The Hybrid Room: Beyond the Basics

Over the past decade, many hospitals across the United States have focused on expanding and enhancing existing services. From fully integrated diagnostic cardiac centers to therapeutic cardiac catheterizations with cutting-edge access techniques, to novel approaches to the treatment of cardiac fibrillation, the clinical landscape is no doubt changing dramatically. 

Corazon believes that with this current combination of rapidly expanding therapies and an aging population, real and immediate opportunities for program implementation and enhancement have never been greater. While basic EP therapies like device implants have long been the standard of care, newer ablative techniques, along with procedures that enlist a more collaborative model among specialists for procedures (e.g., left atrial appendage repair), are no longer located only in large academic centers. In fact, many of these advanced services can be safely performed in the community setting, but only with appropriate planning, strong and dedicated physician leadership, and a continuous eye on quality of care. 

In an effort to gain efficiency and improved utilization of existing EP infrastructure, many hospitals are exploring the idea of a hybrid suite delivery model in conjunction with neuroscience services. Over the past six months, Corazon has assisted many clients in evaluating the feasibility of combining EP services with neuro-interventional therapies for large vessel occlusions performed in the same “hybrid” lab. 

Corazon has worked with hospitals in many highly regulated states on both the planning and implementation of expanded services, which require a strategic focus in order to understand the possibilities and challenges associated with the next level of service offerings, especially when considering a combined/shared space between specialties. Understanding the array of clinical options available, the impact of any state regulations (i.e., Certificate of Need), available manpower (both on-site and in the marketplace), and how to justify the associated cost are only a few of the factors to be considered.

A NEW APPROACH 

Several factors drive this increased interest in a closer collaboration between EP and neurointerventional services. Not the least among them, the numerous studies released at the International Stroke Conference (ISC) in early 2015. These national and international studies definitively showed a significant benefit for patients with stroke caused by large vessel occlusions. Patients treated with both antithrombotics, along with a catheter-based clot retrieval procedure, fared significantly better than those treated with I.V. antithrombotics alone. These findings were only reinforced through the long-term outcomes data reviewed at ISC this year. Neurointervention has become THE standard of care in large vessel occlusions causing stroke. 

A well-thought-out plan to utilize existing resources and infrastructure (EP lab and staff) as a springboard to ischemic stroke therapies makes this service expansion entirely feasible for a community hospital. Even if a program is limited to only clot retrieval, and does not include more complex neurointerventional procedures such as intracranial coiling end embolization, existing imaging equipment is often adequate, as many neurointerventional therapies do not require biplane imaging. In hospitals with underutilized EP labs — either due to low volume or the luxury of multiple labs — such a partnership, with particular attention to patient flow issues, can serve to increase both space utilization and efficiency across both services. 

In organizations that introduce coordinated care of the stroke patient, or for those that pursue certification as a Primary Stroke Center, an engaged and experienced EP lab staff can do much to ensure programmatic success. Care of the emergent neurovascular patient and care of the critically ill cardiac patient are remarkably similar. Both are based on the need for rapid triage and assessment, as well as aggressive intervention within a very limited time frame. 

The organization, patient flow, and established processes used for cardiac patients can serve as an effective roadmap to the development of the program-specific processes that need to be in place for a successful stroke (or full neurovascular) program. In this scenario, the expertise and leadership of the EP lab staff is invaluable in developing a program that makes sense — AND that delivers best-practice, quality care. 

Given the nature of the typically non-emergent EP patient, the flexibility to combine both EP and neurointerventional services in one lab realistically exists. As many neurovascular patients requiring this complex therapy would expect to be transferred into the hospital, or present directly to the hospital’s Emergency Department (ED), adequate time would be available to clear the table in a primary EP lab in order to allow for timely neurointerventional therapy.

OPERATIONALIZING CHANGE 

In Corazon’s experience, we find that the infrastructure improvements that must occur in order to be successful in collaborative program development serve as a strong foundation for any further neuro or EP service line expansion. Imaging upgrades, process and patient flow improvements, and a commitment to staff education as pertaining to a particular (but unfamiliar) disease cohort will all be integral to the success of a broader effort to share space and resources. 

We believe that the lessons learned in developing and running a vibrant cardiac subspecialty program like EP, whether a full interventional program or not, will be of significant benefit when properly applied to this new but very similar neurointerventional population. In fact, such lessons can assist with more rapid implementation of a specific service line program, and help program administrators and clinicians avoid common pitfalls. 

Corazon recommends that the following be considered when evaluating the feasibility of this collaborative approach for your organization:

• Age and functionality of existing imaging equipment. Equipment that is outdated or nearing end of life may not produce images of the quality necessary for neurointerventional procedures. Equipment failure in a typically elective EP lab can be managed through rescheduling in many cases. While certainly not optimal, rescheduling an elective case does not jeopardize patient safety. In the case of an emergent neurointerventional patient, the result could be catastrophic.
• The education and skill level of existing staff related to the neuroscience patient. This will allow you to develop a comprehensive staffing plan that will ensure redundancy in assigned staff with respect to examination and treatment of the complex neurointerventional patient.
• The results from a comprehensive market assessment related to opportunities associated with neurointerventional services. Understanding existing networks of care, regional transport protocols, and competitor landscape are key to this effort.
• The level of full physician engagement. Close collaboration is not only necessary between the EP specialist and the neurointerventional physician, but others within the program as well. Implementation of a neurointerventional program will affect essentially every member of the medical staff, particularly those from the ED, Anesthesia, and Critical Care. Success can only be achieved with the full support of the medical staff, mostly through continuous and ongoing discussions related to strategy and implementation, inclusion with programmatic decision-making, and collaborative leadership, governance, and goal setting.

As with any proposed expansion, hospitals must fully understand current capabilities and limitations, and then plan accordingly. It is only through a comprehensive understanding of the opportunity, the resources, and most importantly, the “level of commitment” from the hospital and the physicians and clinicians alike, that a reasonable plan including expected results can be developed. 

THE RATIONALE FOR EXPANSION

The neuro subspecialty is one of the fastest growing in healthcare today, and organizations may indeed have difficulty keeping up with cutting-edge treatments that have become available only within the past several years. Catheter-based and minimally invasive treatment techniques for neurovascular conditions offer the greatest hope for patients, while at the same time present some of the greatest challenges for organizations in terms of securing the necessary physician expertise and technology upgrades. 

Using the EP lab as a starting point for an expansion of neuroscience capabilities allows for increased utilization of existing infrastructure in a truly innovative way. Further, the potential financial benefit to an organization is clear. Clot retrieval procedures are reimbursed at the same level as an open intracranial procedure. Given the shorter length of stay and improved patient outcomes, the contribution margin can be significantly increased with diligent processes in place. 

For the benefit of the patient, it is incumbent upon organizations to explore an expansion into clot retrieval therapies, and when appropriate, make that expansion a reality. It is clear that clot retrieval therapies are top-of-mind for national healthcare providers. The savvy consumer is likewise beginning to expect this level of care from a selected provider. Hospitals who do not act will be affected by EMS bypass laws that mandate patients “suspected of having a stroke” are transported to a certified Primary Stroke Center for care. Without this designation, loss of volumes (and accompanying revenue) for stroke patients is a very real and imminent possibility — in some states more than others — though at this time, legislation is pending and governing bodies are beginning to consider such laws in the majority of the country. 

Corazon encourages providers to ask these important questions:

• What is the level of stroke care currently provided in my organization’s primary and secondary service area? Careful consideration of the market dynamics is surely necessary, as implementing a service won’t necessarily bring volume if the local or regional area is saturated with providers already offering neurointervention, whether in tandem with EP services or not. 
• Similarly, what is the competitive landscape? The anticipated response from competitors cannot be ignored. Consideration must be given as to how your program can be one of distinction, established as THE best place to go for treatment of stroke. Fully understanding both the proposed and current service capabilities, as well as existing community and EMS perception, are good first steps.
• Does capacity currently exist in the EP lab? To reap the most benefit with this hybrid approach, the use of an existing EP lab is ideal, but only if adding the neurointerventional volume can be managed in a way that will not interfere with current EP procedure capacity. A hybrid approach is best for supplementing volume for a lab that is efficient in scheduling and has strong processes in place to facilitate patient flow for elective EP procedures.
• Has my organization completed the foundational work to become certified as a Primary Stroke Center? Preparing for certification as a Primary Stroke Center ensures that the foundational work necessary for managing acutely ill stroke patients is in place. This provides a significant benefit when elevating a program to include neurointervention.
• What is the likelihood of gaining endorsement for an expansion of the services by the medical staff? Buy-in from this group is essential, as the physicians will be the ones sharing the space and schedule of the lab. In order to gain the support of physician colleagues, an open and honest dialogue must be established at the beginning of consideration. Common concerns center around the impact to existing practice, allocation of capital and marketing dollars, and negative impacts for staff. By demonstrating not only the value to the organization as a whole, but also the direct benefits brought to existing medical staff as a result of expansion, these concerns can often be overcome. Interventional stroke patients are typically medically complex. As a result, referrals are generated to cardiology, neurology, neurosurgery, wound care, home care, rehab services, and sleep, to name a few. 
• Outside of the EP lab, what is the level of existing infrastructure that could serve as a foundation for neurointerventional programming? Are adequate support services in place? Is anesthesia trained in and comfortable with the care of the complex stroke patient? Is neuromonitoring available? Is intensivist coverage available in-house 24/7? These are just a few examples of the basic support necessary to launch a neurointerventional program.

The decision to implement a neurointerventional program is not one to be taken lightly. These patients can be considered the “sickest of the sick” upon presentation — a situation that doesn’t lend well to poor planning or haphazard operations. 

Following a full feasibility study, an internal evaluation must also take place. Also, Corazon believes that only through a frank and thorough assessment of existing capabilities, along with the identification and correction of potential hurdles in advance as well as adherence to a detailed and comprehensive work plan, can organizations be positioned to successfully offer cutting-edge EP and neuroscience services in a dual-purpose “hybrid” lab.

Ultimately, and perhaps most importantly, creating greater access to innovative neuro therapies will only improve the health and well-being of patients already served with EP in a given market. Elevating the level of service already provided while also expanding into a new subspecialty is a worthwhile goal for any organization — especially if this expansion is made possible through the dual use of existing capabilities, along with minimal expenditures of time, effort, and capital. Being able to offer neuroscience services with minimal changes to EP infrastructure and relatively low financial investment can most certainly lead to healthier patients AND a healthy bottom line as well.

Corazon, Inc. is a national leader in strategic program development for the heart, vascular, neuro, and orthopedics specialties, offering consulting, recruitment, interim management, and IT services to clients across the country and in Canada. To learn more, visit www.corazoninc.com or call 412-364-8200. To reach the authors, email anewell@corazoninc.com, or slang@corazoninc.com.