Should you open your cath lab on weekends?
On-call, reorganization met these facilities’ needs
Some cardiovascular services units in facilities around the country have tried Saturday cath lab hours, and many depend on on-call teams for their weekend needs. One of those is Jewish Health System of Cincinnati.
Debra Caskey, RN, the administrative director there, says they have quite a few cases that could be done over the weekend and have considered opening the cath lab for Saturday hours. A team at Caskey’s facility recently ran a feasibility study similar to that run by Beth Israel. (See cover story on Beth Israel Deaconess Medical Center in Boston.)
"We tracked our weekend activity for several months and found on average, if we opened a Saturday lab, it would be busy for about five hours," she says. "If a facility had a larger lab than ours, like that at Beth Israel Deaconess, I can see where its volume might sustain Saturday opening."
Rotating on-call staffs chosen
The Jewish Health System team looked at an alternative approach: keeping a rotating staff on-call on Saturdays. "We chose not to have scheduled Saturday hours. Instead, we established an on-call team to covers those cases," explains Caskey. "We preschedule Saturday caths the Friday before, and this is working well for us."
She says that to schedule regular hours on Saturdays would increase their staffing costs. The staff agreed to an on-call regimen, and now the on-call staff take care of both prescribed nonemergency patients and urgent cases.
"Sometimes on a Friday, a physician will order a Saturday cath even for a nonemergent patient, either because of his time commitments or simply based on lab availability," she says.
This applies only to inhospital patients who for some reason were admitted later in the day on Friday. "We wouldn’t schedule a nonemergent outpatient on the weekend," she adds. "The decision to go to on-call Saturday caths was made for economic reasons — we don’t want to extend the LOS."
On-call has worked out well at Caskey’s facility where they apply a 40-hour rule — when staffers take on-call, if that brings them over 40 hours, they are paid at time and a half. If not, it’s straight time. Their on-call has a three-hour minimum.
"We would have to add a minimum of two-and-a-half full-time employees in order to cover for one day off during the week to cover the Saturday, so it’s more economically feasible to cover for that day by on-call staff," Caskey explains.
Staffers think it’s worthwhile, she says, yet it’s less expensive for the facility. "If we’ve had a super-busy week, and the staff have had a lot of late cases, the money doesn’t seem to be as important to them. But if things are quieter, they appreciate the extra in their paychecks. Also, they see it as part of the territory when you work in that department."
Lab staff cross-trained for radiology
Jewish Health System’s cath lab comprises three rooms with a staff of three per room, plus at least one floater and a charge person who can plug into any room as needed. The cath lab staff is cross-trained to do special radiology procedures as well. On any given day, there are usually at least 11 staff — RNs and radiology techs — in the three rooms, plus two or three staffers in the holding bay. The facility has a dedicated pre-op holding recovery area, so they keep outpatients, then discharge them from the area.
"Patients like this arrangement," Caskey says, "because they know where they are going and where they will be, instead of being moved all around the house."
Francine Nigrello, MS, the executive director of the George E. Reed Heart Center at Westchester County Medical Center in Hawthorne, NY, says Reed’s cath lab used to be open on weekends, but staff stopped their weekend schedule two years ago when they discovered it wasn’t worthwhile financially. They drew the line at five cases. A routine cath runs one to three hours.
"We improved our efficiency during the week and are now able to fit in all the cases so patients aren’t waiting over the weekend," she says. "If six or more cases are awaiting caths, and it looks like patients will be waiting over the weekend, we bring in an on-call team on Saturday. We haven’t had to do that in a long time."
Reed Heart Center ran a feasibility analysis of Saturday openings based on salaries. "For a Saturday schedule," says Nigrello, "you need one room open and two RNs and two techs." At Westchester County Medical Center, RNs make about $60,000 per year, and techs make between $30,000 and $55,000.
In addition to those expenses, she says, when you run a regular Saturday cath lab, it cuts down on the number of staff you have during the week. "Also," Nigrello adds, "physicians prefer to cath during the week, because they are typically on call over weekends."
How did they improve the efficiency of their labs during the week? "We extended the hours of the lab one hour so it’s now open from 7:30 a.m to 8:30 p.m. And we hired more MLEs," says Nigrello.
What are MLEs? She explains that they are extra hands that do everything, thus, they "make life easier." They have multiple job responsibilities such as cleaning the room and moving patients. They free up the RNs and techs so they can concentrate more on the patients.
"Formerly, we were doing 28 patients a day in four rooms," she says. "With our new reorganization, we can do 40 cases a day in the same four rooms."
Kathy C. Fox, MSN, RN, the cardiac service line director at St. Francis Hospital & Health Centers in Beech Grove, IN, says they are not open on weekends, but each year, they review that possibility with their interventionalist group.
"St. Francis’s situation differs somewhat from that at a large institution like Beth Israel with a large cath referral base. It’s a bigger issue for them. Our referral base of feeder hospitals do their own caths, but not open-heart," Fox explains. "If for some reason, we did have to do a cath under those late-week circumstances, we’d do it on an on-call basis." Fox’s facility has a call team in place.
"When we looked at the cost of having the cath lab open on a Saturday vs. calling in a team, it made more sense to call in the team," she says. "We found that for us there was about a $10 difference between the two."
With St. Francis’s situation, Fox says, typically patients need a day or two to get the anticoagulants out of their systems or to stabilize in the case of an infarction, so they are not generally faced with that unnecessary pre-catheterization weekend delay that other facilities may have.
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