The competition is stiff on Long Island, NY. The almost 3 million residents are able to choose from five tertiary care hospitals offering bypass surgery and angioplasty and related procedures.

“Physicians have the opportunity to go to many centers, so one way we’ve been able to attract them is by making our cath lab high-tech, in terms of the imaging equipment; and user-friendly, in terms of ability to bring patients in,” says Stephen Green, MD, associate director of the cardiac catheterization lab at North Shore University Hospital (NSUH). The hospital is an 849-bed tertiary care facility located in Manhasset, Long Island, and last year, its eight cath labs performed more than 14,000 procedures. “That has been part of our approach from the very beginning.”

At NSUH, the technology has always been a means—never the ultimate goal. Green and the facility’s administrators believe customer service is the best way to win over clinicians.

“Before there was software, there were people, and we’ve always want to have a can-do attitude, where the answer is always yes. This applies even to the very basic things, such as scheduling a test or a transfer,” Green says, noting that treating clinicians like the customers they are has had a significant impact on the lab’s business. “We have ingrained that philosophy into our policy about accepting transfers, and subsequently, we accept about 2,500 transfers a year for cath.”

When technology is brought into the lab, it is done so only if it furthers these service-oriented values. Just one example is the lab’s early adoption of an automated, report-generating system (see “The Informatics Component” below). Another is the flat-panel imaging technology the lab has used since just after the turn of the century.

Increased Quality, Decreased Dose

NSUH installed its first flat-panel in the cath lab in September 2000; it now boasts eight flat-panel cath labs.

“The two major things we look at in cath labs, and for x-ray equipment in general, is image quality and the amount of radiation that the patients and the people around them are getting,” Green says. “We find with these new systems that, paradoxically, you can actually decrease the dose at the same time you also are improving the image quality.”

In 2003, the hospitals’ existing relationship with a major industry vendor led to the installation of a new, big flat-panel, which, up to that point, had been installed only for use in interventional radiology. Green and his team put the hardware, which measured 40 x 40 cm, through its paces with coronary and peripheral procedures.

The most recent updates to the cath lab were made in 2005 with an eye toward making the most of the available space and the technology housed within it.

“We were looking to see how we could enhance what utilization we get out of the equipment,” Green says. This viewpoint was framed around the fact that while the essential procedures—coronary angiography, angioplasty, and stenting—will continue to be mainstays of the cath lab, the volume has decreased nationwide.

“It’s also clear that in some areas of the country, a lot of cardiologists, vascular surgeons, and interventional radiologists have become more interested in looking at peripheral vascular disease, carotid disease, and other diseases,” Green says. “So it was important when we put in these new labs that we have the flexibility to use them for the other processes, too.”

In addition to the initial large-format digital flat-panel, the cath lab selected several small (20-cm-square) and medium-sized (30-cm field of view) solutions. This collection provides ample flexibility in terms of who can use the lab, because the smallest systems work well with the cardiology procedures; the larger ones better accommodate peripheral work; and the intermediate sizes serve a multipurpose function, such as for neurological and carotid procedures, as well as leg, coronary, and renal work.

In addition to the roughly 50 cardiologists who regularly access these labs, interventional radiologists and vascular surgeons also occasionally perform procedures.

“Our philosophy is if you’re credentialed to put in a carotid stent or to do a peripheral intervention in one place in the hospital, as far as we are concerned you are credentialed to do it in any other place,” Green says. “It doesn’t make sense that the site be the issue—the issue is whether you are credentialed, and I think the market is entering into a time frame now where cath labs in general have to be more flexible.”

Making Room

Bringing other types of procedures into the cath lab also helps stave off any slowdowns that may result from the increasing popularity of CT angiography (CTA).

“CTA is going to affect the cath labs in various ways, and while it’s not clear to me at this point whether it’s going to be a positive or a negative, so far it’s been mostly positive,” says Green, who also helps with reading for the hospital’s 64-slice CT scanner. “In general, the people who have had the scans have not necessarily been the people who would have otherwise had a CT, so it’s not like we’re taking people who would have been cathed and bringing them to the scanner.”

Scans generally are performed on patients earlier in the diagnostic process, Green notes. Many are completely healthy, of course, while others require catheterization after the CTA.

“I think it’s actually adding volume to the cath lab, not decreasing volume,” says Green, who adds that CTA might have a negative impact on volume should it become overwhelmingly used for diagnostic angiography in patients who need an angiogram. “I don’t see that happening that much, but if it does go in that direction, it will actually bring more people into the system, and we will end up doing more interventions in the cath lab.”

Such a possibility is all the more reason to have a lab capable of handling a range of procedures and specialists.

“We are always happy for patients when they have normal blood vessels, but as interventionalists, we’re interested in fixing things,” Green says. “If we can have a higher percentage of people in the lab who need to be fixed, then that’s good for everybody.”

To that end, the future of NSUH’s cath lab involves continued expansion. Green is eager to accommodate electrophysiologists and neuro-interventional radiologists in the lab. Slated for installation by year’s end is a biplane flat-panel system that will be used for ablations. Green believes atrial fibrillation ablation is one of the big possible growth industries in interventional cardiology, as the equipment gets better and the indications improve. It also is hoped that the biplane systems will be useful for NSUH’s neuroradiologists, who perform numerous aneurysm clippings and embolizations.

Building the Future

Medical centers eager to upgrade and improve won’t go wrong by gearing their cath labs toward increased flexibility and functionality, according to Green. It is also critical for the growth that is anticipated. His advice is to think of today’s cath labs as the computer-based systems they are, and be ready to invest in regular software and hardware upgrades to maintain performance.

Staying on top of these improvements requires some diligence on the part of administrators. In addition to reading journals and attending conventions, Green recommends connecting with peers in the industry.

“When people visit our site, it’s a two-way street: I’m not just telling them about our story, I’m listening to their stories too and finding out what they’re doing,” Green says. “From the smallest lab to the biggest lab, they all have different stories to tell, and we learn things that we otherwise wouldn’t have thought about.”

For NSUH, putting together a state-of-the-art cath lab was a cumulative effort.

“This is a consistent process; it didn’t just start last year. We’ve had a 10% to 15% growth year-in and year-out over the past 15 years by having this sort of user-friendly approach and looking for new, cutting-edge technology, whether for imaging, report-generating, or archiving,” Green says. “And I think you have to have flexibility; getting the surgeons, radiologists, and cardiologist to all realize that there’s some synergy and some usefulness to working together.”

Dana Hinesly is a contributing writer for  Medical Imaging. For more information, contact .

The Informatics Component

Stephen Green, MD

Last year, the cath lab at the North Shore University Hospital (NSUH), Manhasset, NY, was the site for some 14,000 procedures. Success-fully treating vast numbers of patients while simultaneously satisfying the needs of the clinicians involved is no small feat. It is, however, the focus of the lab.

“Over the past 15 years, it’s been a deliberate policy to make this lab high-tech and user-friendly, in terms of throughput and report generation,” says Stephen Green, MD, associate director of the cardiac catheterization lab at NSUH. “And through the years, we have been able to find technologies to help us.”

This eagerness to adopt systems designed to improve productivity led to the lab’s installation of a Macintosh-based, automated report-generating system in the mid-1990s. By using pull-down lists and templates that demanded only that users select their choices from those provided, the amount of time required to generate reports was significantly shortened. All 30 physicians who were regularly using the cath lab at the time adopted the new system, and soon, transcription services were a thing of the past.

Being familiar with the technology meant that when the time came to move to a new system, in 2004, the transition was smooth.

“When we brought in our new Oracle-based, database- and report-generating system, we had to bring 50 physicians into the learning process, but it wasn’t particularly painful,” Green explains. “They had been exposed to the concept of a computer-derived, report-generating system for the previous decade, so it wasn’t so hard to move them onto the next phase of our cath lab process.”

Although the new program does allow for notes to be entered when necessary, the goal is to make such instances the exception to the rule. Not only does eliminating text editing and transcribing speed the process, it also makes it easier to collect, organize, and search data.

“From a data and space evaluation, it is much better if they fill data fields, so we can search the information in the future,” Green notes. Because databases are formed through the use of templates, this approach provides an advantage that cannot be equaled by incorporating voice recognition in the cath lab. “Voice recognition generates text and, though it can be searched, is more difficult to search and more difficult to quantitate.”

According to Green, when physicians make selections from predetermined options, it makes it possible for searches to be extremely precise—seeking information on only left main coronary arteries, for example—which is a critical component of many of the hospital’s processes, including quality assurance.

“So much of what we do is database driven now—through either the ACC [American College of Cardiology] databases or the state databases—we are required to collect so much information and data that voice-recognition technologies are not appropriate in the cath lab,” Green says. “In the 21st century, you definitely need to have a system that helps build databases for you.”

In addition to improving patient throughput, automating the report process also allows for an impressive turnaround time.

“We have always had the philosophy that the final report is done as a patient is coming off the table and we’ve been able to adhere to that with this system,” Green explains. “No one is entering data at a later date; 99% of our reports are actually finalized at the time of the procedure.”

Once generated, these reports are loaded into the hospital’s PACS, to ensure that they are archived and readily available for clinicians to view images—in or out of the cath lab.

“You must have the ability to pull up studies and review both the images and the reports all at the same time, at any time,” Green says. “This ability really helps patient care, because knowing about prior issues—and seeing how you took care of them the last time—can get the patient off the table faster and safer, with less radiation.”

—D. Hinesly