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Fellowship Manual
 

Fellowship Manual

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    Fellowship Manual Fellowship Manual Document Transcript

    • University of Colorado Hospital and Denver VA Medical Center Cardiac Cath Rotation 2005-2006 Fellowship Manual for the Interventional Cardiology & Cardiac Catheterization Laboratories at University of Colorado Hospital & Denver VA Medical Center John D. Carroll, M.D., Director of Interventional Cardiology, UCHSC John Messenger, M.D., Director, Cardiac Catheterization Laboratory UCH and Interventional Training Program, UCHSC Ivan Casserly, MB, BCh, Director, Interventional Cardiology, DVAMC and Associate Director, Interventional Training Program, UCHSC Vicki Blume, Fellowship Program Coordinator
    • University of Colorado Hospital and Denver VA Medical Center Cardiac Cath Rotation 2005-2006 Overview for 2005-2006 The rotation of fellows through the cardiac catheterization laboratory is an integral part of their overall training as a cardiovascular specialist. In addition the Interventional Fellowship is a 1 year ACGME-accredited program focused on training as an interventional cardiologist with an emphasis on research in the cardiac catheterization lab. The regular (i.e. rotating) cardiology fellow and the interventional fellows (two interventional fellows approved by ACGME) are key members of the catheterization lab team responsible for providing clinical care and in fulfilling our missions as an academic institution including education and research. Changes in UCHSC’s program in Interventional Cardiology for 2005-2006 include: 1. Expansion of the UCH program to include diagnostic and interventional services at UCH-Fitzsimons Campus. 2. Expansion of our program’s training goals to include a limited volume of diagnostic and interventional peripheral training under the direction of Ivan Casserly. We hope to increase collaboration with our colleagues in Vascular Surgery and Interventional Radiology as we further develop the Cardiac and Vascular Center. 3. Expansion of the program of percutaneous implantation of intra-cardiac defect closure devices utilizing ICE (intra-cardiac ultrasound), for the treatment of PFO’s, ASD’s, and VSD’s. This will provide fellows a unique opportunity in the treatment of patients with congenital heart disease and in patients with a history of TIA/stroke. The randomized trial RESPECT has begun. 4. Expansion of our Program for Hypertrophic Obstructive Cardiomyopathy. Dr. Bertron M. Groves has initiated a program of non-surgical septal reduction therapy (or Alcohol Septal Ablation) for patients with medically refractory Hypertrophic Obstructive Cardiomyopathy. 5. Expansion of the 3-D Coronary Lab. This represents the first 3-D cardiovascular clinical lab to be created in the world and has started an extensive and exciting research collaboration between the University of Colorado and Philips Medical Systems, Inc. The last year has seen the completion of studies on rotational coronary angiography. An additional development is further expansion of Dr. James Chen’s NIH funded basic imaging science 3-D research program using both 3D reconstruction of ultrasound and angiographic data sets and their fusion. The development of a 3-D angiographic core lab will be ongoing starting with several projects in 2005. 6. On-going expansion of the Program in Percutaneous Treatment of Valvular Heart Disease that brings over 100 patients to UCH each year with mitral, aortic, pulmonic, and tricuspid valve stenosis. This includes participation in mitral valve clipping as part of the EVEREST-II trial assessing the clinical efficacy of the E-valve clip for mitral regurgitation. 7. Further expansion of the Adult Congenital Intervention Program under the direction of Dr. Joseph Kay. 8. On-going commitment to providing high-quality supportive services to the Programs in Transplantation (Cardiac, Lung, Liver, Kidney), Pulmonary Hypertension, and Heart Failure. Eligibility and Selection Policy All applicants entering the interventional cardiology program must have completed an ACGME-accredited cardiovascular disease program or its equivalent. This program does not discriminate with regard to sex, race, age, religion, color, national origin, disability, or veteran status. 1. Applicants must document compliance with one of the following: a. graduate from a Liaison Committee on Medical Education (LCME) accredited medical school; b. graduate from an American Osteopathic Association (AOA) accredited college of osteopathic medicine; c. be a foreign medical graduate holding a valid ECFMG (Educational Commission for Foreign Medical Graduates) certificate; d. hold a full, unrestricted license to practice medicine in a U.S. licensing jurisdiction; e. successfully complete a Fifth Pathway program provided by an LCME-accredited medical school. 2. Applicants must successfully pass a criminal background investigation (criteria specified in UCHSC and GMEC background investigation policies). The CU School of Medicine recognizes that fellows enrolled in its programs are trainees, not employees. As such, all applicants also must be able to meet conditions of the institutional houseofficer (resident) training agreement. Specifically, individuals must meet one of the following requirements: (1) be a U.S. citizen; (2) hold a valid U.S. resident alien card; (3) possess (or be eligible to possess) all of the following: 1
    • University of Colorado Hospital and Denver VA Medical Center Cardiac Cath Rotation 2005-2006 a) valid passport; b) valid 1-94 card (obtained upon entry to the U.S.) that indicates D/S J-1 (Duration of Status for J-1 visa) c) d) J-1 visa sponsorship from the ECGMG to train at the CU medical school in the specific training program. The Training Program in Interventional Cardiology Faculty John D. Carroll, MD, FACC, Professor of Medicine UCHSC, Director Interventional Cardiology, Director Cardiac & Vascular Center John C. Messenger, MD, Associate Professor of Medicine, UCHSC; Director, Cardiac Catheterization Laboratories, UCH and Director, Interventional Cardiology Fellowship Program Bertron M. Groves, MD, Professor of Medicine/Radiology UCHSC. Ivan Casserly, MB, BCh, Associate Director, Interventional Cardiology Fellowship Program; Director, Interventional Cardiology, Denver VAMC; Assistant Professor of Medicine, UCHSC. Joseph D. Kay, MD, Attending at both UCH and TCH, Adult Congenital Cardiology Program, UCH; Assistant Professor of Medicine, UCHSC. Fellow Supervision To ensure that fellows are provided adequate and appropriate levels of supervision during the course of the educational training experience and to ensure that patient care continues to be delivered in a safe manner, all program faculty members supervising fellows must have a faculty or clinical faculty appointment in the School of Medicine or be specifically approved as supervisor by the Program Director. Faculty schedules will be structured to provide fellows with continuous supervision and consultation. Fellows must be supervised by faculty members in a manner promoting progressively increasing responsibility for each fellow according to their level of education, ability and experience. Fellows will be provided information addressing the method(s) to access a supervisor in a timely and efficient manner at all times while on duty. The program provides additional information addressing the type and level of supervision for each post-graduate year in the program that is consistent with ACGME program requirements and, specifically, for supervision of fellows engaged in performing invasive procedures. Goal of Training Program To provide a structured and supportive clinical and academic training experience that will allow the trainee to become, at program completion, an independent, ethical, and competent interventional cardiologist, skilled in all aspects of pre- procedure, procedural, and post-procedural patient care, capable of completing all requirements for ABIM added qualifications in Interventional Cardiology, and, if interested, of successfully initiating an academic career as a faculty member. Educational Objectives of Rotation: To become skilled and competent in the evaluation of individual patients being considered for interventional cardiology procedures and applying evidence- based indications as set forth by ACC/AHA guidelines. To become skilled and competent, including both cognitive and technical aspects, in the performance of all standard interventional cardiology procedures including related diagnostic tests/procedures and medications. To become familiar with diagnostic and therapeutic procedures that are not widespread in the interventional cardiology community but are utilized at UCHSC. To develop an attitude of life-long learning and critical thinking skills needed to gain from experience and incorporate new developments. To understand and commit to quality assessment and improvement in procedure performance. 2
    • University of Colorado Hospital and Denver VA Medical Center Cardiac Cath Rotation 2005-2006 To acquire introspective skills to realize one’s strengths and weaknesses in interventional cardiology and specific procedures. To learn to function as a member of a team in the cardiac catheterization laboratory. To learn how to direct and lead a team in the cardiac catheterization lab including during emergency conditions. To learn how to efficiently and competently complete all documentation of care provided. To become skilled in recognizing and responding to adverse events that may occur during and after procedures. To learn how to effectively and humanely communicate with patients and their family including during the process of obtaining informed consent before the procedure and in explaining results after the procedure whether successful and uncomplicated or unsuccessful and/or complicated. To learn how to effectively and professionally communicate with other health care providers concerned with the patient. To learn how to be responsive to the needs of the referring physicians requesting consultative and procedure services. To learn how to become an effective teacher of diagnostic cath skills to cardiology trainees To develop clinical research skills including critical scientific thinking, commitment to quality data, and patient safety. To successfully complete basic training in clinical research ethics (COMIRB 101 and 201). To successfully complete ACLS/BLS certification. Methods of Teaching/Learning: Direct, one-on-one instruction by the faculty in the Section of Interventional Cardiology and other Cardiology faculty. Direct, by introspection during and after all patient care experiences. By reading and analyzing written elements of core curriculum. By attending scheduled conferences of summer core curriculum, Mortality and Morbidity, research, Cardiology Grand rounds, VA Cath-Surgery conference, Cardiovascular Interventional Society meetings, Journal Club, and Medical Grand Rounds. By attending at least one national meeting of Interventional Cardiology. By attending the spring national Interventional Cardiology Fellow Conference. By participating in all clinical trials in the cardiac catheterization laboratory. By participating as an investigator in a specific research project directly related to Interventional Cardiology and under the mentorship of a faculty member. Method of Evaluation & Feedback of Interventional Cardiology Fellow’s Performance By daily verbal feedback from all involved faculty. By ad hoc meetings with the training program director. By verbal feedback from cath lab manager and nursing staff as organized by the training program director. By formal meetings with training program director every 3 months involving both verbal feedback, written evaluation form, and a written summary by the training program director. The formal written evaluation shall: • Address each of the six ACGME core competencies. • Include well-defined scoring and rating criteria that seek to minimize subjective assessment of performance. • Include language indicating satisfactory performance, or provide specific actions and performance requirements by the fellow to return to a level of satisfactory performance. • Be signed and dated by the fellow and Program Director • Become part of the permanent record file for the fellow. In the event that academic status of a fellow is changed to probation or Termination, a letter of notification to the fellow will be co-signed by the Assoc. Dean for GME. Additional information is provided in the institutional policy titled “Grievance Policy and Procedure”. 3
    • University of Colorado Hospital and Denver VA Medical Center Cardiac Cath Rotation 2005-2006 Method of Evaluation & Feedback of Faculty and Program in Interventional Cardiology by the Interventional Cardiology Fellow By ad hoc meetings with training program director. By written questionnaires of individual faculty member’s performance at 6 and 12 months of clinical year and at end of any formal research period. This will be integrated with an evaluation performed by the rotating fellow to promote the confidentiality of the evaluation. By end-of-the-year formal meeting with training program director. By ad hoc communication with the training program director after completion of Interventional Cardiology training program (i.e. stay in touch and reflect back on the training program after you have “moved on”). Orientation At the beginning of a fellow’s first rotation in the cardiac cath lab an orientation is necessary. This will be accomplished by meeting with the nursing staff, the attending staff and the interventional fellows. The following topics will be covered: 1. Responsibilities & Policies 2. Cath reports 3. Cath lab technologies 4. Radiation safety 5. Research protocols 6. Cardiac Cath Conference 7. Suggested Reading 8. Substance Abuse/Impairment Policy 9. Moonlighting Policy 10. Duty Hours Each fellow new to the cath lab will be oriented by the staff, attendings, and interventional fellow. Lockers are provided for Cath Fellows; however the Cath Fellows must provide their own locks. Male Cath fellows will use room 2005 at 9th Avenue and the Men’s locker room on the 2nd floor AOP. Female Cath Fellows will use room 2004. At the VAMC lockers are available immediately adjacent to the CCL. Keys will be provided to Cath Fellows for Procedure Rooms, Viewing room etc. The key must be returned after your rotation is over. Radiation Badges will be arranged through University of Colorado Hospital Cath Lab. Core Reading Curriculum All fellows should plan their own reading course covering the following topics commonly found in standard textbooks: 1) Vascular access and post procedure removal of sheaths, use of closure devices, and control of bleeding. 2) Coronary angiography and interpretation. 3) Hemodynamic techniques and findings in different disease states. 4) Left ventricular and aortic angiography. 5) Pre-cardiac transplant work-up and post-transplant monitoring of rejection. 6) Interventions for coronary artery disease. 7) Interventions for valvular heart disease and congenital heart disease in the adult. 8) Pharmacology of cardiovascular drugs used in the cath lab. 9) Radiation safety. 10) Complications associated with cardiac catheterization. Required Core Curriculum For All Interventional Cardiology Fellows • Guidelines for Coronary Angiography: A report of the ACC/AHA Task Force on Practice Guidelines. 1999. • Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. International Consensus on Science. The American Heart Association in Collaboration with the International Liaison Committee on Resuscitation. • ACC/AHA Guidelines for Percutaneous Coronary Intervention: A Report of the American College of 4
    • University of Colorado Hospital and Denver VA Medical Center Cardiac Cath Rotation 2005-2006 Cardiology/American Heart Association Task Force on Practice Guidelines. 2001. • Catheterization laboratory standards: a report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents. 2001. • Ethics Manual. Fourth edition. American College of Physicians. 1998. • Grossman’s Cardiac Catheterization, Angiography, and Intervention, Sixth edition, edited by D.S. Baim and W. Grossman. 2000. • CathSAP II—Cardiac Catheterization and Interventional Cardiology Self-Assessment Program. American College of Cardiology, 2001. Responsibilities of the Rotating Cardiology Fellow at UCH 1. Actively work with the attending staff and the cardiac cath lab staff to deliver outstanding clinical care for all patients undergoing diagnostic and therapeutic procedures. 2. Under the direction of the interventional fellow, the rotating fellow will work-up patients before they come to the cath lab. See below for details. On occasion, patients will be worked-up and consented by Jana Keller, RN, ANP, or Cathy Kenny, RN, ANP, the cath lab nurse practitioners. The fellow is responsible for discussing the patient’s history in detail, confirming the indications for the procedure, as well as the scope of the procedure to be performed, and communicating any concerns or questions to the attending before the start of the case. 3. With an attending cardiologist, the rotating fellow will perform diagnostic cardiac catheterizations and occasionally assist in therapeutic procedures. 4. The rotating fellow will write post-cath orders, communicate with any other physicians involved in the post- cath care of the patient, and complete the final cardiac catheterization report. 5. Subsequent post-procedure care including sheath removal, discharge summary dictation, and discharge planning and implementation may be completely or partially handled by the cath fellow, in conjunction with Cathy Kenny, RN, ANP and Jana Keller, RN, ANP, for outpatients or short-stay inpatients on the Cath/ Interventional service. 6. Participation in the general cardiology on-call schedule is required of the rotating fellow per Howard Weinberger, MD, Director of General Cardiology Fellowship. Cardiac cath lab call will be covered by the interventional cardiology fellows and the third year interventional cardiology research fellow. 7. Organize at least one Cardiac Catheterization Conference per month. 8. Participate in screening patients for ongoing research activities. 9. It is the cath fellow's responsibility to notify the cath attending immediately whenever emergent patient- related problems arise. Cath attendings should be contacted by digital pager first or via their offices during the day. If the cath attending does not respond immediately to the digital page during nights or weekends, call him by using his home phone number which is included in the monthly call schedule. 10. Unplanned absences from this rotation cause major disruptions in clinical service. Written requests for time away are to be submitted to the lab director before the start of the rotation with specific plans for coverage. This is also covered in the Cardiology Fellowship Vacation Policy distributed each year. Responsibilities of the Interventional Fellow 1. Actively work with the attending staff and the cath lab staff to deliver outstanding clinical care for all patients undergoing diagnostic and therapeutic procedures. 2. Both the interventional fellow and the rotating fellow will work-up patients before they come to the cath lab. The interventional fellow will direct this process. See below for details. 3. With an attending cardiologist, the interventional fellow will perform diagnostic and therapeutic cardiac catheterizations. 4. On occasion the interventional fellow will train/assist/supervise rotating fellows in the performance of diagnostic catheterization and, in so doing, truly become ready to be autonomous and competent in diagnostic catheterization. 5. The interventional fellow will write post-cath orders, communicate with any other physicians involved in the post- cath care of the patient, and complete the final cardiac catheterization report. 5
    • University of Colorado Hospital and Denver VA Medical Center Cardiac Cath Rotation 2005-2006 6. Subsequent post-procedure care including sheath removal, discharge summary dictation, and discharge planning and implementation may be completely or partially handled by the cath fellow for outpatients or those who are short-stay inpatients on the Cath/Interventional service. 7. Participate in the on-call schedule. The on-call schedule is to be maintained by the interventional fellows. 8. Oversee the Cardiac Catheterization Conference, helping fellows prepare their cases, assists in the computer presentation of cases, and at times the interventional fellow will prepare cases for presentation. 9. Participate in ongoing research activities as a co-investigator whenever possible. 10. It is the cath fellow's responsibility to notify the cath attending immediately whenever emergent patient- related problems arise. 11. Written requests for time away need to be submitted to the cath lab director with specific plans for coverage. 12. Participate in the QA/QI process by helping maintain records regarding the acute MI program at UCHSC. 13. Maintain an electronic database (XCEL) of all cases performed at UCH and DVAMC including indications, procedures performed and complications for review and sign of by attending physicians. Moonlighting To ensure that professional activities falling outside the course and scope of the training program are consistent with policies and guidelines set forth by the Accrediting Council for Graduate Medical Education (ACGME) and Graduate Medical Education Committee. Moonlighting is defined as any professional activity not considered an integral part or required rotation of the curriculum for a postgraduate training program, irrespective of remuneration. Residents will not be required to participate in moonlighting activities. Note: Internal moonlighting must be counted against any duty hour limitation in effect at the time a request for moonlighting privileges is considered by the program director. Note: Individuals possessing a J-1 visa are not eligible to moonlight. The program recognizes that moonlighting is not an activity associated with part of the formal educational experience. Moonlighting is allowed for those fellows demonstrating satisfactory performance in duties relating to the formal academic program and who meet the following requirements: The individual wishing to moonlight must obtain prior written permission from the Program Director. 1. The individual seeking permission to moonlight must possess a valid license to practice medicine in the State of Colorado. A “Physician Training License” does not meet this requirement. For additional information see Colorado Revised Statutes Article 36, also known as the Medical Practice Act. 2. The individual seeking permission to moonlight must secure professional liability (malpractice) insurance coverage apart from that provided to house staff personnel as part of the formal academic training program. Coverage provided house staff personnel as part of the residency contract does not include activities occurring as part of a moonlighting experience. Permission to moonlight may be revoked by the Program Director if academic performance is determined to no longer be at a satisfactory level, e.g., probation, or other major concerns arise. The obligation to notify an outside employer is the responsibility of the fellow who established that employment relationship, not the responsibility of the University or training program. House staff personnel continuing to moonlight following revocation of permission can be dismissed from the program. Procedure for Seeking Moonlighting Approval Fellows seeking approval to moonlight should obtain the required written approval by completing the appropriate program form. The program director must provide written approval prior to engaging in moonlighting activities. A copy of the completed approval form must be supplied upon request to the Office of GME. The program will maintain a copy of the completed form in the individual’s permanent file. Responsibilities of the Cardiology Catheterization Fellow at the Denver Veterans Administration Medical Center 6
    • University of Colorado Hospital and Denver VA Medical Center Cardiac Cath Rotation 2005-2006 Primary Responsibilities: 1. Evaluate all patients referred for cardiac catheterization or pacemaker placement. This evaluation should include review of all previous cardiac or vascular studies. All patients should have a brief pre-procedure note documenting indications for the procedure, a focused H&P, a review of pertinent labs, and a plan documenting the procedure to be performed entered into the CPRS computer system. The fellow will be responsible for writing all pertinent orders for the procedure or ensuring that they are performed by the primary team. A signed consent needs to be on the chart prior to the procedure. Consents need to be witnessed by a person unassociated with the cardiac cath team. A pre-procedure worksheet needs to be filled out on each patient and dropped off in the box outside the cath lab nurse’s office on the evening before the cases. As part of our current policy, patients will not be receiving pre- procedure sedation. 2. All cases and their order of performance should be reviewed with the cardiac cath attending on the evening before the procedure. All add-on cases should be discussed with the attending and cath lab staff as soon as possible. At the beginning of the month, we will review ongoing research studies, and the fellow will be asked to screen patients for these studies. Consent for research studies will be the responsibility of the attending physician or the cardiology research nurse. 3. Cardiac cath reports completed using the CART application in CPRS will be completed by the attending physician unless otherwise discussed with the fellow. The fellow is responsible for communicating the results and the plan with both the cardiology consult team and with the primary care team to ensure that discussed plans are implemented. In the event a patient is unstable, the fellow is responsible for contacting the Cardiology Fellow on- call to discuss the patient. For certification and patient safety issues, most PTCA procedures will be performed by one of the interventional cardiology fellows if available. The performance of all procedures by the rotating fellow will be determined based on attending preference and skill level of the individual fellow. Prior to performance of percutaneous arteriotomy repair, formal hands-on training by the representative from Abbott will be encouraged. This will be facilitated by the interventional attending faculty. 4. If outpatients need admission following cardiac catheterization, they will be admitted to an inpatient medicine team with consultation provided by the cardiology consult service. All outpatient procedures are coordinated by Phyllis Wagar, ANP in the Section of Cardiology. She is available Monday through Friday and coordinates the outpatient cath schedule. The fellow is responsible for talking with her daily to coordinate the cath schedule. In the event a patient requires a device check following pacemaker placement, the fellow is responsible for ensuring a follow-up CXR and ECG is performed and personally checked and that a device representative is available for device interrogation. This can be coordinated through either Brack Hattler, MD or Kathy Liberatore, RN who coordinates the pacer clinic. 5. Fellows will obtain operative reports (or have the primary team obtain them) prior to a catheterization. These include op reports, prior cath reports, and reports of vascular studies. 6. Cardiac catheterization conference: Cath conference is the responsibility of the cath fellow. It is at 7:30 AM on Monday mornings (except holidays). The fellow is responsible for bringing relevant cath films on CD-ROM, and for bringing ECHOS, copies of ECG’s, and nuclear studies for display. The presentation on each patient should be a brief powerpoint style computer presentation, with a focused H&P, labs, pertinent studies and results from the cardiac catheterization. If the fellow is on vacation, he/she is responsible for arranging coverage for the conference in advance. All cardiology conferences are mandatory. Other Responsibilities: 1. The fellow will round on the Cardiology Service at least 2 weekend days/month. Scheduling will be through the general fellowship scheduling mechanism. 2. Assist in performance of non-invasive studies or ECG reading in the event one or more of the other fellows is on vacation or otherwise unavailable. Patient Scheduling for Cardiac Catheterization Patients are scheduled for cardiac catheterization in a variety of ways. Elective procedures are handled via the cath lab office at UCH. Emergent, urgent, and elective procedures for inpatients are "added to the schedule" in an ad hoc fashion via the cath lab office or by direct physician to physician communication. If a case needs to be added on, it is imperative that the charge nurse be told of the case. At the VAMC, the cath attending should be consulted for inpatient add-ons and outpatients may be added by discussing with Phyllis Wagar, ANP. It is important to notify the nursing staff at all hospitals if an add-on needs to be scheduled. 7
    • University of Colorado Hospital and Denver VA Medical Center Cardiac Cath Rotation 2005-2006 When a cath fellow receives a page to evaluate a patient for possible emergency cath, she/he must notify the cath attending immediately before leaving his/her home to evaluate the patient. Effective and timely communication with the attending and cath lab staff is essential. The on-call cath lab staff will be mobilized via the hospital operator by the attending or by the fellow at the attendings request. If the cath lab staff is already on-site, communicate emergency add- ons directly with the cath lab charge nurse. Patient Evaluation Before Cardiac Catheterization Patients coming for a procedure should be referred for a clear indication with a complete understanding of potential benefits and risks, with all essential labs completed, and with all other clinical issues adequately assessed. Failure to adequately work-up patients before a planned procedure may result in patients being sent home or waiting hours or even days for these issues to be clarified. In the current intense environment to deliver expeditious and potentially efficient, cost-reducing care, it is imperative that the pre-cath lab work-up be completed. Often, the pre-cath evaluation will be performed by the cath lab nurse practitioner. The pre-cath evaluation typically consists of the following: 1) A targeted history and physical. 2) A review of tests and reports of the patient’s outpatient and/or inpatient work-up (chest x-ray, ECG, echo/Doppler, treadmill stress test + thallium scintigraphy, and routine lab tests. In all patients who have had previous coronary angiography and/or CABG bypass surgery and are scheduled electively for catheterization, the cath fellow should obtain (with assistance from the cardiac cath lab secretarial staff) cath reports and/or operative notes (to determine specific SVG's and/or LIMA grafts etc). 3) When patients are scheduled, the indication for the planned procedure will be noted along with other essential information (allergies, exact procedure(s) needed, special medical, emotional, or/and other personal/family needs). 4) The referring physician(s) must be identified for all patients and we must know their wish to participate in any decisions in the diagnostic to therapeutic catheterization transition that frequently occurs within minutes of a "combination" procedure. For inpatients it is important to identify housestaff involved in the care of the patient, as well as the patient's regular, outpatient physician. Referring physicians should be listed in the dictated cath report to guarantee that they receive a copy. 5) Whenever possible, the day before the planned procedure the fellow will review the planned cases to identify missing labs, lack of other information, and other items that need to be clarified or planned for. The cath lab office staff is skilled and experienced in assembling material that is identified as important in the pre-cath evaluation. The fellow should discuss any potential medical, technical, or schedule problems with the attending of the day as soon as she/he identifies them. 6) Obtain formal written consent from each patient and have it witnessed by a nurse before the patient is delivered to the cath lab. 7) Review each catheterization candidate with the scheduled cardiac catheterization attending prior to the procedure to formulate a "game plan" which must also be communicated to the nursing staff. This information should include the specific procedures to be performed, access site, sheath size, catheter needs, type of contrast, etc. 8) Every morning the attending, charge nurse, and fellows will meet briefly to discuss the cases, plan the staffing, etc. In planning for the day great efficiencies can be achieved if the staff is fully aware of the exact procedure to be performed and any special patient needs or medical problems. While the majority of patients coming to the cath lab are emergent to urgent and the schedule is constantly undergoing updating, it is not acceptable to have inconveniences, waste, and delays caused by inadequate pre-cath evaluation. Transfers of Patients and Utilization of the PACU/6N at UCH for Transfers Fellows frequently are intimately involved with the transfer of patients between institutions. The most frequently 8
    • University of Colorado Hospital and Denver VA Medical Center Cardiac Cath Rotation 2005-2006 encountered transfer situation is with DHMC or DVAMC. The transfer process involves several key steps: 1. The attending physician at another hospital makes the decision to transfer. 2. A UH attending physician must be aware of the patient and officially be ready to accept the transfer. 3. University Hospital admissions (ACCESS Center) must be notified of the patient’s name, age, location, medical condition, reason for transfer, accepting attending physician, and estimated length of stay. They will verify insurance status. 4. Transportation is then usually arranged and coordinated by the transferring institution. Who arranges for the transfer must be discussed in the initial phase of decision making. 5. The specific location to where the patient is going to be transferred must be decided. If it is the cath lab, the cath lab staff needs to have a room available. If it is the CCU, bed availability must be assured. If the patient is to go to the PACU or 6 North pending the availability of the cath room, the PACU/6 North must agree to this first. The Role of the Fellow in Performing Procedures The goal of the training experience in the cardiac catheterization laboratory for a rotating fellow is not technical and clinical proficiency in performing all diagnostic and therapeutic procedures. The primary goal is an introduction to the techniques and integration of the cath lab experience into the rest of the training experience. While 3-6 months in a cardiac catheterization laboratory may familiarize the fellow with many techniques, it usually provides her/him with only the initial phase of learning basic skills and performing straightforward procedures in a highly supervised environment. For fellows wishing to achieve the goal of being adequately trained to autonomously perform diagnostic and therapeutic procedures, further training is necessary and should be discussed with the training program director and faculty within the cath lab. With this in mind, it still is the tradition to have fellows who spend only a limited time in the cath lab to perform a fairly broad range of diagnostic techniques and some therapeutic procedures such as intra-aortic balloon insertion and pericardiocentesis. The level of attending supervision and the point at which the attending will assume the primary role in performing the procedure is quite variable. The medical condition of the patient, the experience level of the fellow, and the attending’s perception of how the immediate task is being performed are some of the variables that dictate who does what in the cath lab. No significant compromise of patient care is allowed for training purposes and the attending is legally and morally responsible for the performance of the procedure and its outcome. With these guidelines in mind, it is common that the rotating cath fellow will perform, with attending supervision, guidance, and active assistance, many of the diagnostic cardiac catheterizations by the end of her/his first month in the cardiac cath lab. When an occasion arises for the rotating fellow to assist an attending in an interventional procedure, it should not be expected that the first year fellow will be allowed to manipulate angioplasty guidewires or balloons. Her/his role will be that of a first assistant. The interventional fellow will perform most of the interventional procedures and many diagnostic procedures. Similar guidelines dictate the respective roles of fellow and attending, but it is assumed that at the end of the first year of dedicated interventional training the fellow will be the primary operator on the majority of standard interventional techniques in a variety of patient subsets. It is the cath fellow's responsibility to ask the cath attending for additional instruction or assistance with any procedure or technique with which she/he does not feel comfortable based upon his previous experience. Do not feel you have to perform a procedure if you do not feel ready/experienced enough for it. Post-Procedure Care All patients must be seen by the fellow during the post-procedure period. This includes inpatients and outpatients. A note must document this visit. All routine, scheduled cardiac catheterization procedures (diagnostic and PTCA) which are performed on outpatients who remain in the hospital less than 72 hours are the primary responsibility of the cath fellow, the nurse practioner, and the cath lab attending. Also cath fellows and cath attendings will serve as the primary care team for most patients who are admitted directly to the cath lab from Denver Health Medical Center to undergo uncomplicated PTCA after having had their diagnostic catheterization at DHMC. No housestaff or other faculty will be involved in the patient's care unless an emergency arises during the night. The cath fellow should notify the on-call housestaff of any anticipated problems to ensure a rapid and appropriate response by the housestaff to cover an emergency until the cath fellow and/or cath 9
    • University of Colorado Hospital and Denver VA Medical Center Cardiac Cath Rotation 2005-2006 attending are present. Complicated patients will be admitted to the CCU team post-procedure. Discharge of patients on the cath lab service will be performed by the fellows in conjunction with the nurse practitioner. A discharge summary must be dictated at the time of discharge on all patients, regardless of their length of stay, and the disposition must be communicated to the primary care physician or cardiologist assuming subsequent care of the patient. The majority of patients who come to the cath lab from the ER or from an in-house service (CCU, telemetry, etc.) are the primary care responsibility of the cardiology attending faculty (CCU or consult) and their housestaff (cardiology fellow and/or resident). The cath attending and cath fellow will be responsible for management of the patient during the procedure and for any post cath removal of sheaths in addition to assisting in the management of any cath related complication. The cath fellow is responsible for monitoring and removing the sheaths and maintaining hemostasis. If an emergency patient is admitted directly from the ER to the cath lab before the CCU cardiology attending has evaluated the patient, the cath lab attending will manage the patient until the CCU attending assumes responsibility. Any significant clinical problems (such as post cath recurrent ischemia), or decisions (such as when to remove an IAB catheter), must be discussed with the responsible CCU cardiology attending as well as the cath attending The cath fellow is required to routinely document in the progress notes of the hospital chart when sheaths have been removed (date and time should be noted along with a statement regarding the presence or absence of any bleeding, new arterial bruit, hematoma, or altered pulses). In patients who are considered to be at increased risk of bleeding (large sheath size, IABP removal, aortic insufficiency, significant hypertension, etc.), it is recommended that a hemostatic pressure device be used. Use of these devices (Femo-Stop) must be monitored closely by the fellow to avoid thrombosis and/or bleeding. Prior to placing the device, ensure that you have a complete understanding of the device and have been trained in its appropriate usage. The interventional fellow will be responsible for reviewing the use of these devices. Before leaving the patient's bedside with a mechanical hemostatic device in place, the fellow should review with the nurse in attendance how to make appropriate adjustments should bleeding occur while a STAT page for assistance is made to the fellow/attending. When a hemostatic compression device is used, a follow-up note must be written in the patient's chart by the fellow to document when the device was removed and whether or not any of the above complications were present after removal of the device. Likewise when a closure technology is used, i.e. Perclose (sutures), similar documentation is necessary during the post-cath check. At any time a cath fellow is notified of any post procedure complication she/he should evaluate the patient with the cath attending involved and document the assessment in the patient's chart with an appropriate plan of action indicated. The Cath Report Cath lab policy requires that the final cath reports be edited and signed by the cath fellow within 48 hours of the procedure to facilitate communication with the referring physicians and optimize patient care. Completion of an accurate, timely cath report should be considered by the fellow to be equally important to skillful performance of the procedure. If a fellow fails to meet this time requirement and accumulates 10 "overdue" cath reports, she/he will be required to catch up with her/his reports before she/he is allowed to perform additional catheterization procedures. All cath reports must be completed before the fellow begins her/his next clinical rotation. The cath fellow is responsible for requesting assistance from the cath attending if circumstances out of her/his control make it impossible for her/him to maintain this time commitment for finalizing cath reports. The current reporting system is based on an ACCESS database. All aspects of patient care including scheduling, pre-procedure evaluation, H&P, procedures performed, billing information and report generation are included in this electronic database. Following completion of a procedure, the nurses will document in the case log who is responsible for final cath report generation. Currently, the Attending’s are responsible for report generation in case of endomyocardial biopsies or annual transplant evaluations. The fellows are responsible for all other report generation, unless discussed with individual attendings. Timely completion of preliminary reports and placement in the Attending’s file drawers for completion is of utmost importance. Technologies and Equipment Used in Cardiac Catheterization All fellows will be encouraged to become as familiar as possible with the computerized systems in the catheterization laboratories which are state-of-the-art digital imaging (Philips Medical Systems) and physiologic recording systems (GE MacLab, Witt, Philips). Quality Improvement Program and Data Base Critical self-review is an important ingredient to a life-long commitment to learning and improving in the delivery of 10
    • University of Colorado Hospital and Denver VA Medical Center Cardiac Cath Rotation 2005-2006 clinical medicine. The cardiac cath lab has an active QA/QI program to facilitate the constant process of observing what and how we function and what improvements should be implemented and whether they succeed in achieving specific goals. Fellows participate in this process directly via the cath conference that is case based and often deals with procedural benefit/complication issues. Furthermore, fellows will be asked to participate in data collection efforts that form the basis for all QI and regulatory mandated monitoring activities. As our database system continues to evolve and improve, it is anticipated that fellows will receive summaries of their cath lab experience for both documentation purposes but also to allow their own review of cases they were directly involved with. Duty Hours The program policy on duty hours for fellows follows the intent and language found in the Accreditation Council for Graduate Medical Education (ACGME) guidelines addressing this topic and is consistent with policy adopted by the Graduate Medical Education Committee. The program director and faculty will monitor the demands of at-home call and make scheduling adjustments as necessary to mitigate excessive service demands and/or fatigue. a. Duty hours are defined as all clinical and academic activities related to the residency program, ie, patient care (inpatient and outpatient), administrative duties related to patient care, the provision for transfer of patient care, time spent in-house during call activities and scheduled academic activities such as conferences. Duty hours do not include reading and preparation time spent away from the duty site. b. Duty hours must be limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities. c. Fellows must be provided with 1 day in 7 free from all educational and clinical responsibilities, averaged over a 4-week period, inclusive of call. One day is defined as one continuous 24-hour period free from all clinical, educational and administrative activities. d. Adequate time for rest and personal activities must be provided. This should consist of a 10-hour time period provided between all daily duty periods and after in-house call. On-Call Activities The objective of on-call activities is to provide fellows with continuity of patient care experiences throughout a 24-hour period. In-house call is defined as those duty hours beyond the normal workday when fellows are required to be immediately available in the assigned institution. a. In-house call must occur no more frequently than every third night, averaged over a four-week period. b. Continuous on-site duty, including in-house call, must not exceed 24 consecutive hours. Fellows may remain on duty for up to 6 additional hours to participate in didactic activities, transfer care of patients, conduct outpatient clinics and maintain continuity of medical and surgical care. c. An individual fellow may accept no new patients after 24 hours of continuous duty. d. At-home call (pager call) is defined as call taken from outside the assigned institution. 1) The frequency of at-home call is not subject to the every third night limitation. However, at-home call must not be so frequent as to preclude rest and reasonable personal time for each fellow. Fellows taking at-home call must be provided with 1 day in 7 completely free from all educational and clinical responsibilities, averaged over a 4-week period. 2) When fellows are called into the hospital from home, the hours fellows spend in-house are counted toward the 80-hour limit. 3) The program director and faculty will monitor the demands of at-home call and make scheduling adjustments as necessary to mitigate excessive service demands and/or fatigue. The on-call system for the cath lab involves three groups of individuals: 1. The staff: Nurses and Cardiovascular Technicians (2-3 individuals) 2. The attending. 3. The Fellow The on-call schedule for the fellows is first worked out by those sharing the rotating call in the cath lab. The resultant schedule is published and distributed with that of the cath lab attendings and staff. On-Call scheduling will be coordinated with the interventional fellow and the Cath Lab Administrative Assistant. All on-call scheduling must be submitted two weeks in advance of the end of the month for the following month. 11
    • University of Colorado Hospital and Denver VA Medical Center Cardiac Cath Rotation 2005-2006 Substance Abuse/Impairment Policy This program complies with The University of Colorado institutional policy on alcohol and drugs which states: “it is a violation of University policy for any member of the faculty, staff, or student body to jeopardize the operation or interests of the University of Colorado through the use of alcohol or drugs. Sanctions that will be imposed by the University of Colorado for students and employees who are found to be in violation of this policy may include expulsion and/or termination of employment. Compliance with this policy is a condition of employment for all employees.” Procedures for probation, remediation, suspension, termination and grievances for any substance abuse violation require a mandatory referral to the Colorado Physician Health Program (CPHP). The house officer shall sign a release of information from CPHP as a condition of probation. If the fellow’s performance again becomes unsatisfactory during the length of his/her training, he/she may be dismissed without any additional remedial period. If a house officer’s behavior is considered potentially dangerous to patients, immediate suspension of clinical responsibilities may be imposed by the program director with a remedial or probation period. Specific Procedures and Patient Groups 1. Acute Myocardial Infarction. The University of Colorado Hospital has a mature program in direct angioplasty for acute myocardial infarction. Approximately 100 patients a year go directly from the Emergency Room to the cath lab. It is imperative that the fellow on call respond immediately to notification of a patient. The goal is an open artery in less than one hour. This can only be achieved with the rapid work-up of the patient and transport to the cath lab. In a similar vein, patients from Denver Health Medical Center or Denver VAMC with ST elevation infarctions are often emergently transferred to the cath lab for diagnostic and therapeutic procedures. Efficient communication with our DHMC or DVAMC colleagues is essential. Any questions regarding transfers of patients for emergent cardiac catheterizations needs to be discussed immediately with the on-call cath attending to facilitate rapid triage and transportation. 2. Percutaneous Mitral Balloon Commissurotomy and Valvuloplasty for Aortic, Pulmonic or Tricuspid Stenosis. This program has been initiated in the last several years and the volume is expected to include 20-30 patients per year with the majority being mitral patients. The vast majority of these patients are referred by outside cardiologists. When they come for the same-day procedure the mitral stenosis patients typically are scheduled for a TEE to exclude left atrial appendage thrombus and sort out other issues. They frequently then come directly to the cath lab. Therefore, consent must be obtained early in the day before the patient gets sedated for the TEE. During the valvuloplasty TTE and ICE (inter-cardiac echo) are performed between inflations to assess the degree of mitral regurgitation and whether the commissures have been successfully split. The fellow must discuss that morning the planned time of the procedure with the echo tech on call. 12
    • University of Colorado Hospital and Denver VA Medical Center Cardiac Cath Rotation 2005-2006 3. Pulmonary Hypertension Patients. These patients frequently come for involved protocols to assess etiology, pathophysiology, and response to vasodilator therapy. Special techniques and equipment are used. Therefore, it is key to discuss with Dr Groves or the attending involved with these patients, the exact nature of the procedure involved. This information must be communicated in a timely fashion with the cath lab staff to allow proper preparation for the procedure. 4. Transplant Patients form a significant percentage of this cath lab’s volume. Following their transplantation these patients come for frequent endomyocardial biopsies. Subsequently they come every year for an “annual” cath that includes coronary arteriography to assess the possible development of coronary arteriopathy. The fellow should review prior procedures to determine if special patient or technique approaches are needed. Significant abnormalities should be communicated immediately to the transplant attending. Inpatients should have a preliminary note written in the chart before the patient leaves the cath lab. 5. Intra-Cardiac Defect Closure Patients. These patients are often referred for either the closure of a secundum atrial septal defect or a patent foramen ovale. These patients will frequently have a history of stroke/TIA or pulmonary hypertension. In addition, these patients may have varying hypercoaguable states requiring specific post-procedure anti-coagulation therapy. The fellows must discuss the planned post-procedure care with the attending cardiologist prior to patient discharge. These patients will come to the cardiac catheterization lab the morning following the procedure for routine rotational fluoroscopy to ensure proper device placement. 6. Hypertrophic Obstructive Cardiomyopathy Patients. Recently a procedure has been developed for the non- surgical treatment of these patients through ablation of the obstructing interventricular septum using absolute alcohol. All patients undergoing this procedure who have not previously had a permanent pacemaker in place will have a temporary pacer placed overnight. Frequently (~85%) patients will have a right bundle-branch block following the alcohol septal ablation procedure. 7. Brachytherapy Patients. These patients have been referred for the treatment of in-stent restenosis using intra- coronary brachytherpy. Post-procedure care is similar to the care given to patients undergoing routine PCI with the exception of clopidogrel therapy. All post-procedure brachytherapy patients will be given clopidogrel for one year. 13
    • University of Colorado Hospital and Denver VA Medical Center Cardiac Cath Rotation 2005-2006 Safety in the Cath Lab All fellows must wear protective shielding. Furthermore utilizing lead shields, prudently using fluoroscopy, keeping the image intensifier close to the patient’s chest, and announcing to the staff when fluoro/cine runs are about to begin are all necessary practices to minimize radiation exposure to yourself, the staff, and the patient. Radiation badges must be worn and changed on monthly intervals. All fellows should review written materials on radiation safety, radiation badge interpretation, and attend any related lectures. Cardiac Catheterization Conferences Cardiac catheterization conference is organized by the Interventional Fellows. Rotating cath fellows from UCH, and DHMC will participate in cath conference. The weekly Cardiac Cath/CT Surgery Conference at UCH meets every Tuesday morning at 0730 hours in Glaser Auditorium. Cath Fellows at DVAMC will present cases at the CT Surgery/Cardiac Cath Conference at DVAMC at 0745 in the 6th floor conference room on Wednesdays. A combined Radiology/Cardiology imaging conference will be incorporated into the monthly Cath Conference schedule due to the overlap between noninvasive imaging techniques and the invasive identification of cardiac disease. A scheduled monthly M&M conference will allow for critical review of complications during diagnostic and therapeutic procedures. In addition, we will re-introduce several EP lectures as part of the conference schedule. The focus of cath conference is on case-based presentations with challenging or controversial management issues. It is expected that the cath fellows from each hospital will present clinical patients to illustrate one or more cardiovascular topics of general interest with an appropriate literature review and didactic discussion to amplify the clinical presentations. When appropriate, the cath fellow should notify cardiology and CT surgery attendings when their cases will be presented to encourage their participation. At this time, we have the ability for multimedia display in a digital format therefore; all presentations will need to be computer based. Presentations should be PowerPoint based. We have a laptop computer available for the presentation. If images need to be digitized for incorporation into a presentation, please contact the interventional fellow at least one week before the presentation to assist you. The interventional fellow can assist with scanning ECG’s, photos, and other graphics using a flat-bed scanner, with digitizing video of ultrasound, echos etc. and with computer presentation software, as well as with conversion of digital angio data to mpeg files. All presentations should be discussed in advance with the Interventional Fellow who is responsible for the content and organization of this weekly conference. In general, cath conferences at UCH should use the following format: 1) At least two cases should be presented. 2) Each conference should have a title and subtitle that will be used to let people know what kind of case will be presented and the reason for presenting the case. For example: Title: . . . . . An 85 Year Old Woman with CHF and Aortic Stenosis Subtitle: . . The Role of Balloon Valvuloplasty 3) A focused brief review of the literature (no more than three studies, if possible) should be presented for each case and ideally a faculty discussant identified to point out salient educational features of the case during the discussion. 4) At completion of the conference the fellow may wish to have a succinct summary of the discussion that 14
    • University of Colorado Hospital and Denver VA Medical Center Cardiac Cath Rotation 2005-2006 occurred during the conference. 5) A desktop PC will be available in the research lab for fellows to use in preparing for the cath conference. 6) A digital stethoscope is also available, for the recording of auscultatory findings. Research Activities A central goal of the cath lab rotation is to involve fellows in clinical research. Furthermore the Interventional fellow is expected to be an active member of the investigative team. Fellows who wish to participate in clinical trials are encouraged to discuss their interest with the director early in their fellowship. For 2005-2006 the research studies include ongoing studies in 3-D coronary reconstruction, rotational angiography, pulmonary hypertension, development of digital multimedia technologies, industry sponsored studies of acute infarction intervention, IVUS, alcohol septal ablation registry enrollment, and new generation stents. Currently we are involved in several clinical trials. On the first day of the rotation, these will be reviewed with you by Kathy Kioussopoulos, RN, BSN. You will not be expected to consent patients for these studies, but you will be expected to screen every patient for participation in one of our many protocols. At our center, we expect that every patient should be considered for inclusion in a research protocol. Evaluation at End of Rotation of Rotating Fellow At the end of the first month in the cath lab it is important that constructive feedback be given to the fellow regarding his/her performance. This will be performed by one of the cath lab attendings. At the completion of cath lab rotations a written report will be submitted to the fellowship director by the cath lab director with input from all attendings. Fellows should feel free to consult with the medical director or any of the attendings regarding their performance and/or plans for further training in invasive cardiology. All evaluations will be forwarded to Howard Weinberger, MD, for incorporation into the fellow’s permanent file. Evaluation at End of Rotation of Faculty Faculty evaluations shall be completed by all rotating fellows and interventional fellows. Rotating fellows will complete these per the General Cardiology Fellowship Guidelines. Interventional fellows will perform evaluations at 6 months and at the end of the year. These will be returned to Dr. Weinberger so that they may be anonymously combined with the general fellow evaluations for feedback to individual attendings by Dr. Weinberger. In addition, feedback regarding the educational content and structure of the cath rotations at UCH and DVAMC as well as the interventional fellowship at UCHSC will be obtained. 15
    • University of Colorado Hospital and Denver VA Medical Center Cardiac Cath Rotation 2005-2006 Staff Attending Physician Staff John D. Carroll, M.D. Ivan Casserly, MB, BCh Clifford Greyson, M.D. Bertron M. Groves, M.D. Brack Hattler, M.D. Joseph D. Kay, M.D. Brian Lowes, M.D. John C. Messenger, M.D. Ronald Zolty, M.D. Administrative Staff at UCH Medical Director: John C. Messenger, M.D. Lab Manager: Cathy Clark, R.N. R.C.V.T. Hospital Administration: Jeff Woods, PhD Administrative Assistants: Kelly Bejaoui and Jocelyn Chaney Program Coordinator, Interventional Cardiology: Vicki Blume Computer Applications Analyst: Rebecca Loucks-Schultz Clinical Research Staff Research Coordinator: Kathy Kioussopoulos, R.N., B.S.N. Etta Abaca, R.N. Christine Neuman, R.N. VAMC Nursing Staff Phyllis Wagar, R.N, A.N.P. Darcy Donaldson, R.N. Mary Hall, R.N. Marsha Hallahan , R.N. Steve Musler, R.N. Mary Ann Olsen, C.M.A. Lori Harvey, R.N. Tracy Rankin, R.N. UCH Nursing/Technologist Staff Sally Barker, R.N. Colleen Campbell, R.N. Kory Foa, R.N. Cari Jukes, R.N. Jana Keller, R.N., A.N.P. Cathy Kenny, A.N.P. Peggy Kuhn, R.N. Sandy Lascola R.N. Marie Maguire, R.N. Jennifer Ostermiller, R.T.(R)(CV)(M) Michael Panagos, R.N. Donna Prince, R.N. Emily Schmitt, R.N. Katy Rafferty, R.N., Cath Lab Charge Nurse David Thompson, R.N. UCH Technical Staff Jo Norman 16
    • University of Colorado Hospital and Denver VA Medical Center Cardiac Cath Rotation 2005-2006 3-D Imaging Research Lab Shiuh-Yung James Chen, Ph.D., Chief Research Scientist Kathy Kiossopoulos, R.N., Research Coordinator Onno Wink, Philips Medical systems Adam Hansgen, 3-D Research Technician Useful Telephone Numbers UCH Hospital Operator 372-0000 Hospital ACCESS Center 372-3648 UH Emergency Room 372-8901 Lifelink 372-5465 Hospital Administrator On-Call 266-9180 Cath Suite #1 372-6020 Cath Suite #2 372-6035 Cath Suite Fitzsimons 720-848-1565 Review Room 372-6033 Break Room 372-6560 ASU 372-6800 PACU 372-0040 Cath Lab Offices 372-6029 and 372-6046 Cath Lab Fax Machine 372-6644 Heart Center 372-0600 UH 6 West 372-8000 CCU 372-0251 DVAMC VA Cardiology 303-393-2826 VA Cath Lab 303-399-8020 x5865 17