Raise your hand if your hospital is required to do more with less. Every facility feels the pressure to improve clinical outcomes, increase efficiency and reduce costs. The healthcare industry now appreciates the importance data plays in creating real change. If you can’t measure it, you can’t improve it. Room utilization is a good example.
How could a hospital effectively decide to replace or construct a new cath lab procedure room without data? Perhaps by physician opinion? Staff opinion? Visual observation? Cardiac Partners has created a database, CPLink Cardiovascular Database System, that tracks key performance indicators to help with decision-making. CPLink reports Room Time, Room Turnaround Time, total Room Time per procedure room, and many related measures of Room Utilization.
The simplest use of data to determine room replacement or construction is case counts. You have likely been asked, “How many cases should I be doing in my cath lab before I need to add another one?” It is expensive to construct, equip, and staff a new procedure room, so this is a high-stakes question. A simple answer may be: 500 cases; 1,000 cases; or, perhaps even as many as 1,500 cases per year. There are many variables: What kinds of cases does your facility perform: Interventional radiology? Coronary? Electrophysiology? Neuro? What is the mix of these cases? How long does each type of case take? What is the Room Turnaround Time per case? In truth, the answer to the number of cases needed may surprise you. It is not the number of cases, but the “Room Utilization” that should determine when to add a new room.
David Fuller, of Corazon, wrote an insightful article about capacity and room utilization published in Cath Lab Digest earlier this year. In the article, “Running Out of Space? Evaluating The Cath Lab Capacity and Utilization”1, he describes methods to calculate utilization. His methods rely on good data collection and reporting systems, both for use in certificate of need (CON) states to get CON approval, and for internal use as a management tool.
In the remainder of this article, we will review academic literature related to operating room utilization, then apply those standards to a proposed definition of optimal cath lab utilization. We will share a real-world case study, and a new approach to visualization that simplifies decision-making.
A handful of definitions will be helpful. Room Utilization is made up of two parts: 1) Room Time and 2) Room Turnaround Time. It is obvious that a procedure room is utilized when it is occupied by a patient, because no other patient can share the room. From the time a patient enters the room, until he or she leaves, the room is exclusively occupied. Room Time can be defined as “wheels in to wheels out” where the procedure room is dedicated to a single patient. The second component of Room Utilization is Room Turnaround Time. This is the time from wheels out of one patient, until wheels in of the next patient. Rose Czarnecki, RN, BSN, MPM, noted, “Some labs define turnaround time as the time that one patient leaves the procedure room until the time the next patient enters the same room. Another may measure it as the time one patient leaves the procedure room until the room is ready for the next case.”2 For the purposes of measuring Room Utilization, the first definition (wheels out to wheels in) is a better measure. If, for example, there is an endless supply of patients ready to enter the procedure room, a room is fully utilized when back-to-back cases with a successive string of Room Time plus Room Turnaround Time occurs (refer to Figure 1 for Room Time and Room Turnaround Time markers and definitions).
In the literature
We were unable to find articles addressing optimum room utilization of a cardiac cath lab. On the other hand, there are several articles that address operating room utilization, including standardized terms and definitions, and factors that improve or degrade operating efficiency.
Tyler et al3 studied OR utilization and came up with many valuable conclusions that can also be used to create standards for cath lab utilization. Their work incorporated mathematical simulation techniques to determine optimum utilization. Surprisingly, optimum utilization is not full utilization. Underutilization was defined as time during the scheduled hours of operation that the OR is not used; and, overutilization as the time used by scheduled cases past the end of the scheduled time.3 Underutilization results in idle time, unused room capacity, paid staff that are not productive, and similar unfavorable economic results. The consequences of overutilization include patient dissatisfaction from excess wait time, physician scheduling difficulties, staff overtime, and difficulties of retaining staff due to burn out.
Tyler established a mathematical ideal utilization of 85%, but cautioned, “Our model creates a situation that is unlikely to be achieved in the real world.”3 He proposed a balancing of economic interests with patient and staff satisfaction, “For the simple situation studied here, a target utilization of 85% would approximate what we would like to achieve in terms of patient delay and overtime. This is perhaps the maximum utilization that can be achieved within the goals that we have set. For more complex OR suites, the optimum utilization will be less. Any change, such as cases of different duration, changes in the variability of case duration, emergencies, cancellations, and so on, will decrease the optimum utilization.”3 Other stated utilization rates vary based on real-world situations. One vice president of operations for multiple ambulatory surgery centers has indicated they “usually shoot for at least 75-80 percent utilization”4 in the operating room.
Let’s examine each of these OR variables to try to determine the optimum utilization of a cardiac cath lab.
1) Cases of different duration.
This could vary per facility, but overall, the vast majority of cath labs have a broad variation of case durations, depending on the type of case to be performed. Cath lab case duration not only varies per type of case (cath vs. percutaneous coronary intervention [PCI]), but also has a lot of variability within similar case type (PCI vs. multi-vessel PCI).
Again, this can vary by site, but most cath labs have significant schedule impacts related to unplanned emergencies.
This happens all the time depending on lab results, clinical conditions, and the like. Rather than developing a fixed percentage for optimum utilization of a cath lab, perhaps there should be a range based on the above factors at a specific site. An outpatient cath lab, performing only diagnostic cardiac cath cases may be able to achieve the ideal 85% figure suggested by Tyler. Most other facilities should probably assess the impact from the above factors, and identify the ideal utilization as within a range of 65%-80%.
The genesis for this article was a real-world decision that needed to be made at a Cardiac Partners-managed facility. Two hospitals, Hospital A and Hospital B, have a total of 6 procedure rooms. Limited capital was available to upgrade equipment or to build a new lab. There was a clear sense that additional capacity was needed, but disagreements about how to prioritize specific improvements or capabilities.
Hospital A facts
- Hospital A has five procedure rooms plus shell space for a sixth.
- Room 1 and Room 2 are dedicated coronary rooms with one-year-old equipment, good imaging, shared transportable intravascular ultrasound (IVUS) (Volcano Corp.), and reasonable floor plans.
- Room 3 and Room 4 are dedicated electrophysiology (EP) rooms. They each have a St. Jude Medical Workmate EP Recording system and share transportable BioSense Webster Carto Mapping and intra-cardiac echo (ICE) equipment.
- Room 3 has seven-year-old equipment, minor floor plan flaws, and inferior imaging. The flat detector is large size, since the room was designed as an overflow EP and interventional radiology suite.
- Room 4 has seven-year-old equipment, a built-in St. Jude Medical EnSite Velocity Mapping System, reasonable floor plan, and reasonable imaging.
- Room 5 is empty, but construction-ready.
- Room 6 is primarily an interventional radiology room with three-year-old biplane imaging equipment.
The coronary doctors are satisfied with the equipment. The interventional radiology doctors have their needs met. However, the EP doctors are unhappy. An electrophysiologist and a neurosurgeon have been recruited to practice at Hospital A. The neurosurgeon is active in the interventional radiology suite, so the parties expect scheduling conflicts.
Hospital B facts
- Hospital B has one room that performs both coronary and interventional radiology cases.
- The image quality and room layout are common complaints.
- Case volumes are at or near 400 cases per year. A new cardiologist has been recruited to practice at Hospital B, and there are concerns about upcoming scheduling and capacity issues.
- With a single procedure room, hard-down time means closure of the cath/interventional radiology service line with ambulances on divert.
- Add another EP room to Hospital A.
- Add an additional room to Hospital B to address imaging or layout complaints, and to provide back-up if the system goes down.
- Replace or upgrade the EP/interventional radiology combo room at Hospital A.
Several physician and hospital stakeholders prepared position statements supporting their proposed use of the limited capital funds. The decision-makers requested objective information to help with decision-making. Cardiac Partners used CPLink to prepare case counts per lab, Room Time Utilization per lab, and graphics showing usage trends. The data was helpful, but took effort to study and digest. We needed a new way to visualize the room utilization. A new graphic was created that showed utilization for each room for each hour of the day (Figure 2). The newly developed report correlates color shades to the percentage of utilization (Light green is lower utilization and dark green is higher utilization). The graphic indicated:
- The single room at Hospital B, the combo cath/interventional radiology suite, is the least utilized of all of the procedure rooms;
- Room 4 at Hospital A, the EP complex ablation room, is the most utilized room (Figure 3), with a high of 79% at 9-10 am, to a low of 35% for the latest hourly band of 3-4 pm. Daily utilization of Room 4 shows the highest utilization of 87% on Thursdays at 9 am, with much lower utilization late in the day and on Friday;
- Room 3, the EP/interventional radiology overflow room, is the least utilized room at Hospital A.
This information was very effective at eliminating further posturing and debate around anecdotal evidence. The physicians, to their credit, seemed to immediately recognize and prioritize needs of their peers. The parties decided to prioritize increased capacity of complex EP ablations and neuro/interventional radiology procedures. After those needs are addressed, future projects will address Room 3 shortcomings at Hospital A, and a decision will be made to either replace or add a second room to Hospital B.
In this article, we sought to provide some insight into room utilization, offering definitions, industry research and a suggested optimal use for cardiac cath labs. We hope that this will spur discussion to better define standards for cath lab procedure room utilization and that readers will share their thoughts. We would all benefit from working together toward industry-wide standards for cath lab room utilization.
Cardiac Partners has developed and managed cath labs since 1984. Visit www.cardiacpartners.com.
- Fuller D. Running out of space? Evaluating true cath lab capacity and utilization. Cath Lab Digest. 2014 Apr; 22(4): 36-37. Available online at http://www.cathlabdigest.com/articles/Running-Out-Space-Evaluating-True-Cath-Lab-Capacity-Utilization. Accessed September 16, 2014.
- Czarnecki R. An evaluation of cath lab turnaround time. Cath Lab Digest. 2008 Feb; 16(2). Available online at http://www.cathlabdigest.com/articles/An-Evaluation-Cath-Lab-Turnaround-Time. Accessed September 15, 2014.
- Tyler DC, Pasquariello CA, Chen C. Determining optimum operating room utilization. Anesth Analg. 2003 Apr; 96(4): 1114-1121. Available online at http://journals.lww.com/anesthesia-analgesia/pages/articleviewer.aspx?year=2003&issue=04000&article=00038&type=Fulltext. Accessed September 12, 2014.
- Kurtz R. How to ensure maximum operating room utilization in a surgery center: Q&A with Dawn Q. McLane of Health Inventures. Becker’s Hospital Review. February 1, 2011. Available online at http://www.beckershospitalreview.com/asc-turnarounds/how-to-ensure-maximum-operating-room-utilization-in-a-surgery-center-qaa-with-dawn-q-mclane-of-health-inventures.html. Accessed September 12, 2014.