A Successful Suture-MediatedClosure Program: Turning YourLab Into a Profitable Entity

Purpose: To describe how the cardiac catheterization lab at Westchester Medical Center increased hospital revenues as a result of changing its groin management protocol. Methods: In June 2000, Westchester Medical Center (WMC) implemented an arterial closure program. The primary endpoint of this program was to measure changes in the profitability of the cardiac catheterization lab (CCL) at WMC based upon implementation of a new groin management program. Profitability was measured by analysis of average Medicare reimbursement, average hospital cost for a catheterization procedure at WMC and comparison of the number of procedures before and after the new groin management protocols (January 2000 through December 2002). Results: Patient turnover (measured as number of outpatients treated per bed in outpatient recovery area) increased from a baseline of 20 patients per bed to 25 patients per bed (a 25% increase) in 6 months, to 32 patients per bed (a 60% increase) by the end of 2002. The increased number of procedures resulted in an estimated net revenue gain of $628K.* Conclusion: Routine use of Perclose has allowed for greater scheduling flexibility for outpatient procedures and improved inpatient and outpatient procedural capacity. *Cost analysis is based on the unadjusted median values for CPT 93510, based on 2001 Medicare claims files which indicate the median charge for a Left Heart Catheterization is $2502. The Medicare payment is $1531 and average hospital costs are $833 (including the cost of the closure device). (1531-833 = $698 profit per procedure multiplied by 901 additional procedures = $628K.) Introduction Most interventionalists have made a conscious decision to either incorporate arterial closure devices into their practice or exclude them entirely. In this era where the ability to obtain information immediately dictates how we make decisions, we have come to expect immediate results from the decisions we make. When it comes to utilization of arterial closure devices, what often gets overlooked is that the results and their impact on the institution are gradual. This is because there is an initial investment of time and effort to become proficient with the devices before the cost and clinical benefits of the technology investment are realized. As new technology is learned, physicians and staff become more comfortable implementing new policies and procedures to optimize results and make the closure program successful. As shown in this case study, complete and successful integration of a closure device program requires administrative and physician support, a commitment to change, and an understanding that measurable results happen in stages. The return on investment of an arterial closure device by Westchester Medical Center (Valhalla, NY) has been a combination of increased efficiency, cost savings and improved patient care. Background Westchester Medical Center’s cath lab is a 5-lab facility with 8 ambulatory beds. The lab performs approximately 7,000 diagnostic and interventional procedures annually. Prior to June 2000, the standard of care for achieving hemostasis of the femoral artery was manual compression. The CCL was operating at 100% capacity and was still unable to meet the demand for bed space. WMC implemented a femoral artery closure program using the Perclose system (Abbott Vascular Devices, Redwood City, CA) in order to assess the clinical safety of the device and to investigate the potential to reduce the need for overnight admissions for those patients with late afternoon cases. The outpatient recovery area was not staffed after 7:00 pm. Patients having diagnostic angiography procedures after 2:00 pm were admitted for an overnight stay that resulted in an average of 15 overnight admissions per month. This was costly, and utilized valuable staff time and bed space. Furthermore, spending unnecessary time in the hospital can be taxing on patients and their families. Implementation of an arterial closure program was expected to increase the available bed space, improve patient care and patient satisfaction. The CCL had to work within the existing limitations of the hospital structure to find creative ways to improve patient turnover while containing costs. The objective of the arterial closure program was to limit the number of diagnostic patients forced to stay overnight due to manual compression ambulation protocols and to increase the number of outpatient procedures per day. Prior to the implementation of this program, procedures such as pacemaker implants, which can be performed in the CCL, were being done in the operating room (OR) due to a lack of available space in the CCL recovery area. A suture-based closure device was chosen because it permits faster patient discharge without increasing complication rates.^1-3 Patients are eligible for discharge in 1-2 hours after a diagnostic catheterization with Perclose versus 4-6 hours after receiving manual compression. Methods Utilization of the Perclose system was instituted at Westchester Medical Center in June 2000. The first step in the program was physician and staff training. Physicians planning to use the device received proctorship from a certified Perclose representative and educational training sessions were held for cardiac cath lab staff, recovery area personnel, and floor nurses. Upon completion of the 10-case training process, physicians received certification to use the device. Adoption of the Perclose system from manual compression was gradual. Initially, two days per week were dedicated to physicians using Perclose and patients were chosen selectively. Once efficiency was demonstrated, use of Perclose increased to include multiple operators. Within 6 months, the device was used for all eligible diagnostic and interventional cases. Procedure volume was tracked by procedure type to confirm that patients were being discharged according to the new protocols (1-2 hours after diagnostic catheterization). Total procedure volume was analyzed from January 2000 (5 months prior to the introduction of Perclose) through December 2002 (Table I). Results Initially, the adoption of Perclose led to a 25% increase in outpatient bed utilization from 20 outpatients per bed to 25 patients per bed each month. By the end of 2002, outpatient bed occupancy had increased 60%, to a rate of 32 patients per bed each month (Figure I). The advantage of a device that provides mechanical closure of the vessel is that the integrity of hemostasis could be promptly assessed in the lab. This allowed for diagnostic patients to be taken directly to the ambulatory area and for interventional patients to be taken directly to an inpatient bed, bypassing the holding area where sheaths were traditionally removed. This meant less congestion in the holding area, freeing up valuable nursing time to care for patients requiring additional monitoring. Reduced congestion in the holding area also resulted in the cardiac cath lab at WMC being able to accommodate other types of inpatient procedures that could be performed on a routine basis. Prior to June 2000, standard practice was to perform pacemaker implants and implantable cardioverter-defibrilator procedures in the OR during off peak hours. Hospital administration was concerned with low patient satisfaction due to the late hours spent waiting for standard OR procedures to be completed and cardiac procedures to begin. Finally, pacemaker implant procedures were returned to the CCL (Table II). As suture-mediated closure became the standard of care at WMC, the increase in bed utilization and faster patient turnover allowed physicians to perform more peripheral work (renal, femoral, and carotid diagnostic and interventional procedures). The capacity to perform these procedures resulted in the lab inpatient procedural volume increasing by over 600 cases annually (Table II). In addition to increased procedural volume, routine use of the Perclose suture-mediated closure system afforded greater scheduling flexibility for outpatient procedures. By requiring early morning procedures to use Perclose for vascular hemostasis (patient condition permitting), procedures can be systematically scheduled throughout the day and patient turnover is maximized. Late afternoon and early evening procedures can be scheduled and patients discharged the same evening, virtually eliminating overnight admissions following diagnostic procedures. Clinical Outcomes Since utilization of the Perclose suture-mediated closure system altered the standard of care, we tracked overall complications on a routine basis. During the training period, 3 infections occurred in Perclosed patients. This experience raised awareness about the importance of sterile technique and physicians now administer prophylactic antibiotics to high-risk patients (immunocompromised, morbid-obese, diabetic, etc.). There have not been any infections in the two years since this protocol was instituted. Anecdotal analysis of complication rates has shown a trend towards fewer complications, particularly large hematomas. Conclusion Medical professionals share the goal of providing the best patient care and collectively face the challenge of having to cut costs and become more efficient. It is the responsibility of the physician, lab director, and administration to work together to finds ways within the existing budget to make room for exciting new technologies that will continue to improve patient care. We have prepared for this new era by becoming a high-revenue generating entity with a hospital that operates efficiently at full capacity a status we achieved with a successful suture-mediated closure program. Routine use of the Perclose hemostatic device has allowed for greater scheduling flexibility for outpatient procedures and increased procedural capacity for both inpatient and outpatient procedures. At WMC, faster patient turnover is the key to the 5-lab, 8 ambulatory bed facility keeping pace with the high demand for cardiac and peripheral procedures, and so we have come to rely on the benefits of a closure device program. The success of this program has increased patient turnover by 60% and generated an estimated $628k in hospital profit from the cath lab alone. *Numbers are approximate and are based on the unadjusted median values for CPT 93510 based on 2001 Medicare claims files. Estimate does not include patient co-payments. The 2001 Medicare claims files indicate the median charge for a Left Heart Catheterization is $2502. The Medicare payment is $1531 and the average hospital costs are $833(including the cost of the closure device). [$1531-833=$698 profit per procedure multiplied by 901 additional procedures equals $628K. (Estimate does not include any revenue that is received from patient co-payments.)] The authors have no conflicting interests to disclose.

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