Catheterization delays can be avoided by opening lab on Saturdays
On-call staff can also help eliminate those expensive days of waiting
Some cardiovascular service departments are struggling with a conundrum: Open the catheterization laboratory on the weekend and avoid those expensive inpatient days when patients are merely waiting for the procedure, or absorb those costs and deal with the issue in other ways that may not antagonize staff? Other departments have tried then abandoned the concept, turning to other solutions instead.
As a major academic tertiary care center, the Beth Israel Deaconess Medical Center in Boston derives a significant portion of its business from cardiac catheterization.
Delays prompt pilot program
Managed care organizations recently noted significant nonmedical delays for patients going for nonemergency caths, and the companies did not want to pay for those delay days. Managed care committees typically review their patients to see if they are being managed as efficiently as they should be.
In response to the problem of delay days, Apurv Gupta, MD, MPH, associate medical director, and his colleagues in the Invasive Cardiology Division at Beth Israel reasoned that delays may be due to the fact that the cath lab is not available to nonemergency patients on weekends. The team decided to pilot a program of opening the cath lab temporarily for regular hours on Saturdays to see if it saved money. First, they needed to gather data to support such a decision.
"When we looked at some preliminary data, we found evidence of delays for people coming in for caths on Friday or Saturday," says Gupta. "Their caths were not getting done until Monday. We reported that finding to the lab staff, and they agreed to proceed with a three-month trial to see if opening on Saturdays was feasible."
Beth Israel Deaconess gets many referrals and transfers from outlying hospitals. "When we were gathering our data," Gupta explains, "we found that if patients were transferred between Sunday and Thursday, they were cathed within 24 hours." But if they came in on a Friday or Saturday, their caths were delayed.
"Based on our new information," he says, "we’d like to be able to say to referring hospitals, Since we can’t do caths on Saturday, don’t transfer [patients] here on a Friday. Wait and send them in on Sunday or Monday so they can get taken care of efficiently.’"
The pilot study had more than one goal. In addition to determining if the Saturday cath lab pilot program would be effective in reducing delays, the team also studied the care processes leading to caths in the hope that they could identify which processes generated system inefficiencies.
Over a nine-week period, interventional cardiology nurses reviewed 231 admitted cath patients. For any patient not cathed within one day of admission — the departmental target standard — a nurse performed an in-depth review to determine the cause of the delay. Only deferments for nonclinical reasons were coded as system delays. Delay rates, length of stay (LOS), and pre-cath LOS were entered into a database, re-checked for completeness, and analyzed.
Results showed room for improvement
Out of the 231 inpatient cases, the number of delays was 26 (11.3%). The average overall LOS was 4.41 days and the average pre-cath LOS was .77 days. Based on the day of the week on which delayed patients were admitted, it was determined that about half of the 26 delays were due to the cath lab not being open on the weekend. The team saw that clearly there was room for improvement. They proposed that opening the cath lab on Saturday for regular hours would reduce by half the delay rate and improve efficiency.
The reduction in delay rate and pre-cath LOS is documented in Table 1 (see p. 62), which shows the variables that were found to be associated with a high degree of systems efficiency.
Table 2 (see p. 62) shows, in contrast, the variables that were associated with more inefficient processes. The change that led to the improvements primarily was opening the cath lab for regular hours on Saturdays. But, says Gupta, by itself the very establishment of a process of data collection, chart review, monitoring, and reporting led to good outcomes as well.
"We all agreed that improvements in efficiency noted over the weekdays was due to the data collection/monitoring process," he says. "Attendings [attending physicians] and other staff on the unit became more aware of processes when they were monitored," he says.
"The pilot trial was a useful process," says Gupta, "but it never really got off the ground," mainly due to the fact that the organization is going through a merger of campuses — Beth Israel Hospital and Deaconess Hospital. A product of the large merger in progress will be an amalgamation of the cardiology divisions of the two entities, and a consequence of Gupta’s pilot study would be to incorporate this new scheduling once the departments merge.
"But that hasn’t yet happened," says Gupta. "The only way we can get the Saturday cath schedule is to merge the two labs. The pilot study has been bogged down with management and political issues associated with the merger, so we haven’t been able yet to merge the cath labs and execute our changes. Now, we’re back to where we started."
Staff resistance can be roadblock
Gupta says there was tremendous resistance to Saturday openings among the staff because they were being asked to flex their schedules so Saturdays wouldn’t count as extra time.
"That resistance can be a powerful roadblock to an improvement plan’s moving forward." He saw additional resistance to the pilot among those who discerned no reason, beyond the economic one, to step up the cath process. They argued that the procedure could be delayed safely because typically cath patients are stable.
"If a patient stays in the hospital a few days pre-cath, it doesn’t matter much clinically, except for iatrogenic complications," says Gupta. But on the other hand, there’s no medical reason to delay. In his opinion, "Let’s get them done right away so we can get them out."
But all is not lost, he says. Even though, so far, the pilot study has produced no lasting gains; it has raised a lot of issues. Data was presented and positively received by multiple committees.
"There have been lively discussions about what should happen in the future regarding the cath labs," he says. "Our pilot made people — all the way up to the organization’s CEO — aware of what goes on in the cath lab. The executives are now aware of inefficiencies in the present system and the potential to remove them. I see that as a gain. We are happy with the dramatic results of our pilot."
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