A Suggested Approach for Improving Flow in the Cardiac Catheterization Laboratory

Cardiac catheterization laboratories have been in existence for nearly forty years, offering specialized cardiac care to patients with a wide array of cardiac disease and etiology. These laboratories are often viewed as stressful environments in which multiple variables play a part in day-to-day flow.¹

Patients cared for include outpatients, inpatients, and emergencies. Variability in physicians’ schedules, procedure add-ons, procedure time length, and patients’ medical urgency contribute to scheduling variability, long patient wait times, incidental staff overtime, and poor patient flow and satisfaction.² Following is an overview of the potential variants of patient flow in the cardiac catheterization lab and a look at how strict adherence to procedural start time impacts department productivity. 

What’s the problem and why? 

Cardiac catheterization labs are one of the most significant capital investments for hospitals.³ However, in recent years, due to various changes in health care with regard to changes in diagnosis-related groups (DRGs) and Medicare reimbursement, it has become increasingly difficult for hospitals to maximize their cardiac cath lab’s potential economic return.³ As a result, cath lab management is being pressured to increase productivity without expending additional capital. Due to poor patient flow, room downtime, and lack of sufficient staff and resources, cath teams across the country are working longer hours than ever and are often required to stay late to complete case loads, frequently with underutilized physicians and procedure rooms.⁴ These factors impact quality improvement and patient safety concerns. 

Quality cardiac cath lab flow is an essential element to providing exceptional cardiac care. Timely, effective procedures can drastically change a patient’s hospital course and outcome. Therefore, our aim is to evaluate and analyze the current patient flow and practices in the cath lab, and then identify ways patient flow can be more productive and cath lab practices can be more efficient.

How can cath labs improve?

Literature demonstrates that poor patient flow in cardiac catheterization laboratories is not an isolated phenomenon, but a common theme among departments with similar levels of uncertainty, high stress, and high volume.^4-6 In order to tackle the patient flow quandaries of delayed start times, physician unavailability, improper staffing, and excessive non-productive time in the cardiac catheterization lab, we suggest the use of a combined Six Sigma and Lean System quality improvement methodology. Six Sigma’s focus on customers (in this case, patients) and quality improvement will be beneficial in identifying areas of concern and will provide a structure for the identification of and changes to poor patient flow in a cardiac catheterization lab. Specifically, the “Define, Measure, Analyze, Improve, and Control” (DMAIC) process improvement method advocated by Six Sigma will allow for specific identification of barriers and potential outcome strategies to facilitate effective flow. 

Due to excessive down times and non-productive times found in cardiac catheterization laboratories, a Lean System approach to improving patient flow is also beneficial. A close look at various processes within the department can lend itself to identifying and ultimately eliminating wasteful procedures, routines, equipment, and incidental overtime by the staff, ultimately improving patient flow, safety, and satisfaction. A cardiac catheterization lab, while fast-paced and stressful, has the potential to act as a methodical, well-oiled machine, if — and only if — certain processes and quality improvement issues are identified and resolved by the department as a team.

Showing how it works: a cath lab example

The current patient flow process in the cardiac cath lab is somewhat simple, but because it is subject to so many variations, it is often interrupted. For the purposes of this article, let’s focus on what can be done within one hypothetical cath lab, staffed with 5 to 6 nurses and 3 to 4 radiologic technologists on any given day. On most days, there are two interventional cardiologists available to perform procedures. The procedure schedule consists of hourly time slots in two different procedure rooms. Lab hours of operation are between 8:00 am and 4:00 pm; however, a call team consisting of two nurses and one radiologic technologist is available twenty-four hours a day for emergencies. 

Patients include pre-scheduled outpatients, inpatients with stable and unstable cardiac symptoms, and emergencies. Emergencies arrive into the cath lab either referred by the emergency department or because paramedics with the authority to decide whether a patient should be admitted directly to the lab from outside the hospital bring them from the field. Aside from emergencies, outpatient procedures are performed according to the time scheduled, with inpatient add-ons following all elective procedures. Of course, there are exceptions to the rules, as when physician deems a patient a priority over scheduled outpatients. In such circumstances, the physician will “bump” a scheduled outpatient. All add-ons are completed the day they are added to the schedule, regardless of time, unless a physician declares otherwise. The nurses work in a designated procedure room and are responsible for transporting patients to and from the procedure room, as well as prepping patients for their procedures. A charge nurse aids in transportation and is responsible for running the patient flow for the day.  

Current processes include alerting physicians to patient arrival in the outpatient area (or to the cath lab if they are an inpatient or emergency), completing the procedure (usually within a one-hour time frame), and returning the patient to their room. 

Delays that contribute to poor patient flow include: 

1. Late arrival by a patient to the facility; 
2. Delayed patient preparation in the holding area; 
3. Physician readiness; 
4. Patient transportation times; 
5. Delays in set-up of procedure or equipment;
6. Inadequate staff to transport patients to their rooms following procedures and to turn over procedure rooms for the next cases at the same time.  

Additional factors leading to poor patient flow can be seen in Table 1.

Moving forward with improvement 

Using the Six Sigma model, DMAIC, it is possible for our hypothetical cath lab to effectively identify ways to improve flow. 

Define. Defining the issues and their importance is not difficult. Since starting the first case of the day plays such an important role in the flow for the rest of the day, a quality and process improvement plan must address this issue. Cases need to begin on time to maximize unit staff, physician resources, and area hours of operation. Patients expect their procedures to begin at the scheduled time. Thus, first case start time is clearly a quality initiative. Ultimately, the goal must be to begin cases each day at the scheduled start time of 8:00 am.

Measurement. The measurement phase of DMAIC should consist of various collections of data pertaining to the beginning of the first cardiac catheterization procedure of the day. For example, the schedule can be reviewed ahead of time to identify cases scheduled for 8:00 am. Other factors such as staff arrival, patient arrival, patient preparation, and physician arrival times must be gathered and analyzed.

Analyze. The analyze phase is the time to determine where the delays are originating. It may be patients are arriving on time, but are being delayed in admitting. Staff members may be arriving on time, but there is insufficient time to set up a procedure room. It may turn out that patients are not being properly shaved and prepped for the procedure, and therefore these steps are being repeated once the patient is in the procedure room. Additionally, we may find that transporting inpatients is a lengthy process and does not lend itself to a desired 8:00 am start time. We may also find that outpatients are not being scheduled in the early morning time slots to allow for inpatient add-ons in the afternoon, leaving periods of non-productive time. Finally, physician availability varies and an untimely arrival to the department can delay the process. The analyze phase is very useful in determining processes for improvement and alerts the team to wasteful procedures and more effective ways to productively fill downtime. The Lean System approach can also be utilized during this phase.

Improve. The fourth phase of the DMAIC project is the improve phase. At this point, several strategies have been identified to improve flow, based on the previously mentioned scenarios for late procedural start times. First, after identifying that patients are being delayed in admitting, the cath lab may request that the patient arrive to the admitting department at an earlier time than traditionally requested. This would allow for sufficient time to admit the patient and for them to progress to the outpatient holding area for prep. Second, in order to ensure that the procedure room is set up and ready to accommodate an 8:00 am case within thirty minutes of staff arrival, a process to allow for one staff member to arrive early to set up rooms can be initiated. If allowing for additional staffing is not an option, a process to set up a room immediately upon arrival to the department by the staff could be implemented, and all staff could be cross-trained on room set-up techniques. Adequate patient preparation is essential to the timely flow of a patient procedure. Rectifying a sub-par preparation would require educational remediation, which could be established and implemented by the area clinical educator.  

Due to the fast-paced nature of the cardiac catheterization lab, it is essential to secure prompt and efficient patient transportation. Often, delays in patient transport are responsible for delays in patient procedure start times.⁶ An improvement plan to confront this challenge could utilize the close-by interventional care unit for our hypothetical cath lab. In the past, this area has been used as a pre-procedural holding area. Patients can be brought to this area by hospital transportation 1 to 2 hours prior to their procedure to be properly prepared, meet with the physician, and sign informed consent prior to coming to the procedure area. This could drastically decrease the amount of downtime in procedure rooms between cases, leading to increased productivity and decreased incidental overtime.

Additionally, collaboration between the cardiac catheterization lab and the cardiology offices could easily assist in ‘front-loading’ the day’s schedule. Scheduling outpatients in the morning time slots would allow for early morning productivity and increased time slot availability during the afternoon for the late-morning inpatient add-ons.

Finally, when one cardiac cath lab used a regression analysis to consider delays in procedural start times, it was noted that, “cases were more likely to start on time when the physician was called eighteen minutes before the desired procedure start time.”³ This information can be utilized to implement a standard practice of notifying the performing physician twenty minutes prior to the beginning of the procedure, a noble attempt to coordinate the physician and staff duties with the procedure start time.

How do we know if we are successful?

Outcomes to define successful implementation of the process improvement plan can be evaluated by the development of a Six Sigma S.M.A.R.T. goal (Specific, Measurable, Achievable, Relevant and Time-bound). In our hypothetical cath lab, the specific goal is to achieve and maintain an 8:00 am procedure start time in the cath lab during days of normal operation. Successful outcomes thus would include 8:00 am start time, along with less frequent staff overtime. Success can be easily measured by reviewing the department’s schedule with documentation of the first procedure start time, as well as tracking the amount of staff overtime.  In our hypothetical lab, the cath lab team agrees this goal is attainable and allows for a 6-month initiation. The goal is relevant and time bound. It will always focus on first procedure of the day start time. Within 6 months, then, cath lab procedures will be consistently commencing at 8:00 am. Additional secondary outcomes the team agrees will demonstrate success include decreased procedure room down time, a decrease in incidental staff overtime, decreased patient wait times, and increased patient satisfaction scores as evidenced by patient satisfaction surveys.

Ideas on sustaining the gain

Control. The final phase of the Six Sigma improvement methodology is the control phase. There are several factors that will contribute to the successful sustenance of improved outcomes. It will be very important that certain aspects of the plan be made unit policies from their point of initiation. For example, unit policy should include that staff must arrive on time and prepare the procedure room upon arrival to the department. In our hypothetical cath lab, the charge nurse must also be required to alert the performing physician at least twenty minutes prior to the start of every procedure. These two interventions can be directly controlled from within the department and can be used as identifiers of successful 8:00 am start times. In addition, these identifiers can be utilized for annual performance evaluations.  

Several factors that contribute to success rely upon the cooperation and initiative of several other departments, management, and personnel. For this reason, a committee consisting of the cardiac cath lab medical director, cath lab manager, cardiology practice office manager, and outpatient area manager should meet quarterly to discuss the successes or failures of the plan. Accordingly, further recommendations and interventions can be discussed and implemented within the various departments. Each department can be held accountable for gathering information from their department that is related to those factors contributing to delayed case start times. For example, the cardiac cath lab director can be responsible for monitoring daily case start times, physician arrival, and incidental staff overtime. The cardiology practice office manager can be held accountable for the scheduling of patients and decreasing open slots in the morning. The manager of the interventional care unit can monitor and ensure timely and effective patient preparation.  

Committee meetings with quarterly reports serve as a checks and balances review, and hold all parties accountable for their respective departments. These quarterly meetings also serve as a platform to discuss new and possible concerns with the process and allow for these matters to be considered and remedied.

Did the cath lab meet its goals?

Our hypothetical cath lab was successful in meeting its 6-month target goals and continues to work on the control phase. Using a combined Six Sigma and Lean approach to evaluate and implement strategies for successful patient flow in the cath lab has been found to be an advantageous tool, and lends itself to continuous evaluation and intervention. Continued success will be demonstrated by the team’s dedication to providing quality, timely, and compassionate care to the populations we serve.

Jennifer Papin, RN, BSN, can be contacted at jems@live.maryville.edu.

References and recommended reading

1. Herndon D. Change is constant in the cath lab. ASRT Scanner. 2011; 43(4): 20-21. 
2. Swaminath D, Kumar A. Effective ways to decrease costs of labor in a cardiac catheterization lab. Physician Exec. 2011 Jul-Aug; 37(4): 54-57.
3. LeBlanc F, McGlauglin S, Freedman J, Sager R, Weissman M. A six sigma  approach to maximizing productivity in the cardiac cath lab. J Cardiovasc Manag. 2004 Mar-Apr; 15(2): 19-24.
4. Siegrist RB Jr, Gutkin M, Levtzion-Korach O, Madden S. Improving patient flow in the cath lab. Healthc Financ Manage. 2009 Apr; 63(4): 92-6, 98.
5. Czarnecki R. An evaluation of cath lab turnaround time. Cath Lab Digest. 2008; 16(2). Available online at https://www.cathlabdigest.com/articles/An-Evaluation-Cath-Lab-Turnaround-Time. Accessed June 20, 2013.  
6. Gonzales L, Fields W, McGinty J, Gallo A. Quality improvement in the catheterization laboratory: redesigning patient flow for improved outcomes. Crit Care Nurse. 2010; 30(2): 25-32. doi: 10.4037/ccn2010832.
7. Gupta D, Natarajan MK, Gafni A, Wang L, Shilton D, Holder D, Yusuf S. Capacity planning for cardiac catheterization:  a case study. Health Policy. 2007; 82: 1-11.  doi: 10.1016/j.healthpol2006.07.010. 
8. Pickard B, Warner M. Demand management: a methodology for outcomes-driven staffing and management. Nurse Leader. 2007; 5(2): 30-34.  doi: 10.1016/j.mnl.2007.01.002.
9. Venkatadri V, Raghavan VA, Kesavakumaran V, Lam SS, Srihari K. Simulation based alternatives for overall process improvement at the cardiac catheterization lab.  Simulation Modelling Practice and Theory. 2011; 19(7): 1544-1557. doi: 10.1016/j.simpat.2011.04.004.
10. Vieth C, Pexton C. Increasing cath lab capacity through six sigma. Available online at: https://www.isixsigma.com/new-to-six-sigma/dmaic/increasing-cath-lab-capacity-through-six-sigma/. Accessed June 20, 2013.