High Volumes and Exceptional Outcomes: Dedication, hard work and standardization at Mount Sinai cath lab

Cath Lab Digest talks with Samin Sharma, MD, FACC, Co-Director of the Zena and Michael A. Wiener Cardiovascular Institute and the Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, and Director of Interventional Cardiology and the Cardiac Catheterization Lab, Mount Sinai Hospital, New York, New York
Cath Lab Digest talks with Samin Sharma, MD, FACC, Co-Director of the Zena and Michael A. Wiener Cardiovascular Institute and the Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, and Director of Interventional Cardiology and the Cardiac Catheterization Lab, Mount Sinai Hospital, New York, New York
Mount Sinai Hospital cath lab accomplishes over 5,000 interventions annually, making it one of the busiest cath labs in the country. In 2008, the cath lab performed 5,254 interventions, a 7% increase over 2007 (4,908 interventions). The cath lab has also maintained a very low major complication rate (Tell us about the increase in volume at Mount Sinai over the past five years. Our growth has been tremendous over the past five years, occuring in both coronary and non-coronary (or endovascular) interventions (Figure 1). The major growth occurred in percutaneous coronary interventions (PCI), with the number almost doubling in the last five years (from 2,500 in 2003 to about 4,800 in 2008). Many labs are experiencing growth mostly in non-coronary interventions. Before 2004, Mount Sinai did not have any expertise in endovascular intervention. In December 2008, out of 5,254 interventions, 540 were endovascular interventions, and in addition, we did 90 balloon aortic valvuloplasties and 20 balloon mitral valvuloplasties. This realm of structural heart disease also includes atrial septal defect (ASD) and patent foramen ovale (PFO) closure, which we also do (78 in 2008), but are not counted in our interventional numbers; they are done by our pediatric cardiologist, Dr. Barry Love. Balloon aortic valvuloplasty patients are typically very elderly. Some are 90, 95 or even 99 years old, but otherwise functional. They take care of themselves, they go shopping, but they are having recurrent heart failure requiring admission. Surgeons don’t want to touch them because these patients had a stroke in the past, and/or some lung disease, high-risk features meaning they are not good candidates for valve surgery. We don’t do percutaneous valve replacement yet, but we expect to start once the FDA gives approval to go ahead with the trial, probably in late summer of this year. Your outcomes remain very low despite increasing volumes. Major complications are counted as someone dying from the percutaneous procedure, need for urgent open heart surgery or having a heart attack. If you combine all three of these numbers, at Mount Sinai for the past five years, that number has been less than 0.5%, and mortality from the procedure is less than 0.25% (Figure 2). Despite taking tertiary and tough cases all the time, mortality has not increased at our center. In fact, it has continued to decline. Difficult cases which even surgeons decline are often sent to us and patients are getting a very good outcome. These good outcomes, along with patient satisfaction, are what have led to the excellent growth of the cath lab, something of which we are quite proud. It’s not uncommon when centers come out on the top in rankings that the next year they go down. The reason is, when you are on top, all the tough cases are sent to your institution, and because of the complexities, your outcomes go down. Yet despite increasing volumes, being on top and getting more complex cases, our outcomes have remained excellent over the years, irrespective of patient baseline status. Tell us about your cath lab staff and the nature of teamwork at your facility. All cath lab staff are very important. The interventionalist gets the glory or the heat with what happens, but that is short-lived. Unless you have the whole team working with you to achieve the same goal, you cannot deliver the topmost care. What does it require? First, you have to build teamwork, starting from the physician. Second, your support staff, nurses and cardiovascular technologists, needs to have strong education. Every month, we teach our nurses and technologists, in addition to the fellows. Third, everything at Mount Sinai is done by protocol. We have protocols on how to take care of patients on coumadin, patients with kidney dysfunction, how long aspirin/clopidogrel should be given, and so on. Protocols have helped to build the concept of the team over the years. I trained all the five full-time attendings at Mount Sinai and as a result, we all have very similar thinking. Of course, we continue learning. A physician may suggest something different and if it is better, we adopt it into our protocols. Adopting everything in a uniform way means that everyone works with little variation. Finally, we focus on the care of the patient not just before and during the case, but after the procedure. We tell our fellows that post-care is sometimes more important than what you do inside the cath lab. Many times, patients have a bad outcome because the patient leaves the cath lab with a little bleeding or a slightly high pulse rate that goes undetected, or has a reaction to medication. Care of the patients by the entire team — nurses, technologists, fellows and attendings — has led to our good outcomes, and standardization has helped to deliver the best care to the patient. It is important that our cath lab staff feel they are an integral part of the whole team. We continue to appreciate staff expertise and send them for educational meetings. For each ACC and TCT meeting, we sponsor two nurses and one cardiovascular technologist from our interventional fund. Names are taken by lottery so that everyone gets to attend. We want staff to feel that they are not just doing the hard work, but also gaining some professional satisfaction. Hard work and dedication are important from top to bottom. We have various shifts, which usually start from morning to evening. No one will go home at 11:30 if there are three patients waiting. Many times we go until midnight even though the shift ends at 11. A few years ago, at about 9 pm, one of our new nurses was asked by a patient, “This looks like a very busy place. When are you done?” The answer from this new nurse was, “When all cases are done.” She didn’t say 11:00 or 11:30, she said, “When all cases are done.” This is a prime example of our work ethic and team concept. Very few employees leave our cath lab. Of course, those who are not working or those who do not fit in the system tend to leave, but we have very few transfers or people leaving the cath lab. In 2006, when we had our first celebration of 5,000 cases, Dr. Valentin Fuster, Chief of Cardiology, made the observation, “I come here all the time and over the years, I see the majority of the same faces.” It’s about taking ownership. The only way you will succeed, the only way you will not feel bothered by the work, is that you take ownership of what is happening and feel pride in it. Only then will you be happy and help to build the lab further. What role does standardization play in relation to your ability to maintain high volumes? Great question. The New York state medical director has visited Mount Sinai to review how we maintain high volumes with such a low complication rate. He was amazed at our protocol booklet, but somewhat skeptical as to whether it was actually utilized. So the medical director decided to come and quiz our interventional fellows, asking questions based out of the booklet. Our fellows were perfect in their responses. We teach that ‘your eyes can see only what your mind knows.’ Every day, some sort of teaching takes place in the morning from 7:15 to 7:45 am, whether a case review, general class, coronary anatomy, etc. We concentrate on teaching the fellows and once a month, our nurses and technologists, but many times the nurses do participate in our teaching. We also do a monthly quality assurance and review our complications. The idea is that you should try to criticize your own self and actions, in order to do better in the future. Physicians visit our cath lab at least 2-3 times a month and everyone wants to take the booklet. Every week, I send part of our protocol by request to at least one or two facilities, on areas ranging from how we give bivalirudin, to our clopidogrel strategy, to handling patients with kidney disease, etc. Visiting physicians happily take it back to their institution and we are equally happy to share our good results. It’s the Indian way that you distribute your knowledge to help society. When encountering any new technique or technology, if it makes sense, it is implemented into our protocols. We are open to change, but it has to be better than what we are doing already. Only then is it incorporated into our everyday practice. For example, in the past, we used two stents in bifurcation lesions. Slowly we learned that unless the side branch is very big, two stents are not good. It’s better to just do one main artery stent and not do anything to the side branch. We have a protocol not to go after the side branch and put in a stent, unless the branch is closed or the patient is having chest pain. We have invented a simultaneous kissing stent (SKS) technique for large side-branch bifurcation lesions with extremely satisfactory outcomes. I also keep hearing about some operators putting in a pacemaker for AngioJet. We know that those also are superfluous. What are some important ways you save time? Not only is standardization important, but also efficiency. Decisions need to be made rather quickly, although that doesn’t necessarily mean abruptly. I go to many places and see people doing the angiogram, reviewing it and reviewing it again — they are not confident. It delays the procedure. If I see our voluntary physicians thinking quite a bit, I will say, hey, have some confidence in yourself. Do the case. We are always here. But don’t waste time for unnecessary things. Try to do things that make sense. For example, many doctors want to puncture the vein to put in a venous sheath at the time of angioplasty. We have said, absolutely not. Maybe in a high-risk case you should do a venous sheath, but otherwise you don’t need it, because it will increase vascular complications. Another example is for obese patients who may have issues with their leg arteries. In these patients, go with the radial approach, which will decrease your vascular complications in tough cases. We have a few physicians who use this approach 90%+ of the time, but overall in our cath lab, the radial approach is used in about 12% of cases. I personally use the radial approach about 6% of the time. I believe Mount Sinai is now the leader in interventions in the United States. I am extremely proud to be in the field of coronary interventions, which over the years has become an extremely safe, predictable and reliable procedure, with continous new advances and developments. I woud also like to send a message to aspiring interventionalists who wish to distinguish themselves that concentration, dedication, hard work and extreme focus on basic as well as advanced techniques can make all the difference. Dr. Sharma can be contacted at Samin.Sharma@mountsinai.org