Rural CV Service Line Challenges and the Cardiac Catheterization Lab: Optimizing Constrained Resources

Corazon, Inc., offers consulting, recruitment, interim management, and IT solutions for hospitals and practices in the heart, vascular, neuro, and orthopedics specialties. To learn more, call (412) 364-8200 or visit www.corazoninc.com. To reach the authors, email rswanson@corazoninc.com or fraulina@somc.org.

Fortunately, cardiovascular (CV) services are one of the few clinical specialties that receive focused attention from the industry due to ever-growing demand, revenue potential, and subsequent strategic importance for acute care hospitals. Experienced cardiovascular administrative leaders realize that the CV service line alone can bring market distinction within the expanded community, and it can often equate to up to 40% of the hospital’s total revenue. Developing and/or sustaining a CV service line that includes key departments like the cardiac catheterization laboratory often requires large amounts of resources. The availability of these resources can be scarce, particularly as increased patient comorbidities are coupled with more advanced cardiovascular service capabilities (such as percutaneous coronary intervention [PCI] with surgery off-site) in rural communities. We are now entering an era of healthcare reform measures that often require hospitals to “do more with less” – which is particularly true in the case of rural hospitals with advanced CV services. 

Based on diverse experience in urban areas, rural settings, and every variation in between, Corazon believes that to successfully support the CV service line in a geographically confined location, leaders must employ creative measures to ensure that the resources required to operate safely and effectively are never compromised. The key resources include an available patient base, a skilled employee pool, and existing or potential ancillary services. And of course, quality is the foundation upon which all of these components should be built. This is difficult, as rural communities often have a small population of patients from which to draw, coupled with with little of the industry that creates a more favorable economic environment in urban areas. We recommend close attention to these aspects of a service line, especially in rural communities where the geographic isolation can place severe limits on the availability of the entire span of resources mentioned above. But despite the challenges, optimizing resources that are available, and finding creative strategies to obtain those that aren’t, will bring success, regardless of a remote location.

The patient base

One of the main challenges in rural communities relates to a combination of health disparities that are not necessarily found in larger communities. Noted gaps with economic status, education, unemployment, cultural and social differences, and overall access to healthcare exist. These gaps no doubt also exist in larger urban areas; however, the diluting effect of greater physical distances spread across fewer people creates a greater conundrum for the rural provider. Thus, a cardiovascular service line leader in a rural setting faces a medically underserved population, which results in a patient base traditionally having little or no preventative care. Ultimately, this equates to higher mortality rates. Patients present in larger numbers, sometimes sicker and with higher co-morbidities, simply from the lack of preventative or previous healthcare. Due to economic status, rural hospitals unfortunately see patients who are less likely to have employer-based healthcare coverage, Medicaid, and/or prescription drug coverage.  

With these challenges, the prevalence of heart disease-related co-morbidities such as hypertension, diabetes, high cholesterol, obesity, and tobacco use is typically much higher in these communities, and therefore, access to CV services must remain a top priority. Rural CV leaders must advocate for health screenings and concentrate on preventative care in these underserved areas. Corazon believes that reaching out, having a presence, and establishing trusting, caring relationships, especially in “small town America,” can help secure patient loyalty to an organization for lifelong comprehensive healthcare. 

Another key priority for rural populations should be hospital connectivity with first-line responders.  Unfortunately, the lack of primary care leads to emergency departments being inundated with non-urgent medical needs. Unlike urban areas with paid emergency medical systems (EMS) in place, smaller communities often have local volunteer EMS providers, who, though passionate about their work, are often lacking in mentoring, formal education, and even paramedic manpower.  

Establishing a formal relationship with EMS providers is a must. This relationship should include hosting regular meetings, establishing common protocols, identifying goals, sharing metrics, and distributing feedback. CV administrators can also partner with EMS systems to raise funds and/or apply for grant monies to acquire the monitoring systems and software needed to transmit electrocardiograms (EKGs) from the field, since rural EMS systems often lack equipment with this capability. This type of technology is a necessity when transporting patients, such as those experiencing a ST-elevation myocardial infarction (STEMI), from areas greater than 30 minutes away.  

Even as some rural locations have extremely solid EMS resources, rural hospitals are often plagued with the phenomenon of “walk-ins” to the emergency department (ED). Chest pain patients often drive themselves or are driven by their loved ones to the ED, most likely due to the lack of public education and the perception of long response times for volunteer EMS systems. We advocate for frequent community education on early heart attack care and encourage CV leaders to create a formalized marketing plan to target all populations in their service area. Indeed, education to the public about the importance of calling 911 in the event of chest pain should be a main priority.  

Finally, rural CV leaders need to effectively plan to deliver care to remote locations and distant market catchment areas. With healthcare reform, hospital downsizing, centralization of services, and the need to contain costs, the challenge is greater than ever to deliver adequate care to populations in rural areas. Administrators must study the geographical areas, understand the travel times, identify the population barriers to healthcare, and find appropriate means to measure and assess their impact on the populations affected. Hospitals must guarantee their catchment areas are well served or market leakage is inevitable.  

One solution is hiring mid-levels to subsidize the lack of primary care physicians and/or specialists in rural areas. Placing primary outreach clinics where there is little access is a major financial commitment for an organization, but a necessary one for delivering basic care. There is even government-subsidized funding for those mid-level providers who choose to offer primary care services in “geographically disadvantaged” locations that are often rural. The rotation of providers through these outreach clinics can “wow” the customers and solidify the future relationship with CV services.  

The employee pool

Overall, cardiovascular services present one of the most unique challenges of all the clinical service lines when evaluating the specialty staffing required for highly critical patients that can present to the ED without advanced warning. This scenario is complicated in rural locations with a limited pool of skilled talent compared to large urban areas, based on sheer population numbers alone. And, our experience reveals that when CV specialists from rural settings learn advanced services, they often leave that environment to practice their skills in higher volume centers. So, how should a rural hospital approach staffing for a CV service line?  

In cardiovascular, the question of whether the correct physician is in the right place at the right time is always present. The number of subspecialists, coupled with the shortage of cardiovascular specialists overall, can make this question particularly difficult to answer with any level of comfort. CV physicians with advanced skill sets who are willing to take strenuous on-call schedules do not often choose rural settings unless they have prior experience or perhaps family located nearby. While the number of cardiology subspecialists has decreased nationwide overall, trends reveal they are searching for larger centers in which to establish their practice. 

The catheterization laboratory is the perfect example for evaluating the correct physician talent for advanced services, as we often find cardiologists who may or may not have diagnostic (invasive included) skill sets, but are also not skilled in performing coronary angioplasty (PCI).  Also of note, incentive dollars from the federal government to recruit physicians to underserved areas (that are often rural) are not usually available to highly specialized physicians such as interventional cardiologists. Government stipends are typically reserved for primary care physicians (PCPs).   

We often find that key stakeholders in the hospital may not have reached out to physicians who were raised in the community and then moved to larger centers after receiving advanced education. One of the best strategies for rural hospitals to obtain the necessary physician skillset is to remain tightly connected to the community leaders and leverage existing relationships with these types of providers. Also, rural hospitals will often have to evaluate the decision of whether to hire locum tenens into these key roles, as the recruitment process for these specialists can become protracted. Corazon has worked with several rural cath lab providers where locum tenen support has provided the necessary bridge to keep the services available to the community. 

Meanwhile, access to highly skilled staff working in key patient care areas can be just as difficult as locating the scarce physicians referenced above. Most often, hospitals in rural settings have historically offered limited services because that is all that community has required or even expected from the local facility, which has left the staff with limited skill sets compared to their urban counterparts. Significant challenges emerge when a facility begins offering new services such as PCI with open-heart surgery off-site, as existing staff are suddenly unable to handle to higher level of care necessary for a different patient mix.  

Recruiting for experienced cath lab registered nurses (RNs) and technologists (techs) in any service line and in any location is becoming clouded with less-qualified candidates; but, in rural settings, the recruitment techniques must especially rely on out-of-the-box strategies in order to draw experienced staff to these isolated markets. 

Often, the community may not even have the local resources (adequate temporary housing, entertainment activities, etc.) to entice traveler resources; meanwhile, the hospital human resources department must contend with higher salary demands and even sign-on bonus requests to develop these highly skilled teams. One of the most successful recruitment strategies is partnering with the closest educational institutions (which can be greater than 30 miles away) and offering staff internships or residencies. Nursing and technical staff interns will often choose to become hired by these facilities once they graduate, given a positive work experience in these novice roles. 

In cardiovascular services, the access to skilled talent is not the only issue that can arise with the geographic isolation inherent to the hospital’s location. The unique demands of working in a rural area must also be considered. For instance, the emergency department is often called the “front door” to the CV service line, as many patients enter the hospital due to emergent needs such as STEMI. It is also well known that response times related to best practice for cardiac emergencies have been published and benchmarked for many years. Ensuring cath lab preparedness in less than 90 minutes once a patient presents with a STEMI can be challenging, considering the staff may be travelling from distant locales that may not have well-maintained roads. 

Key leaders also need to consider items such as appropriate cell phone coverage if on-call staff is out in the local community(ies). We have worked with many programs that require key on-call personnel (such as the cath lab staff) to retain a 24/7 on-site presence during their call shifts so that minimal response time can be maintained. The idea of an in-house call team usually requires resources to determine where the staff is housed while on-site, as well as if payment differentials will be necessary compared to other call teams that are not required to remain on-site. 

The final concern with the employee base is often related to fostering innovation in isolation. Key clinical personnel in large cities have steady access to information from neighboring facilities regarding innovative change(s) in clinical practice. Rural hospitals often lack competing hospitals in any reasonable proximity where the competition fosters cutting-edge practice and technology. Urban hospital centers often drive innovation through research activities and the availability of large capital budgets to assist with the purchase of new technology.  

To combat this lack of external influence on innovation, we often recommend that rural centers empower their clinical staff to form best practice and/or research teams to help spark innovation at the bedside. This approach works well for centers with limited funds, as the financial expense to support this activity is minimal. However, if the necessary funds are available, Corazon believes sending staff from rural centers to tour or have preceptorship experiences at other facilities is a worthwhile investment to garner new clinical practice skills. 

Support and ancillary services

Many CV service lines have outsourced providers to assist with ancillary program needs for decades. In fact, in Corazon’s hometown of Pittsburgh, Pennsylvania, several competitive facilities within the city have shared one outsource provider for temporary ventricular assist device (VAD) support due to the limited longevity of the disposables and their high costs. However, as more facilities in rural locations seek to advance their CV service offerings, which might include items such as VAD technology, limited support services are available. 

Consider that many programs offering open-heart surgery services will outsource key components of the pharmacologic needs of the program, including cardioplegia preparation. Also, these same programs routinely outsource perfusion services, including both the personnel and the equipment associated with cardiopulmonary bypass (heart-lung machine). In isolated locations, the number of vendors that may be able to assist with these services for growing programs can be limited, and the costs of performing these services in-house can be extremely prohibitive.  

We have found that hospitals taking an assertive approach with vendors that provide these services will usually develop a formal relationship so that the services can be rendered. Our motto is to keep pressing the vendors to provide the support, because they can usually find the ability to geographically and economically distribute their services well, as other rural providers in adjacent markets require the same services. 

One of the most important services to augment the CV service line patient care is the availability of key support (often consulting) physicians. It is widely known that any advanced CV service line, inclusive of PCI and/or open-heart surgery, must have access to skilled physicians in critical care, neurology, pulmonology, nephrology, and other specialties. Similar to the difficulty in accessing cardiology specialists, the availability of these other specialists can be very limited. We have worked with facilities that are successfully leveraging telemedicine technology to augment the capabilities of many clinical service lines by bringing the correct specialist “virtually” to the bedside. 

Initiating or maintaining a clinically, operationally, and financially successful CV service line in a rural location comes with unique challenges. While urban-based centers can face challenges of their own, rural hospitals must contend with the greatest scarcity of resources to provide advanced cardiovascular care. Patients in rural communities rarely want to travel to “the big city,” and would much prefer to seek healthcare close to home, if they seek care at all! As mentioned, education is perhaps the most important factor in communities where potential patients are unaware of key health information such as CV risk factors, symptoms of heart attack, benefits of preventative care, and so on.  

Corazon believes that even with the difficulty of finding adequate resources, rural hospitals hold the greatest need to provide advanced services locally and of high quality. While quality is over-arching for all clinical services, in rural areas, word of mouth has the potential to make or break a program’s reputation. The lack of people in the market may pose one advantage over urban centers, as rural hospitals may have little need for billboards — the news of one great patient experience in a small town can potentially boost the image of the entire CV service line.