Neuro Intervention in the Cath Lab Setting: A Contemporary Model for Care

Organizations that experience success with a well-established, fully-functional cath lab often find that initial success quickly followed by questions about how to sustain it for the long term. Questions about program expansion are usually the first to emerge, often accompanied by considerations to either open additional labs or grow the scope of clinical capabilities. We often recommend these strategies to clients, but only if the decision has been carefully weighed in terms of the benefits and challenges associated with such efforts, and whether the market will support expanded capacity or capabilities. Indeed, making the decision to expand isn’t always easy. In fact, many established programs find it difficult to take the next step in cath lab development due to the clinical, financial, and operational challenges associated with such an initiative, especially in today’s economy. The investment required in terms of equipment and facility upgrades, as well as in the recruitment and training of additional staff, can be significant. However, the projected return on investment (ROI) based on increased cardiac volume projections alone may be insufficient to gain the go-ahead to proceed. When considering such an expansion, we advocate looking beyond the patient population traditionally associated with cardiac cath labs and considering the integration of programs outside cardiac alone. For example, the inclusion of neurovascular interventional capabilities within the cath lab setting can be key to optimal utilization of resources, increased staff efficiency, and streamlined operations. Furthermore, the decision to offer neuro-interventional treatments to stroke patients who would most benefit brings significant clinical merit as well, especially as the nation recognizes and accepts the need to have a high-quality level of care for acute stroke patients. For organizations that have already taken the first step in delivering best practice care to stroke patients through the implementation of a Primary Stroke Center, the transition to offering interventional services through a Comprehensive Stroke Center is a natural progression. This evolution to a higher level of services can be eased significantly through the existing infrastructure and experienced leadership present in a well-established cath lab. By incorporating lessons learned, and through the use of experienced cath lab staff, the normal learning curve associated with the treatment of complex stroke patients through neuro-intervention can be lessened considerably. The standards of care and clinical programmatic requirements associated with Primary Stroke Center Certification are remarkably similar in comparison to those required for the emergent cardiac patient. Likewise, the steps necessary to offer comprehensive, neuro-interventional treatments is very similar in process to those followed by cardiac programs expanding from diagnostic caths to PCI and then to open heart surgery. A review of the standards identified by the Brain Attack Coalition (Table 1) as being necessary for primary certification as a stroke center illustrates the similarities in necessary program components. From these standards, the below ten clinical measures of performance were developed. These areas of focus serve to highlight the nature of stroke as a disease of the vascular bed as opposed to a stand-alone “neuro diagnosis.” Performance Measures • Deep vein thrombosis (DVT) prophylaxis • Discharged on antithrombotic therapy • Patients with atrial fibrillation receiving anticoagulation therapy • Thrombolytic therapy administered • Antithrombotic therapy by end of hospital day two • Discharged on statin medication • Dysphagia screening • Stroke education • Smoking cessation/advice/counseling • Assessed for rehabilitation As an initial step in exploring a move toward implementation of a Comprehensive Stroke Center, we recommend an in-depth review of the types and volume of stroke patients currently treated in the emergency department (ED). A detailed review of patients with ischemic stroke and patients suffering from hemorrhagic stroke, arteriovenous malformations (AVMs), aneurysms, and unspecified intracranial hemorrhage who may currently be transferred to other competing facilities for tertiary-level care will provide a clear picture of the types and numbers of patients being transferred, as well as the projected loss of revenue associated with them. This volume is easily quantifiable and it is based on history rather than growth projections. Although no formal, national certification program for Comprehensive Stroke Centers exists at present, the recommendations released by the Brain Attack Coalition (BAC) in 2005 are widely accepted and serve as the foundation for centers offering interventional treatment to stroke patients. The recommendations identified in the BAC guidelines for Comprehensive Stroke Centers are in addition to those identified above for Primary Stroke Centers. The recommendations address personnel, advanced neuro-imaging capabilities, surgical and endovascular techniques, and other elements key to establishing a sound infrastructure. Established Comprehensive Centers have capabilities that extend well beyond the ability to rapidly diagnose stroke and to administer thrombolytics. Clinical capabilities include rapid advanced imaging, mechanical thrombectomy, intra-arterial tPa, coiling, and open surgical treatments for hemorrhagic stroke where indicated. A major hurdle for many organizations in the pursuit of expanded clinical capabilities both in the cath lab and in the area of neurosciences can be the significant capital investment required to serve the needs of both patient populations. A second consideration is room utilization and when to install an additional cath lab. The idea that “if you build it they will come” is not often adequate to justify the required capital outlay and the time it may take to cultivate additional interventional cardiology volume. A dual-use room affords an organization the ability to rapidly realize additional patient volume through the retention of patients previously transferred out of the ED. Equipment Needs Recent advances in dual-purpose imaging equipment make the development of a fully-functional, dual-purpose cath lab completely possible in terms of both clinical capabilities and the financial investment required. Multiple configurations of dual-purpose equipment, available from several vendors, allow full run-off views while preserving the high level of detail required for intracranial imaging. The addition of bi-plane capability in these next-generation units meets the requirements for full neuro-interventional capability and allows the neuro interventionalist to perform the most complex therapies currently available. The additional imaging requirements, identified in Table 2, allow for the completion of the detailed diagnostics and interventional follow up required in this population. The turf wars associated with any expansion either via geography or equipment are well known to any seasoned cath lab manager. The idea of inviting a second service into the lab is sure to raise eyebrows and create at least some degree of trepidation for physicians already practicing. Forward-thinking physicians, however, will realize that an expansion of capabilities within the organization to include care of the complex stroke patient is sure to benefit the cardiac program as well, through additional patient volume and an elevation of program perception in the community at large. Strong leadership, open communication, and equal attention to all concerns raised at the outset can significantly increase the opportunity for a successful integration of service lines. The Endovascular Approach The most common procedures performed to treat stroke patients (Table 3) are reason enough to consider the addition of Comprehensive Stroke Center capabilities. It is important to remember, however, that the endovascular specialist will work in tandem with neurosurgery to provide embolization for tumors, minimally-invasive spine therapies, and diagnostic angiography for treatment planning and preoperative mapping. Thus, the endovascular service can supplement diagnostic and therapeutic procedure volume with non-emergent scheduled cases, again, helping to increase room utilization. Physician Recruitment The subspecialty physician expertise that is necessary to provide comprehensive care for the stroke patient is significant. Particularly, recruitment of endovascular specialists is quite competitive, as the number of graduating fellows each year falls short of the national demand. We often find that the willingness of an organization to invest in the necessary infrastructure (i.e., a fully-equipped lab) in tandem with the recruitment process speaks volumes to potential candidates about the willingness to support his/her efforts to build a successful practice. This proactive approach has the additional benefit of shortening the amount of non-productive time between the successful hiring of a physician and the completion of an interventional suite. Although the idea of integrating neuro-interventional capabilities into a fully functional cath lab may be received with initial skepticism by some, a careful review of the opportunity and of the similarities of patient need will illustrate the opportunity. Corazon experience proves that with proper planning, quality dual-purpose equipment, appropriately trained staff, capable physicians, and strong leadership, an organization willing to embrace the challenge can build a truly extraordinary service. As the incidence of stroke continues to rise, hospitals will need to consider new strategies for treatment — ones that are clinically and financially right for both the organization and its patients. While making the decision to move forward with an expansion effort can be daunting, with proper planning and a solid foundation of existing services, the traditional cath lab setting can seamlessly evolve into a new model for care. Stacey is a Senior Consultant with Corazon, offering consulting, recruitment, and interim management for the heart, vascular, and neuro specialties. To learn more, visit www.corazoninc.com or call (412) 364-8200. To reach Stacey, email slang@corazoninc.com

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