Upon arrival, I am still struggling to wake up as I punch in a little before 6:30 am. The schedule has 12 cases on for two rooms to complete. This caseload is over our average daily caseload of 10, and is much more than other days of the week. You see, the schedule makers at the hospital facility will not limit the number of outpatients on Fridays. Mostly, everywhere else I have worked (all busy hospitals that would receive transfers from outside facilities), had a limited outpatient load on Friday due to the potential for inpatient add-on procedures (patients the physicians didn’t want to keep over the weekend to treat, both in and outside the facility). Despite the fact that I am on-call for the night and the weekend, who really wants to be overworked the day before the weekend?
Recommendation #1: Limit the number of outpatients on Fridays due to the increased potential for inpatient and transfer add-on procedures.
Early Morning Brew
Before I can think, I need to pour my coffee. I listen to a couple cath team nurses discuss the upcoming day and complain about… I don’t even know what, because of the deaf ear I have developed over the two years of working at this facility. My stay at this facility has been a tumultuous one, full of segregated professionals and malcontents. The fact of the matter is that there are things to do. The procedure rooms need stocking, sterile trays need to be prepared, and outpatients need to be admitted. None of these things are being done by the cath lab nurses complaining in the lounge.
As I remove myself from earshot of their discussion, I go to the procedure room to prepare two trays. The first shift of four people started a half hour earlier, but could not make more than two trays in the first half hour of work. Our facility typically runs 3 people to a room: two RNs and one Invasive Specialist (a technologist of various credentials). Generally, all attempts to cross-train have failed. In fact, most attempts to simply enforce policy have failed. The policies themselves are flawed due to the lack of integration of the Invasive Specialist (IS). The only policy in which the IS is mentioned is in the sheath-pulling policy.
Recommendation #2: Integrate your teams. Make sure policy supports diversity and the individual credentialed (talented) people of your teams. Make sure the policies enforce / support cross-training.
As a result of the failure to cross-train, I will be scrubbing every procedure today. I am RCIS-credentialed and have been formally trained in all three positions in the cath lab. I have multiple years of experience in all positions in the cath lab, but despite this, I am working in a facility which does not support the RCIS credential through policy or reimbursement. I am the most experienced staff person in the room, the most versatile, the most credentialed and also, paid the least.
In the hospital’s eyes and in my team members’ eyes, I cannot monitor a procedure because I do not have the clinical skills necessary to do so. Even if I was considered to have the skills necessary to monitor a case, the other two RNs in the room could not scrub/ pan. It is not that my teammates are not talented, because they are. They are not cross-trained, and therefore, can not always understand the various elements of the procedure, such as scrubbing and equipment selection.
The glaring issue behind these problems is how irresponsible policy-making and lack of training have long-term effects, realized years down the line. If your department stops budgeting for off-site seminars or conferences, somewhere down the line the staff is not going to be highly trained or behind the times and unaware of the latest techniques. For instance, we have nurses with numerous years of critical care experience that have yet to achieve the skills necessary to scrub. In addition, every lab I have worked in has their typical low performers (who lack experience, motivation, knowledge of coronary anatomy, knowledge of equipment, etc.). This being said, both of my team members will make more than $3.00 per hour more than I will today, based on their RN license alone. Also, my hourly wage is below the average fair market value as published in Cath Lab Digest by $4.23 per hour.1
Recommendation #3: Same skill set / job duties should have the same pay rate. If the staff does not have the skills, they should NOT get paid like they do. Pay for performance should apply to the cath lab setting.
New Hire, Fresh Ideas
As I continue to prepare my sterile trays for the day, a set of three individually-wrapped diagnostic catheters are used for each case. In my two years at this facility, I have begun the conversion to individually-wrapped catheters for the cost savings, until a three-catheter pack can be ordered. A very real disconnect exists between our department and materials management. Despite a cost-savings analysis (Chart 1), which would save the hospital $22 per procedure, the materials management department refuses to convert from our customary Diagnostic Packs (three catheters, a diagnostic wire, and a sheath) to the three-catheter packs. Without figuring in special considerations for doctors who use less than three catheters per procedure, if the hospital would have taken my idea and put it to good use, over two years, the hospital would have saved:
2,300 diagnostic cases per year x $22 per case x 2 years =
$101,200.00 potential savings on diagnostic catheters.
To date, I continue to be the only staff member to drop the three individual catheters (to save money) rather than the Diagnostic Pack.
Similarly, I made a cost savings analysis to use contrast savers rather than spiking individual contrast bottles (Chart 2). My model assumed a modest 20% savings in volume of contrast used and savings by utilizing larger bottles. Above all, contrast savers are a patient safety issue because the devices do not allow air into the contrast line, which could potentially become an injected air embolus. This too, has not been implemented.
Recommendation #4: The advantages of a new hire are the novel ideas that they bring with them through experience. Utilize the new ideas for process efficiencies, workflow upgrades, and cost savings.
My staff has grown very negative toward the administration and has told me, Why should I try to save money when the first thing they do when we are slow is send you home? Not to mention, we are understaffed and work too hard!
This is the staffing model according to the staffing formula from IMV,* a national benchmarking firm (2003 data).
(Annual number of cases x 0.0036 ) + 3.2754 =
(Clinical + administrative)
(Annual number of cases x 0.0046) + 4.1359 =2
Using these equations and the 2,600 procedures (LHC, PCI + PCI standalone) per year at our hospital, the hospital I work with is 5 full-time clinical staff members short and 7.5 full-time total staff members short.
Administration should pay attention to requests for staff if your staffing model doesn’t meet this formula. In this case, administration is not responsive to this model, and as a result, the staff, who must take call every other day and every other weekend, have become malcontents.
Recommendation #5: Patient safety and data speaks volumes. Call time that totals over 10 days per month means staff need to monitored for long-term burnout and fatigue.
Recommendation #6: When counting staff, don’t count holding area staff. It is unfair to count support staff as full-time cath lab staff if they are not sharing the burden of call.
Does the end always justify the means?
Our policies, which are so closely followed when convenient, fail us often. Expectations from policies and performance evaluations need to be clear and uniformly enforced. Throughout my Friday, I made every sterile tray despite being part of a team of three. Our procedures continued to mount from the initial 12 to a total of 18. Our last patient, on my 13th hour of work, turned into a dissection caused by a diagnostic catheter. After pacing the patient and frantically placing three stents to cover the dissection, I finally punched out at 9:15 pm, tired and exhausted.
Total Sterile Trays made: 10
Money saved by opening individual catheters: 10 trays x $22 per case = $220
Total Procedures Scrubbed: 9
Total Time Scrubbed and in Lead (case end time -case start time): 254 minutes
Total Fluoro Time: 69.8 minutes
On my drive home, as my back was aching, my feet throbbing, my leg joints fatigued, I reflected on my day. I thought of the caseload, the isolation of each profession and lack of teamwork. It was shocking to me to realize just what I have become accustomed to as normal working conditions. When I was a senior in college trying to make decisions about my future (grad school, technical school, medical school), I wish at that moment I had a crystal ball to see my life years later. On Saturday morning, as I sit here on the deck of my home, amongst beautiful surroundings, still aching from the day before, I think to myself: what makes me care? What makes me want to moderate healthcare costs? What makes me want to advance my profession? What makes me want the best for my colleagues and patients?...and others don’t?
I can’t wait to take call the Friday after next.
The author can be contacted via firstname.lastname@example.org
**Note to Cath Lab Digest readers from IMV Limited: This formula is based on data from over 1,200 sites with cath labs. The data was then used to generate the regression formula. There was a wide variance in the reported numbers. Variables such as the complexity of the procedures performed, the total number of rooms in the department, and the efficiency of the department are some of the reasons for variation in FTE staff reported. So facilities need to consider their own situation; some sites may need more FTE, others fewer.
IMV Medical Information Division, 1400 East Touhy, Suite 250, Des Plaines, IL 60018
1. The 2005 Cath Lab Digest Salary Survey. Cath Lab Digest 2005;13(12):44-45.
2. 2003 Cardiac Cath Benchmark Report published by IMV Medical Information Division, Des Plaines, IL. Available for purchase at: http://www.imvlimited.com/mid.
3. (Editor’s note: On April 19, 2006, IMV confirmed that the 2003 formula utilized in this article is the one published in their report. See article footnote.)