renal work.

Karlsberg’s solution is an open lab that allows cardiologists, vascular surgeons, neuroradiologists, interventional radiologists, gastroenterologists and peripheral vascular surgeons to all share the same work space. Who will be using the equipment is a very important consideration when designing a cath lab, he says. “The majority of hospitals will need to consider having multi-functional cath labs which service not only the coronary arteries, but the peripheral and carotid arteries, electrophysiology neuroradiology, renal services (especially the maintenance of dialysis shunts) and other subspecialty needs.”

 
Quality and safety


Aside from wider range of use, newer equipment helps clinicians be more precise than ever, says Davis. For example, a rotational angiogram “gives us the equivalent of 16-slice CT overlay images. We can send them to a physician in surgery and tell him the exact slice of the aneurysm. Taking the digital technology of multiaxial modality readings into the surgery suite with the patient is tremendous.”

Another big concern, says Davis, is dye consumption. “It’s one of the biggest safety issues.” Her facility uses Philips’ StentBoost which helps pinpoint stent implantation and therefore reduces contrast needs. Davis has used the tool in other labs and says it allows for better stent placement. During her 30 years in healthcare, Davis says she’s seen fluoroscopy time decrease from 60 minutes to no more than 25 minutes. “There’s been such an evolution and [radiation reduction techniques] are being developed more and more.”

Greater scrutiny of care standards as well as insurance coverage changes have led to a change in the condition of patients arriving in cath labs, Karlsberg says. “Patients getting to cath labs now are in greater need of intervention and are potentially sicker than before and have already failed medical management. Workflow becomes increasingly important.”

Noninvasive coronary imaging with cardiac CT (64 slice or greater) and the Courage trial, which addresses the issue of medical therapy for some patients instead of primary stenting, is already associated with reduced volume in laboratories across the country. So, “it’s increasingly important, when designing and planning, to have flexible, reliable equipment that will accommodate a multi-functional lab and the ever-changing approach to the diagnosis and treatment of the cardiac patient.”

 However, percutaneous coronary intervention remains absolutely proven to be the best treatment for acute myocardial infarction, Karlsberg says. That raises the level of reliability for cath labs—they need to be read and available 24 hours a day and within minutes.

“Cardiac CT is a force that needs to be considered in reducing diagnostic volume and improved medical approaches challenges intervention,” Karlsberg says, so cath labs need to be a more versatile workplace. And hospitals should consider an open policy in the lab that maintains volume by cooperating with the specialties that may benefit from a well-planned lab. “Many patients do not need to go to the cath lab when you can image their coronary arteries with cardiac CT. We solved the problem of designing a flexible lab with the Toshiba Dual Plane DP-i which enables one lab to perform like two.” One C-arm has an 8 X 8 inch imaging chain optimized for cardiac work and the other C-arm, which can be exchanged in seconds, is 12 X 16 inches optimized for work outside of the heart, such as the carotids, renals and legs.


Ongoing advances


Karlsberg also uses Advanced Image Processing from Toshiba to upgrade an older lab. “Because of the ability to image coronary arteries outside of the cath lab, cath labs will need to be increasingly fine-tuned for performing [non-traditional] interventions, and upgrades should be routinely considered,” he says. Often, the coronary anatomy is known, but complex stenting increases imaging demands. “Most systems have to be set up to adjust for arms, legs, even the brain and the abdominal vasculature.” The Toshiba Duel System DP-i Infinix can change image intensifiers during a case whenever needed so optimal imaging is always available.

Another technological advancement for the cath lab is development of fifth access, Karlsberg says. “Fifth access as available from the Toshiba CF-i/SP Infinix allows you to take radiographic equipment down to the toes or hands. No matter what angle you set the C-arm at, up is always up, unlike other equipment that may rotate the image at, for example, 45 degrees.”

“Cath labs today are infinitely more flexible than those designed just for cardiac patients,” Karlsberg says. Now interventional cardiologists can replace aortic and mitral valves and even perform procedures to treat aortic aneurysms previously treated with invasive surgery, among other newer procedures.

Ongoing advances can be an obstacle when purchasing for a cath lab, Davis says. She advises that you arrange for an inclusive package for software upgrades and, since lead time can be up to six months, make sure your vendor contract allows for inclusions of upgrades available since your time of purchase.