Clinical Editor's Corner

Changing Behavior and Culture in the Cath Lab: Addressing Motivations and the ODNT (Old Dog/New Trick) Syndrome

Morton Kern, MD Clinical Editor Professor of Medicine Associate Chief Cardiology University of California Irvine Orange, California
Morton Kern, MD Clinical Editor Professor of Medicine Associate Chief Cardiology University of California Irvine Orange, California
I was recently asked at our Cath Lab Basics 2009 course in Seattle, “What can the techs/nurses do to introduce a new and better way of doing something in the lab to the physicians and ultimately to the patients?” For example, how does one implement physicians changing to routinely using 6F rather than 8F guides for percutaneous coronary intervention (PCI), performing intravascular ultrasound (IVUS)/fractional flow reserve (FFR), or starting the radial approach? In other words, can you cure the “OD can’t learn NT syndrome” (remembering that some of the old dogs are not really so old)? This is a great question and interestingly, it goes in both directions; that is, how do you teach old cath lab techs/nurses new tricks? Both are tough questions and each is deserving of strong individual consideration as to where you stand in this philosophical battle front. What motivates a change in behavior? At the heart of change is an underlying motivation. What motivates a person to change in general? The short answers are money, power, love, and duty, or a combination thereof, and not necessarily in that order. What specifically motivates a behavior change in the cath lab (or in any healthcare work environment)? For our particular specialty, I believe the first and strongest motivator is duty, translated as better patient care and outcome. To change behavior, answer this question, “Does this technique/device/drug provide evident significant benefit?” A ‘yes’ produces an immediate motivation to use this device. We only need to remember how quickly stents answered this question and how quick was their adoption. Adoption occurred immediately after product introduction because of the strong effect on patient care in the cath lab. Answer another question, “Does this device make the procedure safer, shorter, and more comfortable for the patient (and as a side motivator, the staff)?” A ‘yes’ is another strong motivator for use. We can remind ourselves of the early PCI era with increased clotting and bleeding problems. We now have excellent, focused and highly effective anti-thrombins, antiplatelet agents, and anticoagulants that address these critical issues. However, their adoption lagged somewhat compared to stents due to the longer experience and larger data sets required to appreciate their benefits. “Does this device make long-term outcome better?” The immediate adoption of drug-eluting stents (DES) was another example of a device supported with strong outcome data that motivated change with worldwide acceptance, even by the Old Dogs, and nearly overnight. “Does this device reduce complications?” Likewise, such a product is absolutely a game changer. Consider the array of vascular closure devices now present in nearly every cath lab across the country. On the promise of reduced complications, they were rapidly adopted, some types more than others, based on different learning curves. And now, for the same reason, radial access is gaining traction in many labs across the country. “Does this device make the procedure quicker?” A ‘yes’ to this question also has strong ability to make a change in practice, but not as much as something which really influences the patient’s outcome. I believe operator-assisted contrast power injectors and table-side installed IVUS/FFR systems fall into this category. “Does the device help make better decisions?” The ‘yes’ answer here is more difficult to link directly to a change in practice, because of the physician’s skepticism about changing his own decision-making process using the tried and true methods on which he was trained. As the most common example of this, we continue to see the over-reliance on the angiogram as the definitive imaging modality for decision-making in the cath. After more than a decade, we know that FFR/IVUS helps interventionalists make better decisions than “eyeballing the angiogram” alone in many, many circumstances. The adoption of these tools into the cath lab despite good data has been slow. One can speculate whether this slow adoption was related to the next two questions. “Does this device save money for the hospital?” and the corollary, “Does it make money for the physician?” These questions address money as the motivating factors. Some new interventional devices suggest benefit to the patient, but at higher cost to the hospital. Use is likely if the device is not too complicated or too pricey. This response differs for a diagnostic tool, like FFR, wherein the use favorably affects not only the hospital economics but also improves patient care (see FAME). Reimbursement as a physician motivator is very strong but rarely discussed. We should not be so naïve to think that we are fully altruistic all the time. Devices that are reimbursed to hospital, and even more to the physician, are adopted faster than other similar devices which are not reimbursed, sometimes regardless of the strength of the data. Motivating behavior in the cath lab should follow a hierarchy of patient benefit, lab/hospital benefit, and personal benefit. Sometimes we may become confused and have to re-ask, “What motivates us?” Maybe, in real life, the order of this motivating list is reversed, but I am hopeful that the recognition of patient requirements over physician requirements (speed, money and outcomes) is a universal truth. What motivates you? Every individual who works in the cath lab should examine his/her motivation for staying in this wonderful environment. What motivates you? Caring for patients, learning new things, overcoming challenges of PCI, assisting in complicated cases? Going home early? Hopefully, you are not an ‘old dog,’ set in his ways, resisting change because of the discomfort of having to learn something new, and reach beyond yourself, struggle to work through a new process. That said, a speedy and well-done day in the cath lab is a common goal we should all work toward. As one who continues to be active in our cath lab, I understand the pressure to do cases quickly, smoothly, safely and move on to the next case, and whenever possible, help the lab leave early to enjoy family and friends. This keeps everybody happy. It’s not possible to make this happen every day, but it’s worth trying. When asked about how to change practice and then getting your wish, please remember that implementing new practices in the cath lab needs time. For physicians and nurses/techs alike, it’s worth spending that extra time to learn radial access technique because the outcomes are so good. It’s worth spending time learning a new thrombus aspiration system because the outcome is good. Nonetheless, some operators (and nurses/techs) are locked into their old ways and do not believe they can change. For the good or the bad, as long their practices are safe and without complications, it is hard to suggest changing their old methods for new ones, despite convincing data that they should. For example, what do you say to the senior operator using 8F guides when the rest of the world is using 6F or smaller (with the exception of using 7F or 8F for complex bifurcation/trifurcation work)? Bigger access means more bleeding problems; routine 8F guide selection does not make sense today. The same might be said for routine femoral access, given what we know about radial access. Femoral access means more bleeding and more complications. Some change must be accompanied by significant internal struggle or powerful external motivation. What can you do to implement change? Step 1. Finding a motivated and knowledgeable champion of the device, technique, or drug is the first step. How did we change the culture in our lab to become a “Radial First” operation? I met a motivated cardiologist, learned what he had done, understood his laboratory’s approach and believed it was the best thing for our patients. Step 2. From the tech/nurses’ side, contact a motivated associate, learn about the new technique, discuss its advantages, disadvantages, outcomes and cost with the lab and staff. Find or form a motivated physician champion (see Step 1). The physician champion and the tech/nurse team up to carry the ball, share the experience of benefits and subsequently implement culture change. Step 3. Test the new device or approach in the lab in small doses. Try it sparingly, then as the benefit is seen, repeat the practice and emphasize the good results with the other physicians and tech/nurses. Prepare comparisons of alternatives to share with the lab and ultimately with the physicians to assist the new and old dogs to try new tricks (safely, of course). Whenever a better technique appears, it’s appropriate to ask the nursing director and physicians, how (and when) will this apply to my patients in my lab? The cure for the ODNT syndrome is seeing your motivation clearly and implementing the desire to do better. Let’s put this cure to work. Disclosure: Dr. Kern reports that he is a speaker for Volcano Therapeutics and St. Jude Medical, and is a consultant for Merit Medical and InfraReDx, Inc.