Baystate Cardiology's most recent digital lab installation was the Siemens Artis zee digital cath lab. Dr. Schweiger and Dr. Giugliano discuss how the lab makes it easier to visualize the femoral head to help with sheath insertion, as well as its ergonomic, workflow and image quality advantages compared to other labs.
Can you describe your cath lab and imaging systems?
Dr. Schweiger: Baystate Cardiology has 4 digital labs, with the most recent being the Artis zee (Siemens Medical Solutions, Malvern, PA). We actually have 2 Siemens labs and 2 Philips (Bothell, WA) labs. As the only interventional cardiology center in western Massachusetts, we are very busy with an acute patient population. We see most of the patients with coronary disease admitted to the 12 referral hospitals taking care of patients in western Massachusetts. We do somewhere around 1400 coronary interventions, 300 peripheral interventions, and 4,000 diagnostic catheterizations per year. We treat roughly 300 acute myocardial infarctions each year.
Can you describe the image quality of the Artis zee?
Dr. Giugliano: Our Artis zee is our newest lab, and when I compare it to our other three labs, it is clear that the image quality is best in that room. In particular, the ability to see vessel edges and stent edges — as well as the distinction of where a stent is within a vessel — is clearly better with the Artis zee. In the past, we’ve had equipment where it was impossible to see where you were implanting a stent in obese patients. It was very difficult unless you took a cine image as you positioned the stent. Yet we’ve had very successful experiences with several people over 300 pounds in the Artis zee room.
Does it accommodate peripheral procedures?
Dr. Schweiger: For us, the Artis zee is mainly a coronary lab because it does not have the large flat-panel, but you can pan down to the mid-thigh if need be. Dr. Giugliano: You can also do digital subtraction in this room, which would allow you to perform certain peripheral procedures, such as renal angioplasty. What kind of technology does the Artis zee offer in terms of reducing radiation exposure and documenting patient dosages?
Dr. Schweiger: In Massachusetts, we are now required to obtain radiation dosage on every patient. The radiation exposure per patient is easily obtained off the monitor. As far as radiation dosing, because the image is sharper and easier to see, by definition you wind up taking fewer pictures. The other thing the Artis zee does have is the ability to fluoro-record, so, for example, we used to document our balloon inflation by cine, but now we can document it by fluoro-record.
Do you maintain dosage cumulatively, over all a patient’s procedures?
Dr. Schweiger: We do not. That is a very important point, and when you consider the big picture, it becomes a public health concern. The challenge is that patients tend to go to multiple healthcare facilities. While I think one can and should figure out a way to monitor radiation across parameters, ultimately, it means you also have to figure out a way to monitor radiation across different hospitals. If a patient goes to three different emergency rooms and gets a 64-slice CT in all of them, ultimately, we need to have a way to be able to track their radiation exposure. It’s something that in the future we will be appropriately forced to do.
Are there any additional capabilities of the Artis zee which aid in diagnosis and treatment?
Dr. Giugliano: The Artis zee allows us to move the camera into a lateral position, which enables visualization of the groin area. This means we can visualize the femoral head in all patients, regardless of their height, which is a limitation in other labs. We do this routinely to ensure that our entry site into the femoral artery is over the femoral head, which minimizes inappropriately high or low sticks associated with bleeding complications. In other labs it is a limitation that you cannot move the camera in that fashion, especially for patients taller than 6 feet.
Dr. Schweiger: It also moves quickly and easily. We have a number of labs where you can in fact move the equipment laterally, but it’s much more involved. Ergonomically, the Artis zee is easy and quick. Dr. Giugliano: Yes, it’s a single joystick maneuver. The ability at the tableside to adjust your fluoroscopy rates for your digital capture rates, frames per second, is also a nice feature. In other rooms, we have to yell out to the back, “Change it from 15 to 30 frames a second.” You have that control at your fingertips in this lab.
With the abilities you have with this lab, do you see any trends or techniques emerging that you feel should be standardized across the community?
Dr. Schweiger: What we have started doing on all our patients is visualizing the sheath before we go ahead and do our procedure. We see where the entry site is, and on some occasions, it helps us with our anti-coagulation strategy. You do two things: you look to see where you are planning to insert, so you look at a hemostat in relation to the femoral head. I think that in and of itself decreases groin complications and the possibility of high sticks and low sticks. It doesn’t eliminate them, because everybody’s anatomy can be a little different. Occasionally, we will take pictures after the sheath is in, and we can see that there could be a little extravasation of dye with blood outside of the femoral artery — at that point, you are certainly not going to give a GP IIb/IIIa inhibitor. If the patient is on a GP IIb/IIIa inhibitor, you are likely to stop it. If the patient is stable, you are likely to avoid any further complications. I think that has been helpful in minimizing our groin complications, not eliminating them, but minimizing them. The fact that it is easy to do, I think, helps. It is something we are all doing now and we weren’t doing a year ago. If something is easier to do, you are more likely to have buy-in.
Any other enhancements to workflow?
Dr. Giugliano: The table moves very easily with power assist. I think there is also a patient comfort benefit with the Tempur-Pedic mattress pad. It is much more comfortable than the thin mattress pads used by the competitors right now. That is something that the physicians aren’t always aware of, but the patients, I think, have noticed the difference.
Dr. Schweiger: There are 10 interventional cardiologists who use the lab. We have 3 interventional fellows yearly, so you have a lot of people utilizing different laboratories, and every time you have a new lab, people have to learn the controls because they are always a little bit different. Despite the number of people we have using the various labs, adapting to use of the Artis zee was fairly seamless from my perspective.
What about tools for designing optimal views for PCI?
Dr. Schweiger: With the smaller flat detector, it’s much easier to get very steep cranial and caudal views. That is really a function related to the size of the flat detector and is always a tradeoff. In the large detector labs, you can do peripheral work and see a larger area, but when you are working in the coronaries, you have some limitations in your view angles. With the smaller detector, it is reasonably easy to get fairly steep LAO caudal and very steep LAO cranials, which are more difficult to do in large detector rooms.
Dr. Giugliano: Another workflow aspect I would add is that every time we store an image or take a digital run in our Artis zee lab, it’s automatically transmitted to our database archiving system. I’m not sure we are even capable of doing that in our other rooms. In the other rooms, a full transfer occurs at the end of the case. It’s nice to have the images transferred in real time, and it becomes important from a workflow standpoint if you are asking someone to take a look at the films and give an opinion.
That leads into the reporting aspect of the Artis zee. Are there any other things that make reporting easier?
Dr. Giugliano: Admittedly, we do not have the full line of Siemens integrated syngo-dynamics report generation or their hemodynamic monitoring system. We have a PhysioLog monitoring system (Oakleigh, Victoria, Australia) and a Camtronics database reporting structure (Emageon, Birmingham, AL).
Dr. Schweiger: The Artis zee integrates reasonably well with what we do have. Dr. Giugliano: Yes, I think the software integration, as I outlined with the way the films come over in real-time, has been easier to work with than in our other labs.
Can you share more about Baystate Medical Center’s door-to-balloon time initiative?
Dr. Giugliano: We pride ourselves in treating our acute myocardial infarction population and achieving goals in how rapidly we reperfuse their obstructed vessel. It is a national effort and something that we have been able to significantly improve upon, from the time the patient hits the door of our emergency room to the time a balloon is inflated in their artery to restore flow. That is the most important clinical outcome that has changed, in no small part due to the improved workflow.
Dr. Schweiger: We’re in the top 10% of the hospitals in the country for door-to-balloon time, and we have a very busy program. To be fair, we don’t only use the new Siemens lab for our STEMI patients. The fact is that we have a number of labs, but the Artis zee lab is a pleasure to use; it’s easy to get people in, get them on the table and get them started. That’s certainly contributed toward that initiative.
Dr. Schweiger: We’ve been at this for a good couple of years. We’ve broken it down: first of all, what’s most important is good communication with the emergency room (ER). We have various time checkpoints, the door-to-EKG, EKG to calling the interventionalist, and taking the patient to the lab. We work to improve our times at every one of these checkpoints. The ER calls in the whole team. We obviously have people on 24 hours a day. The ER puts out the page — acute STEMI — and the people involved know to get right to the lab at night. We have also begun having EMS do EKGs in the field, which saves a tremendous amount of time. To be honest, there is no one thing that has led to our improved door-to-balloon times. It’s a collection of efforts across an entire collaborative system. We look at our results every quarter, and surprisingly, we continue to get better. I think it becomes a mindset and a little bit of a game; if you are the interventional cardiologist on call, you want to get that artery open as quickly as you can because: a) we know it’s good for the patient, but b) because we’re all competitive. Dr. Giugliano: There are people out there who have been doing it longer and/or better, and we have not been shy about trying to learn from others to take away points that can improve our own program. You don’t have to copy everything from other programs; I think every program probably tweaks things a little differently, but there is always something you can learn. We’ve visited Minnesota, Boston and elsewhere, and all of these things add up to getting us into that top percentile. In addition, communication cannot be emphasized enough. We have regular meetings with our ER physicians, nurses and critical care unit nurses, to talk about every single acute myocardial infarction we do. If there is an outlier leading to any delay at all, there is an effort to try and identify the cause.