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July / August 2007

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Special Feature

coronaryheart.com

Making The Solucient Top 100 ....and is it Important?

LATEST NEWS, EDUCATION + more...

Education ICD’s - What’s in the Can?

Site Visits • Ochsner Hospital, New Orleans • Royal Perth Hospital, Australia

EMP

Eileen Wimsatt - Inova Fairfax Hospital, VA

LO

Interview

Y

NT E M

“The World’s Fastest Growing & FREE Cardiac Magazine!!”


FIRST IN THE FALL

September 5-8, 2007

New Orleans

A MultidiSciplinARy confeRence 2007 New Cardiovascular Horizons Achievement Award Recipient

Earl E. Bakken

pReviouS AwARd RecipientS: 2006 ~ Michael E. DeBakey, MD 2005 ~ John B. Simpson, MD, PhD 2004 ~ Thomas J. Fogarty, MD 2003 ~ Martin B. Leon, MD 2002 ~ Edward B. Diethrich, MD 2001 ~ Julio C. Palmaz, MD

for

Cardiovascular & Endovascular Professionals, Interventionalists, RNs, Cath Lab Techs and Venous Specialists David E. Allie, MD & Craig M. Walker, MD Conference Co-Chairmen

Breakthrough PeriPheral interventional, CritiCal limB isChemia, endovasCular and CardiovasCular toPiCs Presented By 125+ emininent FaCulty inCluding: Julio Palmaz, MD ~ Edward Diethrich, MD ~ Thomas Fogarty, MD ~ Mark Wholey, MD ~ Jay Yadav, MD John Simpson, MD ~ Zvonimir Krajcer, MD ~ Lynne Jones, RN, RCIS ~ Thomas Malony, MS, RIC Kenneth Gorski, RN, RCIS ~ Chris Nelson, RN, RCIS, FSICP ~ David Katz, MD Marsha Holton, RN, RCIS ~ Chris J. Hebert RT(R), RCIS ~ Gary Chaisson, RT(R), R-CVT (tentative NCVH faculty)

SICP & ACVP’s Review Courses ~ SICP’s Review Courses for RCIS Exam

Wednesday, September 5- Friday September 7, 1-5:30 pm

~ ACVP’s Basic Cardiovascular Science Exam Wednesday, September 5, 1-4 pm

~ ACVP’s CCT Exam Review

Thursday, September 6, 1-4 pm

ses a C Live Forts l l a C strac Ab

ConFEREnCE HIGHLIGHTS ~ 3rd International Multidisciplinary CLI Summit ~ Multiple Live Cases From CIS ~ SCCT Sponsored PV-CTA Symposium ~ 2nd Global Endovenous DVT Symposium ~ Horizons Cath Lab Professionals Symposium ~ SICP & ACVP Members Receive $50 Discount* (*Discount includes full conference registration & review course)

Register Today! www.newcvhorizons.com or (337) 261-0944


CONTENTS

July / August 2007

CORONARY HEART

Contents

Designed specifically for cardiology directors and managers, helping their department and staff become the best.

THIS EDITION 04

Welcome Editorial

05

Latest News

08

ECG Quiz

09

Future

10

Special Feature

16

Page: 35

‘The 100 Top Hospitals: Cardiovascular Benchmarks for Success’

Management

Interview: Eileen Wimsatt - Inova Fairfax Hospital, VA, USA

32

‘Do Nationally Published Quality Rankings Matter?’

20

Site Visit (USA) ‘Ochsner Medical Center, Louisiana’

23

Site Visit (AUS) ‘Royal Perth Hospital, Western Australia’

28

40

‘Persistent Junctional Reciprocating Tachycardia (PJRT)’

41

SICP ‘President’s Letter’

42

Nursing

45

Conferences

46

Employment

Interview

‘Eileen Wimsatt - Inova Fairfax Hospital, VA’

Language Assistance

‘How to work as a nurse in the USA’

‘Russian’

CRM Education ‘Pacemakers and ICD’s: What’s in the can?’

31

35

EP Education

Page: 20

Competition ‘Win 12-Lead ECG Course’

Page: 10

Site Visit: Ochsner Medical Center, LA, USA CORONARY HEART ™ 3


EDITORIAL

Welcome Editorial

W Coronary Heart Publishing Ltd Independance Wharf 470 Atlantic Avenue, 4th floor Boston, MA 02210 United States Phone: +1 (617) 273-8012 Visit us online at

www.coronaryheart.com Director / Chief Editor Tim Larner Clinical Editor Dr Rodney Foale Consulting Editors Dr Richard Edwards Ms Voncile Hilson-Morrow Mr Ian Wright Mr Stuart Allen ADVERTISING Request Media Kits online CIRCULATION USA edition 8072 Cardiac Professionals

elcome to the start of Year Two for Coronary Heart. What a great last twelve months we have had. If some of you have visited our website and downloaded our early issues you will be able to see just how far we have come in such a short space of time. Our first magazine had a distribution of only 460 copies into the UK and Australia. Today with Edition 7 we are well over 10,500 copies distributed internationally, with over 8000 copies being sent into North America. Such rapid growth wouldn’t have been possible without the support of the Alliance of Cardiovascular Professionals (ACVP) and the Society of Invasive Cardiovascular Professionals (SICP), along with our newly formed partnership with Healthworks, Inc.

Tim Larner Director

Late June also heralded the establishment of our first satellite office in the USA, located at Independance Wharf in Boston, MA. Whilst initially managed from our main UK office, the site gives us the perfect location for expanding our company. Edition 8 (Sept/Oct) will also see us change the magazine size away from the current metric A4 to American Magazine Standard which is slightly smaller and the most common for US publications. Back to the magazine you will notice in the Latest News section a lot of products you have never seen or heard of which appeared at the recent EuroPCR conference in Barcelona, Spain. For legal reasons companies are not allowed to promote products that aren’t available for sale yet in their country, so you are lucky you get to see them here first. We all hope you will enjoy this USA edition.

Tim Clinical Editor

Subscribe Online to get your own free copy

Dr Rodney Foale, Copyright 2006 by Coronary Heart Publishing Ltd. All rights reserved. Material may only be reproduced by prior arrangement and with due acknowledgment of Coronary Heart Publishing. The publication of an advertisement or product review does not imply that a product is recommended by Coronary Heart Publishing Ltd.

Disclaimer:

FRCP. FACC. FESC. FCSANZ. Clinical Director, Surgery, Cardiovascular Sciences and Critical Care. SMHT. COVER PHOTO: Group photo of staff at Royal Perth Hospital Cath Lab, WA, Australia

Coronary Heart should never be regarded as an authoritative peer reviewed medical journal. Coronary Heart has been designed as a guide only, to inform readers who work in the cardiology environment about latest news stories and the different techniques used by others around the world. Whilst all care is taken in reviewing articles obtained from various companies and contributors, it is not possible to confirm the accuracy of all statements. Therefore it is the reader’s responsibility that any advice provided in this publication should be carefully checked themselves, by either contacting the companies involved or speaking to those with skills in the specific area. Readers should always re check claims made in this publication before employing them in their own work environment. Opinions expressed by contributors are their own and not necessarily those of their institution, Coronary Heart Publishing Ltd or the editorial staff.

4

CORONARY HEART ™


LATEST NEWS

CATH LAB CAUTION: Some products within this magazine may be restricted to specific regional usage, and may not be available in your region. Always check with the manufacturer to determine availability.

Tryton Medical’s Side Branch Stent

Latest News

Image Courtesy Tryton Medical

W

ith an estimated 540,000 bifurcation lesions treated every year the need for a easy to deploy system has finally become a reality. Some of you may have already heard of the Tryton, but it was at EuroPCR, with live case presentations that demonstrated the ease of use to thousands of interventional cardiologists. The stent is a unique balloon expandable, 5 French compatible system that is delivered with a single wire. Once expanded in the side branch and main vessel, a traditional stent is placed through the side branch stent into the main vessel and deployed. Refer to diagram for explanation. The first case demonstrated how patients with complex bifurcated lesions can be definitively treated in

NASA Software For Ultrasound

T

hose intelligent scientists at NASA have been at it again developing technology to help us live longer lives on Earth. Originally developed to improve spacecraft imagery such as photos from Mars and the solar system, the Jet Propulsion

scenarios where provisional stenting is impractical. The second case demonstrated the versatility of the “treat the side branch first” approach in a lesion located far down the right coronary artery. The side branch, which was at risk of eminent closure, was stabilized with Tryon’s stent, after which the main vessel was treated with a superb angiographic result. The third case was in a patient with an extremely tortuous and calcified artery whereby the Tryton secured the side branch, after which a workhorse stent was delivered to Lab developed a version for use within ultrasound units. Called the ArterioVision, this software which is actually used at several sites in the USA recently obtained FDA approval. The software can distinguish between 256 shades of gray at a subpixel level. So when examining the carotid artery, an echocardiographer has a higher level of accuracy in determining the

the main vessel yielding a successful result. Intravascular ultrasound was performed at the end of each case and demonstrated complete coverage of the side branch origin. At present the Tryton stent has not received CE or FDA approval, however the product is hoped be available in Europe with a CE mark in the first quarter of 2008. Visit www.trytonmedical.com for more information

carotid intima media thickness (CIMT) measurement to calculate the age of the patient’s arteries. This extra visualisation of arterial thickening provides the earliest evidence of atherosclerosis, the beginning stage of a disease process that leads to heart disease. Now don’t worry about buying a new ultrasound system. The software is designed to function with traditional systems. All you need to do is install. Check with your ultrasound provider first though in case of any warranty issues. Check it out at www.i-mti.com

CORONARY HEART ™ 5


LATEST NEWS

CATH LAB

Latest News

CAUTION: Some products within this magazine may be restricted to specific regional usage, and may not be available in your region. Always check with the manufacturer to determine availability.

Medtronic Endeavor Resolute Trial

T

he nine month results were in on the Medtronic Endeavor stent RESOLUTE Trial, with Professor Ian Meredith, M.D., Monash Medical Centre, Melbourne, Australia presenting the findings at EuroPCR. The next generation Endeavor Resolute® stent features a new BioLinx™ polymer designed to address the special needs of patients who have complex medical conditions. It has been engineered to match the duration of drug delivery with the longer healing duration often required by these patients. At nine months the results showed no Target Lesion Revascularization (TLR), no Target Vessel Revascularization (TVR) and a Major Adverse Cardiac Event (MACE) rate of just 7.0%. The trial involved 130 patients with an

SJM Announce FDA Approval of Optisense™ Pacing Lead

I

n early May, St Jude Medical announced FDA approval of its new Optisense™ pacing lead. Referred to as a “Smart” lead, it is designed to offer more accurate sensing in the right atrium. The lead also incorporates a new tip design to reduce extraneous signals from the ventricles. Therefore physicians now have more flexibility in programming atrial sensitivity settings whilst avoiding sensing signals from the ventricles. Visit www.sjm.com for more information. 6

CORONARY HEART ™

Endeavor Resolute® Stent Tip Photo courtesy: Medtronic

average lesion length of 15.5mm, with 82% clinically regarded as challenging lesions. These results show that the Zotarolimus drug is very potent at preventing restenosis, and combined with the BioLinx™ polymer seems to deliver the drug as it is intended.

Boston Achieves CE Mark for their LONG Stent

S

ize definitely did matter at EuroPCR, with Boston Scientific having bragging rights with the longest stent on the market. Now with a CE mark, the 38mm speciality stent is designed for lesions longer than 32mm.

The only downside is availability. At present it is not actually available in any country, however the current findings will be used to support the CE application for Europe. Visit www.medtronic.com for more information

Before this stent came along, patients with long coronary lesions had to have two overlapping stents placed which increased x-ray dose, procedure time, and cost. The TAXUS Liberte Long stent is CE Marked for all of the same indications as the TAXUS Liberte stent system and comes in four diameters 2.75, 3.0, 3.5, and 4.0mm. Visit www.bostonscientific.com for more information


LATEST NEWS

CATH LAB

Latest News Abiomed Impella Gives Alternative to Traditional Balloon Pump

and actively unloads the ventricle, increasing the cardiac output and both coronary and end-organ perfusion. It is minimally invasive and can be inserted into the left ventricle in a catheterization lab via a standard guidewire through the femoral artery.

and at four months, respectively, in the Impella 2.5 group as compared to 2% and 5% in the control group. Visit www.abiomed.com for more details

The initial Mach 2 study which was presented at ACC in March found that the Impella 2.5 improved cardiac function for pre-shock acute myocardial infarction (AMI) as compared to conventional care including intra-aortic balloon pump (IABP) therapy. The preliminary results of the 20 patient study showed an increase in ejection fraction of 9% and 13% at three days

I

n late April, Abiomed completed its enrollment for the pilot study of the Impella 2.5 in patients undergoing high-risk angioplasty procedures. Several hospitals across the USA are involved. The Impella 2.5 can deliver in excess of 2.5 liters of blood per minute

FIRST IN THE FALL Abiomed Impella 2.5

September 5-8, 2007

Cypher Results Similar To Bypass Surgery

New Orleans

A MultidiSciplinARy confeRence

I

for

Cardiovascular & Endovascular Professionals, Interventionalists, RNs, Cath Lab Techs and Venous Specialists

SICP’s Review Course

Wednesday, September 5; Thursday, September 6 & Friday, September 7 - 1:30-6:00 pm

Moderators: Marsha Holton, BS, CCRN, RCIS & Kenneth A. Gorski, RN, RCIS, SICP

RCIS Exam Review n n n n n n

Cardiovascular A&P Coronary Artery Anatomy and Angiography Hemodynamics and Calculations Pharmacology Radiology and Radiation Safety Legislative Update

n n n n n n

Calculations Workshop Patient Care and Assessment Cardiac Catheterization Equipment and Procedures Interventional Techniques Cardiovascular Disease Process 12 Lead EKG Identification of Myocardial Infarction

Register Today! www.newcvhorizons.com or (337) 261-0944 SICP 1-4 ad.indd 1

5/15/07 9:26:47 AM

n a late-breaking clinical trials presentation at EuroPCR, Cordis Corporation announced that its Cypher Stent had results comparable to coronary artery bypass grafting and better outcomes than bare metal stents in diabetic patients with blockages in two or more coronary arteries. The CYPHER® Stent does not have an approved indication in the United States for diabetic patients or patients with multivessel coronary disease. Visit www.cordis.com for more details. CORONARY HEART ™ 7


LATEST NEWS

Latest News The Ostial Pro Stent Positioning System

CATH LAB CAUTION: Some products within this magazine may be restricted to specific regional usage, and may not be available in your region. Always check with the manufacturer to determine availability.

Right coronary is engaged with guiding catheter.

The stenosis is crossed with guide wire and stent.

The guiding catheter is backed out slightly.

The Ostial Pro is advanced from distal end of guiding catheter until the gold-plated feet expand.

The guiding catheter is slightly advanced until the gold-plated feet of the Ostial Pro are touching the aortic wall at the ostium of the right coronary artery.

The stent is pulled back until the gold-plated proximal marker band is aligned with the gold-plated feet of the Ostial Pro, and the stent is deployed.

T

he FDA recently approved a new product from Ostial Solutions, the Ostial Pro Stent Positioning System. This new device is used to safely deploy stents in the ostium of the coronary arteries, such as the Left Main, a traditionally risky and generally hit and miss affair. Ostial Pro has tiny gold-plated “feet,” which open like a flower in bloom and can be braced against an opening near a narrowed or closed artery. Often the offending plaque is difficult to visualize in angiography and the system greatly increases the likelihood that the stent will be implanted at the correct location for maximum benefit with an accuracy of plus or minus 1 millimeter. Refer to the images on the right for a full overview of how this system works. Visit www.ostialsolutions.net for more information

ECG Quiz

Compiled by: Mr Stuart Allen Technical Head CRM, Southampton General Hospital, UK

Clue. This 16yr old patient has a dual chamber pacemaker implanted for congenital complete heart block, and has been getting dizzy episodes on exercise. This ECG is from his exercise test. What’s the problem? Visit coronaryheart.com for answer. 8

CORONARY HEART ™


FUTURE

Cardiology Advances Non-Invasive Cardiac Ablation Coming Soon

A

ccuray Incorporated famous for its CyberKnife® Robotic Radiosurgery System has entered into an agreement with CyberHeart Incorporated to develop a non-invasive method for performing cardiac ablation. At present cardiac ablation is done either in an EP lab or surgical environment, however with the CyberKnife System’s intelligent robotics, accuracy and unique tracking capabilities it looks possible to target the heart’s affected tissue and create an ablation lesion, even with a moving heart. The CyberKnife System is the next generation of radiosurgery systems that combines continuous image-guidance technology with a compact linear

OrbusNeich’s BioEngineered R stent results

B

efore we go into the findings it is best to explain what the OrbusNeich Bio-engineered stent actually is. Called the Genous, this CE marked stent differs from traditional drug-eluting stents because it is coated with an antibody that captures a patient’s endothelial progenitor cells (EPCs) to accelerate the natural healing process. EPCs circulate in the bloodstream and are involved in the repair of blood vessels.

The CyberKnife® Robotic Radiosurgery System accelerator that has the flexibility to move in three dimensions according to the treatment plan. Patrick Maguire, M.D., Ph.D., President and CEO of CyberHeart said, “Accuray’s CyberKnife System is the only technology available today that offers the precision needed to ensure When attracted to the surface of the Genous, EPCs rapidly form an endothelial layer over the stent that provides protection against thrombus and minimizes restenosis. The interim analysis of postmarketing data presented at EuroPCR by Robert de Winter, M.D., Ph.D., showed data collected from more than 120 sites in 29 countries. • For 2,175 patients at 30 days, the target lesion revascularization (TLR) rate was 0.05%, the major adverse cardiac events (MACE) rate was 1.61%, and the sub-acute thrombosis (SAT) rate was 0.37%

only very specific regions of the heart are treated. We expect to begin initial clinical trials in 12 to 18 months and it is our objective to bring the product to market in the next three to four years.” To see how the CyberKnife System is currently used in surgery visit www. accuray.com • For 1,039 patients at six months, the TLR rate was 2.89%, the MACE rate was 5.87%, and the thrombosis rate was 0.88% “The importance of this interim data is that Genous appears to be as effective as drug-eluting stents with only the need for minimal dualantiplatelet therapy, which is safer for patients and less expensive.,” stated de Winter, a co-principal investigator of the study and director of the catheterization laboratory at the Academic Medical Center in Amsterdam. Visit www.orbusneich.com for more details. (not available in USA)

CORONARY HEART ™ 9


SPECIAL FEATURE

The 100 Top Hospitals: Cardiovascular Benchmarks for Success A Hospital Performance Improvement Scorecard Thomson Healthcare Center for Healthcare Improvement Dave Foster, PhD, MPH Chief Scientist, Center for Healthcare Improvement Jean Chenoweth Sr. VP, Performance Improvement and 100 Top Hospitals Programs

T

he Solucient 100 Top Hospitals: Cardiovascular Benchmarks for Success study stands alone in offering a scorecard designed solely for hospital use to improve inpatient cardiovascular performance. Despite its limitations, the 100 Top Hospitals Cardiovascular study has been used by hundreds of hospitals to measure comparative performance levels of cardiovascular

services and improve performance of cardiovascular services. The value of these cardiovascular benchmarks lies in enabling hospitals to raise targets for improvement of cardiovascular services to national levels of performance. The study, published annually by Solucient — now a Thomson Healthcare business — ranks performance based on a composite of clinical process, clinical outcomes, efficiency, and cost. Hospitals assess variance of their performance from the benchmark for each measure as well as the median for hospitals in their class (teaching status and presence of cardiovascular residency), thereby providing targets for achievable improvement within the limits of valid

Layout & Imagery by Coronary Heart

use of administrative data. To raise the visibility of the benchmarks as well as performance variation, the 100 hospitals that have the best performance on the study measures are named publicly (individual hospital ranks are not released because administrative data is not reliable at that level). The hospitals, together with benchmarks and peer median data, are published in Modern Healthcare and at www.100tophospitals.com and www.modernhealthcare.com. Solucient deliberately selected a publishing partner with broad industry visibility to reach as many hospital executives, chief medical officers, cardiovascular service administrators, and physicians as possible. This broader audience has a vested interest in the quality and efficiency of the hospital-based cardiovascular service performance as do cardiologists and thoracic surgeons.

The Origin of the 100 Top Hospitals: Cardiovascular Benchmarks for Success

Community Hospitals Category Avera Heart Hospital of South Dakota 10

CORONARY HEART ™

The introduction of the 100 Top Hospitals: Cardiovascular Benchmarks for Success study in 1999 was the first step for Solucient (then known as HCIA) to build objective national benchmarks for a specific clinical service to help hospitals improve care and efficiency. The study was initiated as a result of the success of the 100 Top Hospitals: National Benchmarks for Success program, which began in 1993


SPECIAL FEATURE

The 100 Top Hospitals (cont...) and focused on measuring hospitalwide performance. The cardiovascular service was selected as a service line study because of its high patient volume, high risk for patients, and high costs, as well as the variation in care – all of which make it extremely important to all stakeholders. The key goal of the 100 Top Hospitals Cardiovascular study was to enable improvement in cardiovascular performance levels by raising visibility of the variation in cardiovascular outcomes and by encouraging a shift to using national benchmarks, rather than average performance, for comparison. At the time, transparency was anathema to the industry and no cardiovascular benchmarks were universally available. The Society of Thoracic Surgeons database, with extensive clinically rich data, was available to participating hospitals and physicians, but not to all hospitals. The study is aimed at hospital cardiovascular improvement and visibility of the national benchmarks. Therefore, Solucient covers the cost of producing the study through only the sale of hard copy Results Reports to hospitals – not through hospital advertising fees or sale of hospital performance information to consumers. To that end, when a hospital is selected a 100 Top Hospitals Cardiovascular winner, Solucient provides the hospital with its own performance Results Reports and the publication at no charge. Non-winners are charged $1,095 to obtain their own Results Report. The Results Report is deliberately priced too high for consumers, but extremely reasonably for hospitals.

Composite Ranking and Groups The 100 Top Hospitals Cardiovascular study was the first to objectively

measure, rank, and publish the names of hospitals setting the benchmarks. The hospitals are ranked, based on a composite score that includes all equally weighted measures. To create reliable benchmarks, three groups of cardiovascular hospitals are used: Teaching with Cardiovascular Residency Programs, Teaching without Cardiovascular Residency Programs, and Community Hospitals. These three groups were necessary for validity of the benchmarks because the scorecard incorporates clinical measures and cost metrics. Also, the separation of all hospitals with open heart units into the three groups facilitates objective examination of common assumptions that are not always true: •

All teaching hospitals treat sicker cardiovascular patients. (The study shows the highest cardiovascular case mix in teaching hospitals with cardiovascular residency programs.)

Teaching hospitals have better results than community hospitals. (The study shows similar outcomes for the two groups.)

Our physicians and epidemiologists use only publicly available data including: CMS cardiovascular process of care measures, MedPAR administrative data, and Medicare cost reports to guarantee transparency and to be sure all U.S. hospitals are eligible for inclusion. Today, the study results are used by more than 300 hospitals annually to review and improve cardiovascular performance. While initially only administrative data was available publicly, as more clinical process data has become available through the Centers for Medicare & Medicaid Services (CMS) and AHRQ, the scorecard has been expanded.

The methodologies used in the study are very similar to those used by the Agency for Healthcare Research and Quality (AHRQ); indeed, two of the measures, post-operative hemorrhage or hematoma and post-operative sepsis, are actual AHRQ Patient Safety Measures. These AHRQ Quality Indicators are used in at least nine states in the U.S. for hospital-level, public reporting. All methods used in the study have been peer reviewed, and the study metrics and methodology are reviewed and updated annually to increase relevance and validity of the benchmarks. Much of the information generated from the Cardiovascular study, and all of the 100 Top Hospitals studies, is made available in the public domain to facilitate performance improvement. For example, a number of peer-reviewed studies1-5 related to the 100 Top Hospitals Cardiovascular project are available to the public. As cost and efficiency measures are refined and the transparency of inpatient and outpatient clinical data grows, the 100 Top Hospitals Cardiovascular scorecard will evolve.

Reduction in Variation on 100 Top Metrics over Eight Years An important goal of the 100 Top Hospitals Cardiovascular study has been to make hospitals and physicians aware of the variation of cardiovascular

>>

CORONARY HEART ™ 11


SPECIAL FEATURE

The 100 Top Hospitals (cont...) 100 Top Hospitals Cardiovascular Metric – Performance Change Over Time Metrics

1999 Performance

2006 Performance

Bench

Peer

Variance

Bench

Peer

Variance

CABG risk-adjusted mortality

0.79

1.16

32.2%

0.79

0.99

20.0%

PCI risk-adjusted mortality

0.63

1.08

42.1%

0.83

0.97

14.4%

* % CABGs w/ internal mammary arteries

73.2

68.2

5.0%

90.4%

88.2%

2.2

**Average number of CABGs performed

391

223

75.3%

119

79

50.6

**Average Number of PCIs performed

555

248

123.8%

406

232

75.0%

* Use of internal mammary arteries for CABG is the gold standard - Society of Thoracic Surgeons ** Leap Frog began using volume of procedures as a measure in 2001.

Notes: 1999 100 Top Cardiovascular study used MedPAR data years 1997/98 and 1998 cost reports

2006 100 Top Cardiovascular study used MedPAR data years 2004/05 and 2005 cost reports Other metrics from the 1999 study have undergone changes in methodology. Direct comparisons were not readily available at publication deadline.

performance and to help them reduce it. Indeed, performance variation has been reduced nationally over the past eight years, due to the concern generated nationwide by the National Institutes of Health publication, The Quality Chasm, and the ensuing massive effort by many organizations, including Solucient, to improve quality of care. A comparison of the variance between benchmark and peer hospital performance on 1999 100 Top Cardiovascular metrics to performance in the 2006 study bears proof of this reduction. The table below shows that the variation in the mortality index (actual deaths compared to expected deaths for 12

CORONARY HEART ™

matched patient risk of death) for both CABG and PCI has narrowed. This is despite a huge increase in the number of PCIs performed and an increase in the severity of both PCI and CABG patients treated in 2006. The use of internal mammary arteries in CABG procedures has increased greatly since 1999 and the variance in use of internal mammary has been cut in half. And variation in volume of CABG and PCI procedures (Medicare only) performed has narrowed considerably between the benchmark and peer hospitals.

Evolution of the Study and Metrics The study metrics have evolved over

time as clinical practice has changed, methodologies were refined, and a handful of richer clinical process metrics has finally become public. Four adjustments to the study during the past eight years are worth noting: 1. Service line measurement versus procedure measurement – The 100 Top Hospitals Cardiovascular composite score has evolved to better reflect the overall performance of high volume cardiovascular medical and surgical services of hospitals with open heart units. Solucient limits the study to hospitals with open heart units because they believe that they offer the most sophisticated and effective cardiovascular services.


SPECIAL FEATURE

The 100 Top Hospitals (cont...) 2. Addition of new public data — As the government and the Hospital Alliance have forced an increase in transparency, Solucient has added Core Measures to the 100 Top program overall. Solucient will continue to do so. 3. In testing the measures through the 2006 study, two were deemed too unreliable for attribution to inpatient care. The 30-day mortality rate was reviewed but not adopted due to inability to validate attribution to hospital care using publicly available data. Additionally, research has shown that in-hospital and 30-day mortality are similar,6 and most hospitals are not able to systematically monitor post-discharge mortality for their patients. Moreover, if a validated 30 day mortality rate is made available publicly, that metric will be adopted. 4. Comparison of date of death on death certificate with date of discharge and discharge status. This change in 2002 significantly improved the reliability of mortality scores across in-study hospitals.

2. congestive heart failure 3. percutaneous coronary intervention (PCI) 4. coronary artery bypass graft (CABG) The main steps in selecting the 100 Top hospitals are: •

Building the database of hospitals, including special selection and exclusion criteria

Classifying hospitals into comparison groups

Scoring hospitals on a set of weighted performance measures

Determining the 100 Top performers by ranking hospitals relative to their comparison group

The data come from public sources— the Medicare Provider Analysis and Review (MedPAR) data set, the Medicare Cost Report, and the CMS Hospital Compare data set.

Classifying Hospitals into Comparison Groups Bed size, teaching status, and residency program involvement have a profound effect on the types of patients a hospital treats and the scope of services it provides. When analyzing the performance of an individual hospital, it is crucial to evaluate it against other similar hospitals. To address this, each hospital is assigned to one of three comparison groups according to its teaching and residency program status: • • •

Teaching Hospitals with Cardiovascular Residency Programs Teaching Hospitals without Cardiovascular Residency Programs Community Hospitals

>>

2006 Measurement and Comparison of Hospital Cardiovascular Services In its current form, the study7 focuses on short-term, acute care, non-federal U.S. hospitals that treat a broad spectrum of cardiology patients. It includes patients requiring medical management only, as well as those who receive invasive or surgical procedures. Because multiple measures are used, a hospital must provide all forms of cardiovascular care, including open heart surgery, to be included in the study. Specifically, the study includes those undergoing: 1. acute myocardial infarction (AMI)

Teaching Hospitals with Cardiovascular Residencies Category Geisinger Medical Center, PA CORONARY HEART ™ 13


SPECIAL FEATURE

The 100 Top Hospitals (cont...) •

Residency Programs group 40 hospitals in the Teaching Hospitals without Cardiovascular Residency Programs group 30 hospitals in the Community Hospitals group

This stratification was chosen to maintain consistency with the representation of hospitals throughout the country, as identified in the original study research.

Teaching Hospitals without Cardiovascular Residencies Category Deaconess Medical Center, WA Scoring Hospitals on Weighted Performance Measures Solucient has compiled a group of eight measures of clinical quality practices and efficiency of operations that it believes constitutes the most reliable, scientific way possible to produce benchmarks for superior hospital performance. They also believe that using publicly available data for all hospitals supports this goal. The measures used in the 2006 study were: 1. Risk-Adjusted Medical (AMI and CHF) Patient Mortality Index 2. Risk-Adjusted Surgical (PCI and CABG) Patient Mortality Index 3. Risk-Adjusted Complications Index (includes post-operative hemorrhages and post-operative infections) 4. Core Measures Score 5. Percentage of CABG Patients with Internal Mammary Artery Use 14

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6. Procedure Volume Threshold 7. Severity-Adjusted Average Length of Stay 8. Severity- and Wage-Adjusted Cost per Case

Determining the 100 Top Performers Within each of the three hospital comparison groups, hospitals were scored based on their performance on each of the measures relative to other hospitals in their group. First, each hospital was given a single score for each of the eight measures. These scores were then summed to arrive at a total score for each hospital within each of the three groups. The number of hospitals selected to receive the Solucient 100 Top Hospitals award in each hospital category was: •

30 hospitals in the Teaching Hospitals with Cardiovascular

To reduce the impact of unsustainable performance anomalies and/or reporting anomalies or errors, hospitals with one or more mortality or complications index scores that were high statistical outliers (90% confidence) were not eligible to be winners.

Summary The Solucient 100 Top Hospitals: Cardiovascular Benchmarks for Success offers a unique tool for comparing hospital-based cardiovascular service performance. The need for a comparative balanced scorecard for inpatient and outpatient cardiovascular services that integrates clinical outcomes, clinical process, patient safety, efficiency of delivery of care, cost of care, and patient satisfaction will grow in the future, not decline. Focus on quality alone will not be adequate to effect the transformation necessary in delivery of future cardiovascular care. The lion’s share of medical error is a result of failure of systems and care hand offs. As a consequence, the 100 Top Hospitals Cardiovascular scorecard, which integrates disparate information sources to assess overall performance of Cardiovascular Services, will continue to be an important tool for hospital-based performance improvement.


SPECIAL FEATURE

The 100 Top Hospitals (cont...) References 1. Foster DA, Heller ST. Associations between outcomes reflecting quality of care and Medicare’s Hospital Compare Quality Measures. Academy Health Annual Research Meeting. June 2007, Orlando, FL. 2. Foster DA. Consequences and Costs of Medical Injuries in Medicare Inpatients. Academy Health Annual Research Meeting. June 2006, Seattle, WA. 3. Young JK, Foster DA, Heller ST. Cardiac revascularization in specialty and general hospitals. N Engl J Med. 2005 Jun 30;352(26):2754-6; author reply 2754-6. 4. McCollam PL, Foster DA, Riesmeyer JS. Cost and effectiveness of glycoprotein IIb/ IIIa-receptor inhibitors in patients with acute myocardial infarction undergoing percutaneous coronary Photo Competition Global

Teaching Hospitals without Cardiovascular Residencies Category Hillcrest Hospital, OH intervention. Am J Health Syst Pharm. 2003 Jun 15;60(12):12516. 5. Young JK, Foster DA. Cardiovascular procedures in patients with mental disorders. JAMA. 2000 Jun 28;283(24):3198; author reply 3198-9. 6. Rosenthal GE, Baker DW, Norris DG, Way LE, Harper DL, Snow

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CORONARY HEART ™ 15


MANAGEMENT

Do Nationally Published Quality Rankings Matter? Which Ones? And to Who?

Written by: John Florio, Executive Director, Cardiovascular Services, University of Kansas Hospital, Kansas City, Kansas; President, ACVP

organizations throughout the country. My version goes something like this: Joint Commission, CMS, Healthcare Quality Alliances, the death list Hospital Compare, Solucient’s 100 Top Hospitals®: Cardiovascular Benchmarks for Success Leapfrog, HealthGrades Physician Quality Reporting Initiative, U.S. News & World Report Best Hospital List, and can’t forget Quality Check. (Chorus) We didn’t start the fire It was always burning Since the world’s been turning …

Mr John Florio “Harry Truman, Doris Day, Red China, Johnnie Ray South Pacific, Walter Winchell, Joe DiMaggio Joe McCarthy, Richard Nixon, Studebaker, television North Korea, South Korea, Marilyn Monroe … (Chorus) We didn’t start the fire It was always burning Since the world’s been turning …”

I

n case you aren’t familiar with these lyrics, they are from a 1989 song by Billy Joel on his album, Storm Front. Unless you know that the song references events that happened each year during Joel’s lifetime, the lyrics appear somewhat random and meaningless. Listening to this song recently inspired me to craft a new version, which refers to the organizations involved in publicly reporting quality information and rankings for various health care 16

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It is doubtful Billy Joel will ever sing or write music to go with my lyrics. Yet just as some of the lyrics in Joel’s original song are a mystery to some of today’s listeners, quality and ranking organizations may be equally mysterious to today’s healthcare leaders and consumers. As with the original song, some background information is necessary in order to understand the collective meaning.

Trouble in Dodge

(That’s in Kansas, by the way.) Each year, cardiovascular administrators around the country eagerly await the release of the top lists of cardiovascular programs either from U.S. News & World Report or Solucient. While it has never been fully understood whether these lists actually increase business, it does give bragging rights to those programs that make the list, especially hospitals with multiple appearances. But at the end of the day, what does it really mean for a hospital to be named to one of these lists?

According to Modern Healthcare, U.S. News & World Report relies on hospital outcomes, such as mortality rates and other methods, to create its ranking. A three-part process gives equal weight to scores for reputation based on a random survey of physicians in that specialty, scores for severityweighted mortality rates and a grab bag of other measures, such as nursepatient ratios, the availability of key technologies, etc. According to Joseph Conn, the author of the article “U.S. News & World retort (JCAHO study questions magazine’s ranking system),” JCAHO’s quality studies and ratings of hospitals based on heart disease treatment is at odds with the rankings of hospitals appearing in the U.S. News & World Report best hospitals list. JCAHO (Joint Commission on Accreditation of Healthcare Organizations) says, “Thirteen hospitals in the country performed better than 41 hospitals of the 50 hospitals on U.S. News & World Report’s list of the best heart and surgery hospitals using the JCAHO’s process-focused evaluation. The U.S. News & World Report comment was, “Interesting, but so what?”1 The JCAHO quality website is www. qualitycheck.org. Another website, Hospital Compare, is sponsored by the United States Department of Health and Human Services and is available at www. hospitalcompare.hhs.gov. This site notes that it is a quality site for adults, including those who have Medicare. The site itself is very easy to use, and you can quickly check hospitals in your area and compare results. There are eight questions that address heart attack


MANAGEMENT

National Quality Rankings? treatment quality and four questions for heart failure. Question number six reports quality data on the percentage of heart attack patients given percutaneous coronary intervention (PCI) within 120 minutes of arrival at the hospital. As an example, during the fourth quarter of calendar year 2006, The University of Kansas Hospital averaged 68 minutes for “door-to-balloon” time – the period between a patient coming through the emergency room door to receiving angioplasty. The national standard recommended by the American Heart Association (AHA) is 90 minutes, and Medicare funding standards are 120 minutes. Patients transferred to The University of Kansas Hospital from other hospitals averaged 107 minutes of door-to-balloon time in the fourth quarter of 2006 compared to the national average of three hours for patients transferred for primary PCI. The Hospital Compare data, for a comparable period, reports that 93 percent of the time, The University of Kansas Hospital provides patients PCI within 120 minutes of arrival. A review on this website of some of the top heart centers as determined by the U.S. News & World Report shows the following results: Mayo Clinic’s St. Mary’s Hospital at 96 percent; Massachusetts General Hospital at 80 percent; Brigham and Women’s Hospital at 80 percent; St. Luke’s Episcopal Hospital at 55 percent; Duke University Medical Center at 83 percent; New York Presbyterian Hospital at 65 percent; and

Barnes-Jewish Hospital at 67 percent. This doesn’t mean The University of Kansas Hospital is “better” than some of the hospitals I mentioned, but more to the point, supports the JCAHO notion that there may be more than one way to look at quality data. Furthermore, some of the information reported by Hospital Compare or other groups may be more meaningful. What this data does suggests is local hospitals are doing a great job, and, in some cases, their data is better than top nationally-ranked hospitals. As an organization, The University of Kansas Hospital has chosen to benchmark itself against the top institutions in the country, and that is the beauty of having a national ranking such as the one produced annually by U.S. News & World Report. The question remains: Do national lists, such as the one published by U.S. News & World Report, have a local market impact by attracting patients to far-away centers? Actually, the market shift is relatively small in the Kansas City metropolitan area, where The University of Kansas Hospital is located. In fiscal year 2005, 2,370 heart surgery discharges were noted for patients living in the 15-county Kansas City metro area. Of that total, only 53 patients or 2.2 percent left the area for a heart surgery procedure.

Size Matters One of U.S. News & World Report’s selection criteria is program volumes. The Cleveland Clinic website’s quality section shows 3,503 heart surgery procedures for a comparable period of time, which is 1,133 more surgical procedures than all of the hospitals in Kansas City. That and other quality factors account for Cleveland Clinic being ranked number one for 12 years (www.ccf.org). Another source for quality information is Solucient. This company freely admits that its data is really for hospital administrators and board members. Solucient has published its top hospital list since 1993. According to the company’s website (www. solucient.com), “Solucient’s 100 Top Hospitals National Benchmarks for Success study annually examines changing performance levels in U.S. hospitals and objectively identifies 100 benchmark hospitals based on overall performance. Solucient, a part of Thompson Healthcare, is the market leader in providing tools and vital insights that healthcare managers use to improve the performance of their organizations.” These various tools are not free, and it is not unusual for health care organizations to have six-figure annual bills from Solucient. All of us have probably seen billboards advertising the fact that a hospital is on Solucient’s Top 100 list. But does the public really understand what a Solucient ranking really means? In the Kansas City metro area, billboards along the interstate CORONARY HEART ™ 17


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National Quality Rankings? cost $8,000 to $10,000 per month, so hospitals have to carefully evaluate the impact of these advertising investments. It is interesting to note the answer given by a senior cardiovascular administrator whose hospital was on the Solucient list of Top 100 Heart Hospitals when he was asked about the value of being on the list. He commented that you could choose to live by the list, but then you would die by the ranking as well, if you were left off in subsequent years. Would our hospital advertise if it were included in a Solucient Top list? Probably to some extent. (The University of Kansas Hospital was on the Solucient Most Improved List in 2004, I think.) Would our hospital advertise if we were named to a U.S. News & World Report Top Heart Hospitals list? You bet! Another quality website is HealthGrades, owned and operated by “HealthGrades, Inc. …HealthGrades has advanced profile information that has only been available to clients. HealthGrades believes that consumers would also benefit greatly in having access to this information. Therefore, this information is now made available, along with the information that was free, for a minimal cost. In this way, everyone has the opportunity to have the best information available to make an informed, healthcare decision.” (from www.healthgrades.org ) One of the biggest criticisms of HealthGrades is the fact that it charges hospitals large fees for the use of information about the hospital, particularly if the hospital gets a “five-star” ranking. Fees can range up to $80,000. Again, hospital leadership has to make a decision about the value of the information versus the price and determine just what the impact would be in a given market. Our facility was named a “five-star” facility, and, at the present time, we have declined purchase rights to market 18

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this to the public.

The Death List Report Cards The “death list” is not a variation of the Clint Eastwood/Inspector Harry Callahan movie The Dead Pool, but rather a Centers for Medicare and Medicaid Services (CMS) list or publication released in June 2007. The reports will cover heart attack and congestive heart failure death rates. The risk-adjusted death rates are for any patient who died for any reason within 30 days from entering the hospital. Hospitals will be categorized as “better than U.S. national rate,” “no different than U.S. rate” or “ worse than U.S. national rate.” According to the information contained in the initial CMS communication, 17 hospitals performed better than the U.S. national rate, 7 hospitals performed worse and 4,453 hospitals performed “no different than U.S. national rate” for AMI admissions in 2005-2006. Nationally risk-standardized AMI mortality rates for hospitals ranged from 10.8 percent to 24.0 percent with a median of 16.8 percent.2 Similar rankings are available and will be published for heart failure.

So What’s the Problem? CMS has suggested that hospitals should not compare themselves, since most will fall into the general category, “performed no different than U.S. national rates,” but, in fact, comparisons have already begun. Heart attack and heart failure mortality rates were mentioned in a USA Today article showing the national mortality average for all hospitals at 16.4 percent.3 Of the 12 leading medical centers that released their rates to USA Today, The University of Kansas Hospital had a mortality rate that was better than two-thirds of the hospitals mentioned, including some that are on the U.S.

News & World Report Top Hospital list. The CMS publication is going to name the high-risk hospitals, as well as those that have the best rates, but withhold rates for hospitals in the “performed no different” category. If you go to the Hospital Compare website and scroll down to your hospital, in most cases, you will see just a “no difference” check mark. Richard Lange, chief of cardiology at Johns Hopkins University, says in the USA Today article, “Isn’t it amazing 4,477 hospitals that treat heart attacks are all the same?” 3

At the End of the Day The U.S. News & World Report list is great because it gives us all a valid list of top hospitals that we can use to benchmark against our programs. Why compare your program to the hospital across town? Will that really help you improve to higher levels of care? What about the public? Does the type of quality data drive the public to select certain health care facilities? Perhaps it was best said by Eileen Sampanes, the clinical excellence and patient-safety officer at Christus Health in Houston, who was quoted in Modern Healthcare: “People are still selecting quality on convenience or where their doctor sends them. It is more relationshipdriven than data-driven. Still, you have to have confidence in your caregiver. Having that, people are more likely not to pay attention to that data.”4 Most of us in the business completely agree with Ms. Sampanes. Decision are and will continue to be made on other factors and not data or advertising. Having said that, perhaps the best advice is for all of us is to do what we do best — take care of our patients and their families and, of course, each other. The quality dilemma will ultimately sort itself out.


MANAGEMENT

National Quality Rankings? As Billy Joel sang, We didn’t start the fire, but when we are gone, will it still burn on, and on, and on, and on…? Author’s note: The song “We Didn’t Start the Fire” was written by Joel after a conversation with John Lennon’s son, Sean. Sean was complaining that he was growing up in troubled times. Wikipedia, the free online encyclopedia, has an explanation of all of the names, events, and things in the song for our younger readers. The song is often used in history classes as a teaching aid.

References

e%2FQnetTier2&c=Page

Conn J. U.S. News & World retort (JCAHO study questions magazine’s ranking system). Modern Healthcare August 28, 2006;36(34):10.

Centers for Medicare and Medicaid Services (CMS). Hospital-Specific Report Version: June 2007. Acute Myocardial Infarction 30-Day Mortality Measure – Heart Failure 30-Day Mortality Measure. Accessed June 20, 2007. Available at: http://www.qualitynet.org/dcs/ ContentServer?cid=116301039855 6&pagename=QnetPublic%2FPag

Sternberg S, DeBarros A. Does where you live determine if you’ll live? USA Today May 25, 2007. Accessed June 21, 2007. Available at: http://www.usatoday.com/ news/health/2007-05-22-deathrates_N.htm

Zigmond J. Take Two on CMS’ Release of Hospital Mortality Rates. Modern Healthcare May 28, 2007:8-9. Accessed June 20, 2007. Available at: http:// modernhealthcare.com/apps/pbcs. dll/article?AID=/20070601/FREE 70531004&SearchID=73284755 984571

Next Issue: Radiation Dose Management We’ll take a look at what you should do for patients who receive a high dose during procedures, and what each each of the imaging companies have installed on their equipment to reduce dose to you and your patients.

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Call us for details: 1.800.396.9998 CORONARY HEART ™ 19


CARDIAC SITE VISIT

UNITED STATES OF AMERICA

Ochsner Medical Center, New Orleans, LA ADDRESS

Ochsner Medical Center 1514 Jefferson Highway New Orleans, LA 70121 United States of America

FAST FACTS 1. Number 1 Hospital for treatement of Hurricane Katrina patients. 2. 483 Bed Hospital. 3. 4 Cath Labs, 3 EP Labs. 4. 13 Staff. Dr. Grant, Dr. Miller, Gus Rome, Brandon Hebert, Ashley Simoneaux

MAP Here is a basic rundown of how it unfolded: •

T

he Ochsner (pron. Osh-na) Hospital is located in New Orleans, Louisiana, and became recognised internationally two years ago when Hurricane Katrina struck the Gulf Coast, leading to widespread destruction from its powerful winds and flooding. As the hospital was located above the flood waters it was spared damage, unlike several others located within the city that had to be evacuated. The Ochsner Hospital became the number one hospital for the treatment of patients, as a Mobile Army Surgical Hospital (MASH) unit was set-up in the hospital grounds. 20

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September 1st: Marshal Law in New Orleans.

September 3rd: MASH unit set up in hospital grounds.

September 6th: IM, Cardiology, OB-GYN and Pediatrics outpatient clinic back in service.

First 2 weeks: 62,750 hospital cafeteria meals served.

2) Staff Numbers & Roles? •

i. RN’s administer medications including conscious sedation and monitoring. ii. RT’s pan/drive the table, monitor, set-up equipment such as rotational atherectomy, thrombectomy, laser, pressure wire, IVUS. •

4,500 Immunizations in one day!

1) Size of the Department? •

4 Cath Labs = 3 dual plane and 1 biplane lab

3 EP Labs = 1 biplane, 1 single plane, and 1 syncope room

Hospital beds = 483

Cath Lab = 8 RT’s and 5 RN’s

EP Lab = 1 RT, 1 Scrub Tech, and 5 RN’s

3) Procedures? •

Cath Lab = diagnostic coronary and peripheral angiography, RHC, LHC, heart biopsies, alcohol septal ablations, PFO and ASD closures, valvuloplasties, intracardiac ultrasound, coronary interventions, and peripheral interventions.


UNITED STATES OF AMERICA

CARDIAC SITE VISIT

Ochsner Medical Center •

EP Lab = cardioversions, tilt test, EP studies, RF ablations, pacemaker and defibrillator implants

4) Equipment? • • • • • • • • •

5)

Toshiba x-ray equipment Witt Hemodynamic Monitoring System IVUS Pressure Wire Angiojet Rotablator Laser Carto XP Prucka Cardio Lab From Left: Mark Foster, Michelle Perniciaro, Heather Lejeune, Brandon Hebert, Steve Collins, Ashley Simoneaux, Amy Liuzza, Chad Stouder, Kim Touchet, Chris SanMarco

Day cases?

Some of our patients return home the same day as their procedure and some are admitted after their procedure.

6) Cross-Training? •

The RN and RT staff are

partially cross trained. All staff is responsible for circulating, inventory control and monitoring vital signs.

cross trained.

7) Procedures performed per year?

In the future, the goal is to have both the Cath and EP lab staff

• •

Cath Lab = 3400 EP Lab = 1300

8) New Procedures Recently Implemented? • •

Left Atrium Appendage Closure Percutaneous Mitral Valve Repair

9) Inventory management?

Dr. McMullan, Dr. Reilly, Dr. Sharma, Amy Liuzza

Each employee is responsible for maintaining certain equipment in the department. We will soon have an inventory management system that will have scanning capabilities, and par levels to notify us of what is in need to order. This system will be linked to our purchasing system.

>>

CORONARY HEART ™  21


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Ochsner Medical Center 10) Hemostasis? We use several different closure devices, but they can not be used on all patients. The cardiology fellows manage all manual compressions to obtain hemostasis.

11) Private cases? Any special considerations? We do not allow private cardiologists to come work in our lab

15) Competency checks for staff once employed? •

RN’s have to be recredentialed every two years for conscious/ deep sedation

BLS and ACLS training is done every two years

Annual recertifications of certain pieces of equipment

Annual fire and safety

16) Some of the challenges in the department after the hurricane?

WHY NEW ORLEANS? Why not New Orleans? Sure, the city is still rebuilding after the damage of Hurricane Katrina but all the services are up and running, including the main tourist attractions. Property is a bargain, and with the government strengthening the cities defences, it won’t be long before the city returns to its best.

“Laissez les bons temps rouler!” (Let the good times roll!)

12) Measures Implemented to cut costs?

Keeping/Recruiting nurses and technologists

Things to see and do:

Maintaining competitive salaries

Mardi Gras: Always 47 days before Easter, this is America’s Greatest Street Party!!!!

French Quarter: New Orleans’ oldest neighbourhood famous for its architecture, shopping, and dining. The walled courtyards in many sites are from the Spanish influence.

Bourbon Street: Stretching over 13 blocks in the French Quarter this is where New Orleans comes alive. Closed to traffic at night the people take over enjoying the packed bars and restaurants. Sip a Hurricane with the locals to get you in the spirit.......quickly!!

We have talked with our vendors for better pricing, consignment of inventory so vendor is responsible for exchanging expired equipment.

We are looking into changing to premixed flush to decrease waste.

Once we implement our inventory management system, this will help with streamlining our par levels.

13) Training for new employees? We have a 6 week orientation period. This time will vary depending on the experience level of each individual.

14) Continuing education programs for staff? We offer product inservices from vendors for CEU’s.

22

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17) Biggest lesson learnt from the hurricane for all employees in the department? Better communication

18) What is the best part of working at your facility? •

We have the honor of working with internationally renowned physicians.

There is always something new to learn when working in a teaching/ research institution.


CARDIAC SITE VISIT

AUSTRALIA

Royal Perth Hospital, Western Australia ADDRESS Cardiac Cath Lab Royal Perth Hospital Wellington Street Campus Box X2213 GPO, Perth 6847 Western Australia AUSTRALIA

FAST FACTS 1. Site of first coronary stent implantation in Australia in 1988. 2. Hospital famous for previous Nobel Prize and Australian of the Year Winners. Clinical Nurse (CN) Personal Care Assistant (PCA) Registered Nurse (RN)

MAP

R

oyal Perth Hospital was the first hospital established in Western Australia in 1855 and is the largest teaching hospital, providing a full range of emergency services for adults (except obstetrics) and serving the State Referral Centre for many supers-specialities. Areas of excellence include interventional cardiology, cardiac and lung transplant, burns management,

From Left: Helen Wood (CN)/ Dr Matthew Erickson (Interventional Fellow)/ Dr Sharad Shetty (Consultant) bone marrow transplantation, rehabilitation medicine and trauma services. Royal Perth Hospital has always been a world-leader in medical technology and research and is the home of respected health care professionals such as our burns surgeon, and the 2005 Australian of the Year, Clinical Professor Fiona Wood. The Hospital has been home to many significant breakthroughs in medical research - significantly, research into the bacterium Helicobacter pylori, which was found to cause stomach ulcers. This research work won the 2005 Nobel Prize for former staff members Dr Robin Warren and Professor Barry Marshall.

1. Size of the Department The cardiology department performed the first coronary stent implantation in the country in 1988. The Cath. Lab. has three rooms (Siemens Hicor/coroscop) two being dedicated to coronary work and one to

pacing and electrophysiology. The RPH Cardiac Pacing and Electrophysiology Unit is the longest running and premier public hospital unit of its kind in Western Australia which treats both adult and paediatric patient populations. It is staffed by 1 fulltime electrophysiologist and 2 parttime electrophysiologists. We have 6 trained pacing and EP technicians who are NASPEx Testamurs. The unit has a substantial and varied caseload Our Heart-Lung Transplant Unit is forging an international reputation as a centre of excellence in the field of transplantation and mechanical circulatory support. The unit has only been in operation for 11 years but its success rate in many cases is better than other larger, well-established centres around the world. The unit continually punches above its weight, providing Western Australians in need of a new lung or heart with exceptional medical expertise and dedicated service. Echo cardiography studies are performed by 5 full time qualified CORONARY HEART ™ 23

>>


CARDIAC SITE VISIT

AUSTRALIA

Royal Perth Hospital cardiac sonographers and 2 specialist echo cardiologists providing service for Cath Lab ( Mitral valvuloplasties) pulmonary vein ablations, accident and emergency in our busy trauma unit and the Surgical and General Intensive Care Unit. The hospital is divided between two campuses. The larger Wellington Street campus is in the centre of Perth, while the Shenton Park campus is located 6 kilometres away. The hospital treats about 73,000 inpatients a year, receives about 225,000 outpatient attendances a year, and has one of the busiest Emergency Departments in Australia, with more than 54,000 presentations a year

2. Staffing Roles? Total 28 – 22 FTEs, 3 part time and 3 casual staff. Roles: • 1 Cardiac Cath Lab Coordinator • 1 Senior Radiographer • 1 Database Manager/ Senior Radiographer • 3 Radiographers • 2 Clinical Nurses • 2 Registered Nurses • 8 Cardiac Cath Lab Technicians

From left (back row): Grace Skiers (Cath.Lab.Tech.) / Andrew Hartley (Cath. Lab.Tech.) / Irene Evans (PCA) / Steve Collett (Senior Radiographer) / Dr Matthew Erickson (Interventional Fellow) / Dr Sharad Shetty (Consultant) From left (front row): Visha Buchholz (RN) / Erin Mailer (Clerk) / Sheryl Kannapin (Cath. Lab. Coordinator) • • •

6 Cardiac Technicians ( Pacing & EP) 1 Data Clerk 3 Patient Care Assistants

3. Procedures? We perform a full range of procedures in pacing and electrophysiology in our dedicated “EP room”. In the “angio. rooms” we mainly concentrate on coronary work using all the modern tools that contemporary cardiology requires such as; IVUS, Pressure Wire, Thrombectomy devices, Rotational Atherectomy. We have a 24 hour service for acute myocardial infarction that has been in place for over 13 years.

4. Day Case Procedures? Probably 30 – 40% depending on which day of the week it is. Patients are booked for coronary diagnostic procedures, Permanent Pacemaker Implants, Electrophysiological Studies, Right Heart Studies, Endomycardial Biopsy and Cardioversion.

From Left: Steve Collett (Senior Radiographer)/ Dr Geoffrey Cope (Senior Consultant) / Helen Wood (CN) 24  CORONARY HEART ™

5. Procedures/Volumes per year? •

Cardiac Catheterisations

1800


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Royal Perth Hospital • • • • • •

PTCA Pacemakers Defibrillators / BiVent. Electrophysiology studies Myocardial Biopsy PTMC/ASD/PFO

1000 200 100 200 200 30

6. Cross Training? All Nurses and Cath Lab Technicians are cross-trained to competently manage and assist with all diagnostic and interventional procedures. RNs administer all Intravenous medications. The technicians can give oral medications. Our Cath Lab technicians have recently undergone and successfully completed a Hospital based Medication Administration Course.

7. Staffing Roles? Radiographers • • •

Physical presence in the room is mandatory during x-ray emission In charge of x-ray equipment, IVUS, thrombectomy device (Possis) and rotablator Equipment maintenance of the

• • • •

above and daily quality assurance Supply disposable equipment during PTCA Data entry pertaining to PTCA and cardiac catheterisation Be part of a 24 hour on call roster Also responsible for supply and ordering of disposable equipment

Nurses and Cardiac Cath Lab Technicians • •

• • • •

All cath staff Scrub, Scout and are responsible for the Haemodynamic Monitoring Each day a senior staff member is allocated as the Recovery person to organise patient transfers and post op care including sheath removal Staff development is shared by senior staff Participate in 24 hour on call roster Some staff are responsible for maintaining our sterile stock of supplies and set ups Cardiac Technicians work exclusively in EP lab, Holter and Pacing Clinics

8. Surgical Back-up? Surgical back-up is provided by the cardio-thoracic surgeon who offer a 24 hour on call service. In case of

emergency a surgeon is always available. Of interest, over the last 2 years there has been only one case referred for emergency CABG following PTCA as compared with 3 cases, which required emergency PTCA within 24 hours of undergoing CABG.

9. New Procedures Implemented? Atrial fibrillation pulmonary vein isolation utilising the Bordeaux technique. We are active participants in research working on a variety of trials, encompassing broad areas of cardiology, including comparing revascularisation techniques in studies such as TYPHOON, OAT and FREEDOM. We are also proud to be one of only 2 Australian sites selected to participate in a novel approach to managing Radiocontrast Nephropathy and Acute MI’s through intravascular cooling in the COOL-RCN and COOL-MI 2 studies. Our Cath lab staff assists with various drug trials such as APEX-AMI and SHINE, and in collecting angiographic data for a variety of other clinical trials

>>

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AUSTRALIA

Royal Perth Hospital such as PLATO, CURRENT and VIVIFY. We believe that research is an important factor in the progression of interventional cardiology, and we are excited to play such a large part.

10. Inventory Management? Inventory is managed with the help of clinical staff and on a part time basis by a clerical person. We currently use an in-house designed electronic inventory management system. We are planning to develop in the near future a fully automated system using barcode and/or microchip technology. Perth is said to be the most isolated capital city in the world and as most of the vendors have their warehouses in the Eastern States and keep limited stock in Western Australia, supply is occasionally challenging and requires from our part diligent management. The two hour time difference between the Eastern States and Western Australia requires an efficient and rapid ordering process for next day delivery of goods.

11. Haemostasis Management? Most sheaths are pulled in our recovery area by Cath lab staff. PTCA patients’ sheaths remain in situ until transferred to Coronary Care Unit and then later removed by CCU staff. Mechanical Clamp is the preferred practice. Digital occasionally or in the event of a re-bleed post clamp removal. Closure devices for patients who are anticoagulated or possibly unable to comply with routine post sheath removal and the need to expedite patient discharge.

12. Private cases? Any special considerations? Yes we do. Mostly the patient presents as an emergency Acute MI. Also patients needing procedures which 26  CORONARY HEART ™

From Left: Andrew Hartley (Cath.Lab.Tech.) / Dr Wen Yeow (Registrar) are complex requiring technology not available in Private practice. Regardless all patients

13. Measures Implemented to cut costs? The purchase of prosthesis and disposable equipment is regulated by a state tender which helps us to lower the cost of equipment (at least this is the rationale!)

14. Alliances with other hospitals for the treatment of patients? Several hospitals within the South Perth metropolitan area transfer patients to us. We also receive patients from country centres all over Western Australia. The health department has embarked itself in the biggest health reform that Australia has ever witnessed. The department of cardiology will move en bloc to a new hospital in 2012 (to be called The Fiona Stanley Hospital) which will be the state flagship hospital. Fremantle hospital will also be part of the move;

we already share a number of services with them.

15. Training for new Employees? We have a Cardiac Cath Lab Orientation package for all new staff. A preceptor is allocated to the new person. This is a comprehensive training program to ensure that the new staff member is provided with the essential knowledge and the skills to competently work in our Cath Lab. All achievements and competencies are signed off once completed. Discussions on progress are reported to Coordinator then evaluated. We encourage new staff to share any issues they may have during the training period. The hospital has its own compulsory Induction Day plus there is a number of Hospital Based Mandatory Competencies.

16. Continuing education programs for staff? Clinical Cardiology study days are organised by our hospital’s Centre of Nursing Evidence Based Practice, Education, and Research. Cath Lab


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AUSTRALIA

Royal Perth Hospital staff are invited to attend. Our Cardiology department has scheduled presentations and educational sessions 2 mornings each week. When time permits in services to demonstrate new equipment or drugs is arranged usually once a month or more frequently if time permits. Our hospital offers many other study days which staff can apply to attend. These include Computer training courses.

17. Competency checks for staff once employed? Basic Life Support, Manual Handling, Management of Aggression, Emergency Learning etc all part of our hospital’s annual mandatory training. We also have Cath lab specific competencies for mechanical support devices such as Intra Aortic Balloon Pump, Radi Wire, IVUS and Defibrillation.

18. Some of the challenges in the department? One of the recent challenges in the department has been acquiring new x-ray equipment. The biggest problem is recruiting qualified staff. Western Australia is experiencing a huge economic boom in resources. The surge in demand for workers is very competitive. Another issue is the dire shortage of hospital beds. We cancel patients scheduled for booked procedures most days.

19. Training facility for cardiac registrars?

WHY PERTH?

Yes, 3 Fellows – 1 interventional, 1 EP, 1 Heart Failure and 2 trainees. The cardiac interventional fellowship at Royal Perth Hospital is a wonderful opportunity to gain technical skills and knowledge from some of Australia’s best and most experienced operators. With a 24 hour acute Angioplasty service, complex angioplasty with access to IVUS, Rotablater, Possis thrombectomy (only site in Australia) and other thrombectomy devices, as well as closures devices and mitral valvuloplasty, there is a fantastic and interesting case mix everyday.

The Capital city of Western Australia, Perth, with a population of 1.5 million, is at present the fastest growing city in Australia, and one of the most isolated in the world. Adelaide, the closest large city is 2,104 km away. The city is famous for its beaches, nightlife, and relaxed outdoor lifestyle in the sun. You can’t help but fall in love with this ultra modern city on the banks of the Swan River.

Things to See and Do: •

Perth Beaches: With over 12,000 km of pristine coastline, there’s a beach to suit everyone.

Rottnest Island: A short ferry from Perth, this island is perfect for scuba diving and relaxing on its 63 beaches.

Fremantle: 20min from Perth at the mouth of the Swan River this port city has vibrant markets, and laid back cafes and pubs.

20. What is the best part of working at your facility? Every day offers new challenges. The experiences and opportunity to be part of such a dynamic and progressive team treating the different patient mix often with complex medical conditions. We have excellent sources of support and influence, which constantly encourage an environment for good practice.

Perth, Western Australia

CORONARY HEART ™ 27


CRM EDUCATION

Pacemakers and ICDs What’s in the Can?

T

oday’s permanent pacemakers and implantable cardioverter defibrillators (ICDs) are truly marvels of medical science. The complex timing cycles and fundamental algorithms that are programmed into these “small wonders” are the result of extensive research - as well as some trial-and-error over the years.

Written By: Jeffrey A. Stiffler, BA, AST, RCIS IBHRE Recognition AP/Pacing and AP/EP Manager, Electrophysiology Division Healthworks, Inc. Douglassville, PA

Devices have two main parts to their generator: a header and a can. The header is made of a clear plastic and contains pin ports, set screws, metal contacts, wires, a radiopaque manufacturer marker, and a small suture hole. All of these parts are visible through the transparent housing. The can, on the other hand, is composed of a titanium shell (see Figure 1). This metal case does not allow visualization of the contents within. This article will look at the components contained inside a device

can. These components include the battery, pacing circuit, sensing circuit, timing circuit, rate-adaptive sensor, memory, telemetry antenna, and reed switch.

BATTERY In the attempt to make devices as small as possible, space inside the can is prime real estate. Because electricity is the most valuable commodity for an implantable device, the battery occupies about 50% of a pacemaker’s volume and about 25% of the space within an ICD can (50% of an ICD’s can space is inhabited by the high-energy capacitors used for defibrillation) (see Figure 2). Many energy sources have been tested for implantable devices, including nuclear power, photoelectric cells, and even the harnessing of the body’s energy. Today’s pacemakers are powered by lithium iodine batteries, while ICDs utilize lithium silver vanadium oxide batteries as their source.

PACING CIRCUIT

Figure 1. The titanium can of a pacemaker (left) and an ICD (right) hides from view the components inside. 28

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A fully-charged pacemaker battery has a charge of about 2.8 volts. If we were to pace the heart with this amount of energy for each beat, the battery would deplete quickly. However, if half of this energy was delivered with each beat (1.4 volts), the battery life would be doubled. The pacing circuit within a device allows the output voltage to be adjusted in 0.1-volt increments through the use of a voltage amplifier. In this way, the minimum energy needed to pace safely can be utilized to maximize battery life.


CRM EDUCATION

Pacemakers & ICD’s (cont...) SENSING CIRCUIT A pacemaker should only pace when the heart rate is too slow. A device “sees” intrinsic heart electricity through the sensing circuit. This circuit collects electrical information from the intracardiac leads, filters it, amplifies it, and compares it to some reference value. This reference value, called sensitivity, serves as a benchmark for incoming signals: any signals smaller than this size are ignored by the device. Smaller signals may originate from another heart chamber, nearby skeletal muscles, or external sources. Larger signals are sensed, and the device “decides” what to do in response to these signals. All pacing devices have a fail-safe mechanism built into the sensing circuit. This noise-reversion circuitry ensures pacing is not withheld in the presence of electromagnetic interference (EMI). This is especially important for patients that are pacemaker-dependent. Any inhibition of pacing in these patients causes ventricular standstill. ICDs have a second safety mechanism built into their sensing circuit to

ICD - Device Components Overview Courtesy Medtronic

prevent the large defibrillation energy from traveling up the intracardiac lead and into the delicate electronics of the can (called a Zener diode).

TIMING CIRCUIT Programming a pacemaker’s rate limits adjusts the commands for the timing circuit. This component acts like a

stopwatch, utilizing a crystal oscillator as a time reference. Following each sensed or paced beat, the timing circuit begins counting down to time zero (i.e. from 1000 msec to 0 msec for 60 beats per minute). If time zero is reached and no intrinsic beat is sensed, the device delivers a paced beat. If an intrinsic beat is sensed before time zero, the countdown is reset and starts over. This beat-by-beat vigilance is driven by the many complex algorithms programmed into the timing and logic control board. All pacing “decisions” are made on this board.

RATE-ADAPTIVE SENSOR As pacemakers evolved, there was an evident need for adjusting pacemaker rates based on patient activity level. Patients had no way to influence their pacing rate. This was especially problematic for very active patients. Rate-adaptive sensors were created to address this issue. ICD - Device Components Courtesy Medtronic

The first attempt at a rate-adaptive sensor solution was the activity sensor.

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CORONARY HEART ™ 29


CRM EDUCATION

Pacemakers & ICD’s (cont...) This quartz sensor was mounted to the inside of the can and increased the rate when the crystal was stressed by vibrations or pressure. Unfortunately, patients sleeping on the same side as their pacemaker experienced inappropriate rate increases due to pressure on the can. This type of sensor was also limited because it only sensed up-and-down motion. Bicycle riding and swimming are two examples of activities that were poorly sensed by the activity sensor.

Pacemaker can

battery other components capacitors

The next rate-adaptive sensor developed was the accelerometer. Learning from the activity sensor’s design flaw, this quartz crystal sensor is mounted to the circuit board, not the metal shell. A small weight is attached to the opposite end of the crystal, resembling a diving board. Inertia causes the board to flex and generate an electrical current proportional to the amount of flex (i.e. amount of activity). This sensor can “see” up-and-down AND back-andforth motion. Most devices have an accelerometer as part of their rateadaptive sensor. The other part of most modern rateadaptive sensors is comprised of minute-ventilation circuitry. Because minute-ventilation is proportional to metabolic demand, an increase in breaths per minute is a good indicator of increased activity. This circuitry continuously measures the impedance from the can to one intracardiac lead. This transthoracic impedance increases and decreases with inspiration and expiration, respectively. The impedance change reflects the down-and-up movement of the heart within the chest cavity as the diaphragm moves beneath it. More impedance cycles per minute trigger increases in the pacing rate through this sensor.

30

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ICD can

battery other components capacitors

Figure 2. A pacemaker can devotes half of its space to battery, while an ICD fills half of its volume with capacitors.

MEMORY

TELEMETRY ANTENNA

Current devices have two types of memory. ROM (read-only memory) houses the commands for the pacing, sensing, and timing circuits. RAM (random access memory) stores intracardiac electrograms and other clinical data. This data becomes very important in patient management, allowing the physician to customize the device for the patient and have access to a continuous rhythm monitor. RAM also makes it possible to upload new software to implanted devices noninvasively.

All devices have an antenna built into their cans, allowing for non-invasive telemetry between the device and the device programmer (a portable, proprietary computer used to “talk” to devices). This telemetry antenna allows for two-way communication of all clinical data and programming instructions for the device. The company-specific nature of the device programmers ensures a device is not inadvertently reprogrammed (called phantom programming).


CRM EDUCATION

Pacemakers & ICD’s (cont...) REED SWITCH The last can component, the reed switch, serves two purposes in pacemakers and ICDs. The first purpose is shared by both types of devices. To guard against phantom programming, the reed switch must be closed to initiate device telemetry for most devices. Closing the switch is accomplished by placing a magnet near the device. The second purpose of the reed switch differs depending on the type of device. In pacemakers, a magnet closes the reed switch and forces the device to pace asynchronously (constantly, without regard to any intrinsic rhythm). Trans-telephonic monitoring, where a pacemaker patient can have their device checked over the phone line, utilizes this magnet-dependent feature. Based on the pacing rate and patterns evoked by the magnet, information regarding the battery life and pacing status can be obtained. Clinicians can also use the magnet response to determine the manufacturer of a pacemaker, which is helpful in choosing a device programmer when the patient does not know their device’s company name. In ICDs, the second purpose of the reed switch is to disable the tachycardia detection circuitry. This feature is especially important for ICD patients undergoing operative procedures where electrocaudery will be used. If an ICD were to detect this electrical signal, it would inappropriately “treat” it as ventricular fibrillation (VF) with a high-energy shock. All of these components fit neatly into a modern device generator. Every part contributes vitally to the whole, culminating in a modest-looking little metal device capable of life-saving feats. A can’s outward simplicity masks an inner complexity that deserves respect.

REFERENCES •

Barold SS, Stroobandt RX, Sinnaeve AF. Cardiac pacemakers step by step: an illustrated guide. Malden, Massachusetts: Blackwell Publishing Company, Inc., 2004.

Ellenbogen KA, Wood MA. Cardiac pacing and ICDs. 3rd ed. Malden, Massachusetts: Blackwell Publishing Company, Inc., 2002.

Hayes DL, Lloyd MA, Friedman PA, eds. Cardiac pacing and defibrillation: a clinical approach. Armonk, New York: Futura Publishing Company, Inc., 2000.

Mallela VS, Ilankumaran V, Rao NS. Trends in cardiac pacemaker batteries. Indian Pacing and Electrophysiology Journal, 2004;4:201-12. CORONARY HEART ™ 31


EP EDUCATION

Persistent Junctional Reciprocating Tachycardia (PJRT)

Written By: Mr Ian Wright, St Mary’s Hospital, London, UK.

P

ersistent (permanent) junctional reciprocating tachycardia (PJRT) is an unusual form of supraventricular tachycardia with a 1:1 AV relationship. PJRT classically occurs in children and is characterized by an incessant and sometimes even permanent narrow complex tachycardia – the tachycardia may be the patient’s predominant rhythm. PJRT does occur in adults but in about half these patients it is paroxysmal rather than incessant/permanent. Patients with persistent/permanent tachycardia tend to demonstrate a slower tachycardia than those in which the rhythm is paroxysmal. The ECG during periods of sinus rhythm is normal. PJRT can be a serious arrhythmia, particularly in children because of tachycardia-induced cardiomyopathy (TIC) - deterioration of ventricular contractile function caused by very prolonged periods in tachycardia. TIC can also occur in adults with the tachycardia and this is sometimes the sole presentation. Fortunately the LV dysfunction generally resolves following successful ablation of the tachycardia. The arrhythmia is sometimes an incidental finding with the patient essentially asymptomatic Fig 1 shows an ECG from a 29-year patient with PJRT. The tachycardia was an incidental finding on a routine ECG and the patient was asymptomatic. The tachycardia is described as a long RP tachycardia (see below). The p wave looks different to sinus rhythm – it is typically inverted in the inferior leads (II, III and aVF) - indicating atrial activation from “low to high” (the opposite direction to sinus rhythm). The p-R interval is typically relatively normal. 32

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Figure: 1 PJRT is a form of orthodromic AVRT and is caused by a concealed slowly conducting decremental accessory pathway. Anterograde conduction occurs over the AV node and His bundle. Retrograde conduction in orthodromic AVRT is always via an accessory pathway. But where PJRT differs to more commonly seen types of AVRT (such as the tachycardias associated with WPW) is that the conduction properties of this pathway are similar to the conduction properties of the AV node. Usually, the behaviour of accessory pathways is very different – displaying “all or none” conduction but in PJRT the pathway conduction is slow and decremental (conduction slows with increasingly premature stimuli).

Why is PJRT often incessant?

P

JRT is a re-entrant rhythm. In a re-entry the cells in the circuit must have sufficient time to recover

after each cycle if the rhythm is to continue. Changes in the speed of conduction in one part of the circuit may result in the impulse arriving at another portion of the circuit while it is still refractory – causing termination. In PJRT both limbs of the circuit are decremental - they will conduct more slowly if an impulse is more premature and this slowing protects other parts of the circuits that might otherwise be refractory. In the more usual form of AVRT only one limb – the AV node is decremental and changes in the circuit often result in termination. For re-entry rhythms to start an impulse must travel only one direction round the circuit. This is called unidirectional block. The pathway in PJRT does not conduct anterogradely from atrium to ventricle (it is concealed) and so anterograde unidirectional block is always present. In patients with incessant or permanent PJRT the AV node usually exhibits poor or absent retrograde conduction and so retrograde unidirectional block


EP EDUCATION

PJRT (cont...) is also always present. Hence both atrial and ventricular beats can easily induce tachycardia.

Long RP Tachycardias

T

achycardias can be classified according to their appearance on the surface ECG. One such classification is narrow vs broad. A further classification of narrow complex tachycardia is into long RP vs short RP. In long RP tachycardias the time interval between the R wave and the following p wave is longer than the interval between the p wave and the R wave that follows it. Sinus tachycardia is (almost always) an example of a short RP tachycardia where the interval between p wave and subsequent R wave is shorter than between that R wave and the next p wave. In sinus tachycardia the R –P interval will change as a function of the sinus rate – it will be longer at slower rates and shorter at faster rates. In the case of sinus tachycardia and all other atrial tachycardias the p wave is not “retrograde” and the RP interval is not dependent on conduction through any kind of retrograde pathway. In a narrow complex tachycardia the p-R interval is determined by the rate of conduction through the AV node. The reason for classifying tachycardias as long RP or short RP is to narrow down the differential diagnosis:

Figure: 2 Long RP

Short RP

• •

Atypical AVNRT AVRT utilising a slowly conducting accessory pathway (AP) (e.g. PJRT) Atrial tachycardia

• •

Typical AVNRT (The p wave in typical AVNRT s not always visible however) AVRT utilising a typical rapidly conducting AP Atrial tachycardia is less likely but still possible - but it must

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Figure: 3 CORONARY HEART ™ 33


EP EDUCATION

PJRT (cont...) be conducted to the ventricles with very significant AV conduction delay. The R-p interval in PJRT is long because the retrograde limb of the circuit is over a slowly conducting pathway The ECG in fig 2 shows a different long RP tachycardia. Note that the p wave (inverted in II, III and aVF) is further from the R wave to its left than to its right. The appearance and p wave morphology are very similar to the ECG of PJRT. However at EP study this tachycardia was shown to be atypical AVNRT – a tachycardia with a similar appearance to PJRT. The pathway in PJRT is often located in the right postero-septal region – near the coronary sinus ostium. Consequently the earliest atrial activation during tachycardia is often on the proximal poles of the coronary sinus catheter. However PJRT pathways have been described in many other locations around both the tricuspid and mitral annulus. During the EP study PJRT must be distinguished from atrial tachycardia and atypical AVNRT. Differentiation from atypical AVNRT may be made more difficult because His synchronous V pacing may not advance the circuit due to decrementation in the accessory pathway. The pathway can be successfully ablated. Fig 3 shows termination of PJRT with carotid sinus massage (CSM). CSM causes increased vagal tone that may cause termination of the tachycardia by blocking conduction either in the AV node or the pathway, which is also sensitive to autonomic tone. In this 34

CORONARY HEART ™

Figure: 4 example the last inscription on the ECG is a retrograde p wave - indicating block in the anterograde limb of the circuit – the AV node. Termination of tachycardia with AV block strongly suggests that the rhythm is not atrial tachycardia because the atrial tachy would have to coincidentally terminate at exactly the same moment that AV block occurred – an unlikely scenario. Fig 4 is from the same patient as fig 3 following cessation of CSM. The tachycardia resumed as soon as the autonomic tone normalised and the tachycardia was again incessant. Tachycardia re-initiation after a pause always requires in intervening sinus beat which is not the case with atrial tachycardia. © Ian Wright, April 2007

Inside Humour


Interviewed by Ms Voncile Hilson-Morrow CEO Baltimore/Washington Division of Healthworks, Inc. Previous Director of Invasive Cardiology at Washington Heart at the Washington Hospital Center

INTERVIEW

Eileen Wimsatt

What were you doing before Cath and EP? I have been in leadership roles in critical care nursing. Please give us an overview of your program and your area of responsibility.

Eileen Wimsatt, RN, MSN Director of Cardiac Cath and Electrophysiology (EP) at the INOVA Heart & Vascular Institute INOVA Fairfax Hospital.

Eileen Wimsatt defines her leadership role at Inova Heart and Vascular Institute as exciting, challenging, and rewarding. You spend a lot of your life at work. So your workplace has to be a lot more than a place to earn a paycheck. You have to be responsive to its requirements and committed many needs. Feel valued for your skills and experience and know you’ll be heard by administrators. Inova Heart and Vascular Institute provides state-of-the-art treatment, with its advanced technology and its commitment to personal care, today, the Inova Heart Center is one of the largest and most successful heart centers in the nation. This institute is the result of the vision and hard work of people like Eileen Wimsatt. Eileen, how long have you been in your present position? I’ve been in the Cath and EP director position for 11 years and with INOVA for 30.

The Inova Heart and Vascular Institute, is a four-story, $152.2 million institute on the campus of Inova Fairfax Hospital, and was constructed as the main cardiac center for the Inova Health System. The center contains 156 patient rooms, in which nearly all of them private, and 48 intensive care beds. It offers six operating rooms, and an 11-room suite dedicated to cardiac catheterization and electrophysiology procedures and is equipped with a rehabilitation center. For educational purposes, a glass dome sits atop the operating rooms which allow visitors to view the operation process. Inova also has constructed “healing gardens” to encourage and accelerate the healing process. The Cardiac Catheterization Laboratory (CCL) and EP are located on the ground floor of the Inova Heart and Vascular Institute. It is comprised of 7 cardiac catheterization laboratories, 3 EP labs and 1 cardiac catheterization/ electrophysiology combination laboratory: Procedures are scheduled from 7:00am to 15:00pm or until all procedures are completed Monday through Friday. There is an on-call team after hours, weekends, and holidays to respond to the hospital within 30 minutes for emergency procedures. If there is an emergency procedure during normal working hours, the emergency procedure goes into the first available room, and then the scheduled case will follow in the first available room. The patient population served includes neonates through geriatric patients, inpatient and outpatient populations requiring elective, urgent or emergency

modalities for diagnostic and/or treatment of cardiac/peripheral vascular disease. Do you have a short stay or Trans care unit? Yes, we call it ICAR (Interventional Cardiovascular Admission and Recovery). This thirty nine (39) bed outpatient admission and recovery area is located adjacent to the laboratories. Although it is not under my direct supervision, I partner with the director of that area and we work together to accomplish the goals of safety, efficiency and throughput. What is the organizational structure? The overall structure is that we have an Administrator of the Heart and Vascular Institute, a service line Senior Director, a Nursing Senior Director, and Patient Care Directors. I am a Patient Care Director. Could you discuss some of your service excellence programs with regards to the Cath and EP labs? We provide patient centered care. Our service excellence program utilizes six pillars to achieve that goal. They are quality, service, cost, people, growth and community. Although we have all of the technology and equipment, we want to make sure we keep our patients as our focus. We round on our patients in the ICAR area at least once every hour. Our staff is educated on different techniques in communication. We utilize a methodology called AIDET(Acknowledge, Introduce, Duration, Explanation, Thank you). We have scripts that staff use when talking to patients. When entering a room, staff members begin by introducing themselves and providing some background information. They CORONARY HEART ™ 35

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INTERVIEW

Director of Cardiac Cath and Electrophysiology INOVA Heart & Vascular Institute, INOVA Fairfax Hospital.

Eileen Wimsatt then explain what they are going to do to the patient and offer answers to questions. Finally, they thank them for utilizing our facility. In addition to service excellence with our patients, we have also set up standards of behavior for how the staff interacts with each other. To measure our success with these initiatives we have a national company that does our patient satisfaction and benchmarks across the nation. They measure our key driver’s specific to Cath and EP. They are: overall quality, safety, privacy and teamwork. Inova employees are expected to demonstrate our commitment to Service Excellence through the following behaviors: • •

• • • •

Positive attitude—we approach our work in an upbeat and supportive way. Professional appearance—we present ourselves, our facility and our environment in a welcoming way. Respectful—we are considerate of everyone. Ethical—we do what is right. Helpful—we assist others in any way that we can. Courteous—we act and respond politely.

It sounds like you have clearly identified what is expected and then you measure the results. Are there any financial incentives or benefits to employees who participate in the service excellence program? The benefit is a better working environment for the employees. They feel respected and supported. So it is not tied into the performance appraisals? Standards of Behavior are part of the 36

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staff’s yearly performance appraisal. Regarding financial benefit, we have a clinical ladder program which is based on clinical performance and leadership skills. We have about 75 FTE’s in Cath and EP labs. They consist of Registered Nurses (RN), Registered Cardiovascular Invasive Specialists (RCIS) and military personnel that completed training from the Naval School of Health Sciences. We do not call our RCIS’ Cardiovascular Technologists (CVT). Most of our people are Bachelors of Science in Biology, or Radiology Technology and Bachelors of Science in Nursing. I do emphasize professionalism and emcourage people to go to school and get their degrees because it enhances their practice. Within a year of hire, we require that they be Registered invasive specialists. We have a program through an alliance with Geneva College in Beaver Falls, Pennsylvania. It’s a four year Bachelors of Science program which can include one year (12 months) of clinical time. They then have to take the registry within a year. Most do it within the first three months after completion of the program. Some people get their bachelors and then do the one year of clinical totaling five years, and others incorporate the clinical within the fourth year. You have 11 procedure rooms including pediatric/adult cardiac cath, Vascular and electrophysiology, and your staff are all cross trained in all of those areas? Correct. Additionally, we do have a group of people that are experts in pediatrics due to the volume in that area. We do more than 200 pediatric cases. Each room has an expert in that particular area whether it is pediatric, EP or peripheral, and everyone rotates on a daily basis. There is also a subgroup of individuals that are cross trained in EP and Cath and can go

back and forth. We rotate them every month (Cath for a month and EP for a month). How do you think your program differentiates from other programs in the area? I think the major difference is the flexibility in where the people work and their job responsibility. They are not pigeon-holed into any one thing so they are constantly learning and constantly challenged. They can be RN/RCIS or just RCIS. The jobs are very unique in that any staff member can rotate into any position. Our staff is able to monitor, scrub, or circulate. You cannot tell the difference between an RN and an RCIS in our grouping because they are all required to do those jobs. Every year our RCIS’ amd RN’s are required to take a medication competency exam. In addition to the exam, the RN’s do precept those on their medication administration; and then our partner school, Geneva College offers a semester of pharmacology. So the RCIS’ that we hire from there already have a semester of pharmacology. We do extensive medication/sedation testing to be sure our technologists are prepared. I know in some states the law will not allow health care providers to administer medication; however, it is permitted in the state of Virginia if the physician is present in the room; and of course the physicians are present in our rooms. Now Eileen, has your program always been setup this way or was this your vision? My vision was the cross-training with EP. And when did you start this? I would say about five years ago.


INTERVIEW

Eileen Wimsatt So prior to that Cath and EP staff were separate? Yes, and I started that because you cannot find as many people skilled in the field of electrophysiology. In talking with the staff, I discussed the marketability of being able to do both specialties. They are both very distinct and require different skills. Prior to the implementation of crosstraining, we would take staff from the critical care units; however, that can be a huge and costly learning curve. Now with the people utilizing the school program we have here, we have an EP rotation that prepares them for the EP modality. Once graduated, they become a valuable asset to our entire program. Eileen I think you have just explained how you are a visionary. To recognize five years ago the need for cross-training between Cath and EP is visionary. Five years ago EP was just starting to move to advance device procedures. Their staff are now leaders in this area and a step ahead of many other programs across the country. Yes, and it helps to have the flexibility in your daily staffing. How old is the Heart Institute? It will be three years old October 2007. That is also another step in the right direction. Do you think this has enhanced your program? Yes, one of the major benefits, we are totally focused on is the service line of cardiovascular medicine and surgery. When building the facility, we planned as best we could to vision what would make this system work. We had input on the equipment, the lab design, the office space, the lounge, the sleep area, and the ICAR pre and post recovery

Inova Heart and Vascular Institute Falls Church, Virginia, USA

area which was a total growth of a new area. In the past, it was just a small area with curtains. We even sat down and reviewed processes on how we would move patients and have been able to tweak them as we went along. We now have a wonderful reception area for patients to register and wait that was not there before. To ensure we designed a facility that would best yield our visions, we made visits to several sites around the country. In constructing our facility from the ground up, we have created a healing environment with our hospital system. When patients arrive, they are not greeted with the hustle and bustle; the care areas are all in the back portion of the hospital.

I found that extremely important when I came out to visit your facility. A stone-lined water fountain greets visitors as they

come though the institute’s main doors. Most enjoyable was the central outdoor garden area used to provide patients with fresh air and green space. Glass and wood is featured prominently at the institute. Now that you can look back is there anything you may have done differently on this project? I think more than anything it would be the aesthetics in the ICAR area --making it less sterile looking. The labs we already did by putting the lighted scenes above the table, but in the ICAR, we really didn’t. On the patient care units, the environment is very calming related to room design, lighting and artwork and I think we would have liked to have done that in ICAR.

>> CORONARY HEART ™ 37


INTERVIEW

Director of Cardiac Cath and Electrophysiology INOVA Heart & Vascular Institute, INOVA Fairfax Hospital.

Eileen Wimsatt Now I know we’ve discussed a lot of great things about your program, can you give more information on the clinical ladder you briefly mentioned earlier? Yes. We developed the clinical ladder because there was only a certain amount of people that could enter into management track. The clinical ladder has two tracks – clinical and management. The clinical track is based on the RN advance program, and it is called the Achieve Program. There are certain requirements that the employee has to have. They need a certain amount of years of service, years of expertise and high level skills such as IVUS and balloon pumping. Each candidate designs a project that will enhance the department; they discuss themselves and why they went into healthcare, and presents a case study outlining what role they had in helping a patient. They then present their project, bio and case study in a book and are interviewed by a committee. The committee is made up of someone from the cardiac floor, administration and peers who then decided whether the candidate is ready to move forward to that clinical level. They then present their project in a staff meeting. How many clinical levels are there? Four levels. We have level one for new graduates and they don’t stay at that level very long. We hire from the outside at level two – most staff are at this level. The Achieve Program is for levels three or four. What is the difference between levels three and four? Higher CEU requirements, leadership ability, communication skills, relationship building, 6% pay increase and experience.

Now what about the management track? The management track is supervision. The requirements are CEU’s, either RN or a Bachelors of Science, and at least five years in the field. Candidates do not have to complete levels three and four of the clinical track to participate in the management track. The supervisors of the lab are responsible for everything in that lab, and they are 100% clinical. They handle all of the situations that may come up in their lab including physicians, patients, staff and equipment as well as the regulatory tasks for the department. Tell us about the physician relationship. We have a medical director of Cath and a medical director of EP. Both have been appointed by the administrator and have been in those positions for quite awhile. They assist us with any issues we might have. We have a large community of cardiologists and our medical directors help us communicate changes in equipment or processes. We do our best to collaborate with them and have an open communication relationship. How do you go about equipment selection and the financial aspects of the lab?

CORONARY HEART ™

I now have an IT person who maintains the system and develops reports; however, it is still a work in progress. I am proud of the staff as they have successfully transitioned to the new system and they continue to work together to tweak the system so that it may yield the desired results. With this project were there things put in place to make the transition easier. We had key people that were super users that were sent for training. They would rotate around the rooms all day long to help the staff with the transition. It was particularly difficult because we have two different systems for x-ray and monitoring, and we had to make sure they talk to one another. How does your staff stay on the cutting edge of technology?

We have a product review committee for the cath lab, EP, and peripheral. Physicians are appointed to sit on it and our medical directors are on that committee. A physician puts in a request for a new product and we do the financial analysis and present that at the product review committee. The requesting physician then discusses the product and why it should be added, replacement or deleted.

I think with their CEU’s. We have a great education coordinator on staff that provides CEU’s right here. We have speakers coming in from around the country, our vendors provide speakers at our staff meeting and we send our people out to the national meetings like ACC and TCT.

What are some of the most difficult decisions you have had to do in your role?

I am passionate about my staff and they are most important to me because they are the ones that are on the front line taking care of the patients. I’ve always enjoyed being on the front line and I mentor and help the staff in any

Selecting the vendor for our cardiology information systems. Looking globally 38

at heart and vascular and how it was going to be hard wired, we realized that the equipment choice on the clinical units would have to be the same for the labs, to ensure uniformity and continuity. However, the cath lab staff did not like this. We had to help the staff understand that we needed a system that was not department specific. Although the transition was difficult, it was for the best for the system as a whole.

Is there anything you would like to say about your leadership?


INTERVIEW

Eileen Wimsatt

My strengths are my people skills, my communication, and my sincerity. My weakness is consistency with regards to laying it on the line. I surround myself with people that are strong in my areas of weakness and I take a team approach. Would you say you’re a boss or leader and why? I’m a leader. A boss tells people what to do. I like to guide and help people to grow and allow them to take the responsibility and accountability for the things that they do. Do you have any professional needs now or in the future?

Do you enjoy writing and would like to share a topic with the cardiac community? Then write an article for us. Visit us online at www.coronaryheart.com to see what you need to do.

WEBSITE ADVERTISING Would you like to advertise on our website. Advertising opportunities start in July 2007. Email advertising@coronaryheart.com for details.

NEW SIZE USA MAGAZINE

T

o celebrate our transition into a complete USA version of Coronary Heart, and after establishing a satellite office in Boston, MA, as of Edition 8 (Sept / Oct) we will be bringing USA readers a new size. Say goodbye to the UK metric A4 size you are currently holding. This will be replaced with American Magazine Standard. USA Advertisers Note: Revised 2007 Media Kits are available upon request by emailing to advertising@coronaryheart.com

From This

To This

July / August 2007

Issue 7 FREE SUBSCRIPTION!!

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July / August 2007

Issue 7

Special Feature

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Making The Solucient Top 100

Special Feature

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Making The Solucient Top 100

....and is it Important?

....and is it Important?

LATEST NEWS, EDUCATION + more...

Education ICD’s - Complete Overview

Site Visits • Ochsner Hospital, New Orleans • Royal Perth Hospital, Australia

LO

Interview Eileen Wimsatt - Inova Fairfax Hospital, VA

LATEST NEWS, EDUCATION + more...

Education ICD’s - Complete Overview

EMP

Well, I have my Masters in Health Promotion Management. In the future, I don’t know when, I’m going to move from disease to health and use all of my experiences that I’ve had to help people stay healthy in the cardiovascular arena. way that I can. I genuinely care for them. They are a great group, and I feel like they are a part of my family. I enjoy working with them. They do marvellous things every single day and they don’t even realize it because they do it day in and day out. I can’t tell you how many times I go through the labs and have been amazed what it is that they do. It is wonderful to see and be part of such a team.

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“The World’s Fastest Growing Cardiac Magazine!!”

Interview Eileen Wimsatt - Inova Fairfax Hospital, VA

Site Visits • Ochsner Hospital, New Orleans • Royal Perth Hospital, Australia

LO

What would you say are your strengths and weaknesses as a leader?

SUBMIT AN ARTICLE

EMP

way that I can. I genuinely care for them. They are a great group, and I feel like they are a part of my family. I enjoy working with them. They do marvellous things every single day and they don’t even realize it because they do it day in and day out. I can’t tell you how many times I go through the labs and have been amazed what it is that they do. It is wonderful to see and be part of such a team.

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“The World’s Fastest Growing Cardiac Magazine!!”

American Magazine Standard CORONARY HEART ™ 39


LANGUAGES

RUSSIA

Language Assistance

T

o assist you in the cardiac environment with patients whom have limited knowledge of English we have given you a helping hand. With the assistance of internationally recognised translators we have converted common cardiac phrases into foreign languages, and also provided their phonetic pronunciation in English. This issue we look at the language of Russian, spoken by approximately 147 million people. Following the dissolution of the Soviet Union in 1991 the Russian Soviet Federative Socialist Republic in the USSR became the Federation of Russia. It is the largest country in the world, almost twice as large as Canada, and contains the world’s eighth largest population.

English

Russian

Phonetic

Привет

Pri’vet

Доброе утро

‘Dobroye ‘utro

Yes.

Да

Da

No.

Нет

Net

Don’t Move!

Не двигайтесь

Ne ‘dvigaytes

Breathe in.

Вдохните

Vdokh’nite

Don’t breathe.

Не дышите

Ne dy’shite

Дышите нормально

Dy’shite nor’malno

Хорошо

Khoro’sho

Медленно, медленно

‘Medleno, ‘medleno

Вы не беременны?

Vy ne be’remeny?

В кафетерии больницы не подают водку

V kafe’teriye bol’nitzy ne poda’yut ‘vodku.

Hello Good Morning.

Breathe normally. Good Slowly, slowly. Any chance of being pregnant? We don’t serve vodka in the hospital cafeteria. 40

CORONARY HEART ™

Translated with the assistance of Inessa Akhmetova, from Tula, Russia


CARDIAC SOCIETIES

SICP President’s Message Lynne Jones, RN, RCIS, FSICP

T

he SICP has been busy at conferences the last two months! Concepts in Contemporary Cardiovascular Medicine was held in April. Not only were the lectures and speakers extraordinary, the live conferences were exciting. As always, the Saturday morning Debates in Cardiovascular Medicine were very lively. The Nurse/ Technologist Program on Saturday afternoon included information for all disciplines taking care of the cardiovascular patient. My sincere “THANK YOU” to the course directors, Dr. Richard Smalling, Dr. Zvonimir Krajcer, Dr. Steven Bailey, and Dr. Alan Lumsden for including SICP in this great conference and providing educational opportunities for the invasive professionals working in the cath lab. The SCAI Annual Conference in May was held at Disney World in Orlando. Our bi-annual SICP Board of Directors Meeting is held at this meeting every year. As usual, this conference covered every topic in invasive cardiovascular medicine. The SICP held a one day review course on the last day. The SCAI 31st Annual Scientific Sessions will be held next year at Caesars Palace in Las Vegas, May 28-31, 2008. I hope to see you in Vegas! Then we will hold our annual conference in St. Louis, MO., September 20-22, 2007. The keynote will be delivered by Dr. David Allie. New this year and courtesy of Medtronic, will be a breakout session for EP Overview. The Medtronic simulation bus will be on site during the conference. Attendees will have the opportunity to practice both coronary and EP techniques.

Many thanks to Medtronic for partnering with SICP to provide great education opportunities. Please visit www.sicp.com for information about the conference. As always, we strive to offer high quality education at the lowest cost possible. I look forward to seeing and meeting you there! I m now preparing to hand over Presidency to our President-Elect, Todd Chitwood, RCIS, FSICP. Todd has worked tirelessly for the last two years, focusing on Legislative Issues. He has represented the SICP at the CARE Bill Alliance meetings and has kept all of us updated on the position of the SICP and the recognition of the RCIS. I am confident that the SICP will continue to grow under his leadership. The SICP has grown tremendously

over the last 3 years. We now have 10 chartered chapters and 18 in the process of forming! I believe the chapter initiative is fundamental to our success. Get involved! If you know of a chapter near you, please attend a meeting. If there isn’t one already started or still in the process, find out how you can help. Participation in SICP helps not only you, but all of us working in invasive cardiovascular laboratories. There are many opportunities to get involved at the national level as well. As we prepare for Todd’s presidency, answering the call for nominations and volunteers is a great way to start helping out, whether as a board member, committee chair, or committee member. I urge everyone to get involved and give your time to your profession. Not only will you grow professionally, but you will meet extraordinary people with whom you can learn and share.

SICP in St. Louis

The Only Specialty Conference for Invasive Cardiovascular Professionals September 20-22, 2007 • Millennium Hotel St. Louis Keynote by David E. Allie, MD, Chief of Cardiothoracic and Endovascular Surgery, Cardiovascular Institute of the South This year’s conference will include: • Hot Topics in Cardiology • EP Overview • Diagnostic Imaging for PVD PV-CTA: A Revolution in Diagnosis and Management • Concentrated Calculations Review • Cath Lab 101 presented by Michael J. Lim, MD This course is AACN and SICP approved. ASRT approval is pending for Category A CE credit. Make your accommodation arrangements today by calling 800-325-7353. Be sure to reference SICP to receive the discounted rate of $129 per night. www.millenniumhotels.com

Registration information coming soon to www.sicp.com. Register early and reserve your time in the Medtronic Therapy and Procedure Training Center mobile unit. Early Bird Conference Registration Rates: SICP members ................................................................ $179 Non-Members................ $229 (includes 2007 membership) One Day........................................................................... $139 Students ........................................................................... $109

Thanks to our Industry Partners:

CORONARY HEART ™ 41


NURSING

H

ow to Work as in the USA for internationally trained nurses

S

o you have had enough. The unreliable weather of London, the sweltering heat of northern Australia, or the shear cold of southern New Zealand. Maybe you are a US hospital and would like to know what nurses abroad need to do to work in the USA. Here at Coronary Heart we are here to help. So every so often we will explore how you go about making the big change. This issue will look at international nurses applying to work in the USA. From the beaches of California, to the mountains of Colorado, and across the plains to the Big Apple, the US has it all, and with a high demand for qualified nurses, and great pay, there has never been a better time to pack your bags and move on over.

First things ďŹ rst: Before you do anything make sure you are actually entitled to obtain a work visa in the USA. The last thing you want to do is go through the entire process of completing the appropriate exams only find the US Government turns you way because you are not eligible for a visa. Visit the following website to get the low-down on visa requirements for foreigners: www.uscis.gov Also check with your US Embassy in your country for additional details.

42

CORONARY HEART ™


NURSING

a Cardiac Nurse The Basics of US Nursing: The National Council of State Boards of Nursing (NCSBN) - www.ncsbn.org is the main group you will be in contact with when you make the decision to apply. Basically this council a not-forprofit organization whose membership comprises the boards of nursing in the 60 states and US territories, including the District of Columbia, and four United States territories-American Samoa, Guam, Northern Mariana Islands, and the Virgin Islands. They are responsible for administrating the NCLEX examinations (explained later) for nurses.

Licensing Requirements? If you want to work in the USA you naturally have to obtain a license. The licensing system has been implemented for the complete protection of patients, ensuring that foreign nurses meet stringent guidelines to be able to work safely. Licensure provides title protection for those roles. It also provides authority to take disciplinary action should the licensee violate provision of the law or rules in order to assure that the public health, safety and welfare will be reasonably well protected.

First Steps:

by examination. Request an application specific to your qualifications for licensure as an RN or an LPN. Once you have submitted your application from them they will inform you if you are eligible for NCLEX exam, which is your ticket to the USA. The state boards are the best to speak to about gaining eligibility for the US. Visit the NCSBN website (www.ncsbn.org) for a directory of each state’s nursing board.

General licensure requirements include proof that you: • • •

• •

Have comparable nursing education Safely practiced nursing in home country Proof that you passed an approved test that demonstrates that you can read, write, speak and understand the English language (if you were not educated in English). Passage of the NCLEX examination Application fee

The NCLEX Exam is not as scary as it sounds, and the process is rather simple. For a simple tutorial to understand the testing format visit www.pearsonvue.com/ nclex

CGFNS and VisaScreen™ Some boards also require you CGFNS Certificate, CGFNS Credentials Evaluation Service or in some cases a VisaScreen™ certificate, before they will issue a nursing license. Visit www.cgfns.org for more information on these but check first if they are required by speaking to the nursing board you have chosen.

NCLEX Examinations: In order for you to obtain a license in the state of your choice you must first sit an NCLEX exam. If you are trained outside of the US there is no way around this, no matter where you studied.

The daily ride to the hospital just became enjoyable!!

This is the fun part of the application process; deciding where you want to work. Soaking up the rays in Malibu, dog sledding each evening in Alaska, or the reliving a lost childhood in Kansas searching for Toto. Either way you need to contact the appropriate state nursing board. Each site has link to their licensing requirements and contacts. Tell the board that you were educated outside the U.S. and ask them to send you an application to apply for a license

Colorado, USA CORONARY HEART ™ 43


PLACE TITLE HERE NURSING

Cardiac Nursing in the USA The NCLEX® examination is designed to test knowledge, skills and abilities essential to the safe and effective practice of nursing at the entry level and is only provided in a computerized adaptive testing format. You are not expected to know how to use a computer before you take the examination, as a tutorial will be included as part of the examination at the start. This tutorial will instruct you on the use of the mouse and how to record an answer. You have a total of six hours to complete the exam, so no need to worry. There are two types of tests: a NCLEXRN for registered nurses, and the NCLEX-PN for practice nurses. Contact the board of nursing or the testing department at NCSBN for assistance (e-mail nclexinfo@ncsbn.org)

Examination Fee: The fee for taking the NCLEX® examination is US$200. There also may be other fees for licensure required by the board of nursing in the jurisdiction in which you are applying. If you choose to schedule your NCLEX examination at a test center outside of the United States, you will have to pay a scheduling fee of $150 plus a Value Added Tax (VAT) where applicable. These fees will be charged when you schedule your examination appointment.

Applying for NCLEX: Once you have received your Aurthorisation to Test (ATT) confirmation from the state licensure you are applying to, you are eligible to take a NCLEX exam, the easiest way internationally is to apply online. Go to the NCLEX Candidate Web site (www.pearsonvue.com/nclex) and select the Registration option. Answer the questions, pay the fee, and 44

CORONARY HEART ™

you are ready.

Test Content:

Your ATT is only valid for a certain period, usually 90 days, and cannot be extended for any reason.

The practice of nursing requires knowledge of the health needs of clients as well as an understanding of integrated processes fundamental to nursing practice.

Scheduling Your Examination Appointment: Visit the NCLEX Candidate Web site (www.pearsonvue.com/nclex) and select Locate a Test Center at the top of the screen. For Area of Study select Professional Licensure & Certification and click Continue. From the list of testing programs select NCLEX Testing and click Continue. Then just find your location in the world. Simple!!

At the Testing Center: We suggest you download the NCLEX Candidate Bulletin from the NCLEX Candidate Web site (www.pearsonvue. com/nclex). It may be 21.8MB but provides you with all the information you need. We have provided you with a brief rundown. You need to take along your valid ATT and a current passport. No other identification will be accepted. A digital fingerprint, signature and photograph will be taken at the test center and will accompany your examination result. Your fingerprint, signature and photograph may be used to confirm your identity by the board of nursing to which you have applied for licensure. You cannot be tested without having your fingerprint, signature and photograph taken. During the test you will be observed at all times. This will include direct observation by test center staff as well as video and audio recording of your examination session.

After the Test: Congratulations on passing! Remember to ask for a copy of the Nursing Practice Act in the state you are licenced to practice. Also read the paperwork carefully as some states issue temporary permits which means you may have to apply for a U.S. Social Security Number, to finalize your nursing license.

Changing State License: So, you have discovered that the skiing is better in Colorado than Washington, but you already have a license in Washington. No worries. Just contact either the NCSBN or the State Board you wish to transfer to, fill in the forms, pay the fee and you’re done. This is called a Licensure by Endorsement, and is only applicable for those who have completed the NCLEX from another state or territory. There is no need for you to retake the NCLEX test.

References: www.ncsbn.org/InfoINTLRevised.pdf

Websites to get started: www.ncsbn.org www.uscis.gov www.pearsonvue.com/inclex

Don’t forget to check on our website for more cardiac cath jobs.


CONFERENCES

Meetings 2007 - 2008 Date

Name

Location

Website / Contact

July 23-25

Endovascular Summit

Colorado Springs, CO, USA

www.endovascularsummit.com

August 9-12

55th ASM of the Cardiac Society of Australia and New Zealand

Christchurch, New Zealand

www.csanz.edu.au

September 1-5

European Society of Cardiology Congress (ESC)

Vienna, Austria

www.escardio.org

September 5-8

8th Annual New Cardiovascular Horizons

New Orleans, LA, USA

www.newcvhorizons.com

September 20-22

SICP Annual Conference

St Louis, MO, USA

www.sicp.com

October 6-10

SICP’s Signature RCIS Review Course at ACE

New York, NY, USA

www.sicp.com

October 6-10

ACE: Advances in Cardiac & Endovascular Therapies

New York, NY, USA

www.ny-ace.com

October 18-21

American Association of Cardiovascular and Pulmonary Rehabilitation 22nd Annual Meeting

Salt Lake City, UT, USA

www.aacvpr.org

October 20-24

Canadian Cardiovascular Congress 2007

Quebec City, Canada

www.css.ca

October 20-25

TCT 2007: Transcatheter Cardiovascular Therapeutics

Washington DC, USA

www.tct2007.com

October 21-22

TCT SICP’s Signature RCIS Review Course

Washington, DC

www.sicp.com

October 29-31

Heart Rhythm UK Congress

Birmingham, UK

www.ukheartrhythm.org.uk

November 4-7

AHA Scientific Sessions

Orlando, FL, USA

scientificsessions.americanheart.org

November 25-30

RSNA

Chicago, IL, USA

www.rsna.org

December 12-13

Madrid Arrhythmia Meeting

Madrid, Spain

www.mamweb.org

Advanced Angioplasty 2008

London, UK

www.andvancedangioplasty.co.uk

March 29 - April 1 ACC 2008 + i2 Summit

Chicago, IL, USA

www.acc08.acc.org

May 14-17

Heart Rhythm 2008 - 29th Annual Scientific Sessions

San Francisco, CA, USA

www.hrsonline.org

May 28-31

SCAI 31st Annual Scientific Sessions

Las Vegas, NV, USA

www.scai.org

2007

2008 January 23-25

CORONARY HEART ™ 45


EMPLOYMENT ADVERTISING

United States of America

Enjoy A Quality of Life

Second to None

You’ll enjoy a great work environment, generous compensation and benefits, state-ofthe-art technology, relocation assistance and the satisfaction of working with a dynamic team of professionals. Join us and see where it will take you!

• Cath Lab RNs • Cardiovascular Technologists CVPH Medical Center is on the shores of Lake Champlain at the Foothills of the Adirondack Mountains. We’re just one hour south of Montreal and an hour northeast of the Lake Placid Olympic region. The marriage of high technology, small town charm and friendliness make CVPH a unique opportunity for health care professionals.

Visit our website at: www.cvph.org or call 800-562-7301 Please apply to: Human Resources, CVPH Medical Center, 75 Beekman Street, Plattsburgh, NY 12901 or fax to 518-562-7302 or email: hr@cvph.org EOE

July / August 2007

Valley View Hospital

is looking for a few good

hearts

Dedicated professionals who are caring and compassionate people.

A meaningful mission, an exceptional workplace

PLANETREE

t Valley View Hospital, an 80-bed, full service community hospital, all of our patients are lucky enough to benefi t from our Planetree philosophy of patient-centered care. A holistic approach to healing, it combines conventional medical therapies with alternative therapies and therapeutic massage to maximize healthcare outcomes. Our community hospital is located halfway between Vail and Aspen and a three-hour drive west of Denver in scenic Glenwood Springs, Colorado. Our community is nestled in the Rocky Mountains where life is exhilarating and recreation is plentiful. Here, you can explore the Glenwood caverns, camp, hike, bike, ski, raft, kayak and fish. If you’d like to be part of our progressive and exciting healing environment, join us for a rewarding future.

CATH LAB RN

Full-time position available in our Cath Lab. Required: ACLS and RN, with 5 years of experience. Preferred: Cardiac and peripheral experience. We offer an excellent compensation package that includes health/dental coverage, a pension plan, 22 paid days off per year, daycare availability, discounted ski passes, and more.

Apply online using our new application system! If you have not checked us out lately, be sure to go to

www.vvh.org. EOE

Valley View Hospital 1906 Blake Avenue • Glenwood Springs, Colorado • 970.945.6535

CLINICAL EXPERTISE DOESN’T JUST HAPPEN Clinically analyzing what patients need comes from a dedication to education, scientific inquiry, and a desire to be the best. Working with the Hospital of the University of Pennsylvania, you will have the opportunity to work where technology is making a remarkable impact on health care and how nursing is practiced. Explore our EPS Lab opportunities and find a commitment to your professional growth, excellent compensation, 100% prepaid tuition and much more. We are expanding our services and seeking the following EPS professionals to join our team: EPS LAB REGISTERED NURSE — Job Code # 968569 Critical Care experience, a current PA RN License and BLS and ACLS Certification are required. A BSN and EPS Lab experience is preferred. EPS LABORATORY MANAGER — Job Code # 15611 Current PA RN license with a BSN and BLS/ACLS certification or Technician with RCIS certification. EPS RN EDUCATION SPECIALIST — Job Code # 968703 A minimum of 3 years of EPS experience, and BLS, ACLS and either RCIS certification or a current PA RN license are required. NASPExAM TESTAMUR certification preferred. EPS EDUCATION SPECIALIST — Job Code # 901613 A minimum of 3 years of EPS experience, and BLS, ACLS and RCIS certification are required. NASPExAM TESTAMUR certification preferred. CARDIAC CATH/EPS LAB TECHNICIAN — Job Code # 19095 BLS and ACLS Certification is required. RCIS is preferred. For a complete position description and to apply on-line, please visit: www.pennhealth.com/jobs and select the appropriate Job Code # as listed above.

www.pennhealth.com/jobs AA/EOE, M/F/D/V

46  CORONARY HEART ™


United States of America

EMPLOYMENT ADVERTISING

July / August 2007

Looking for the Best Travelers and Travel Assignments? Specializing in Nurses & Technologists for: • Cardiac Cath • ElectroPhysiology • Interventional Radiology • Special Procedures • Computerized Tomography

S P E C I A L I Z E D

M E D I C A L

w w w . M e d S o u r c e Tr a v e l e r s . c o m

Your New Dress Code...

Sunglasses, Sandals & Swimsuits! Looking for an exciting work environment, wonderful team members & the beautiful Delaware beach resort right in your own backyard? Join the Beebe family today! We are experiencing unprecedented growth and are very excited about our new Interventional and Invasive Cardiology program. CARDIAC CATH TECHS Excellent opportunities for registered Cardiac Cath Techs. Must obtain Delaware licensure. Be a part of our new interventional cardiac program and expand your career with this exceptional team. ECHO TECHS Seeking RDCS or RCS Echo Techs. Two-three years exp., with exceptional technical and diagnostic skills. Immediate need due to expansion. WE OFFER A FANTASTIC SIGN-ON BONUS AND RELOCATION ASSISTANCE PROGRAM Ask HR for details. Please visit our website for more information and detailed job descriptions: www.beebemed.org We offer competitive compensation and benefits.

Beebe Medical Center

424 Savannah Rd., Lewes, DE 19958 302-645-3336 • fax: 302-645-0965 Apply online at: www.beebemed.org employment@bbmc.org • EOE

R E S O U R C I N G

To l l F r e e : 8 0 0 4 4 0 1 9 0 9

Recruitment Advertising Rates

Why Pay More?

Online only: $150 for 60 days + hypertext link

Magazine + Free Online: 1 Column (2.4”)= $50 per inch 1/4 Page = $400 1/2 Page = $600 Full Page = $1000

COLOR

no extra cost Contact:

advertising@coronaryheart.com Prices are Net and do not include agency commission

CORONARY HEART ™ 47


Let us help you solve your cardiovascular and imaging challenges. EDUCATION Boost employee retention and cut the productivity losses that often accompany new hires or service lines with Healthworks clinical education programs, available both onsite and online.

CONSULTING Resolve challenging service line issues like staffing shortages, quality assurance, inventory control and cath lab planning and construction with expert advice from Healthworks consultants.

STAFFING “When I call Healthworks, I don’t have to worry about quality.”

Meet your staffing needs with help from our experienced technologists and nurses. Or achieve financial efficiencies of up to 30% when Healthworks manages and staffs your lab. Staffing services are currently available in the Mid-Atlantic region. To find out more, just call us at 1-610-385-1227 or e-mail marketing@ healthworksonline.cc.

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Solutions for cardiovascular and imaging services 515 Old Swede Road, Suite C-1, Douglassville, PA 19518 Phone 610-385-1227 n Fax 610-385-1229 www.healthworksonline.cc


Coronary Heart #7 US