ACVP Management Corner

A Project to Improve Efficiency in the Cardiac Catheterization Laboratory: An Operational Excellence Initiative

Barbara Boston, Senior Director, Cardiac Services, Hahnemann University Hospital, Philadelphia, Pennsylvania
Barbara Boston, Senior Director, Cardiac Services, Hahnemann University Hospital, Philadelphia, Pennsylvania
Hahnemann University Hospital’s cardiac catheterization laboratory, based in an urban teaching hospital, is one of the busiest in the region, performing thousands of procedures each year. The cath lab consists of four laboratories and a 13-bed holding area. It is staffed by six technologists, 10 nurses and three nurse aides with other ancillary assistance for inventory and administrative functions. Through improving lab efficiencies, we can achieve operational excellence — a goal we all share. In sharing our story, we hope to share how inefficiencies can be minimized. Problem/Opportunity The cardiac catheterization lab was identified as having both remarkable strengths and significant weaknesses as a hospital department. The most substantial weakness of the lab was identified as inefficiency. This is a multi-factorial problem, due to staffing, staff culture, physician behavior, lack of patient readiness for procedure, patient transport and nursing units. As a tertiary leader in cardiac care, the hospital sought to improve its cardiac catheterization laboratory’s efficiency. Since the state legislature of Pennsylvania allowed the certificate of need for new programs to lapse in December 1996, most Philadelphia suburban hospitals have built cardiac interventional programs. The competition has been fierce to maintain physician referrals in urban hospitals. Laboratories with competent staff and an efficient process provide an attraction to busy physicians. The efficiency project was also expected to promote cost conservation by reducing overtime expenses and eliminating canceled cases. In addition, more cases performed earlier in the day would result in a shorter length of stay and less denied days of payment. Patient satisfaction was likely to improve, as the most frequent complaint from patients about the cath lab was the wait time. Evidence In 2006, the process for data collection was defined with the cath lab staff and data collection began. We had to outline what information we were collecting and the rationale as to why we were collecting it. It was only through a combined effort that we would be able to adequately track our progress in making real and lasting changes. The cath lab began to benchmark its delays, turnover time and overtime hours. Data showed inefficiencies and delays which affected overtime and denied payment days, as well as patient satisfaction, and increased the number of canceled procedures. Data collection also revealed that 70% of cases (as a baseline) in the cath lab were delayed. An Intervention Plan The senior director of cardiac services and a lead physician developed an intervention plan to specifically address the delays. This plan included a steering committee to function as a focus group. The committee consisted of key hospital department directors, such as nursing, transport, the chief operating officer and medical director of the cardiac catheterization laboratory. Our research had indicated inefficiencies and delays from multiple sources, both hospital-based and physician-related. These delays were attributed to cath lab staff, physician lateness, improper preparation of the patient pre-procedure, patient transport and nursing. Data was logged monthly to track potential sources of inefficiencies, to be specifically addressed as we went forward. We tracked delays over several months, looking at the following contributors: transport, cath lab staff, equipment, physicians, fellows, labs not done or screened, consent, patient not prepared, ambulatory unit, ancillary unit, heart failure clinic, patient emergency, patient arrived late, “other,” and environmental. We outlined our goals with physicians and staff alike, and informed everyone regarding our project and the intent behind its implementation. Two senior nurses were promoted to lead charge nurses to assist in promoting efficiency. We recognized early on that the only way to ensure program success would be to have everyone on board with our goals, particularly the directors of key departments, including transport, nursing, and environmental services. Our lead physician and senior director of cardiac services formulated ideas for intervention and drafted a document describing the issues we faced regarding inefficiencies, along with a proposed plan for correction. This draft plan was distributed to the hospital’s practicing physicians and cath lab staff for additional input. Once everyone had an opportunity to review and comment on the plan, it was finalized and prepared for implementation. It served as a covenant amongst the involved parties. Plan details included the following: • Support Services º All outpatients are prescreened by staff from the ambulatory unit. º INRs and pregnancy tests will be screened more efficiently. Ancillary unit needs the ability to do point-of-service INR and pregnancy testing. (INR is required when patient is on coumadin and may need to be done just before procedure. A pregnancy test is required for women of child-bearing age on the day of the procedure.) º Ambulatory unit will have first cases ready by 7:15 am and second cases ready by 8:30 am. The early case needs to be ready by 7:00 am (except Tuesdays: first case ready by 8:00 am and second by 9:00 am). º Transfers will be screened by transfer center. (The transfer center is a hospital-based service provided to facilitate efficient and accurate placement of patients from other hospitals. Staffed by nurses, comprehensive triage and communication are done.) If patients have contraindications to procedure, physician will be consulted to review. (Cath lab staff will make a tip sheet for transfer center of contraindications.) º Patient transport will take no longer than 30 minutes from cath lab’s phone call to transfer a patient to cath lab. º Nursing interventional units will take planned interventions pre-procedure and post-procedure to the same bed. º Floor nurses need to have medications, weights and any other pertinent data documented on chart before sending patient to lab. Nurses need to note if patient is on ASA and or clopidogrel. º If a patient comes from a physician office with a full history and physical within 30 days or less, there is no need to redo these, as a brief update on the chart will suffice. º Nurse on the floor will develop a mechanism to take report from the procedure nurse when the case is done. • Physicians º All outpatients need to have complete labwork, ECG, and history and physical at least 2 business days before admission to the ambulatory unit for NPs to screen. (This is the responsibility of physician offices.) º Outpatient will not be rescheduled if lab work or history and physical is not in order. No patient is accepted with P.A.T. (pre admission testing) on admit. º A better method needs to be designed for consent. (Consent is obtained in cath holding room right before procedure. This process causes delay and is inappropriate.) º Attending physicians will arrive before procedure start time to meet patients. º Attending physicians will not schedule meetings in the middle of serial cases. º Physicians who have four or more cases need to be available to start first case time slot. º If a physician group has more than six cases in one day, two or more physicians need to be available. (The exception is right cath, only). º The nurse coordinator needs to communicate schedule changes effectively to the cath lab charge nurse. º Communication of the physician assignment must be made to that physician by physician’s office. º If one physician has three or more cases, the physician must remain close to the cath lab environment so that nurses and techs will not have to search for them to start a case. Meeting times will be allotted for affected physicians to conduct other business, but we will fill in gaps in the day with another cath physician. º Cases will not be cancelled for any reasons, other than medical. º When feasible, consent will be done for a subsequent intervention in the cardiac care center by a cath physician before the patient is discharged. º When physicians are proctoring other physicians, the schedule needs to be designed to not hold up a cath room during proctoring. º Cath reports will be signed each day by attending physicians. Cath attendings will be responsible for fellow completion of report. º Physicians are not to switch the order of cases, unless there is an emergency or the next patient is not ready. When the order is switched after the schedule has been made, it delays outpatients and creates patient dissatisfaction and needless overnight stays. (This was the main complaint from satisfaction surveys.) º It is helpful to staff when specific procedure needs are communicated on the schedule. (For example: if the physician knows that it will be a Rotablator case, list it on the schedule.) • Cath Lab º Cath lab will try to schedule inpatients as first cases. º Cath lab will have early staff each day to start a case. º Cath lab will have staff available to start three rooms by 8:15 am each day. (Start means ready for puncture.) º Lab turnover will be no longer than 20 minutes. (Cath will need more than two staff per room to accomplish this consistently.) Special cases, such as abdominal aortic aneurysm repair, require longer turnover time. º No rooms will close for lunch. (Need appropriate staffing to accomplish). º Need charge nurse/manager who is free from cases to run schedule, promote efficiency, troubleshoot, eliminate delays. º Next, two technician/technologist hires will be on a five-day-per-week schedule to allow more staff at the cath lab each day. º Permanent charge nurses or assistant managers who possess the ability to move the schedule and motivate employees will be appointed. º Use telemetry nurses to staff recovery room. • Fellows º Early fellows will be available to cath lab by 7:15 am to assist with patient set up. º Late cath fellows will be available at 5 pm or earlier, depending upon case completion time. If any patients remain in recovery waiting for hemostasis or a bed, a fellow needs to be within cath intercom range for emergency assistance. º Fellows will complete cath report within 24 hours of the procedure. º Fellows will receive sanctions for report delinquencies. Medical staff bylaws dictate that procedure reports are completed within 24 hours of the procedure. The medical director will review outstanding report list each week. Fellows will be taken off of clinical duties if two weeks occur with any delinquencies. They will be warned the first week. º Fellows will be on time for case start. º First-year fellows will pull their own lines. º Cath fellows are to obtain consent for procedure on all inpatients the night before the procedure will take place. º Cath lab fellows will rotate hemostasis duty. • Heart Failure Clinic º “Add on” heart failure patients for biopsy need to be communicated in time to accomplish the biopsy by 5pm when the pathology lab closes. º Heart failure staff need to communicate accurate arrival time to patients and reassure cath staff that they can make the appointed time. Each month, data describing turnover time and delays was presented to the steering committee. The group analyzed the findings and recommended improvements for the subsequent month. Results As a result of our efforts, we were able to achieve some remarkable results. Our average turnover time was reduced by 40%. Delays related to hospital services have been reduced to the most minimal. Our overtime expenses were reduced by 16% in comparison to the previous year, equivalent to a savings of $15,163. Employee satisfaction within the cath lab improved by 8.1% over the previous year. The cardiac catheterization lab was named “department of the year” in 2008 for the hospital, which translated into positive results for staff morale and recruitment. This project is applicable to any institution with a catheterization lab or a similar procedural area, such as an electrophysiology lab, operating room, interventional radiology or endoscopy. We are pleased that the efforts of all involved, including staff, physicians and administration, resulted in increased revenues while decreasing expenses and improving retention. Barbara Boston can be contacted at