No Surgical Backup On Site: Orange Park Medical Center Moves from Diagnostic to STEMI Care and Beyond

Orange Park Medical Center (OPMC/HCA) in Orange Park, Florida, has transitioned its diagnostic-only cardiac cath lab to a fully functional interventional lab. Our cardiac services now include diagnostic catheterizations, interventional percutaneous coronary interventions (PCIs) (scheduled and ST-elevation myocardial infarctions), peripheral angiography with PCI (including limb salvage), and pacemaker and loop recorder implantation. We are currently in the process of acquiring staff and privileges for automatic implantable cardioverter defibrillator (AICD) implants and developing a future carotid stent program. The beginning of our story is unique to our area, but not so nationwide. Orange Park Medical Center is a 252-bed community hospital in Orange Park, Florida. It offers a wide variety of specialty services, including a Healthgrades-awarded 5-star birthing center. Our cardiac services however, i.e. cath lab, had been limited to diagnostic procedures only, due to the lack of surgical backup on the premises and state legislature restrictions. Upon applying for waiver, approval was granted to our 1000+ page application and the waiver granted on October 13, 2008. We were then allowed to perform primary percutaneous interventions on patients experiencing acute ST-elevation myocardial infarctions (STEMIs). The endeavor has become a huge success under the guidance and leadership of Dr. Youssef Al-Saghir, OPMC Medical Director Invasive Cardiology (First Coast Cardiology Institute) and with the support of Dr. Thomas Wolford, interventional cardiologist (Southern Heart Group, P.A.). Our lab has transitioned seamlessly and with the unwavering encouragement and support of our current, forward-thinking CEO, Thomas Pentz. Mr. Pentz has many ambitious goals for our future. He hopes to move our facility to the forefront of our community by growing us into a tertiary care center. These plans include the construction of a cardiothoracic surgery facility to perform “open heart” coronary bypass and other thoracic surgical procedures here on our campus. Although debated and perhaps controversial for hospitals to intervene without surgical backup on site, Orange Park Medical Center was approved for percutaneous interventions. The only caveat being an OR must be reachable emergently within 60 minutes by ground, in a worse-case scenario, or by air, when weather permitting. Our OR coverage is provided through our sister HCA hospital, Memorial Hospital in Jacksonville, FL. It has been proven, time and time again, that the interventional field is at a point with technological advances, operator skills, experience, and proper conservative safety practices, that facilities such as ours and many others around the country can perform these procedures safely and successfully without on-site surgical backup. Our staff includes two original senior staff nurses with an extraordinary in-depth knowledge of invasive cardiology and the facility as a whole. They laid the groundwork and provided stability during this transition from diagnostic to interventional services. The original team included a third member, our charge nurse, who worked days and sometimes sleepless nights pushing this application forward, working hand-in-hand with the cardiopulmonary director and our consultation company. Months before making the transition, the hospital brought four more seasoned interventional cath lab techs and nurses onboard to finish out the team. We were now ready to go live! The story of our very first STEMI could not have been written or executed any better. It began on October 16, 2008, just three days after going “live.” A 54-year-old man from a nearby community arrived in our ED complaining of left arm and abdominal pain. Almost immediately after arrival, the patient decompensated, became lightheaded, and went into cardiopulmonary arrest. CPR was initiated and he was emergently intubated. Upon further examination, the patient was noted to be in ventricular fibrillation, for which he was defibrillated numerous times. The patient continued to flip between VT and sinus bradycardia. The ECG showed ST elevation in the inferolateral leads. With a blood pressure of barely 80, the patient was immediately transported to the cardiac cath lab, where the team was ready and waiting. He arrived on amiodarone, a GP IIb/IIIa inhibitor, and dopamine. A transvenous pacer was floated to the right ventricle, arterial access was achieved, and the coronaries were injected and visualized. The left circumflex was occluded with no collaterals noted. This picture correlated with the ECG changes and it was confirmed to be the culprit vessel. A wire was advanced, the lesion pre-dilated and a 2.75mm x 15mm bare-metal stent was deployed. After TIMI-3 flow was established post intervention, a balloon pump was placed and the patient soon became stabilized. During his 10-day stay, he continued to progress without incident. By the time of discharge, he was alert oriented times three, and ambulating without assistance! The most amazing part of this whole story is that had this patient come to our facility three days prior, he would not have survived. We would never have been able to stabilize him to the point of being transferred to another facility. It was at that point we realized we saved the life of our first and sickest patient. For this to be our first STEMI was amazing. We immediately knew we are going to make a big difference in Orange Park, to all of its residents and nearby communities, and that felt great! Initially, our door-to-balloon time goal was the standard 90 minutes followed across the country, which we have consistently met. We are attempting to shave minutes off by creating more efficient practices and now shoot for 75 minutes, with an ultimate goal of 45 minutes. Obviously, many measures and practices require upgrading and streamlining to make this possible, but we aim high and strive to raise the bar and standard of care at every opportunity. Our one-room cath lab has performed 42 STEMIs since our waiver was approved on October 13, 2008. On January 8, 2009, we finally received our license to perform PCIs on “scheduled” non-STEMI patients as well. To date, we have performed 140+ PCIs collectively. We are happy, proud and excited to be a part of this diagnostic to interventional transition. We prove day after day, patient after patient, that a community hospital with all the necessary tools, educated staff and right attitude, can successfully perform PCIs with or without surgical back up. Everyone at OPMC has done a tremendous job working together and collaborating for the most optimal patient outcomes. We must recognize all of our ED staff, physicians, CCU, step-down, ancillary staff, paramedics and all other members inside and outside of OPMC who have directly or indirectly influenced the success of our new PCI program. A heartfelt thanks to the “wizard” Dr. Youssef Al-Saghir of FCCI, our Medical Director of Interventional Cardiac Services, who envisioned the birth and success of this program. We also want to give a special thanks to the “magic man,” Dr. Thomas Wolford, interventional cardiologist with Southern Heart Group. We express our gratitude to the superb, knowledgeable and dedicated staff in our cath lab including our charge nurse, Bettye Durant, RN; John Messer, RN; Cindy Hess, RN; Whitney Fulgencio, CVT; Caryn Vorster, RN; DeAnna Rewis-McDuffie, CVT; and myself, Paul Trenteseaux, CVT. Finally, we’d like to offer thanks and recognition to all staff members, management, and administration involved in the success of our program. Paul Trenteseaux can be contacted at Paul.Trenteseaux@hcahealthcare.com

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