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Cardiac catheterisation Laaboratory - Altaf Faiyaz

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1. Cardiac Catheterisation Lab 2. Presented By : Dr Altaf K. Faiyaz 3. “ Coronary Artery Disease is currently one of the leading causes of premature death in both…
  • 1. Cardiac Catheterisation Lab
  • 2. Presented By : Dr Altaf K. Faiyaz
  • 3. “ Coronary Artery Disease is currently one of the leading causes of premature death in both developing as well as developed countries “
  • 4. Contents <ul><li>Introduction </li></ul><ul><li>History </li></ul><ul><li>Evolution & Advancement </li></ul><ul><li>Procedure & Conduct </li></ul><ul><li>Types of Facilities </li></ul><ul><li>Physical Arrangement & Space Requirement </li></ul><ul><li>Equipment </li></ul><ul><li>Human Resource </li></ul><ul><li>Performance Evaluation </li></ul><ul><li>Quality Assurance </li></ul>
  • 5. Introduction <ul><li>The Cardiac Catheterisation Lab is one of the Biggest Advances of this century in Cardiology. </li></ul><ul><li>The expansion & widespread application of this technology throughout the world today could hardly have been imagined by Wenner Frossman, when in 1929, he was the first to pass a catheter into the heart of a living person himself. </li></ul><ul><li>Procedures in the Cardiac Cath Lab have evolved from purely diagnostic & research techniques to potentially life-saving interventional procedure </li></ul>
  • 6. How It All Began ! <ul><li>1941 – Right Heart Catheterisation in Humans to study cardiac physiology </li></ul><ul><li>1950 – First retrograde left heart catheterisation, by Zimerman & co-workers </li></ul><ul><li>1950s(Late) – Advent of selective coronary angiography </li></ul><ul><li>1960s(Late) – Development of aorto-pulmonary bypass surgery </li></ul>
  • 7. <ul><li>1970 – Balloon tipped flow directed catheters introduced by Swan & Ganz </li></ul><ul><li>1977 – Percutaneous transluminal balloon angioplasty, by Gruntzig </li></ul><ul><li>1970s(Late) – Dr. Mason Sones introduced Brachial approach. </li></ul><ul><li>Safe & expeditious catheterisation from femoral route- Dr Judkins & Amplatz </li></ul>How It All Began !
  • 8. & Here We Are ! <ul><li>In the 1980s , the scope of interventional Cardiology increased with the introduction of new therapeutic modalities( Valvuloplasty,Stent etc. ) </li></ul><ul><li>ACC/AHA guidelines for Cardiac Catheterisation Labs published in 1991 </li></ul><ul><li>Cath Labs have now evolved into multipurpose facilities, by performing ‘non-cardiac’ vascular investigations involving peripheral, renal & carotid vasculature. </li></ul>
  • 9. How It Works ! <ul><li>Cardiac Catheterisation is the insertion & passage of small plastic tubes ( catheters ) into the arteries & veins upto the heart to obtain X-ray pictures of coronary arteries & cardiac chambers as well as to measure pressures in the heart ( intra-cardiac haemodynamics ) </li></ul><ul><li>Locate & identify irregularities within the heart & its vasculature, in the aorta ad venacava and to define size & severity of the lesions. </li></ul>
  • 11. Procedures 1. Diagnostic <ul><li>Coronary Angiogram </li></ul><ul><li>Right & Left heart Catheterisation </li></ul><ul><li>Electrophysiological Procedures </li></ul><ul><li>Intravascular Ultrasound </li></ul>2. Therapeutic <ul><li>Coronary angioplasty with stenting </li></ul><ul><li>Rotablator Atherectomy </li></ul><ul><li>Percutaneous Transluminal Valvuloplasty </li></ul><ul><li>Pacemaker Implantation </li></ul><ul><li>Implantation of Cardioverter Defibrillator </li></ul><ul><li>Retrieval of Broken Catheters </li></ul><ul><li>Deployment of various devices for closure of septal defects </li></ul><ul><li>Laser Angioplasty </li></ul>
  • 12. Conduct Patient Preparation Informed Consent from patient/guardian Strictness of Sterile Techniques Special Clothing For workers Hepatitis B vaccination for Employees Following SOP Adequate post-procedural Holding area, proper nursing care and monitoring
  • 13. Types of facilities ! <ul><li>Hospital-Based Labs with in-house thoracic surgical programmes </li></ul><ul><li>In-Hospital labs without Cardiac surgery capability </li></ul><ul><li>Free Standing Labs </li></ul><ul><li>Mobile Labs </li></ul>
  • 14. Goals of Free-standing / Mobile Labs <ul><li>To reduce cost </li></ul><ul><li>Convenience of Location </li></ul><ul><li>Used in case of low-risk patients </li></ul><ul><li>Mostly used for diagnostic purposes. </li></ul>However the setting up of such labs is still controversial and a matter of debate
  • 15. Design Elements The following facilities are required when the cath lab is a stand-alone entity <ul><li>Main Divisions </li></ul><ul><li>Procedure Room – Should be constructed to contain radiation and provide electrical safety </li></ul><ul><li>Control/Console Room – Should be of a size & configuration to allow ready and unencumbered access to X-ray controls, image recording devices ( video tapes, discs and digital controls) and physiological monitors & recorders </li></ul><ul><li>Equipment Rooms – Proper temperature control for computers and data storage </li></ul><ul><li>Clean Utility Room – For clean & sterile supplies and disposables </li></ul>
  • 16. Other Important Facilities 5. Patient Holding Room ( preferably equipped with ECG monitors ) 6. Patient Recovery Room 7. Technician’s Work Room 8. Dark room for 35mm film ( if necessary ) 9. Chemistry Lab ( for blood gas analysis ) or Electrophysiology Labs 10. Scrub Facilities 11. Storage space for case carts 12. Alcove for wheelchairs & stretchers 13. Soiled Utility Room 14. Toilets
  • 17. Model of a 2-lab Cardiac Catheterisation Setup
  • 18. Suggested Lab Requirements 30 Pharmacy Space 30 Staff Toilet 30 Patient Toilet 70 Staff Dressing Room 70 Patient Dressing Room 100 Catheter & Other Storage Room 120 Recovery Room 120 Patient Preparation Room >120 Holding Room 30 Scrub facility 100-120 Equipment Room 150-200 Control Room 500-600 Procedure Room Suggested Minimum Size (sq. ft.) Use
  • 19. Suggested Lab Requirements Library 120 Conference Room 70 Offices ( space per office) 20 Janitorial space 70 Soiled Utility 70 Darkroom Processing ( or Computer Management) 70 Archival Area 70 Film viewing Area 70 Reception Area 70 Staff Lounge 20 Blood Gas Analysis
  • 20. Salient Design Features <ul><li>Traditionally located within the diagnostic radiology suite. </li></ul><ul><li>Aseptic Conditions similar to surgical suites </li></ul><ul><li>Advantage of 2 procedure rooms – can have single control room </li></ul><ul><li>for both, thus economical </li></ul>Architect Cardiologist Administrator Equipment Manufacturer
  • 21. Salient Design Features <ul><li>Safety & Efficacy depends on available equipment & its physical arrangement </li></ul><ul><li>Space for development & access to newer technology will require modification. Eg. Computer review stations are replacing cine film and record storage. </li></ul><ul><li>Larger areas to allow more space for ancillary equipment. </li></ul><ul><li>Dimensions vary in accordance with the type of radiographic equipment & manufacture. </li></ul><ul><li>Control Room at foot-end of the table </li></ul>
  • 22. Imaging Issues ! Radiographic Equipment <ul><li>High Quality Digital Video display </li></ul><ul><li>Therapeutic Procedures require more detailed fluoroscopy </li></ul><ul><li>Biplane Fluoroscopy – Saves time for interventional procedures. </li></ul>Goal – Highest Quality Images with least radiation exposure to staff Limitation – Cost & space requirement
  • 23. Radiographic Equipment <ul><li>X-ray generator </li></ul><ul><li>X-ray Tubes </li></ul><ul><li>Image Intensifiers </li></ul><ul><li>X-ray Detectors </li></ul><ul><li>Video Camera </li></ul><ul><li>Contrast Injectors </li></ul><ul><li>Cinefilm Viewer ( optional ) </li></ul>All these should be compatible
  • 24. Radiographic Equipment <ul><li>Digital Storage & Display </li></ul><ul><li>For medium and long term storage, digital media based on DICOM standards </li></ul><ul><li>Should be used </li></ul><ul><li>Advantages of DICOM </li></ul><ul><li>Data Equivalence is assured </li></ul><ul><li>Any receiving system that uses this interface can be used for storage </li></ul><ul><li>and review </li></ul><ul><li>Iii Telemedicine Application </li></ul><ul><li>Electronic transmission of clinical image data over long distances to </li></ul><ul><li>support clinical decision making at remote sites </li></ul>However as far as possible, analysis should be made on original image data acquired at the time of procedure
  • 25. Precious Human Resource # Chief Cardiologist # Assistant Angiographer # Laboratory Director # Cardiovascular Trainee # Nursing Personnel - Scrub Nurse Float/Circulating Nurse # Technical Staff – Radiation Technologist Radiation Physicist Lab Technologist Dark Room Technician Computer Technician Monitoring Technician # Non-Technical Staff – Medical Transcriber Clerks, Aides
  • 26. Precious Human Resource The department staff is responsible for procuring necessary supplies as well as preparing the room and the patient before the procedure and for monitoring patient’s recovery. Important Qualification and Experience are of prime importance while recruiting personnel for the cardiac catheterisation laboratory All members of catheterisation team must complete a basic course in CPR
  • 27. Radiation Safety Radiation Exposure Recommendations <ul><li>Measuring Radiation Exposure </li></ul><ul><li>Film Badges </li></ul><ul><li>Thermo-Luminescent Dosimeter ( TLD ) badge </li></ul><ul><li>Dosimeter badge should be worn with the front of the badge in direct line </li></ul><ul><li>of the scattered x-rays. </li></ul>Average background radiation exposure - 0.1 rem/year Average operator exposure ( per procedure ) - 0.004-0.016 rem Maximum Annual exposure for Medicos - 5 rem/year Maximum Lifetime exposure for medicos - 1 rem x Age
  • 28. Administrative Issues Utilization levels Lab performance Evaluation Quality Assurance
  • 29. Utilisation Levels <ul><li>Laboratory </li></ul><ul><li>For optimum lab performance & cost-effectiveness – </li></ul><ul><li>Adult Studies – Min. caseload of 300/year </li></ul><ul><li>Paediatric Studies – Min. 150 cases/year </li></ul><ul><li>2) Physician- Operator </li></ul><ul><li>For adequate performance & preventing excessive radiation exposure – </li></ul><ul><li>Individual physician – About 150 cases/year </li></ul><ul><li>Paediatric Physician – 50-100 cases/year </li></ul><ul><li>PTCA - 50 cases/year </li></ul><ul><li>Electrophyiological Studies – 100 cases/year </li></ul>
  • 30. Lab Performance Evaluation Laboratory Safety and Efficiency is measured by – 1. Complication Rates ( through records ) 2. No. of studies that must be repeated because of inadequate data or image quality. Indicators Deaths related to catheterisation - < 0.1-0.2% <ul><li>To Limit Complications, Ensure : </li></ul><ul><li>Stringent Credentials for training and experience </li></ul><ul><li>Regular performance review </li></ul>
  • 31. Quality Assurance <ul><li>The QA program in Cardiac Cath Lab has 3 components – </li></ul><ul><li>Clinical Proficiency </li></ul><ul><li>Equipment Maintenance & Management </li></ul><ul><li>Quality Improvement Program Development </li></ul>The Cardiovascular program should be assessed within context of 3 outcomes - <ul><li>Clinical ( Mortality, Complication, Readmission rates ) </li></ul><ul><li>Financial ( Volumes, Cost per case, Profits per case ) </li></ul><ul><li>Satisfaction ( patient & relatives ) </li></ul>
  • 32. ReCeNt tReNdS <ul><li>Increase in Community Hospitals without CV surgical backup and free standing laboratories </li></ul><ul><li>Decline in risks associated with diagnostic & interventional cardiac catheterisation </li></ul><ul><li>Cinefilms being replaced by compact discs & computerised archiving system </li></ul><ul><li>Evolution of paediatric cardiac cath. from purely diagnostic to interventional lab. </li></ul>
  • 33. Think About ….. Fluctuation of Patient load on a day to day basis Long Break-Even Point Market Competition
  • 34. Bibliography <ul><li>Hospital: Facilities planning & Management </li></ul><ul><li>G.D. Kunders </li></ul><ul><li>2. </li></ul>Special Thanks To : Dr. Samarendra Hota, MHA 2 nd Year
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