Off-hour Cath Lab Scheduling
Shaving after-hours D2B minutesReperfusion 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."
Lab sharingLouisville 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 a single on-call model and compensation scheme.
"Angioplasty volume will ultimately determine the best on-call model for an individual facility," Tu says. "Systems that develop organically are acceptable to a point, but if volume gets too high, the only way to achieve additional efficiencies is to establish a uniform protocol."
Round-the-clock staffingAurora St. Luke's Medical Center in Milwaukee performed approximately 3,000 PCIs and 6,000 diagnostic caths in 2009. Back in 2004, they undertook a pilot project to assess how the presence of an onsite interventional cardiologist 24/7 would impact D2B times in STEMI patients during regular versus off hours.
"This program required a systems and culture change," says M. Fuad Jan, MD, a cardiac fellow at Aurora St. Luke's. "On any given month, there are 12 to 15 interventionalists involved with the 24/7 program."
The protocol stipulates an interventional cardiologist, a registered nurse and two cardiovascular technologists must be in the hospital for 24 hours. Their shift begins at 7:30 a.m. with the pager handed off to the next cardiologist on schedule the following day at 7:30 a.m. Once a STEMI is diagnosed in the ED, the four-person 24/7 interventional team assumes care of the patient after a single-call activation process. The team is expected to be in the cath lab in five to 10 minutes. The protocol also requires an on-call interventionalist for the rare incidence of a second STEMI presentation.
"In early 2004, we only were achieving a 90-minute door-to-balloon time in 40 percent of our cases," says Jan. "Around the same time, the [American College of Cardiology's] NCDR registry data indicated a similar national percentage of 36 to 39 percent. Therefore, we decided to undertake an out-of-the-box strategy."
To determine the program's effects, Jan and his colleagues assessed 790 consecutive STEMI patients who were treated sequentially. There were 297 in the on-call from home group (the "pre-24/7" group) versus 493 in the post-24/7 group, and the pre-24/7 patients were treated between Jan. 1, 2002, and March 31, 2004 (Catheter Cardiovasc Interv 2010:75(7);1015-1023).
Overall, the authors found that the median D2B time decreased from 99 minutes in the pre-24/7 group to 55 minutes in the post-24/7 group, and was not influenced by time of day or day of week. Prolonged D2B times were associated with higher one-year overall mortality in the pre-24/7 group compared with the post-24/7 group (12.8 vs. 8.1 percent). The 24/7 STEMI protocol also resulted in lower overall major adverse coronary event rates, reduced length of stay for STEMI patients and decreased in-hospital cardiovascular mortality.
"We acknowledge that the applicability of the current protocol may not be possible in all hospitals, for example, those with a more limited number of interventional cardiologists," the authors concluded. "However, in most hospitals with major cardiovascular programs (e.g., large urban hospitals), instituting an in-hospital call would be an attractive option."
In his accompanying editorial, Jonathan M. Tobis, MD, director of interventional cardiology research at the University of California, Los Angeles, expressed "worry about the increased cost not only financially, but in terms of exhaustion for the interventionalists of the future" (Catheter Cardiovasc Interv 2010:75(7);1024-1025).
Jan responds that while the actual time in the hospital for interventionalists has increased, the on-call time is less. Also, on the day of a 24/7 rotation, an interventionalist does not see patients in clinic. He notes that compensation has not changed for the interventionalist team with the new protocol.
Tobis says that he "would rather see hospital administrations spending money on digital transmission of ECGs than asking cardiologists to sleep over."
Despite reservations with 24/7 call, Jan sees the positive results of "removing the inertia that can sometimes prohibit time-sensitive cardiovascular treatments."