Royal Perth Hospital was the first hospital established in Western Australia in 1855 and is the largest teaching hospital, providing a full range of emergency services for adults (except obstetrics) and serving the State Referral Centre for many supers-specialities. 
Areas of excellence include interventional cardiology, cardiac and lung transplant, burns management, bone marrow transplantation, rehabilitation medicine and trauma services.

Royal Perth Hospital has always been a world-leader in medical technology and research and is the home of respected health care professionals such as our burns surgeon, and the 2005 Australian of the Year, Clinical Professor Fiona Wood.

The Hospital has been home to many significant breakthroughs in medical research - significantly, research into the bacterium Helicobacter pylori, which was found to cause stomach ulcers. This research work won the 2005 Nobel Prize for former staff members Dr Robin Warren and Professor Barry Marshall.

Interview

1. Size of the Department
The cardiology department performed the first coronary stent implantation in the country in 1988.
The Cath. Lab. has three rooms (Siemens Hicor/coroscop) two being dedicated to coronary work and one to pacing and electrophysiology. 
The RPH Cardiac Pacing and Electrophysiology Unit is the longest running and premier public hospital unit of its kind in Western Australia which treats both adult and paediatric patient populations. It is staffed by 1 fulltime electrophysiologist and 2 part-time electrophysiologists. We have 6 trained pacing and EP technicians who are NASPEx Testamurs. The unit has a substantial and varied caseload.

Our Heart-Lung Transplant Unit is forging an international reputation as a centre of excellence in the field of transplantation and mechanical circulatory support. The unit has only been in operation for 11 years but its success rate in many cases is better than other larger, well-established centres around the world. 
The unit continually punches above its weight, providing Western Australians in need of a new lung or heart with exceptional medical expertise and dedicated service.
Echo cardiography studies are performed by 5 full time qualified cardiac sonographers and 2 specialist echo cardiologists providing service for Cath Lab ( Mitral valvuloplasties) pulmonary vein ablations, accident and emergency in our busy trauma unit and the Surgical and General Intensive Care Unit.

The hospital is divided between two campuses. The larger Wellington Street campus is in the centre of Perth, while the Shenton Park campus is located 6 kilometres away.
The hospital treats about 73,000 in-patients a year, receives about 225,000 outpatient attendances a year, and has one of the busiest Emergency Departments in Australia, with more than 54,000 presentations a year

2. Staffing Roles?

Total 28 – 22 FTEs, 3 part time and 3 casual staff.

Roles:

• 1 Cardiac Cath Lab Coordinator
• 1 Senior Radiographer
• 1 Database Manager/ Senior Radiographer
• 3 Radiographers
• 2 Clinical Nurses
• 2 Registered Nurses
• 8 Cardiac Cath Lab Technicians
• 6 Cardiac Technicians ( Pacing & EP)
• 1 Data Clerk
• 3 Patient Care Assistants

3. Procedures?
We perform a full range of procedures in pacing and electrophysiology in our dedicated “EP room”. In the “angio.rooms” we mainly concentrate on coronary work using all the modern tools that contemporary cardiology requires such as; IVUS, Pressure Wire, Thrombectomy devices, Rotational Atherectomy. We have a 24 hour service for acute myocardial infarction that has been in place for over 13 years.

4. Day Case Procedures?
Probably 30 – 40% depending on which day of the week it is. Patients are booked for coronary diagnostic procedures, Permanent Pacemaker Implants, Electrophysiological Studies, Right Heart Studies, Endomycardial Biopsy and Cardioversion.

5. Procedures/Volumes per year?

• Cardiac Catheterisations 1800
• PTCA 1000
• Pacemakers 200
• Defibrillators / BiVent. 100
• Electrophysiology studies 200
• Myocardial Biopsy 200
• PTMC/ASD/PFO 30

6. Cross Training?
All Nurses and Cath Lab Technicians are cross-trained to competently manage and assist with all diagnostic and interventional procedures.
RNs administer all Intravenous medications. The technicians can give oral medications. Our Cath Lab technicians have recently undergone and successfully completed a Hospital based Medication Administration Course.

7. Staffing Roles?

Radiographers

• Physical presence in the room is mandatory during x-ray emission 
In charge of x-ray equipment, IVUS, thrombectomy device (Possis) and rotablator
• Equipment maintenance of the above and daily quality assurance
• Supply disposable equipment during PTCA
• Data entry pertaining to PTCA and cardiac catheterisation
• Be part of a 24 hour on call roster
• Also responsible for supply and ordering of disposable equipment

Nurses and Cardiac Cath Lab Technicians

• All cath staff Scrub, Scout and are responsible for the Haemodynamic Monitoring
• Each day a senior staff member is allocated as the Recovery person to organise patient transfers and post op care including sheath removal
• Staff development is shared by senior staff
• Participate in 24 hour on call roster
• Some staff are responsible for maintaining our sterile stock of supplies and set ups
• Cardiac Technicians work exclusively in EP lab, Holter and Pacing Clinics

8. Surgical Back-up?
Surgical back-up is provided by the cardio-thoracic surgeon who offer a 24 hour on call service. In case of emergency a surgeon is always available.
Of interest, over the last 2 years there has been only one case referred for emergency CABG following PTCA as compared with 3 cases, which required emergency PTCA within 24 hours of undergoing CABG.

9. New Procedures Implemented?
Atrial fibrillation pulmonary vein isolation utilising the Bordeaux technique.
We are active participants in research working on a variety of trials, encompassing broad areas of cardiology, including comparing revascularisation techniques in studies such as TYPHOON, OAT and FREEDOM.
We are also proud to be one of only 2 Australian sites selected to participate in a novel approach to managing Radiocontrast Nephropathy and Acute MI’s through intravascular cooling in the COOL-RCN and COOL-MI 2 studies.
Our Cath lab staff assists with various drug trials such as APEX-AMI and SHINE, and in collecting angiographic data for a variety of other clinical trials such as PLATO, CURRENT and VIVIFY.
We believe that research is an important factor in the progression of interventional cardiology, and we are excited to play such a large part.

10. Inventory Management?
Inventory is managed with the help of clinical staff and on a part time basis by a clerical person.
We currently use an in-house designed electronic inventory management system.
We are planning to develop in the near future a fully automated system using barcode and/or microchip technology. Perth is said to be the most isolated capital city in the world and as most of the vendors have their warehouses in the Eastern States and keep limited stock in Western Australia, supply is occasionally challenging and requires from our part diligent management. The two hour time difference between the Eastern States and Western Australia requires an efficient and rapid ordering process for next day delivery of goods.

11. Haemostasis Management?
Most sheaths are pulled in our recovery area by Cath lab staff. PTCA patients’ sheaths remain in situ until transferred to Coronary Care Unit and then later removed by CCU staff. Mechanical Clamp is the preferred practice. Digital occasionally or in the event of a re-bleed post clamp removal. Closure devices for patients who are anticoagulated or possibly unable to comply with routine post sheath removal and the need to expedite patient discharge.

12. Private cases? Any special considerations?
Yes we do. Mostly the patient presents as an emergency Acute MI. Also patients needing procedures which are complex requiring technology not available in Private practice.
Regardless all patients

13. Measures Implemented to cut costs?
The purchase of prosthesis and disposable equipment is regulated by a state tender which helps us to lower the cost of equipment (at least this is the rationale!)

14. Alliances with other hospitals for the treatment of patients?
Several hospitals within the South Perth metropolitan area transfer patients to us. We also receive patients from country centres all over Western Australia. The health department has embarked itself in the biggest health reform that Australia has ever witnessed. The department of cardiology will move en bloc to a new hospital in 2012 (to be called The Fiona Stanley Hospital) which will be the state flagship hospital. Fremantle hospital will also be part of the move; we already share a number of services with them.

15. Training for new Employees?
We have a Cardiac Cath Lab Orientation package for all new staff. A preceptor is allocated to the new person. This is a comprehensive training program to ensure that the new staff member is provided with the essential knowledge and the skills to competently work in our Cath Lab. All achievements and competencies are signed off once completed.

Discussions on progress are reported to Coordinator then evaluated. We encourage new staff to share any issues they may have during the training period. The hospital has its own compulsory Induction Day plus there is a number of Hospital Based Mandatory Competencies.

16. Continuing education programs for staff?
Clinical Cardiology study days are organised by our hospital’s Centre of Nursing Evidence Based Practice, Education, and Research. Cath Lab staff are invited to attend. Our Cardiology department has scheduled presentations and educational sessions 2 mornings each week. When time permits in services to demonstrate new equipment or drugs is arranged usually once a month or more frequently if time permits. Our hospital offers many other study days which staff can apply to attend. These include Computer training courses.

17. Competency checks for staff once employed?
Basic Life Support, Manual Handling, Management of Aggression, Emergency Learning etc all part of our hospital’s annual mandatory training. We also have Cath lab specific competencies for mechanical support devices such as Intra Aortic Balloon Pump, Radi Wire, IVUS and Defibrillation.

18. Some of the challenges in the department?
One of the recent challenges in the department has been acquiring new x-ray equipment. The biggest problem is recruiting qualified staff. Western Australia is experiencing a huge economic boom in resources. The surge in demand for workers is very competitive.
Another issue is the dire shortage of hospital beds. We cancel patients scheduled for booked procedures most days.

19. Training facility for cardiac registrars?
Yes, 3 Fellows – 1 interventional, 1 EP, 1 Heart Failure and 2 trainees. The cardiac interventional fellowship at Royal Perth Hospital is a wonderful opportunity to gain technical skills and knowledge from some of Australia’s best and most experienced operators. With a 24 hour acute Angioplasty service, complex angioplasty with access to IVUS, Rotablater, Possis thrombectomy (only site in Australia) and other thrombectomy devices, as well as closures devices and mitral valvuloplasty, there is a fantastic and interesting case mix everyday.

20. What is the best part of working at your facility?
Every day offers new challenges. The experiences and opportunity to be part of such a dynamic and progressive team treating the different patient mix often with complex medical conditions. We have excellent sources of support and influence, which constantly encourage an environment for good practice.