At this point, we're going to move on to a roundtable led by Dr. Adir Shroff at the University of Illinois Chicago, where he's chief of clinical cardiology, and he's going to be discussing implementing these guidelines in the hospital setting. All right. Well, hi, everyone. Good evening. Thanks for having me on this really cool session. It's really just a little bit of a background. When I started my practice in 2004, a leading fellowship, I was asked to start a PCI program without surgery on site at the Jesse Brown VA. I was the first VA in the country to have PCI without surgical support. You can see from Dr. Grinz's presentation in 2005, the guidelines that it was a class C indication. We were pretty obviously nervous about doing PCI in this type of site, but our patients were really suffering because they were locked in the VA system. The wait at one other center in Chicago was several weeks to months long for PCI, and people were not getting done. We made up a lot of the criteria that we wanted to put in place. That's what I want to cover. I really thank the organization and the group for putting all these criteria together, and not just talking about the types of patients and the types of lesions, but really talking about the type of lab that you have. That's what we're going to focus in this roundtable and get all of your opinions. Really, the way I thought about it was that when we're thinking about your infrastructure and your cath lab, it's really, I think the first topic I wanted to talk about was process, staffing, infrastructure. Maybe I'll start with that. Maybe I could just go through the panel and get people's opinions. I think Soha practices in Maine, or wait, Salem. She actually practices in a site without surgery on site. In terms of process, staffing, and infrastructure, what are some of the things that you had to take into consideration in your lab that you wanted in place to do these procedures safely? Right. Thank you so much. Yes. I think you actually mentioned a few of these in the chat already. It really depends on the case selection, but if you're planning on doing what you think is appropriate, especially in MI patients, it should be good to have the right materials in place. Things that have come up already are covered stents, some sort of mechanical support device. What I actually came into a lab that had CV backups, just like Dr. Grimes was saying, had CV surgery on site and was taken away about seven years ago. It was interesting because we were a lab that was fully functioning before I got there and then had to adapt and actually kept moving forward, which is great. What we've done recently is we started our impella program for mechanical support and shock patients. I work in the MG Mass General Brigham system and we have mobile ECMO now. In terms of really pushing the envelope to make sure that we can do what we think is appropriate for our patients, we have those in place as well. Staffing, we have specifically, we try to recruit interventional cardiologists that have a couple of years of training only because you want a little bit of that expertise, but I don't think that's a definite. I think it just needs the right mentoring. Those are some of the things that came into play for us. Great. Mladen, I know you're my boss at the VA and obviously you've been the chief there for probably a decade now, right? In terms of staffing and the process, are there anything in particular that you've really focused on there as sort of leadership in the cath lab at the VA? Yeah, thank you. Thank you for bringing this up. I think when you staff a cath lab without surgical backup, I think you have to also look at quality of the staff you have and education and to provide continued education. One thing that we found is you do have to have sufficient staffing and assumptions does give you a little bit of a headache with cost of that additional staffing that you have to have to cover. Call, 24-hour coverage, expertise, and sometimes a redundancy. You may end up needing to finesse your relationship with the leadership. Are they willing to actually pay for that extra staffing to actually maintain competency and let's say coverage at all times? Another topic you have here is transfer agreements. I'm going to just jump ahead of this, but this seems like two simple words, but this is actually very complicated because you really have to set up front expectations with who will pick up your complicated case and how will this really happen in practice. What does this really mean? Do you have a relationship with a surgery center? Do you maintain that relationship? Then who will transfer this patient when really there's dire straits and bad things are happening? Again, it's two simple words, but it includes maintaining relationship with your surgical backup and then maintaining relationship with the ambulances and then who comes and picks the up. Not ambulances are made the same way. They come in a variety of flavors. Some may transfer decimo as we heard, or some may do impella, some may not. Some may not have the expertise. Again, keep that in mind. This is what I usually find as an issue. Redundant staffing and good friendly transfer agreements. Dr. Schreiber, I know of your practice in terms of the really complex work that you've been doing in Detroit, but tell me a little bit about your practice with relation to this in terms of developing and having a cath lab without surgical backup. How do you build it? What things do you think are really important to have in that type of scenario? The hospital where I do most of my cases, an Ascension Hospital in Macomb County, north of Detroit, basically gave up its open heart program and recommendation from outside consultants because we were only doing about 100 cases a year for several years. However, we had the ingredients of multiple very experienced interventionalists as we define in our 2023 consensus document, and we had a very mature lab with circulatory support. For us, we started out with the ingredients, but we got to the situation of no surgery on site because we just didn't think that maintaining a low volume cardiac surgery program was the right thing to do. In fact, we were the first of 39 open heart surgery programs in the state of Michigan that decided to give up its open heart program. We already have the ingredients of circulatory support. We had the ingredients of proper staffing as part of giving up our surgical program, the mothership institution, the tertiary institution of Ascension Michigan in St. John's in Detroit. We already had the transfer agreement readily in place, although I might mention, we do about 900 to 1,000 cases a year over the last decade. The last time an individual went from the cath lab to open heart surgery was in 2015. Some of that is not because we're such great interventionalists, but to be very frank with our panel and our audience, low volume cardiac surgery programs or lower volume are not interested in getting a patient that's going to die. With all due respect to my colleagues, the surgeons, when a patient crashes, we frequently find out that we're on our own and we have to bail out as best as we can. I think the one thing that's unique about our program that I would recommend is we have a senior interventionalist of the day de facto or de jure in our program. The sorts of cases that the 2014 consensus document listed as foreboding in a place such as ours might be cases where the opinion of an experienced interventionalist is sought by the more junior interventionalist. That's the primary operator. Great. Well, thank you, Dr. Sharber. That's a ton to think about. I know that when we started, one of the things that we did was we really did a similar kind of staging as what they described in the algorithm of really doing type A and B lesions first and then before we went to type C lesions. I think that was really something. We didn't start our STEMI program for about a year after we started our elective PCI program. I think we're wrapping up soon here. I just wanted to see if anyone else... We're talking a lot about doing the PCIs, but I think that the third topic here was quality assurance, informed consent, how do we go back and check what we're doing. I know Mladen has a really nice program that we do at the VA where we can review all of our bad outcomes, but I'm assuming other people do that as well. I'm wondering what other things that are people doing in their center. I know, Dawn, you have a hospital that you work at that also doesn't have surgery on site. What do you guys do from a quality standpoint or quality assurance or improvement? I do think it's important to recognize that quality independent of the institution you practice and the NCDR PCI registry is not limited to sites with surgery. We report all PCIs from both of our surgery center and our non-surgery center, and we review the quarterly outcomes. They're obviously quite similar, but that's a way to get a little more granular into the details of the types of patients that you end up treating over the years, because you have the detailed reporting feedback from the NCDR. Even OBLs and ACS can submit data to NCDR, and that will be really important from a societal perspective for us to be able to review that and ensure quality risk adjusted, of course, because that's always so important. But I think having those tools, getting the infrastructure in place no matter where you are for the data abstractors and submitting good data that represents the truth about the patient is really important. If I can just add to that. Yeah, I was going to mention, Jeff, that Jeff and I have been working on. Well, you can continue, Jeff. Yeah, no, that's fine. In addition to the NCDR, and that's great, but the OEIS, the Outpatient Endovascular and Interventional Society, is partnering with SCI. Cindy's on our advisory panel, as well as multiple SCI leaders, and we are developing a cardiac module to be able to track outpatient or same-day discharge types of patients, really avoiding the inpatient type of high acuity patients, but more of the stable type of patients in all sites of service. And so we plan to launch that this year, so stay tuned for that. I think it would just complement really what we have now and really just add to what you're saying, which is transparency. That's what we really need to assist with as we forage and move ahead and continue to expand our services. Advantage to this is the cost. Sometimes it's cost prohibitive for the NCDR, and this is very low cost. There's a few questions on the chat you want to mention. One of the things that came up is what's the ideal distance or timeframe for a patient needing emergency surgery to be transferred? We discussed this. It's a little bit on the conference calls, and I'm not sure that we actually came up with an absolute number. And I can tell you it's not that great, even in the current setting. If you look at onsite surgery, it's more than two hours, like two and a half hours. And so I think that's one of the reasons we did not want to mandate actual time. And of course, it all depends on the patient. I mean, if you're giving active CPR, that's one thing, as opposed to a patient that just, I couldn't dilate that calcified right coronary lesion, so he needs something else. So is there any disagreement among the panel? No, I think it's also, you know, you're trying to have access to patients who might live in remote locations. And so it really depends on how close distance wise geography a little bit is out of control, out of our control. I think it brings up a good point about the transfer agreements that was brought up earlier, you know, pick the location that has the highest quality, but the closest to your location. You know, I think, you know, there's politics and every everywhere. And so yet, you know, sometimes you want to be careful about it, but really pick that that has that quality and proximity.

PCI

hospital setting

cath lab

data registries

patient care