“Image-Guided Therapy” Thrives at Miami Cardiac & Vascular Institute After Completion of $120 Million Expansion Project

Tell us about the MCVI expansion.

This was a project that started conceptually as far back as 2008, so quite a few years ago, in terms of the planning and design phase. It was driven by interest on our part to become more operationally efficient, to expand our capacity, and to try and create from a design point of view, a platform for innovation. Many of the procedures we are doing in the cardiovascular space didn’t really exist 10 or 15 years ago, and it’s been the nature of our specialty to continue to invent and develop new solutions to complex problems. Frequently, the environments in which we work are pretty much boilerplate. You put in a cath lab/angio suite, and you work around it. We began our process by trying to design an environment that would be more of a platform for innovation, in that the platform itself could undergo change, and be able to accommodate some of the demands that we essentially don’t yet know about. If you look at procedures like AAA repair, TAVR, complex PCI, or critical limb ischemia, the disease processes we are treating have changed so much in terms of challenges to the technology we use. We tried to design for an environment that would allow us to adapt in the future by optimizing the imaging and work environment. Conceptually, that is what was driving our design, and then of course, historically, dating back to the early 1990s, MCVI had a physical plant that reflected two important things: one is multidisciplinary collaboration, meaning physicians of different specialties worked side by side, and we had an architectural design that reflected that. The second was the idea of transparency or working in the sunshine, where everybody’s work is open to peer review. Historically, we have had a lot of glass rather than walls, all the rooms were open, and visible to everybody, more or less, and we never separated the rooms or control areas, so rather than having a cardiology side, a radiology side, a vascular side, and a neuro side, the rooms are interdigitated. Physicians of different disciplines are doing different tasks working side by side. 

The design of a physical space can either discourage or encourage interaction.

I believe that architecture and design can reflect these kinds of important ideas. It’s easy to talk about physicians of different specialties working together, particularly in the invasive arena, but if they are geographically isolated and separated, it makes it a lot harder for that to happen. What we found in our experience from, say, 1993 up to the design phase in 2008, was that architecture and design can actually be an enabler of multidisciplinary collaboration, by preventing the development of silos, architectural or geographic silos, and creating a milieu where everybody is literally working side by side. Many people have come down to visit the design, and some, at their own facilities, have tried to implement a similar design. But it’s not simply architecture, because there has to be an institutional will and a leadership will present to integrate services.

What do you recommend?

When we look at people who are trying to achieve true, multidisciplinary collaboration, with integrated care as a result, the most common cause of failure is lack of medical leadership — not lack of money. I think developing medical leadership and getting a group of people that are really committed to the idea of integrated, multidisciplinary care is a really important step. 

Can you tell us about some of the technology you are utilizing in the new expansion?

We have had a development relationship with one imaging equipment manufacturer, and we have been working on imaging changes and dose reduction that can facilitate the performance of these procedures. Some it is actually a result of new products by the manufacturer. One of our clinical research initiatives is to improve design of the interventional environment. Basically, interventional cardiologists, like others who work in this space, are image-guided therapists, in the broader sense. They are part of a large group of specialists that use imaging guidance to work inside the body. We hope to help improve the environment for cardiologists and others to both see inside the body and better see what they need in order to improve patient care. We are also focused on ergonomics and the workspace, with attempts to reduce the incidence of career-long orthopedic issues, and reduce x-ray dose, which also has career-prolonging implications. We have tried to incorporate all these factors into the design. So, in terms of new technology, there are the beginnings of next-generation technologies for doing caths, complex PCIs, and so forth. We have also created what are called advanced endovascular suites. In the cardiology space in particular, semantics are sometimes important. So, in our health system, we do not have so-called “hybrid operating rooms” in the surgical department. Instead, we brought the surgical environment to the cath lab environment. All image-guided therapy has been integrated into one physical environment, including the interventional cardiology environment, but also including the so-called “hybrid” or advanced endovascular environment, so that if somebody wants to do a procedure that might involve opening the chest in a percutaneous approach, we have the environment to do that. It is seamless within what you call a traditional cath lab environment. One of the unique things in the expansion is that within the traditional cardiovascular interventional environment, you walk through the center and at a certain point, it transitions to a red line area where all the rooms on the other side of the center are actually surgical environments. We have full capacity to bring physicians of different disciplines and skills together to accomplish pretty much anything, without any barriers. The diversity of procedures would include things like cardiopulmonary bypass. Our concept seeks to elevate image-guided therapy and bring full surgical capacity to image-guided therapy, while also integrating the diversity of procedures that can be done in these environments. For example, an interventional cardiologist may be thinking of TAVR or maybe a hybrid CABG interventional procedure. There may be another procedure where we may need to do debranchings and put in a thoracic endograft. In the PAD space, we may combine some kind of surgical procedure, perhaps a femoral endarterectomy, with an SFA angioplasty and stenting. Integration creates an environment without barriers to create solutions for patients.

Tell us about the importance of the phrase “image-guided therapy”.  

What we have done is try to draw similarities between all the different disciplines. It started out 30 years ago as a ring around multidisciplinary care, around atherosclerosis, let’s say — a disease process — and we worked to find similarities that could bring people together around disease management. From the expansion, though, comes the idea of seeing all the similarities that exist between these different specialists, from the treatment of acute stroke to the treatment of acute MI, the treatment of a cold leg, treatment of a ruptured vessel, treatment of a ruptured aneurysm…there are many more similarities than differences. We have viewed the bigger field as “image-guided therapy” and with this expansion, have consolidated that concept within a single physical plant. There are benefits to the physicians, certainly huge benefits to patients, but also benefits to the institution in terms of avoiding duplication, consolidation of inventory, consolidation of physician skills and technologist skills, and so on.

What are the benefits to patients?

If you start at the most basic level, it is patient comfort. We have created a much better environment for taking care of our patients before and after procedures. We do a large percentage of outpatient work. Part of the expansion is a 36-bed pre and post care unit, with specially trained nurses. Much of the quality of care from a patient point of view as well as patient satisfaction is what goes on before and after the procedure. There is technology in the room to try and improve the environment when the patient actually comes in the room, including things like music and a video integration system, so on the monitors, we can have pleasing scenery — all things that soften the shock of coming into the cold, high-tech environment of an interventional suite when you are awake.

What do you see in the future?

The expansion represents our strong institutional commitment to less invasive therapies. At MCVI, we have a strategic commitment to less invasive therapies, both the performance of them and in seeking to reduce the invasiveness of whatever the status quo is. We believe it will be a continued direction, and wherever we can reduce invasiveness, whether it includes reducing the invasiveness of something that’s already an open surgical procedure and making it a less invasive open surgical procedure, or by combining skills to reduce invasiveness, is a big part of the future. The technology is directed at continuing to explore and develop the fields of image-guided, less invasive therapies.

How are things going now that the expansion is complete?

We’ve had a very tough road to this point. The expansion involved new space, which is easy from a construction and design development space, but also significant renovation of our core space — it was about 40,000 square feet of procedural space that needed to be renovated. The past year and a half has been extremely difficult in terms of working in a construction zone while performing the level of technologically demanding procedures that we are talking about. It has been a striking change, connecting the old and the new, and opening up the new space. Completion of the project has had definite and beneficial effects on both physician and staff morale. Everyone really sees why we went through the difficulties of the past few years to get to where we are. I think there is a sense of being on an exciting trajectory. Also, functionally and operationally, almost all the things that we have incorporated into the design have proven to be very effective. I think people are really enjoying working in this very special place.