2012  Heart and VascularOutcomes Report
Heart and Vascular Outcomes               2012W       elcome to the 2012 Heart and Vascular        Outcomes Report for the...
The Heart of Asante Rogue Regional Medical Center                                       Cardiac disease is the leading cau...
Heart and Vascular Outcomes                                                                                               ...
Quality: Our Approach Quality: Our Approach Quality: How We Measure It                                 Leapfrog Guidelines...
Heart and Vascular Outcomes                          2012 CMS Quality Measures Acute Myocardial Infarction               C...
CORONARY ARTERY DISEASE Coronary Artery Disease                                             Cardiac Catheterization and Co...
Heart and Vascular Outcomes        2012Myocardial Infarction: The ASSET Program                                           ...
CORONARY ARTERY DISEASE Coronary Artery DiseaseThe Chain of SurvivalGloria Ferguson, 52Vancouver, WashingtonGloria, a math...
Heart and Vascular Outcomes              2012       –          ASSET Patients Average Median Time to Treatment for STEMI  ...
CORONARY ARTERY DISEASE Coronary Artery DiseaseCoronary Artery Stenting                                    ASSET STEMI Pat...
Heart and Vascular Outcomes  2012Historical Myocardial Infarction Mortality RatesHistorical National Hospital Mortality Ra...
CORONARY ARTERY DISEASE Coronary Artery Disease                                               National Recognition for the...
Heart and Vascular Outcomes       2012Annual Volume of Diagnostic Coronary Angiograms  Asante Rogue Regional Medical Cente...
CORONARY ARTERY DISEASE Coronary Artery DiseaseAsante Rogue Regional Medical Center Cardiovascular Lab at the Cardiovascul...
Heart and Vascular Outcomes  2012Radial Artery AccessThe radial artery is increasingly being used as theaccess site to the...
CORONARY ARTERY DISEASE Coronary Artery Disease                                   Stent between fingers                   ...
Heart and Vascular Outcomes                 2012Fractional Flow Reserve                                      Chronic Total...
CORONARY ARTERY DISEASE Coronary Artery Disease              Percutaneous Cardiac Assist Devices: Impella and Tandem Heart...
Heart and Vascular Outcomes               2012Impella Use in High-Risk Coronary Stenting                                  ...
CORONARY ARTERY DISEASE Coronary Artery DiseaseEnhanced External Counterpulsation                                         ...
Heart and Vascular Outcomes              2012                                                                             ...
Hospital Physicians Hospital Physicians                                                                                   ...
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
2012 Heart and Vascular Outcomes Report
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2012 Heart and Vascular Outcomes Report

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Heart and Vascular Center at Rogue Valley Medical Center hopes you find this information both interesting and helpful in choosing the best treatment options for your patients. Together we can provide our patients the best cardiovascular care.

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2012 Heart and Vascular Outcomes Report

  1. 1. 2012 Heart and VascularOutcomes Report
  2. 2. Heart and Vascular Outcomes 2012W elcome to the 2012 Heart and Vascular Outcomes Report for the Heart and VascularCenter at Rogue Valley Medical Center. Among the Rogue Regional to Asante Three Rivers and to Sky Lakes Medical Center in Klamath Falls. The satellite TV link allows active participation from the remote the variety of databases and quality assessment organizations in which we participate. A commitment to ongoing quality improvement is essential; and asmany new aspects of our program is the hospital’s new sites. We believe that top-quality patient care requires discussed in the Quality: Our Approach section of thisname: Asante Rogue Regional Medical Center. It’s the collaboration and teamwork. The teamwork begins report, we describe the new Performance Improvementsame buildings and the same capable staff, but there when the primary care physician refers a patient to one in Cardiac Care Team (PICCT), which took the leadis an increased emphasis on creating an integrated, of our physicians; continues as that patient is served in optimizing patient outcomes.collaborative system of patient care. by our skilled nurses, technicians, and therapists; and ends only after that patient has been treated and As in previous editions, this report will also reviewThe cardiologists, cardiac surgeons, and vascular educated and returns to his or her community. new technologies and procedures as well as providesurgeons now all have offices in the same building—the an overview of our programs.Cardiovascular Institute on the Medford campus. This We work hard to provide excellent cardiovascularworking arrangement facilitates communication and care to the patients we serve. This report outlines our We hope you find this information both interesting andconsultation among the various cardiovascular specialists. approach to giving the patient a positive experience, helpful in choosing the best treatment options for yourThere is an active satellite cardiology program at Asante and it details the statistics we use to objectively evaluate patients. Together we can provide our patients the bestThree Rivers Medical Center in Grants Pass, staffed our outcomes. How does one evaluate a cardiovascular cardiovascular care.by cardiologists who also manage patients in Medford. program? It isn’t simple because many factors mustThe weekly cardiology conference, which began in be considered. In this report we present our statistics — The physicians and surgeons of the Heart and Vascular1974, continues and is video-linked from Asante supporting program volumes and outcomes. We describe program at Asante Rogue Regional Medical Center
  3. 3. The Heart of Asante Rogue Regional Medical Center Cardiac disease is the leading cause of death in Oregon and California. Fortunately, effective therapy is available. Asante Rogue Regional Medical Center is a tax-exempt 378-licensed-bed facility created more than 50 years ago by and for the people of Southern Oregon and Northern California. Our heart and vascular program is nationally recognized and provides highly specialized heart and vascular care. Our Mission 1958 1968 1973 1977 1981 2003 2005 Asante exists to provide quality healthcare services in Asante Rogue Cardiac First Cardiac First open First coronary ASSET Patient Tower a compassionate manner, valued Regional opens Intensive Care Catheterization heart surgery balloon program constructed by the communities we serve. Unit opens Laboratory opens angioplasty established Cardiac Facilities at Asante Other Team Members Our Vision Rogue Regional Medical Center The first numeral represents the total number of people working in that department. Numerals in parentheses represent people • Cardiac Intensive Care Unit (16 beds) with 10 or more years of experience in that particular field. Asante will be recognized for • Heart Center (40 telemetry beds)medical excellence, for outstanding • Operating room: 10 (7) • Cardiac catheterization laboratories • Cardiac perfusionists: 4 (4) customer service, and as a · 2 outpatient labs • Cardiac surgery physician assistants: 4 (4) great place to work. · 5 inpatient labs • Cardiac Intensive Care Unit: 54 (21) • Cardiovascular Recovery Unit • ICU-based nurse practitioner: 1 (0) • 3 operating rooms for cardiovascular procedures • ICU-based physician assistant: 1 (0) · 2 dedicated to open heart procedures The Values in · The region’s only endovascular angiographic suite • Cardiac catheterization laboratory · Asante Rogue Regional: 20 (10) Which We Believe • Imaging Services · Asante Rogue Regional Cardiovascular Lab · Echocardiography at the Cardiovascular Institute: 12 (5) Excellence in everything we do · Stress nuclear • Cardiovascular recovery: 18 (6) · Cardiac CT Respect for all • Heart Center: 112 (36) • Cardiac Clinical Case Managers: 7 (6) Physicians (all board certified) Honesty in all our relationships • 13 cardiologists • Cardiac Rehabilitation: 7 (5) • Echocardiographers: 12 (7) • 4 cardiothoracic surgeons Service to the community, • Vascular ultrasound: 3 (2) • 6 vascular surgeons physicians, and each other • 8 cardiac anesthesiologists • Stress testing: 13 (9) • Cardiopulmonary: 7 (3) • 6 intensivists Teamwork always • Clinical quality analysts: 6 (2) • 15 hospitalists • STEMI nurse coordinator: 1 (0) • Critical Care clinical practice adviser: 1 (0)4
  4. 4. Heart and Vascular Outcomes 2012Table of ContentsWelcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Arrhythmias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Natural History of Carotid DiseaseThe Heart of Asante Rogue Regional Medical Center . . . . . . . . . 4 Electrophysiology Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Risk of Ipsilateral Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45Cardiac Facilities at Asante Diagnostic Electrophysiology Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Who Should Be Considered for Carotid Stenting? . . . . . . . . . . . 45Rogue Regional Medical Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Tilt Table Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Criteria for Increased Surgical Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45Other Team Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Intracardiac Ablation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Current CMS Coverage for Carotid Stents . . . . . . . . . . . . . . . . . . . . . . 45 Pulmonary Vein Antral Isolation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Patients at Normal Surgical Risk:Quality: Our Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Device Implantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 NIH–Sponsored CREST Trial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46Quality: How We Measure It and Lead Extractions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47Continuously Strive to Improve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Indications for ICD Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Noninvasive Diagnostic Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47Leapfrog Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Indications for Biventricular Pacing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Cardiac CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49CMS Quality Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 New Anticoagulants: Dabigatran, Medicare Coverage for CT Coronary Angiography . . . . . . . . . . . 49Coronary Artery Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Rivaroxaban, and Apixaban . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31Cardiac Catheterization and Coronary Intervention . . . . . . . . . . . 8 Heart Transplant Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Preventive Cardiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50Myocardial Infarction: The ASSET Program . . . . . . . . . . . . . . . . . . . . . . . . 9 Cardiac Rehabilitation, PreventiveASSET Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Congenital Heart Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Medicine, and Cardiac Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50The Chain of Survival . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Adult Congenital Heart Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Cardiac Educators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51Coronary Artery Stenting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Some Comments from Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Cardiac Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Historical Myocardial Infarction Mortality Rates . . . . . . . . . . . . . . . . 13 Cardiothoracic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Therapies on the Horizon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52National Recognition for the ASSET Program . . . . . . . . . . . . . . . . . . . . 14 Coronary Artery Bypass Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Cryptogenic Stroke and Patent Foramen Ovale . . . . . . . . . . . . . . . . 52Asante Rogue Regional Medical Center Asante Valve Clinic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Resistant Hypertension: RenalCardiovascular Lab at the Cardiovascular Institute . . . . . . . . . . . . 16 Valve Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Artery Radiofrequency Ablation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52Radial Artery Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Minimally Invasive Valve Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Atrial Fibrillation: Preventing StrokeAppropriate-Use Criteria for Using a Left Atrial Appendage Occluder . . . . . . . . . . . . . . . . . . . . . . . . . . 53Percutaneous Coronary Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Prosthetic Heart Valves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38Fractional Flow Reserve Measurement 3D Echocardiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Close Working Relationship withwith a Pressure Wire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 STS Risk Adjustment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Oregon Health & Science University . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53Chronic Total Occlusion: Increasing Success Endovascular Treatment of Thoracic Aortic Aneurysm . . . . . 40with Percutaneous Coronary Intervention . . . . . . . . . . . . . . . . . . . . . . . . 19 Physician Biographies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Transmyocardial Revascularization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Asante Cardiovascular and Thoracic Surgery . . . . . . . . . . . . . . . . . . . 54Percutaneous Cardiac Assist Devices: Atrial Fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Impella and Tandem Heart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Southern Oregon Cardiology, LLC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Maze Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Impella Use in High-Risk Coronary Stenting . . . . . . . . . . . . . . . . . . . . . . 21 Oregon Surgical Specialists, PC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Enhanced External Counterpulsation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Vascular Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63Hypothermia for Cardiac Arrest Patients . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Comprehensive Vascular Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Carotid Endarterectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44Hospital Physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 5
  5. 5. Quality: Our Approach Quality: Our Approach Quality: How We Measure It Leapfrog Guidelines and Continuously Strive to Improve Coronary Artery Bypass Grafting Percutaneous Coronary Intervention Asante Rogue Regional Medical Center has a rigorous quality improvement program. Patient • Favorable hospital volume • Favorable hospital volume volumes and outcomes are carefully tracked and (450 or more procedures per year) (400 or more procedures per year) compared with external benchmarks. Quarterly • Participation in STS data collection • Participation in the American College of Morbidity and Mortality (M&M) conferences are • STS score exceeds the national average Cardiology National Cardiovascular Data held to review program statistics and individual patient for risk-adjusted mortality Registry or > 80 percent adherence to the experiences. These conferences provide our physicians • Minimum surgeon volume per year Leapfrog Expert Panel and staff with the opportunity to see what is going for coronary artery bypass grafting (CABG) • Endorsed Process Measures for Quality well and to identify areas in need of improvement. (100 cases per year) Score better than the national average The recently organized Performance Improvement in for risk-adjusted mortality Cardiac Care Team has been charged with identifying • Minimum surgeon volume per year for areas in which the care process can be improved and percutaneous coronary intervention (PCI) facilitating those improvements. The team consists Leapfrog Evidence-Based (75 cases per year) Hospital Referral Safety Standard of a senior cardiologist, an experienced nurse data coordinator, and a clinical nurse specialist. The PICCT Recommended Annual Volume organizes the quarterly M&M conferences, reviewing Asante Rogue Regional Medical Center Volume American Heart Association’s and presenting statistical data as it becomes available. ACTION Registry-Get with the Guidelines® The team meets with various members of the care team to help solve problems and improve patient flow. Award for Coronary Artery Disease: Gold Status in 2008 to 2010 and Asante participates in a variety of national quality Platinum Status in 2011 improvement initiatives and databases, including the American College of Cardiology and the Society of Volume Thoracic Surgeons (STS). We strive for a high level of compliance with subspecialty guidelines and with the Centers for Medicare & Medicaid Services (CMS) core measures for best practice guidelines. We support the transparent public reporting of healthcare quality data by participating in the following quality initiatives: Percutaneous Aortic Valve Coronary Replacement • CMS Hospital Compare Intervention www.hospitalcompare.hhs.gov Coronary Artery Abdominal Aortic • STS Consumer Reports Bypass Gra ing Aneurysm Repair www.sts.org • Healthgrades Asante Rogue Regional Medical Center www.healthgrades.com performance improvement staff 6
  6. 6. Heart and Vascular Outcomes 2012 CMS Quality Measures Acute Myocardial Infarction CMS Quality Measure Congestive Heart Failure CMS Quality Measure Top Percent of Hospitals in the Nation Asante Rogue Regional Medical Center Top Percent of Hospitals in the Nation Asante Rogue Regional Medical CenterCompliance Compliance Aspirin Smoking Primary Percutaneous at Discharge Cessation Coronary Intervention Le Ventricular within Minutes Assessment Aspirin ACE Inhibitor/Angiotensin Receptor Beta-Blocker at Arrival Blocker for Le Ventricular LV at Discharge Clear Discharge ACE Inhibitor/Angiotensin Systolic Dysfunction at Discharge Instructions Receptor Blocker for LV Systolic Dysfunction at Discharge Coronary Artery Bypass Gra Surgery CMS Quality Measure Top Percent of Hospitals in the Nation Asante Rogue Regional Medical Center American Heart Association Mission Lifeline Recognition forCompliance Heart Attack Care Performance Achievement Award in 2012 Prophylactic Prophylactic Beta-Blocker within Antibiotics within Antibiotics Discontinued Peri-Operative Hour within Hours Period Acumentra Health Hospital Prophylactic Controlled A M Urinary Catheter Quality Awards for Excellent Care: Antibiotics Selection Post-Operative Removed by High Performance (95 percent) on Serum Glucose Post-Operative Day SCIP and Heart Failure Measures in 2010 and 2011. Thomson Reuters® Top Quintile Health Systems Award in 2011 7
  7. 7. CORONARY ARTERY DISEASE Coronary Artery Disease Cardiac Catheterization and Coronary Intervention Cardiac catheterization facilities at Asante Rogue Regional Medical Center were established in 1973. Five catheterization and angiographic laboratories are dedicated to state-of-the-art diagnostic coronary angiography, coronary interventions, peripheral angiography and interventions, electrophysiologic procedures, and device implants. Board certification in cardiology is required of all cardiologists. Cardiologists who perform coronary interventions are board certified in interventional cardiology. Expertise is maintained by focusing procedural Asante Rogue Regional Medical Center continues to experience within a small group of high-volume, adhere to the PCI guidelines written and recommended experienced interventionalists whose low complication by the American Heart Association, the American rates and excellent outcomes exceed national College of Cardiology, and the Society for Cardiac benchmarks. Coronary interventional volume for Angiography and Interventions. These guidelines the institution and for each interventionalist exceeds are as follows:* volume recommendations established by the Leapfrog Group, Thomson Healthcare, and the American College • Operators perform at least 75 procedures at of Cardiology. A proven record of satisfactory outcomes high-volume hospitals (more than 400 procedures Asante Rogue Regional Medical Center and active participation in quality improvement per year) with on-site cardiac surgery. cath lab team programs is mandatory for all physicians. • Operators and institutions should have outcomes comparable to those reported in contemporary national data registries. The five interventional cardiologists are board certified • For ST-segment elevation myocardial infarction in both cardiovascular disease and (STEMI), emergent PCI should be performed interventional cardiology and provide by experienced operators who do more than 75 elective PCI procedures per year and, ideally, at around-the-clock coverage. least 11 PCI procedures for STEMI each year. Ideally, these procedures should be conducted in 1981: Coronary institutions that perform more than 400 elective interventional program started 14,751 coronary PCIs per year and more than 36 primary PCI procedures for STEMI per year. at Asante Rogue Regional interventions have been Medical Center performed since 1981. *Levin GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, 13 cardiologists and four Ting HH. 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report of the American College of Cardiology cardiothoracic surgeons work together Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and to provide care around-the-clock. Interventions. Circulation. 2011;124:e574-e651.8
  8. 8. Heart and Vascular Outcomes 2012Myocardial Infarction: The ASSET Program ASSET Regional STEMI receiving hospital for primary PCIASSET (Acute ST-Segment Elevation Task Force) is a regional heart attack response team that coordinates thesimultaneous activation of paramedics, emergency departments, and the cardiac catheterization laboratory at Asante • Asante Rogue Regional Medical CenterRogue Regional Medical Center for rapid identification, triage, and treatment of ST-segment elevation myocardial Meets all American Heart Associationinfarction patients (severe heart attacks) throughout Southern Oregon and Northern California. The ASSET program Class I criteria for STEMIhas received national recognition for its dramatic reduction in death rates from heart attacks and is serving as a modelfor other programs in development across the country. The program represents the integration of care supported by the ASSET STEMI receiving hospital for primary PCI if patient requestedefforts of hospitals within the direct ASSET service area, hospitals within the regional support services area whose initialmanagement may include thrombolytic therapy followed by emergent transfer for possible rescue PCI, and those hospitals • Providence Medford Medical Centerhaving PCI capability supported by the cardiothoracic surgical program at Asante Rogue Regional Medical Center. ASSET Service Area STEMI referring hospitals for primary PCI ASSET Program Mission Statement • Ashland Community Hospital • Fairchild Medical Center To facilitate the accurate and rapid diagnosis, treatment, and transport • Asante Three Rivers Medical Center of patients with acute ST-segment Elevation Myocardial Infarction (STEMI) from throughout the region to the Asante Rogue Regional Medical Center ASSET Regional Support Services Area hospitals providing thrombolytic therapy cath lab for emergent percutaneous coronary intervention (PCI). with emergent transfer to Asante Rogue Regional Medical CenterASSET Service Area • Curry General Hospital • Lake District Hospital Coos Bay O R E G O N • Sutter Coast Hospital ASSET Service Area Coquille Bandon Roseburg ASSET Regional Cardiothoracic Surgery Support Myrtle Point Support Services Area Myrtle Creek • Mercy Medical Center • Sky Lakes Medical Center Port Orford Paisley Core Partnership—Emergency Services Chiloquin Grants Pass • American Medical Response (AMR) Redwood • Ashland Fire & Rescue Gold Beach Rogue River Asante Rogue Regional Medical Center • Jackson County Fire District 3 Medford Altamont Klamath Falls • Medford Fire Department • Mercy Flights Brookings Cave Junction Ashland Lakeview • Northern Siskiyou Ambulance Harbor Malin Dorris • Rogue River Fire District 5 Tulelake Happy Camp Crescent City Yreka Montague Participating Heart Specialists C A L I F O R N I A • Asante Cardiovascular and Thoracic Surgery • Southern Oregon Cardiology, LLC 9
  9. 9. CORONARY ARTERY DISEASE Coronary Artery DiseaseThe Chain of SurvivalGloria Ferguson, 52Vancouver, WashingtonGloria, a math and science coordinator, was accompanying her 13-year-old son on a five-dayBoy Scout bicycling trip that began at Crater Lake National Park. On the first day, she was bicyclingand developed severe angina. A Boy Scout leader recognized the symptoms and drove her to the park’snorth entrance, where she lost consciousness soon after arrival. “Fast and deep” chest compressionswere promptly begun by two Boy Scout leaders. Seven park rangers quickly descended on the scene,and a physician from a waiting car arrived as well. Approximately six to seven minutes after Gloria lostconsciousness, an automated external defibrillator (AED) was brought to the scene. Three shocks weregiven over three to four minutes, with chest compressions in between, before a pulse was noted. Thrombotic occlusion in proximal Large thrombusThe Mercy Flights helicopter crew promptly This resuscitation exemplifies what can left anterior descending in filter basketarrived, diagnosed an acute anterolateral happen when each link in the chain of survivalSTEMI, and brought the critically ill patient works: the prompt recognition of cardiacdirectly to the Asante Rogue Regional Medical symptoms by the Boy Scout leader; the quickCenter cardiac catheterization laboratory. decision to head to the ranger station; the “fast andEmergent coronary angiography revealed a deep” chest compressions; the AED availabilitythrombotic occlusion in the proximal LAD and prompt and proper use; the rapid arrival and(i.e., widowmaker lesion) (figure 1). Emergent transport of a critically ill patient by helicopter;mechanical thrombectomy was successful the direct transport from the helipad to the(figure 2) and reestablished flow, followed by awaiting cath lab for emergent angiography,stent deployment (figures 3 and 4). Gloria was mechanical thrombectomy, and stent deployment figure 1— Baseline angiogram figure 2— Mechanicalin cardiogenic shock and required epinephrine (door-to-balloon time of 29 minutes, including showing a “widowmaker lesion” thrombectomyboluses, norepinephrine, dopamine, and an intubation); the cardiac support with intra-aortic (i.e., proximal thrombotic occlusionintra-aortic balloon pump. She also had 12 balloon pumping; the subsequent hypothermia in left anterior descending) Stent with large patent leftepisodes of ventricular tachycardia/fibrillation protocol to prevent brain injury; and the anterior descendingrequiring electrical cardioversion. round-the-clock vigilant care in the Cardiac Intensive Care Unit. Her situation was precariousShe was then transferred to the Cardiac Intensive throughout, and any failures along the wayCare Unit and improved over the next hour to would probably have resulted in her death.the point that hypothermia could be initiated.She improved on a daily basis, was taken offthe ventilator five days after admission, and 12days later was discharged home functional andneurologically intact. Gloria is now back to workfull-time and has resumed playing golf. figure 3— Balloon inflation and figure 4— After stent deployment stent deployment10
  10. 10. Heart and Vascular Outcomes 2012 – ASSET Patients Average Median Time to Treatment for STEMI Time at Referring Hospital Paramedic Transport Time Time from Emergency Department Door to Cardiac Cath Lab Door Cardiac Cath Lab Arrival to Open Artery at Asante Rogue Regional Medical Center minutes door–to–balloon time All ASSET Patients Jun –Dec n minutes door–to–balloon time All ASSET Patients Jun–Aug n minutes door–to–balloon time All ASSET Patients Jan–Dec n minutes door–to–balloon time All ASSET Patients Jan–Dec n minutes door–to–balloon time All ASSET Patients Jan–Dec n minutes door–to–balloon time All ASSET Patients Jan–Dec n minutes door–to–balloon time All ASSET Patients Jan–Dec n minutes door–to–balloon time All ASSET Patients Jan–Dec nTime in Minutes Arrival at Asante Rogue Regional Medical CenterMyocardial Infarction: Time Is MuscleCross-sectional image of the left ventricle during an inferior myocardial infarction Healthy heart muscle Dead heart muscle i e myocardial infarction heart a ack Blood within the heart hours hours hours 11
  11. 11. CORONARY ARTERY DISEASE Coronary Artery DiseaseCoronary Artery Stenting ASSET STEMI Patients Coronary artery atherosclerotic plaque Transfer from Referring Hospital Paramedic Asante Rogue Regional Medical Center TotalLow-profile stent and balloon advanced across blockage Balloon inflation results in stent deployment Balloon removed; stent maintains an open arterySTEMI In-Hospital Mortality Patients with Door-to-Balloon Time within Minutes – – Total number of STEMI patients from 2003 through 2011 = 1,19312
  12. 12. Heart and Vascular Outcomes 2012Historical Myocardial Infarction Mortality RatesHistorical National Hospital Mortality Rates for ST-Elevation Myocardial Infarction Heart A ack 3.9 percent is the mortality rate for 2011 and is also the cumulative mortality rate for the ASSET program since its inception in 2003 (1,193 patients)—among s s s ASSET Program at the lowest reported in the nation. Asante Rogue Regional Medical CenterSource: Clinical Practice Guidelines AHCPR Publication No. 94-0602. – nST-Elevation Myocardial Infarction In-Hospital Mortality ComparisonAsante Rogue Regional Medical Center versus Other Hospitals 89 percent of patients had hospital door–to–balloon times within 90 minutes in 2011, making ASSET one of the elite myocardial infarction National Registry of Asante Rogue Regional ASSET Program at Myocardial Infarction Medical Center Asante Rogue Regional programs in the country. “Similar Hospitals” Medical Center n 1,193 patients were treated at Asante Rogue Regional Medical Center for STEMI from June 2003 through December 2011. 13
  13. 13. CORONARY ARTERY DISEASE Coronary Artery Disease National Recognition for the ASSET Program “An Approach to Shorten Time to Infarct Artery Patency in Patients with ST-Segment Elevation Myocardial Infarction” American Journal of Cardiology 2007;99:1360-63. “Integration of Pre-Hospital Electrocardiograms and ST-Elevation Myocardial Infarction Receiving Asante Rogue Regional Medical Center Center (SRC) Networks: Impact on Door-to-Balloon Emergency Department staff Times Across 10 Independent Regions” Journal of the American College of Cardiology: Cardiovascular Interventions 2009;2(4):339-46. Primary percutaneous coronary intervention is the most complex, multidisciplinary, and time-sensitive therapeutic intervention in the world of medicine today. The process is measured in minutes. The outcomes are measured in mortality. Teamwork and smooth transitions are essential. Asante Rogue Regional Medical Center cardiopulmonary and enhanced external — Ivan Rokos, MD counterpulsation (EECP) staff STEMI Systems, May 200714
  14. 14. Heart and Vascular Outcomes 2012Annual Volume of Diagnostic Coronary Angiograms Asante Rogue Regional Medical Center Asante Three Rivers Medical Center Asante Rogue Regional Medical Center Cardiovascular Lab at the Cardiovascular Institute Combined Volume Asante Rogue Regional Medical Center cardiac studies staffAnnual Volume of Coronary Interventional Proceduresat Asante Rogue Regional Medical Center 67,200 cardiac procedures have been performed at Asante Rogue Regional Medical Center since 1973. Asante Rogue Regional Medical Center cardiovascular recovery staff 15
  15. 15. CORONARY ARTERY DISEASE Coronary Artery DiseaseAsante Rogue Regional Medical Center Cardiovascular Lab at the Cardiovascular InstituteEach year 13 cardiologists and six vascular surgeons perform a high volume of diagnostic cardiac catheterizations, peripheralangiograms, and peripheral vascular interventions at the Asante Rogue Regional Medical Center Cardiovascular Lab.Located in a comfortable, state-of-the-art facility within the outpatient facilities of the Cardiovascular Institute (CVI) onthe Medford campus, our lab allows elective studies to be performed conveniently; total stays average just four hours.Peripheral Intervention Volume Peripheral Angiography Volume Cardiac Catheterization/Coronary Angiography Volume Includes carotid angiography, upper- and lower-extremity angiography, renal angiography, mesenteric angiography, and abdominal angiographyIncludes upper- and lower-extremity angiography, renal angiography,mesenteric angiography, and iliac angiography Peripheral Angiography Complications No stroke, myocardial infarction, Stroke Myocardial Infarction Death or death occurred at the time of coronary angiography/cardiac catheterization from 2007 to 2011.16
  16. 16. Heart and Vascular Outcomes 2012Radial Artery AccessThe radial artery is increasingly being used as theaccess site to the arterial system when performingcoronary angiography, cardiac catheterization, andpercutaneous coronary intervention (i.e., coronary We use the Americanstent) procedures. Historically, the brachial and College of Cardiology’sfemoral arteries have served as the points of access tothe arterial system. Radial artery access is associated National Cardiovascular Datawith greater patient comfort, shorter bed rest times, Registry database to trackshorter hospital stays, and less bleeding. If a coronary patient outcomes.intervention is performed via the radial approach,same-day discharge is an option in some circumstances.Femoral artery access is still used for complexcatheterization and interventions, depending onthe patient’s situation. Radial artery access was Cath lab staff at CVIfirst performed on a routine basis at Asante RogueRegional Medical Center in 2009 (the first program Appropriate-Use Criteria forin Southern Oregon) and is now routinely performed Percutaneous Coronary Interventionby five of the cardiologists. Over the past 10 years, there has been a paradigm change in the treatment of patients with coronary artery disease. In the past, if a patient had a 75 percent coronary artery stenosis resulting in symptoms, a cardiologist would have felt compelled to mechanically fix that blockage. We now know it is the patient with A wide range of diagnostic unstable or intractable symptoms who benefits. The and interventional procedures American Heart Association and American College are performed in seven of Cardiology evidence-based treatment guidelines state-of-the-art catheterization have reviewed the large cardiology research trials and have found that revascularization is beneficial in laboratories—five at Asante Rogue patients with acute coronary syndrome (i.e., plaque Regional Medical Center rupture resulting in unstable angina, non-ST-segment and two at CVI. elevation myocardial infarction, or ST-segment elevation myocardial infarction), a high-risk stress test or pressure wire assessment, congestive heartRadial artery hemostasis after removing failure, or debilitating stable angina despite optimalthe radial artery access sheath medical therapy. 17
  17. 17. CORONARY ARTERY DISEASE Coronary Artery Disease Stent between fingers Courtesy of Cordis Pressure wire measurement of a hemodynamically significant coronary artery blockage Courtesy of Volcano Drug-eluting stent Courtesy of Fairman Studios Workhorse balloon for angioplasty Courtesy of Boston Scientific Intravascular ultrasound image (cross-sectional view) of a coronary artery with an eccentric atheromatous plaque Courtesy of Volcano Diamond-coated burr that spins at 150,000 revolutions per minute to drill through heavily calcified lesions Courtesy of Boston Scientific18
  18. 18. Heart and Vascular Outcomes 2012Fractional Flow Reserve Chronic Total Occlusion: Increasing SuccessMeasurement with a Pressure Wire with Percutaneous Coronary InterventionCoronary anatomy is best assessed by coronaryangiography. If a patient has unstable symptoms and Huntley Barns, 80a severe stenosis, revascularization is clearly indicated. Medford, OregonThere are many other instances in which it is unclearif a specific coronary lesion is the culprit in causing Huntley is a retired pastor who had debilitating exertional anginathe patient’s symptoms. Coronary physiology can despite optimal medical therapy. He had a large 3+ reversible perfusionbe assessed using a pressure wire to measure the defect in the inferior wall. Wall thickening in the inferior wall confirmedfractional flow reserve (FFR), which is the mean viability. Angiography revealed a chronic total occlusion in the mid-rightproximal pressure divided by the mean distal pressure. coronary artery with collateral flow to the distal vessel (figure 1). NewA pressure wire is a 0.014-inch soft coronary wire coronary wire technology and techniques permitted crossing of thewith a pressure transducer on its tip. The pressure tough fibrous cap in the chronic total occlusion with subsequent stentwire transducer is placed distal to the coronary lesion. deployment. A good angiographic result was noted (figure 2), and theThe pressure distal to the coronary lesion is measured patient was discharged home the next day.via the pressure wire, and the pressure proximal to thelesion is measured via the guiding catheter, permittingmeasurement of the pressure gradient (i.e., FFR).Adenosine (a short-acting vasodilator) is then given,and the FFR is measured. A normal fractional flowreserve is 1.0. Clinical outcome studies have shownthat a fractional flow reserve < 0.80 is best treatedwith revascularization (i.e., coronary stent orCABG surgery) and > 0.80 is best treatedwith medical therapy. Pressure wire and intravascular ultrasonography provide additional physiologic and anatomic information regarding coronary artery plaques. figure 1— Chronic total occlusion (> 3 months figure 2— Patent right coronary artery old by definition) in mid-right coronary artery after stent deployment 19
  19. 19. CORONARY ARTERY DISEASE Coronary Artery Disease Percutaneous Cardiac Assist Devices: Impella and Tandem Heart For acutely ill patients with failing hearts, temporary cardiac assist devices can mean the difference between life and death. The Impella device is a low-profile pump (impeller) mounted on a pigtail catheter that is advanced across the aortic valve into the left ventricle via femoral artery access. It provides up to 2.5 liters per minute (L/min) of blood flow for cardiac support. The inlet is in the left ventricle, and the outlet is in the ascending aorta. Only the left ventricle can be supported at the moment. This device can be placed solely by the interventional cardiologist and is currently available. The Impella 4.0 L/min device should be available in February 2013. The Tandem Heart device can provide left These devices serve as a bridge to coronary heart support, right heart support, or both and is artery repair (e.g., high-risk percutaneous coronary placed either in the operating room or in the cardiac intervention such as distal left main bifurcation stenting catheterization laboratory. A centrifugal pump is in a patient with low left ventricular ejection fraction used. For right heart support, the inflow cannula is (LVEF) who is not felt to be a candidate for CABG placed in the right atrium and the outflow cannula surgery by the CT surgeons) or to provide time for in the pulmonary artery. For left heart support in the the left ventricle to recover (e.g., acute anterolateral cath lab, the inflow cannula is placed in the left atrium ST-elevation myocardial infarction with cardiogenic via a transseptal puncture, and the outflow cannula shock, metabolic acidosis, and pulmonary edema). is placed in the iliac artery. This device requires a team approach with the interventional cardiologist, the electrophysiologists, and the cardiothoracic surgeons. This device has already been used by the cardiothoracic surgeons and will hopefully be available for use in the cath lab in February 2013. Impella Tandem Heart Courtesy of Abiomed Courtesy of Cardiac Assists20
  20. 20. Heart and Vascular Outcomes 2012Impella Use in High-Risk Coronary Stenting Ken Harrison, 55 Yreka, California Ken was admitted with unstable angina and was subsequently diagnosed with a non-ST-elevation myocardial infarction and acute systolic heart failure. Despite optimal medical therapy, he had debilitating angina frequently at rest and simply walking across the room. Coronary angiography revealed a 95 percent stenosis in the distal left main trunk extending into both the left anterior descending and the left circumflex arteries. Given his liver disease, the cardiothoracic surgeons felt he was at prohibitively high risk for coronary artery bypass graft surgery. He then underwent high-risk percutaneous coronary intervention of the distal left main while simultaneously using a percutaneous left heart assist device (Abiomed Impella 2.5) for circulatory support (2.5 L/min). The coronary intervention involved simultaneous kissing-stent deployment into Balloon inflation both the left anterior descending and the left circumflex coronary arteries. Despite the 14F access sheath and the complex nature of the intervention, Ken was discharged home the following day. Six months later he has no angina, is active, and has markedly improved his lifestyle. His liver function has also improved. Inflow port in left ventricle Left mainOutflow port in Left anteriorascending aorta Catheter descending Stent deployment with simultaneous balloon inflation Widely patent left main, left anterior descending, and left circumflex Severe Left stenosis circumflex Impella device in left ventricle Baseline coronary angiogram Approximate location of aortic valve Final angiogram after stent deployment 21
  21. 21. CORONARY ARTERY DISEASE Coronary Artery DiseaseEnhanced External Counterpulsation Hypothermia for Cardiac Arrest PatientsFor patients with debilitating chronic angina not Although the mechanism at work is unclear Cardiac arrest (ventricular fibrillation) results inamenable to coronary revascularization (stent or (possibly improved collateral flow), studies have impaired blood flow to the brain. A prolongedbypass surgery), enhanced external counterpulsation repeatedly shown that 60 to 80 percent of patients cardiac arrest (more than five minutes) can cause(EECP) is a well-tolerated, atraumatic, noninvasive experience the following results: brain damage (anoxic encephalopathy). On occasionprocedure that can reduce the symptoms of angina • Reduced frequency and intensity of chest pain the heart can be stabilized, but the patient remainspectoris, presumably by increasing coronary blood • Increased exercise tolerance unresponsive due to inadequate cerebral perfusion.flow to ischemic areas of the heart. • Reduced need for anti-anginal medications Inducing mild hypothermia to a core body temperature (such as nitroglycerin) of 33 degrees C via an external cooling blanket reducesThe EECP device uses a series of compressive cuffs • Improved sense of well-being and quality of life cerebral metabolism and edema and increases thewrapped around the patient’s calves, thighs, and likelihood of making a meaningful neurologic recovery.buttocks and synchronizes their inflation and deflation Patients typically undergo 35 one-hour sessions This treatment has been proven to save one additionalto the cardiac cycle. During diastole the cuffs inflate over a seven-week period and should first be evaluated life for every seven patients treated and is currentlysequentially from the calves proximally, resulting by a cardiologist. We have had 189 such patients since recommended by the American Heart Association.in augmented diastolic central aortic pressure and the program was established in 2003. At Asante Rogue Regional Medical Center,increased coronary perfusion pressure (when coronary 75 patients were treated from November 2006artery flow is maximal). Rapid and simultaneous through December 2011. Thirty-three patientsdecompression of the cuffs at the onset of systole reduces survived, and 11 required rehabilitation care.the systolic pressure and the cardiac workload. 70 percent of patients noted an improvement in distance that Approved by the federal Food and Drug can be walked in six minutes. Administration (FDA) and Medicare Change in Nitroglycerin Use nChange in Chest Pain n Two Weeks a er One Year Later At Completion of Therapy One Year Later Completion of Therapy Large Slight Unchanged Worse Good Slight Unchanged Worse Reduction Reduction Improvement Improvement in Use in Use Courtesy of Abbott Northwestern Hospital22
  22. 22. Heart and Vascular Outcomes 2012 Henry Trujillo, 49Cumulative Survival in the Grants Pass, OregonHypothermia and Normothermia Groups Henry is a US Navy veteran and a former truck driver who Hypothermia Normothermia had a sudden cardiac arrest while sleeping. His wife awoke to hear C No Temperature Adjustment him say, “Ahhhh!” before he lost consciousness. His wife initiated cardiopulmonary resuscitation (CPR) and paramedics found him in ventricular fibrillation. Electrical cardioversion was successful, and he required mechanical ventilation. Upon arrival at Asante Rogue Regional Medical Center, Henry was comatose and his 12-lead electrocardiogram (EKG) showed ST-elevation in leads V1 and V2 Survival consistent with myocardial infarction or Brugada syndrome (figure 1). Emergent coronary angiography showed mild luminal irregularities with no spasm, ulceration, or thrombus, confirming Brugada syndrome (sodium channel mutation). The hypothermia protocol was initiated to minimize cerebral edema. Henry’s neurologic function recovered four days later, an intracardiac defibrillator was implanted, and he was discharged home 10 days after his cardiac arrest. DaysSource: The Hypothermia after Cardiac Arrest Study Group,New England Journal of Medicine. 2005;352:225-37.Hypothermia Patient Survivors atAsante Rogue Regional Medical Center Nov through n n n n Dec figure 1—12-lead EKG showed ST-elevation in leads V1 and V2 n with right bundle branch block pattern Average age years Average length of stay days 23
  23. 23. Hospital Physicians Hospital Physicians Asante Rogue Regional Medical Center intensivists front row: Petey Laohaburanakit, MD, FCCP; Tamara Dixon, FNP; Matthew Klee, MD; Somnath Ghosh, MD back row: James Stubenrauch, PA-C;, Francisco Paz, MD; Radek Dutkiewicz, MD not pictured: Krish Umapathy, MD Asante Rogue Regional Medical Center hospitalists front row: Nha Le, MD; Erin Brender, MD; EeLin Wan, MD; and Elizabeth Hirni, DO; back row: Jose Mondesi, MD; Ahsan Jaffar, MD; Thu Han Aung, MD; Jonathan Gell, MD; Tim Johnston, MD not pictured: Ahmed T. Ahmed, MD; Tino Bauer, MD; Theresa Chan, MD; Six intensivists at Asante Rogue Regional Agnieszka Dobiecka, MD; Kenneth Sanford, MD; Donna Tribelhorn, MD Medical Center are board certified in critical care medicine; one is additionally board certified in pulmonary medicine. 15 hospitalists provide care for many cardiac patients. All hospitalists are board certified. An intensivist is present in the hospital around-the-clock. Hospitals with an intensivist program are associated with better outcomes and lower mortality rates. 24

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