Nurses Help Normalize Start Times, Decrease Turn Times in Cath Lab

When Scott Hantz, BSN, RN, EMT-P, joined Cleveland Clinic’s cardiovascular cath lab as nurse manager in April 2014, he made it a priority to normalize start times and decrease turnaround time between cases. Because of the growth in patient complexity and the proportion of new catheter-based procedures, many cases in the cath lab were taking increasingly longer to finish. This, in turn, led to the labs frequently running over time, which increased costs and wore down nurses and other staff.

It took an all-staff approach to boost efficiency under the leadership of Hantz and Samir Kapadia, MD, section head of invasive/interventional cardiology at Cleveland Clinic and director of Sones Cardiac Catheterization Laboratories. The team began by measuring all the metrics available and studying the cath lab’s workflow.

Improving start-time efficiency

The eight-room cardiovascular cath lab begins operations at 7:30 a.m. In early 2014, the first case of the day started on time only 40 to 50 percent of the time, says Hantz. The team made several changes to improve start-time efficiency, including the following:

• They obtained consent from the first scheduled patient the night before the procedure.
• The front desk staff began arriving earlier, so patients were completely registered in advance of the set procedure time.
• Nurses implemented a 7 a.m. huddle to address any potential issues and fix them prior to the arrival of patients.
• Patient transportation is alerted to pick up patients a few minutes early.
• If the first patient of the day is delayed for any reason, the cath lab takes the next patient who is ready for his or her procedure.
• Every room is now assigned a charge nurse who sees that things run smoothly.
• Hantz considered the skills and engagement of his entire nursing team and carefully chose complementary nurses to work together in each room.

The cath lab also began using a documentation sheet in each room. “It’s a very simple piece of paper with the room number and question, ‘Did you start on time?’” says Hantz. “The charge nurse circles ‘yes’ or ‘no.’ If the answer is no, they explain why.” Using the documentation sheets, Hantz and his peers discovered that a lot of delays were related to consent and sedation issues. They have worked with the appropriate staff to improve upon those delays.

Since making the changes, the cath lab now starts approximately 92 percent of its cases on time.

Reducing time between cases

Once the cath lab team improved its start times, it began working on decreasing the time between cases. Turn times for rooms typically took more than 20 minutes. The main change was to assign tasks to specific individuals so that the necessary preparations for the next patient occurred. Some of the new procedures are highlighted here:

• One staff member is assigned to take a patient out to recovery, while another one brings the next patient in. In the interim, an X-ray technician preps the table for the next patient.
• The team replaced a low-tech patient tracking system that used phone calls and handwritten notes with a web-based monitoring system that tracks each patient’s location. The information is displayed on monitors in each cath lab room as well as the physician’s office.
• The web-based system lists the nine tasks associated with preparing a patient for catheterization. If any of the steps isn’t preformed on time, the system alerts the person responsible.
• When the cath lab team breaks scrub, a colored light signals that it’s time for the next patient.

Since instituting these changes, the cath lab turnaround times have been consistently in the 15-minute range.

Effect on the cath lab and staff

The lab runs much more smoothly now, says Hantz. “When you can drop about 10 minutes per case for eight cases each day, that’s an hour and 20 minutes saved in each room,” he says. Hantz says the cath lab saved just over $300,000 last year in wage-based productivity. Room utilization in 2015 ranged from 107 to 110 percent.

Equally important is the effect these improvements have had on the morale of nurses, who frequently worked over time to finish cases. The cath lab’s manager readiness score on the Gallup® employee engagement survey rose from 70 to 88 this year, and the total engagement score went from a 3.78 to a 4.3. “We changed our culture and engaged our staff members,” says Hantz. “It’s brought the group together as a whole, and we’re able to accomplish things.”