Over the past decade, the new mantra for healthcare leaders has become cost reduction, increased efficiency, and stellar quality outcomes. Given this current scenario, Corazon advocates that cardiac services leadership in any busy cardiac catheterization laboratory, if not currently using radial artery access (also known as transradial access, or TR) for invasive cardiac procedures, should explore this option to assist in achieving these goals.
Although not a foreign concept, the use of radial artery access in the United States has not yet been as widely adopted as elsewhere in the world. In fact, use rates in the U.S. are less than 10% of diagnostic cases and less than 2% of interventions.1 In other regions of the world, use rates are as high as 36% of cases.2
Indeed, there are multiple reasons for cardiac program leadership and invasive cardiologists to discuss the potential of transitioning to a broader use of this technique. The radial approach has demonstrated a reduction in complication rates, can facilitate better throughput and overall facility use, decreases length of stay, and above all, provides increased patient satisfaction, all of which contribute to a better bottom line for the hospital, and let’s not forget a potentially superior outcome for the patient! Transitioning an organization from primarily femoral access to increased radial artery-based access can be challenging; however, this approach can provide multiple benefits from clinical, operational, facility, and outcomes perspectives, which can assist in preparing for reimbursement changes and the move to the outpatient setting for cardiac interventions.
Clinical and operational benefits
Initially, radial access procedures may have a slightly longer prep and procedure time; however, recent articles dispel the argument that the use of radial artery access in invasive procedures causes any significant increase in procedure time and fluoroscopy exposure. As physicians and staff gain knowledge and proficiency with the preparation process and the procedure, Angioplasty.org reported in a July 2012 research summary article3 that the difference in procedure time is only 1 minute and 23 seconds overall, and the fluoroscopy time increase was less than one minute when compared to femoral access procedures. Any increases in procedure time are more than offset by the significant reduction in post-procedure recovery time and the opportunity to safely discharge patients significantly earlier, thus leading to a more efficient cardiac cath lab and a happier patient. Therefore, we believe it is not the procedure itself, but the reduced post-procedure care needs and improved clinical outcomes that produce the major benefits that are possible through the use of TR access.
Post-care for the TR patient produces several benefits, among them, saving staff time as well as preventing potential staff injury that may result from moving or lifting patients from the procedural table. Patients may, if not significantly sedated, move directly from the procedure table to the recovery area via wheelchair. In the post care area, nursing time per patient is reduced, in part, due to the elimination of long manual compression and the associated potential patient care issues related to sheath removal (vasovagal reactions, hematoma, pseudoaneurysm, and/or re-bleeds). Recovery time is typically reduced from 4-6 hours to as low as 1-2 hours, and most organizations work to have same-day discharge for not only diagnostic cases, but also the low-risk percutaneous coronary intervention (PCI) patients who meet the TR patient selection criteria. This reduction in length of stay has a significant positive impact on the cost per case.
Currently, the move to outpatient PCI may not be recognized as a financial benefit to the organization, as in most instances, observation or inpatient status is reimbursed at a higher rate than outpatient PCI. However, Recovery Audit Contractors (RACs) are closely examining this practice and it seems inevitable that CMS (Centers for Medicare and Medicaid) will expect low-risk PCI patients to move to outpatient status in the near future. In order to be better prepared to meet the reimbursement challenges with higher outpatient rates, Corazon recommends that hospitals explore all avenues to reduce cost, and certainly labor is one of the most significant contributors to operational costs. Two recent studies cite significant time savings in nursing care for the post cath/PCI patients when using radial access, showing as much as a 47-minute reduction in post-procedure care time for interventional patients.4 When the time savings per case is extrapolated to a facility’s annual volume, there is not only a significant reduction in the staffing dollars, but the time savings per patient also allows for additional throughput in the recovery area.
For example, a time savings of 47 minutes for 100 cases is 4,700 minutes or 78.3 hours. When multiplied by the hourly rate and benefits, this can add up to be a significant savings for an organization. The decrease in post care time also moves the patient through the recovery to discharge more quickly and makes recovery space more readily available for other more complex patients. Freeing up bed space is especially valuable for an organization with growing volumes and/or an existing recovery space hovering at or near capacity.
For facilities performing a significant number of TR cases with limited recovery space, one option gaining attention is the use of a radial recovery “lounge” (Figure 1). It contains reclining lounge chairs for the patient recovery period, replacing the use of stretchers in rooms or cubicles. The recovery lounge can be modeled after current ambulatory care center Stage II recovery areas, and can allow for the accommodation of more patients in a smaller space (Figure 2). Organizations that have moved to the radial lounge model sometimes also include space for family to be with the patient, televisions, Wi-Fi availability, and refreshments. In fact, in many cases, these areas reflect a “concierge” type atmosphere. The shorter recovery time and revised use of space, along with patient amenities, lead to better throughput, accommodation of greater daily volume, and happier patients and families. No doubt, these benefits positively impact patient satisfaction scores for the procedure, the cath lab, and the hospital at large.
Outcome and satisfaction benefits
Cost reduction from operational efficiencies is another benefit of using TR access for procedures. Cohen reports “it was the expense incurred in dealing with complications that was the major driver in the lower costs of radial.”3 Bleeding and vascular complications from a TR approach were cited at 0.7%-1.5%, while bleeding and vascular complications from femoral access PCI have been reported as high as 3%-5% in some studies.4 Vascular complications, when they occur, translate to potential blood transfusions, additional diagnostics (ultrasound, vascular imaging), longer lengths of stay, and/or readmissions, which, in turn, increase the overall cost of care.
Patients who have experienced procedures from both femoral and TR access have voiced increased satisfaction with the approach and typically request it when future procedures are indicated. Cooper et al noted this “strong patient preference for transradial” in a study examining the quality of life benefits.5 Patients indicated less pain, were able to ambulate more quickly, noted the shorter length of stay, and appreciated fewer overall activity restrictions with TR procedures.
Limitations to the transradial approach
In general, limitations with the TR approach stem from the patients themselves and the availability of TR-trained cardiologists. As with any clinical procedure, not all patients are appropriate candidates for this approach.
Instances when TR can be an inappropriate choice:
- With women who have smaller vasculature, which can cause increased bleeding and/or vascular complication rates (which are already higher for women than for men);
- The patient experiences vascular spasms (such as Raynaud’s);
- The patient has a hemodialysis shunt or fistula;
- An abnormal result for the pre-procedure Allen’s test (which indicates potential insufficient circulation while radial is occluded);
- The planned use of radial artery for surgical conduit.
As mentioned earlier, TR access has been embraced more slowly by cardiologists in the United States in part due to the steep learning curve, requiring anywhere from 50-150 cases for developing competency with the approach.1 Currently, no defined training for TR exists in cardiology fellowships, and experienced invasive cardiologists may have limited exposure to the approach. The Society for Cardiovascular Angiography and Interventions (SCAI) has provided an Executive Summary from their Transradial Committee that outlines training objectives, along with three proposed levels of competency. SCAI, as well as several other organizations and equipment vendors, have been more recently making training programs and TR clinical sites more accessible to those cardiologists wishing to gain comfort or increase competency with the TR approach. If this trend continues, Corazon believes that as more cardiologists are trained, this “limitation” on TR will be lessened.
Limitations aside, it is evident that the TR approach has much to offer a busy cardiac catheterization laboratory (Table 1). The benefits, including improved use of recovery space, increased throughput, reduction in staffing hours per patient, decreased complication rates, and most importantly, improved patient satisfaction, cannot be overstated. All of these elements assist in the overall goal to provide safe, efficient, quality care in a cost-effective manner — a goal of ALL HOSPITALS in today’s competitive and highly regulated healthcare landscape. While an organization must note that the cost reduction benefits of TR may not be realized until a threshold of 15% or more of total cases are being done by TR access6, it is worthwhile to consider whether working towards this approach would better prepare the organization to manage changing reimbursements and the push to outpatient procedures…clinically, economically, and operationally.
Marsha is a manager with Corazon, Inc., offering strategic program development for the heart, vascular, neuro, and ortho specialties, as well as consulting, recruitment, interim management and physician practice and alignment services for clients across the US and in Canada. To learn more, visit www.corazoninc.com or call (412) 364-8200. To reach Marsha, email firstname.lastname@example.org.
- Ball W, Sharieff W. Characterization of operator learning curve for transradial coronary interventions. Circ Cardiovasc Interv 2011 Aug;4(4):336-341.
- Cadet J. Transradial interventions: helping cath labs stay cost savvy. Cardiovascular Business 2010 Aug. Available online at http://www.cardiovascularbusiness.com/index.php?option=com_articles&view=article&id=23880:transradial-interventions-helping-cath-labs-stay-cost-savvy. Accessed August 21, 2012.
- Cohen B. Transradial wrist angioplasty saves money and lowers complications over groin access. July 8, 2012. Available online at http://www.ptca.org/news/2012/0708_RADIAL.html. Accessed August 21, 2012.
- Shroff A. Economic opportunities of transradial angiography and intervention. Cardiac Interventions Today 2011 Sept/Oct; 31-37. Available online at http://bmctoday.net/citoday/2011/10/article.asp?f=economic-opportunities-of-transradial-angiography-and-intervention. Accessed August 21, 2012.
- Cooper C, El-Shiekh R, et al. Effect of transradial access on quality of life and cost of cardiac catheterization: a randomized comparison. Am Heart J 1999; 138: 430-436.
- Cadet J. Roundtable: cost-control strategies in the cath lab. Cardiovascular Business 2010 August. Available online at http://www.cardiovascularbusiness.com/index.php?option=com_articles&view=article&id=23887:roundtable-cost-control-strategies-in-the-cath-lab. Accessed August 21, 2012.
- Caputo RP, Tremmel JA, Rao S, Gilchrist IC, Pyne C, Pancholy S, Frasier D, Gulati R, Skelding K, Bertrand O, Patel T. Transradial arterial access for coronary and peripheral procedures: executive summary by the Transradial Committee of the SCAI. Catheter Cardiovasc Interv 2011 Nov 15;78(6):823-39. doi: 10.1002/ccd.23052.
Northside Hospital Case Study:
A Q&A with Jack P. Chen, MD, FACC, FSCAI, FCCP
Medical Director of Cardiology
Northside Hospital Heart and Vascular Institute
“Transradial PCI is here to stay. Be the first or, at least, not the last…”
What has Northside seen as the clinical and operational benefits from the radial approach?
Since adoption of the transradial approach, our vascular complication rate has essentially disappeared. In addition to the obvious safety benefits, associated costs of vascular surgery and extended length of stay are avoided. The patients seek out our hospital and physicians specifically for “wrist caths.” Patients who have had previous transfemoral catheterization/percutaneous coronary intervention (PCI) procedures are especially delighted to have immediate ambulation and bathroom privileges. Additionally, nursing satisfaction cannot be overemphasized. The lack of need for sheath pulls and ease of the TR Band (Terumo) care are greatly appreciated by our ancillary staff.
Facility-wise, our Radial Lounge requires less intensive nursing care. The spatial requirements are likewise more efficient; a lounge chair takes less space than a stretcher. Same-day transradial PCI discharge is a big plus in times of hospital “bed crunches” and outpatient payer reimbursement schedules.
How has this approach impacted the facility – specifically in terms of patient flow and throughput?
Post-transradial cath/PCI patients are essentially on auto-pilot. Without excessive sedation, they can feed themselves, ambulate, and use the bathroom. They watch TV and answer emails on their laptops and iPads. The nurse simply checks on them every 30 minutes to gradually deflate the TR Band.
How has this approach affected outcomes and patient satisfaction?
When compared with the transfemoral strategy in ST-elevation myocardial infarction (STEMI) cases, transradial PCI has been shown to improve mortality in a recent major trial.1 In the same study, the largest randomized transfemoral versus transradial PCI trial to date, high-volume transradial centers and operators are likewise associated with a lower PCI mortality. These benefits are reflective of the reduction in bleeding and vascular complications. A previous study, the ACUITY trial, had brought bleeding to the forefront of our attention by identifying it as a powerful predictor of post-PCI death.2
Aside from a rare transfemoral complication, our extremely low vascular complication rate is no longer a topic of discussion. Transfusions post-PCI are essentially nil. While first-time catheterization patients are impressed by the ease of the procedure, those who have undergone a previous transfemoral procedure are even more impressed by the contrast in comfort and the post-procedural freedom of ambulation. Our patients are our best advertisement.
What would you see as limitations in offering the transradial approach?
With the sophistication and low profiles of today’s interventional devices, almost all cases can be performed transradially. Even rotational atherectomy (up to 1.5mm burr) can be performed via a 6-French sheath. The one notable exception is simultaneous kissing stents for bifurcation lesions. This technique, however, has declined in significantly in popularity; regardless, even in these rare cases, a 7-French system can likely be accommodated in most average- to large-size patients. Moreover, the sheathless technique allows the operator to upsize to 7-French, while preserving the same outer diameter as a 6-French sheath.
What fiscal impact has the radial approach had at Northside?
The cost savings from decreased ambulation and discharge times are clear. Also, the TR Band is significantly less expensive than femoral sealing devices. Furthermore, while many transfemoral operators use Judkins/pigtail diagnostic catheters, most transradial diagnostic catheterizations are performed using only a single universal curve catheter. As several guide catheters also feature universal curves, a combined diagnostic/interventional case can likewise be performed with a single guide catheter (as in STEMI cases),3 all of which have great potential to reduce supply costs.
Any lessons learned you’d like to share?
While we initially started with a single transradial operator, our transradial volume now comprises half of our case volume. Both physicians and patients understand and appreciate the inherent advantages. Nonetheless, there is a fairly steep learning curve. I would strongly recommend that any hospital considering building a transradial program identify a physician champion. That physician, along with a staff member, should attend one of the many training courses now available. Alternatively, a preceptor/proctor can be invited to your own facility.
Initially, frustration and the temptation to quit are inevitable. As with any new technique, ancillary staff support is paramount. A novice transradial physician will become quickly discouraged if constantly faced with resistance from the staff. However, with perseverance, the physician, staff, administration, and (most importantly) the patient will all benefit from adoption of this strategy.
- Jolly SS, Yusuf S, Cairns J, et al. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomized, parallel group, multicentre trial. Lancet 2011;337:1409-1420.
- Stone GW, McLaurin BT, Cox DA, et al. Bivalirudin for patients with acute coronary syndromes. N Engl J Med 2006; 355: 2203-2216.
- Chen JP, Kwan T. An expedient and versatile catheter for primary STEMI transradial catheterization/intervention. Cath Lab Digest 2012; 20 (4): 1-12.