Inside the State-of-the-Art Cath Lab

The presence of high-resolution, flat-panel digital systems is increasing in the cardiac cath lab—just in time as placements of drug-eluting stents, coronary angiographies, atrial septal defect closures and EP procedures surge.

in many hospitals, the cardiac cath lab is in a state of transition. Business is booming with increasing patient volumes pushing labs—and staff and equipment—to capacity. Procedures are expanding and changing, and now include advanced procedures, like drug-eluting stent placements, coronary angiographies and atrial septal defect (ASD) closures that require greater precision and a more sophisticated combination of imaging and physiologic data.

At the same time, the cath lab is evolving into a multi-disciplinary center. Peripheral vascular volume is swelling at many sites, placing an additional strain on the cath lab. What's more, the tools of the electrophysiology trade have become more sophisticated and require higher image quality. That means cardiologists performing electrophysiology studies can no longer manage with archaic cath lab equipment or hand-me-down C-arms.

The upshot? The cath lab is ripe for improvement, and digital imaging systems fit the bill. Hospitals that have transitioned to the digital environment report a number of benefits on both the patient care and workflow fronts. The recipe for a successful digital implementation boils down to a few key ingredients:

• A vision for the cath lab program is essential. This includes an understanding of current and future procedures and volumes as well as the equipment that can support the program. For example, understanding growth in the peripheral vascular and cardiac cath arenas informs decisions about what type of x-ray systems can best meet the hospital's needs.
• High-quality digital imaging equipment is critical and will bring improvements in both image quality and workflow. Systems to support digital workflow, such as structured reporting tools and electronic image and report distribution systems, bring additional benefits.
• IT involvement is crucial. A dedicated cath lab IT staffer can help the hospital make the most out of its new equipment by facilitating the digital implementation, servicing the imaging system and ensuring smooth integration with archiving, monitoring and hospital systems.

The Cath Lab Environment

Over the last few years, cath labs already stretched to capacity have faced increased demand. It's not uncommon for cath lab volume to double every few years. The results include a push to open new rooms and pressure to maximize use in existing rooms. Sometimes, new construction may be the best solution.

"It's very difficult to put a cath lab of the future in the footprint of an old cath lab," says John Gurley, MD, director of interventional cardiology at Linda and Jack Gill Heart Institute at the University of Kentucky (Lexington, Ky.). "[Both new construction and retrofits] require a careful assessment of the hospital's strengths and weaknesses, opportunities for growth and the marketplace. There are so many choices to make that the hospital needs a strategic plan. New physical space and equipment should match that plan."

Competitive pressures are a reality in many markets. "We operate in a very competitive environment," explains Rick Stouffer, MD, director of interventional cardiology, University of North Carolina (UNC) Hospitals (Chapel Hill, N.C.). "We're trying to position the hospital as ready for 2010."

The situation is similar in Houston, where Methodist Willowbrook Hospital positions itself as a patient-friendly community hospital. The new cath lab relies on both human resources and technology to advance this mission.

The Clinical Scene

The practice of cardiology is evolving. Advanced procedures like drug-eluting stent placement, coronary and renal artery angiographies are performed daily in the cath lab and create a need for improved visualization of major and minor vessels. "With newer drug-eluting stents, it's crucial to place the right size stent in the right place," explains Stouffer. Digital imaging equipment provides the high image quality needed to facilitate advanced procedures.

There are other clinical issues to consider as well. For some sites, peripheral vascular volume increases outpace growth in traditional cath lab procedures. That was exactly the scenario at the University of Massachusetts Memorial Medical Center (Worcester, Mass.). In 2004, the center installed a GE Innova 3100 digital cardiovascular imaging system to accommodate the growth in peripheral vascular procedures. "[The 31 square centimeter] detector size accommodates both cardiac and peripheral vascular cases, allowing us to maximize our investment," explains Kathryn Green, manager for cardiac cath and electrophysiology labs.

Ohio Health System (Columbus, Ohio) went one step farther and equipped half of its Philips Integris cath labs with dual-purpose peripheral vascular equipment that can complete both vascular and cardiac cath procedures. The other half use Integris cardiovascular systems. "This keeps our options open," concludes Eric Seymour, manager for imaging engineering.

Gurley notes, "The technical advances of the last few years, especially flat-panel digital detector imaging systems, have made it possible to build truly functional, high-quality combination rooms." The ingredients for a multipurpose system that can handle peripheral vascular procedures include a wide field of view and subtraction and road mapping features.

The practice of electrophysiology brings other changes. Traditionally, cardiologists were willing to accept lower image quality in electrophysiology labs. Those days disappeared with new, sophisticated catheters and ablation techniques, which rely on visualization of fine details. "The only way to get [the required image quality] is to place digital imaging equipment in the electrophysiology lab," says Seymour. Ohio Health relies on InfiMed's Omega Gold system to meet its imaging needs in electrophysiology rooms.

Finally, cath lab users need to keep their eyes on the future. "In the next 10 years, there will be a lot of new things we can do angiographically," predicts Stouffer. "We'll need good imaging equipment and a high degree of col|aboration between x-ray and cardiovascular imaging."

One of the newer cath lab procedures at UNC Hospitals is the ASD closure. After assessing the equipment and images needed for the procedure, the cath lab dedicated one monitor to ultrasound images as the procedure relies heavily on both ultrasound and x-ray images. "The trend toward interventional procedures in the cath lab will continue. I have no doubt that we will be integrating CT and MRI data in the cath lab of the future," concludes Gurley.

Reaping the Benefits of Digital Technology

Ohio Health System, a three hospital system, read the writing on the cath lab walls in the late 1990s and began transitioning its cath and electrophysiology labs to digital imaging systems in 1998. "The big news is that once we rid ourselves of handling cine films, we eliminated all of the problems associated with processing and storing films," says Seymour.

This translates into a workflow boon for cardiologists who used to spend three to four minutes sorting film for each case. Now it takes less than 20 seconds to load the entire case on a workstation. In the pre-digital days, staff spent 13 to 14 minutes moving cine film magazines to and from the dark room. Not anymore. Throughput hinges on how fast the patient is moved on and off the table, which depends on clinical factors rather than film issues, says Seymour.

Methodist Willowbrook Hospital in Houston opened a new cardiac cath lab late in 2004 and employed digital technology to advance its patient-friendly mission. After each procedure is complete, the physician completes the report on the Siemens Axiom workstation in a control room equipped with dual flat-panel displays that show images from the Artis imaging system and a patient report pre-populated with a history and presenting diagnosis from the Sensis monitoring system. "The cardiologist's time is streamlined in the control room. He adds his findings, any complications and a treatment plan from a series of dropdown windows in the reporting system," explains Lyle Muhammad, cardiac cath lab manager. The technology has cut reporting time to seven to 10 minutes, and allows the cardiologist to spend time consulting with the patient's family in a viewing room equipped with a large screen flat-panel TV and wireless mouse and keyboard that enable the cardiologist to provide a clear picture of diagnosis and treatment.

The IT Factor

Digital imaging equipment does boost image quality and enable cath labs to dispense with film processors and projectors and implement high-tech, patient-friendly processes. But digital image acquisition is only one piece of the puzzle. Hemodynamic monitoring, hospital and archiving systems all play a role in the state-of-the-art cath lab.

At UNC, Toshiba Infinix-i vascular x-ray systems are integrated with Witt Biomedical's Hemodynamic Monitoring system. Images and clinical data are both archived digitally on an internal system and available for digital review in the cath lab. The cath lab system links with the HIS and EMR so all physicians can access cath lab results.

"This approach works well within the cath lab because we're hard-wired," says Stouffer. "We'd like to set up the system so that referring physicians at a satellite clinic can log on and view coronary angiograms online. This is a challenge with firewalls."

UMass Memorial Medical Center has successfully navigated the sometimes choppy waters of systems integration by employing the one-stop shop approach. All electrophysiology and cath lab procedures are completed on a GE Mac-Lab IT hemodynamic monitoring system, which is integrated with other GE systems throughout the enterprise. When the hospital admits a patient to the cath lab, the Mac-Lab IT pulls his name from the HIS and automatically populates demographic information in the system. This avoids errors associated with manual data entry. Efficiency is improved as there is no duplication of entry, and information resides in one database instead of several disparate locations. Finally, patients no longer need to answer the same questions multiple times as they progress through admittance and the procedure.

UMass relies on a GEMnet archive to facilitate access and distribution of cath lab images and provide instant access to images throughout the hospital. The medical center aims to improve service to off-site community cardiologists by implementing Web X and Centricity Cardiology Data Management System (DMS) this year. Web X, a Microsoft tool, transmits information in real-time, and in combination with other systems, will allow off-site community cardiologists to view images over the hospital intranet. "This is a great tool for patient communication," confirms Green. Centricity DMS serves providers with other options for distribution as well; the physician reporting and database system enables physicians to electronically sign reports and then automatically faxes them to referring physicians. "In the past, it might take days to complete a final report. Now it's instantaneous, which means medical staff has the information they need to better treat patients," Green explains.

Ohio Health System has achieved a similar level of integration and digital distribution. Its Heartlab Encompass archiving system includes a modality worklist and automated reporting features. The modality worklist automatically transfers patient information from the HIS to cath lab systems. Reports can be automatically emailed or faxed to referring physicians. Other image distribution options include CDs with embedded image viewing software or a web server that allows referring physicians to access cath lab studies. "Digital brings a whole new ability to disseminate information," concludes Seymour.

The hitch? Attaining this high level of integration and digitization is no small feat. IT provides the foundation and support. "You need an IT specialist who is capable and savvy enough to work with the various systems," says Green. A dedicated cath lab IT specialist is generally responsible for training, troubleshooting and liaising with hospital IT staff.

At Methodist Willowbrook Hospital, an IT super-user trained every cardiologist on the new digital reporting system to help even the most technophobic physicians master the system and drop report time to a minimum. The IT specialist also incorporated physician input into the dropdown menus in the reporting system to make the process shorter for all users, says Muhammad.

The cath lab IT specialist is a complex position and not every IT guru is cut out for the job. Ohio Health System trained its imaging engineering staff to maintain the cath lab network and server. "It isn't a good idea to have IT people work on cath lab equipment because they aren't trained to service imaging equipment. It takes years to become adept at servicing cath lab equipment," says Seymour. He recommends providing basic network training to engineers already trained to service cath lab equipment.

Dollars & Details

"One challenge that grows out of the multifunctional cath lab is inventory management. When the lab expands to the full range of peripheral vascular cases and ASDs, the inventory grows exponentially with multiple stents, catheters, guidewires and sheaths for all of the procedures," says Gurley. The pressure to pinch pennies is constant, and no cath lab can afford to let inventory like drug-coded stents expire.

"The cath lab needs a well-organized storage space and a sophisticated system for inventory management," continues Gurley. Green says UMass Medical Center relies on an integrated inventory management, billing and scheduling system to give the lab a clear handle on its costs and revenue.

Conclusion

The cath lab is growing and evolving, refining bread-and-butter functions and adding new procedures. Sites across the country are feeling the pressures of competition and struggling to find ways to improve patient care. Digital imaging systems fit the bill on all ends—improving image quality and making the most of the cardiologist's time. Digital archiving, monitoring and reporting systems multiply the benefits by distributing images and information instantly, providing all stakeholders access to up-to-the-minute updates of patient information. Finally, the latest and greatest auxiliary tools complement digital imaging systems and aid the bottom line as well by streamlining the increasingly complex task of inventory management.

STATE OF THE ART CATH LABS AT A GLANCE

Linda and Jack Gill Heart Institute at University of Kentucky, Lexington, Ky.

• Philips Allura Xper FD 10 (2 systems)
• Philips Allura Xper FD 20
• Philips Integris Allura bi-plane system
• Philips Xcelera cardiac archive system with system-wide deployment of workstations and a web browser for inter-and intra-campus viewing of echo and cath
• Witt Biomedical Hemodynamic Monitoring System

Methodist Willowbrook Hospital, Houston, Tx.

• Siemens Artis TC
• Siemens Sensis Hemodynamic & Electrophysiology Reporting System
• Siemens Axiom Sensis Report Workstation

Ohio Health Systems, Columbus, Ohio

• Seven Omega Labs with the InfiMed GoldOne Cardiac and GoldOne EP systems
• Philips Integris Labs (14 systems)
• Heartlab Encompass archiving system

University of Massachusetts Memorial Medical Center, Worcester, Mass.

• GE Innova 2000 (4 systems)
• GE Innova 3100 system
• GE Mac-Lab IT hemodynamic monitoring system
• GEMnet archive
• GE Centricity DMS
• Microsoft Web X

University of North Carolina Hospitals, Chapel Hill, N.C.

• Toshiba Infinix CS-i (single plane)
• Toshiba Infinix CB-i (bi-plane)
• Toshiba Infinix DP-i
• Toshiba Infinix CC-i