Updated 7/19/23VA CATH
overview:
This is a first year rotation at the VA where the fellows primary responsibility is to learn how to plan and perform basic diagnostic catheterizations. You will work with one of several invasive or interventional cardiologists to facilitate the study, perform pre-procedure evaluations and consent and provide post-procedural guidance. As of now the VA cardiology department sees much more general cardiology than UWMC and generally at a lower volume, so it is a good opportunity to learn the basic skills of catheterization at a more leisurely pace.
RESPONSIBILITIES:
Review & consent patients for all outpatient/inpatient caths
Learn how to perform diagnostic coronary angiograms and right heart catheterizations
Read up to three Zio Patches daily. Documentation will need to be completed in CPRS (see VA resources button above for instructions).
Present a patient case during the Heart Team Meeting on Fridays on a topic of your choosing. Discuss with attending.
Review cath reading material:
2021 Coronary Artery Revascularization and 2022 Chest Pain Guidelines.
Review cath trials collected by Dr. Jake Doll: Click here.
daily schedule:
7:00 AM - 5:00 PM, M-F with significant variability depending on case load. As of now there are providers who perform routine diagnostic studies three days a week (Tuesday, Thursday and Friday) with other days considered on an as needed or emergent basis. This may change with a new incoming interventional cardiologist.
The case schedule is usually laid out on the white board in the lab the week before. On non-catheterization days your main obligation is to see the outpatients scheduled for the next day.
Types of outpatients
1) FOPR patients are VA referrals from outside the Seattle metro area (IE Boise, Spokane). They will arrive to the pre-procedural area the day before for labs, RN and MD evaluations. The VA will put them up in a local hotel for the night and they will return the next morning for their procedure. They frequently have minimal documentation in the local CPRS, therefore you will have to go to Vista to learn their history. For billing purposes we are required to have a full H&P. This can be initiated in the CART-CL system. After completed you can copy/paste directly into CPRS.
2) ROPR patients are essentially the same as FOPRs but the above process is completed by the inpatient resident. Therefore FOPRs represent significantly less work. If you have time it is good to meet the patient and review their history the day before, but you do not have to perform documentation.
3) Standard outpatients are referred directly from the local VA. They still require a CART note but it does not need to be as expansive with a full H&P, and does not need to be copied into CPRS. They also do not come in the day before and will get their pre-procedure labs in the morning. You should meet them in the pre-procedural area the day of the study to obtain their basic history and make sure they are appropriate for the study being performed (e.g. stability, allergies, renal function, post-procedure ride, etc.)
4) Inpatients will also need CART notes but like the outpatients, the documentation can be less extensive. After the procedure they will likely return to the floor.
WORKFLOW:
Patients will be brought from the preprocedural area or the floor to the holding area behind the lab. Here is where the consent should be done (CPRS-based module). From here they are brought into the lab where verification is done and the attending comes in to meet them prior to the procedure. The attending will decide access and sedation dosing. You will have a few minutes here to discuss the case with the attending and review pertinent imaging. Once the case starts you are expected to do as much of the case as you and the attending feel comfortable. There is limited role for the general fellow if an intervention or advanced assessment (IE FFR, IVUS) is planned. Interventional fellows come several times a week for VA cases and will likely step in. You are welcome to stay scrubbed in but it is unlikely you will be manipulating catheters unless you are far advanced in the year and there is no interventional fellow. After the case, you will review the angiograms with the attending and make sure the anatomy and lesions are defined. After this, you will write the angiogram report. Make sure to save, (not sign) it so the attending can edit it afterwards. You then need to put in the post-procedure orders, which is an order set in the cardiology tab. If the patient is a FOPR or ROPR, technically the visit represents a consult and they need a consult note. You can copy the procedure report into a consult note and just add an addendum at the end if there are additional management points. Frequently if medical management is advised the attending will ask you to print out new scripts for the patient. They also ask that you would speak with any family members in the waiting room after the procedure to explain the findings.
USEFUL TIPS
The rotation will likely be one of your lightest rotations, unless the volume increases dramatically at the VA. That being said, you are expected to be on the premises everyday, whether it is for cases, preprocedural assessments or other activities either attendings or staff will ask you to do. On off days without cases scheduled you should not leave early (or even not show up at all) without letting an attending know your plans, because unexpected cases or tasks do occur.
Plan on bringing study material or research work on off days.
ALL patients need CART notes, and the CART note must be completed before the case starts.
ROPR/FOPR patients require a complete H&P including HPI, past medical history, social/family history and review of systems. It needs to be in the CART note as well as the copied CART note within CPRS. There are tabs in the CART note for family history, but this is insufficient. It needs to be written out.
Make sure that you list the primary operator in the procedure note as the attending. The fellow is the secondary operator.