Definitions of turnaround times
Today, there are several definitions of turnaround times in use at different facilities. The two most common are measurements of the time from: a) when one patient leaves a procedure room until the time the next patient enters the same room; b) when the physician leaves the procedure room until the time the next physician presents himself in that same room.
Each methodology has its pros and cons. For example, the patient-centered definition does not take into account physician wait times. The physician-centered definition takes the physician wait times into account, but does not recognize the impact of emergent cases such as a ST elevation myocardial infarction (STEMI). Neither definition takes into account the fact that sheath removal is an integral part of the procedure, but is usually performed in the post procedure area. Regardless of the definition used, the key is to make continuous process improvements so that the consistent trend is to lessen turnaround times. At CMC, we use the first definition because we feel it is a truer reflection of room utilization.

Impact of readiness of the next patient on turnaround times
According to CMC data, the most common variable negatively impacting turnaround time is patients not ready to be placed in the procedure rooms. Reasons include, but clearly are not limited to, unacceptable or inaccessible lab work, lack of appropriate paperwork or incomplete paperwork, late patient arrival in the holding area, difficulty in obtaining IV access and staffing challenges.
Lab work. Since this is an essential element for cardiac catheterizations, at CMC, outpatient advance scheduling for relevant blood tests and their transmittal to the cath lab prior to patient arrival has significantly reduced this impediment to faster turnaround time results. It also has permitted us additional time to deal with abnormal results through treatment or rescheduling of the procedure, thus freeing up the time slot for another patient.
Documentation. Key documentation requirements include: written physician orders with specificity as to the procedure, a statement of patient acknowledgement of risks and benefits, and a properly executed, signed consent. Requiring this documentation to be in place prior to arrival at the holding area has also significantly lowered turnaround times.
Late patient arrival to the holding area. For inpatients, an escort provided by the cath lab picks up the patients from their rooms at the appropriate time. This service also returns these patients to their rooms from the holding area upon completion of the procedure process. For outpatients, the escort picks them up from the Carolinas Heart Institute waiting area and is available to discharge them post recovery. Having control over patient movement in and out of the lab assures better turnaround times and also relieves the nursing and procedure room staff of transport duties.

CMC™s strategy to overcome patient readiness issues: The CARE Program
The key program incorporating many of these features and instituted by CMC to assist in reducing turnaround times (among other things) was the introduction of the CARE Program: the Cath lab Admission, Registration, and Education Program. The goal is to provide a pre-admission process that includes registration and patient/family education for all outpatients to the cardiac, vascular and electrophysiology labs.
All outpatients are contacted to schedule this session and to obtain insurance information. At the pre-registration appointment, the workup is handled by a mid-level practitioner. The paperwork is completed and blood is drawn by a nurse. Pre-procedure guidelines and procedure-specific educational material are provided. If a chest x-ray or consults from physician, anesthesia or social work are required, then they are also accomplished at this time. This program has reduced patient cancellations and had a significant impact on the reduction of turnaround times.

Impact of housekeeping on turnaround times
The process of accomplishing procedure room clean-up also has the potential to favorably or negatively impact turnaround times. In some labs, responsibility for procedure room clean-up is handled by the housekeeping department and in some labs by the procedure room staff. Each approach has its pros and cons. When housekeeping staff is assigned to the lab or is readily available, they can turn the room around while the procedure room staff is picking up the next patient. When it is not readily and consistently available, this can be a major impediment to expeditious turnaround times. The choice for the procedure room staff can become one of either wait for the room to be prepared or do it yourself.
For those locations, including CMC, where the procedure room staff assumes this responsibility, the average turnaround time appears to be better. Turnaround times at CMC run seven minutes on average. During the CMC process, the following actions occur simultaneously: the scrub tech takes the completed patient to the holding area and gives report to the RN; the circulator cleans the bed, equipment, table, floors and removes trash; and the recorder finishes the report on the previous cases and takes the chart to the holding area. Upon completion of the procedure room housekeeping chore, the circulator begins the process of setting up the tray for the next procedure. The recorder assists the previous scrub tech in picking up the next patient from the holding area.

Incentives provide a second successful CMC approach to turnaround times
In addition to the CARE Program, the second key initiative to improve overall lab efficiency and lessen turnaround times was the establishment of a Productivity Incentive Program. The program was designed to recognize and reward outstanding work performance and to challenge the team to grow professionally.
The financial incentive is available only if the department achieves certain productivity and customer service goals. It is weight-adjusted for differences in procedure types and is based on the percent of average volume targets achieved between the hours of 7:30 am and 6:00 pm, Monday through Friday. This program has had a very positive impact on the effective management of our turnaround times.

Conclusion
Whatever the definition of turnaround times might be, the challenge for all is to make constant process improvements to minimize it. Identify each area of negative impact and take appropriate corrective action. At CMC, we have seen enhanced patient/staff and physician satisfaction, and increased hospital revenue as a result. We are making this a long-term process improvement program and expect positive results will continue.

Erin Rice can be contacted at erinrice20@hotmail.com