A Joint Venture Creating a For-Profit, Freestanding Cardiac Catheterization Lab: Heart Center of the Rockies
At HCOR, we perform diagnostic and some therapeutic procedures, including: Cardiac and peripheral angiography; Dobutamine stress-echo (DSE); Transesophageal echo (TEE); and Cardioversions. The lab itself is physically connected to the Heart and Vascular Clinic and is located about three miles from Poudre Valley Hospital. The hours of operation are Monday through Friday from 6:00 A.M to 4:00 P.M. We are currently doing about 60-75 diagnostic cath and peripheral cases/month, and 15 procedures/month.
Cath Lab Daily Operations
The HCOR has a spacious work area, which includes a pre- and post-care area with 13 patient bays. There is also a large procedure room where the DSEs, TEEs, and cardioversions are done. The cath lab itself is oversized and has Toshiba equipment with digital acquisition. Patients are admitted to the pre-procedural area about one hour before their procedure. The necessary paperwork is prepared the day before, so that when the patient is admitted, there are only a few nursing tasks to do before the patient is ready to go back to the cath lab. Patient charts in HCOR’s cath lab are linked electronically to the Heart and Vascular Clinic, so the patient’s electronic medical record, etc., is all available to us through our computer system. We are also linked to the PVHS computer system to gain access to lab work, previous patient admissions, and so on. Consents, financial paperwork, and insurance qualifiers are all taken care of when the patients are seen in the Heart and Vascular clinic. On an average day, we do about 4 caths and/or procedures. Staffing for this volume level is 3 nurses and 1 unit assistant/orderly. We stagger hours so that the first staff member comes in at 5:30 A.M. to open the department. This is followed by the manager at 6:00 A.M and the last nurse and unit assistant at 6:30 A.M. Our first case begins at 7:00 A.M. Two nurses do the cases, with one nurse scrubbing in with the physician, and the other nurse circulating and monitoring. Our nursing staff is ACLS-certified and we have all the necessary resuscitative equipment, including an IABP. If we were to have an emergency, we have a call button that summons the nurse from the admission area. We are also physically attached to the Heart and Vascular Clinic, which has additional nursing staff that can be pulled over to assist. The state of Colorado does not require a radiologic technologist to be present for procedures. Patient charting in the cath lab is all done through the GE Marquette Mac-Lab® 7000. After the patient is done with their procedure, they are brought out to the post-recovery area and their sheath is pulled. Since Medicare does not reimburse sealing devices in a separate outpatient clinic, most of our sheaths are pulled and a clamp is used for hemostasis. If necessary we will use Angio-Seal (St. Jude Medical, Minnetonka, MN), but use it discriminately. We use 5 and 6F catheters at HCOR. Patients are placed on bed rest for 2-3 hours and sent home. We do follow-up calls one week after the patient has had their procedure and have been very pleased with patient feedback. We have one cardiologist for the morning that does all the cases for the day. He is usually due in the clinic to see patients at 10:00 A.M. Our mornings are very busy, but because most of the paperwork is done prior to the procedure, the workflow goes very smoothly. Our unit assistant helps clean and turn over the rooms, as well as pulling sheaths and handling general patient comfort issues. We offer patients some nourishment after they wake up and hemostasis is satisfactorily achieved. Prior to discharge, the patients are ambulated and then put in a comfortable adjustable recliner. Post-procedural teaching is done at that time, and a folder with instructions and pictures are sent home with the patient. Follow-up appointments and interventions are scheduled before the patient is discharged. The few pieces of the patient chart that we did need to actually write on (flow-sheets) are then scanned into the patient’s electronic medical record. Paperwork is kept to a minimum.
Finding our Niche: Job Sharing
The management position for HCOR remained open for many months and no one applied for it. At this point, Carol Mackes and I were both staff nurses working in the cath lab at the hospital. We were both asked to consult and help get the lab started. There were many details on which we needed to work: policies and procedures had to be written, orders placed, staff hired, etc. After working on this project, we began to take ownership and found the idea of working together exciting. Carol and I had worked together for many years in the cath lab at the hospital prior to the outpatient lab opening. We had several discussions about the concept of job sharing, and decided that with our combined expertise and years of experience we had a lot to offer. It was at that point that we both agreed it would be fun and rewarding to make a go of this position together. The two of us put together a job proposal that outlined what we could do for the physician group, and what our management style would be like. After a brief discussion, our proposal was accepted.
Staffing
When Carol and I accepted this management position, the conceptual model of how the cath lab would be staffed and what the hours would be had already been formulated. Since the staffing model for the lab was very lean, the physicians chose to staff the department with nurses and a unit assistant. We both had reservations about whether the numbers would work. We wrote up job descriptions for the remaining positions and started thinking about what kind of employees it would take to make our outpatient lab a success. In the end, we hired one full-time nurse and two other nurses who split a full- time position. One of the nurses had cath lab experience and the other two had ICU experience or had worked in the Heart Center Procedure Unit at the hospital. We oriented and trained our staff in the hospital cath lab before our actual outpatient lab opened. On August 1, 2000, we did our first patient. After being open for about four months, we oriented two relief nurses to help fill in for heavier days and vacation time. Our department functions as a team and being a small group it is easy to communicate changes and/or information. Patients are often cared for by the same nurse who admitted them, was with them throughout their procedure and through discharge. Patients are particularly happy with getting their procedures done on time, as there are no emergencies to bump them of their scheduled slot. The atmosphere is quiet and relaxed, without the daily activity of a hospital.
Certification
Since the concept of a freestanding outpatient cath lab is fairly new, the State of Colorado doesn’t have a Certificate to bestow on us. HCOR is not JCAHO-certified, but we set up all of our procedures and policies as if we were certified. If the day comes where for some reason we need to be JCAHO-approved, we have do doubt we would pass without difficulty. Staff are all still employees of the PVHS and are leased by the Heart and Vascular Clinic. Our wages and benefits continue through PVHS.
Finding a Balance & Seeing Success
It has been an interesting and rewarding two years since we began working on this project. Carol and I communicate with each other via phone and email several times a week about the daily happenings at work. We have each settled into our niches and work comfortably together. Job duties are spread evenly, with each of us doing the tasks we are best at. Since we are both flexible with our days and schedules we have had no problem with covering the management position. We have seen our numbers increase this year and hope for continued growth in the years to come. One of our biggest struggles has been receiving reimbursement from Medicare to be able to do more than diagnostic studies. We have the capacity and are set up to do peripheral interventions, cardioversions (Medicare patients) and drug-infusions for heart failure patients. Another area we are working on is increasing our contracts with insurance companies. We have no doubt that HCOR can be more cost-effective than the hospital. Before HCOR opened, we made lists of what it cost to do a procedure, and eliminated items that weren’t particularly necessary. I do all the processing to order supplies and medications. Our unit assistant shops at a local Sam’s Warehouse for our patient nourishment. We found we could save a lot of money by brainstorming cost-savings ideas together. At this time, we are in the process of writing a Health Care Finance Administration (HCFA) demonstration grant seeking reimbursement for doing peripheral interventions in this setting. We submitted our grant at the end of September. It has been a timely learning experience. Wish us luck!
