Planning for the Ideal Cath Lab Requires the Multidisciplinary Approach

Planning and creating the best cath lab for your facility and market requires a wide range of considerations, from current and future business patterns to space design to workflow and communication concerns. A good plan that includes input from all the relevant stakeholders goes a long way toward a successful long-term venture.

A successful cath lab or heart center requires a realistic view of current and future business. You don’t want to overestimate and spend a small fortune on space that is underused and offers little return on the investment. You also don’t want to underestimate and not have enough space to accommodate current and growing volume. Unfortunately, hindsight is 20/20 vision, which is particularly applicable to the planning and design of cath labs.

Among the first considerations is whether to build new or renovate existing space. Depending on the status of the existing space, it can be cheaper to build new, says Georgann Bruski, director of contracting CVI at Beth Israel Deaconess Medical Center in Boston and principal consultant for radiology and cardiology services of ADVANCE Healthcare Consulting. If the ceiling height has to change to accommodate equipment, or the existing conduit is not compatible and floor drilling has to occur, costs can quickly add up.

More recently, Bruski says facilities are overestimating their cath lab business and building more than they can use. “They believe that ‘if they build it, patients will come.’ That might have been true five years ago, but it’s not true now.”

She cites a facility that built two cath labs but now performs only five procedures a day. The organization should have partnered with physicians and created a business plan to determine where their patients will come from, she says. “You have to design an RFP [request for proposal] for your needs. Set a goal of expected revenue.” A cath lab is a very expensive undertaking. Besides the initial set-up costs, people often don’t consider the annual operational fees—which can run more than $100,000 a year in equipment maintenance.

Facilities and practices need to thoroughly evaluate the marketplace to determine if it will generate enough volume to pay for a cath lab, says Susan N. Heck, vice president of Corazon, a cardiology consulting firm in Pittsburgh, Pa. “It’s a complex question. It’s not all about bricks and sticks,” she says. Aside from ensuring that there are enough patients, a good program requires reliable cardiologists. Since you can’t run a cath lab without physicians, you need doctors willing to commit to the facility.

“Our experience is that, if you work at it, you’ll find doctors who will partner with the hospital and commit to provide that service.”

South Shore Hospital in Weymouth, Mass., transformed its cardiovascular services in 2006. Accurate volume projections were essential, says Bill Burke, director of cardiology, since the hospital was considering a $13.5 million expenditure—its largest expenditure ever. The whole project took 18 months from first drawings to the open house. Corazon oversaw task forces for clinical workflow, patient and family experience, and facilities, which included IT infrastructure, equipment and staffing. Corazon’s work allowed the facility’s team to “focus purely on building and designing rather than worrying about the operational piece,” Burke says.

Data indicated that the area had a slightly higher than state average prevalence of cardiovascular disease, Burke says. To capture the market right away, the facility went live with a 24/7 emergency angioplasty program, which quadrupled volume in short order. Soon after, the hospital began offering elective angioplasty. South Shore is participating in the Mass Comm Trial, a randomized trial comparing the safety and long term outcomes for percutaneous coronary intervention between Massachusetts hospitals with cardiac surgery onsite and community hospitals without cardiac surgery backup. At this point, the first batch of data is being reviewed and Burke hopes the results will provide a “stamp of approval” on the process.

For now, the hospital has realized the fruits of its labor in terms of door-to-balloon (D2B) outcomes, Burke says. Last year, 88 percent of patients had D2B times of 90 minutes or less. This year, the number improved to 95 percent. The facility also is about four standard deviations below the mortality rate for acute myocardial infarction of angioplasty patients for its area. “That crystallized it for us as far as what we built and why,” Burke says. “The infrastructure is in place and it has all translated into the outcomes we hoped for.”

CT and MRI vie for cath lab presence

Whether CT or MRI will have a place in the cath labs of the future is still unknown, according Georgann Bruski, director of contracting CVI at Beth Israel Deaconess Hospital in Boston and principal consultant for radiology and cardiology services of ADVANCE Healthcare Consulting. She predicts that one or the other will take the place of diagnostic catheterization within the next five to seven years.

“We’re seeing facilities be very deliberate in the placement of noninvasive services close to the cath lab,” says Bruski. She worked with a tertiary care center that was very specific about where to locate the MR scanner in relation to the cath lab. “How each modality will work in conjunction with other diagnostic tools is developing day to day,” she says.

For now, catheterization is still considered the gold standard, says Carolyn Weaver, executive vice president of John O. Goodman and Associates, a consulting firm in Las Vegas. “We have not developed coronary CT to the level that we need to be able to say that it is going to take over the cath lab. We thought it would come along sooner.”

Home for hybrid care

One way to get more out of the cath lab investment is by creating a hybrid space, that is, a cath lab able to perform cardiovascular interventions throughout the body and certain surgical procedures. Hybrid rooms raise some concerns. According to Bruski, a lot of peripheral vascular physicians don’t want to go to cardiology or radiology. They want to do their diagnosis and have the ability to go right to an open procedure in an operating room setting. If you build a good electrophysiology (EP) room, this is possible. That kind of facility runs about $1.5 to $2 million. “A lot of EP labs just break even, so it’s a big decision. You have to look at your payor mix and remember that it takes 10 private-practice physicians to make one cardiologist profitable.”

Areas in which the market cannot support cardiac services alone often can succeed by combining cardiology with vascular care. “Tapping both sides of the bench,” however, requires a different mindset and space configuration to accommodate cardiac and vascular cases with the right equipment profile and technology that allows for great images, says Heck. As capital dollars for hospitals get tight and it comes time to replace an older cath lab or radiology specialty suite, many facilities are making the decision not to buy two new sets of equipment but rather asking people to work together in new ways. The hybrid suite allows for both interventional and operative procedures by using equipment that fits both worlds.

Turf wars among radiologists and cardiologists are a concern, but the two disciplines have to reach an accord as cardiac care becomes more collaborative and less invasive. “Having interventional radiologists and cardiologists working out of the same lab is something hospitals have to overcome,” says Heck. “I think programs that have done it are delivering better care.”

In their new space, South Shore Hospital wanted to eliminate disparate services between departments and isolated components of cardiovascular care. Plans called for the new heart center to occupy half of the hospital’s first floor. “It allowed us to refine our resources to avoid having three or four redundant areas with underutilized space,” says Burke.

Because services such as peripheral vascular care didn’t exist before the new construction at South Shore, the hospital issued an open invitation to all clinicians to work in the heart center. Rather than fight over resources, the physicians were interested in working together to build up the center and provide a comprehensive service, Burke says.

Marion General Hospital in Marion, Ind., opened two cardiovascular suites last year, created out of old office space, says Melo-Dee Perez, administrative director of the cardiovascular service line. The hospital decided to create a totally digital facility completely networked with its electronic medical record system. Rather than sending patients to various areas of the hospital for blood work and other testing, the new space offers “one-stop shopping.” The staff of nurses and technologists are cross-trained so patients never have to leave the department.

Mulling over modular set-up?

Several companies offer the ability to set up temporary, modular cath labs. This option addresses a couple scenarios, says James Easter, director of the healthcare planning department at HFR Architecture Engineering in Brentwood, Tenn.

For example, if a facility is trying to determine whether it has enough business to warrant the investment of new cath labs, they can essentially go modular as a short-term test. Typically, facilities with a full-time cardiologist and a strong, growing cardiac program should create a heart center, says Easter.

Another scenario is one in which the facility is dismantling the current cath lab space to make way for a new heart center. It takes at least a month to install a new cath lab, which is too long for many facilities to go without cardiac services revenue. A modular setup works as an effective interim solutin, he says.

Cost and space considerations

Once a facility decides on the building plan, it’s time to consider costs. Construction costs often are the most overlooked variable when setting up cath labs, according to James Easter, director of the healthcare planning department at HFR Architecture Engineering in Brentwood, Tenn.

The total project budget is frequently inaccurately prepared because the owner mistakenly focuses solely on construction costs. Only about half of the total investment goes to getting the space operational, Easter says. Everything from the price of equipment, lighting and other fixed items to architectural fees go into the spreadsheet to help reach an accurate dollar assessment “If we don’t take it all the way to the bottom line, we’ve only got half the answer,” he says.

Regardless of the specific clinicians working in the space, giving them plenty of room is essential. Generally, the spaces are too small, says Easter, a function of trying to keep the budget tight and save money. The decision about size should be made on the space available and the strategic plan for the future. It’s one thing to convert an old operating room or obstetrics room because the space is available. But how does that space fit the overall plan for future growth? Many hospitals are “landlocked” without much room for future growth. The American Institute of Architects guidelines call for a minimum of 400 square feet for procedure space. Easter says that once you add in a scrub area, circulation, equipment hold, prep space and technologist/student space, you’re back up to 1,200 to 1,500 square feet of departmental gross area for the cath suite. That larger space goes a long way in helping cath labs run smoothly, efficiently and comfortably, especially if teaching and research is involved. Easter recommends building expansion space into the plan.

One way to maximize space is by creating an endovascular suite that can convert to an OR. “Lots of facilities are building sterile ORs that are cath lab-capable,” says Carolyn Weaver, executive vice president of John O. Goodman and Associates, a consulting firm in Las Vegas. This type of configuration can reach $2 million in construction and set-up costs but it can be used all day long because of its multifunctionality.

Today, much of the equipment in a cath lab is ceiling mounted. When retrofitting older spaces, the equipment buying team has to consider if the space has the proper floor-to-ceiling height, as well as enough space for lighting, ductwork and wiring. If the wiring doesn’t fit in the floor or ceiling, an artificial set-up along the sidewalls will be necessary.

It is also important to plan for the reams of cabling needed for today’s electronically connected cath lab. Information services is the biggest problem with every healthcare building project, Burke says. “Cardiovascular centers are not about machines or even process modes. They are all about sharing information—getting reports to physicians, scheduling information and redundant data entry.”

The old facility at Marion General Hospital did not have enough electrical outlets. The two new cardiovascular suites were designed to have all wires and cables underneath the tables, including oxygen and suction, says Perez. “You never really think about how many things are plugged in,” she says. Another improvement at Marion is the holding space, which now has eight fully equipped private beds, rather than curtains separating restricted-use beds. Marion also saved space by creating a combined monitoring area for both labs and a shared supply area.

Allowing elbow room

Providing enough space for staff and patients is a crucial concern. The trend is running toward holding cardiovascular patients overnight, so space for enough beds is important. “We say if you have an average of 25 patients in the hospital that are heart and vascular related, you should have at least half as many beds for outpatients,” says Weaver.

The area also needs enough room for all the people working in the space. Many cardiac cath programs include teaching and training components, says Easter, which can result in up to 10 people in the procedure area at any one time. Unfortunately, sometimes it’s not until people are using and working in the space that they notice these types of problems. Adequate space is needed for observation and stretcher access and the ability to comfortably move patients in and out. “When you cut space out of functional areas, you are reducing the value of the end product,” he says.

And don’t forget the family. A pleasing environment for both patients and their families can go a long way toward a successful heart services center. Oftentimes, the patient is worried about family members. One should design a new waiting room centered around comfortable seating, beverage machines, reading material and private space for family members to meet with clinicians. When South Shore Hospital demolished its old space, it invited families to give input for the future design of the waiting and check-in area. “The literature shows that the more patients and their families are integrated into care, the better the outcomes,” says Burke.