Expansion from PCI to Open Heart: Key Considerations for Success

Hospitals nationwide continue to see increased opportunities to expand invasive cardiac services to include PCI (percutaneous coronary intervention) without the requirement of on-site open heart surgery. As this movement continues across the country, these hospitals are realizing that although they now have the advantage of being able to provide advanced interventional cardiac care to their community, they are still unable to offer “full” services to those patients whose best treatment option is open heart surgery, whether coronary artery bypass or more complex valve replacement. In such cases, the patient must be referred to another facility, which then compromises the idea of “one-stop” care within the cardiovascular continuum. For that reason, it comes as no surprise that many cardiovascular service line directors are asking the question, “Should we consider expanding our services to offer open heart surgery?” We believe that hospitals must seriously consider this opportunity, especially if located in a competitive marketplace where tertiary and quaternary centers abound, and/or in regions where cardiac mortality is high, perhaps due to a lack of access to necessary advanced care like open heart surgery. Hospitals in rural areas, too, can consider this growth strategy, since patient transfer to more advanced centers can involve long distances and travel hardships for patients living in these more remote communities. In light of such initial considerations of market dynamics and patient need, we have assisted many facilities in understanding these factors and determining the best option moving forward through business plans and market analyses. If expansion is a viable strategy, the next step involves what it would take to move to open heart surgery; specifically, the determination of resources (clinical, operational, and financial) and how readily the facility can obtain them. Corazon believes a key consideration early on is the clinical staffing resources required (both physician and non-physician), as these are often high-cost and time-intensive positions to fill. Initial program staffing first involves finding experienced Cardiovascular Operating Room (CVOR) surgical staff, such as nurses and surgical techs. However, two major clinical team members who support the cardiovascular surgeon should be considered first: the cardiac anesthesiologist and the perfusionist. Critical to the surgical component, a program cannot exist without either one. These roles are important to fill early because they are: • Essential for every open heart surgery program • Necessary for 24/7/365 coverage • Positions that command a high salary • Not easily recruited • Generally not currently available in a non-surgical facility Further, hiring of these key team members usually requires surgeon approval, or, at the very least, surgeon involvement in the recruitment, which could prolong the process due to scheduling. Though both the anesthesiologist and the perfusionist will have limited productivity during program start-up, having them on board at the outset of the service expansion will allow for these specialists to provide additional education to the existing clinical staff, as well evaluate any remaining needs for the program. Anesthesiology Services Although anesthesia services are undoubtedly already available in the facility, a cardiovascular service line director would need to explore how those services are currently being provided, along with the qualifications of the anesthesiologists. Anesthesia services can be provided to a hospital under several different models, but most commonly through either employed anesthesiologists or a contract with an anesthesia group. Additional skill sets and experience (and perhaps even additional hospital credentialing) are necessary in order to manage complicated hemodynamic changes (especially with position changes in midCAB or ”off pump” surgical procedures), arrhythmias, re-warming, and post op management. Such skill sets and experience may not be readily available within existing anesthesia services, and will therefore need to be recruited specifically for the open heart surgical service. A cardiac anesthesiologist should have the following: • Board certification in anesthesia • Additional training in cardiac anesthesia (or, in lieu of formal training, at least two years experience working in the cardiothoracic specialty) • Documentation of proficiency in the performance of transesophageal echocardiography (TEE) • Documentation of 200 cardiac anesthesia cases within the last two years, or a minimum of 100 cases in the most recent 12 months Recruitment for anesthesiologists is expensive, as well as time intensive. In addition, the cardiac anesthesiologist hired would need to be willing to cover other surgical case types due to the cost and productivity issues involved with the limited caseload of an open heart start-up program. Corazon experience proves that in any program, back-up coverage will be necessary for vacations, personal time off, and any unforeseen circumstances. We recommend training one of the current non-cardiac anesthesiologists to eventually provide this back-up, or contracting anesthesiologists (locums or temporary) can be used. Hospitals with anesthesia services provided through a contracted group will need to review the current terms to determine if the language obligates the group to provide anesthesia coverage should the hospital expand to open heart surgery. Options in this case include additional training for existing personnel, pulling trained cardiac anesthesia from other facilities, or recruiting additional staff with the appropriate qualifications. If the contract language does not obligate the group to provide coverage for new services, hospital administration will need to renegotiate for coverage or explore options to recruit and employ a separate anesthesiologist to provide this service. This could create dissention among the anesthesiology ranks and cause higher expenditures for the service, as the contract would most likely preclude the cardiac anesthesiologist from providing services on any other case type, thus decreasing productivity. The hospital would also need to explore options for back-up coverage such as locums, which could further increase the expense. Perfusion Services Perfusion coverage alternatives are easier to explore, as this service is generally not in place, and there are no existing employees or contracts to restrict the options on providing the service. As with anesthesia services, perfusion services may be provided through the hospital employing the perfusionist or through a contracted service. It is not unusual for a surgeon in a start-up cardiac surgery program to request that the hospital extend employment to a perfusionist that he or she already knows and has worked with. This concept of the surgeon “bringing a perfusionist” provides the surgeon with confidence in the services; however, this locks the hospital into an employment model, which has its benefits and drawbacks. Regardless, in the employed model, we advocate building other responsibilities into the job description in order to maximize the use of these personnel (Table 1). Employment of the perfusionist also eliminates the ability of the hospital to tie capital equipment and disposable supplies into a single agreement, which can be done when perfusion services are contracted. When exploring the provision of perfusion services through a contracted service, there are several options as to how the services can be provided and billed. Contract options can include personnel only, personnel and capital equipment (bypass machine), or ‘all-inclusive’ (personnel, capital equipment, and disposable supplies). Rolling equipment and supplies into the perfusion services agreement allows the hospital to move some of the capital costs from the project start-up into operating costs, which can be beneficial, because this will then allow for those dollars to be utilized in other ways for the program. Contract negotiations should include — in writing — any supply cost increases during the length of the contract, equipment maintenance and repair, options to replace personnel who are not a good organizational fit, surgeon approval for supplies/equipment/personnel assigned, and the job description, including details of the roles and responsibilities outside of perfusion responsibilities (POC testing, database entry, etc.). The contracted agency should provide all credentials, policies, procedures, and templates to be used. Contracted services can be billed to the facility on a per case basis, with a per diem rate, or through a monthly rate. Some services will build a minimum case rate so as the volume increases, the rate will decrease. In our experience, most vendors request a minimum of two years for the agreement, but if pressed, this can generally be negotiated to a shorter timeframe. Contract considerations are critically important for an upstart program in which volumes may increase dramatically, as there may be a desire to eventually move from contracted to employed perfusion sooner than later. One advantage of a contracted service is that should a perfusionist become ill or incapacitated in some way, the group is obligated to find a replacement to be available on site, which assures perfusion coverage at all times. Such is not the case with employed staff and minimal back-up coverage. Exploring the coverage needed and options to provide that coverage for just these two service areas can prove time-consuming and complex. But understanding the options available, and the pros and cons in terms of cost and time commitments for these options, can do much to make the implementation of open heart much smoother from a staffing perspective. We have found that programs armed with this information will be in a better position to make wise choices when expanding to open heart surgery services. Overcoming the initial challenges of recruiting these two key players within the new program can set the stage for clinical quality, operational efficiency, and financial viability from the start — which can provide a solid foundation for excellence moving forward. Marsha is a Consultant with Corazon, offer consulting, recruitment, and interim management services for the heart, vascular, and neuro specialties. For more information, call (412) 364-8200 or visit www.corazoninc.com. To reach Marsha, email mknapik@ corazoninc.com.

NULL