On a recent visit to a hospital on the mid-California coast, a senior cardiologist and director of the cardiac cath lab at a community hospital asked me, ‘How do I manage it when a doctor seems to be taking an excessively long time to perform a CTO angioplasty?’This is a difficult question to answer. How do you know when a case, any kind of case, has gone on too long? How do you address an individual who seems to be taking an excessive amount of time to do a routine procedure as an expression of poor time management, lack of skill and sophistication, talent, knowledge, or common sense? Is the lab helping or hindering case throughput?
How long should a cardiac cath procedure take?
A cath lab procedure should take exactly as long as necessary to produce excellent results in the safest possible manner. That is the starting point without addressing the setup and room turnover time. If an operator is chronically late, taking 20 minutes or more to show up, keeping both the staff and the patient waiting, arriving and spending an excessive time on phone calls and unnecessarily delaying procedure start times and further delaying the entire day’s schedule, this operator is slow, no matter how fast his procedure time is. He is also inconsiderate and slow. Occasional late starts are part of the lab routine, but a chronically late operator hurts the lab’s productivity, costs (e.g. overtime) and morale.
There are also problems that prolong cases outside the control of the operators. Vascular access can be complicated and prolong case times. However, the operator should identify the fact in advance that vascular disease may be present. With this information, the lab can be prepared to suggest earlier in the access period that the arm approach may be needed to complete the case in a timely manner.
Once vascular access has been obtained, manipulation of catheters for coronary angiography and ventriculography should take less than 20 minutes, barring complicating features of vascular disease, aortic tortuosity or hemodynamic instability. Start to finish, a routine left heart catheterization should probably take no more than 30 minutes. Add 15 to 20 minutes for a right heart catheterization. The time for cath lab room turnover should be no longer than the case time.
The issue about how long an angioplasty may take is more difficult and dependent on many factors. The operator selects angioplasty cases based on the severity and number of the lesions, potential for complications (risk level), and his skill and judgment. The time allotted for ‘routine’ angioplasty/stenting thus varies widely. Remember the old adage of experienced interventionalists that says, “There is no such thing as a simple angioplasty,” meaning things can go bad at any moment due to the unanticipated response of patient’s artery (as an aside, that’s why we never say, “This case will be a slam-dunk,” a sure way to invoke evil spirits and a complication). All of these factors vary from operator to operator, but a routine time allotment for an uncomplicated angioplasty should probably be no more than two hours, barring unforeseen difficulties.
If we focus strictly on chronic total occlusion (CTO) interventions, how much time should be allotted is more operator dependent. While there may be no upper limit to the hours that an operator may work, in my own experience, if indeed you cannot cross a total occlusion within an hour (or 2 at the very most), continuing to try and force your way through a CTO despite the numerous specialized guide wires and multiple niche devices, it is unlikely you will be productive. Complications will increase with time on the table. While I understand that in Japan the art of CTO angioplasty has risen to new levels, matching that of bypass surgery in some centers, I do not believe most operators in clinical practice will be willing to spend more than three hours on a single chronic total occlusion angioplasty. Should these operators decide to take on the “endless” CTO procedure, then arrangements must be made in advance for this type of case, since it can kill an entire schedule for the laboratory and other operators on that day.
How does a cath lab director assist in making cath cases start and finish at reasonable times? This is a delicate problem and is best handled with diplomacy and tact. However, plain speaking also works. One method may be to provide a list of procedure times, case types, and identification of those cases which took an excessive amount of time (of course, being HIPAA-compliant) to all the cath lab operators in a blinded fashion. In this way, the list can serve to bring peer pressure and new insight into operator’s performance through the cath lab’s unbiased perspective. In concert with the peer process described above, a problem operator can be provided the data to demonstrate that his comparative procedure times are a significant deviation from his peers for similar cases on an average day. To further assist the operator and his procedure times, the lab can also suggest ways they can help. For example, using an especially experienced and trusted assistant may mitigate this problem. In this way, lab turnover on his working day might improve so that the staff, patient and the operator will not suffer. There is no perfect solution to improving case times and lab turnover, but awareness of a problem and supporting data is a good starting point. Addressing factors which slow cath lab room turnover are as important as addressing case times, but these issues are generally easy to identify and fix. For example, in our system, the biggest delay in case start times is transportation from the floor to the lab. Document the times and call the hospital supervisor.
It is important to recognize that many of our perceptions about our own performance (both in and out of the lab) may be at odds with others’ views. It is a wise manager (and friend) who can put this into perspective and gently assist the unknowing back to reality.