The Cath Lab That Could: Children`s National Medical Center Implements Medcon`s TCS System

A 137-year-old center dedicated to meeting the full medical needs of children and adults suffering from congenital diseases, CNMC provides programs varying from well-baby visits to treatments for cancer and heart problems. The center has a 279-bed main campus with 17 affiliated regional outpatient facilities. Our cath lab is the only fully dedicated pediatric and congenital lab in the region. It performs about 350 catheterizations annually and patients come from all over the world. CNMC also participates in multiple, new intra-cardiac device clinical trials. From Analog to Digital: Eliminating Bottlenecks Before new labs and the TCS system were installed in 2002, CNMC had a single analog cath lab. It was used for everything, including diagnostic and interventional caths, electrophysiology (EP) procedures and interventions, and a range of related special radiology procedures. There was no database for angiograms and the amount of resources required for the analog film development, splicing, and storage was staggering. In 2002, the CNMC built a new, 7,500-square-foot wing to house two new bi-plane invasive procedure rooms from Siemens (Malvern, PA). One is used full-time for diagnostic and interventional cardiac catheterization, including intracardiac echo. The second room is primarily used for EP and for special radiology procedures that include cerebral angiography and interventional neuroradiology. When the lab opened, we implemented the TCS system for the first time in our hospital. The Diverse & Complex Needs of Pediatric Imaging Although this project was the hospital’s first serious foray into digital imaging environment, over the years, I had opportunities to try systems from most major manufacturers. Based on these experiences, I had a sense of which systems were particularly suited to the demands of pediatric and congenital cardiac procedures. Unlike a conventional cath lab that typically focuses on coronary artery imaging, pediatric and adult congenital cardiac imaging is far more diverse and involves more complex variety of anatomical structures. Pediatric angiograms are frequently filmed at faster frame rates in order to provide the necessary detail with a child’s faster heartbeat. Due to the average pediatric imaging run being longer and having a much larger file size than those resulting from adult coronary procedures, we needed significantly greater data storage space and conduit bandwidth. Therefore, we had the understanding that the viewing, managing and archiving system that we would choose would handle the large files that are inherent to pediatric and congenital cases. We needed a system that could reliably access and display such large files. Of course, high image quality was an absolute must. Also extremely important was our need for the system to retrieve and transmit data-intensive, high-quality images and information at a rapid speed. Moreover, our cath images are almost exclusively acquired in bi-plane format. A typical bi-plane study with 12 to 16 runs is 550“800MB and poses storage challenges. In addition to generating enormous files, bi-plane images require a system that can display two synchronized images obtained by both cameras simultaneously for side-by-side comparison. For an efficiently functioning cath lab, we also needed a system capable of storing and communicating high-resolution images over network connections throughout the hospital. As congenital images involve more variety and complexity of anatomical anomalies than do conventional cath images, they need to be reviewed and clearly understood by other physicians involved in the care of the patient. Surgeons and others need a comprehensible, detailed rendering of each image. In addition, the selected product had to suit the diverse needs of a whole additional group of users our radiology special procedures room required the importing of digitally subtracted images, as well as 3-D reconstruction. Of primary importance to us was selecting a system that would accommodate a wide range of procedures, equipment and file formats. Most hospitals perform many repetitive adult procedures. Because of the broad range of congenital abnormalities, we perform a diverse range of procedures, but in a much lower volume. For example, neuroradiology requires specialized equipment as well as a specialized format for image viewing and storage. Few systems could accommodate this requirement in addition to our need for digital subtraction angiography (DSA) image management, and we were unable to offset the cost of multiple specialized systems. Along with all our specialized requirements for congenital procedures, we also had a list of IT demands: 1. A system with standards-based open architecture that would accommodate future expansion and upgrades. 2. Reliable connectivity to the hospital’s Intranet, which also links 17 regional outpatient centers. A Considerate Approach And Technology to Get Excited About Not surprisingly, our search lasted more than two years. Along with cardiac cath and radiology teams, I evaluated numerous manufacturers’ technologies through site visits and live demonstrations. At the same time, we worked with biomedical and systems engineers and an IT architect to design a plan for our system. Eventually we narrowed our search down to four manufacturers and examined their systems in depth. Medcon’s TCS system proved able to accommodate our broad range of procedures and users. It had network connectivity which could move large files over both our fiber optic in-house LAN and the hospital intranet. The interface also was a big plus. The software took minimal time to learn and start utilizing. Another key factor was Medcon’s willingness to work with us to customize the system to meet our specific needs. Our facility was the first in the country to install and use Siemens Axiom Artis bi-plane x-ray labs. Since the hook-up to this x-ray system was unprecedented, Medcon’s engineers had to validate the DICOM connectivity in Siemens laboratories in a several-hour long testing sessions that were ultimately successful. It was important to us that Medcon was willing to make this connection. Never did I hear those fateful words: We can’t do that. We acquired ten TCS review stations, which capture images from cardiology and the special procedures room, offer 3-D reconstruction and support image review at multiple locations throughout the hospital system simultaneously. Thus, we now have the ability to handle all of the different procedures and can support the specialized operators: neuroradiologists, interventional radiologists, and electrophysiologists, in addition to interventional cardiologists. Our echocardiograms are stored in a database (Enconcert) limited to the echo lab area only. Currently, the echo studies are stored in a proprietary (non-DICOM) format. When Enconcert is able to support DICOM Q/R, we plan to access the echo cases directly from our TCS system. To work around our at capacity hospital data network, we requested a high-speed fiber optic LAN. Today the images and information are dispensed through a dedicated fiber optic network. They are carried to ten key locations, including the cardiac operating room, PICU, and neonatal ICU, as well as the outpatient clinic and conference center. They are available not only via the LAN, but also through the Internet, in and outside of the hospital. To achieve this, we have implemented Medcon’s MDWeb application. MDWeb is a secure Web publishing software that allows any authorized user to view recent as well as deep archived angiograms and reports by using a standard Web browser. We can access images from ordinary office PCs throughout the hospital and its extensive network of regional outpatient centers. Our archiving needs have been addressed through utilization of a main server and a DVD-R jukebox. Studies can typically be retrieved in 15-30 seconds or less. Happy Staff, Healthy Patients This was a challenging project, and Medcon has been with us every step of the way to overcome hurdles and to fine-tune the system. The cardiac cath department is delighted with the system, and in particular with its image retrieval, transfer, quality, and reliability. Doctors throughout the hospital and at outlying locations can get instant angiograms over the LAN and through the Internet-based application. The MDWeb application has also proven extremely popular and beneficial. All of these system attributes have resulted in the ultimate goal behind this project: improved patient care at CNMC.

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