Coronary Heart #7 US

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July / August 2007Issue 7

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

Ochsner Hospital, New OrleansRoyal Perth Hospital, Australia

••

LATEST NEWS,EDUCATION

+ more...

EMP

LO

YMENT

MMPP

LLOOMM

PPLLO

Eileen Wimsatt - Inova Fairfax Hospital, VA

Special Feature

“The World’s Fastest

Growing& FREE Cardiac

Magazine!!”

Interview

Site Visits

ICD’s - What’s in the Can?

Education

September 5-8, 2007 New Orleans

FIRST IN THE FALL

A MultidiSciplinARy confeRence

Cardiovascular & Endovascular Professionals, Interventionalists, RNs,

Cath Lab Techs and Venous Specialists

for

New Orleans New Orleans

Julio Palmaz, MD ~ Edward Diethrich, MD ~ Thomas Fogarty, MD ~ Mark Wholey, MD ~ Jay Yadav, MDJohn Simpson, MD ~ Zvonimir Krajcer, MD ~ Lynne Jones, RN, RCIS ~ Thomas Malony, MS, RIC

Kenneth Gorski, RN, RCIS ~ Chris Nelson, RN, RCIS, FSICP ~ David Katz, MDMarsha Holton, RN, RCIS ~ Chris J. Hebert RT(R), RCIS ~ Gary Chaisson, RT(R), R-CVT

(tentative NCVH faculty)

David E. Allie, MD & Craig M. Walker, MDConference Co-Chairmen

pReviouS AwARd RecipientS:2006 ~ Michael E. DeBakey, MD2005 ~ John B. Simpson, MD, PhD2004 ~ Thomas J. Fogarty, MD2003 ~ Martin B. Leon, MD2002 ~ Edward B. Diethrich, MD2001 ~ Julio C. Palmaz, MD

2007New Cardiovascular HorizonsAchievement Award Recipient

Earl E. Bakken

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 ExamWednesday, September 5, 1-4 pm

~ ACVP’s CCT Exam ReviewThursday, September 6, 1-4 pm

~ 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)

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ConFEREnCE HIGHLIGHTS

Breakthrough PeriPheral interventional, CritiCal limB isChemia,endovasCular and CardiovasCular toPiCs

Presented By 125+ emininent FaCulty inCluding:

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

CONTENTSJuly / August 2007

ContentsCORONARYHEART

CORONARY HEART ™ 3

04 Welcome Editorial

05 Latest News

08 ECG Quiz

09 Future

10 Special Feature‘The 100 Top Hospitals: Cardiovascular Benchmarks for Success’

16 Management‘Do Nationally Published Quality Rankings Matter?’

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

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

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

31 Competition‘Win 12-Lead ECG Course’

32 EP Education‘Persistent Junctional Reciprocating Tachycardia (PJRT)’

35 Interview‘Eileen Wimsatt - Inova Fairfax Hospital, VA’

40 Language Assistance‘Russian’

THIS EDITION

41 SICP ‘President’s Letter’

42 Nursing‘How to work as a nurse in the USA’

45 Conferences

46 Employment

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

Page: 35

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

Page: 20

Site Visit: Ochsner Medical Center, LA, USA

Page: 10

Welcome EditorialEDITORIAL

Welcome 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 fi rst 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.

Late June also heralded the establishment of our fi rst satellite offi ce in the USA, located at Independance Wharf in Boston, MA. Whilst initially managed from our main UK offi ce, 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 fi rst. We all hope you will enjoy this USA edition.

Disclaimer: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 diff erent 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 confi rm the accuracy of all statements. Th erefore 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 specifi c 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 .

Coronary Heart Publishing LtdIndependance Wharf

470 Atlantic Avenue, 4th fl oorBoston, MA 02210

United States

Phone: +1 (617) 273-8012

Visit us online at www.coronaryheart.com

Director / Chief EditorTim Larner

Clinical EditorDr Rodney Foale

Consulting EditorsDr Richard Edwards

Ms Voncile Hilson-MorrowMr Ian WrightMr Stuart Allen

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CIRCULATION

USA edition8072 Cardiac Professionals

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.Th e publication of an advertisement or product

review does not imply that a product is recommended by Coronary Heart Publishing Ltd.

Subscribe Online to get your own

free copy

Tim LarnerDirector

TimClinical Editor

Dr Rodney Foale, 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

4 CORONARY HEART ™

LATEST NEWS

Latest NewsTryton Medical’s Side Branch Stent

With an estimated 540,000 bifurcation lesions treated every year the need for

a easy to deploy system has fi nally 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.

Th e 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.

Th e fi rst case demonstrated how patients with complex bifurcated lesions can be defi nitively treated in

scenarios where provisional stenting is impractical. Th e second case demonstrated the versatility of the “treat the side branch fi rst” approach in a lesion located far down the right coronary artery. Th e 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.

Th e third case was in a patient with an extremely tortuous and calcifi ed artery whereby the Tryton secured the side branch, after which a workhorse stent was delivered to

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 fi rst quarter of 2008.

Visit www.trytonmedical.com for more information

NASA Software For Ultrasound

Those 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

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. Th e 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

carotid intima media thickness (CIMT) measurement to calculate the age of the patient’s arteries.

Th is 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. Th e software is designed to function with traditional systems. All you need to do is install. Check with your ultrasound provider fi rst though in case of any warranty issues.

Check it out at www.i-mti.com

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.


Software

Ultrasound hose intelligent scientists at NASA have been at it again

developing technology to help us live longer lives on Earth. Originally developed to improve




shades of gray at a subpixel level. So when examining the carotid artery, an


Software

Ultrasound hose intelligent scientists at NASA have been at it again

developing technology to help us live longer lives on Earth. Originally developed to improve





Image Courtesy Tryton Medical

Latest NewsLATEST NEWS

Medtronic Endeavor Resolute Trial

The 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 fi ndings at EuroPCR. Th e 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%. Th e trial involved 130 patients with an

average lesion length of 15.5mm, with 82% clinically regarded as challenging lesions.

Th ese 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.

Th e only downside is availability. At present it is not actually available in any country, however the current fi ndings will be used to support the CE application for Europe.

Visit www.medtronic.com for more information

SJM Announce FDA Approval of Optisense™ Pacing Lead

In early May, St Jude Medical announced FDA approval of its new Optisense™ pacing lead.

Referred to as a “Smart” lead, it is designed to off er more accurate sensing in the right atrium. Th e lead also incorporates a new tip design to reduce extraneous signals from the ventricles. Th erefore physicians now have more fl exibility in programming atrial sensitivity settings whilst avoiding sensing signals from the ventricles.

Visit www.sjm.com for more information.

Boston Achieves CE Mark for their LONG Stent

Size defi nitely did matter at EuroPCR, with Boston

Scientifi c 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.

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. Th e 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.bostonscientifi c.com for more information

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.

Endeavor Resolute® Stent TipPhoto courtesy: Medtronic


Latest NewsLATEST NEWS

AbiomedImpella Gives Alternative to Traditional Balloon Pump

In 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.

Th e Impella 2.5 can deliver in excess of 2.5 liters of blood per minute

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.

Th e 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. Th e preliminary results of the 20 patient study showed an increase in ejection fraction of 9% and 13% at three days

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

Cypher Results Similar To Bypass Surgery

In 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.

Th e 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.

CATH LAB

Abiomed Impella 2.5

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

September 5-8, 2007 New Orleans

FIRST IN THE FALL

A MultidiSciplinARy confeRence

Cardiovascular & Endovascular Professionals, Interventionalists, RNs,

Cath Lab Techs and Venous Specialists

for

New OrleansSeptember 5-8, 2007 September 5-8, 2007 New Orleans New Orleans New Orleans New Orleans

SICP’s Review CourseWednesday, September 5; Thursday, September 6 & Friday, September 7 - 1:30-6:00 pmModerators: Marsha Holton, BS, CCRN, RCIS & Kenneth A. Gorski, RN, RCIS, SICP

RCIS Exam Reviewn Cardiovascular A&Pn Coronary Artery Anatomy and Angiography n Hemodynamics and Calculations n Pharmacologyn Radiology and Radiation Safety n Legislative Update

n Calculations Workshopn Patient Care and Assessmentn Cardiac Catheterization Equipment and Proceduresn Interventional Techniquesn Cardiovascular Disease Processn 12 Lead EKG Identification of Myocardial Infarction

SICP 1-4 ad.indd 1 5/15/07 9:26:47 AMCORONARY HEART ™ 7

LATEST NEWS

Latest News


The Ostial Pro Stent Positioning System

The FDA recently approved a new product from Ostial Solutions, the Ostial Pro Stent

Positioning System. Th is 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 aff air.

Ostial Pro has tiny gold-plated “feet,” which open like a fl ower in bloom and can be braced against an opening near a narrowed or closed artery. Often the off ending plaque is diffi cult to visualize in angiography and the system greatly increases the likelihood that the stent will be implanted at the correct location for maximum benefi t 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

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.

•

•

ECG Quiz

Clue.

Th is 16yr old patient has a dual chamber pacemaker implanted for congenital complete heart block, and has been getting dizzy episodes on exercise. Th is ECG is from his exercise test.

What’s the problem?

Visit coronaryheart.com for answer.

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

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.


FUTURE

Cardiology Advances


Non-Invasive Cardiac Ablation Coming Soon

Accuray 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 aff ected tissue and create an ablation lesion, even with a moving heart.

Th e CyberKnife System is the next generation of radiosurgery systems that combines continuous image-guidance technology with a compact linear

accelerator that has the fl exibility 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 off ers the precision needed to ensure

only very specifi c 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

OrbusNeich’s Bio-Engineered R stent results

Before we go into the fi ndings it is best to explain what the OrbusNeich Bio-engineered

stent actually is. Called the Genous, this CE marked stent diff ers 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.

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.

Th e interim analysis of post-marketing 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%

• 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%

“Th e importance of this interim data is that Genous appears to be as eff ective as drug-eluting stents with only the need for minimal dual-antiplatelet 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)

The CyberKnife® Robotic Radiosurgery System


SPECIAL FEATURE

A Hospital Performance Improvement ScorecardThomson HealthcareCenter for Healthcare Improvement


The Solucient 100 Top Hospitals: Cardiovascular Benchmarks for Success study

stands alone in off ering 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. Th e value of these cardiovascular benchmarks lies in enabling hospitals to raise targets for improvement of cardiovascular services to national levels of performance.

Th e study, published annually by Solucient — now a Th omson Healthcare business — ranks performance based on a composite of clinical process, clinical outcomes, effi ciency, 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

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). Th e 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 offi cers, cardiovascular service administrators, and physicians as possible. Th is broader audience has a vested interest in the quality and effi ciency of the hospital-based cardiovascular service performance as do cardiologists and thoracic surgeons.

Th e Origin of the 100 Top Hospitals: Cardiovascular Benchmarks for Success

Th e introduction of the 100 Top Hospitals: Cardiovascular Benchmarks for Success study in 1999 was the fi rst step for Solucient (then known as HCIA) to build objective national benchmarks for a specifi c clinical service to help hospitals improve care and effi ciency. Th e study was initiated as a result of the success of the 100 Top Hospitals: National Benchmarks for Success program, which began in 1993

The 100 Top Hospitals: Cardiovascular Benchmarks for Success

Dave Foster, PhD, MPHChief Scientist, Center for Healthcare Improvement

Jean ChenowethSr. VP, Performance Improvement and 100 Top Hospitals Programs

Layout & Imagery by Coronary Heart

Community Hospitals CategoryAvera Heart Hospital of South Dakota

SPECIAL FEATURE

The 100 Top Hospitals (cont...)


and focused on measuring hospital-wide performance. Th e 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.

Th e 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. Th e Society of Th oracic Surgeons database, with extensive clinically rich data, was available to participating hospitals and physicians, but not to all hospitals.

Th e study is aimed at hospital cardiovascular improvement and visibility of the national benchmarks. Th erefore, 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. Th e Results Report is deliberately priced too high for consumers, but extremely reasonably for hospitals.

Composite Ranking and Groups

Th e 100 Top Hospitals Cardiovascular study was the fi rst to objectively

measure, rank, and publish the names of hospitals setting the benchmarks. Th e 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. Th ese 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. (Th e study shows the highest cardiovascular case mix in teaching hospitals with cardiovascular residency programs.)

Teaching hospitals have better results than community hospitals. (Th e 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.

•

•

Th e 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. Th ese 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 effi ciency measures are refi ned 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

>>


SPECIAL FEATURE


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, Th e Quality Chasm, and the ensuing massive eff ort 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.

Th e table below shows that the variation in the mortality index (actual deaths compared to expected deaths for

matched patient risk of death) for both CABG and PCI has narrowed. Th is 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. Th e 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

Th e study metrics have evolved over

time as clinical practice has changed, methodologies were refi ned, and a handful of richer clinical process metrics has fi nally become public. Four adjustments to the study during the past eight years are worth noting:

1. Service line measurement versus procedure measurement – Th e 100 Top Hospitals Cardiovascular composite score has evolved to better refl ect 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 off er the most sophisticated and eff ective cardiovascular services.

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 Th oracic 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.

100 Top Hospitals Cardiovascular Metric – Performance Change Over Time


SPECIAL FEATURE


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. Th e 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 certifi cate with date of discharge and discharge status. Th is change in 2002 signifi cantly improved the reliability of mortality scores across in-study 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. Specifi cally, the study includes those undergoing:

acute myocardial infarction (AMI)

1.

congestive heart failure percutaneous coronary intervention (PCI) coronary artery bypass graft (CABG)

Th e 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

Th e 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.

2.3.

4.

•

•

•

•

Classifying Hospitals into Comparison Groups

Bed size, teaching status, and residency program involvement have a profound eff ect 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

•

•

•

Teaching Hospitals with Cardiovascular Residencies Category

Geisinger Medical Center, PA

>>


SPECIAL FEATURE


Scoring Hospitals on Weighted Performance Measures

Solucient has compiled a group of eight measures of clinical quality practices and effi ciency of operations that it believes constitutes the most reliable, scientifi c way possible to produce benchmarks for superior hospital performance. Th ey also believe that using publicly available data for all hospitals supports this goal.

Th e measures used in the 2006 study were:

Risk-Adjusted Medical (AMI and CHF) Patient Mortality Index Risk-Adjusted Surgical (PCI and CABG) Patient Mortality Index Risk-Adjusted Complications Index (includes post-operative hemorrhages and post-operative infections) Core Measures Score Percentage of CABG Patients with Internal Mammary Artery Use

1.

2.

3.

4.5.

Procedure Volume Th reshold Severity-Adjusted Average Length of Stay 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. Th ese scores were then summed to arrive at a total score for each hospital within each of the three groups.

Th e 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

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Residency Programs group 40 hospitals in the Teaching Hospitals without Cardiovascular Residency Programs group30 hospitals in the Community Hospitals group

Th is stratifi cation was chosen to maintain consistency with the representation of hospitals throughout the country, as identifi ed in the original study research.

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% confi dence) were not eligible to be winners.

Summary

Th e Solucient 100 Top Hospitals: Cardiovascular Benchmarks for Success off ers a unique tool for comparing hospital-based cardiovascular service performance. Th e need for a comparative balanced scorecard for inpatient and outpatient cardiovascular services that integrates clinical outcomes, clinical process, patient safety, effi ciency 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 eff ect the transformation necessary in delivery of future cardiovascular care. Th e lion’s share of medical error is a result of failure of systems and care hand off s. 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.

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Teaching Hospitals without Cardiovascular Residencies Category

Deaconess Medical Center, WA

SPECIAL FEATURE


References

Foster DA, Heller ST. Associations between outcomes refl ecting quality of care and Medicare’s Hospital Compare Quality Measures. Academy Health Annual Research Meeting. June 2007, Orlando, FL.

Foster DA. Consequences and Costs of Medical Injuries in Medicare Inpatients. Academy Health Annual Research Meeting. June 2006, Seattle, WA.

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.

McCollam PL, Foster DA, Riesmeyer JS. Cost and eff ectiveness of glycoprotein IIb/IIIa-receptor inhibitors in patients with acute myocardial infarction undergoing percutaneous coronary

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intervention. Am J Health Syst Pharm. 2003 Jun 15;60(12):1251-6.

Young JK, Foster DA. Cardiovascular procedures in patients with mental disorders. JAMA. 2000 Jun 28;283(24):3198; author reply 3198-9.

Rosenthal GE, Baker DW, Norris DG, Way LE, Harper DL, Snow

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RJ. Relationships between In-Hospital and 30-Day Standardized Hospital Mortality: Implications for Profi ling Hospitals. Health Serv Res, 34, no. 7 (Mar 2000): 1449-68.

Solucient, LLC. Evanston, IL. 100 Top Hospitals: Cardiovascular Benchmarks for Success, 2006 study abstract.

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Grab a copy of our magazine. Grab a camera. Convince your work collegues to be in a photo. Th e most innovative photo wins, but our magazine must be in the photo somewhere. Email hi-res photo to [email protected]

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How to win?

Friday August 17th, 2007 at 5pm GMTEntries Close:

Grab a copy of our magazine. •How to win?

PhotoCompetition

Global

Win a Site Visit Article!!

Join our Online Forums

Special forums especially for all cardiovascular professionals around the world.Designed for students through to leading department managers.Ask questions of our community to help you solve problems in your department.

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www.coronaryheart.com

Teaching Hospitals without Cardiovascular Residencies Category

Hillcrest Hospital, OH


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

MANAGEMENT


“Harry Truman, Doris Day, Red China, Johnnie RaySouth Pacifi c, Walter Winchell, Joe DiMaggioJoe McCarthy, Richard Nixon, Studebaker, televisionNorth Korea, South Korea, Marilyn Monroe …(Chorus)We didn’t start the fi reIt was always burningSince the world’s been turning …”

In 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

organizations throughout the country. My version goes something like this: Joint Commission, CMS, Healthcare Quality Alliances, the death listHospital Compare, Solucient’s 100 Top Hospitals®: Cardiovascular Benchmarks for SuccessLeapfrog, 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 fi reIt was always burningSince the world’s been turning …

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 (Th at’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 severity-weighted mortality rates and a grab bag of other measures, such as nurse-patient 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, “Th irteen 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. Th e U.S. News & World Report comment was, “Interesting, but so what?”1 Th e 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. Th is site notes that it is a quality site for adults, including those who have Medicare. Th e site itself is very easy to use, and you can quickly check hospitals in your area and compare results. Th ere are eight questions that address heart attack

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

Mr John Florio

National Quality Rankings?

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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, Th e 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. Th e national standard recommended by the American Heart Association (AHA) is 90 minutes, and Medicare funding standards are 120 minutes. Patients transferred to Th e 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. Th e Hospital Compare data, for a comparable period, reports that 93 percent of the time, Th e 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.Th is doesn’t mean Th e 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, Th e 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.

Th e 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 Th e University of Kansas Hospital is located. In fi scal 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. Th e 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. Th at 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. Th is 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 identifi es 100 benchmark hospitals based on overall performance. Solucient, a part of Th ompson Healthcare, is the market leader in providing tools and vital insights that healthcare managers use to improve the performance of their organizations.” Th ese various tools are not free, and it is not unusual for health care organizations to have six-fi gure

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

MANAGEMENT



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. (Th e 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 profi le information that has only been available to clients. HealthGrades believes that consumers would also benefi t greatly in having access to this information. Th erefore, 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 “fi ve-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 “fi ve-star” facility, and, at the present time, we have declined purchase rights to market

this to the public.

Th e Death List Report Cards Th e “death list” is not a variation of the Clint Eastwood/Inspector Harry Callahan movie Th e Dead Pool, but rather a Centers for Medicare and Medicaid Services (CMS) list or publication released in June 2007.

Th e reports will cover heart attack and congestive heart failure death rates. Th e 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 diff erent 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 diff erent 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 diff erent 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, Th e 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.

Th e 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 diff erent” category. If you go to the Hospital Compare website and scroll down to your hospital, in most cases, you will see just a “no diff erence” 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

Th e 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 offi cer 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 relationship-driven than data-driven. Still, you have to have confi dence 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. Th e quality dilemma will ultimately sort itself out.

MANAGEMENT



As Billy Joel sang, We didn’t start the fi re, but when we are gone, will it still burn on, and on, and on, and on…?

Author’s note: Th e 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. Th e song is often used in history classes as a teaching aid.

References

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-Specifi c 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=1163010398556&pagename=QnetPublic%2FPag

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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-death-rates_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/FREE70531004&SearchID=73284755984571

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450 Veit RoadHuntingdon Valley, PA [email protected]

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Next Issue: Radiation Dose ManagementWe’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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Ochsner Medical Center1514 Jefferson HighwayNew Orleans, LA 70121 United States of America

FAST FACTS

Number 1 Hospital for treatement of Hurricane Katrina patients.

483 Bed Hospital.

4 Cath Labs, 3 EP Labs.

13 Staff.

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Ochsner Medical Center,

UNITED STATES OF AMERICA

New Orleans, LA


The 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 fl ooding. As the hospital was located above the fl ood waters it was spared damage, unlike several others located within the city that had to be evacuated. Th e 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.

Here is a basic rundown of how it unfolded:

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.

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

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2) Staff Numbers & Roles?

Cath Lab = 8 RT’s and 5 RN’s

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.

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.

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Dr. Grant, Dr. Miller, Gus Rome, Brandon Hebert, Ashley Simoneaux

CARDIAC SITE VISIT

Ochsner Medical Center



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

4) Equipment?

Toshiba x-ray equipmentWitt Hemodynamic Monitoring SystemIVUS Pressure Wire Angiojet Rotablator Laser Carto XP Prucka Cardio Lab

5) 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

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

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

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cross trained.

7) Procedures performed per year?

Cath Lab = 3400EP Lab = 1300

8) New Procedures Recently Implemented?

Left Atrium Appendage ClosurePercutaneous Mitral Valve Repair

9) Inventory management?

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.

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From Left: Mark Foster, Michelle Perniciaro, Heather Lejeune, Brandon Hebert, Steve Collins, Ashley Simoneaux, Amy Liuzza,

Chad Stouder, Kim Touchet, Chris SanMarco

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

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Ochsner Medical Center

CARDIAC SITE VISIT


10) Hemostasis?

We use several diff erent closure devices, but they can not be used on all patients. Th e 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

12) Measures Implemented to cut costs?

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 fl ush 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. Th is time will vary depending on the experience level of each individual.

14) Continuing education programs for staff ?

We off er product inservices from vendors for CEU’s.

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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 recertifi cations of certain pieces of equipment

Annual fi re and safety

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

Keeping/Recruiting nurses and technologists

Maintaining competitive salaries

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.

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

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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!)

Th ings to see and do:

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. Th e walled courtyards in many sites are from the Spanish infl uence.

Bourbon Street: Stretching over 13 blocks in the French Quarter this is where New Orleans comes alive. Closed to traffi c 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!!

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WHY NEW ORLEANS?

CARDIAC SITE VISIT

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Cardiac Cath LabRoyal Perth HospitalWellington Street CampusBox X2213 GPO, Perth 6847Western AustraliaAUSTRALIA

FAST FACTS

Site of first coronary stent implantation in Australia in 1988.

Hospital famous for previous Nobel Prize and Australian of the Year Winners.

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Royal Perth Hospital, Western Australia

AUSTRALIA


Royal Perth Hospital was the fi rst 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,

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.

Th e Hospital has been home to many signifi cant breakthroughs in medical research - signifi cantly, research into the bacterium Helicobacter pylori, which was found to cause stomach ulcers. Th is research work won the 2005 Nobel Prize for former staff members Dr Robin Warren and Professor Barry Marshall.

1. Size of the Department

Th e cardiology department performed the fi rst coronary stent implantation in the country in 1988. Th e Cath. Lab. has three rooms (Siemens Hicor/coroscop) two being dedicated to coronary work and one to

pacing and electrophysiology. Th e 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 staff ed by 1 fulltime electrophysiologist and 2 part-time electrophysiologists. We have 6 trained pacing and EP technicians who are NASPEx Testamurs. Th e unit has a substantial and varied caseload Our Heart-Lung Transplant Unit is forging an international reputation as a centre of excellence in the fi eld of transplantation and mechanical circulatory support. Th e 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. Th e 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 qualifi ed

From Left: Helen Wood (CN)/ Dr Matthew Erickson (Interventional Fellow)/ Dr Sharad Shetty (Consultant)

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Clinical Nurse (CN)Personal Care Assistant (PCA)Registered Nurse (RN)

CARDIAC SITE VISIT AUSTRALIA

Royal Perth Hospitalcardiac 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 in-patients 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 Coordinator1 Senior Radiographer 1 Database Manager/ Senior Radiographer3 Radiographers2 Clinical Nurses2 Registered Nurses8 Cardiac Cath Lab Technicians

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6 Cardiac Technicians ( Pacing & EP)1 Data Clerk3 Patient Care Assistants

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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.

5. Procedures/Volumes per year?

Cardiac Catheterisations 1800 •

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

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)


CARDIAC SITE VISIT

Royal Perth Hospital

AUSTRALIA

PTCA 1000 Pacemakers 200 Defibrillators / BiVent. 100 Electrophysiology studies 200 Myocardial Biopsy 200 PTMC/ASD/PFO 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

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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 rosterAlso 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 MonitoringEach day a senior staff member is allocated as the Recovery person to organise patient transfers and post op care including sheath removalStaff development is shared by senior staffParticipate in 24 hour on call rosterSome staff are responsible for maintaining our sterile stock of supplies and set upsCardiac 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

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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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CARDIAC SITE VISIT


AUSTRALIA


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

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

From Left: Andrew Hartley (Cath.Lab.Tech.) / Dr Wen Yeow (Registrar)

CARDIAC SITE VISIT


AUSTRALIA


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 off ers many other study days which staff can apply to attend. Th ese 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 specifi c competencies for mechanical support devices such as Intra Aortic Balloon Pump, Radi Wire, IVUS and Defi brillation.

18. Some of the challenges in the department?

One of the recent challenges in the department has been acquiring new x-ray equipment. Th e biggest problem is recruiting qualifi ed staff . Western Australia is experiencing a huge economic boom in resources. Th e 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?

Yes, 3 Fellows – 1 interventional, 1 EP, 1 Heart Failure and 2 trainees. Th e 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.

20. What is the best part of working at your facility?

Every day off ers new challenges. Th e experiences and opportunity to be part of such a dynamic and progressive team treating the diff erent patient mix often with complex medical conditions. We have excellent sources of support and infl uence, which constantly encourage an environment for good practice.

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.

Th ings 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.

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WHY PERTH?

Perth, Western Australia

CRM EDUCATION

Pacemakers and ICDs What’s in the Can?


Today’s permanent pacemakers and implantable cardioverter defi brillators (ICDs) are truly

marvels of medical science. Th e 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.

Devices have two main parts to their generator: a header and a can. Th e 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.

Th e can, on the other hand, is composed of a titanium shell (see Figure 1). Th is metal case does not allow visualization of the contents within. Th is article will look at the components contained inside a device

can. Th ese 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 defi brillation) (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

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. Th e pacing circuit within a device allows the output voltage to be adjusted in 0.1-volt increments through the use of a voltage amplifi er. In this way, the minimum energy needed to pace safely can be utilized to maximize battery life.Figure 1. The titanium can of a pacemaker (left) and an ICD

(right) hides from view the components inside.

Written By:

Jeffrey A. Stiffler, BA, AST, RCISIBHRE Recognition AP/Pacing and AP/EP

Manager, Electrophysiology DivisionHealthworks, Inc.Douglassville, PA

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. Th is circuit collects electrical information from the intracardiac leads, fi lters it, amplifi es it, and compares it to some reference value. Th is 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. Th is noise-reversion circuitry ensures pacing is not withheld in the presence of electromagnetic interference (EMI). Th is 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

prevent the large defi brillation 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. Th is 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. Th is 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 infl uence their pacing rate. Th is was especially problematic for very active patients. Rate-adaptive sensors were created to address this issue.

Th e fi rst attempt at a rate-adaptive sensor solution was the activity sensor.

ICD - Device Components OverviewCourtesy Medtronic

ICD - Device ComponentsCourtesy Medtronic

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CRM EDUCATION



Th is 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. Th is 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.

Th e next rate-adaptive sensor developed was the accelerometer. Learning from the activity sensor’s design fl aw, 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 fl ex and generate an electrical current proportional to the amount of fl ex (i.e. amount of activity). Th is sensor can “see” up-and-down AND back-and-forth motion. Most devices have an accelerometer as part of their rate-adaptive sensor.

Th e other part of most modern rate-adaptive 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. Th is circuitry continuously measures the impedance from the can to one intracardiac lead. Th is transthoracic impedance increases and decreases with inspiration and expiration, respectively. Th e impedance change refl ects 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.

MEMORY

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. Th is 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 non-invasively.

TELEMETRY ANTENNA

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). Th is telemetry antenna allows for two-way communication of all clinical data and programming instructions for the device. Th e company-specifi c nature of the device programmers ensures a device is not inadvertently reprogrammed (called phantom programming).

Pacemaker can

batteryother componentscapacitors

ICD can

batteryother componentscapacitors

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

CRM EDUCATION



REED SWITCH

Th e last can component, the reed switch, serves two purposes in pacemakers and ICDs. Th e fi rst 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.

Th e second purpose of the reed switch diff ers 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. Th is 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 fi brillation (VF) with a high-energy shock.

All of these components fi t 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 defi brillation: 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.

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EP EDUCATION

Persistent Junctional Reciprocating Tachycardia (PJRT)


Persistent (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. Th e 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. Th e arrhythmia is sometimes an incidental fi nding with the patient essentially asymptomatic

Fig 1 shows an ECG from a 29-year patient with PJRT. Th e tachycardia was an incidental fi nding on a routine ECG and the patient was asymptomatic. Th e tachycardia is described as a long RP tachycardia (see below). Th e p wave looks diff erent 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). Th e p-R interval is typically relatively normal.

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 diff ers 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 diff erent – 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?

PJRT is a re-entrant rhythm. In a re-entry the cells in the circuit

must have suffi cient 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. Th is is called unidirectional block. Th e 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

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

Figure: 1

EP EDUCATION

PJRT (cont...)


is also always present. Hence both atrial and ventricular beats can easily induce tachycardia.

Long RP Tachycardias

Tachycardias can be classifi ed according

to their appearance on the surface ECG. One such classifi cation is narrow vs broad. A further classifi cation 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.

Th e reason for classifying tachycardias as long RP or short RP is to narrow down the diff erential diagnosis:

Long RP

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

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Short RP

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

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Figure: 2

Figure: 3

EP EDUCATION

PJRT (cont...)


be conducted to the ventricles with very signifi cant AV conduction delay.

Th e R-p interval in PJRT is long because the retrograde limb of the circuit is over a slowly conducting pathway

Th e ECG in fi g 2 shows a diff erent 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. Th e 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.

Th e 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. Diff erentiation from atypical AVNRT may be made more diffi cult because His synchronous V pacing may not advance the circuit due to decrementation in the accessory pathway. Th e 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

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 fi g 3 following cessation of CSM. Th e 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

InsideHumour

Figure: 4


INTERVIEW

Eileen WimsattInterviewed by Ms Voncile Hilson-MorrowCEO Baltimore/Washington Division of Healthworks, Inc.Previous Director of Invasive Cardiology at Washington Heart at the Washington Hospital Center


Eileen Wimsatt defi nes 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. � is 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.

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.

Th e 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. Th e center contains 156 patient rooms, in which nearly all of them private, and 48 intensive care beds. It off ers 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.

Th e Cardiac Catheterization Laboratory (CCL) and EP are located on the ground fl oor 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. Th ere 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 fi rst available room, and then the scheduled case will follow in the fi rst available room.

Th e 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). Th is 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, effi ciency and throughput.

What is the organizational structure?

Th e 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. Th ey 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 diff erent techniques in communication. We utilize a methodology called AIDET(Acknowledge, Introduce, Duration, Explanation, Th ank 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. Th ey

Eileen Wimsatt, RN, MSN Director of Cardiac Cath and

Electrophysiology (EP) at the INOVA Heart & Vascular Institute

INOVA Fairfax Hospital.

>>CORONARY HEART ™ 35

INTERVIEW

Eileen Wimsatt


then explain what they are going to do to the patient and off er 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. Th ey measure our key driver’s specifi c to Cath and EP. Th ey 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?

Th e benefi t is a better working environment for the employees. Th ey feel respected and supported.

So it is not tied into the performance appraisals?

Standards of Behavior are part of the

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staff ’s yearly performance appraisal. Regarding fi nancial benefi t, 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. Th ey 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. Th ey then have to take the registry within a year. Most do it within the fi rst three months after completion of the program. Some people get their bachelors and then do the one year of clinical totaling fi ve 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. Th ere 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 diff erence is the fl exibility in where the people work and their job responsibility. Th ey are not pigeon-holed into any one thing so they are constantly learning and constantly challenged. Th ey can be RN/RCIS or just RCIS. Th e 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 diff erence 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 off ers 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 fi ve years ago.

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


Eileen Wimsatt

INTERVIEW


So prior to that Cath and EP staff were separate?

Yes, and I started that because you cannot fi nd as many people skilled in the fi eld of electrophysiology. In talking with the staff , I discussed the marketability of being able to do both specialties. Th ey are both very distinct and require diff erent skills.

Prior to the implementation of cross-training, 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 fl exibility in your daily staffi ng.

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 benefi ts, 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 offi ce space, the lounge, the sleep area, and the ICAR pre and post recovery

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. Th e 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.

Inova Heart and Vascular InstituteFalls Church, Virginia, USA

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INTERVIEW

Eileen WimsattNow 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. Th e clinical ladder has two tracks – clinical and management. Th e clinical track is based on the RN advance program, and it is called the Achieve Program. Th ere are certain requirements that the employee has to have. Th ey 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. Th ey then present their project, bio and case study in a book and are interviewed by a committee. Th e committee is made up of someone from the cardiac fl oor, administration and peers who then decided whether the candidate is ready to move forward to that clinical level. Th ey 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. Th e 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?

Th e management track is supervision. Th e requirements are CEU’s, either RN or a Bachelors of Science, and at least fi ve years in the fi eld. Candidates do not have to complete levels three and four of the clinical track to participate in the management track. Th e supervisors of the lab are responsible for everything in that lab, and they are 100% clinical. Th ey 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. Th ey 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?

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 fi nancial analysis and present that at the product review committee. Th e requesting physician then discusses the product and why it should be added, replacement or deleted.

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

Selecting the vendor for our cardiology information systems. Looking globally

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 specifi c. Although the transition was diffi cult, it was for the best for the system as a whole.

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. Th ey would rotate around the rooms all day long to help the staff with the transition. It was particularly diffi cult because we have two diff erent 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?

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.

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

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

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



INTERVIEW

Eileen Wimsattway that I can. I genuinely care for them. Th ey are a great group, and I feel like they are a part of my family. I enjoy working with them. Th ey 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.

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

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?

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. Th ey are a great group, and I feel like they are a part of my family. I enjoy working with them. Th ey 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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July / August 2007

NEW SIZE USA MAGAZINE

From ThisTo This

To celebrate our transition into a complete USA version of Coronary Heart, and after establishing a satellite o� ce 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 [email protected]

UK A4 Metric American Magazine Standard

WEBSITE ADVERTISINGWould you like to advertise on our website. Advertising opportunities start in July 2007.

Email [email protected] for details.

SUBMIT AN ARTICLEDo 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.


LANGUAGES

Language Assistance

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


To 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.

Th is 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.

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

eighth largest population.

English Russian Phonetic

Hello Привет Pri’vet

Good Morning. 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

Breathe normally. Дышите нормально Dy’shite nor’malno

Good Хорошо Khoro’sho

Slowly, slowly. Медленно, медленно ‘Medleno, ‘medleno

Any chance of being pregnant? Вы не беременны? Vy ne be’remeny?

We don’t serve vodka in the hospital cafeteria.

В кафетерии больницы не подают водку

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

RUSSIA

CARDIAC SOCIETIES

SICP


President’s MessageLynne Jones, RN, RCIS, FSICP

The 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. Th e 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.

Th e 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. Th e SICP held a one day review course on the last day. Th e SCAI 31st Annual Scientifi c Sessions will be held next year at Caesars Palace in Las Vegas, May 28-31, 2008. I hope to see you in Vegas!

Th en we will hold our annual conference in St. Louis, MO., September 20-22, 2007. Th e keynote will be delivered by Dr. David Allie. New this year and courtesy of Medtronic, will be a breakout session for EP Overview. Th e 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 off er 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 confi dent that the SICP will continue to grow under his leadership.

Th e 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, fi nd out how you can help. Participation in SICP helps not only you, but all of us working in invasive cardiovascular laboratories. Th ere 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. LouisThe Only Specialty Conference for Invasive Cardiovascular Professionals

September 20-22, 2007 • Millennium Hotel St. LouisKeynote 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, MDThis course is AACN and SICP approved. ASRT approvalis pending for Category A CE credit.Make your accommodation arrangements today bycalling 800-325-7353. Be sure to reference SICP toreceive the discounted rate of $129 per night.www.millenniumhotels.com

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

Thanks to our Industry Partners:

NURSING

So you have had enough. Th e 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.

Th is 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 qualifi ed nurses, and great pay, there has never been a better time to pack your bags and move on over.

First things fi rst:

Before you do anything make sure you are actually entitled to obtain a work visa in the USA. Th e

last thing you want to do is go through the entire process of completing the appropriate exams only fi nd 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.

o you have had enough. Th e 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





Before you do anything

last thing you want to do is go through the entire process of completing the appropriate exams only fi nd the US Government turns you way because you are not eligible for a

Visit the following website to get the low-down on visa requirements for foreigners:


So you have had enough. Th e 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.





last thing you want to do is go through the entire process of completing the appropriate exams only fi nd 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:


in the USAow to Work as a Cardiac NurseH

for internationally trained nurses


NURSING

Th e Basics of US Nursing:

Th e 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-for-profi t 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. Th ey 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. Th e 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:

Th is 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

by examination. Request an application specifi c to your qualifi cations 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.

Th e 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 educationSafely practiced nursing in home countryProof 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 examinationApplication fee

•

•

•

•

•

CGFNS and VisaScreen™

Some boards also require you CGFNS Certifi cate, CGFNS Credentials Evaluation Service or in some cases a VisaScreen™ certifi cate, before they will issue a nursing license.

Visit www.cgfns.org for more information on these but check fi rst 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 fi rst 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!!

Colorado, USA

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

ow to Work as a Cardiac Nurse


PLACE TITLE HERENURSING

Cardiac Nursing in the USA


Th e NCLEX® examination is designed to test knowledge, skills and abilities essential to the safe and eff ective 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. Th is 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.

Th ere are two types of tests: a NCLEX-RN 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 [email protected])

Examination Fee:

Th e fee for taking the NCLEX® examination is US$200. Th ere 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. Th ese fees will be charged when you schedule your examination appointment.

Applying for NCLEX:

Once you have received your Aurthorisation to Test (ATT) confi rmation 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

you are ready.

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

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 & Certifi cation and click Continue. From the list of testing programs select NCLEX Testing and click Continue. Th en just fi nd 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 identifi cation will be accepted.

A digital fi ngerprint, signature and photograph will be taken at the test center and will accompany your examination result. Your fi ngerprint, signature and photograph may be used to confi rm your identity by the board of nursing to which you have applied for licensure. You cannot be tested without having your fi ngerprint, signature and photograph taken.

During the test you will be observed at all times. Th is will include direct observation by test center staff as well as video and audio recording of your examination session.

Test Content:

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

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. SocialSecurity Number, to fi nalize 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, fi ll in the forms, pay the fee and you’re done. Th is is called a Licensure by Endorsement, and is only applicable for those who have completed the NCLEX from another state or territory. Th ere is no need for you to retake the NCLEX test.

References:

www.ncsbn.org/InfoINTLRevised.pdf

Websites to get started:

www.ncsbn.orgwww.uscis.govwww.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

2007July 23-25 Endovascular Summit Colorado Springs, CO,

USAwww.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

2008January 23-25 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


Valley View Hospitalis looking for a few good

CATH LAB RNFull-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 Hospital1906 Blake Avenue • Glenwood Springs, Colorado • 970.945.6535

heartsPLANETREE

Dedicated professionals who arecaring and compassionate people.

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 fi sh. If you’d like to be part of our progressive and exciting healing environment, join us for a rewarding future.

A meaningful mission, an exceptional workplace

CLINICAL EXPERTISE DOESN’T JUST HAPPEN

AA/EOE, M/F/D/V

Clinically analyzing what patients need comes from a dedication toeducation, scientific inquiry, and a desire to be the best. Working withthe Hospital of the University of Pennsylvania, you will have theopportunity to work where technology is making a remarkable impacton health care and how nursing is practiced. Explore our EPS Labopportunities 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 EPSprofessionals to join our team:

EPS LAB REGISTERED NURSE — Job Code # 968569Critical Care experience, a current PA RN License and BLS and ACLSCertification are required. A BSN and EPS Lab experience is preferred.

EPS LABORATORY MANAGER — Job Code # 15611Current PA RN license with a BSN and BLS/ACLS certification orTechnician with RCIS certification.

EPS RN EDUCATION SPECIALIST — Job Code # 968703A minimum of 3 years of EPS experience, and BLS, ACLS and eitherRCIS certification or a current PA RN license are required. NASPExAMTESTAMUR certification preferred.

EPS EDUCATION SPECIALIST — Job Code # 901613A minimum of 3 years of EPS experience, and BLS, ACLS and RCIScertification are required. NASPExAM TESTAMUR certificationpreferred.

CARDIAC CATH/EPS LAB TECHNICIAN — Job Code # 19095BLS 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 # aslisted above.

www.pennhealth.com/jobs

EMPLOYMENT ADVERTISING


United States of America July / August 2007

Enjoy A Quality of LifeSecond to None

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.

You’ll enjoy a great work environment, generous compensation and benefits, state-of-the-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

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: [email protected] EOE

RecruitmentAdvertisingRates

RecruitmentRecruitment

Online only:

Magazine + Free Online:

$150 for 60 days + hypertext link

1 Column (2.4”)= $50 per inch1/4 Page = $4001/2 Page = $600Full Page = $1000

COLOR no extra cost

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Why Pay More?

Prices are Net and do not include agency commission

Your New Dress Code...

Looking for an exciting work environment, wonderful team members& the beautiful Delaware beach resort right in your own back-yard? Join the Beebe family today! We are experiencingunprecedented growth and are very excited about ournew Interventional and Invasive Cardiology program.

CARDIAC CATH TECHSExcellent opportunities for registered Cardiac Cath Techs. Must obtainDelaware licensure. Be a part of our new interventional cardiac programand expand your career with this exceptional team.

ECHO TECHSSeeking RDCS or RCS Echo Techs. Two-three years exp., with exceptionaltechnical and diagnostic skills. Immediate need due to expansion.

WE OFFER A FANTASTIC SIGN-ON BONUSAND RELOCATION ASSISTANCE PROGRAM

Ask HR for details. Please visit our website for more informationand detailed job descriptions: www.beebemed.orgWe offer competitive compensation and benefits.

Beebe Medical Center424 Savannah Rd., Lewes, DE 19958302-645-3336 • fax: 302-645-0965Apply online at: [email protected] • EOE

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EMPLOYMENT ADVERTISING


United States of America July / August 2007

Solutions for cardiovascular and imaging services

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Let us help you solve your cardiovascular

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EDUCATIONBoost employee retention and cut the productivity losses that oftenaccompany new hires or service lines with Healthworks clinical education programs, available both onsite and online.

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To find out more, just call us at 1-610-385-1227 or e-mail [email protected].

Documents

Coronary Heart #7 US