Feature: Changing cath lab shortcomings into long-term gains
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“It is not so much that the proper background information isn’t obtained or that the proper thought isn’t put into deciding to perform a catheterization,” said Howard P. Grill, MD, medical director of the cardiac cath lab at Excela Health in Greenburg, Pa., in an interview. Excela, one of the 10 facilities in the analysis, earned ACE accreditation in January. “It is a question of getting all that information in one spot where it is properly documented and can be found quickly.”
ACE reviewed 478 angiograms and cath reports randomly selected from the 10 facilities and found that missing and limited information made it difficult to determine appropriateness of the procedure and patient risk. For instance, only 46 percent of patients had documentation on ischemia, and half of studies for intravascular ultrasound and other procedures such as fractional flow reserve (FFR) for assessing the need for a procedure were inadequate or indeterminate. The appropriateness of a quarter of elective PCI cases was ranked as uncertain because of limited documentation.
The FFR documentation for Excela, for instance, existed but was buried in the electronic report, Grill said. “If you picked up the report and saw that there was a borderline stenosis that was dilated you wouldn’t immediately know that the appropriate measurements had been done to document the hemodynamic significance of that lesion,” he said. Their solution was to place the information more prominently in the report.
The goal of the ACE program is to help facilities improve by showing them where those opportunities exist, provide feedback and offer a centralized resource to promote best practices. While documentation is only one of several practices evaluated in accreditation, it is important for assessing appropriateness and quality care.
It also is challenging, because facilities are at various stages of transition between paper and EHRs and each facility has its own protocols and preferences, Bonnie H. Weiner, MD, chief medical officer for ACE, said in an interview.
“There was significant variation among the sites,” said Weiner, adding that ACE provides standards for the elements that should be listed in a cath report.
In another ACE study that looked at quality processes in the 10 facilities, researchers evaluated 441 medical records of patients who underwent diagnostic catheterization, PCI or both. Documentation for radiation exposure and absorbed radiation dose was spotty, at 87 percent and 77.5 percent, respectively.
ACE helped Excela determine radiation safety parameters for patients, operators and staff, Grill said. Excela then created protocols for reporting patient doses that are below the state’s mandated reporting threshold. Grill said that no patient has received that amount set by the provider, but if that were to happen, then the protocols also spell out follow-up care for the patient. Excela also has a process in place for the tech staff to inform physicians when doses reach certain limits.
“There is going to be a certain number of procedures where you have to deliver more to complete the procedure,” Grill said. “In addition to documentation, it makes everyone more aware of radiation safety.”
Besides offering guidance, ACE also serves as a forum for participants to share ideas. Weiner offered an example of a cath lab that developed a system for tracking accumulated radiation dose for patients that is now used across the hospital and has been emulated by other facilities. Grill said that Excela’s cath lab manager contacted peers for advice as Excela underwent the accreditation review process, too.
Excela has since implemented weekly angiographic and appropriate use meetings to review the quality of randomly selected films and PCI cases to assess diagnostic quality and appropriateness. Grill said the appropriate use meetings have made them more aware of what constitutes appropriate, uncertain and inappropriate cases and in practice has allowed them to recognize which cases might fall into the inappropriate category.
Having ACE resources centralized and available has been valuable as well, Grill said. “We can look in one spot and ask, ‘What are we doing perfectly, what are we doing just so-so well, and what are we doing that is perfect but not documented?'”
Weiner said that the accreditation process was an eye opener for many facilities as the gaps, highlighted in the two studies, became apparent. “All of them saw this as a valuable exercise,” she said. The studies were presented May 10 at poster sessions at the 35th annual meeting of the Society for Cardiovascular Angiography and Interventions (SCAI) in Las Vegas.