Tell us about your lab.
Rajul Patel, MD, FACC: The CardioVascular lab at Phoenix Heart consists of a 4-bed pre and post procedure area, and a single interventional suite. We have 4 full-time staff members in the lab; two are registered nurses and two are registered radiologic technologists. All the staff members and physicians are ACLS-certified. We use the Mindray DPM 5 patient monitors in the pre and post care area, as well as a DPM 6 monitor in the interventional suite. All monitors are connected to a central monitoring station. The imaging suite consists of an OEC 9900 C-arm (GE Healthcare) and NuBOOM visualization system (CompView Medical). The patient images and procedure documentation are archived using the Medstreaming Vascular Information system. Our group is comprised of 16 cardiologists and 1 nurse practitioner. We have a mix of 4 coronary and peripheral interventionalists; all our interventionalists that do peripheral work also do coronary work. We have two electrophysiology (EP) doctors and 10 primary cardiologists. Our outpatient-based lab (OBL) started on July 15, 2014, and in the first 12.5 months of operation, we performed a total of 778 invasive procedures, including 213 interventions, 17 inferior vena cava (IVC) filter retrievals, and 6 IVC filter insertions.
Jerry VanHorn, RT(R)(CV), ARRT, CardioVascular Manager: Our diagnostic procedures include cardiac catheterization, carotid cerebral angiography, aortography, upper and lower extremity angiography, upper and lower extremity venography, and vena cavagrams. Interventions include IVC filter implantation and retrieval, subclavian, renal, and, iliac artery percutaneous transluminal angioplasty (PTA) and stenting, and femoral popliteal and tibial peroneal atherectomy, PTA, and stenting. The pre and post procedure area is also utilized for infusion therapy, such as giving intravenous (IV) dobutamine for end-stage cardiomyopathy patients, and we have done 263 infusion therapies thus far. We have performed 74 synchronized cardioversions.
What sparked the desire to build the lab and how long did it take?
Dr. Patel: It was a gradual discussion. In our group, the partners had been talking about it for a couple of years, and finally, last year, we took the jump and decided to go ahead in the month of February. The clinical benefit for such a lab is consistent, reproducible quality patient care. The patients and the families appreciate the focused attention and service they receive. The patients continually comment on how comfortable they are compared to the apprehension that they experience in the hospital. We focus on a core set of tests and procedures, and in doing so, we have been able to decrease the cost of the procedures to the patient and also to the health plans.
Jerry VanHorn: From the time that construction began until the first procedure was performed, it was about 4 months. During this time, all equipment and supplies were acquired, policies and procedures were drafted and reviewed, and staff was hired.
The fact that you are out of the hospital setting is the reason for the decreased cost?
Dr. Patel: Yes.
When your group was thinking about creating a freestanding lab, what had you heard or seen?
Dr. Patel: We had been talking about it at our partnership level as to whether we should start a lab, knowing there were other, similar labs out there in different areas of the country. So we had heard about labs in other parts of the country, but I personally had never visited one.
Can tell us about your location?
Dr. Patel: Glendale is a suburb of Phoenix. The patient population is mostly middle-aged. Sun City is about 7 or so miles away from our lab and has many elderly, retired people, but 7-8 miles is a long drive for them, and there already are a few hospitals that are very close to Sun City. So most of our patients are middle-aged. We do have a lot of primary care physicians in our area and there are two hospitals very close by, within 5 minutes of driving distance from our lab.
Can you talk about how your protocols were set up? Did you work with the hospitals that are nearby?
Jerry VanHorn: All of our physicians have privileges at both hospitals. As far as emergency protocols, these were established mostly with the hospital to the north of us, Arrowhead Hospital, just because they were a smaller hospital system at that point in time and it was much easier to get things in place. We have also had discussions over time with the Glendale Fire Department. They have a firehouse that is about ¾ mile away from our location, meaning rapid response from EMS is just a phone call away and a short drive. We have not had to utilize EMS, but we do have emergency protocol transfer procedures in place. Everybody that works here in the lab comes from a local hospital as well. We used that experience to help set up policies and protocols that mimic hospital policy and procedure manuals. We all have a good idea of what needs to be done.
What were some of the challenges you faced when creating and setting up a freestanding lab?
Jerry VanHorn: We needed to access a lot of resources, spend a lot of time online, and do a lot of talking to other people across the country. I came here out of industry, so I had a lot of connections through my previous work, even in other states. I talked to cardiologists and vascular surgeons who had set up office-based labs in their areas. I also had experience with opening up a hospital-based cardiac cath lab in the past.
Dr. Patel: From the physicians’ perspective, our focus was mostly delivering the best patient care that we could, obviously keeping an eye towards fiscal responsibility. The four interventionalists and our group as a whole had bought into the program, and our challenge was that we wanted to slowly phase in. We didn’t want to begin with very complex cases. We thought, let’s start out slow, let’s start out going for lower-risk patients, and then as we get more comfortable, we can take on more challenging cases.
A year in, where are you now in that process?
Dr. Patel: We are very comfortable now with challenging patients. To give an example, today we had a 100% occluded superficial femoral artery (SFA) right after the origin from the common femoral. We were done 30 minutes after starting and the patient is actually now at home.
How do you manage inventory?
Jerry VanHorn: Virtually 100% of our supplies are on consignment. I do just-in-time ordering for all of our non-essential supplies through McKesson. They have next-day delivery for 4x4s and things like that. As a result, I don’t have to have a big stock of them on hand. We partner with a single company for balloons and stents, a single company for atherectomy, two companies for vascular closure, and two different companies for wires and catheters. Since we have limited the number of vendors, it allows us to give them a large percentage, if not upwards of 85%, of the procedure volume. We are able to negotiate very strong contracts and for the most part, next-day delivery as well. The longest I have is 48 hours from the time I order something to the time it hits the office. I do all of the ordering of all the supplies for every procedure. I have a good handle on what we use on every case, because I am also in every procedure. I know what we use on what procedures on a day-to-day basis, and by the end of the day, generally, those supplies are re-ordered.
Do any of your interventionalists use radial access or any other unique access?
Jerry VanHorn: All 4 of our interventionalists are trained in radial access. We use it sparingly. We actually do more pedal access for peripheral interventions than we do radial access for diagnostic procedures. We have wholeheartedly adopted pedal access here, because we do a significant number of total occlusions of SFAs and other below-the-knee vessels, and have found that by using pedal access we are able to cross those occlusions, treat those patients, and send them home in a relatively short amount of time.
Can you talk about the process a patient might go through once they see a cardiologist in your practice and needs a procedure. What happens at that point?
Dr. Patel: Because we are a large-enough group, the transition is very seamless. We have all the imaging modalities, such ankle-brachial index (ABI) testing, arterial ultrasounds, carotid duplex studies, abdominal ultrasound for abdominal aortic aneurysms (AAAs), nuclear medicine for stress tests, and echocardiograms. A patient may see me, for example, for claudication. We will do the ABI testing and find out that this patient has significant lifestyle-limiting claudication, supported by the non-invasive studies. Then we will talk to the patient and say, the first thing of order is to do an angiogram. We are just going to take a look because it will help us select a roadmap: what is the severity of the narrowing? If it is 100% occlusion, how long is the blockage? Then we can come up with a game plan as to how we are going to approach and treat this particular occlusion. The process is very seamless.
I am an interventional cardiologist and get a lot of referrals for peripheral vascular disease. On any given day, we have 5-6 cardiologists who are here. One or two may be interventionalists, and 3 or 4 may be non-invasive cardiologists. Dr. Douglas Jensen, one of our non-invasive physicians, will routinely grab one of the interventionalists to look at a patient’s records right then and there. We can decide, let’s do a diagnostic here in the lab and then decide on further treatment. We do see a lot of aortic valve disease and mitral valve disease. Those are cases that we can easily do in our lab to get the necessary information. In those patients, after we diagnose critical mitral stenosis or aortic insufficiency, we set up an appointment with a cardiothoracic surgeon in the next 2-4 days. That patient is given a CD and a copy of our dictated report, and an appointment time with a surgeon. The surgeon sees them and then schedules the surgery at any given institution. It has been very seamless, having most of our cardiologists here on campus, along with most of the non-invasive testing on campus. An open dialogue between the physicians who are involved goes a long way.
Jerry VanHorn: Patients in need of percutaneous intervention are generally scheduled for revascularization within one to two weeks. Vascular interventions are brought into the pre/post procedure area 1 hour prior to their procedure for lab work, IV, and consent. All peripheral interventions are performed in the surgical suite and hemostasis is achieved prior to return to the pre/post procedure area. All patients are recovered in the pre/post procedure area until they achieve discharge criteria. Post procedure follow-up is initiated by our nurses within 48 hours of the procedure via telephone. Patients are scheduled to follow-up with their provider in one week.
In terms of time, is it faster for your patients to get into your lab versus a hospital-based lab?
Jerry VanHorn: It is absolutely quicker for them to be done here. The reason for that is that we don’t have a holding list of different cardiology groups waiting to get into our lab. We have 4 interventionalists that schedule their patients in our lab. On any given day, we will scoot another patient into the lab if they need to be moved up. That is one thing about having exclusive control over the schedule. If a patient needs to be done quickly, we can get them in that day or the next day. If they don’t need to be done quickly, then we schedule it out. We have certain days that certain cardiologists like to use the lab. Any of them can utilize the lab on any given day, but Dr. Patel loves to work on Mondays at 7 o’clock in the morning. So we have a full day with him every Monday, and we’ll have a full day with him every Thursday, with 4-5 patients scheduled each day. If he needs a 5th or 6th patient added on those days, we can generally work that in.
What are the hours that you are working?
Jerry VanHorn: Ideally, the staff is here from 6:30am to 2:30pm. That is an 8-hour shift and we work 5 days a week. 2:30pm is always a wonderful ending point to go for. We are always done with procedures well before 2:30, but patient recovery is also done in the area, so sometimes patient care extends well after 2:30pm. I have two very understanding nurses that tend to stay for some overtime to recover those patients. The next day, if we are not busy, they will take those 2-3 hours off and go home.
What are the challenges you have experienced (or continue to experience)?
Jerry VanHorn: Labs are a lot alike in that staffing is always an issue, overhead is always an issue, and patient throughput is always an issue. So those aren’t specific to an office-based lab. Being a 1-room lab, keeping on schedule is a challenge. We schedule very tight. Our schedule is sometimes 45 minutes for procedures, so anything that throws the schedule off a little bit is always concerning, but we have been good at getting back on schedule. Staff is a total of 4. If someone calls in sick, it’s always concerning, but we have 18 per diem staff members. In other words, we’ve all been in hospitals for so long that we all have friends that also work in cath labs and hospitals. People have signed up to help us, saying, okay, if you need me on a given day, call me and if I’m available, I will come in. So I have 18 people on my list to call in if someone calls in sick.
Dr. Patel: To be honest, I think at a personal level, I have not had any challenges. I have worked with our two nurses and our two RTs, including Jerry, for many years, so there has been a comfort level. In a sense, being blessed with staff that has a lot of experience has made this transition very smooth and easy. So, for me, I would say there have been minimal challenges.
How have you reached out to the local primary care physicians?
Dr. Patel: Phoenix Heart has been on this side of town practicing cardiology for almost 30+ years. We started out with a small group. When I joined, we were at about 6 physicians, and now we are at 16. It has always had a good reputation and a good relationship with the healthcare providers in our community. As the area has grown, we have added new physicians and continue to maintain that relationship with our healthcare providers. Bijal is in charge of our physician liaison (see sidebar). She has done a wonderful job meeting with the primary care providers, letting them know what we are capable of doing. We have supported the local health education programs and participate in community education. Just 5 minutes away there is a DO school and a podiatry school. Some of us are on the teaching faculty, so we also have students and residents come over from there. All in all, we have had a pretty strong relationship with the healthcare providers in the community, and because of our long-term presence and the stability of our group, people have been able to see us grow and really provide quality patient care. Most of our healthcare providers are very thankful to us that the care given to their patients has been excellent and the follow-up communication has been excellent.
Do you have advice for others who might be interested in opening up their own in-office lab?
Jerry VanHorn: Make sure that you have the patient volume and the financial ability to support a lab. There is a lot of financial outlay in the beginning, especially with the startup of a lab like this. Make sure you have the patient volume for it. Make sure you are doing it for the right reason — that you are doing it to provide high-quality patient care. Don’t think that you are going to be starting with the procedures that you are doing now and then expand your procedures. In other words, make sure you can stay within your scope of service. I have seen other places start out thinking, Right now I only do this one procedure, but I am going to start doing 5 more procedures that I have never done before. I think that is the wrong way to look at starting up an office-based lab. Providing quality patient care in your office, with the same procedures and same care you provide to those patients inside the hospital, is what you have to look to do.
What are your plans as you look ahead?
Dr. Patel: We are in the process of gathering information to look at expanding to allow patients and providers from outside the practice area. We are looking at interventional radiologists, for example, or someone else to come in. We are also looking at whether we can change from being an outpatient-based lab to an ASC, ambulatory surgery center, although no decisions have been made yet, and we are still in the information-gathering stage.
Are you participating in any data registries?
Jerry VanHorn: We don’t currently participate in any registries. We do gather multiple data points for continuous quality improvement. Our vascular information system is well suited to capture all pertinent procedural data. I’m a numbers geek and love pulling statistics, but I don’t send them out to anywhere else as of right now. We are just in the first year. Actually, the first-year data looks so good, I wish we were sending this information out to show others! As we move forward and expand, and possibly morph into an ASC, then we will be probably providing information to various registries.
Any final thoughts?
Jerry VanHorn: We promote fiscal responsibility while providing superior, cutting-edge care. We always put patient care above all else. Through just-in-time inventory control and excellent vendor relationships, we are able to provide quality patient care in a fiscally responsible fashion.
I feel that the key to our success is our staff. Though they are few (4), they have extensive experience, with a combined 82 years in cardiovascular interventional procedures. The secret to any successful endeavor is dedication to a common goal. Our physicians and staff are dedicated to the common goal of providing superior patient care and outcomes.
Dr. Patel: I would summarize by saying that we have had a very good, stress-free journey this last year. Part of it is the physicians who are practicing and part of it is the people who work in the lab. We are able to hire really high-quality individuals and I do attribute much of the success we have achieved to them. A lot of the credit goes to them. It has been a very gratifying and a very satisfying journey so far. Hopefully we are able to continue to grow. That’s the whole plan.
Networking with Referring Physicians
Cath Lab Digest talks with Bijal B. Dave, Physician Liaison, Phoenix Heart, Glendale, Arizona.
Can you tell us about your work with the CardioVascular Lab at Phoenix Heart?
I am the Physician Liaison with Phoenix Heart, PLLC. As a physician liaison, I am primarily responsible for developing and implementing a marketing and sales plan to maintain and grow referrals from providers and/or physician practices. When we opened our CardioVascular (CV) Lab, I approached providers to let them know that Phoenix Heart has started a CV lab to do procedures, and that we can do coronary and peripheral diagnostics, and peripheral interventions. The physicians I typically speak with are interested and will ask for more detail about what type of procedures we can do. They have not been hesitant at all in sending patients over, particularly once I talk with them about the quick recovery time for patients. Our patients are coming in the morning and are being discharged home within 2 to 2 ½ hours. Patients and referring physicians love to hear that.
Does the lab provide referring physicians with a report fairly quickly after the patient has the procedure?
Our physicians prefer to dictate immediately after they are done with their procedures, because they already know offhand, for example, that this is the stent that I’ve done, this is the percentage stenosis, is there a residual, whether the diagnostic was positive or negative. As soon as the report is done, it is electronically faxed to the providers’ office.
Can you talk more about your outreach?
I network with referring providers or hospitals, reaching out to family practice, endocrinologists, and podiatry groups. I will share information about our group, who is involved in what aspect of care, and what areas our physicians are specialized in. Dr. Patel, for example, specializes in critical limb ischemia, so if you have patients that you want to save from amputation, he’s the physician to see. Dr. Shakeel Khan is a trained specialist in varicose veins, radiofrequency ablations, and sclerotherapy, along with doing coronaries and structural heart. I have also worked with Dr. Khan in starting up a structural heart program, networking with other outside referring providers. I often get questions from referring physicians about whether we have any women physicians, because some patients like the comfort of having a female physician. Dr. Kristine Sellberg is our female interventionalist specializing in women’s heart health, but she also does interventions in the coronaries and peripherals. I share what specialties all our physicians are involved in, how long they have been with the practice, the number of cases we do overall, and how many cases individual physicians have done.
Did referring physicians have concerns or questions about the outpatient-based lab?
We actually had a group of physicians come to our office to take a look at the facility and they loved it. They feel at ease. We also work with two hospitals that have been supportive as well. So if there is an issue (knock on wood, because we haven’t had any), hospitals are about 2.5 miles from our main location.
How have the hospitals reacted?
The relationship has strengthened. We do bring cases to them as well and do procedures at the hospitals. If anything, it has enhanced our relationship.
Any final thoughts?
Our patients love the comfort of having procedures done here, because it is such a quick turnover for them to be in and out. We have a wonderful group of physicians and staff, and it is a pleasure to be working alongside them.