Spotlight Interview: MD Anderson Cancer Center Cardiac Cath Lab

Tell us about your cath lab.

MD Anderson Cancer Center is the only cancer center that has its own cardiac cath lab. Our work is specifically focused on providing cardiovascular care to cancer patients. A significant percentage of our patients require extensive cardiovascular care in almost all phases of their cancer treatment. Cardiovascular procedures are necessary to evaluate and risk-stratify patients, treat patients with cardiotoxicity during chemotherapy, and ensure their long-term survival after completing therapy.

We have one lab with three registered nurses (RNs) including the manager and one radiologic technologist (RT). Each of us has more than 10 years of experience in the cath lab, with the longest at 16 years, with a combined cath and EP experience of almost 50 years.

What procedures are performed in your cath lab? 

We perform diagnostic catheterizations, endomyocardial biopsy, pericardiocentesis, optical coherence tomography (OCT), fractional flow reserve (FFR) studies, peripheral interventions, and pacemaker and automatic implantable cardioverter defibrillator (AICD) implantations. Outside the acute setting, we perform  FFR-guided percutaneous coronary intervention (PCI); we average about 10-12 diagnostic cases per week. We began doing diagnostic cardiac catheterization in high-risk cancer patients and have progressed to performing OCT and FFR studies, and peripheral interventions. While in the general population thrombocytopenia is a rare occurrence (4:100,000 patients), annually 140,000 patients are diagnosed with hematological malignancies and during cancer therapy will become thrombocytopenic, representing more than 15% of our patients in the cath lab.

While we do not perform emergent revascularization and our lab does not take call, we are equipped to perform emergent interventional procedures should the need arise.

What percentage of your patients is female?

Our female patient percentage is 38% and male patient percentage is 62%.

What percentage of your diagnostic cath patients goes on to have an interventional procedure?

Fifteen to twenty percent undergo interventions. We have decreased the number of stents by using FFR-guided PCI.

Do any of your physicians regularly gain access via the radial artery?

Our interventional cardiologist performs radial access in 20-30% of our cases, especially in patients with thrombocytopenia.

Who manages your cath lab?

Our lab is managed by a registered nurse who is also active in the cath lab.    

Do you have cross-training? Who scrubs, who circulates and who monitors?

All of our staff is cross-trained to perform every role in the cath lab. Our nurses are equally skilled to perform duties outside nursing, including scrubbing, monitoring or operating the x-ray equipment. 

Does an RT (radiologic technologist) have to be present in the room for all fluoroscopic procedures in your cath lab?

No, an RT does not have to be present, as long as a physician credentialed in fluoroscopy is present. 

Which personnel can operate the x-ray equipment (position the II, pan the table, change angles, step on the fluoro pedal) in your cath lab?

Our staff operates the x-ray equipment and our physicians step on fluoroscopy.

How does your cath lab handle radiation protection for physicians and staff?

The institutional physicist has provided an annual in-service to our physicians and staff about radiation safety. Everyone in the cath lab is required to wear a radiation badge that is monitored, and wear protective lead during procedures. The institutional physicist has marked the floors where one could potentially get increased radiation exposure. The physicist is notified about the patients that have received radiation treatment within the last 6 months and if the dose of radiation has exceeded 5000mGy; thus far, this has not occurred. At discharge, we provide our patients with instructions on signs of radiation skin injury.

What are some of the new equipment, devices and products recently introduced at your lab?

We were the second hospital in the state and one of the first in the country to own a St. Jude Medical OCT system. Our work at MD Anderson Cancer Center is focused on risk stratification and perioperative management of cancer patients, and use of the OCT system is an excellent tool for this purpose. We use OCT to evaluate severity of coronary artery disease, stent endothelialization, presence of microthrombi, and plaque structure. We tailor the patient’s antiplatelet therapy to the OCT results and we have started the PROTECT Registry (A Prospective Registry of OpTical CohErenCe Tomography/Cardiac Catheterization Data in a Cancer Population).

Using the pressure wire, we are able to safely defer interventions in cancer patients, avoiding unnecessary stenting and a subsequent need for dual antiplatelet therapy (DAT). Using FFR, we were able to minimize delays in cancer care and decrease the risk of bleeding (patients do not have to be on DAT for an extended period of time), without an increase in major adverse cardiac events (MACE) at one year (per data in the MD Anderson Cancer Center Cardiac Catheterization database). 

How does your lab communicate information to staff and physicians to stay organized and on top of change?

At MD Anderson, each physician and mid-level provider carries a pager that receives both emails and pages. We utilize an electronic system to send immediate results to the ordering physician and everyone on our team. We have daily morning reports, and weekly scheduled Journal Club (Monday), Cardiology Updates (Tuesday) and Grand Rounds (Wednesday), as well as morbidity & mortality (M&M) and case presentations where we share important information with our colleagues and establish practice guidelines for cancer patients.

How is coding and coding education handled in your lab?

MD Anderson uses an electronic charging system (the MedAptus system). Our staff stays current with new codes by purchasing coding books and attending webcast updates for the changes in coding.

Where are patients prepped and recovered?

Patients are prepped in the PACU area and go through the same preparation as surgical patients. There are a few elements specific to cath lab patients such as EKG, distal pulses, contrast allergy prophylaxis, etc. Our post cath patient recovery is in a phase 2 area with PACU nurses. We use Perclose AT (Abbott Vascular) and Angio-Seal STS (St. Jude Medical) as closure devices on our access sites, and manual compression if we do not use any closure devices. For patients with severe thrombocytopenia (<50K) and femoral access, we use the Neptune Pad (TZ Medical).

What is your lab’s hematoma management policy?

Our goal is not to have any hematomas at all… But, if we have a hematoma, we will apply manual compression to the site 150% longer than we initially considered before pulling the sheath and will include the case in our monthly quality improvement meeting. We generally hold 20 minutes for all arterial sheaths; 30 minutes if the platelet count is between 50-100K, and 40 minutes if the platelet count is 1-50K. Thus far, our “small” hematoma rate is 0.36% (no large hematomas) and 15% of our patients have thrombocytopenia (platelets <100K). 

How is inventory managed at your cath lab? 

Each staff member has an inventory to maintain. Staff collaborates with the hospital purchasing department and handles daily ordering as needed. Our management seeks to minimize inventory for cost control, yet provide sufficient products/equipment for operational demands.  

Has your cath lab recently expanded in size and patient volume?

Since its inception in November 2009, our cath lab has increased the volume and complexity of cases. Our initial goal was to establish safety and protocols. In the second and third years of our operation, we have experienced a sharp increase in the number of cases, and consequently, doubled our volume. As the number of cancer survivors continues to increase, we expect to have a steady growth in volume.

Do you have a hybrid cath lab, or are you planning to build one?

We are working with Thoracic Surgery and we are involved in the plans for a hybrid OR/cath lab room. We plan to expand and increase the complexity of our procedures to include coiling, with the goal of decreasing vascular supply of cardiac tumors. Our plans also include utilizing intracardiac echo (ICE) in the diagnosis of cardiac pathology in patients with gastrointestinal (GI) tract (i.e. esophageal) tumors where transesophageal echo (TEE) is impractical. We are already one of the few centers worldwide performing TEE-guided intracardiac tumor biopsies. 

Is your lab involved in clinical research?

We have unique experience in cardiac procedures in patients with thrombocytopenia, and OCT and FFR in cancer patients. Also, due to the high incidence of stress-induced cardiomyopathy (Takotsubo) in patients undergoing cancer therapy, our group has developed a special interest in understanding and treating this subgroup of high-risk patients.

Due to the large volume of pericardiocentesis, pericardial diseases represent another area of focus for our group.

A significant number of patients with multiple myeloma have been diagnosed after hemodynamic assessment and endomyocardial biopsy with restrictive cardiomyopathy and cardiac amyloidosis, with important clinical implications.

Our group is leading the effort to understand the mechanism of anthracycline-induced cardiomyopathy.

Have you had any cath lab-related complications in the past year requiring emergent cardiac surgery?

Fortunately, none at all!

What measures has your cath lab implemented in order to cut or contain costs?

We conduct our business purchases through our purchasing department. Although we only have one lab, purchasing products through our purchasing department allows us to negotiate pricing at an institutional level to guarantee the lowest price.  

What quality control/quality assurance measures are practiced in your cath lab?

Our lab uses a product from Verge Solutions called V Survey. We have designed a data collection tool that we use to track performance. Items such as case mix, complications, system events, patient events, and Joint Commission audit elements, such as timeout and invasive procedure notes, are logged into this system. We generate reports from this “data collection” tool and list all events for review. The Department of Cardiology Quality Officer, Cath Lab Medical Director, Cardiopulmonary Center Director, and the Chairman of Cardiology review any events and decide corrective measures.

Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) or any other outside data collection registry?

Yes, we use the NCDR ICD Registry. 

How does your cath lab compete for patients?

We are the only freestanding cath lab in a cancer institute. Our main referral base is MD Anderson Cancer Center surgical and medical oncology teams, as well as radiation oncology.  We are developing a unique expertise in managing both cardiovascular disease and cancer. We have started receiving patients outside MD Anderson for a second opinion in the management of cardiovascular disease. The first “Cancer and the Heart Conference” with international experts and 210 participants was organized last year in Houston. Additionally, a second Conference is scheduled for November 9-10, 2012. 

How are new employees oriented and trained at your facility?

All of our team members were working in Texas Medical Center cath labs and were individually recruited by the MD Anderson Cancer Center in November 2009. Each of our startup-team members had more than ten years in the cath lab field. Everyone who works at MD Anderson goes through an institutional orientation. In addition to that orientation, each cath lab member receives an orientation pathway for the cath lab.  

What continuing education opportunities are provided to staff members?

Aside from participating in our two weekly conferences and Grand Rounds, our nurses participate in the “Cancer and the Heart Conference” and “Concepts in Contemporary Cardiovascular Medicine Symposium” in Houston, Texas. In addition, nurses are provided with funds to attend seminars or conferences they wish to attend. 

How do you handle vendor visits to your lab?

Vendors are allowed per physician request and only with an appointment. 

How is staff competency evaluated?

Each year, staff nurse competency is managed and reviewed by MD Anderson’s nurse educators. Our laboratory department organizes the competency in the use of our Hemochron ACT machine and the Avoximeter.

Does your lab have a clinical ladder?

MD Anderson Cancer Center has what is called the CNAP (Clinical Nurse Advancement Program). The lab also uses this clinical ladder for our nurses.  

Do you have flextime or multiple shifts?

Not at this time.

Has your lab recently undergone a national accrediting agency inspection?

The Joint Commission visited the cath lab a year ago and commended our standard of practice in the cath lab. They were most impressed with the accuracy and completeness of the procedure notes (e.g. date, time, and signature). The procedure notes must be completed 24 hours before the procedure and after case end, but before transferring out to the post care unit. Proper timeout procedure is essential. Our philosophy is that if staff meticulously follows documentation protocol every day, then it becomes second nature.   

Where is your cath lab located in relation to the operating room (OR) and emergency department (ED)?

The cath lab is located two floors below the OR. The Emergency Center is one floor below the cath lab.  

What is unique or innovative about your cath lab and staff?   

MD Anderson Cancer Center is the only cancer institute in the world with a cath lab. More than 1,500,000 patients are diagnosed every year with cancer and more than 140,000 will be thrombocytopenic during their treatment. Knowledge regarding coronary artery disease and cancer is in its infancy and consequently, many things we do are unique and new.  Cancer patients with concomitant cardiovascular disease are excluded from clinical trials that address cardiovascular care; the same holds true for cancer trials where cardiovascular patients are excluded. We are trying to fill this gap in medical knowledge in a systematic way.  Our greatest challenges include timing the cardiac procedures without delaying cancer therapy, as well as treating “frail cancer patients” where any cardiovascular complication could delay cancer therapy, thus jeopardizing their life. Meticulous access using a micropuncture kit has been our key to minimizing access-site complications.

The Society of Invasive Cardiovascular Professionals (SICP) has added two questions to our spotlight:

Do you require your clinical staff members to take the registry exam for Registered Cardiovascular Invasive Specialist (RCIS)? Does staff receive an incentive bonus or raise upon passing the exam?

Not at this time.

Are your clinical and/or managerial team members involved with any professional organizations that support the invasive cardiology service line, such as the SICP, ACVP, or regional organizations?

We are members of the SICP.

The authors can be contacted via Gerryross Tomakin, RN, at GUTomakin@mdanderson.org, or Dr. Cezar Iliescu at CIliescu@mdanderson.org.