Establishing a successful cardiac service-line in a rural town: how to keep quality and safety

Emporia, KS lies perched at the mouth of the beautiful flint hills. It is isolated by distance of at least 1hr to the next nearest hospital with cardiac service. It has a population of 25000. Despite being a descent size rural town, its residents and the greater surrounding catchment area of southeast Kansas, had no established cardiac service until 4 years ago. I was recruited to establish a full cardiac service from ground up. This would include a cardiac catheterization laboratory (cath lab), an in patient and out patient services.

Establishing such service required a tremendous willingness from the hospital administration and the public. It also required setting a goal of achieving the highest quality and safety standards as a benchmark and working backwards to achieve this goal. Video link

Building a safer cath lab environment

Unlike cath labs in major cities where it is part of a hospital that has a cardiac surgical service, this cath lab was being built without any of such. In an event of any complication in the cath lab that would require a surgical intervention, the patient has to get transferred an hour away. This issue has been the main impediment to establishing cath labs in rural areas. However, advances in technology in the past 5-10 years has improved the safety of  cardiac cath procedures to the point of almost eliminating the need for emergency surgical backup. To this effect, we designed the cath lab around eliminating medical errors to the maximum possible. The first area was to buy a state-of-the art equipment with enhanced safety capability. A Seimens cath lab was chosen.  An automated contrast injector (Acist injector) was added to reduce manual injection-related complications. It is well known that the highest area of cath lab related side-effects lies in initial access site (bleeding from the arterial puncture area). We implemented two strategies to prevent this. The first is a radial-first approach. 75% of our cardiac procedures were performed from the arm (radial access). The second is to employ ultrasound (sonosite) guided arterial puncture rather than the traditional anatomy based approach. This has tremendously reduced groin (femoral) access complications.

Staffing the cath lab

Staffing the cath lab was another major challenge as there was no locally available personnel or school to tap from. Since there is no room for error, recruiting less experienced personnel would doom the program from its outset. Hence, extra effort was done to recruit and maintain seasoned personnel from neighboring major cities. Safety in the cath lab starts way before the patient comes in to the lab. To create a seamless flow of care, a check list was established that follows the patient from the time of registration to completion of the procedure. All orders were crafted to reflect consistency and evidence-base. A grass-roots intensive education was given to the floor nurses and personnel to consistently follow the checklists and protocols. Communication between the different teams is the lynch pin of our success.

Outcomes

The success of our cath lab was a huge financial windfall to the hospital which was in a significant financial trouble at the time of its opening. With over 1600 procedures performed and counting, there was no need for emergency referral for surgical need. The cardiac service is now rated in the top 10 in the state of kansas. Our service has demonstrated that the three basic tenets of a successful high quality cardiac service are check-lists, communication and consistency.

Newman Regional Health transformed due to addition of cardiology services.

See related article: http://www.kumc.edu/Documents/ruralhealth/spring2013.pdf