Your Path to Program Success: Expert Advice

SDD – Developing Health Access: The value of outpatient procedures in a high-demand Mexico City hospital

Gary Clifton talks with interventional cardiologists Jorge Emiliano Carrillo Guevara, MD, and Andrés García Rincón, MD.

Gary Clifton talks with interventional cardiologists Jorge Emiliano Carrillo Guevara, MD, and Andrés García Rincón, MD.

Terumo Business Edge continues to expand its reach outside of the United States. During a recent visit to Mexico City, we were introduced to Drs. Garcia and Carrillo from Hospital de Especialidades Centro Médico Nacional La Raza IMSS. At the hospital, we encountered their solution to managing a very real problem: how to treat the necessary number of patients clinically and cost effectively. Their solution was the adoption of transradial access and same-day discharge. I think this program is a testimony to how cardiology programs can adapt to the circumstance and create a beautifully efficient and safe program that maximizes efficiency and minimizes cost. — Gary Clifton, Vice President, Terumo Business Edge

First, let me please thank you for having us into your lab. Please tell us more about your program. 

We are very pleased you decided to visit our lab and I have to tell you we were both surprised at the reaction to our outpatient transradial intervention (TRI) program. Your desire to do an interview and your reactions to what we have accomplished here were something of a surprise, as our TRI program has evolved over time; it was a necessity for us and has therefore become a normal process. 

Our cath lab has existed for many years, more than 40, in fact, during which few changes have been made. The lab currently has 3 rooms: 2 dedicated 100% to perform interventional cardiology procedures and a third to perform electrophysiology procedures. Currently, the lab is open 24 hours, 7 days a week, but this has only been in the last 5 years, prior to which we only worked for 12 hours without including nighttime. The medical staff has, for many of these years, been consistent, with 3 interventional cardiologists staffing the first daytime shift and only one interventional cardiologist for the rest of the shifts. We have a 2-year interventional cardiology training program and in total, we have had 8 fellows for 2 years.

With these physical and human resources, we have a level of productivity that allows us to do 5000 diagnostic and 2000 percutaneous coronary intervention (PCI) procedures a year, including mostly multivessel, left main, and chronic total occlusion (CTO) procedures, but also structural heart disease treatment, including atrial septal defect (ASDs), patent ductus arteriosus (PDA), and transcatheter aortic valve implantation (TAVI). Of all our diagnostic procedures and coronary interventions, 95% of the cases are radial access and of this percentage, a total of 90% are outpatient.

How long has your lab been doing transradial? 

We started doing radial procedures in 2006 and began our TRI program in 2007.

Our hospital is a general hospital, so it is not an exclusively cardiology medical center. The radial access route started out of our need for physical space, since previously, under the schemes of our hospital, the average duration of hospitalization was 5 days for a PCI. The patient was expected to be admitted the day before the procedure and discharged the day after;  however, this was  before any urgency or any delay in the processes, thus the stay was typically extended and with it, the waiting list, which could be up to 6 months.

Because of this, the productivity of the service was less than 300 total cases, mostly diabetic, with very few interventions of moderate complexity.

What challenges did you face with staff or physicians when beginning efforts to convert to transradial?

The biggest challenge was the resistance to change by the staff of the cath lab. Initially, the greatest support was from the medical director, who heard the proposal and perceived it as a solution to the overpopulation of the hospital; however, it was not well received by the administrative staff, because there were no procedures for the outpatient process. In addition, the older medical staff was 100% trained in femoral access, so they were reluctant to change due to the more complex learning curve of radial access. Fortunately, there was retirement of older physicians and the new physicians who arrived with the appropriate TRI training were eager to use the procedure.

Many physicians are concerned about transradial access in patients that might be complex or ST-elevation myocardial infarction (STEMI) patients.  How did you manage these situations?

At the beginning of the program, there was great concern for the patient’s arm, meaning the possible consequences to the mobility of the patient’s arm or hand. In addition, there were also concerns about performing complex procedures via the radial artery for procedures such as bifurcations, left mains, and so on, because there was little or no experience in the technique. Although there was evidence documenting the approach for these kinds of procedures in the literature, as physicians, we were concerned that it could present with legal concerns. Fortunately, our experience and our willingness to not give up, and our ability to achieve good clinical results for our patients over the years showed that transradial is the best access for the patient, and it is now the technique we use daily in our center.

When did you begin your journey on same-day discharge and why? 

As I mentioned, at the beginning of this adventure, the waiting list was too long and the hospital was saturated, so same-day discharge was a great alternative to reduce length of stay and treatment costs. With the TRI technique available to us, we felt comfortable that it was safe and more cost-effective to send our patients home the same day as the procedure. Without same-day discharge, there was no way we could increase the number of patients necessary for treatment needs.

Did you experience any challenges with evolving a same-day discharge program?  

It was important to have an interventionalist training in a place where the radial approach was in full development (in our case, we looked to Spain). We worked to achieve the experience and confidence in approaching procedures to know how to treat patients and any potential complications. Initially, we began discharging diagnostic procedures the same day and then we migrated to PCIs performed without complications. This began our journey to an outpatient pathway in 2007.

Can you describe your logistical space for recovering patients that are going home the same day? 

In the last 10 years, the cath lab has been remodeled twice. The physical space was very old and obsolete. It included three procedural rooms, a recovery room with 2 stretchers, a small area with capacity to seat 10 patients in uncomfortable chairs, and a big laboratory area that was underused. Six years ago, the entire physical space was remodeled, and we were able to obtain a big room split in two, with 7 comfortable sofa chairs where patients waited for their procedure and to which they returned after the procedure to facilitate their recovery. This room is separated by a glass wall from the recovery area of patients who are bedridden and have undergone more complex procedures such as TAVI,  closure of septal defects, and so on, where femoral access was required. There they are monitored for a short time.

On how many patients have you performed same-day discharge during the past 15 years?

In those 15 years, we averaged 1000 patients per year. Thirty percent of those patients had some type of asymptomatic coronary intervention (1- or 2-vessel disease) and 70% were just diagnostic, coronary, or valvular without symptoms awaiting future treatment. On average, 83 patients per month undergo same-day discharge. Since the beginning of the program to achieve these rates, there were three difficult years of working against a reluctance and resistance to change. In this last year, however, we managed 2000 patients through our outpatient same-day discharge program.

Do you have advice for programs that want to start a same-day discharge program?

Running a same-day discharge program is very attainable. You can achieve a high volume of patients per year with low costs for the hospital. It requires a solid, well-founded program in administrative and medical matters. It will also require effort to include physicians who are familiar with the technique, and its potential complications and treatments to solve them, as well as being able to provide adequate guidance to the staff to support the entire outpatient process. Patience and expertise will be required to overcome resistance to the process as well as the fear of early discharge of cardiovascular intervention patients. 

Dr. Andrés García can be contacted at andyrincon@yahoo.com. Dr. Jorge Carrillo can be contacted at drjcarrillog@gmail.com.