Process Redesign of the Cath Lab/Post Area at Bethesda North Hospital

Since 2001, Bethesda North’s Cardiac Program has experienced a 14% increase in cath volume and a 46% increase in PTCI volume. The hospital is seeking to become a trauma facility, which will significantly increase the acuity of patients needing cath lab interventions. Additionally, there have been rapid and extensive changes in the use of technology to perform an increasing variety of diagnostic and interventional procedures. The need to address multiple issues prompted the initiation of the performance improvement team. These include: Increasing demand for both diagnostic and interventional procedures Rapidly changing technology Staffing challenges, including excessive overtime due to increased volume The performance improvement team was commissioned to critically evaluate and make recommendations to improve the care and safety of cath lab patients. In addition, they were to redesign the workflow of the unit to improve efficiency and productivity, essential to meeting the growing demands on the department. Specific Goals of the Team Included: Developing a process that enhances patient privacy, safety and flow through the department Streamlining and organizing paperwork to improve access to patient information Increasing communication with family members regarding patient status Enhancing communication between staff members regarding patient needs Standardizing physician pre-procedure order sets Team members included: Jean Ackner, Cath Lab Manager Jennifer Lanzilotta, RN, Procedure Room Regina Evans, Radiological Technologist, Procedure Room Sharon McDonough, RN, Pre/Post Area of Cath Lab Vicki Ulland, RN, Pre/Post Area of Cath Lab Linda Galvin, Sr. Performance Improvement Consultant Nancy Glorius, Sr. Performance Improvement Consultant Key cardiologists, including the Cardiology Section leader, were involved in evaluating and supporting the team’s recommendations, revising the pre-op/post-op orders and recommending chart content. The team began their work in October 2002 by reviewing the current flow of patients and highlighting process bottlenecks. They concentrated their efforts on the pre/post area. They also evaluated types of patients treated in the cath lab, such as recovery of special procedure patients, helping to get IVs started in Radiology, and chemical stress testing. All staff members were interviewed in the pre/post area to identify trends and problem areas. Key Findings from Flowcharting: Multiple caregivers were involved in the preparation of the patient and no one person had a total picture of the patient’s needs. Patients were cared for in the recovery area by the first available nurse who took report on the phone. This did not always provide a consistent workload distribution. Patients were recovered in the patient care area in the back of the department, where there were constant interruptions by personnel, phones and traffic. Physicians did not routinely come to the pre/post area as they were in another location talking with the family or performing the next procedure. Pre/post nursing personnel did not have the advantage of hearing the discussions with the family nor have the opportunity to ask any questions about the post op orders and patient condition without having to initiate a call to the physician. There was no easy mechanism to communicate with the staff, physician or procedure room regarding the location of the patient and any significant clinical needs for the patient. All documentation was placed in a folder with no designated order. This made it difficult to determine if all labs, assessments, H&Ps, consents, etc. were complete. Staffing patterns did not provide adequate coverage in the pre/post procedure area considering the increase in volume, acuity of patients and frequent add-ons to the procedure room schedule. No one was available at the reception desk after 2:30 p.m. to receive visitors or patients Lack of H&Ps caused procedure delays The procedure room communicated with the physician 30 minutes prior to scheduled procedure time to determine if the physician was going to be on time. At times, a later procedure time was negotiated. This communication was not shared with the pre-procedure area and was done without the procedure area knowing the patient's preparation status. The team identified an opportunity to standardize the order sets used in the cath lab Before the team began the redesign phase of the project, they developed a data collection tool to collect baseline data on processes, types of procedures and delays. This data helped to focus the team on key areas for improvement. Data collection was conducted for two weeks. Both inpatients and outpatients were included in the study. The data was summarized and presented back to the team. Key Findings from the Data Collection: Delays found in prepping the patient for procedures Prior to the data collection, the team perceived that many of the delays they experienced were due to issues around obtaining lab results, lost tubes of blood and abnormal results which caused delays in cases. Interestingly, they found that the turnaround time on lab results averaged 51 minutes, below their expectation of 60 minutes. However, the patient did not have their labs drawn until an average of 31 minutes after the patient arrived to the pre/post area. Delays found in prepping the patient in the procedure room. The procedure room was averaging 25 minutes in the preparation phase. This was a combination of physician wait time and preparation time. Many times the patient was not prepped immediately, because the procedure room knew the physician was going to be late, so they would wait for the physician to arrive before prepping. Delays in transferring patients to an inpatient bed. Bethesda North, like many healthcare organizations, is experiencing significant capacity and throughput issues. The cath lab found their average wait time for an inpatient bed assignment was three hours and 28 minutes. This caused a great deal of overtime and staff dissatisfaction because they would have to stay over their shift to hold the patient until they could be transferred to an inpatient unit. Once the data collection and flowcharting were completed, the team began the task of redesigning the unit. They developed a vision statement and outlined specific elements of the ideal cath lab experience from the patient, family, physician and staff perspective. This vision statement helped in designing a flow that was efficient, effective and enhanced patient/family satisfaction. Vision Statement: The Bethesda North Cardiac Cath Lab is dedicated to patient outcomes that exceed national standards by providing state of the art care with compassion in an atmosphere of teamwork, collaboration and mutual respect. Over the next several months, the team redesigned processes, did a trial run to make sure it went smoothly and addressed the issues that they had uncovered through the interviews, flowcharting and data collection. Process Improvement Recommendations: Specific RNs assigned to patient during the preparation. Previously, patients were not assigned to specific nurses or areas. In the preparation area, nurses commonly worked with all patients to get them ready for procedures. Care was provided based on tasks to be completed with no clear assignment of overall responsibility for assuring the completion of the patient's preparation. In the new design of care, there are dedicated preparation staff with clearly defined tasks and responsibilities. A patient care technician role was created to assist with tasks such as blood draws, EKGs and shaving of the patient. The assistance of the tech decreases the 31 minutes delay in drawing lab specimens and will free the RN to complete assessments. The nurse preparing the patient for a procedure also has the responsibility of communicating special needs or clinical issues to the physician and procedure room staff prior to transferring the patient to the procedure room. This assures all pertinent patient information is known by all caregivers in a timely manner. The recovery area was divided into pods with a specific nurse assignment. Each pod has a designated recovery nurse. This enhances communication about patient condition and needs. Each procedure room has a wireless phone they can use to reach the pod RN who will be recovering their patients. Any add-ons, delays, change in procedures, or patient complications are easily communicated to the correct caregiver. Limiting the number of caregivers involved in the recovery of the patient provides the caregivers with a more comprehensive patient history. Reverse the design of the unit. Patients were routinely prepped in an area close the to the reception area. The thought was that this would provide the family quicker access to the patient. However, it resulted in recovery patients being placed near the nursing station. Here there was a great deal of activity, phone calls, discussion and noise that provided a less than conducive environment for the patient to recover. In the new design, patients are recovered in a pod area away from the nurse's station. This provides quiet, privacy, and easy access for families. Phones calls are rerouted to the front UC to decrease the number of interruptions for the recovery nurse. This change resulted in fewer distractions, allowing caregivers to focus on the care provided. The physician completes post op orders and brings the chart to the pod area. As part of the current process, the patient is moved to recovery while the physician finishes writing post procedure orders. The chart is left in the procedure room for the procedure staff to return to the recovery area. At times this process resulted in delays in carrying out post procedure orders. The family was called to the consultation room to wait for the physician. There were times when the physician could not find the family or a delay resulted in missing the family. In the redesign, the physician completes the orders as the patient is moved to a pod in the recovery area. The family is paged to come to the pod to see their family member. When the physician has completed post procedure orders, he brings the chart to the pod area and discusses findings with both the patient and family. The pod nurse is included in the physician's discussion of the case and can review and clarify orders immediately with the physician. This assures the pod nurse is aware of clinical issues and findings that would influence the course of recovery care. Redesign of the master communication board. This board is now designed to communicate to the procedure room, the physicians and the pre/post areas, the location of the patient and their status. Previously, it was not clear if the patient was still in the procedure room and/or if a patient's case was delayed due to clinical issues such as abnormal labs, EKG, or high blood pressure. It was not clear if the patient had an inpatient room assignment. The master board was redesigned to provide a quick snapshot of which patients are in the prepping area, procedure rooms and recovery area. The board includes the method of discharge and any delays. Specific roles have been given the responsibility to keep the board updated. A chart system is instituted to organize patient information. Patient information is placed behind tabs in the chart. Paperwork was randomly placed on a clipboard. This could result in missed or delayed response to abnormal lab results or other items that could impact the care of the patient. Charts with tabs are used to organize patient information in a consistent manner. A designated area of the chart is used for post op order sets and the recovery flowsheet for ease of access. Staffing levels adjusted to provide adequate coverage during peak times. The pre-post area is staffed entirely by RNs. Staffing patterns were changed based on data collection showing more staff was needed at the peak times of 11:00am-2:00pm. A patient care technician position was recommended to assist with the preparation of patients for procedures. Team coordinator hours were extended to provide clinical expertise over the critical hours that the cath lab is operating at maximum capacity. Notification of the physician 30 minutes prior to the schedule time of the procedure. The procedure room communicates with the RN from the prepping area to determine if the patient will be on time for the procedure. The procedure room then calls the physician to alert him that the patient will be ready to start at the scheduled time. The procedure room has the patient on the table and prepped at the scheduled time, and will no longer wait for the physician to come to the department. The hope is that by modeling this behavior, physicians will make it a priority to start the procedure on time. Move the unit coordinator to the front desk and transfer all calls to this desk. As the hours of the cath lab have lengthened, it has become more critical to have someone at the reception desk during hours of operation. Reversing the unit also allowed for the unit coordinator to be moved to the front desk with the receptionist. This provided an overlap for lunch coverage and also placed a person at the front desk during the afternoon/evening hours. All calls directed to the back unit coordinator are funneled to the front desk. Lack of H&P day of the procedure. On occasion a patient would come to the cath lab without an updated H&P. A new process was put in place to request an current H&P from the physician’s office the day before the scheduled procedure. A tracking tool is placed on the patient chart to communicate with others. On the day of the procedure, if the H&P is not available, the physician’s office is again notified. The RN in the prepping area has the responsibility of notifying the procedure room the H&P is not available when they inform the procedure room of the patient's preparation status. The procedure room communicates with the physician the patient's readiness and lack of H&P 30 minutes prior to the procedure. Physicians have agreed that no patient will be placed on the procedure table without an updated H&P. Streamlining the Paperwork Minor but significant changes were made to some of the paperwork. The medical staff approved a standardized pre-op order set. Post-op orders were revised for clarity. Duplicate information was removed from the pre-cath checklist. The procedure room information system and recovery flowsheet were matched to assure similar sedation scales were being used. Bed Capacity Issues The cath lab team did not address the issue of delays in obtaining an inpatient bed. During the course of the team’s work, the hospital had a concurrent team in place to resolve the hospital bed capacity issues. Several interventions were implemented, including: A Patient Placement Specialist: The role of this position is to actively manage the assignment of inpatient beds, facilitate transfers between units and manage the admission of direct admits. A bed tracking software system was implemented to improve housekeeping turnaround time and to accurately track real time bed status throughout the inpatient units. Bed meetings are held several times a day to discuss ED holds, admissions, and anticipated discharges. All inpatient departments, as well as ED, PACU, Environmental Services, Staffing, and Care Coordination come together to plan for meeting the patient demands of the day. These changes significantly improved the ability of the cath lab to transfer inpatients to telemetry. Barriers to Implementation While the work of the team was completed in May 2003, the implementation was delayed. Since staff schedules needed to change to accommodate the new design, HR assisted the staff with a process of position selection. In addition, there were significant changes in management and a loss of staff. While this is common in a redesign, it impacted the rollout of the new design. By January 2004, all vacancies were filled and the team reconvened to review their plans and determine if any changes needed to be made to the patient flow in the cath lab. The redesign was implemented in May 2004. Remeasurement A significant data collection process was conducted prior to the redesign. A similar data process was conducted in early November, 2004 to determine the level of improvement made. Since the project’s emphasis was on patient safety and privacy, organizing paperwork and enhancing communication, a staff survey was completed to determine if improvements had occurred in the organization of the patient's information and the communication that occurs between the pre/post area and the procedure rooms. Staff were asked to rate survey items on a scale of one to five (1-Strongly Disagree to 5-Strongly Agree). Significant improvements were recorded in the preparation of the patient and the availability of test results. Staff reported patient and families were more informed about any delays in their treatment and communication had significantly improved between the pre/post area and the procedure rooms. The results of the data collection also showed an eight-minute improvement from the time the patient arrived until their labs are drawn. Once the patient was taken to the procedure room, the staff were able to trim four minutes off their prep and drape time. Prior to the process improvement, the time from patient arrival to taken to the procedure room was 137 minutes. Post implementation, this time decreased to 124 minutes, a decrease of 13 minutes per case. Given the 3122 cath s and 1425 PTCIs performed in the past fiscal year, this results in a 19 hours/week improvement in departmental throughput. No significant improvement was seen in the time it takes to move patients to an inpatient bed. Since this project started, the hospital continues to see inpatient volumes grow while bed availability remains unchanged. The organization continues to investigate methods to enhance throughput while plans are being made to add patient beds. Summary This project not only has a significant impact on patient care and safety but also the staff morale, working relationships between areas within the cath lab and reputation of the department within the organization. The team members themselves have gained a broader knowledge base regarding performance improvement tools and the impact their department has on other parts of the organization. Bethesda North’s Cardiology Program is rated one of the top three programs in the state of Ohio. This redesign will assure a strong reputation continues as market share increases and more critical patients are transported to the facility. The authors can be contacted at Linda_Galvin@trihealth.com

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