Vascular Care in the Cath Lab: Planning a Smooth Transition

James Burns, Vice President, Corazon, Inc. Pittsburgh, Pennsylvania
James Burns, Vice President, Corazon, Inc. Pittsburgh, Pennsylvania

There is significantly more peripheral vasculature than cardiac, and often disease in one area indicates disease in another. Furthermore, many of the diagnostic and interventional procedures to treat cardiac and vascular disease are based on the same percutaneous platform, and as such, are similar procedure performed in different blood vessels. Yet with all of this opportunity, one of the most challenging areas today is incorporating vascular procedures into a new or existing cardiac cath lab. There is plenty that can be done to make sure that the staff and the labs themselves are ready to care for these types of patients. In this article, we will take a brief look at some of the critical areas that need to be addressed.

Change Your Thinking
Many new state-of-the-art centers are no longer considering themselves as having simply “vascular” or “cardiac” labs. Instead, terms like “interventional suites” and “percutaneous cardiac and vascular labs” are being used to define these workspaces. Yet every procedure performed in the special procedures lab or by an interventional specialist is not always appropriate for a lab that will also perform cardiac procedures. Staff and managers of successfully integrated labs have spent a great deal of time determining what procedures will be the best “fit” in integrated space and then learning as much about these procedures as possible.

Learning About Vascular
Once it has been determined what types of vascular procedures will be performed in your lab, a defined and dedicated education program needs to be developed. Training should include a didactic component that addresses the pathophysiology of vascular disease, interventional diagnostics and treatment, and pre and post procedure care. All medical staff that will work in the area must be involved in developing and providing oversight to this curriculum. This would also be a good time to contact the patient education department at your facility to review and adapt any patient educational material for these procedures.

As part of learning about vascular procedures, of course staff requires hands-on training as well. Cross-training of staff in the vascular areas is critical to the integration of cardiac and vascular procedures into one space. It is usually a smoother transition, however, if you begin first with cath lab staff learning the vascular side. As this is accomplished, vascular staff can be trained in cath lab procedures and, as they become proficient, become part of on-call teams. It is very important to note that staff and managers need to discuss and address this “cross-over” in an open and supportive forum. There are vascular technologists that do not want to work in the more intense cardiac environment and there will still be a large number of procedures, which while considered vascular in some facilities, may not be a good fit for your integrated labs.

Some staff and procedures should remain in the “specials” area. However, this is often a difficult task to accomplish. Many program leaders use the rule of “like procedures” to help guide these decisions, as well as considering procedure “cleanliness,” time and resource utilization. Generally, procedures such as vascular angiography and vascular angioplasty and stenting are always an easy fit. Thrombolysis and some filter procedures present more challenges and can be excluded from “shared” labs. On that note, G-tube and PICC insertions, kyphoplasty, and other “non-like” procedures almost always remain in the special procedures area.

Assess Your Inventory and Equipment
The first step is to assess the current equipment and determine its functionality in performing vascular procedures. It is important to involve the physicians who will be performing these procedures, as well as key staff members. More often than not, there will need to be some type of capital outlay, but keeping everyone involved in the process can help to eliminate the urge to buy all of the latest technology without thought of its appropriateness. A similar approach should be used for supply and device discussions, as some of the new technologies available can cost more than the actual procedural reimbursement.

Learn the Coding and Reimbursement
As many people who have transitioned to offering vascular procedures can attest, the coding and billing for vascular procedures is very different. Vascular coding and billing is dependent on where the catheter is placed for its final diagnostic or interventional procedure, and all of the imaging and other work performed as part of the case is evaluated and coded separately. This is even more difficult when considering that branches of main vessels are considered differently than when entering a new vessel. Needless to say, a coder needs to be very skilled to accurately capture and bill these procedures, and documentation needs to be very detailed as to exactly what was performed where. It is highly recommended that all staff, including physicians, be well educated on the fiscal side of these procedures. This situation is further compounded by the fact that many of these cases are outpatient, so the coding is even more closely related to reimbursement. Understanding and preparing for the financial impact is one area where many centers that integrate these procedures fall short.

Overall, the most important part of incorporating these procedures into your lab is planning. Programs can succumb to physician or administration pressures before there is a completely thought-out plan to implement change. With that said, if you haven’t been approached about starting or expanding your vascular program, you will. Remember that forethought and planning can make the transition a much smoother endeavor.

Look for our article next month that will discuss how to determine whether you should stay in a current job and what steps to take when you have decided to go.