Optimizing Cath Lab Operation

Today’s cardiac catheterization laboratory must be many things to many people: fast and efficient for cardiologists, user-friendly for nurses and technologists, cost-effective for administrators and, most of all, expeditious and accurate for patients. That’s why the Richard L. Roudebush Veteran’s Administration (VA) Hospital, whose physicians are all current faculty at the Indiana University School of Medicine, sought out a system that would provide finished catheterization reports within minutes of completing a procedure. The Roudebush VA ultimately chose to implement the ProSolv® CardioVascular image and information management solution (ProSolv CardioVascular, a Fujifilm Company, Indianapolis, IN). Back in 2002, the Roudebush VA was a primary beta test site for ProSolv CardioVascular’s cath lab module. It was a stimulus driving development of the cardiac catheterization program at the Roudebush VA; the physicians were looking for something that would allow for easier storage and retrieval of images, an easier way to have a completed report without dictating or typing, and a easy-to-use database for information queries. Working together to develop the cath lab reporting module was a win-win situation. Today, six years later, ProSolv CardioVascular’s solution is a key element of the Roudebush VA Hospital’s cardiology operation. The Roudebush VA is a major cardiac referral center for all services focusing on cardiology, consisting of diagnostic and interventional cath procedures. Referral locations encompass VA facilities at Ft. Wayne and Marion, Indiana, and from nearby Danville, Illinois. The Roudebush VA has two cath labs that perform coronary diagnostic and interventional procedures, as well as electrophysiology procedures. Six full-time physicians perform 2,000 procedures annually. The cardiovascular image and information system (CVIIS) helps keep the cath lab running despite our being inundated with cases on a daily basis. Reports are generated, in final form, before the patient leaves the catheterization suite. At the Roudebush VA, we acquire images using a Philips bi-plane catheterization system (Bothell, WA), which, along with a GE MacLab hemodynamic monitoring system (Waukesha, WI), is networked to the CVIIS system. All information, from images to hemodynamics to balloon pressure recordings to data input by nurses and technologists, is automatically sent to the system as it is received. Demographic information automatically populates the report, and when the nurse or technologist finishes a case and closes the program, all data from the catheterization is automatically sent to the ProSolv CardioVascular system, where it is, by design, added to the clinical report. With the report 90% complete by the time the procedure is finished, our cardiologists can focus on the analysis of the results and the diagnosis. They can review the images and data, add percent stenosis and recommendations, and finalize the report. Usually these reports are finalized in the control room immediately after a procedure, but they can be generated anywhere in the hospital where the CVIIS resides on a computer terminal, or offsite in the physician’s office. An electronic signature enables immediate transmission of the report to the referring physician or surgeon via a common central hospital information system, or via electronic email to the referring physician. ProSolv CardioVascular also offers the option to purchase an integrated application for the automated analysis of the left ventricle and coronary arteries. This application is designed specifically for cardiac catheterization. The left ventricular analysis (LVA) software package measures LV ejection fraction and volumes, as well as LV wall motion; the software utilizes edge detection techniques, including single plane and standard RAO projection, to enable automated delineation of the left ventricle. The LVA package also offers selectable area length, user-defined regression equations and distance measurements up to 16 calipers, in addition to other functionalities. The system also has quantitative coronary analysis (QCA) software that assesses the severity of coronary narrowing and allows for correlation with other diagnostic modalities. Its calibration routines allow expression of vessel dimensions in absolute terms; results are based on geometrical and densitometrical analyses, and can be reported in tables or graphs. Other QCA features include automated arterial contour detection and computer-defined references. Both software packages support 1024x1024 images. The physicians currently use these options only for clinical investigations where they are required; quantitative analysis is not a requirement at this time. Fortunately, we had the option to purchase these applications only as needed. While we don’t use them on a routine basis, we did realize the benefit of participating in clinical trials when the opportunity arises, which was ultimately why we decided to purchase the advanced analysis applications. In the future, we hope to bring the ProSolv CardioVascular catheterization module to Clarian Health Partners as well, but that decision likely won’t be made until 2009. Clarian Health Partners, ranked in the top 25 connected healthcare facilities by Health Imaging & IT for 2008, is now also looking to replace its cath lab information system. The Clarian network encompasses the Indiana University School of Medicine, which the Roudebush VA has an active affiliation with due to its position as a teaching hospital. Clarian currently performs around 3,500 diagnostic cardiac catheterizations and around 1,800 interventions annually. And those numbers are constantly growing at a rate of 7% annually. In the larger Clarian system, both Philips and Siemens catheterization labs are in use, making vendor neutrality crucial. The ProSolv CardioVascular solution is built on an open database that enables it to communicate with any vendor’s equipment, and it supports all our cardiology modalities in addition to x-ray, from nuclear to CT and MR. The system is built on industry standards DICOM, HL7 and IHE. Coupled with the fact that ProSolv CardioVascular is hardware-neutral, this means it can be seamlessly integrated into our existing infrastructure, including the hospital information system in place. Additionally, the platform is easily modifiable, meaning we can have customized reports. Equally efficient is the system’s treatment of clinical priors. Before, cases generated at the Roudebush VA were recorded to DVDs, which were subsequently filed in a file room; access to priors necessitated physically going to the file library and pulling the right disc. Now we have archived images, along with the associated reports, and they can be viewed from any computer with web access. The images are crisp and clear, and can be frozen, panned and otherwise enhanced for comparison. Additionally, if a patient has had a diagnostic catheterization in the past and none of his or her information has changed, we can automatically populate the new report with the appropriate information from the old one. Since the system is online, we have the ability to streamline collaboration. If a patient’s cardiac catheterization reveals three-vessel coronary disease requiring immediate surgery, the surgeon can call up the application from his office and consult with the cardiologist via telephone. That’s more efficient than the previous method of consultation, which involved the surgeon running down to the catheterization lab to check out the images — a distance of a couple of thousand yards in a best-case scenario. Meanwhile, our referring physicians can receive completed and signed reports (via either e-mail or fax, depending on their preference) with the push of a button from cardiologists, and electronic reports can also include moving images. Because the system automatically builds a database from the information generated by each report, and because the reports are standardized irrespective of the cardiologist who created them, the platform can be leveraged for fast, cost-effective QA. Another critical component for us has been the ability to track key information to allow administration to make informed business decisions. How many cases has a physician performed in the past year? How many cases were successful, and how many led to complications? What percentage of patients received bare-metal versus drug-eluting stents? The system can aggregate specific data elements and send them anywhere, or can be used for internal benchmarking. Monthly reports can be generated based on an array of metrics, enabling staff meetings targeted specifically at topics like morbidity and mortality. The VA has used this feature in tracking its door-to-balloon time after initiating a primary PCI program for ST-elevation myocardial infarction. For all non-VA hospitals, interaction with the American College of Cardiology’s National Cardiovascular Database Registry (ACC-NCDR) or other registries of its kind has become a necessity. Many hospitals employ two or more full-time equivalents (FTEs) to pull this data and send it to organizations like the ACC. ProSolv CardioVascular is ACC-NCDR-certified; the system enables automatic transmission of the requisite information. Data can even be filtered according to physician group, enabling benchmarking against ACC standards on a more individualized basis. While we don’t utilize this benefit at the Roudebush VA, it will likely be something that we’ll examine further when evaluating systems for use at Clarion. The learning curve for the system was short; very little memorization is required. Additionally, the workflow is the same across different modalities. Cardiologists can learn a single workflow on a single system, and begin reading across multiple modalities on the system. The Richard L. Roudebush Veteran’s Administration Hospital is a teaching affiliate for the Indiana University School of Medicine. Cardiology fellows traditionally do most of the work when it comes to generating the reports for cath cases. But cardiac catheterization is such a breeze with our system that our cardiologists don’t mind doing the reports themselves; some, like me, even enjoy it, because it is simple, easy and quick to complete. Dr. Breall can be contacted at jbreall@iupui.edu.

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