Partnering with CardioSolution to Build an Interventional Program at St. Joseph Regional Medical Center

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Tim Sayler, President/CEO of St. Joseph Regional Medical Center in Lewiston, Idaho

CardioSolution guarantees comprehensive interventional cardiology service lines specifically to rural and regional hospitals. A unique model allows them to attract the most talented and experienced interventional cardiologists in the country, and bring these physicians to rural hospitals. Unlike a traditional physician practice, CardioSolution drives patient loyalty to its hospital clients, not to the company or physicians.

Tim, thank you for taking the time to talk with us. Can you share a little about St. Joseph Regional Medical Center (SJRMC)?

SJRMC is a regional medical center with one cath lab, serving about 180,000 people. We are a smaller regional medical center with 120 beds and an average daily census of between 70 to 80 patients, with a significant shift to more outpatient delivery of care. We are the leader in the region for inpatient care, but also have a growing outpatient business.

We are between Boise and Coeur d’Alene, Idaho, or Spokane, Washington, depending on how you view the map. It is about 110 miles to Spokane or Coeur d’Alene. SJRMC definitely serves a rural market. Out our back door are several wilderness areas throughout Idaho, Oregon and Washington. The Lewiston market has about 50,000 individuals residing between Lewiston and Clarkston. Thirty miles to the northeast is the University of Idaho in Moscow, Idaho, and 30 miles to the northwest is the city of Pullman, Washington, home to Washington State University. It is a very interesting combination of different environments. While these different populations live within a short distance of one another, it is still definitely a rural market.

SJRMC has a cardiology cath lab and was offering some basic diagnostic services a year ago. What did your cardiology department look like at that point?

I first came on board about a year and a half ago, and at that time, SJRMC had two excellent medical cardiologists working in the community. One cardiologist does strictly medical cardiology, and the other does medical cardiology and also diagnostic caths, at that time about 75 procedures a year. Shortly after taking this position, I became aware that we would need to take cardiology to a different level, after having conversations with our hospitalists and our emergency department (ED) physicians. Typically, when individuals presented to our ED, they would provide proper care to these individuals, stabilize them, and then commonly, send them either by helicopter or ambulance to Spokane, about a two-hour trip. Individuals were not able to get any kind of interventional service in our community. Our physicians expressed the desire to have cardiology available to work with patients in the clinic setting and within our hospital, meaning patients would not have to be transported out of the community. More importantly, physicians were concerned about the limitations in the care we could provide in our ED. It quickly became a priority for us moving forward as a regional medical center. The problem is not just the distance between Lewiston and Spokane; it is also the distance between here and some of the other outlying areas that we serve that are much more rural than Lewiston. People may come to us from Riggins, Idaho, which is about 120 miles away, or all the way from Enterprise, Oregon, which is an 80-mile, rugged drive that can easily take two hours. Our helicopter is busy for a rural community. As they say in the heart business, time is muscle. Time is an important consideration. The ability to help people more quickly is very important and that is why we took a look at putting an interventional program in place.

We knew that recruiting physicians to our center would be difficult, because there were a fair number of physicians that were resistant to the idea of doing intervention without cardiovascular (CV) surgical backup. We spent a great deal of time with our physician leaders, about 10 physicians that sit on a physician council. We started out with a feasibility study, and brought in a national consultant that had a strong reputation in cardiovascular programming. Time was spent processing that information, and then we did a business plan and allowed physicians to be the decision makers as to whether or not SJRMC proceeded with the program. This meant that when we were at the point of making a decision to go ahead, it was supported by most of the physician thought leaders in our community.

The C-PORT trial has finished and concluded that it is safe to do no-backup PCI in rural or regional hospitals using experienced interventional cardiologists.  Healthgrades and the American College of Cardiology have also confirmed the majority opinion that no-backup PCI is not only safe, but in fact is essential to better patient outcomes in rural hospitals. Idaho does not have a rule on surgical backup for PCI, but many states still have regulations that do require surgical backup, or they have a lengthy certificate of need (CON) process.

Yes. In Washington, hospitals without CV surgery backup can do interventions, but in order to do elective cases, there must be CV backup present. Truly, it has not been an issue for us at SJRMC. Our interventional program began February 1, 2012 and it has now been just under a year. If we have emergent patients, we move them quickly through the ED to our cath lab, and we do elective cases as well. Our physicians have good clinical judgment and our outcome data has been excellent. Our door-to-balloon time averages 50 minutes.

Typically, a regional hospital has a couple of different options when introducing or enhancing a cardiology service line. You can recruit a cardiologist straight out of fellowship, partner with a larger practice in a neighboring city, or try and entice a pair of cardiologists to come to your community and start a practice. Why did you take the road less traveled and go with a model that was less familiar?

The combination at SJRMC of two medical cardiologists and some resistance to interventions without CV backup meant that recruitment was going to be difficult. We knew that we needed a different solution. We came across CardioSolution by chance. When I knew we needed to take our program to the next level, I spoke with some cardiologists I know in other parts of the country to see if we could get a program up and running. I was eventually referred to a facility in Aberdeen, South Dakota, where CardioSolution got its start. We had the opportunity to talk to individuals who had worked at that particular facility to get a feel for how it had worked for them. Shortly after that, we began talking to CardioSolution about the possibility of extending their program to Lewiston, Idaho. Once we got the conversation going, it was less than six months to actually going live with cardiology services being provided by CardioSolution in our organization.

CardioSolution offers cardiologists the opportunity to work here for a week (or at the most, two weeks), and then return home and do the things they enjoy outside of their work life, spend time with their family, etc., with no interruption. It is appealing, because individuals can focus on their work and then focus on their family. CardioSolution believed that they could recruit physicians into our environment and did so successfully. When we looked at the price of doing this arrangement, it was not dissimilar from what it would cost us to hire two to three cardiologists on our own to provide a 24/7 service. It was well within what we had anticipated and budgeted for creating an interventional program. CardioSolution had the ability to recruit and provide an interventional program to meet our needs, and we have integrated our respective organizations quite well. We have had four different cardiologists that have come to us through CardioSolution (three primary) with one on site at a time. At times, there has been more than one cardiologist on site, typically for less than a day, but there is always at least one here.

You mentioned that there was some initial resistance due to the lack of CV surgical backup. Has it decreased due to the success of the program?

Yes, I think it was a philosophical difference that some of our physicians have about doing PCI without CV backup. It was the main issue that had prevented this service from growing after the cath lab was first put in place ten years ago.

We are now ten months into the interventional program with CardioSolution, just under a year. Has the resistance gone away? Yes and no. Generally speaking, physicians are looking at the outcomes and seeing that it is working. Are there still some physicians that are resistant to the idea? I think it is fair to say that is the case.

However, the program continues to grow. More referrals are coming in from the region and the clinic volume continues to grow. Observing it from an administrative perspective, I think that people have become much more accepting of the service and recognize how valuable it is to those heart patients when they present in our ED. 

You’ve had your program since February 2012, almost a year now. How many procedures have you performed?

We have performed 207 heart caths, of which 87 required stents. At present, our average door-to-treatment (door-to-balloon) time is right at 50 minutes.

Have there been any cases where you have had to transfer patients out for surgery?

It has been rare, with only a few instances that I’m aware of, none of which were emergent. We put the patient first and if the patient’s best interest is to be cared for in a larger tertiary facility, then we will transfer them.

What impact has implementing a complete cardiology service line had in the short term?

It is night and day from where we were, to where we are now. At the same time that we brought in this service, we also brought in an interventional radiologist. Our cardiovascular team supporting both our interventional radiology and interventional cardiology programs has been very busy. We have seen a halo effect, because we are able to keep patients in our organization that previously would have been transferred to Spokane. In addition, we are seeing a greater utilization of some of the ancillary services within our organization.

How do you see the next five years developing with this new program in place?

We plan to work with CardioSolution over time to get some additional cardiologists here on the ground in Lewiston. Right now, I do not anticipate that we will develop into a cardiovascular surgery site. Our population base puts us in a grey area, so while it is possible, it is not necessarily our goal. Our goal right now is to have a solid group of cardiologists to provide 24/7 care, do interventions when necessary, and run a strong clinic for ongoing heart care to our population.

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