Five Years of Elective PCI in a Rural Community at Green Clinic Surgical Hospital

A small cath lab has a big impact in Louisiana

Green Clinic Surgical Hospital is an acute care hospital with ten inpatient beds, located in northern Louisiana in the heart of Ruston, which is home to Louisiana Tech University. The hospital opened its diagnostic cath lab in October 2003, and first began performing elective percutaneous coronary interventions (PCIs) in April 2004. The hospital contains one cardiac catheterization lab that performs elective heart catheterizations, temporary and permanent cardiac pacemaker implants, cardioversions, elective coronary stent placement (both bare metal and drug-eluting, and on occasion, emergency percutaneous transluminal coronary angioplasty (PTCA)/stent placement is performed). The same suite is also used to perform diagnostic and interventional radiology/special procedures, and therapeutic bronchoscopy. The Green Clinic cath lab has 4 staff, with 2 cardiologists, 1 cardiac interventionalist, 3 vascular surgeons and 1 pulmonologist utilizing our lab. Our staff includes two registered nurses (RNs), one radiology technologist and one certified cardiographic technician (CCT), totaling 46 years of cath lab experience. Each member is cross-trained within the scope of practice relating to their specific credentials. All staff perform three roles (circulate, monitor and scrub) with the exception that only RNs administer medications. It was important to the city of Ruston to establish an environment successful in performing elective percutaneous coronary interventions (PCIs) because of the large area of small communities served by the hospital. As a result, there is a huge geographical area that now has access to diagnostic, and more importantly, elective interventional procedures that otherwise would have had to be performed at a center located at least 45 minutes away from most patients’ homes. This is an enormous relief for patients, as well as their families, as it is often a burden for families to be able to travel back and forth to larger facilities. Our hospital is fortunate in that we are the only one in the area performing elective PCIs. Currently we have a cardiac interventionalist, Dr. James F. Smith, who performs elective PCIs once a week. Throughout the rest of the week, Dr. William C. Smith and Dr. George B. Smith routinely perform diagnostic heart catheterizations. With the findings of these diagnostic procedures, both cardiologists view the results of the tests. Films are then sent via the PACS Philips system to the interventionalist. It is from these reviewed films/findings that we are able to schedule the elective PCIs for the upcoming week. On occasion, we have received patients requiring emergent stenting, which is performed by our cardiologists on staff with excellent results. During the course of planning our interventional program, there was a great deal of collaboration between the cath lab, the cardiovascular surgeon, and the cardiac interventionalists and their staff in order to provide easy access to cardiovascular surgery in the event of unsuccessful outcomes necessitating emergent surgery requiring revascularization. It required a great deal of planning, forming appropriate protocols and rehearsals of emergent transfer. During all elective PCI procedures, Dr. Keith White and Dr. Blaine Borders with Saint Francis Medical Center in Monroe, Louisiana (34 miles away), provide surgical backup. On the day of scheduled PCIs, Pafford Ambulance Service is on standby for emergent transfer to Saint Francis Medical Center if needed. Since opening the hospital in October 2003, we have performed over 2,000 diagnostic procedures in the lab. Approximately 67% were normal, 3% required coronary artery bypass graft (CABG) surgery and 30% required a stent. Since starting elective PCIs in April 2004, we have performed approximately 450 PCI procedures. At present, we have not had a patient needing to undergo emergent CABG as a result of a failed stent or complications thereof. In addition to our invasive and interventional cardiology procedures, peripheral vascular angiography and interventions are also done in the same lab. Dr. Derek McClusky, Dr. Jeb Butler, and Dr. Kerry Byrnes perform procedures which include aortography, renal arteriography, peripheral arteriography, peripheral stenting and fistulograms. As the treatment of vascular disease progresses to more percutaneous interventions, it is clear that small institutions with active vascular labs and well-trained professionals can play a major role in the treatment of patients in small, rural communities where patients do not have easy access to major academic institutions. This can be done with excellent outcomes, and improve the vascular health of the aging population. As of April 2009, we have had a less than 1% bleeding complication rate resulting from closure problems. We currently use Perclose (Abbott Vascular, Redwood City, CA), Angio-Seal (St. Jude Medical, Minnetonka, MN) and FemoStop (Radi-Medical Systems, Inc., Wilmington, MA). Approximately 75% of patients receive Angio-Seal, 20% receive Perclose, and 5% receive manual pressure. Patients are transferred back to their pre-op bed after the recovery room stay if they are being discharged. If the patient is being admitted, they are most commonly transferred to the PCU. Our cath lab is unique in that our staff does pre-admission testing/ interviews on all patients. We also do same-day admit to recovery or our PCU post procedure. The staff is very dedicated to the patients and to outcomes. They try to follow patients from pre-admission testing to procedure, recovery and then to discharge. All PCI patients as well as the new pacemaker battery implants are followed on the floors each hospital day for post-procedure teaching and discharge instructions. As a small community, acute care, hospital-based lab, it is an ongoing process to educate the community that a smaller institution can deliver state-of-the-art care. We maintain a high level of patient care and continue to surpass benchmarks like maintaining and monitoring low complication rates, and overall patient satisfaction, through hard work, dedication and focus on the basics, as well as advanced techniques. Photos courtesy of Dean Kirby, MD. Jenni Smith can be contacted at: jennilu63@yahoo.com. More information about Green Clinic Surgical Hospital is available at www.green-clinic.com

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