Collaborative Care at Ochsner Cardiac Catheterization Lab
The Ochsner Medical Center has been routinely recognized for their heart program, as an example of how drawing on the experiences and expertise of members of the heart team can lead to better outcomes for patients in the cath lab. In this edition of "Cath Lab Profile," CSWN: Interventions speaks with Stephen R. Ramee, MD, medical director of the Structural and Valvular Heart Disease Programs at Ochsner Medical Center, and John Reilly, MD, current associate director of the cath lab. Dr. Ramee is also Chair of the ACC's Interventional Section Leadership Council.
Can you describe the cath lab—number and type of rooms, specialized personnel?
John Reilly, MD: At Ochsner, we have four cath labs, which are equipped for both coronary and peripheral interventions, and one of those four is a biplane lab. We also have a procedure rom that our heart center team uses for biopsy and right heart caths, and a sixth room which is not a full-on cath lab but contains stand-alone imaging equipment. Each cath lab room is equipped with several types of imaging modalities, including intravascular ultrasound, transesophageal echo, intracardiac echo, and fractional flow reserve.
We currently have five or six nurses and about nine technologists in total. For each case, we staff the cath rooms with two technologists scrubbed, two technologists non-scrubbed—one of whom is at the monitor recording the procedure, the other is in the room helping us at the table—and a nurse.
There is a hybrid suite in the operating room on the floor immediately below us, and this is where we perform TAVR for patients who cannot undergo the percutaneous approach. Here, we frequently use fractional flow reserve and the tables have pressure wires built into the table.
Stephen R. Ramee, MD: While we have an operating hybrid suite, we perform most of our procedures in our cath labs, including all of our transfemoral TAVRs, all of our coronary procedures, all of our peripheral procedures. The hybrid suite is probably used one day a month for TAVRs. The operative TAVRs, or what we call "alternative access" TAVRs, all require surgical access, which can include going through either a thoracotomy (chest wall incision) or a transaxillary cut down. These types of TAVRs are performed in the operating room because are led by the surgeons.
How does your cath lab incorporate new technologies and devices, or implement new programs?
Dr. Ramee: In general, every program starts small. At the beginning of implementation, these programs receive a limited amount of resources, and we add to that as the program grows and as we identify certain areas that would benefit from more extensive resources.
Our TAVR program, as an example, has grown significantly: at the beginning, we performed one TAVR per month—this was when the Food and Drug Administration placed a cap on the number of TAVR procedures we could perform. Now, however, we perform five or six per week. We are also actively working to streamline the TAVR program. This includes, for instance, using deep sedation rather than general anesthesia during procedures; by doing so, we eliminate the need for intubating and extubating the patients. We can easily perform two TAVR procedures per day in the one room that we have.
What kind of special training considerations are there when implementing new programs?
Dr. Reilly: Typically, a physician will identify or champion a new technology or practice that we should incorporate into our practice—whether that's doing radial access procedures or TAVR. Then, as a group, we discuss whether we agree to support it. With TAVR, for instance, we will select usually two physicians to lead the TAVR team who will perform all of the TAVR procedures and really be the "go-to" for TAVR. For each specialized procedure team, we also identify dedicated technologists, as opposed to having a different technologist with every TAVR case. This is also true for nurses; when there are special clinical considerations for caring for patients depending on the procedure, the nurses will be proactively educated in that area.
There is also a standardized approach for incorporating new members into the team—they're not just "thrown to the wolves," so to speak. New personnel will spend time in an orientation period, which typically lasts six weeks, before coming to the cath lab, under a more experienced operators' guidance. From there, they will take some cases by themselves, initially with two nurses or an extra technologist on call who will decide if the newer members are up to speed in that kind of more urgent situation.
With this kind of direct observation, there are also a lot of opportunities for feedback and review. Staff members meet with the physician cath lab director before progressing to the next stage of responsibility, for instance. It's not necessarily a "one-size-fits-all" method; some people may take a little bit longer to catch on or may catch on more quickly.
How do you measure staff competency once the program is put in place?
Dr. Ramee: Honestly, because there is one team performing these specialized procedures, there is not a real need to measure competency because we work closely together on every case. With TAVR, specifically, it is the same team every time—with one or two sort of "second-string" people who may come into play when the "first-string" technologists, nurses, and interventionists are unavailable.
What measures are in place to ensure the safety of patients and cath lab staff?
Dr. Reilly: One of the biggest concerns in any cath lab is radiation safety. At Ochsner, there is, of course, a radiation physicist in charge of the equipment; they also receive reports about patient and staff radiation exposure and are responsible for changing patients' badges. We have a lot of communication about radiation safety throughout the hospital, and on those rare occasions where we exceed the monthly limit, we get letters and are reminded of ways to achieve better dose reduction.
Reducing door-to-balloon times is also a priority for us. We have a standing committee that consists of a member of our cath lab physician staff, a member of the emergency department staff, a representative from the emergency department nursing staff. We meet at least quarterly—closer to every two months—to discuss door-to-balloon times, including identifying cases where we did really well and how we can encourage those best practices, as well as identifying cases where we could have improved.
Have you noticed any recent changes or trends in your patient population, or in terms of which types of procedures you are performing?
Dr. Reilly: Actually, the volume of coronary interventions that we perform has been a bit flat recently, while the numbers of peripheral interventions have been increasing. About 40% of the procedures performed in our cath lab are non-cardiac. These higher rates can be attributed to the work of my senior partners—Dr. Ramee, Christopher White, Tyrone Collins—who have done a great job educating other cardiologists about the importance of peripheral arterial disease in our cardiac patients. This is an area of frequent overlap, and one we feel we should definitely be involved in; so much so that all of our cath lab rooms are equipped to handle both peripheral and coronary cases.
Our radial access numbers have experienced a similar tapering off; two years ago there was a higher rate of radial access, exceeding 50%, but now we are closer to 40%. I would attribute this to the fact that our fellows expressed concern about the imbalance between femoral and radial access procedures. Also, a drop-off was to be expected because our numbers were so high a couple of years ago.
There is a quite a variety in our case mix here, and I think that would be something our cath lab staff enjoy. It's not just the same old thing every time—one of our cardiologists is coming in to do a coronary case, but the next case may be a patient with a structural heart problem, or a vascular surgeon will perform a renal angiogram. So, the job is always challenging.
Our cath lab staff really excels, and that means anticipating the patient's needs, recording things properly, and making suggestions or anticipating what your next move will be. This is particularly impressive when you consider the broad spectrum of procedures that we perform at Ochsner—ranging from TAVR to atrial appendage closure to complex pediatric valvular treatments. Even though we have individual, specialized teams, having that broad range of procedures also helps our team members stay current and engaged.
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