Cath Lab Digest

Purpose: To describe how the cardiac catheterization lab at Westchester Medical Center increased hospital revenues as a result of changing its groin management protocol.

Methods: In June 2000, Westchester Medical Center (WMC) implemented an arterial closure program. The primary endpoint of this program was to measure changes in the profitability of the cardiac catheterization lab (CCL) at WMC based upon implementation of a new groin management program. Profitability was measured by analysis of average Medicare reimbursement, average hospital cost for a catheterization procedure at WMC and comparison of the number of procedures before and after the new groin management protocols (January 2000 through December 2002).

Results: Patient turnover (measured as number of outpatients treated per bed in outpatient recovery area) increased from a baseline of 20 patients per bed to 25 patients per bed (a 25% increase) in 6 months, to 32 patients per bed (a 60% increase) by the end of 2002. The increased number of procedures resulted in an estimated net revenue gain of $628K.*

Conclusion: Routine use of Perclose has allowed for greater scheduling flexibility for outpatient procedures and improved inpatient and outpatient procedural capacity.

*Cost analysis is based on the unadjusted median values for CPT 93510, based on 2001 Medicare claims files which indicate the median charge for a Left Heart Catheterization is $2502. The Medicare payment is $1531 and average hospital costs are $833 (including the cost of the closure device). (1531-833 = $698 profit per procedure multiplied by 901 additional procedures = $628K.)

Introduction

Most interventionalists have made a conscious decision to either incorporate arterial closure devices into their practice or exclude them entirely. In this era where the ability to obtain information immediately dictates how we make decisions, we have come to expect immediate results from the decisions we make. When it comes to utilization of arterial closure devices, what often gets overlooked is that the results and their impact on the institution are gradual. This is because there is an initial investment of time and effort to become proficient with the devices before the cost and clinical benefits of the technology investment are realized.

As new technology is learned, physicians and staff become more comfortable implementing new policies and procedures to optimize results and make the closure program successful. As shown in this case study, complete and successful integration of a closure device program requires administrative and physician support, a commitment to change, and an understanding that measurable results happen in stages. The return on investment of an arterial closure device by Westchester Medical Center (Valhalla, NY) has been a combination of increased efficiency, cost savings and improved patient care.

Background

Westchester Medical Center’s cath lab is a 5-lab facility with 8 ambulatory beds. The lab performs approximately 7,000 diagnostic and interventional procedures annually. Prior to June 2000, the standard of care for achieving hemostasis of the femoral artery was manual compression. The CCL was operating at 100% capacity and was still unable to meet the demand for bed space. WMC implemented a femoral artery closure program using the Perclose system (Abbott Vascular Devices, Redwood City, CA) in order to assess the clinical safety of the device and to investigate the potential to reduce the need for overnight admissions for those patients with late afternoon cases. The outpatient recovery area was not staffed after 7:00 pm. Patients having diagnostic angiography procedures after 2:00 pm were admitted for an overnight stay that resulted in an average of 15 overnight admissions per month. This was costly, and utilized valuable staff time and bed space. Furthermore, spending unnecessary time in the hospital can be taxing on patients and their families. Implementation of an arterial closure program was expected to increase the available bed space, improve patient care and patient satisfaction.

The CCL had to work within the existing limitations of the hospital structure to find creative ways to improve patient turnover while containing costs. The objective of the arterial closure program was to limit the number of diagnostic patients forced to stay overnight due to manual compression ambulation protocols and to increase the number of outpatient procedures per day. Prior to the implementation of this program, procedures such as pacemaker implants, which can be performed in the CCL, were being done in the operating room (OR) due to a lack of available space in the CCL recovery area. A suture-based closure device was chosen because it permits faster patient discharge without increasing complication rates.^1-3 Patients are eligible for discharge in 1-2 hours after a diagnostic catheterization with Perclose versus 4-6 hours after receiving manual compression.

Methods

Utilization of the Perclose system was instituted at Westchester Medical Center in June 2000. The first step in the program was physician and staff training. Physicians planning to use the device received proctorship from a certified Perclose representative and educational training sessions were held for cardiac cath lab staff, recovery area personnel, and floor nurses. Upon completion of the 10-case training process, physicians received certification to use the device.

Adoption of the Perclose system from manual compression was gradual. Initially, two days per week were dedicated to physicians using Perclose and patients were chosen selectively. Once efficiency was demonstrated, use of Perclose increased to include multiple operators. Within 6 months, the device was used for all eligible diagnostic and interventional cases.