Most community hospitals with cardiac catheterization labs share these facilities with multiple, non-interventional cardiology users, which can be challenging to manage various specialties’ needs. Beyond percutaneous coronary interventions (PCI), these labs are frequently shared with electrophysiologists (EP), vascular surgeons conducting endovascular repairs and interventional radiologists (IR) performing an array of non-coronary vascular or peripheral interventions. Multiple-user cath labs are common because of the cost to build labs, and many labs face lower cardiology patient volumes, allowing open scheduling time for other users to keep the labs cost-effective.
Illustrations of how lab managers balance these needs can be found at Northwest Community Hospital (NCH) in Arlington Heights, Illinois, and St. Alexius Medical Center in Hoffman Estates, Ill., in Chicago’s northwestern suburbs. The hospitals are about eight miles apart and offer examples of how they have adopted to multiple users in their labs to maximize return on investment (ROI) in a highly competitive market with multiple hospitals in the surrounding area.
Northwest Community Hospital has three cardiovascular cath labs. All three are used for interventional cardiology procedures; one is outfitted as an EP room, and another with a larger field-of-view angiography detector is used for vascular surgeons performing peripheral procedures.
“We do have a large number of users for our labs,“ said Bonnie DeGrande, RN, MS, executive director, cardiovascular service line, Northwest Community Hospital. “The more you can get them all to sit down together and talk about what is best for the patients the easier it is for cooperation, and that is where I spend a lot of my time. It’s all about integration and how we can share resources and facilities and we try to be as fiscally prudent as possible.”
St. Alexius Medical Center shares its two cardiac cath labs with EPs who perform device implant procedures only, and occasionally with interventional radiology when their separate lab is in already in use. The IRs are in the process of building a new interventional suite next to the cardiac cath labs so they can more closely coordinate efforts as part of cost-cutting measures by the hospital.
Avoiding Turf Wars
Traditionally, various specialties that use interventional labs have been pitted against each other in competition to perform the same procedures. However, collaboration between vascular surgeons, interventional cardiologists, IR and EP has become a necessity at many hospitals due to current economic realities. These factors include stiff competition between neighboring hospitals, decreasing patient volumes, and the need for better procedural proficiency based on higher case volumes.
There were issues between interventional cardiologists and IRs both performing peripheral revascularization procedures at St. Alexius several years ago, said Laura Fiaccato, RN, BSN, MSN, director of the cardiac cath lab, non-invasive cardiology and interventional radiology departments, St. Alexius Medical Center. However, patient volumes for both were low, so it was decided the cardiologists would be the providers of these services, since they were more proficient due to their experience with coronary revascularization procedures. She said IR has concentrated on more traditional work, such as installation of ports, peripherally inserted central catheter (PICC) lines, dialysis catheterizations, fistulagrams, uterine fibroid ablations and biopsies.
St. Alexius cardiologists also once performed abdominal aortic aneurysm (AAA) repairs; the hospital works closely, however, with its sister, Alexian Brothers Medical Center in nearby Elk Grove Village, and now refers these patients to vascular surgeons at Alexian Brothers who perform a higher volume of AAAs. St. Alexius also works with the Alexian Brothers’ EP lab to refer patients who need cardiac ablation procedures.
As collaboration and partnering become the new normal in healthcare, Fiaccato said getting everyone to cooperate is key. “I think the biggest thing is to get all the stakeholders together at the table to talk,” Fiaccato said.
“Good communication between everybody will determine what you want to do, where you want to go and how to do that,” Fiaccato said.
In an effort to make staffing more flexible, both Northwest Community and St. Alexius have cross-trained their cath lab techs to allow interchangeability, regardless of the procedure of specialty involved. St Alexius is cross-training both the IR techs and the cath lab techs so they are interchangeable between labs and between cardiac, peripheral vascular, EP and IR procedures, said Fiaccato. At Northwest Community, all techs are cross-trained in peripheral and EP procedures. DeGrande said this greatly helps efficiency and allows for smooth workflow, since it is the same personnel using the labs, instead of different specialty techs stepping in who may do things differently.
DeGrande said it is not always possible to hire a tech with experience in multiple specialty areas, but she said as long as a tech has interventional cardiovascular and peripheral experience, they will train them on the job for EP, which can be more challenging and is a different type of workflow.
Both hospitals have a policy of scheduling procedures on a first-come, first-served basis. However, rooms scheduled for EP and peripheral cases are booked for longer times, since these procedures generally take longer than interventional cardiology procedures.
The St. Alexius cath labs are both equipped for EP use to install pacemakers and implantable cardioverter defibrillators (ICDs). However, Fiaccato said they try not to schedule two simultaneous device implants at the same time because of the long procedure times and the need to keep one lab open for possible emergency STEMI cases. NCH schedules most of its EP procedures on Tuesday and Thursdays, so it is easier to keep track of how long the EP room will be in use and to have an anesthesiologist available. DeGrande said schedules for the labs are modified as needed when there are acute myocardial infarction patient emergencies.
Northwest Community also uses charge nurses, who help immensely with the smooth flow in coordinating lab usage. “It’s really the charge nurse who really works the scheduling,” DeGrande said. “Their job is a busy one, and they change and manipulate that schedule daily as needed.”
At St. Alexius, IR is currently in the process of being integrated with the cardiac cath lab to streamline supply inventory of many shared interventional devices, such as angiographic catheters, guide wires, introducer sheaths, etc. “This will really allow us to pare down the inventory of devices,” Fiaccato said. “It will really help with reducing redundancy.” She explained it also will simplify tracking of device expiration dates.
For labs that are consolidating for shared use, Fiaccato said they found an important thing to keep in mind is storage space. “If you are building a new lab or considering storage for everything your lab needs, go bigger than you think you will need, especially with storage,” she stressed.
For the three specialties using the cardiac cath labs at Northwest Community, DeGrande said they have standardized the types of devices and supplies each use where possible and consolidated ordering. This simplified lab management and has helped cut costs and supply redundancies.
“You can’t have it all, and we are not going to have six different products that do the same thing,” DeGrande said.
She said the EPs are very cognizant of the cost of their devices and equipment, and they work closely with the lab managers for what they need and to tightly control inventory.
Northwest Community has a separate IR lab, including a neurointervention room. However, DeGrande said IR and interventional cardiology work closely when it comes to ordering supplies. They have consolidated the number of vendors they work with and now negotiate combined contracts with vendors, since both labs use many of the same devices. By working together, she said they have been able to get better rates on combined supplies due to the higher volumes achieved.
“We work with the OR too, since they also use things like guide wires and other transcatheter devices for some procedures,” DeGrande said.
St. Alexius uses CareFusion Pyxis carts for inventory control of high-cost items in the cath lab. In addition to medication, they also stock many of the expensive devices and disposables in the cart as well, so all items taken out are automatically accounted for. The labs also have an inventory specialist who tracks items manually. Fiaccato said some items are just too large to fix inside the Pyxis drawers, such as Impella percutaneous ventricular assist devices, so these and other large items are kept in separate cabinets.
St. Alexius looked into radio frequency identification (RFID) cabinets a few years ago to automate their inventory control process, but they found the RFID tags that are required for hundreds of items in stock at any time cost about $1 each. In addition, once boxes are tagged, they cannot be removed without tearing the boxes, so the consignment system they use with vendors would no longer be viable, as all tagged inventory would have to be purchased and owned outright, Fiaccato said.
New Device Acquisition
DeGrande said when new technologies are introduced, especially those that may cause competition between the various specialties, having all parties involved in early implementation discussions is very important.
“It’s really getting all the right physicians who will be involved with anything new to sit around a table to talk,” DeGrande said. “You need to include all the players early on.”
She also said it is important to have a champion physician for a new technology or procedure who will take the lead on pushing things forward and facilitating discussion with peers and managers.
Northwest Community had a new vascular surgeon join the staff last August who wanted to implement new technologies for peripheral vascular treatments for chronic total occlusions (CTO), drug-eluting balloons and drug-eluting stents. They worked with the cath lab manager to set up supply agreements for the new devices needed. The cath lab also began a carotid stenting program recently where coordination was needed for new types of devices.
St. Alexius is part of Ascension Health, a Catholic healthcare system that includes about 80 hospitals. Ascension negotiates contracts with vendors for all of its hospitals. If there is a new procedure or device technology the St. Alexius operators would like to try, they first look to see if Ascension has a contract with the specific vendor. They have a new product committee that reviews all requests for new inventory items to ensure it is needed and that another device already in inventory cannot be used.
“You need a good cost analysis to see if it will add any value to your program,” Fiaccato said.