Cath lab director Dr. John Wang has transitioned three cath labs away from manifolds to using the ACIST CVi Contrast Management System. We talk to Dr. Wang and some of the cath lab professionals who experienced this transition. Can you tell us about the cath lab at Union Memorial Hospital? Maryanne: In addition to being an open-heart facility, Union Memorial Hospital offers diagnostic and interventional procedures in seven interventional labs. Four labs are cath labs, one is a peripheral lab, one is an electrophysiology (EP)/cath swing lab, and one is solely an EP lab. In our peripheral lab, we do carotid, subclavian and renal interventions. We probably do an average of 300 cath procedures per month, with about 125 of that total being interventions. In our peripheral program, we do perhaps 120 procedures per month. Our department has a total of 6 ACIST injectors, including one portable system. How long have you been using the ACIST injector? Dr. Wang: I started using it in 2004 at another facility. When I came to Union Memorial in 2006, we transitioned shortly thereafter to the ACIST device. It has now been in use for over four years at Union Memorial Hospital. It was your decision to transition the Union Memorial cath lab to the ACIST? Dr. Wang: Absolutely. I’m a big believer in the ACIST device. When you transition a lab to the device, it definitely needs to have a champion behind it, because there is a learning curve, and there are frustrations when you are learning anything new. The manifold has been a part of the cath lab that people are very comfortable with, and when you transition, just the change, in and of itself, is enough to cause people to be resistant to changing to this new technology. Typically, what I have found, is that after a period of months — I wish I could say it is weeks, but it is more a period of months, maybe six months — people look back and say, “I can’t believe we didn’t have the ACIST and that we were using manifolds.” I think that, universally, this is people’s experience, but it does take several months to get to that point. We had a two technologists join the lab during the transition period in mid-2006. To this day, they actually don’t know how to set up a manifold. I don’t think they consider the ACIST complicated. So when I speak to the resistance in change, it is primarily in people who are already comfortable with manifolds. For new staff without that background, it is probably easier to hook up the tubing and flush the system with the ACIST than it is to remember which port is which and set up a manifold. What advantages do you see with use of the ACIST device? Maryanne: I found that towards the end of the period when we were using manifolds, I experienced a lot of wrist pain and hand issues, including numbness in my fingers. I found out it was more of a repetitive, carpal tunnel type of sensation caused by being a nurse for 25 years, probably from using syringes and then using the manifold for the past 10 years working in the cath lab. Using the ACIST is so much easier. You can use either hand; it doesn’t know if you are right-handed or left-handed, and you don’t have the same type of issues with wrist injuries that we were seeing in the past. Vicky: I like the ACIST because you have more control over your contrast. Regardless of what French system it is, it allows for a good injection, meaning you can get good diagnostic results. Jim: I think the ACIST is good for multi-tasking as well. You are able to inject contrast as well as perform additional responsibilities associated with the role as a scrub person. You can do more than one thing at a time. Kim: You can put down the ACIST controller without introducing air into the system. Put it in your left hand when you’re right dominant, and do something else with your right hand. It allows you to flow more easily at the table. The ACIST device has definitely improved our work flow at the table, since we can use either hand to manipulate the contrast controller. Dr. Wang: I think the ergonomic design of the ACIST and its handle is key, as Maryanne mentioned. The physicians don’t typically do the injections, but we do tell staff that if it’s a very large coronary or if there is very brisk flow, to really inject hard. It’s much easier to push the button and change your flow rate than it is to really push hard. Also, in addition to what Vicky said about giving adequate contrast to have good opacification of your coronaries, there is incredible control in how little contrast you can give as well, in order to get a good test. When we are doing angioplasty, we often tell the technologist, “Give me a test.” When you are using a manifold, how much each individual tech is giving you as a test to fill the coronaries is variable, and sometimes you find you are using an incredible amount of contrast just in that testing process. With the ACIST, you can give 2 ccs reproducibly, and even 1 cc sometimes, and get good enough opacification just to do a little test, to see where your wire is. It gives you incredible control. What Jim touched upon was the speed issue, and I think that cannot be underestimated. If the techs get tied up in prepping our angioplasty equipment, we as the physician can then still continue on with the last picture or repeating a picture, and don’t really need to have the other person at the table for that one instance. The one transition that dramatically reduces time is hooking up a Medrad injector for the left ventriculogram. The ACIST completely eliminates the need for this injector, which is great, because if you remember back to manifolds, we do our coronaries, then we fill the injector, and that takes time. From a cost economics and efficiency standpoint, we can use large 500 cc bottles of contrast, and only change the contrast after we have expended that whole bottle, versus multiple small bottles you hang up for each individual case with manifolds. That must be helpful with renally-impaired patients. Dr. Wang: It’s helpful for many reasons. Less is more with contrast. We never want to use more contrast than we need. Even small doses of contrast can be nephrotoxic. Although we think of the diabetic patient with chronic renal insufficiency as the one that ends up getting contrast-induced nephropathy, that’s not always the case. We like to use as little contrast as possible. It is also important from a cost standpoint. Contrast is expensive. If it is being wasted, either in the tubing or in the flush process of prepping a manifold, why do that? We also record the amount of contrast we use for every case, and the one thing you’ll notice is that it is much easier to track the amount of contrast that is delivered in an ACIST device, versus the estimations that are given when you use a manifold. In a manifold, there are always variable amounts left in the tubing, in the flush process, and in the prep of the manifold. Plus, we look up at the bottle that is hanging and see how much residual is left in there. There is so many levels of inaccuracy, that this type of estimation is only accurate to within about 50 ccs of the delivered contrast. The margin for error is much less with the ACIST. What about safety? Jim Steger: With the manifold air could hang up around the stopcock and if you aren’t cognizant of that in each case, there was a higher propensity to inject air. Once we have prepped the ACIST device the likelihood of air to be present within the system is greatly reduced. We flush with saline followed by contrast before we inject into the patient. Using the ACIST removes these variable factors: is your flush bag under pressure or is it not under pressure? Is the contrast bottle empty? Is there air in the line to the transducer? These issues are greatly reduced with the ACIST system. Dr. Wang: When you have a manifold, you are always worried about elevating the back end of the manifold to make sure you are not injecting air. That’s another source of error when you are injecting with a manifold. I don’t want to mislead people. Making sure you don’t inject air with the ACIST device is still very important. Even with this injector, which is very good at giving you messages when it detects air in the line, we need to heed those warnings. If air is injected with the ACIST device, it is usually when people are unfamiliar with how to effectively de-air it and set it up. So there is a learning curve. It is not impossible to inject air with the ACIST device, by any means. There is no device that is 100% fail proof in terms injecting air. Still, once people become familiar with the ACIST and know how to clear the line, the incidence of air embolization is virtually non-existent. Can you tell us more about the learning curve from a staff perspective? Maryanne: I worked in the lab for 10 years before we had the ACIST and was very comfortable working with the manifold system. Setting up the manifold, especially under emergency patients coming in, was a little cumbersome, because you do have to get everything set up, hook everything together, and make sure you don’t have any air in the system. With the ACIST, I guess my learning curve was short — after several days, I was able to get everything together and feel comfortable. The alarms took a little bit longer, because there are several different areas you have to look at. You have to make sure everything is properly closed, the sensors are correct, that you don’t have any flush-through air in the system, and so on. I do think the ACIST takes less time than setting up the manifold. Vicky: When you do your primary set up in the morning, you are ready to roll. Kim: I agree that the set up itself didn’t take that much time; it was more learning what each error code meant and how to fix and troubleshoot the errors. Dr. Wang: That’s a really important point. The actual process of hooking the tubes up and setting up the ACIST is the easy part. It’s knowing how to troubleshoot it when it shows an error message. It is cumbersome in the beginning and I think it takes several weeks for people to really get comfortable with that part of it. How was it introduced to your lab? Kim: ACIST was available from the very beginning. We also had the benefit of having someone — our director, Dr. Wang — with a working knowledge of the equipment before we saw it. He was able to troubleshoot things we had never seen, such as error messages. Dr. Wang helped with that transition. We did have to work with other doctors that weren’t initially comfortable with the ACIST. However, once they knew that we were comfortable with it, they came on board. Some were initially making us still use the manifolds because they didn’t know what the ACIST was about. They had never set it up, they couldn’t troubleshoot it, and they didn’t want to be a part of it. But once the staff competency level went up, they were very amenable to starting to use the ACIST and now no one asks for manifolds anymore, ever. It’s interesting that the physicians became more comfortable once staff was competent with the ACIST. How was it initially presented to physicians? Dr. Wang: I know, having gone through this transition of introducing the ACIST device now in three labs, that it is never met with open arms by the staff nor the physicians that are unfamiliar with it. But it is always something that once they adopt it, they cannot imagine life without it. So I introduced it in all of our labs simultaneously and effectively tried to get away from the manifolds from the beginning. I knew it would be a difficult transition, and there was some resistance. We said to the physicians not that the ACIST was an option, but that using it was where we are headed, because of all the advantages we discussed before. It was my job and our job and the ACIST people’s job to prove and make good on all the aspects that are advantageous with this device. I think we did that. Any final thoughts? Dr. Wang: You know when you are at home watching TV and you can’t find the remote control, and everybody gets up to look for the remote control instead of trying to change the channel on the TV? In general, that’s how we are now with the ACIST device. On the rare times it goes down, we move to another room with an ACIST device, or we have a portable ACIST device that we bring into our room. We do not set up a manifold. We have manifolds, but the TV analogy gives you an idea of how dependent and reliant we are, in a good way, on this technology. We find the ACIST invaluable in patients with renal insufficiency, huge coronaries you otherwise wouldn’t be able to opacify, the speed with which you can go from coronaries to ventriculograms, the ergonomics, and the safety — this is a device that has changed the way we practice. Vicky: We have shown the advantages consistently, to the point where the physicians who travel here from our sister hospital have incorporated the ACIST into their own hospital, because of how well it works in our facility. The authors can be contacted via Jim Steger at James.Steger@medstar.net. Disclosure: The authors report no conflicts of interest regarding the content herein.