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Cardiac catheterisation Laaboratory - Altaf Faiyaz

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Basic Structure, Function & Human Resources in a Cath lab
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Page 1: Cardiac catheterisation Laaboratory - Altaf Faiyaz
Page 2: Cardiac catheterisation Laaboratory - Altaf Faiyaz

Presented By :

Dr Altaf K. Faiyaz

Page 3: Cardiac catheterisation Laaboratory - Altaf Faiyaz

“ Coronary Artery Disease is currently one of the leading

causes of premature death in both developing as well

as developed countries “

Page 4: Cardiac catheterisation Laaboratory - Altaf Faiyaz

1. Introduction

2. History

3. Evolution & Advancement

4. Procedure & Conduct

5. Types of Facilities

6. Physical Arrangement & Space Requirement

7. Equipment

8. Human Resource

9. Performance Evaluation

10. Quality Assurance

Page 5: Cardiac catheterisation Laaboratory - Altaf Faiyaz

The Cardiac Catheterisation Lab is one of the Biggest Advances of this century in Cardiology.

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.

Procedures in the Cardiac Cath Lab have evolved from purely diagnostic & research techniques to potentially life-saving interventional procedure

Page 6: Cardiac catheterisation Laaboratory - Altaf Faiyaz

1941 – Right Heart Catheterisation in Humans to study cardiac physiology

1950 – First retrograde left heart catheterisation, by Zimerman & co-workers

1950s(Late) – Advent of selective coronary angiography

1960s(Late) – Development of aorto-pulmonary bypass surgery

Page 7: Cardiac catheterisation Laaboratory - Altaf Faiyaz

1970 – Balloon tipped flow directed catheters introduced by Swan & Ganz

1977 – Percutaneous transluminal balloon angioplasty, by Gruntzig

1970s(Late) – Dr. Mason Sones introduced Brachial approach.

Safe & expeditious catheterisation from femoral route- Dr Judkins & Amplatz

Page 8: Cardiac catheterisation Laaboratory - Altaf Faiyaz

•In the 1980s , the scope of interventional Cardiology increased with the introduction of new therapeutic modalities( Valvuloplasty,Stent etc. )

•ACC/AHA guidelines for Cardiac Catheterisation Labs published in 1991

•Cath Labs have now evolved into multipurpose facilities, by performing ‘non-cardiac’ vascular investigations involving peripheral, renal & carotid vasculature.

Page 9: Cardiac catheterisation Laaboratory - Altaf Faiyaz

•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 )

•Locate & identify irregularities within the heart & its vasculature, in the aorta ad venacava and to define size & severity of the lesions.

Page 10: Cardiac catheterisation Laaboratory - Altaf Faiyaz
Page 11: Cardiac catheterisation Laaboratory - Altaf Faiyaz

1. Diagnostici. Coronary Angiogramii. Right & Left heart Catheterisationiii. Electrophysiological Proceduresiv. Intravascular Ultrasound

2. Therapeutic

i. Coronary angioplasty with stentingii. Rotablator Atherectomyiii. Percutaneous Transluminal Valvuloplastyiv. Pacemaker Implantationv. Implantation of Cardioverter Defibrillatorvi. Retrieval of Broken Cathetersvii. Deployment of various devices for closure of septal defectsviii. Laser Angioplasty

Page 12: Cardiac catheterisation Laaboratory - Altaf Faiyaz

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

Page 13: Cardiac catheterisation Laaboratory - Altaf Faiyaz

1. Hospital-Based Labs with in-house thoracic surgical programmes

2. In-Hospital labs without Cardiac surgery capability

3. Free Standing Labs

4. Mobile Labs

Page 14: Cardiac catheterisation Laaboratory - Altaf Faiyaz

Goals of Free-standing / Mobile Labs

To reduce cost

Convenience of Location

Used in case of low-risk patients

Mostly used for diagnostic purposes.

However the setting up of such labs is still controversial and a matter of debate

Page 15: Cardiac catheterisation Laaboratory - Altaf Faiyaz

The following facilities are required when the cath lab is a stand-alone entity

Main Divisions

1. Procedure Room – Should be constructed to contain radiation and provide electrical safety

2. 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

3. Equipment Rooms – Proper temperature control for computers and data storage

4. Clean Utility Room – For clean & sterile supplies and disposables

Page 16: Cardiac catheterisation Laaboratory - Altaf Faiyaz

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

Page 17: Cardiac catheterisation Laaboratory - Altaf Faiyaz
Page 18: Cardiac catheterisation Laaboratory - Altaf Faiyaz

Use Suggested Minimum Size (sq. ft.)

Procedure Room 500-600

Control Room 150-200

Equipment Room 100-120

Scrub facility 30

Holding Room >120

Patient Preparation Room 120

Recovery Room 120

Catheter & Other Storage Room

100

Patient Dressing Room 70

Staff Dressing Room 70

Patient Toilet 30

Staff Toilet 30

Pharmacy Space 30

Page 19: Cardiac catheterisation Laaboratory - Altaf Faiyaz

Blood Gas Analysis 20

Staff Lounge 70

Reception Area 70

Film viewing Area 70

Archival Area 70

Darkroom Processing( or Computer Management)

70

Soiled Utility 70

Janitorial space 20

Offices ( space per office)

70

Conference Room 120

Library

Page 20: Cardiac catheterisation Laaboratory - Altaf Faiyaz

Traditionally located within the diagnostic radiology suite.

Aseptic Conditions similar to surgical suites

Advantage of 2 procedure rooms – can have single control room for both, thus economical

Page 21: Cardiac catheterisation Laaboratory - Altaf Faiyaz

Safety & Efficacy depends on available equipment & its physical arrangement

Space for development & access to newer technology will require modification. Eg. Computer review stations are replacing cine film and record storage.

Larger areas to allow more space for ancillary equipment.

Dimensions vary in accordance with the type of radiographic equipment & manufacture.

Control Room at foot-end of the table

Page 22: Cardiac catheterisation Laaboratory - Altaf Faiyaz

Radiographic Equipment

High Quality Digital Video display

Therapeutic Procedures require more detailed fluoroscopy

Biplane Fluoroscopy – Saves time for interventional procedures.

Goal – Highest Quality Images with least radiation exposure to staff

Limitation – Cost & space requirement

Page 23: Cardiac catheterisation Laaboratory - Altaf Faiyaz

Radiographic Equipment

1. X-ray generator

2. X-ray Tubes

3. Image Intensifiers

4. X-ray Detectors

5. Video Camera

6. Contrast Injectors

7. Cinefilm Viewer ( optional )

All these should be compatible

Page 24: Cardiac catheterisation Laaboratory - Altaf Faiyaz

Radiographic Equipment

Digital Storage & Display

For medium and long term storage, digital media based on DICOM standards Should be used

Advantages of DICOM

i. Data Equivalence is assured ii. Any receiving system that uses this interface can be used for storage and reviewIii Telemedicine Application Electronic transmission of clinical image data over long distances to support clinical decision making at remote sites

However as far as possible, analysis should be made on original image data acquired at the time of procedure

Page 25: Cardiac catheterisation Laaboratory - Altaf Faiyaz

# 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

Page 26: Cardiac catheterisation Laaboratory - Altaf Faiyaz

The department staff is responsible for procuring necessary suppliesas well as preparing the room and the patient before the procedure andfor monitoring patient’s recovery.

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

Page 27: Cardiac catheterisation Laaboratory - Altaf Faiyaz

Radiation Safety

Radiation Exposure Recommendations

Measuring Radiation Exposure

1. Film Badges

2. Thermo-Luminescent Dosimeter ( TLD ) badge Dosimeter badge should be worn with the front of the badge in direct line of the scattered x-rays.

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

Page 28: Cardiac catheterisation Laaboratory - Altaf Faiyaz

Administrative Issues

Utilization levels

Lab performance Evaluation

QualityAssurance

Page 29: Cardiac catheterisation Laaboratory - Altaf Faiyaz

1) Laboratory

For optimum lab performance & cost-effectiveness – Adult Studies – Min. caseload of 300/year Paediatric Studies – Min. 150 cases/year

2) Physician- Operator

For adequate performance & preventing excessive radiation exposure –

Individual physician – About 150 cases/yearPaediatric Physician – 50-100 cases/year PTCA - 50 cases/yearElectrophyiological Studies – 100 cases/year

Page 30: Cardiac catheterisation Laaboratory - Altaf Faiyaz

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%

To Limit Complications, Ensure :

Stringent Credentials for training and experience

Regular performance review

Page 31: Cardiac catheterisation Laaboratory - Altaf Faiyaz

The QA program in Cardiac Cath Lab has 3 components –

1. Clinical Proficiency

2. Equipment Maintenance & Management

3. Quality Improvement Program Development

The Cardiovascular program should be assessed within context of 3 outcomes -

1. Clinical ( Mortality, Complication, Readmission rates )

2. Financial ( Volumes, Cost per case, Profits per case )

3. Satisfaction ( patient & relatives )

Page 32: Cardiac catheterisation Laaboratory - Altaf Faiyaz

Increase in Community Hospitals without CV surgical backup and free standing laboratories

Decline in risks associated with diagnostic & interventional cardiac catheterisation

Cinefilms being replaced by compact discs & computerised archiving system

Evolution of paediatric cardiac cath. from purely diagnostic to interventional lab.

Page 33: Cardiac catheterisation Laaboratory - Altaf Faiyaz

Think About …..

Fluctuation of Patient load on a day to day basis

Long Break-Even Point

Market Competition

Page 34: Cardiac catheterisation Laaboratory - Altaf Faiyaz

Bibliography

1. Hospital: Facilities planning & ManagementG.D. Kunders

2. www.google.com

Special Thanks To :

Dr. Samarendra Hota, MHA 2nd Year


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