Improving and Redesigning EP Lab Turnaround Time (TAT)

Introduction 

Many cardiac electrophysiology (EP) programs face the challenge of juggling numerous procedures in one dedicated laboratory. At the same time, patients are concerned with their procedure being on time and become anxious as they wait. Administration constantly struggles with cost containment while focusing on increasing patient satisfaction. For these reasons, efficient turnaround time (TAT) needs be at the forefront of every EP program and re-evaluated on a continuum. Creating change to improve timely patient flow presents both an opportunity and challenge for the staff involved.¹ Is there a way to improve TAT? What activities need to be examined? 

Finally, will the process improvements preserve patient safety, quality of care, and a staff who remain engaged? 

Team members involved in the TAT process often have a variety of opinions and perceptions as to what is wrong and how it can be fixed. The subject of TAT is both simple and complex, but merits assessment. Delivering efficient, cost-effective care affects not only the patient, but the operational performance of a department, and ultimately, the organization itself.²

In this article, I present a study that was done to determine if a single, dedicated EP lab at UPMC Passavant Hospital could improve its TAT efficiency to compare to the Operating Room TAT national average of 20-25 minutes. For the purpose of this article, TAT was defined and a SIPOC diagram was created to examine all of the team members and their activities. After process improvements were in place for three months, TAT tracking was done to compare with the baseline results.

The Process of TAT

UPMC Passavant is a 400-bed hospital located in suburban Pittsburgh, Pennsylvania. The EP lab and its own dedicated staff branched off from the cath lab in 2009. We are fortunate to have the Diagnostic Interventional Recovery, a holding area in close proximity to the lab staffed with nurses, to receive and recover our patients. Anesthesia has been incorporated as a part of our team to support all our procedures. Therefore, our EP team consists of physicians, RNs, a specialized technologist, and CRNAs. Although the number of procedures has grown significantly over the last several years, the process for TAT had remained the same. 

Turnaround time is the time from when one patient exits an OR until the next patient enters the same OR.³ To redesign the process of TAT, every aspect involved needs to be examined. Activities at the end of procedure include:

• Updating recovery area and family.
• Sheath pull for ablation procedures.
• Dressing placed over site for case end.
• Completed procedure report signed and placed on chart.
• Taking patient to recovery area.
• Room cleaning to include paging housekeeping, waste out of room, bed and equipment being wiped down and floor being mopped.
• Setup of equipment for next patient.
• Subsequent patient being assessed with working IV, lab results evaluated, consents signed, pre-procedure checklist completed.
• Report at the bedside between prep nurse, procedure nurse, and CRNA.
• Patient being wheeled to procedure room and prepared by the team.
• Physician being paged and presenting to begin the case.

The next step was to create the SIPOC diagram (Figure 1). This reference was used to list the team members (suppliers) and what they do (inputs), illustrate a process map, and indicate what was produced (outputs) and whom it benefits (customers). When considering the individual aspects of TAT, this diagram showed a clear picture as to what needed to be revised.⁴

A scheduled visit to the OR and interview with the nurse manager about how they handle TAT proved beneficial. Many rooms were observed being turned over. This is the information gathered:

• TAT is tracked daily for each case on a computerized graph, and all numbers that are considered substandard are color-coded by a pie chart to indicate the reason for the delay.
• Results of the daily graph are posted, communicated, and addressed at monthly staff meetings aimed to improve processes.
• The OR has a dedicated team of aides who clean and supply each room when vacated, which is significant for this busy environment. 

Here was what was noted from a discussion with our program director when considering the financial aspects of operating an electrophysiology lab:

• Downtime is expensive due to overhead (direct and indirect) variables that affect the total cost.
• State-of-the-art equipment with constant upgrades to maintain an EP lab is costly when balanced with suboptimal reimbursement from procedures. 
• At the end of the day, inefficient TAT may determine the staff staying overtime, putting a crunch on the department budget.

To appreciate improvement, the EP lab’s current TAT was averaged. A logbook that listed patients in room time and exit time was used to average TAT over a three-month period (Figure 2). 

Barriers to TAT Efficiency Identified

Next, a staff survey identified the “top three factors” that were barriers to TAT efficiency (Figure 3). Twenty-three staff members accountable for TAT, including physicians, anesthesia, nurses, techs, and managers, participated. From this list, the top three problem areas the staff identified were: physician delays to begin a case after the prep was completed; anesthesia delays to consent patients and lack of knowledge of EP ablation procedures; and housekeeping delays to clean the procedure room between cases.

• Physicians: Arrival time in the morning may affect the first case of the day and subsequent cases starting on time. There were many variables to case start time, including if the physician was called after patient is prepped, or delays due to the physician leaving the procedural area to assess their patients and address new consults.
• Anesthesia: Every EP procedure must have anesthesia consent; however, the assigned anesthetist when paged was usually occupied with cases in the OR. Also, there was confusion between CRNAs and the EP team as to optimum patient sedation levels and end results of ablation procedures.
• Housekeeping: Housekeeping communication was through a pager system and then we had to wait for a response. Sometimes it would take five or more minutes for the housekeeper to get to a phone and call back, and at times, there was no response. The next step was to call the supervisor, who would locate a housekeeper, taking even more time. Also, the second shift housekeeper did not carry a pager, so we had to find them to get the room cleaned. Sometimes on busy days, the staff cleaned and wet mopped the room themselves.

Process Improvements

Identifying and then communicating the top three barriers to those involved in TAT brought enough awareness and concern to implement process change. It takes team effort to improve TAT efficiency. Here is how the change took place:

Process Improvement #1:

Improve communication with the physician about their role in the TAT process and ask for their perspective on this subject. When this was done, all of our physicians agreed that although they needed to go to the floors between procedures, a phone call while the next patient was being prepped allows them time to complete unfinished business before presenting to the lab. Physicians need to have the same level of accountability as the rest of the team. When one team member isn’t held responsible, the rest of the team’s dedication and effort may be lost due to feeling unappreciated.⁵ Other issues such as continual tardiness in the morning, which affects the first case of the day, need to be addressed on an individual basis by the management team.

Process Improvement #2:

Improve communication with anesthesia on the goals of the EP department, including the importance of TAT efficiency. Since anesthesia was the last addition to our EP team, we needed to increase the knowledge base as to each person’s role and expectations. Our lead EP physician opened communication by speaking to the CRNAs on types of ablations to include sedation, the end result goals, and length of procedure. Anesthesia opened communication by speaking to the EP staff on legalities of consents, sedation levels, and various medications used for induction. This resulted in positive feedback and two departments that were working independently now working as a team. The anesthesiologist, appreciating our goal of TAT efficiency, began presenting to our department to consent patients within reasonable time.

Process Improvement #3:

Improve communication with housekeeping to avoid delays in room cleaning. Too many minutes were being lost with our paging system. Our staff was wasting time waiting for return calls, seeking out housekeepers, and at times, doing our own room cleaning. Housekeepers were frustrated as well, since they had to stop what they were doing to find a phone to return pages. The simple solution was to have a direct link to housekeeping. Upon meeting with the housekeeping supervisor, she immediately arranged for the staff to have pickle phones for us to make a direct call. This allowed for parallel processing, in which two tasks could be done at the same time.⁵ The staff feels this alone has had a huge impact on improving TAT efficiency.

Three months after process implementation, the EP logbook tracking proved TAT improved between cases by 7.4 minutes (Figure 4). In addition, before this article was published, another improvement was incorporated into our TAT process. Our cardiovascular director and EP technicians worked together to create a customized tray for device implants. They were able to work with supply chain to add more of the supplies we use consistently for implants to be packaged on the sterile tray. This took away the additional time used opening individual packages to add to the tray and also eliminated possible cross-contamination that could occur during this process. 

Summary

TAT involves a detailed study of each step of the process and the role of each member involved. As communication improves, an appreciation and respect occurs between the team members, enabling efficient workflow to occur. Small steps to cut off minutes become impressive in the end result. Also important to note is that staff members in all roles take pride in providing high-quality, safe patient care — efficient TAT by working as a team provides a way to accomplish this.⁵

A future addition to this study might be patient satisfaction surveys from those discharged after their electrophysiology procedures. 

References

1. Fowler P, Craig J, Fredendall L, Damali U. Perioperative workflow: barriers to efficiency, risks, and satisfaction. AORN J. 2008;87(1):187-208.
2. Fairbanks CB. Using Six Sigma and Lean methodologies to improve OR throughput. AORN J. 2007;86(1):73-82.
3. Czarnecki R. An Evaluation of Cath Lab Turnaround Time. Cath Lab Digest. 2008;16(2):28-31.
4. Glover W, Creehan K, Skevington J. 2009. “Case Study on Lean Principles to Improve TAT and First Case Starts in the Operating Room.” Society for Health Systems Conference and Expo.
5. Olmstead J, Coxon P, Falcone D, Ignas L, Foss P. World-class OR turnaround times: secrets uncovered. AORN J. 2007;85(5):947-949.