Scheduling staff for the cardiac cath lab can cause headaches for administrators, especially for time-sensitive, off-hour emergencies. Three facilities explain their methodologies for alleviating this common practice management concern.
Shaving after-hours D2B minutes
Reperfusion is the guideline-recommended strategy for patients who present with ST-segment elevation MI (STEMI). However, timely access to PCI shouldn't depend on what time or day the patient presents.
"Generally, the major delay in door-to-balloon [D2B] times for STEMI patients are avoidable, systematic delays, such as missed beeper alerts and phone calls during off-hours," explains Thomas Tu, MD, director of the cath lab at Louisville Cardiology Medical Group in Kentucky. "Typically, delays can easily be rectified with process changes for the entire interventionalist team."
In its four cath labs, Ochsner Medical Center in New Orleans staffs nine interventional cardiologists, who perform approximately 3,500 interventions annually—a third of which are PCI procedures. In addition to an interventionalist, each procedure is staffed by one nurse, who administers and monitors medications, and two technologists—one of whom records case details, while the other performs fluoroscopy. There also is usually a trainee present for all procedures.
Approximately seven years ago, John P. Reilly, MD, associate director of the cath lab at Ochsner, was tasked with reducing its D2B times, when the average time was 125 minutes. (In 2004, the guideline-recommended benchmark was two hours.) At the time, decision making involved paging either a resident or intern, who then paged the on-call interventional cardiology fellow who determined whether the case was a STEMI, and then paged the on-call interventionalist and activated the cath lab.
"Since then, we have worked through several on-call models, including a single-call beeper notification," Reilly explains. "Currently, if the ED identifies a STEMI case, it activates the cath lab while gathering confirmation from a cardiology fellow. Then, the cardiologist and nurses are called in." Over the past four years, the median D2B time has become approximately 65 minutes.
Currently, Ochsner's interventionalists, who receive fixed salaries, are on-call for one week every six to eight weeks, while the fellows are on-call about once every fourth week. The nurses and technologists are on-call for about one night per week, and receive additional compensation when they are on-call.
"If we had a higher volume of acute MIs, we might consider employing the 24/7 model for our interventionalists, but we also have the benefit of always having an in-house cardiology fellow to assess the state of emergent cases," Reilly notes. "Financially, we can't justify compensating a physician to be in-house, while in-house fellows facilitate the procedures."
Louisville Cardiology serves two cath labs—a hospital lab for inpatients and outpatients at Baptist Hospital East in Louisville and its own office-based outpatient diagnostic lab. The staff performs about 4,500 procedures annually, approximately 1,500 of which are PCIs.
At Louisville Cardiology's in-office lab, seven interventionalists perform diagnostic caths. However, Baptist is an open cath lab, and 10 interventionalists from various independent cardiology practices perform these procedures. The median D2B time for STEMI cases is currently under 60 minutes.
After a series of quality improvement changes to reduce D2B times, Baptist's cath lab established on-call hours for a minimum of four rotating staff members—two nurses, one radiologic technologist and the fourth person can be either. All staff members are required to take on-call hours, and they split after-hours time evenly throughout the year, says Tu. Generally, each staff member takes call about once every four to five nights.
"While our on-call staffing has vastly improved, the fact that multiple physicians from multiple practices cover the lab has caused some challenges," Tu acknowledges. "For example, some groups have non-interventionalists on-call, who then have to seek out an interventionalist to treat a STEMI patient during off hours."
Also, some interventionalists working at Baptist are not employed by the hospital, which further complicates establishing