CardiologyHD #39

OUR FINAL EDITION • THANK YOU FOR YOUR SUPPORT

Issue 39 • Nov/Dec 2012See the online version atCardiologyHD.com

READ ALL OF OUR MAGAZINES ON OUR WEBSITE : CardiologyHD.com

Mobile Cath Lab Effi cienciesThat You Can Implement

2 Nov/Dec 2012 www.cardiologyhd.com

CONTENTS

FINAL EDITION

EDITORIAL BOARD

03PRODUCT NEWSRound-UpGet the latest news from companies related to their new products.

06INTERVIEWDr Magdi El-OmarWe speak with our Lead Consulti ng Editor, Dr Magdi El-Omar.

13ECG CHALLENGEAnswerHere you can fi nd the soluti on to the Charles Bloe Training ECG Challenge.

05CHARLES BLOE TRAININGECG ChallengeAnother challenging ECG Challenge to test your skills. Answer on page 13.

08MOBILE LABSMaximising Effi ciencyAn interesti ng case study of the Regent’s Park Mobile Cath Lab service in Exeter.

Overview, Facts, & ThanksPages 3-5, & 15 contain informati on related to our last editi on of this publicati on. Our company will sti ll conti nue, however we will be working on other exciti ng projects. Thankyou for your support during the fi rst six years of our company’s journey. Now the really cool stuff starts!!

14JOURNALSGlobal UpdateOur popular and entertaining journal trawl from around the world.

10SITE VISITCairns Private HospitalWe visit beauti ful Far North Queensland in Australia for our fi nal site visit.

Dr John PaiseyJournal ReviewerConsultant Cardiologist, Royal Bournemouth Hospital

Dr Dan McKenzieJournal ReviewerConsultant Cardiologist, Musgrove Park Hospital

Prof Simon RedwoodConsulti ng EditorConsultant Cardiologist, Guy’s & St Thomas’ Hospital

Dr Rodney FoaleConsulti ng EditorConsultant Cardiologist, Imperial College Healthcare NHS Trust

Mr Dennis SandemanNursing Consulti ng EditorChest Pain Nurse Specialist, NHS Fife

Ms Sophie BlackmanManagement & CRM Consulti ng EditorHead of Clinical Cardiac Physiology, West Hertf ordshire NHS Trust

Mr Tim LarnerDirector & Chief Editor

Dr Magdi El-OmarLead Consulti ng EditorConsultant Cardiologist, Manchester Heart Centre

Dr Richard EdwardsConsulti ng EditorConsultant Cardiologist, Freeman Hospital

Prof Ahmed MagdyConsulti ng Editor (Middle East)Head Unit Cardiology, Nati onal Heart Insti tute, Cairo

Disclaimer:This publicati on should never be regarded as an authoritati ve peer reviewed medical journal. This publicati on has been designed as a guide only, to inform readers who work in the cardiology environment about latest news stories and the diff erent techniques used by others around the world. Whilst all care is taken in reviewing arti cles obtained from various companies and contributors, it is not possible to confi rm the accuracy of all statements. Therefore it is the reader’s responsibility that any advice provided in this publicati on should be carefully checked themselves, by either contacti ng the companies involved or speaking to those with skills in the specifi c area. Readers should always re-check claims made in this publicati on before employing them in their own work environment. Opinions expressed by contributors are their own and not necessarily those of their insti tuti on, Coronary Heart Publishing Ltd or the editorial staff .

Copyright © 2006 - 2012 by Coronary Heart Publishing Ltd. All rights reserved. Material may only be reproduced by prior arrangement and with due acknowledgment of Coronary Heart Publishing Ltd. The publicati on of an adverti sement or product review does not imply that a product is recommended by Coronary Heart Publishing Ltd.

+ more editors online

Cover Photo (from left): Genalyn Carreon, Sofia Pereira, Penny Cantelon, and Tim Larner from the Regent’s Park Week 1 “A”-Team in the mobile lab in Exeter.

Above (from left): Genalyn Carreon, Sofia Pereira, and Penny Cantelon. See the article on page 8.

- Photos by Bryn Webber, Regent’s Park Clinical Services Director. Camera: Samsung Galaxy S3.

www.cardiologyhd.com Nov/Dec 2012 3

PRODUCT NEWS[ Round-Up ]Siemens delivers advanced cardiovascular CT training with the Briti sh Insti tute of Radiology Siemens Healthcare, in partnership with the Briti sh Insti tute of Radiology (BIR), hosted a successful four day advanced cardiovas-cular CT training course for imaging professionals. It was developed to provide delegates with the case volume, formal teaching and the fi rm understanding of best cardiovascular CT practi ce required for advanced cardiovascular CT training. It was also suited to those working towards BSCI / SCCT accreditati on in cardiovascular CT. The course provided access to 150 cases to develop delegates’ ana-lyti cal CT skills and supplied representati ve cases of non-coronary disease including congenital heart disease, pre-ablati on assess-ment and Transcatheter Aorti c Valve Implantati on (TAVI) assess-ment. 17 recorded cases were also provided, allowing interacti ve discussion. Short didacti c teaching sessions on pathology and related technologies were also provided for delegates. An opti onal additi onal 25 in-room parti cipati on cases were facilitated through att endance at Royal Brompton Hospital and King’s College Hospital aft er the course.

Community Echocardiography Supporti ng NHS Community echocardiography is now very much part of mainstream cardiology with more and more NHS organisati ons commissioning pati ent centred, cost eff ecti ve cardiac ultrasound services delivered in primary care setti ngs.

Last year’s Briti sh Cardiovascular Society publicati on Commissioning of Cardiac Services states, “Transthoracic echocardiography may be performed in a hospital or community setti ng and community based services should meet the requirements of the Briti sh Society of Echocar-diography (BSE) Departmental Accreditati on programme.”

For Echotech, a BSE Accredited Department and the UK’s leading provid-er of community echocardiography services, this has meant a signifi cant increase in the demand for the Company’s service. In response, Echo-tech has purchased fi ve GE Healthcare Vivid ultrasound systems since April. As the demand for Echotech’s service conti nues to rise further, more purchases are expected into 2013.

According to Echotech Managing Director Dominic Elton, “We are com-mitt ed to using the Vivid ultrasound systems due to the high quality of imaging provided and the effi cient sales and support services off ered by the GE Healthcare team.”

This is the fi nal editi on of our magazine both as a hard copy and digital version. The website CardiologyHD.com will conti nue so you can access all the previous arti cles and engage on the

community forum. The magazine started in mid 2006 and has since then grown in popularity to become one of the most popular car-diology general interest publicati ons globally with readers from over 138 countries. Unlike many companies who went bankrupt during the recent fi nancial crisis, our magazine grew in reader popularity, however 2013 looks like a very challenging year as the majority of companies have “no-budget” to adverti se with us. So we chose to cease producti on whilst sti ll in profi t, and on our terms.

Above: EchoTech Clinical Operations Director Keli Glover with Managing Director Dominic Elton

[ Our Final Editi on ]


“Don’t Cut Your Tips”New recycling program buys your whole used EP cathetersIn the past, EP staff could only cut the ti ps of EP catheters as part of a plati num recovery pro-gram. Now these departments are earning up to four ti mes more by recycling many of their whole catheters with EPreward.

Increase your departments earnings up to four fold. EPreward, a U.S. company developed and managed by an EP nurse, purchases a wide variety of whole diagnosti c EP and ultra-sound catheters. Their new program greatly increases the payments earned by Cardiology Departments from outdated plati num ti p companies.

To verify this diff erence in earnings, a prominent NHS hospital conducted a side by side test using an identi cal batch of catheter ti ps. Payment from The London Refi nery, EP Recyclers/Eco-Wires Recycling, EPreward’s high paying Plati num Recovery service and EPreward’s whole catheter “Buy Back” program was determined for the same 345 catheters with the results shown below.

The London Refi neryPlati num Recovery

EP Recyclers/Eco-Wires Recycling

Plati num Recovery

EPrewardPlati num Recovery

EPrewardWhole Catheter Buy Back

£ 651.79 £ 818.06 £ 1,445.90 £ 3,191.00

NHS Hospital’s earnings for an Identical Group of 345 EP Catheters

EPreward documents every catheter and catheter ti p, provides all collecti on materials and pays for shipping. Time to sett lement is one week from the date of receipt. Their website also contains over 75 FREE educati onal programs, a Training and Review secti on and much more. Don’t sett le for less, receive the earnings you deserve with EPreward.

Contact EPreward and your hospital Waste Manager to verify the status of this program for your facility.

Reach them by email: [email protected], website: www.epreward.com or phone: 001-561-375-7857

[ CardiologyHD Facts ]Medisti m’s UK SubsidiaryMedisti m, a world leading medical equipment supplier to cardiac and vascular surgeons as well as other medi-cal specialists, has announced the establishment of a UK subsidiary.

The move strengthens Medisti m’s commitment to the UK market following the Nati onal Insti tute for Health and Clinical Excellence (NICE) recommendati on of its innovati ve VeriQ™ fl ow measurement system for routi ne clinical use and cost savings of more than £115 per pati ent. NICE also supported the clinical evidence, suggesti ng reducti on of early graft failure, stroke, myocardial infarcti on or recurrent angina.

Medisti m President and CEO, Kari E. Krogstad, stated, “We have received considerable interest from many UK cardiac centres in using our VeriQ™ fl ow measurement system fol-lowing the NICE recommendati on for assessing graft blood fl ow during coronary artery bypass graft surgery.

The Medisti m VeriQ system uses two well-estab-lished ultrasound principles to measure graft patency in coronary artery bypass graft surgery (CABG); transit ti me fl ow measurement (TTFM) and Doppler velocity.

For more informati on visit www.medisti m.com

[Medisti m, a world leading medical equipment supplier to cardiac and vascular surgeons as well as other medi-cal specialists, has announced the establishment of a

The move strengthens Medisti m’s commitment to the UK market following the Nati onal Insti tute for Health

clinical evidence, suggesti ng reducti on of early graft failure, stroke, myocardial infarcti on or recurrent angina.

Medisti m President and CEO, Kari E. Krogstad, stated, “We have received considerable interest from many UK cardiac centres in using our VeriQ™ fl ow measurement system fol-lowing the NICE recommendati on for assessing graft blood

• We were the fi rst cardiology publicati on internati onally to be downloadable free as a PDF online.

• In the early years we had 3 diff erent versions of the magazine depending upon geographical locati on: UK/Ireland, USA/Canada, & Australia/NZ.

• Aft er only 18 months we had over 1000 testi monials from all over the world supporti ng our magazine.

• Our Facebook page launched in July 2009. With now over 1300 fans, we have one of the largest fan bases for a cardiology publicati on globally.

• We stopped distributi ng to the Australia / NZ market aft er several leading companies at one of their conferences stated that we were naïve to think they had any interest in reaching managers and staff .


History

This 72 year old man presents at 2pm with a history of chest pain and shortness of breath. The pain came on at rest about 8 hours previously and has varied in intensity since. He describes it as a dull ache in the centre of his chest. It is not radiati ng. He is pale.

His vital signs are within normal limits although his blood sugar is elevated at 16 mmols/L on admission.

What is your conclusion? See the answer on page 13

Online ECG Challenges: We have multi ple ECG Challenges on our website for you to challenge yourself, along with a variety of educati onal topics related to cardiology.

Visit our website: www.cardiologyhd.com

CHARLES BLOE TRAINING[ ECG Challenge ]

• Editi on 1 was promoted as a ‘Double Editi on” because the initi al plan was to release the magazine monthly.

• We were the fi rst publicati on to be endorsed for CPD by the Society of Radiographer’s in the UK.

• 46 Global Site Visits completed. The Heart Hospital in London was the only one completed but never published.

• 62 females, 31 males, and 1 dog have appeared on the cover.

• We changed the name Coronary Heart to CardiologyHD because people thought we just focussed on coronary heart disease. CardiologyHD was chosen aft er we spoke with several companies about launching a medical video service. Unfortunately every company that stated their support in the beginning had “no budget” aft er we launched it. Go fi gure!! We sti ll think it is a prett y cool name though.

[ CardiologyHD Facts ]


INTERVIEW[ Dr Magdi El-Omar ]

Where did you train?

I trained at St Bartholomew’s Hospital Medical School (MBBS) with a BSc in Pathology at Guy’s. My junior doctor years were spent mostly in London and Oxford. In 1993, I became a ‘Career Registrar in Cardi-ology’ (West Midlands Rotati on), but left this early to carry out some research at the John Radcliff e Hospital in Oxford. I then moved to Cardiff to do my MD with Professor Ajay Shah (BHF Junior Research Fellowship), then became ‘Calmanized’ as a Specialist Registrar in Cardiology on the All Wales Higher Training Scheme in Cardiology. In 2001, I travelled to the USA to complete an Interventi onal Cardiology Fellowship, initi ally at Lenox Hill Hospital, then NYU Medical Centre. I then returned to Wales as an ‘expired’ SpR in Cardiology, and in 2004 was appointed a Consultant Interventi onal Cardiologist at the Manchester Heart Centre.

Why did you become a cardiologist?

I suppose I have always been fascinated by the heart: an organ that keeps the body alive, beati ng relentlessly from birth ti ll death. Coupled with a love of practi cal procedures, I initi ally wanted to become a cardiothoracic surgeon, and in fact did my student electi ve at the Brompton and Harefi eld Hospitals with Professor Sir Magdi Yacoub. Following this, however, I quickly realised that Cardiology is a more att racti ve career opti on as it has the right mix of clinical, diagnosti c and interventi onal skill, rather than relying primarily on manual dexterity. Cardiology also is a unique specialty in the sense that the same physician can investi gate, diagnose and treat without necessarily resorti ng to other specialists for help.

What are your interests within interventi onal cardiology?

My main interests lie within the fi elds of acute coronary syndromes and vascular biology. I am parti cularly proud of the fact that I have been local PI for some landmark ACS trials, including HORIZONS, INFUSE-AMI and BRIDGE. As an unwavering, committ ed femoral operator, I have also taken a keen interest in vascular closure devic-es, parti cularly extravascular ones, and have proctored on the use of these devices in internati onal conferences. I am also interested in OCT and am trying to forge research collaborati ons with some of the most respected internati onal names in the fi eld. Finally, and with the help of one of my in-house colleagues, I hope to establish a renal denervati on service at the MHC, aiming to uti lise this thera-py not only for pati ents with resistant hypertension, but also those with other conditi ons where sympatheti c over-acti vati on plays an important pathophysiological role, e.g. heart failure.

What do you see as being the biggest developments in the fi eld of interventi onal cardiology, and can you predict some future developments?

The biggest development has undoubtedly been the introducti on of a 24/7 primary PCI service. More recently, percutaneous treatment of valve disease (e.g. TAVR) and renal denervati on have entered the clinical arena. Bioabsorbable stent technology conti nues to evolve and before long, will have an established place in the treatment of obstructi ve CAD. I think the future will see most valve disease being

treated percutaneously and more hypertensives, and a lot of heart failure pati ents, being off ered renal denervati on therapy at an ear-ly stage of the disease process. I also believe that the concept of coronary plaque sealing will be ‘resuscitated’ at some stage in the future, parti cularly as techniques for the detecti on of vulnerable coronary plaque conti nue to be refi ned.

You started the Manchester Preceptorship for GPs. Please explain what this is?

This is a one-day preceptorship in Cardiology aimed at GPs and other primary health care professionals. The main aim is to foster the relati onship between primary and secondary care and to share with guests clinical experti se and the latest techniques and think-ing in Cardiology, in the setti ng of a large terti ary centre. Att endees have the opportunity to experience diff erent aspects of Cardiology and parti cipate in interacti ve lectures and practi cal sessions, includ-ing at least one case of PCI in the cath lab. The Preceptorship has been on-going for 5 years, and we have had 35 such visits so far. It is industry-sponsored.

What are your interests outside of the hospital?

My family takes precedence over any other leisurely acti vity, and I approach the upbringing of my children very seriously. However, hav-ing had a very reproducti ve career (essenti ally repopulati ng Altrin-cham), such a task is oft en very challenging. What litt le extra ti me I have, I spend oil painti ng (mostly landscapes - see image above), fi sh-ing or playing football. However, because of a recent hip injury, my illustrious footballing career came to an abrupt halt, which caused me dismay, but delighted my team mates! Despite the geographical locati on of where I live, I support neither Man Utd, nor Man City!

CardiologyHD Lead Consulting Editor & Consultant Interventional CardiologistManchester Heart Centre, Manchester, UK

www.manchestercardiologist.co.uk

Edwards LifesciencesIrvine, USA I Nyon, Switzerland I Tokyo, Japan I Singapore, Singapore I São Paulo, Braziledwards.com

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Most staff feel there is never enough space within a cath lab or that producti vity could be improved, but imagine how that is magnifi ed for those working in a high-intensity

mobile lab, with a preset ti me frame and a high number of proce-dures in which to complete them. Over the past weeks we have been two members of a highly specialised cardiac team working on one of Regent’s Parks’ Mobile Cardiac Catheter Labs based at the Wonford Hospital, Exeter. This mobile lab was brought in as part of a wait-ing list initi ati ve to reduce pati ent waiti ng numbers by approximately 400 over a seven-week period.

In this arti cle we describe the lessons we have learnt and some of the processes that were implemented. We hope that by sharing our experience it may open up some interesti ng areas for discussion within your department.

Service overview

The facility

The mobile cath lab was delivered to site in advance of the go-live date to allow for the integrati on of incoming services e.g. Power, Water, IT & Telephony. The facility itself consists of the cath lab (pro-cedure) area, a control area (physiologist workstati on), an offi ce area and a plant room (X-ray cabinets, switches etc).

The mobile lab was set-up alongside a dedicated day-ward with a temporary protecti ve cover installed to protect staff and pati ents from the outside elements. All pati ents were transported to and from the lab using a transport trolley.

The staff

The Regent’s Park cath lab team comprised of 4 members: 2 nurses, 1 physiologist, and 1 radiographer. In additi on, the operator was provided by the Trust. Over the seven-week period several Regent’s Park team members rotated through, however there was always at least one member each week that knew the operati onal processes to ensure a smooth transiti on. It was essenti al that all members of the Regent’s Park team were able to demonstrate the ability to work well under pressure and to functi on as part of a team while maintaining the ability to problem solve and create soluti ons to the unique chal-lenges that this environment requires.

The Hospital

The hospital provided a dedicated six-bed day ward, with ‘ring-fenced’ beds. This was located within a building directly alongside the mobile lab. Although located in a diff erent part of the hospital from their main department it allowed access to/from the mobile lab via one external door thereby keeping pati ent transit ti mes to

an absolute minimum. The day ward was staff ed by the Trust and consisted of two nurses and a ward clerk.

Start of Day: Pati ent Arrival

Pati ent appointment ti mes were sent out several weeks prior to the arrival of the mobile lab. In additi on, on the Friday before their pro-cedure, the ward clerk would call each pati ent to remind them of their appointment ti me, as well as explaining their arrival locati on. Each day was booked for single sex pati ent lists in line with local and nati onal guidelines. The pati ents were scheduled to arrive at inter-vals and would be received by the ward clerk allowing the nurses to concentrate on preparing each pati ent. The consultant cardiologist would ensure the fi rst three pati ents had been consented by 9am to ensure a prompt start ti me.

MOBILE LABS[ Achieving Maximum Effi ciency ]

Mr Tim LarnerDirector of Coronary Heart Publishing Ltd& Senior Radiographer, Regent’s Park

Ms Penny CantelonCardiology NurseRegent’s Park

Regent’s Park Week 1 Team (from left): Genalyn Carreon, Sofia Pereira, Tim Larner, and Penny Cantelon


During Day

Teamwork is essential in any cath lab environment. Whilst everybody had their primary role, each member was prepared to assist others when the need arose. During the day, a runner nurse and radiogra-pher would collect the patient whilst the scrub nurse set-up for their arrival with the assistance of the physiologist. At the end of a case, the radiographer and the scrub-nurse from the case would take the patient back to the day-ward for handover, and the system was then repeated, the 2 nurses exchanging roles. Handover at the bedside, both on collection and arrival established clinical details, approach and plan. The physiologist would ensure the lab was clean and pre-pare the table. In between cases the cardiologist would report the case and consent any remaining patients.

Mobile Lab Post Case

All patients (unless contraindicated or if the patient was to have a TAVI/other procedure requiring an 8F sheath in the near future) received an Angioseal. Except where contra-indicated, Angiosealed patients included patients who were to have a PCI in the next few days within just a few days of their angiogram also received them. Radial approach was also used and provided the opportunity to recover patients in a chair freeing up valuable bed space.

Day Ward Post Case

Patients had a three-hour stay post procedure. The first hour con-sisted of bed rest, with the following two hours spent in a chair. The chairs were arranged at the end of the ward alongside each other and proved popular with patients who were able to chat with other

making for a very sociable environment, whilst allowing the nurses to prepare beds for subsequent patients. Patients relatives were given a contact card with a number to call after three hours to check on the progress and estimated collection time. This helped to ensure they did not attend the department until necessary.

Ultimately we are all working in healthcare with the same goals. This includes providing the highest possible standard of care and improv-ing the experience of our patients during their hospital admission.

We hope that you have enjoyed hearing our experiences of working within a mobile cath lab service. It was truly a wonderful experience with an excellent team, and we look forward to all working together again soon.

About Regent’s Park Cardiovascular Solutions

Regent’s Park Cardiovascular Solutions (RPCVS) has been providing a range of high quality cardiovascular solutions to the healthcare services industry since 2002. Our supply of healthcare equipment and buildings include modular cardiac catheterisation labs, hybrid operating theatres with surgical and imaging capabilities, vascular labs, as well as major radiology equipment such as MRI and CT. Bringing together all of our solutions, we provide the infrastructure to design, build, finance and operate car-diology centres, cardiothoracic hospitals, as well as diag-nostic and imaging centres for cardiovascular disease in both the traditional hospital setting as well as in the com-munity alongside GP’s. See www.rpcvs.co.uk for more information.

RPCVS has a sister company, called Regent’s Park Heart Clinics (RPHC), that develops strategic partnerships with groups of cardiologists, hospitals and primary care organi-sations. See www.rphc.co.uk for more information.

RPCVS and RPHC are part of the Regent’s Park Healthcare group - a consolidation of visionary healthcare companies focused on providing world class standards of healthcare. See www.regentsparkhealthcare.com for more information.

To discuss the requirements of your organisation or to find out more about working for Regent’s Park please contact:

Mr. Bryn Webber Cardiac Services [email protected] +44 (0)7966 987712

Join us at the heart of excellence. LEAD CARDIAC PHYSIOLOGIST Full-time Wellington Hospital, London We have an opportunity for a motivated, experienced and enthusiastic Lead Cardiac Physiologist to join ourhigh-calibre team at the Wellington Hospital - the UK’slargest private hospital, renowned for providing an unquestionably high-standard of care by way of specialist expertise and state-of-the-art technology. Supporting the Cardiology Manager in the delivery of technical cardiology services, you’ll bring highly specialist clinical and technical knowledge and skills, including experience of invasive and/or non-invasive cardiac procedures including echocardiography.

To find out more about the Wellington Hospital, please visit www.thewellingtonhospital.com

To find out more about working for an HCA-affiliated facility, and to apply, please visit www.hcarecruitment.com

Special thanks to Dr Andrew Sharp (RD&E Consultant Cardiologist), Ms Justine Davenport (RD&E Ward Clerk), & Mr Bryn Webber (Regent’s Park Cardiac Services Director) for their assistance with this article.


Cairns Private Hospital, 1 Upward StCAIRNS QLD 4870Australia

CairnsCairns is a regional city in Far North Queensland, Australia, 1700km by road from Brisbane and 2700km from Sydney. The current populati on is approximately 153,000 with residents experiencing a warm tropical climate with temperatures averaging 25oC in the winter to 31oC in the summer.

Tourism plays a major part in the Cairns economy, with the city being classed by Tourism Australia as the fourth-most popular desti nati on for internati onal tourists in Australia aft er Sydney, Melbourne and Brisbane. This is mainly due to the city’s close proximity to the Great Barrier Reef.- Source: Wikipedia

SITE VISIT[ Cairns Private Hospital ]

CairnsCairns

Sydney

The Cairns Private Hospital in Tropical Far North Queensland – Paradise!


What is the size of cardiology department and hospital?

The Cairns Private Hospital’s Cardiac Services incorporates an eight bed Coronary Care Unit, the Cardiac Catheter Lab, a five bed Cardiac Recovery Unit and Exercise Stress Testing Service.

The Cairns Private Hospital is a 123 bed acute care facility owned and operated by Ramsay Health Care. The Cairns Clinic and the Cairns Day Surgery are also separate Ramsay facilities located nearby. The three sites are referred to as Ramsay Cairns.

What is the geographical intake area and population served by your hospital?

The Cairns Private hospital admits patients from Tully in the south, Weipa and Thursday Island in the north and Georgetown in the west. Patients from Papua New Guinea and Fiji are also admitted as are interstate and overseas tourists. Tourists have been admitted while cruising on the cruise ships, visiting family members, and during their holidays to the region. The population in this Far North Queensland catchment area is approximately 280,000 people.

How many cardiologists and staff? Roles?

There are currently five cardiologists at the Cairns Private Hospital: two of whom perform interventional procedures, two perform diag-nostic and pacing procedures and one is a consulting cardiologist.

There is a Nurse Unit Manager for the entire Cardiac Services, a Level 2 Nurse Educator dedicated to the catheter lab, a Level 2 Registered Nurse, 15 Registered Nurses and three Endorsed Enrolled Nurses employed part time and our lone Radiographer.

Types of Procedures?

The types of procedures performed are: Diagnostic Angiograms; Right Heart Studies; Angioplasty; Bi Ventricular PPM, dual and single chamber PPM; ICD; EVAR (Endovascular Abdominal Aortic Aneurysm Repair); as well as endovascular interventions and pain management device insertion (spinal cord stimulator).

Types and brands of equipment used?

Equipment featured throughout the cath lab includes Philips moni-tors (XIMS Patient Archiving Collection Systems), St Jude FFR pres-sure wire, Amexion Angiojet, Maquet IABP and a Toshiba Infinix CF-i/SP which was installed in 2009 and is used for both coronary and vascular procedures. This replaced the original Toshiba system which was at the end of life.

Have you had any new equipment installed recently?

The latest equipment the hospital has acquired is the Angiojet Thrombectomy system. The Angiojet is used for clot removal during vascular procedures.

How many procedures are performed a year?

Cairns Private Hospital performs approximately 1000 studies per year. Procedures for 2012 to date include:

Diagnostic Coronary Angiograms: 600-700Percutaneous Coronary Interventions: 150-200ICD implantations: 30-40Permanent pacemakers: 100Peripheral procedures: 60

Above (from left): Cardiologists Dr Chin Lim, Dr Richard Chan, Dr Joseph Ling, Dr Greg Starmer, Dr Tim Carruthers and Cardiac Services Nurse Unit Manager Claire Harding.


What is the percentage of Cath Lab cases performed radially compared with femorally?

Equal ratio of 50-50.

What new procedures / techniques have you implemented into the department recently? Future?

In June 2011 Cairns Private Hospital commenced endovascular interven-tional procedures in the CCL. This includes peripheral angioplasty stent-ing, EVAR, IVC filter insertion and removal and portacath implantation and removal. The vascular proce-dures performed contribute to the broadening of the services provided within the cath lab.

The CCL is currently developing a 24 hour rescue angioplasty service to provide urgent treatment to the patients within this region. This may be in partnership with the public hospital to benefit the entire community.

What are the benefits to patients attending your facility?

The patients are seen straight away, there is little or no travelling involved (prior to the cath lab opening, patients would be referred to and treated in Townsville), and patients are assessed and treated from diagnosis to rehabilitation.

There is currently little or no waiting time for diagnostic procedures in the cath lab. CPH is the referral hospital for several smaller hospi-tals up to two hours drive away as well as more remote destinations accessible by rescue helicopter and the Royal Flying Doctor Service (RFDS).

Access to the hospital has been made even easier by a service imple-mented in 2011 called 1300ANGINA. General Practitioners can speak to the on-call cardiologist 24 hours a day and if necessary, have their patients brought by ambulance directly to the Coronary Care Unit for admission.

Further benefits include the full range of diagnostic testing, inter-ventions and phase one and phase two cardiac rehabilitation all delivered at the centre.

The interventional service commenced in May 2009. This was the first service in Queensland to be offered without onsite cardiac sur-gery. Prior to 2009, patients travelled to Townsville for PCI and sur-gery. Townsville Mater Hospital remains our surgical back up facility and is 400 kilometres away by road and 45 minutes by air. In order to gain approval for this service, a memorandum of agreements was negotiated with all key stake holders in order to facilitate timely and safe transfers of patients in an emergency and to meet the stringent guidelines of Queensland Health. Since the service commenced there have been no emergency transfers to Townsville as a result of a complication of PCI. However, we do transfer by RFDS for patients on an IABP as a supportive measure prior to planned surgery. This is very challenging but achievable as we have demonstrated on many occasions – usually at night!

How is your inventory managed?

A combination of bar codes and the pen/paper system is used for inventory. As Cairns is technically a remote area, there are occasional supply problems with the onset of the wet weather and the cyclone season. Prior to each cyclone season, stock is increased to prevent shortage of supplies when roads are cut and transport of goods is blocked. Replacement of stock also takes longer during this time especially as it is a 1700km distance from the nearest capital city, so management of stock during this time is vital to continue services. A healthy relationship with the public hospital also enables us to help each other out in times of need.

How does the lab handle haemostasis?

Haemostasis is achieved in the CCL by mechanical closure devices. TR bands are used for those patients who have had a radial approach. Haemostasis devices are used according to cardiologist preference. Patients from the cath lab are either transferred to the CCU if they have undergone an intervention, otherwise all other patients are recovered in Cardiac Recovery prior to discharge, transfer to the CCU or original ward. Patients are monitored on telemetry in this five-bed recovery area opposite the CCL (and should a sheath require remov-al, this can occur either in the Cardiac Recovery unit or CCU). All staff are trained and competent in sheath removal so this can occur in any area of the cardiac services.

What measures has the department implemented to cut costs?

A large proportion of costs for the Catheter Lab is attributed to freight, so staff are diligent in planning ahead and ordering the appropriate stock for pending procedures. Staff members also value the good working relationships with the medical representatives who can be of invaluable assistance in supplying equipment urgently. After Cyclone Yasi in 2011, the road south was cut for a week and we were reliant on cyclone supplies and the good will of many of these companies.

Above (from left): Sheena Cunningham, Catharine Finocchiaro, David Alderson, Robert Blauw, Julie Warman and Neville Manning


What kind of training can new employees expect to receive?

New staff members will receive two weeks supernumery one-on-one education and training with the Nurse Educator, however this depends on the level of experience the new staff member has.

There is an orientation manual for new staff members, annual skills updates available to everyone and specific competencies that nurses undertake to maintain proficiency within the Cairns Private Hospital’s Cath Lab.

Each staff member will also have an orientation to radiation safety conducted by the Cath Lab’s radiographer.

What kinds of continuing education programs are available to staff?

There are ongoing professional development opportunities widely supported by Ramsay Health Care for the CCL. As the hospital is some distance from Brisbane where much of the educational con-ferences are held, travelling is often required by staff members to attend these sessions, and Ramsay offers assistance on these occa-sions to further staff development. Staff members are encouraged to apply for educational sponsorship.

A multidisciplinary meeting is held on alternate Fridays where lively discussion takes place about the more difficult and challenging cases. The cardiologists from the public hospital attend and also discuss their cases. There is also a cardiology teaching session each Tuesday morning where medical and nursing staff take turns presenting on relevant topics

How do you deal with late finishing of cases?

The CCL is in operation five days a week, however working arrange-ments are extremely flexible to suit the needs of the staff members. Staggered start times are used on the busiest days when more staff are required, and a core group of staff members are available to finish late. However, due to the flexible rostering, the staff mem-bers who finish work very late are often offered a later start the following day.

There is a core group of staff members who have been with the CCL since its commencement in 1999 and are flexible with the rostering and on-call component of the service, often at very short notice.

A need has never arisen for use of agency staff and as the service is growing and becoming busier, nurses from the adjoining Coronary Care Unit are undertaking training for rotations within the Cath Lab. There are several nurses who work both in the public hospital cath lab as well as the CPH cath lab.

Unlike major centres where staff can be quickly found to work when the day extends longer than expected, this is just not possible in Cairns.

The team often go above and beyond to get the job done and have learnt to be very creative in managing their time and availability. This flexibility is recognised by the cardiologists and the hospital.

What is the best part of working at your facility?

There is never a dull moment! The cardiologists and Cath Lab team work well together to attain the same goals for the department and have often overcome outside resistance and obstacles faced by a remote hospital to reach these achievements.

As well as the pacing service and commencement of the interven-tional service in 2009, the most recent achievement for the depart-ment is the direct STEMI admission service which is another exciting stage of the Cath Lab’s development.

The staff are friendly, the hours are flexible and it is a very support-ive learning environment for not only newcomers, but existing staff members.

Another great feature of the Cairns Cath Lab is the wide variety of procedures performed by our cardiologists and vascular surgeon. There is no shortage of learning opportunities and the success of the service is attributed to the dedication and commitment of all of the staff members within the Cairns Private Hospital’s Cath Lab team.

Last and by no means least, is the fabulous location almost on the esplanade of stunning Cairns with the ocean visible from the hospital and all the amenities tropical Far North Queensland has to offer.

Above: David Alderson (Radiographer)

[ ECG Challenge Answer ]

• The Rhythm is Mobitz Type I second degree heart block (or Wenkebach heart block) Each cycle begins with a normal PR interval followed by prolongation of the PR interval and a subsequent dropped beat.

• There is ST elevation in leads II, III and aVF suggestive of inferior ST elevation MI. T wave inversion and Q wave formation are also apparent.

• He was taken to the cardiac catheterisation lab where a completely occluded right coronary artery was opened and a stent deployed.

from page 5


JOURNALS[ Global Update ]

Validati ng Risk Scores

EuroSCORE has been a fi xture in cardiac surgical referrals for years. The latest version, EuroSCORE II was developed on over 22 thousand pati ents in 2010 and this study represents its prospecti ve validati on in an independent cohort.

The score performed well overall, although the authors note the predicti ve value was reduced in isolated graft surgery and comment that repeated validati on will be required as populati ons and surgical/anaestheti c techniques evolve over ti me.

Stuart Grant and others. Heart 2012;98:1568–1572.

Bleeding risk scores to balance decisions on anti coagulati on to pre-vent stoke in atrial fi brillati on have not been validated as extensively as the thrombo embolism scores they balance.

The authors of this randomised controlled trial of a novel anti coagu-lant have examined bleeding risk and three scores used to assess risk.

All the scores performed dismally, but of a bad lot HAS-BLED had the advantage of simplicity as well as predicti ng all bleeding, major bleeding and mortality (C-Index 0.6, 0.65 and 0.67 respecti vely). ATRIA and HEMORR2HAGES performed even more poorly.

The poor performance of all the scores in comparison to the ti ghtly correlated and well validated thrombo embolism scores (CHADS2 and CHA2DS2VASc) supports the current guidelines not to use bleeding risk scores as sole reason to withhold anti coagulati on in otherwise indicated pati ents.

Stavros Aposti lakos and others. J Am Coll Cardiol 2012;60:861–7.

AF Ablati on

Renal artery ablati on (denervati on) has been mainly assessed as treatment for drug resistant hypertension but there are suggesti ons it may also have a role in heart failure and atrial fi brillati on. In this small (27 pati ent) hypothesis generati ng randomised controlled study of AF ablati on with or without adjuncti ve renal artery den-ervati on the additi on of renal artery denervati on to PVI increased fi rst procedure success from 29% to 69%. Caveats include an unclear mechanism, small sample size and rather underwhelming AF ablati on results.

Evgeny Pokushalov and others. J Am Coll Cardiol 2012;60:1163–70.

Another paper examining the predicti ve eff ect of achieving sinus rhythm through ablati on, this ti me in a Korean populati on. A step-wise approach was employed on 140 pati ents off anti arrhythmics (amiodarone was stopped for at least 1 month). 68% of pati ents were ablated to sinus rhythm (44% via atrial tachycardias). Atrial arrhyth-mia recurrence post fi rst procedure occurred in 45% of those ablated to SR vs. 69% of those requiring cardioversion.

The study does not address the important issue of whether ablati on to SR is genuinely causal in improving outcomes or merely that those who can be ablated to SR are desti ned to have bett er outcomes.

Yae M Park and others. J Cardiovasc Electrophysiol, Vol. 23, pp. 1051-1058.

Other Arrhythmia

Is defi brillati on testi ng really necessary in routi ne ICD implantati on? The incidence of failed tests is very low and there is no evidence based strategy for dealing with high DFTs.

In a non randomised Italian study of ICD implants comparing those undergoing defi brillati on testi ng and those without there was no sig-nifi cant diff erence in outcomes during follow up.

Michele Brignole and others. Am Coll Cardiol 2012;60:981–7.

Ivabridine was originally licensed for angina and has been studied in heart failure, but its most obvious use is in sinus tachycardia. In a small randomised controlled trial of 23 pati ents with symptomati c sinus tachycardia symptoms, resti ng heart rate and heart rate on exerti on were all signifi cantly reduced by ivabridine.

Riccardo Cappato and others. J Am Coll Cardiol 2012;60:1323–9.

Premature ventricular complexes (PVCs) are strongly correlated with structural heart disease and in these pati ents are associated with adverse outcomes, especially sudden death and heart failure. What is the prognosti c signifi cance of PVCs in pati ents with normal hearts? Following this systemati c review the answer is..........we don’t know. The evidence base consists of studies not of high enough quality in general and specifi cally inadequate in work up to exclude structural heart abnormaliti es.

Victor Lee and others. Heart 2012;98:1290e1298.

Dr John PaiseyJournal ReviewerConsultant Cardiologist, Royal Bournemouth and Christchurch Hospitals NHS Foundati on Trust

Dr Dan McKenzieJournal ReviewerConsultant Cardiologist, Musgrove Park Hospital, Taunton and Somerset NHS Foundati on Trust

Follow me @johnpaisey for the latest reviews

Follow me @danmckenzie73 for the latest reviews


Heart Muscle

MRI provides superb images of fi brosis in hypertrophic cardiomyopa-thy, but we have never really known what to do with this data. Aft er this study of 55 pati ents undergoing MRI approximately two years apart we sti ll don’t. The study does however demonstrate that the degree of fi brosis is rapidly progressive, varies according to patt ern of hypertrophy and is associated with adverse prognosti c factors.

Giancarlo Todiere and others. J Am Coll Cardiol 2012;60:922–9.

Can physical exercise improve outcomes in heart failure? Yes and with dramati c results. Among 123 stable heart failure pati ents ran-domised to either supervised exercise training or standard treatment and followed up over up to 10 years, both quality of life and hard out-comes including VO2 max, EF, cardiac death and HF admission were signifi cantly improved in the trained group.

Romualdo Bellardinelli and others. J Am Coll Cardiol 2012;60:1521–8.

Valves

I thought that we knew this already, but if we didn’t, pati ents with aorti c stenosis and concomitant aorti c regurgitati on (AR) had worse outcomes than those that didn’t have AR, probably.

Satoshi Honda and others. Heart 2012;98:1591-1594.

Balloon Pumps

Now and again, a trial demonstrates something unexpected. It is accepted (and guideline recommended) practi ce to use an intra aorti c balloon pump (IABP) in pati ents with cardiogenic shock complicati ng an acute myocardial infarcti on. The IABP-SHOCK II Trial in Germany randomised 600 pati ents and showed no diff erence between the 30 day mortality in those receiving an IABP (39.7%) and those that didn’t (41%, p=0.69). There was also no signifi cant diff erence in the rates of major bleeding, stroke, sepsis or peripheral ischaemic com-plicati ons. Why? There were 30 cross overs, oft en due to subjecti ve bias, but the data sti ll seems valid. Deaths in MI may occur from haemodynamic deteriorati on, multi organ failure and development of systemic infl ammatory response syndrome. According to this trial and other studies IABP make litt le diff erence to any of these three components. I cannot see my practi ce changing overnight, but this paper will make me think twice.

Holger Thiele and others. N Engl J Med 2012;367:1287-1296.

Cardiopulmonary Resuscitati on

The chances of receiving bystander CPR depend on the income and racial compositi on of the neighbourhood in which the person arrest-ing lives according to this study in America. Survival rates vary from

0.2 to 16% across the USA. The odds of receiving bystander-initi ated CPR were 50% lower in low-income black neighbourhoods than in high income non-black neighbourhoods. Cost of certi fi cati on and risks (both physical and being sued) are put forward as explanati ons. The soluti ons will be more interesti ng.

Cormilla Sasson and others. N Engl J Med 2012;367:1607-1615.

Anti platelet Therapy

Prasugrel is now NICE approved as an alternati ve second anti platelet agent (instead of Clopidogrel) for pati ents with ST elevati on myocar-dial infarcti on (STEMI), stent thrombosis (ST) and in diabeti c pati ents with acute coronary syndromes (ACS). Is it benefi cial in those pati ents not undergoing revascularisati on? Not according to the randomised controlled TRILOGY-ACS study of 7243 pati ents with non ST eleva-ti on ACS. There was no signifi cant diff erence in the primary outcome (cardiovascular death, MI, or stroke).

Matt hew Roe and others. N Engl J Med 2012;367:1297-1309.

Current recommendati ons are that all pati ents receiving a drug elut-ing stent (DES) should be given dual anti platelet therapy (DAPT) for 12 months to reduce the risk of stent thrombosis. However, long term DAPT increases the risk of minor and major bleeding. Recent studies of contemporary practi ce are beginning to challenge this dogma.

Firstly, this cohort study from Spain looked at 1,622 consecuti ve pati ents receiving DES and showed that 10.6% interrupted at least one anti platelet drug within 12 months. Most did so temporarily (median 7 days) and all but one aft er the fi rst month. There was no signifi cant diff erence in the rate of acute coronary syndrome or MACE. One clear limitati on was that the results were based on tele-phone interviews of the pati ents at 3 month intervals and thus relied on accurate pati ent (or a relati ve if pati ent had died) reporti ng with the potenti al for bias.

Ignacio Ferreira-Gonzalez and others. J Am Coll Cardiol 2012;60:1333-9.

Secondly, a study from Korea suggests that 3 months DAPT may be suffi cient in pati ents receiving Endeavor Zotarolimus DES. This ran-domised controlled trial of 2,117 pati ents follows on from the DATE registry in 2010 and shows that the combinati on is non-inferior to standard 12 month DAPT and other DES implantati on for the primary composite endpoint (cardiovascular death, MI, stent thrombosis, target/vessel revascularisati on, or bleeding) at 12 months.

Byeong-Keuk Kim and others. J Am Coll Cardiol 2012;60:1340-8.

How to get in touch

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Free Distributi on of 2800 copies to named individuals within cardiology in UK/Ireland.Distributed to all cardiology departments (invasive and non-invasive) and cardiologists.

All copies are available as a digital editi on on our website at www.cardiologyhd.com.

Thank you to all the editors, contributors, companies, and other service providers around the world who helped make this publicati on what it is today. It could not have done without you all. Our company is now being transformed into something even bett er, going beyond just cardiology. Exciti ng ti mes ahead!!

[ Thank You ]

Sometimes the best medicine is less.That’s why Boston Scientifi c is investing $1 billion annually to develop less-invasive medical devices and procedures that can reduce risk, trauma and treatment cost.

For more than 30 years, Boston Scientifi c has built its global leadership by helping doctors like you improve lives with innovative medical technology solutions. Like you, we’re working to address unmet clinical needs and to reduce the frequency of patient re-intervention. That’s the commitment to innovation we’re making to you.

Learn more at www.bostonscientifi c.com/innovation

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