Cath Lab Management

Use of a Modular Lab to Support the Opening of an Interventional Program

Cath Lab Digest talks with Anthony Zelenka, FACHE, Chief Administrative Officer, and Lynnette Dalton, BSN, MHA, MBA, Director of Cardiovascular and Cardiopulmonary Services, West Virginia University Hospitals-East, Martinsburg, West Virginia.

Cath Lab Digest talks with Anthony Zelenka, FACHE, Chief Administrative Officer, and Lynnette Dalton, BSN, MHA, MBA, Director of Cardiovascular and Cardiopulmonary Services, West Virginia University Hospitals-East, Martinsburg, West Virginia.

Tell us about your hospital and why you needed a modular lab.
Tony: West Virginia University Hospitals-East is part of a four-hospital system, West Virginia United Health System. We are in what is called the “eastern panhandle” of the state. Our county, Berkeley County, is a service population of 150,000. Our sister hospital in Jefferson is a critical access hospital, serving a population of about 90,000. We service the two areas. In our county, we are not in a competitive situation, but we do have a major tertiary hospital 40 minutes to the south, and another hospital that is relocating to a brand-new hospital 45 minutes to the north. Both are in different states, but do provide some competition. For several years now, West Virginia has been a certificate of need (CON) state. We submitted our CON for the cath lab in February 2006 and received approval by the WV Health Care Authority in November 2006. In order to begin full cardiac services, facilities have to progress through a three-step process, as defined by the state plan: 1) diagnostics (regulated in terms of certain time frames and quality outcomes); 2) emergent or STEMI procedures, and 3) elective percutaneous coronary interventions (PCIs). Our president and CEO asked that a cath lab program be initiated and the first patient put on the table within a very short period of time. It was about December 2008 when I told him we could have it accomplished in nine months. He said, get it done in six — and we did. Our first diagnostic patient was done in a modular cath lab on June 1, 2009. We committed 9 million dollars to a new permanent cath lab, now completed, with our first patient on the table October 12th of this year. The cath lab has two rooms. One has Toshiba equipment and is dedicated heart-only. We are in the process of launching a fund drive to support several projects, including the equipment for the second cath lab, which will be a combination peripheral vascular and heart lab. We have completed the first step of performing diagnostics, and if we receive the go-ahead to do both elective and emergent caths, we will start these procedures on January 5, 2011. We hope to time the beginning of emergent and elective caths with the opening of our new ICU, which has 4 CICU dedicated beds and is located right above the cath lab. When we began planning a cath lab program, we had 14-15 players at the table, including people from staffing, billing, equipment procurement, and marketing. We worked with the architectural design team of O’Dell & Associates, out of the Virginia area. We talked with Modular Devices Incorporated (MDI, Carmel, Indiana) about providing a modular unit in order for us to begin diagnostic procedures while construction was completed on the cath labs. I had not used a modular cath lab before and neither had Dr. Neal Gaither, Medical Director of Cardiovascular Services at WVUH-East. MDI flew us out to Columbus, Indiana, to view the actual modular unit that we would use. Both of us had been thinking that we were going to step into a trailer, but the modular unit was actually very large. As we came in, the cath lab team had just completed a patient on the table, so Dr. Gaither was able to review the film and evaluate its quality based on that procedure, and we were able to talk with the team. Our attention was directed to a small creek nearby. There had been a flood on their entire first floor, and that was why they were currently utilizing a modular unit. MDI said they could have a modular to us within a 6-month period. In the meantime, construction was completed on the pre/post area via a design-build construction methodology. Within five months, the pre/post area was finished, inspected, and we had the modular on site. Our first patient was on June 1, 2009. We have now been using the modular lab for about 15 months.

Lynnie: Tony is right on when he talks about the difference between the modular and the mobile. Dr. Gaither and I had both previously worked in a mobile lab, which is, essentially, a trailer, and the challenges were grand. Right from the very beginning, you knew you couldn’t do certain patients, and your worst nightmare was to think of a code in there, because there was barely room to move. In the modular, however, the control room is actually larger than some of the control rooms I have seen in permanent cath labs. The room is very spacious, just an easy flow room, and has a GE Mac-Lab system. It also has built-in cabinetry for the catheters. MDI was absolutely so receptive to everything that we needed. I talked with them about some concerns with the hemodynamics system — it was what I’ll call ‘vintage’ and had some forbidden Joint Commission abbreviations. MDI came out 2 days later and upgraded the system. The company was very responsive to our calls. Any challenges that we had were very minimal. For the startup of the lab, while getting the physicians and staff used to using the table and the hemodynamics system, the company had a two-man team on site.

Tony: One of the challenges we did have initially was finding staff. We advertised heavily in our markets for experienced cardiac cath nurses, but didn’t have much luck, other than my wife, who has been a cardiac cath nurse since 1983. We didn’t have any nursing. Consequently, in the interim period, we ended up hiring some of our critical care nurses. We had to immediately find a site for them to train for the initial startup, which ended up being WVU Hospitals in Morgantown (specifically, Ruby Memorial Hospital). Lynnie came on after our nurses were hired. She has a great deal of cath lab experience, but we are still in a limited market where we are not able to recruit people. It’s quite unlike the Pittsburgh market, where I’m from, where sometimes you run an advertisement and you get 8-9 people who have 6-7 years in the cath lab. In this market, we just weren’t able to do that.

Lynnie: Our last few hires have had cath lab experience. We do have one tech with 20 years in the cath lab, a registered cardiovascular invasive specialist (RCIS) instructor, who is doing very well. We are in the process of making an offer to another cath lab nurse of 10 years. “Build it and they will come” is giving us some momentum. Also, a few of the staff we have brought on have worked at another facility with the same group of physicians, which helps enormously.

Tony: Our cardiologists have been on service to the hospital for many years, so they weren’t new to the community. We have utilized that group of cardiologists under an exclusive arrangement.

How did physicians and staff react to working in a modular lab?
Lynnie: They were thrilled. Again, when you mention the word “modular,” the first thing that comes in your mind is “trailer,” but mobile and modular cannot be interchanged. There is a day-and-night difference. I have said it is the difference between a walk-in closet and the gymnasium. Our physicians and staff could not believe the modular space, and there has been absolutely nothing but compliments.

Tony: I think the most frequent comment I heard from cardiologists, and even when we had open houses to show off the area, is that you don’t realize you are in a modular. It is just like being in another room of the hospital. The interconnectivity between the pre/post area and the modular is seamless. There has not been one complaint about being in the modular, because you don’t realize you’re in one until you go outside and look back.

How long did it take to set up the modular lab once it was delivered?
Tony: It was a very short period of time. Creating the pre/post area serving the modular took almost 4-5 months, but once on site, the modular was in place and ready to go in a 2- to 3-week period.

Did you have any electrical or heating/cooling issues once the lab was up and running?
Tony: Absolutely none whatsoever. From an HVAC standpoint, we did question whether to provide an invasive OR-type setting. Given the air exchanges, an OR type environment was provided. We poured a concrete pad out in front of the hospital to accommodate the modular unit. But we had no issues with the modular itself at all. It was set up quickly and easily.

Are there any doors directly to the outside in the modular?
Lynnie: Yes, there is a door directly to the outside.

Did you have the modular equipment linked to a network archival system or did you burn CDs for storage?
Lynnie: We were going to the Philips Xcelera system in the new lab, so we burned every one of our cases to a CD. If a patient has to travel or we do have to transport a patient, a copy is made. Once we move over to the new lab, it will be a little bit time-consuming, but not a difficult process, to go in and load those cases.

How many patients have you done in the modular lab?
Lynnie: Close to 250. Tony: We were required by CON to have a transfer agreement with a tertiary hospital that provides coronary artery bypass graft surgery. Valley Health was helpful in that regard and we still maintain that agreement.

Were any patients emergently transferred?
Lynnie: Yes, we had a patient who needed an emergent intra-aortic balloon pump insertion. It is important to point out that this lab, from day one, had a balloon pump on site, and we also had bailout equipment. In the event that we had an emergency or an issue that was life-threatening, we could have done what we needed to do with bailout equipment, with stents, etc.

Financially, how did the use of the modular fit in with your plans?
Tony: The ROI in the preliminary budget has been met. We would prefer to have greater volume than what we have, as would most administrators and finance people. Of course, there is a great deal of prescreening and the high-risk cases are still being transferred. We are still performing only diagnostic procedures, so we don’t yet have the interventional piece of the puzzle. From a pro forma standpoint, we are meeting expectations.

Now that the permanent cath lab has been opened, what are your plans for the modular lab?
Tony: My goal is to keep the modular in place for probably a two-week period, minimally, to make sure that the new lab is operating the way it should, i.e. the equipment, the HVACs, and everything else. We did sign, two weeks ago, with MDI, to bring in a peripheral vascular modular lab for a 12-month period. We have been successful in recruiting an interventional radiologist, who will be performing peripheral vascular stenting. At least for another year, our peripheral vascular procedures will be done in a modular lab.

Do you see benefit in having a catheterization program up and running earlier with the help of a modular lab?
Lynnie: Yes, but if you see it as “I’m going to plop down a trailer and start doing business,” that’s not at all what happened. We had equipment and training that we needed in order to provide extremely high-quality care. In the modular, we had some of the devices, like the ACIST injector, for example, that people might think won’t show up until the move to a permanent lab. We were afforded those opportunities and it speaks volumes to the quality of the program to be able to make those kind of investments.

Tony: Yes, absolutely. When you are able to go to what I call a tertiary level of care or higher level of care, the perception of the community regarding the hospital improves.

Tony Zelenka can be contacted at azelenka@cityhospital.org
Lynnie Dalton can be contacted at ldalton@cityhospital.org

Learn more about MDI and visit the website at www.modulardevices.com