He arrived at the emergency room diaphoretic, hypotensive, and with substernal chest pressure. The patient was brought immediately to an emergency room care area and a stat EKG disclosed classic ST segment elevation in the inferior leads. The cath lab team was immediately summoned as the ER team worked to stabilize the patient. Within minutes, the attending cardiologist was on the scene, reviewed the EKG, examined the patient, and explained to the hoardes of family members with the patient what was taking place. In the interest of being expeditious with his consent process as the team was arriving to take the patient to the cath lab, the attending said:
"There is a 1% risk that anything bad that you can think of could happen with this procedure. If you'd like me to detail those things, I can."
The patient didn't want to hear, and off to the cath lab they went to open the patient's occluded right coronary artery to great relief of the patient and family.
Later, in follow-up, the attending cardiologist was making rounds and asked the patient his occupation.
"I'm a malpractice attorney."
Smiling, the cardiologist immediately asked, "How was my consent?"
"Perfect. Absolutely perfect."
-Wes
Showing posts with label angioplasty. Show all posts
Showing posts with label angioplasty. Show all posts
Friday, May 31, 2013
Thursday, November 03, 2011
Hybrid Operating Rooms
Yesterday, the FDA approved Edward Lifescience's percutaneous transvalvular aortic valve replacement catheter for human use. Despite this, it appears unlikely that implants of these valves will progress in short order due to concerns of demand for the expensive technology in the era of increased scrutiny of device utilization by payers, especially CMS. Which constraints will be placed on cardiologists and which institutions will be approved for this technology are issues still being considered. At the current rate, it appears unlikely at this time that this technology will be deployed before the end of the year.
One new trend in cardiovascular circles (and a trend that is very politically-correct in our new "Accountable Care Organization" era of medicine that also plays well with health care marketing teams) has been the installation of new, very expensive 'hybrid' catheterization laboratory/operating rooms capable of transitioning from a conventional operating room to a catheterization laboratory (or back again) in larger hospitals. It is clear that patient selection for percutaneous valve procedures will likely require collaboration between cardiothoracic surgeons and cardiologists and some valvular procedures may require both specialists in complicated cases.
Here's a time-lapse video of the conversion of a hybrid operating room from the University of California, San Diego where a patient first had a DaVinci robot-assisted single-vessel off-pump coronary bypass operation followed by placement of an intracoronary stent in another coronary artery by cardiologists. (Not sure why it was done this way, but I don't know specifics about the case.)
While staged DaVinci robot procedures with angioplasty probably won't be common, these fancy "hybrid" operating rooms (OR's) are much more likely to be used for percutaneous valve implantations or even atrial fibrillation ablations using simultaenous epicardial and endocardial approaches.
Fun times.
-Wes
One new trend in cardiovascular circles (and a trend that is very politically-correct in our new "Accountable Care Organization" era of medicine that also plays well with health care marketing teams) has been the installation of new, very expensive 'hybrid' catheterization laboratory/operating rooms capable of transitioning from a conventional operating room to a catheterization laboratory (or back again) in larger hospitals. It is clear that patient selection for percutaneous valve procedures will likely require collaboration between cardiothoracic surgeons and cardiologists and some valvular procedures may require both specialists in complicated cases.
Here's a time-lapse video of the conversion of a hybrid operating room from the University of California, San Diego where a patient first had a DaVinci robot-assisted single-vessel off-pump coronary bypass operation followed by placement of an intracoronary stent in another coronary artery by cardiologists. (Not sure why it was done this way, but I don't know specifics about the case.)
While staged DaVinci robot procedures with angioplasty probably won't be common, these fancy "hybrid" operating rooms (OR's) are much more likely to be used for percutaneous valve implantations or even atrial fibrillation ablations using simultaenous epicardial and endocardial approaches.
Fun times.
-Wes
Friday, January 15, 2010
Where Were the Techs and Nurses?
Medicine is a team sport. No single doctor can do what they do without tons of help from nurses, technicians, clerical staff, and yes, even adminstrators.
So it was with considerable surprise that I saw this piece from the Baltimore Sun:
So, yes, the doctor's actions in this case are unconscionable and should be met with swift action, but when something like this is allowed to occur it's much more than the fault of a single doctor.
This was a system problem.
-Wes
So it was with considerable surprise that I saw this piece from the Baltimore Sun:
"An internal review, begun last May at the behest of federal investigators and in response to a patient complaint, has turned up 369 patients with stents that appear to have been implanted in their arteries unnecessarily, CEO Jeffrey K. Norman said in an interview yesterday. Patients began receiving letters alerting them to the finding early last month, and more notifications are expected as the review continues.As bad as this might seem, realize that during angiogram procedures there are technicians and nurses that are responsible for prepping the room, administering meds and monitoring the patient. No physician works in isolation and everyone can see the monitors. Face it, the difference between a 95% blockage and a 10% blockage in a coronary artery is not subtle.
"We take our interaction and the care of our patients with the utmost seriousness, and so we wanted to alert patients and their physicians to what we found," said Norman.
In several cases reviewed by The Baltimore Sun, patients who received coronary stents at St. Joseph - purportedly to open a clogged artery to correct a severe blockage - have since learned they had only minor blockage, if any. One 69-year-old man was told his artery had a 95 percent blockage, yet the new review suggests something closer to 10 percent, which is considered insignificant. A 55-year-old woman who agreed to receive a stent after being told she had a 90 percent blockage has since learned she had virtually no problem and that she never suffered from the heart diagnosis that has consumed her life for the past 18 months."
So, yes, the doctor's actions in this case are unconscionable and should be met with swift action, but when something like this is allowed to occur it's much more than the fault of a single doctor.
This was a system problem.
-Wes
Monday, November 16, 2009
How Not to Consent a Patient for Angioplasty
Tuesday, March 03, 2009
Better Care or Economic Necessity?
Now with the Dow Jones Industrial Average parked to it's lowest level since 1997, hospitals are doing the best they can for their patients (and rankings) by shortening their door-to-balloon times for heart attack patients by mandating that their cardiologists be on site in the hospital 24/7. It's such a simple thing to accomplish in the name of patient care, right?
But there's a dark side to government idealism: doctors jumping through hoops in the name of "quality" as they struggle for economic survival.
As competition between hospitals for patients continues to heat up, the press for perfect care becomes more acute lest the hospital's Medicare reimbursements fall. Teams of staff are mobilized to study the door-to-balloon time process. If hospitals find they can't shave enough seconds off the door-to-balloon time process to correct this measure, they resort to constant in-house staffing spun, of course, as "better care." The pressures on doctors to "perform," faster becomes more acute, but so does the toll on their personal lives. Unfortunately, if hospitals are not careful, they may lose doctors to their competitors because of other, non-economic, real life incentives.
Then what will become of the patient's door-to-balloon time?
-Wes
But there's a dark side to government idealism: doctors jumping through hoops in the name of "quality" as they struggle for economic survival.
As competition between hospitals for patients continues to heat up, the press for perfect care becomes more acute lest the hospital's Medicare reimbursements fall. Teams of staff are mobilized to study the door-to-balloon time process. If hospitals find they can't shave enough seconds off the door-to-balloon time process to correct this measure, they resort to constant in-house staffing spun, of course, as "better care." The pressures on doctors to "perform," faster becomes more acute, but so does the toll on their personal lives. Unfortunately, if hospitals are not careful, they may lose doctors to their competitors because of other, non-economic, real life incentives.
Then what will become of the patient's door-to-balloon time?
-Wes
Thursday, February 19, 2009
Syntax Trial Online Chat by Dr. Ted Feldman
Dr. Ted Feldman, Director of Interventional Cardiology at NorthShore University HealthSystem and one of the lead authors of the recently published Syntax trial comparing peripheral coronary interventions (PCI) head-to-head with coronary artery bypass grafting surgery (CABG), held an online chat today at noon to discuss the much ballyhooed results published yesterday online before print in the New England Journal of Medicine. The online chat provides a bit of the interventionalist's perspective on the results.
Although the chat has ended, you can view the transcript here by typing in your name and using the password "DES" (clever, eh?).
-Wes
Although the chat has ended, you can view the transcript here by typing in your name and using the password "DES" (clever, eh?).
-Wes
Sunday, January 25, 2009
How to Scare a Reporter
Just show him an angioplasty with a little Bezold-Jarisch reflex and a brief bout of ventricular fibrillation then watch him bail into the control room.
Heh.
-Wes
PS: Note the size of the clot they aspirated from the artery. (Yes, Mr. President, it doesn't take much to bring a young smoker to his knees.)
Heh.
-Wes
PS: Note the size of the clot they aspirated from the artery. (Yes, Mr. President, it doesn't take much to bring a young smoker to his knees.)
Monday, January 21, 2008
Could Potent Antacids Affect The Effectiveness of Antiplatelet Agents?
Today's Journal of the American College of Cardiology reports that omeprazole (Prilosec®), a potent antacid that works by proton pump inhibition and is commonly presribed to prevent gastrointestinal bleeding in patients administered clopidogrel (Plavix®) following coronary interventions, interacts with clopidogrel to reduce its effectiveness as an antiplatelet agent.
The clinical implications of this remain uncertain but clinicians should be aware of this possible interaction following angioplasty or stenting procedures.
-Wes
The clinical implications of this remain uncertain but clinicians should be aware of this possible interaction following angioplasty or stenting procedures.
-Wes
Friday, November 02, 2007
Thursday, March 08, 2007
Door-to-Balloon Time - Perfecting the Data
Nothing sells papers like bad news.
And no one wants to have bad news shared with the world, especially when you’re a hospital and especially when people can compare your hospital to other hospitals.
So yesterday, this article from the New York Times was brought to my attention. It is a “response” from hospitals found to have the “worst” heart attack care as measured by door-to-balloon times by the government’s "Hospital Compare" database. You see, the New York Times wanted to sell papers, so the New York Times reviewed the database and published the data in the papers, and lots of the “worst” hospitals were offered a chance to “respond” to the article and give their excuse why their data were less than perfect compared to other hospitals. Here's one such response:
But when hospitals get embarrassed publicly once the data are actually used, they are forced to improve their data. So the natural consequence of these disclosures is that hospitals must change something quickly to assure they aren't on the CMS's blacklist. So the question becomes, is patient care at these centers improving or are the data collection and reporting improving by becoming more selective?
Here’s how I see this. Data using all patients' door-to-balloon times were initially entered into the government’s database in a differential fashion between centers. Some centers entered all of their patients that presented with heart attacks, others use highly "selective" criteria about whom to include in the reporting. These data are then exposed to the world in the New York Times. Hospitals are embarrassed and devise ways to improve their data using “aggressive systems approaches” to look good. Data become meaningless. Hospitals (and states) can use meaningless data to promote how great they are. Medicare decides to pay these hospitals because they have corrected the way they collect the data to make the data look good.
Everyone wins.
Except the patient. You see to avoid embarrasment and to ensure reimbursement from Medicare, all data will eventually skew toward “perfection” in the interest of marketing and payment forces.
So, how could hospitals possibly do this? Well, you get better at collecting data. You see, your “aggressive systems approach” looks carefully at the ACC guidelines and notes there are these helpful “exclusions” so the data collection teams can “exclude” reporting on patients that did not receive an angioplasty in 120 minutes because:
-Wes
And no one wants to have bad news shared with the world, especially when you’re a hospital and especially when people can compare your hospital to other hospitals.
So yesterday, this article from the New York Times was brought to my attention. It is a “response” from hospitals found to have the “worst” heart attack care as measured by door-to-balloon times by the government’s "Hospital Compare" database. You see, the New York Times wanted to sell papers, so the New York Times reviewed the database and published the data in the papers, and lots of the “worst” hospitals were offered a chance to “respond” to the article and give their excuse why their data were less than perfect compared to other hospitals. Here's one such response:
John Easton, spokesman, University of Chicago Medical Center: "As an academic medical center on the South Side of Chicago serving a large indigent population, we faced several uncommon hurdles in minimizing the time it takes to assess patients in the emergency room, move them quickly to the catheterization laboratory and initiate definitive care. These include a disproportionate number of patients with co-morbid conditions — such as stroke, respiratory failure requiring intubation, or cardiac arrest requiring resuscitation — which require immediate treatment prior to transfer to the cath lab. We also see uncommonly frequent patient refusal to undergo angiography immediately. In recognition of the impact of such cases, Medicare recently developed systems that allow hospitals like ours to document and exclude these outlier cases. Despite these hurdles, our door-to balloon times have vastly improved in the last year thanks to an aggressive systems approach. Our average time for the last 10 cases in the database (up to December 2006) was 94.4 minutes. From July 1, 2006, until now, 80 percent of patients had a door-to-balloon time of less than 90 minutes, and 100 percent were treated within 120 minutes."Now all cardiologists understand the importance of opening an artery in the throws of an acute heart attack. Time is muscle. There is no question that hospitals need to make it a priority to open arteries as quickly as possible. In fact, this was felt to be so important that the American College of Cardiology initiated their “Door-to-Balloon - D2B” as a measure to assure excellent care. And the department of Health and Human Services added the criteria of door-to-balloon time to their database to assure that hospitals are providing exceptional heart attack care and provide incentives to hospital in terms of higher Medicare reimbursements to reward “quality.” Fair enough.
But when hospitals get embarrassed publicly once the data are actually used, they are forced to improve their data. So the natural consequence of these disclosures is that hospitals must change something quickly to assure they aren't on the CMS's blacklist. So the question becomes, is patient care at these centers improving or are the data collection and reporting improving by becoming more selective?
Here’s how I see this. Data using all patients' door-to-balloon times were initially entered into the government’s database in a differential fashion between centers. Some centers entered all of their patients that presented with heart attacks, others use highly "selective" criteria about whom to include in the reporting. These data are then exposed to the world in the New York Times. Hospitals are embarrassed and devise ways to improve their data using “aggressive systems approaches” to look good. Data become meaningless. Hospitals (and states) can use meaningless data to promote how great they are. Medicare decides to pay these hospitals because they have corrected the way they collect the data to make the data look good.
Everyone wins.
Except the patient. You see to avoid embarrasment and to ensure reimbursement from Medicare, all data will eventually skew toward “perfection” in the interest of marketing and payment forces.
So, how could hospitals possibly do this? Well, you get better at collecting data. You see, your “aggressive systems approach” looks carefully at the ACC guidelines and notes there are these helpful “exclusions” so the data collection teams can “exclude” reporting on patients that did not receive an angioplasty in 120 minutes because:
- Traffic was bad and prevented the angioplasty team from getting to the hospital in time
- Patient initially refused the procedure
- Angioplasty held due to concerns about possible aortic dissection
- Patient wanted to wait for family or clergy to arrive. Patient had to be defibrillated several times before transfer to the lab
- Patient arrived in full cardiac arrest
-Wes
Monday, November 13, 2006
Door-to-Balloon Time: Simple?
You feel heaviness in your chest, throat tightening. You pop and aspirin and have your wife (or husband) take you to the Emergency Room. You've just hit the "door." The story is classic and the ER, fortunately, expedites your evaluation. An electrocardiogram is performed and demonstrates and acute myocardial infarction pattern: a heart attack is in progress. "Guys, call the cath lab," the ER attending pleads.
"Er, sir, it's one in the morning."
"Well, then, call the cardiologist and get them here... yesterday!"
Calls are made. Beepers activated. A cardiologist is roused from sleep, young technicians fumble for their pants and car keys. You hurt like hell, sweat pouring from your brow. Traffic laws are ignored. Red lites make an effective effort to stall. Time is ticking. Faster. Faster!
The cardiologist arrives first, meds are increased, your blood pressure drops. The techs arrive, switches activated. Lites turned on. X-ray system booted. Gown. Hat. Mask. Booties. Scrub. Trays opened. "Call the ER, tell 'em we're ready."
"Okay." The phone is dialed.
"Shit! They have no one to transport the patient! You go!" The tech runs to the lab. IV's hang from every corner of your bed. Doctors look concerned. Minutes. Tick. Hurry. "Get the elevator!" A nurse runs ahead to call the elevator. Tick. Tick. Tick. The door opens. Your bed is pushed into the elevator. You feel and IV yanked from your arm. "Hold it!" the tech screems. His IV pole wheel just got caught in the gap between the floor and the elevator. You feel a warm fluid near your elbow. "Damn it, hold pressure!" The fluid is blood. An IV fell out. Heparin. "We'll get another IV when we get to the lab. Don't worry about it." Go! Go! First floor, second floor. Ding! The elevator door opens. "Easy on the way out of the elevator. Okay, we're clear."
You're hurried to the lab down the hall. Once there, you enter a foreign room, lites blaring. AC/DC's "Hell's Bells" shreaks in the background." You're lifted to the narrowest table ever. Stickers are applied to your shoulders, prongs plugged in your nose, a clip applied to your finger. A big cold jelly-fish-like pad applied to your chest on each side. Pants removed. Warm, wet soap applied to your groins. You hear the scrub sink, with its water running, in the distance. Soon it stops. Another gown worn, another set of gloves applied.
"You're going to feel a little sting down here," the cardiologist says as the anesthetic is applied. Another sting is felt at your forearm."
"Ouch!" The cardiologist pauses. "Did that hurt?"
"Not down there, on my arm!"
"Sorry, I was starting another IV," the tech confesses. The cardiologist continues. The artery entered. A catheter passed to the heart. The coronary artery engaged and contrast administered. "That one's okay," the cardiologist thinks. "JL4 guider." Catheter are exchanged. More die injected, shots taken. The cardiologist turns away, working at the table as quickly as he can. A balloon is prepped, then inserted. "Whisper wire." The lesion is crossed. Your chest is heavier now. The balloon inflated, deflated. Suddenly, the pressure subsides. You relax. "How are you feeling now?"
"Better."
Door-to-balloon time. Simple in theory, yet not so simple in practice. Sweeping changes would have to be implemented in urban areas to achieve this. Techs and cardiologists, likely, would have to reside in-house when on call, or else live very close to their hospital, an impractical option in many cases. And while some recommendations by the American Heart Association and American College of Cardiology seem "simple" to some, their ramifications are significant to all. At least one doctor thinks this is a good idea:
While I do not argue that short door-to-balloon times save heart muscle, serious consideration of the costs to all involved, especially those doing the procedures, needs to be carefully examined. Presently we only get paid for doing the job - not waiting. The real people who are pushing this are the payors and hospitals. Why? Because patients do better, certainly, and costs fall. And their wallets swell.
But if "time is muscle," time waiting for a case is also lost money and personal lives to those doing the procedures.
So, who's gonna pay for all that waisted time?
The answer: Doctors.
-Wes
"Er, sir, it's one in the morning."
"Well, then, call the cardiologist and get them here... yesterday!"
Calls are made. Beepers activated. A cardiologist is roused from sleep, young technicians fumble for their pants and car keys. You hurt like hell, sweat pouring from your brow. Traffic laws are ignored. Red lites make an effective effort to stall. Time is ticking. Faster. Faster!
The cardiologist arrives first, meds are increased, your blood pressure drops. The techs arrive, switches activated. Lites turned on. X-ray system booted. Gown. Hat. Mask. Booties. Scrub. Trays opened. "Call the ER, tell 'em we're ready."
"Okay." The phone is dialed.
"Shit! They have no one to transport the patient! You go!" The tech runs to the lab. IV's hang from every corner of your bed. Doctors look concerned. Minutes. Tick. Hurry. "Get the elevator!" A nurse runs ahead to call the elevator. Tick. Tick. Tick. The door opens. Your bed is pushed into the elevator. You feel and IV yanked from your arm. "Hold it!" the tech screems. His IV pole wheel just got caught in the gap between the floor and the elevator. You feel a warm fluid near your elbow. "Damn it, hold pressure!" The fluid is blood. An IV fell out. Heparin. "We'll get another IV when we get to the lab. Don't worry about it." Go! Go! First floor, second floor. Ding! The elevator door opens. "Easy on the way out of the elevator. Okay, we're clear."
You're hurried to the lab down the hall. Once there, you enter a foreign room, lites blaring. AC/DC's "Hell's Bells" shreaks in the background." You're lifted to the narrowest table ever. Stickers are applied to your shoulders, prongs plugged in your nose, a clip applied to your finger. A big cold jelly-fish-like pad applied to your chest on each side. Pants removed. Warm, wet soap applied to your groins. You hear the scrub sink, with its water running, in the distance. Soon it stops. Another gown worn, another set of gloves applied.
"You're going to feel a little sting down here," the cardiologist says as the anesthetic is applied. Another sting is felt at your forearm."
"Ouch!" The cardiologist pauses. "Did that hurt?"
"Not down there, on my arm!"
"Sorry, I was starting another IV," the tech confesses. The cardiologist continues. The artery entered. A catheter passed to the heart. The coronary artery engaged and contrast administered. "That one's okay," the cardiologist thinks. "JL4 guider." Catheter are exchanged. More die injected, shots taken. The cardiologist turns away, working at the table as quickly as he can. A balloon is prepped, then inserted. "Whisper wire." The lesion is crossed. Your chest is heavier now. The balloon inflated, deflated. Suddenly, the pressure subsides. You relax. "How are you feeling now?"
"Better."
Door-to-balloon time. Simple in theory, yet not so simple in practice. Sweeping changes would have to be implemented in urban areas to achieve this. Techs and cardiologists, likely, would have to reside in-house when on call, or else live very close to their hospital, an impractical option in many cases. And while some recommendations by the American Heart Association and American College of Cardiology seem "simple" to some, their ramifications are significant to all. At least one doctor thinks this is a good idea:
"Thirty-five percent of patients in America have an artery opened in 90 minutes or less. Our goal is 75 percent," said Dr. Steven Nissen, president of the American College of Cardiology.Really? All physicians want this? All physicians want to live in the hospital waiting for that magic moment when an acute heart attack hits the door? How often does this happen? Five, maybe ten times a month? And how many occur after hours? Do all the techs want to live there waiting, too? Who will pay us for our time sitting, waiting?
"Everybody we've asked to do this has said this is the right thing to do. Payers want it. Government wants it. Hospitals want it. Physicians want it."
While I do not argue that short door-to-balloon times save heart muscle, serious consideration of the costs to all involved, especially those doing the procedures, needs to be carefully examined. Presently we only get paid for doing the job - not waiting. The real people who are pushing this are the payors and hospitals. Why? Because patients do better, certainly, and costs fall. And their wallets swell.
But if "time is muscle," time waiting for a case is also lost money and personal lives to those doing the procedures.
So, who's gonna pay for all that waisted time?
The answer: Doctors.
-Wes
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