Saint Thomas Hospital’s Experience with the Acist CVi Contrast Management System

Tell us about Saint Thomas’ two separate cath lab facilities. We have an 8-room interventional cath lab located in the hospital between our emergency department and medical imaging, and a separate one-room outpatient diagnostic cath lab also in the hospital, just across the hall from the hospital interventional cath lab. We usually run about 5 or 6 rooms in our regular cath lab, and do 30-35 cases per day. From December 1, 2008 through November 30, 2009, in our hospital cath lab, we did 5,842 diagnostic caths and 3,098 interventions. The outpatient cath lab does anywhere from 8 to 13 cases per day. In 2009, they did 1,800 total procedures. Looking at the volume in both cath labs, Saint Thomas does more volume than any other hospital in middle Tennessee. We have 60 employees in the main cath lab, including our outpatient holding unit, and 9 in the outpatient cath lab. We are staffed with a mix of nurses, cardiovascular technologists (CVTs) and patient care techs. We also have two registered cardiovascular invasive specialists (RCISs). One is a nurse and one is a CVT. Our cath lab has 11 interventional cardiologists. The outpatient cath lab has 7 diagnostic cardiologists that perform only diagnostic left heart caths. The physicians tend to be separate, but occasionally a few interventionalists will work over in the outpatient cath lab. If the patient from the outpatient cath lab ends up needing an intervention, they will take them off the table, bring them over to the interventional cath lab, and do the intervention. All of our electrophysiology (EP) procedures are done separately in our EP lab. Since we have the highest volume of heart transplants in middle Tennessee at Saint Thomas, all of our heart transplant patients are managed in a separate area where right ventricular (RV) biopsies and right-heart caths are performed on these patients. If these patients should need a diagnostic left heart cath, the procedure is done in the interventional cath lab or the outpatient cath lab. The Acist Power Injector was first introduced in your outpatient cath lab several years ago. Yes, the outpatient cath lab used it for five or six years before the interventional lab began using it in April 2007. We found the Acist system a very good fit for our outpatient lab, because it allows for the use of 4F catheters, and as a result, we were able to get patients up and out a lot faster. Using the Acist system in the main cath lab also helped us reduce length of stay. We were able to do our outpatients much later in the day, and there was a big reduction in hold time and time that patients lay flat on their back. Time to ambulation went from 4-6 hours to 1-2 hours. We knew the outpatient lab had moved to a 2-hour down time with very minimal complications. Previously, our diagnostic patients had to lay flat for hours, but with the Acist, we could get them up much quicker. The guidelines say that you can get patients up within an hour from the time you remove the sheath, but we usually wait about 2 hours. It’s interesting that the diagnostic lab had the Acist contrast management system for so long before the interventional lab started to use it. What’s the interaction between the two labs? They are almost totally separate entities. At one time, the outpatient lab was a joint venture cath lab, so it had to be separate from the hospital in every way. Within the last two years, it’s become more of a hospital cath lab. It’s set up more for speed, since they are doing diagnostics only. They maintain the ability to do 12 cases a day in one room and still be done by 5pm in the afternoon. It’s actually worked out pretty well. What other benefits have you seen from use of the Acist system? Ergonomics! We have several people that have been working at Saint Thomas for a long time and using the manifold system is tough on the hand. Switching to the Acist meant that injecting contrast is done by pushing a button. It is physically much easier. Also, the staff says that it is much easier on their backs. They are able to stand upright and inject instead of leaning or stooping to get torque on the manifold injector system. Another benefit that the Acist provides the scrub person is distance from the radiation source. With the Acist, the scrub nurse/tech can stand further away from the radiation source during an injection. With the old manifold system, the tubing was shorter and the scrub person had to be closer to the radiation source while injecting. Also, we have almost completely stopped the use of closure devices in the cath lab. Before we went to the Acist/4 French system, we used 6 French closure devices on about 25% of our patients. This saves us about $300,000 per year. Using the manifold can be difficult for those with smaller hands. Especially if it’s a small woman with a smaller hand. We have one lady that has been working here for years. She’s very petite with small hands. I remember that when we first got the Acist, within a week, she was just happy as a lark. It was so much easier for her to inject contrast. Your lab saw a reduction in contrast with the use of the Acist, and you divided it into dosage and waste reductions. When we had the old manifold system, we used a burette, and would drop around 80ccs of contrast on each case. We would also drop 50 ccs of contrast into our old power injector to inject the left ventriculogram (LV gram). Depending on if there were grafts involved, we might drop upwards of 150 ccs of contrast. If a diagnostic case turned into an intervention, you might drop 80 ccs and then add another 100 ccs. It was so hard to gauge exactly how much you were going to need, but you didn’t want the circulator constantly going back to the burette filling it up when he or she had other things to do. The Acist system is automated, so you don’t have to continually fill it. It’s filled by the scrub nurse pushing a button. Just in that respect, our waste was much less. Take the example of a left heart cath with grafts. With the old manifold system, if we begin with up to 150 ccs of contrast and ultimately only use 80 ccs, then 70ccs have been wasted. We were averaging around 70 ccs of contrast per diagnostic case. Once we started using the Acist system, we reduced it down to about 50 ccs, which doesn’t sound like a lot, but over several thousand cases, it’s a huge amount. Now we are able to use the Acist for our LV grams, which saves us an additional 50 cc of contrast per procedure. I estimate that we save about $150,000 per year in contrast usage/waste compared to the period that we were using the manifold system. What’s your history with Saint Thomas? I’ve been here since 1997, which is almost 13 years. Do you think the Acist still has as much impact today as when you first started using it? It does, and the more people use it, the more you learn to reduce your contrast and still get as clear a picture as you did with the manifold system. The physicians are very happy with the images that we get using the 4 French system and the Acist. The longer the Acist is used, the better people become at using it. At first, we were a little more conscious of the machine, because we were used to the manifold system and felt it was just like an extension of your hand. But it’s become like that with the Acist. Once staff got used to it and started using it on a regular basis, it became second nature for them. Any increased time from the use of the Acist system? No. There are ways to set up the system and disposables before the patient is actually brought into the room. At that point, basically you hook it up and go. Once you are accustomed to the system and have done it several times, it becomes very easy to use. In fact, in some ways, I think it’s faster, because with the old manifold systems, you have to beat out the bubbles and make sure there is no air in the line. You might have to flush it out repeatedly if you have a bubble hung somewhere in the system. With the Acist, you flush it and in a few seconds, it’s clear. There’s no air in the line at all. Using the manifold also means there is more of a chance of injecting an air bubble down the coronary artery. The Acist system, however, won’t let air come through. Once it is cleared from the system to the patient, you don’t have to worry about any air bubbles. Shooting with the manifold system means you’re always leery, thinking, I hope I didn’t get any air in it, or, I hope there’s not an air bubble upstream that I didn’t see. You don’t have to worry about that with the Acist. What happens if an air bubble is injected? It would have the same effect as a blood clot. Depending on the size, it could occlude the artery if it was big enough, and the patient could actually have ischemia until the air bubble dissipates. It would eventually dissipate, but you still would have the chance that the patient could get ischemia during the time that the air bubble is present. What about maintenance of the system? We have had zero maintenance issues. We have an extra Acist device that’s on hand if something happens to one, so you can move the extra one in and take the old one out. We have only had to do that maybe two or three times over the past two years. There is more maintenance involved in use of the Acist in comparison to the manifold system, but that’s simply because when you do a manifold case, a brand new manifold is used, and when the case is done, it is just thrown away. Staff should make sure they clean the Acist equipment at the end of every case and a more thorough cleaning before closing the room down at the end of the day. We do preventative maintenance checks a couple times a year. That’s it. There are not a lot of parts that wear out. The Acist system is very resilient. David Ferebee can be contacted at dferebee@stthomas.org

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