CardiacCatheterization Laboratory

OperationsManagementPaper
By:AdamPegan,BasmaKhurshid,andLindsayNieman 12/2/2011

Cardiac Catheterization is a complex medical procedure that is used to diagnose and treat a wide variety of heart conditions. During cardiac catheterization, also known as a coronary angiogram, a narrow tube called a catheter is inserted into the femoral artery near the groin with a plastic introducer sheath. The catheter is guided through the blood vessel to the coronary arteries with the aid of an x-ray. The procedure is performed by a cardiologist in a specially equipped room know as a Catheterization laboratory (cath lab). The cath department is an important part of any hospital for several reasons. First, coronary catheterization one of the most common interventional procedures practiced, which leads to high volumes and high revenues. Second, the procedures conducted in a cath lab are far less invasive than those performed in the operating room, which means that patients can often be treated as outpatients, which results in reduced costs for the hospital. However, the highly technical nature of the cath department combined with the extremely high technological costs make the department tricky to manage. In order to manage the department well, it is important for managers to be informed and aware of what goes on in a cath lab. Services and Procedures: The cath lab provides a number of noninvasive and invasive procedures that enable a cardiologist to check the heart and coronary arteries, measure blood flow and inter-cardiac pressure, assess how well the heart valves work, and check for structural defects. In children, this test is used to check for heart problems that have been present since birth (Congenital heart defect). The procedures performed are categorized as either diagnostic or interventional. Diagnostic procedures help the physician to determine the cause of a patients condition, while interventional procedures attempt to cure the condition.

Some of the more common procedures include (Espanto, 2011): Diagnostic

Coronary Angiography Insertion of a catheter into heart to deliver contrast. Electrophysiology Testing Tests electrical conduction within the heart. Cardiac Shunt Detections Blood flow analysis to identify a shunt. Structure Assessment and Confirmation Verify structure of heart and veins. Intravascular Ultrasounds Determine plaque buildup.

Interventional

Cardiac Angioplasty Balloon insertion to open an obstructed artery. Cardiac Stent Placement Placement of stent to keep artery open. Ablations Removal of faulty electrical pathways. Atherectomy/Rotablation Removal of material blocking an artery. Closure of Congenital Heart Defects Correct blood flow pattern. Treatment of Stenotic Heart Valves Correct blood flow amount. Thrombectomy - Removal of blood clots

Other

Pacemaker Implantations Implant device to regulate beating of the heart. Internal Cardiac Defibrillator Implants Implant device to jolt heart in case of cardiac arrest.

Technological Overview Technology in past: The idea of cardiac catheterization was created in 1844 by Claude Bernard, when he placed a mercury thermometer into the carotid artery of a horse to measure blood temperature.

The procedure was soon moved to other animals and used to measure intra-cardiac pressures (Lawrence, N.D.). It was not until 1912 that human catheterization began without x-ray guidance for experimental purposes. In 1929 Werner Forssmann established the cardiac catheterization procedure by performing the procedure on himself, by inserting of a uretic catheter through his antecubital vein and then walked into the x-ray lab and confirmed the catheter in was his right ventricular cavity (Lawrence, N.D.). Soon after the possibility of cardiac catheterization was confirmed, others around the world began to performing the procedure and testing the capabilities of catheterization and the corresponding enhanced visualization of the heart and arteries (Angiography.org, N.D.). Present: Over the years, there have been significant advances in cardiac catheterization that allow for the procedures of today, like angiographies, angioplasties, stent placements, and rotational atherectomies. These procedures are done by interventional cardiologists much more routinely, quickly, and innovatively. The variety of the patients and coronary diseases allows for new applications of catheterization procedures. The Cardiac Cath labs of today have extremely advanced, and extremely expensive, equipment that can deliver real-time x-ray video of the catheter and contrast. This technology allows for immediate results and decisions that can bring on lifesaving procedures in and out of the Cath lab. Whereas the original catheterization procedures were to purely deliver dye to see the heart and blood flow, now it is possible to repair arteries and correct internal structures that would have previously required invasive surgery. The most used cath lab equipment consists of an x-ray generator, contrast, and catheters. The x-ray generators are single-plane (with one view) or bi-plane (with two views) and are designed to rotate in any needed directions about the patient on a bed. These x-ray generators deliver real-

time imaging via video feed, which is quite different from the past where images were developed on films after the procedure for further evaluation of the treatment. Although the procedure itself has not changed much over time, the accuracy of dye delivery and immediate result confirmation did (Espanto, 2011). Cost of Equipment and Supplies: The x-ray generators for each lab cost about $1 million for a single-plane to $2.4 million for a bi-plane, and require enough energy for a city block during each procedure (Espanto, 2011). The catheters themselves vary a lot and preform many different tasks. A general catheter is designed to go through the artery and deliver dye and is not very expensive. However, the special devices to perform the interventional procedures done in the cath lab such as angioplasties, stent placements, and rotational atherectomies are quite costly (Wheelus, 2011). The catheters that contain these additional instruments range in price from a $1000 to as high as $115,000 (Espanto, 2011). Inventory & Supplies: Inventory and suppliers are considered a competitive advantage in the cath lab and overall procedural costs are relative to the patient and were undefined due to the large variation. In terms of technology, the majority of hospitals have adapted the vending machine inventory control system. By implementation of vending machine inventory control, the maintenance department can keep track of accurate, up to date inventory and keep track of deliveries. At Christus, all supplies such as stents, medicines, injections are all placed in vending machines. The machines track the supplies, and automatically send a notification to the supplier when the re-order point is reached (Wheelus, 2011). University Hospital currently does a manual count of the inventory on weekly basis. The staff then enters the data into the database and the director then sends out

order for supplies. They are under the process of installing new shelves that will measure the weight of supplies and order accordingly (Espanto, 2011). Currently there is a move to stretch the limits of catheterization by increasing modalities, or different types of procedures. These new procedures include coronary valve replacement and structural modifications among many others. To meet the needs of these patients and the procedures there is also a push for hybrid procedures and hybrid labs. These hybrid labs consist of the same equipment and staff for a complex catheterization procedure including a bi-plane xray generator and the corresponding supplies, but also include surgical staff and any surgical equipment. University Hospital, has a hybrid lab, one of the first in the country and has performed these procedures with traditionally separate teams working together on the same patient (Espanto, 2011). Process Mapping The cath lab can be a stressful place to work. Days can be hectic and unpredictable. The staff is often struggling with balancing a schedule full of emergent cases and scheduled ones. Some cases are often delayed, leaving patients hungry, anxious and nervous. Cardiologists dislike unpredictability and delay while hospital administrators are concerned with the time inefficiencies by these delays. In the past, hospitals could gain large economic returns from Cath procedures because of high reimbursement rates from payers. However, the decline of Medicare reimbursements and the advent of new technologies pose a threat to economic gains (Espanto, 2011). Despite this, hospitals are finding ways to improve patient flow in a timely manner, reduce the time to prepare the Cath lab for the next patient, and providing quality of care, which can all help reduce cost.

The different patient statuses affect the time of the procedure, but generally the labs move at a pretty consistent pace. A person would be seen in the cath lab if there is an abnormality in their heart, which is usually caused by disease or genetic defect. The effects of these issues would typically be felt by the patient and abnormalities identified in an EKG. At this point, a patient would likely be seen for a less complex diagnostic test such as an x-ray or ultrasound. If an abnormality is discovered, then they would be evaluated, and if approved, seen by the cath lab for a diagnostic catheter procedure (typically a coronary angiography). The diagnostic test is a likely point of entry for an inpatient or outpatient. It is designed to take internal x-rays to show potential issues that may be causing health problems. At this point it may be decided that further intervention is needed, and the procedure will be performed in the cath lab. The diagnostic tests prior to the catheterization procedures are likely done outside of the cath lab. Once it is established that a catheterization procedure should be done, there is usually a wait of about a week or two before the procedure is scheduled to be performed. A week prior to the procedure, an evaluation is done to evaluate the patients health and medical history, to establish capability to undergo the procedure, as well as discussing the potential risks and outcomes. In an emergency situation the evaluation may have to be supplemented with a judgment call by the attending physician. Once a patient arrives to the hospital, they may have to register at the front desk and advise where they are going. As many procedures are outpatient, some facilities have a separate entrance for the cath lab. Once in the cath lab admissions area, the patient provides their insurance and personal information to the admissions, which can also be department nurses who

work in the labs themselves. The patient would then be taken back to a pre-operative nursing unit to prepare for the procedure. The patient is then taken back to lab and generally given light anesthesia so they are not completely under and can make decisions and perform certain physician requests. A diagnostic procedure is then done and usually takes about 20 minutes. There is 1 Interventional Cardiologist, 2 RNs, and 1 Technician for each procedure. At this point if something can be fixed with an interventional procedure, it can be discussed with the patient and then done. An interventional procedure usually will take longer, about an hour or less, and again can be performed in the same venue and time. Should the patient need further work or surgery due to the findings, it is discussed with the patient and a decision can be made. The more complex hybrid procedures would have people already involved. Once the patient is done with the procedure, they are again taken back to the nursing unit to be observed, typically for 2 hours and if there are abnormalities, they can be moved to an observation area or to an inpatient status. There is a lot of variation of each patient and each experience can be vastly different on who they come in contact with or where the go post cath lab. Process Map: Cath Lab Patient Inflow

Overview of Key Metrics The cath lab tries to monitor specific key metrics in a variety of different groups such as Procedural, Patient Flow, Productivity, and Inventory. The cath labs then use benchmarking and

historical data to find out how they are performing (Wheelus, 2011). These measures can give the department a competitive advantage in how they deliver services and provide for increased profits with decreasing reimbursement (Espanto, 2011). The key metrics that are most commonly used are based on the ACC/AHA performance measures and are specific to different diseases; however more common measures described below are used within the department. Procedural Door-to-Balloon Time - Time measurement in emergency cardiac care, specifically in the treatment of ST segment elevation myocardial infarction. The interval starts with the patients arrival in the emergency department, and ends when a catheter guide-wired crosses the culprit lesion in the cardiac cath lab (Espanto, 2011) The goal for this is 90 minutes, but many facilities focus on achieving lower amounts closer to an hour. Average Procedure Time - The average time a procedure should take. The cath labs review the amount of time a procedure took and compare it to the average to come up with statistical information for the physicians practicing out of the lab. The procedures vary in length based on complexity but simple procedures can be between 8 and 20 minutes (Espanto, 2011). Patient Flow Utilization Rate - Rate at which the cath lab is used in regards to each procedure to include allotted time and cleanup. Again the time frames of the procedures vary but cleanup between cases should be less than 20 minutes. Accurate case scheduling should help utilization. Waiting Times - The amount of time the patient waits to be brought back to the pre-operative area. This can also be measured by the time the patient waits in the pre-operative area until when the procedure begins. The wait time prior should be as low as possible and about 1 hour in the pre-operative area (Wheelus, 2011).

Physician Scheduling - How accurately the physicians and their schedules are aligned with the department scheduling. This should be done correctly so the physician is done or arrived as the patient is ready. Productivity Staff Productivity - A measurement of how much work is being done by the staff members. This can be measured by FTEs based on case amount and/or case acuity. Accurate Scheduling - Consistent and correct scheduling of the staff to meet the needs of the daily patient schedule as well as the add-on patients. Assuming this is done correctly, the staff should be productive, have no overtime hours, and no contracted workers. Different facilities staff differently to meet these needs whether rotating in shifts or having on call workers. Inventory Supply Amount Control - Correct control of the supplies available, minimizing excess cost in unneeded supplies. This also includes the management of Just-In-Time supplies should they qualify due to excessive costs and minimal utilization. This is managed in a number of ways, both by the department individually and/or by a separate inventory management department. Supply Cost Control - Correct control of the cost of the supplies used in the cath labs. Different patients need different materials and the physicians may prefer certain supplies, so supply cost in monitored and compared to historical data (Espanto, 2011). Best Practices The cardiac cath lab is focused on complying with the best practices set forth by the American Heart Association and reports information accordingly. The best practices are designed to increase patient safety and clinician education to have better outcomes for patients, physicians, and facilities. The best practices also include guidelines on how to treat diseases

which the cath lab is a part of. The best practices are goals of the department, and the cath lab uses Six Sigma practices to improve processes as well as using 360 Feedback for any improvement suggestions along the way (Espanto, 2011). The guidelines include many different aspects specific to the best practices but generally pertain to the following opportunities and hold the director of the department responsible.

Using unit resources and/or other departments to identify opportunities for improved patient care and expediting change implementation.

Removing barriers to the use of order sets. Encouraging documentation accuracy and compliance, while promoting a culture of mutual respect and physician approachability.

Identifying other in-hospital processes or resources that can be applied to heart failure or stroke care.

Creating unique positions to ensure consistency and core measure compliance. Instituting multi-pronged education efforts. Creating unique education programs, tools, and opportunities. Enacting dedicated data abstraction for timely review of data and fallout resolution. Quantifying cost savings from improved outcomes to justify resources

Conclusions: The cath department is an extremely complicated and important component of hospital operations and financial success. It is important that managers of this department be extremely familiar with the technical details of the procedures conducted. Additionally, they must focus on cost and inventory control in a department that is very expensive to maintain. Managers with clinical backgrounds are an asset to this department because of the technical nature of the

procedures and because of the staff that are working within the department. New hospital administrators and existing department heads must make an effort to stay informed about developing technology and procedures, as these are the primary differentiators between competitors.

References: AHA (N.D.) AHA Guidelines. http://my.americanheart.org/professional/StatementsGuidelines/ByTopic/TopicsAC/AHA-Guidelines_UCM_321692_Article.jsp#.TtlWZdWG6uI Angioplasty.org. (N.D.) History of Angioplasty. http://www.ptca.org/nv/timeline.html Espanto, Franklin. (2011). Cardiac Cath Lab Department Head. University Hospital, San Antonio, Texas. Personal Interview. Lawrence, C. D. (N.D.) The History of Cardiac Catheterization. http://user.gru.net/clawrence/vccl/cath.HTM Texas Cardiac Arrhythmia Institute (N.D). About the Institute. http://www.tcainstitute.com/ourteam/about-the-institute.aspx Wheelus, Matthew. (2011). Director of Cardiology Services, Christus New Braunfels, Texas. Personal Interview.