Anesthesiologists and job satisfaction in cardiac cath lab: Do we need guidelines?

Cardiac cath lab procedures are developing in numbers, complexities and in demands with good outcomes. The complexicity of procedures and high risk patient factors require efficient cardiac anaesthesiologist's care. They need good infrastructure and anaesthesia facilities. These facilities may be available at Metrocity superspeciality centres, but small units at district levels may not have all these facilities. There are many issues existing which make cardiac anaesthesiologists to prefer to work only in cardiac operation theaters than cath lab. They don't get the job satisfaction in cath lab because of higher stress levels to overcome with the lacunaes in cath lab working. Aim: We hypothesize that cath lab in various centres are run by cardiac anaesthesiologists in majority. To analyze the infrastructure and working conditions of cath lab in perspective of anaesthesiologist, we conducted this survey. Setting and Design: Online survey among IACTA members, through email available through IACTA site. The link was https://www.surveymonkey.com/r/9FKZ3TV. Subjects and
Methods: We contacted 500 IACTA members through email addresses available with us. 116 members replied to the online questionnaire done using SurveyMonkey software. Total 12 questions asked and answers analysed. The identity of responders is not disclosed by Survey monkey.
Results: Results were analysed in for options in percentage wise by Surveymonkey software.we compiled all responses and categorized the suggestions by responders.
Conclusion: Role of anaesthesiologist and anaesthesia facilities should be given important priority in cath lab units. Healthy attitude of governing members of cathlab as well as standard guidelines for recommendation of infrastructure of cath lab, monitoring and patient care is need of the hour!

Introduction

The great pioneer of cardiac catheterization was Werner Forssmann.[1] Forssmann started cardiac catheterization in adults followed by Bing who did the first cardiac catheterization in cyanotic pediatric patient.[2] A journey of almost four decades had given very glorious development in the cardiac cath lab technology. From coronary angiography being considered as simpler procedure, spectrum extends to complex procedures such as electrophysiological study and radiofrequency ablation, transaortic valve replacement, abdominal aortic aneurysm and vascular stentings, cerebral coiling, and congenital pediatric cardiac interventions are really beneficial for patients who are at high risk for surgical treatment in operation theaters (OT). These are the advances which make the need of cardiac anesthesiologist at priority.[3] Cardiac anesthesiologists are trained in such procedures and they are well versed with the complete pathophysiology and complications of the condition. Cardiac anesthesiologists play a crucial role in cath lab procedures.

In India, there are around 30 million coronary artery disease patients at present, out of which 16 million are located in rural area where the feasibility of treatment is questionable and 14 million in urban area[4] may get facilities of treatment. At present, only 172 units of cardiac cath lab units are available in India.[5] Because of the increasing number of patients, complexity of disease and patient factors, and huge demand though the cardiologist working in newer cath lab units, the facilities and protocols are not standard or uniform all over the world.[6] Small space-containing cath machinery, inadequate mobility, difficult access to airway and intravenous line, inefficient gas scavenging system, nonavailability of standard anesthesia machine and remote location and less assistant help are the difficult issues for an anesthesiologist to work in cath lab.

Indiscipline schedule, irregular working times, long working hours, energy loss, and radiation exposure with less payment are the major concerns for that one refuses to work in cath lab.

All these issues make cardiac anesthesia little unpopular in postgraduates which should be addressed on a priority basis. These are the challenges not only in the Indian scenario but overall these cath lab issues are universal![7]

Here, we conducted a small survey to know the status and opinions of anesthesiologist who are working in cath lab. We have not done the survey to probe any specialty people or managers of cath units; however, our intention is to point out the compromised ways of running the cath lab. One will never enjoy working in such units which ultimately compromises patient care. Though the responses we got are <25%, we respect the participants who responded us and helped us. We are thankful to all our participants and survey does not reveal the identity of the participants.

For best patient care and successful outcome, strong cath lab recommendation of guidelines to be done and followed is the need of the hour.

Materials and Methods

Aim

We hypothesize that cath labs in various centers are run by cardiac anesthesiologists in majority and in small places they are run by general anesthesiologists too. Cath lab is considered as a remote suit to work and with different protocols. Facilities available are not uniform in all centers specifically small district-level cath lab cardiac centers.

To analyze the infrastructure and working conditions of cath lab from the perspective of an anesthesiologist, we conducted this survey.

Setting and design

An online survey was conducted among the Indian Association of Cardiovascular Thoracic Anaesthesiologists (IACTA) members, through E-mail available on the IACTA site. The link was https://www.surveymonkey.com/r/9FKZ3TV.

Subjects and methods

We contacted 500 IACTA members through E-mail addresses available with us. A total of 116 members replied to the online questionnaire, i.e., 23% [Table 1]. The questionnaire was completed using SurveyMonkey software and the link http://www.surveymonkey.com/ was sent by author in an E-mail and then again followed up in a WhatsApp no. link and E-mail to nonresponders and partial responders. The identity of responders will not be disclosed by SurveyMonkey software.

Table 1

Opinion of participants

Particular	Number of participants(n=112), n (%)
Are you a full timer at your institute or freelancer or group practitioner?
Full-timer	97 (86.6)
Free practitioner group	6 (5.35)
Group practice	9 (8.04)
Is cardiac cath lab happy with anesthesia facilities? Do you have anesthesia machine?
Yes	79 (70.54)
No	33 (29.46)
How is the working of a cath lab? disciplined (schedule management, proper case information) or no protocols
Yes	50 (44.64)
No	62 (55.36)
How many cardiologists govern a cath lab?
One	2 (1.25)
Two	24 (15.0)
Three	25 (15.62)
Four and more	61 (38.12)
On an average, how many PTCAs were done monthly at your center?
<30	19 (15.83)
30-50	35 (29.17)
50-70	25 (20.83)
>70	33 (27.5)
On an average, how many pediatric and adult interventions are done monthly (ASD/VSD device, BPV, BMV, aortic stenting)?
<10	62 (51.67)
10-30	24 (20.0)
30-40	9 (7.5)
>40	17 (14.17)
Is strict working hours for elective procedures followed at your institute (9 a.m. to 5 p.m. or 9 a.m. to 6 p.m)?
Yes	40 (33.3)
No	72 (60.0)
After 5 PM, how frequently elective PTCA or interventions done routinely? Do you agree for such practice? Do you get paid extra?
Routinely done, not agree, not paid	47 (39.17)
Routinely done, agree, get paid	11 (9.17)
Sometimes, agree, get paid	27 (22.5)
Sometimes, not agree, not paid	29 (24.17)
Are you paid satisfactorily for cathlab procedures?
Yes	35 (29.17)
No	77 (64.17)
Do you get stress-free comfort zone to work more in cath lab or cardiac OT?
Cardiac OT	72 (60.0)
Cath lab	10 (8.33)
Both	20 (16.67)
None	10 (8.33)
Are you aware of the radiation exposure at least yearly?
Yes	66 (55.0)
No	19 (15.8)
Not worried	1 (0.83)
Worried but never asked	26 (21.67)

PTCA: Percutaneous transluminal coronary angioplasty, ASD: Atrial septal defect, VSD: Ventricular septal defect, BPV: Balloon valvotomy procedure, BMV: Balloon mitral valvuloplasty, OT: Operation theater

Cath lab questionnaire of survey

A total of 12 questions were asked which are described as follows:

Are you a full-timer/group practitioner/freelancer anesthesiologist?

Is cardiac cath lab happy with facilities available for anesthesia?

How is the working of cath lab-disciplined or no protocols? (schedule management, proper case info)

How many cardiologists govern cath lab?

On an average, how many percutaneous transluminal coronary angioplasty (PTCA) done monthly at your center?

Average how many pediatric and adult interventions are done monthly? (atrial septal defect [ASD]/ventricular septal defect [VSD])

Strict working hours for elective procedures are followed in your institute (9 am–5 pm/9 am–6 pm/institutional working hours)?

After elective working hour time, how frequently elective PTCA or interventions are done routinely and do you agree for such practices? Do you get paid?

Are you paid satisfactorily for cath lab procedures?

You get stress-free comfort zone to work more in cath lab or cardiac OT?

Are you aware of the radiation exposure at least yearly?

Your suggestions for cath lab working.

All questions have multiple choices but with expected single choice answer. Questions were clear and explanatory. We conducted this study from December 2017 to February 2018. Data were analyzed using SurveyMonkey software.

Results

We asked the first question about the type of job, for which 86.6% of responders are full-time cardiac anesthesiologist, 5.35% are freelancers, and 8% do group practice.

Nearly 70.54% of anesthesiologists commented that they have good facility for anesthesia and 29.46% reported lack of facility for the second question related to anesthesia facility in cath lab [Graph 1].

Graph 1

Anesthesia facilities (yes/no)

Almost 55.36% of anesthesiologists opined that there is no protocol or discipline in cath lab in response to the third question about the proper schedule management discipline in cath lab. Around 44.64% of responders said that their center follow disciplined schedule.

The fourth question was regarding the number of cardiologists governing the cath lab. In view of maximum turnover and benefit more than 2 or 3 cardiologist are appointed at many places. Cardiologist work with their convinient timings. Majority of the responders of our survey are from the centers where more than four cardiologists are working with more than 70 PTCA per month done.

Nearly 38.12% of anesthesiologists work in a center where four cardiologists govern the cath lab. Overall 15.0% and 15.62% work in centers where two and three cardiologists govern the center, respectively. Only 1.25% of anesthesiologists from survey group work in centers where only one cardiologist governs the center.

Nearly 27.5% of anesthesiologists do more than 70 PTCA monthly, 20.83% responders do 50–70 PTCA monthly, 29.17% responders do 30–50 PTCA monthly, and 15.83% % responders do less than 30 PTCA per month.

Question 6 was regarding the pediatric interventional procedures such as ASD/VSD device closure and balloon mitral valvuloplasty/balloon valvotomy procedure procedures. Nearly 51.67% of responders do less than 10 such cases per month, 14.17% responders regularly do such procedures, and more than 40 per month. 20.0% of responders do 10–30 pediatric intervention per month.

Question 7 was regarding the strict working hours for elective cases that is daily schedule of 8 h in institution. Nearly 33.3% of anesthesiologists have the privilege to work with such schedule, but 66.04% of anesthesiologists have no proper working schedule for elective procedures and may face more stress [Graph 2].

Graph 2

Working of cath lab – disciplined schedule management – yes/no

Question 8 was an extension of the same working pattern and is connected with remuneration paid to an anesthesiologist for such extra hours working for elective procedures. Nearly 39.17% responders did not agree with such working pattern and even they do not get paid for that, may be because of full-time job. Almost 9.17% [Graph 3] anesthesiologists get paid and agree probably from freelancer group. Nearly 22.50% of anesthesiologists agree for late working hours sometimes and they get paid for that and probably for that they agree. Nearly 24.17% did not agree even sometimes for such a schedule and they do not get paid too.

Graph 3

Discipline and schedule of cath lab (a-d). (a) Frequently, not agree, not paid. (b) Sometimes, agree, get paid. (c) Sometimes done, not agree, get paid. (d) Sometimes done, not agree, not get paid

Overall, anesthesiologists do not get paid satisfactorily as 64.17% responders opined no for this 9th question of payment in cath lab, whereas 29.17% of responders get paid satisfactorily [Graph 4].

Graph 4

Remuneration for cath lab cases, satisfied (yes/no)

Question 10 was regarding to elicit the stress level of working place. We asked where cardiologist feel comfort zone and as expected majority means 64.17% responders feel comfortable in OT. Nearly 8.33% of anesthesiologist feel comfortable in cath lab probably for less duration and simplicity of procedures in case of PTCA as most of the PTCAs are done in monitored anesthesia care (MAC). Almost 16.63% of responders feel comfortable at both places. Nearly 8.33% of responders are with stress in OT as well as cath lab.

Radiation is the most common hazard for the health-care personnel working in cath lab suite; to our surprise, 15.8% responders are not aware and not worried of the radiation hazard. Almost 55.0% are aware of the radiation hazard. Nearly 21.67% are worried but not asked about the exposure measurement.

The last question is about suggestions for cath lab working. Seventy-eight responders gave suggestion and 38 responders replied that they did not want to give any suggestions. We analyzed the suggestions in nine categories with percentage response for that category of improvement [Figure 1].

Figure 1

Feedback analysis – suggestions by responders

Discussion

Cardiological procedures are highly risky and that is why they are very much protocol based than any other procedures. Each and every team member is well versed of the steps and one's own job for the procedure. High risk increases the stress level of the team members too. Cardiac surgery and cardiac anesthesia are developed hand in hand and getting glorious success in all procedures. Cardiac anesthesiologists are always comfortable in cardiac OT, but at the same time, it is stressful to work in cardiac cath lab suite. In India, there is unpopularity for the cardiac anesthesiology among postgraduate students because of stress. Cardiac interventional procedures are rapidly developing with good outcomes. Most of the time, routine PTCA procedures are done in MAC, but all pediatric interventional procedures require sedation or general anesthesia. In adult patients also, general anesthesia is required in specific procedures, need of transesophageal echocardiography, in a randomized trial of general anesthesia with endotracheal intubation versus sedation for patients undergoing atrial ablation, the general anesthesia group had a better outcome.[8]

In a developing country like India where the burden of patient needs more centers to avail the treatment, it is always beneficial for patients getting more centers at district-level tertiary hospitals. However, at the same time, there are many compromised facilities to work for cardiac anesthesiologists which makes them more stressful and less preference to work in cardiac cath labs. Cardiac cath lab is a remote and claustrophobic place to work in a high-risk situation. Sophisticated anesthesia workstation, syringe pumps with battery backups, and monitors are the basic requirements to give general anesthesia in hemodynamically compromised patients.[9] Unlike an OT, cath lab has many issues which are not comfortable to an anesthesiologist for efficient working. We analyzed our survey and found that anesthesiologists mainly do not get respectable remuneration for their services; apart from this, there is no proper communication of scheduled case list and timings, which makes more stressful. Anesthesia facilities should be present in each center but in fact are not available. These are the reasons why many cardiac anesthesiologists stopped working in a cath lab. Aortic aneurysmal stenting, transcatheter aortic valve implantation, carotid stenting, and cerebral aneurysmal coiling are the cases where high risk and skill are required. We asked for suggestions to improve cath lab working out of 116 responders given suggestions pointing out different views. We categorized their suggestions in eight issues, namely (a) communication of cardiologist and cardiac anesthesiologist before the procedures and intraprocedure period (by 19.23% responders) which has a vital role in patient outcome,[7] (b) Discipline in reference to conduct the procedures within scheduled timings, proper preparation of patients and documentation of patient file (24.26%), (c) Equipment of anesthesia and regular maintenance is needed in cath lab by 17.95% of responders, (d) Infrastructure and human resources suggesting need of trained staff to help in procedures or anesthesia assistant for high-risk procedures in remote suite is required as suggested by 17.95% of responders. Planning of procedure is needed as suggested by 11.54% responders which again pointing the indiscipline working of most of the cath labs. Anesthesiologists should be strictly monitored for radiation hazards.[910] Most of the cutaneous burns are secondary to radiation but they go unnoticed. Overall 10.26% responders suggest for the priority of radiation monitoring. Dosimeter for radiation should be compulsory for every cath lab personnel. Nearly 6.41% responders suggest training, for an anesthesiologist to cope up with the place, machines and trained assistant are required.

Safe anesthesia and safe surgery/procedure is the motto of anesthesiologists for best patient care. The American Society of Anesthesiologists has established monitoring guidelines for sedation by anesthesia and nonanesthesia personnel in nonoperating room locations.[11] The Canadian Cath lab consensus guidelines mentioned recommendations for best practices.[12] In the same manner, with reference to the Indian scenario, specific guidelines should be prepared for the working in cath lab all over India. It will definitely improve the patient care, safety, and results as well as the stress level of the anesthesiologists will reduce.

Conclusion

Cardiac cath lab with its increasing number of procedures needs highly trained cardiac anesthesiologists. The role of an anesthesiologist and anesthesia facilities should be given priority. Healthy attitude of governing members of cath lab as well as standard guidelines recommendation of monitoring and patient care is the need of the hour!

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.