Doing More with Less Overtime: Improving Patient Flow Through the Cath Lab
The problems were familiar ones: days were hectic and unpredictable; the staff was constantly juggling the schedule in order to slot emergencies and urgent cases between scheduled ones; cases were too often bumped or delayed with unhappy and hungry patients kept waiting; and the staff was stressed and frustrated. But in the fall of 2007, the administration and staff of the cardiac catheterization laboratory at Kennestone Hospital — WellStar Health System’s 633-bed flagship hospital in Marietta, Georgia — decided to undertake an innovative approach to solving these common problems with the help of PatientFlow Technology, Inc. (Boston, Massachusetts), a leading provider of patient flow tools and services for hospitals. Using rigorous data analysis and the queuing theory — an operations management tool developed by industry and adapted for the hospital environment — the cath lab project team and physicians developed and adopted a plan that calls for setting aside one or two of the existing four labs, depending on the day of the week, for urgent and emergent cases (defined for this project as cases needing to be performed within 24 hours and three days, respectively). This ensures that these patients are treated in a timely manner without causing delays or cancellations for the day’s elective cases. In the first six months after implementation, the average waiting times for urgent cases — cases that cardiologists identified as needing to be performed within 24 hours — dropped by 75%. The average waiting times for semi-urgent cases — those that needed to be performed within the same hospitalization — dropped by 40%. At the same time, emergency cases continued to arrive to the cath lab in less than 90 minutes, the “gold standard” for cardiac care. Notably, the decrease in waiting times occurred, even as the total volume of cases increased by 20%.
The cardiac cath lab at Kennestone Hospital consists of five suites, four of which are used for coronary catheterization procedures (the fourth suite was added in December 2007), and one for electrophysiologic (EP) studies. In fiscal year 2007, procedures were performed on 6,594 patients, 80% of which were coronary catheterization cases, and 20% were EP cases. Door-to-balloon times were excellent and well below the 90-minute target.
However, before the current project began, late and overtime hours were common, with the cath lab running late daily. The schedule was built around elective patients, while patients with acute ST-elevation myocardial infarctions (STEMIs) were rushed into the first available room, and the rest of the inpatient procedures were being performed in “holes” between the elective cases, at the end of the day, or bumped to the next day. Urgent and semi-urgent cases added to the schedule tended to start towards the end of the day. Of particular concern to physicians and administration was the difficulty of fitting existing inpatients into the schedule, causing lengths of stay to be artificially extended. Prolonged hospitalizations are not only problematic from a quality-of-care perspective, but also represent a costly use of resources by tying up beds and keeping patients in the hospital extra days, with no increased reimbursement. In addition, the patients themselves were unhappy waiting and fasting for many hours, the staff was frustrated with the long and unpredictable hours, and physicians were upset when cases were delayed or bumped.
The Solution: Separating Non-Elective and Elective Cases
The staff, administration and medical director of Kennestone’s cath lab, working with the PatientFlow Technology consultant, applied a multistep approach to solving these problems and improving patient flow through the cath lab. The key to success was separating the flow of non-elective (urgent and emergent) from elective cases, and setting aside adequate capacity so that urgent/emergent cases could be handled in a timely manner without interfering with the flow of elective cases. This entailed designating one or two of the four cath labs, depending on the time of day and day of week, for “add-on” cases, with the remaining labs being utilized for scheduled elective cases. The steps involved in developing this approach were the following:
Urgency classification system developed for add-on cases. The cardiologists developed an urgency classification system for all add-on cases based on the clinical presentation of the patient. When a cardiologist called to place a case on the add-on list, he/she included the urgency category for the case. The urgency categories were used to prioritize waiting cases, as well as for data analysis and queuing models to determine the capacity needed to care for urgent and emergent cases in the appropriate time and to monitor waiting times. The urgency categories and the associated waiting time limits developed by the cardiologists at Kennestone were:
• Emergent: (door-to-balloon) within 90 minutes;
• Urgent: within 24 hours;
• Semi-urgent: same hospitalization (within 3 days).
Data collection and analyses. Data on booking date and time, urgency category, case start date and time, and case duration were collected on all cases in the cath lab for three months. Based on this data, queuing models were developed to determine the resources needed to accommodate the add-on cases within the time limits defined by the cardiologists for each urgency category.
Improve accuracy of scheduling system. Before the project, cath lab schedulers allowed one hour for a diagnostic case and two hours for a percutaneous coronary intervention (PCI). Unfortunately, scheduling by the overall average did not reflect the actual time needed for the procedures. With the cath lab staff, the consultants developed a more accurate scheduling scheme based on the procedure itself.
Based on the data analysis and queuing models developed, the cath lab project team agreed to set aside time for the add-on cases in the following way: On Mondays and Fridays, when add-on case volume was highest, two rooms were set aside all day for add-on cases. On Tuesdays, Wednesdays and Thursdays, one room was set aside for add-on cases in the mornings, and two rooms in the afternoons. In the mornings, the second “add-on room” was used for additional EP and pacemaker cases as well as elective cases.
Six months after the plan was implemented, the impact of the new design was evident. Add-on cases were being performed in the designated rooms starting first thing in the morning, and then one after another, based on their urgency. Waiting times for inpatient cases dropped dramatically; these cases were being performed in a timely and predictable manner, with patients no longer having to fast for several hours hoping to be “squeezed in” between unscheduled cases. Waiting times for urgent cases dropped 75% from an average of 25 hours in December, to six hours in July. Waiting times for semi-urgent cases dropped by 40% from an average of 38 hours to 23 hours (Figure 1). At the same time, 100% of emergency cases continued to be performed in less than 90 minutes.
With separate capacity available for the add-on cases, elective cases could be scheduled back-to-back, allowing for an increase in volume. Over the first six months of the program’s implementation, the volume of elective cases increased by more than 20%. Yet even as the volume increased, the amount of time that the staff had to stay at the end of the day decreased by 70% (Figure 2) for elective cases, and by more than 80% for all but emergency cases. Not only did this save a large amount of money in late and overtime costs to the hospital, it also improved staff, physician and patient satisfaction.
Reactions to the Changes
The cardiologists and staff are very pleased with the project. The quality of care delivered to patients has improved, as waiting times have decreased, and the incidence of bumped and delayed cases has also been reduced significantly. In addition, the schedule in the cath lab runs much more smoothly, and the number of hours worked past prime time for all but emergent cases has decreased by 80% to only one hour and 40 minutes for the entire month of July.
Dr. Diosdado Irlandez, a cardiologist at Kennestone, commented, “I do not feel as busy, although we are performing more cases. We used to bump patients from day to day; it was very embarrassing to bump a patient who had been fasting from midnight the day before.”
According to Dr. McKee, another cardiologist working in the cath lab, “We are now providing better care, with patients being treated earlier and not fasting for as many hours. We used to bump patients from day to day… now we don’t bump patients any more.” In addition, the urgency classification “makes it clear which patient should go first.”
Another cardiologist, Dr. DeSatee stated, “I used to go home late at least once or twice a week. Now it rarely happens…having a designated room for the non-elective cases was very important and made a significant difference.”
Dr. Arthur Reitman, medical director of the Kennestone cath lab, concluded: “By performing non-elective cases in designated rooms starting in the morning, and implementing other operational improvements, we have seen a decrease in waiting times. This has helped to improve the quality of care that we provide to our patients, and has decreased the amount of time our patients need to fast. The staff is pleased with the new design. Their days are much more predictable, and they more regularly go home on time or earlier. I am delighted with the results we are achieving here.”
The staff and administration are equally enthusiastic. “The project has measurably improved cath lab efficiency and provided a framework that all the physicians are comfortable with,” said Pat Jansen, Vice President of Cardiac Services at WellStar. “The sicker patients are getting into the lab more quickly,” concurred Brenda Adams and Susan Wheaton, cath lab flow coordinators at Kennestone.