In a proactive move to increase the effectiveness of its ECG services and reduce costs, JFK Medical Center (Atlantis Fla.), decentralized the function and placed the responsibility for acquiring ECGs at the point of patient care into the hands of the primary caregivers. This included cross training nurses, patient care assistants, respiratory therapists, and emergency department personnel to perform the ECG studies.

As a result, the formal ECG department was dissolved, reducing FTEs from eight to 2.99 and saving an estimated $83,000 a year. In addition to saving money, the transition to point-of-care ECG acquisition enabled the hospital to dramatically improve the volume and productivity of its ECG services.

In 1993 we performed 28,450 ECGs, using eight dedicated ECG techs, said Marie Stanley, Vice President of Patient Care Services, and Chief Nursing Officer. This year we project doing 33,850 ECGs with an average of 2.99 FTEs. That's a 20 percent increase in output, using 65 percent less staffing resources.

Healthcare institutions quantify productivity by comparing the amount of time spent on a given procedure with an established industry standard. In the case of ECGs, the national average is about 30 minutes per procedure, including downloading, editing, and posting, which results in a .5 productivity rating. Under the new process, JFK Medical Center has been able to lower its time to less than 10 minutes per procedure for a .17 productivity rating.

Updated cardiology management system sparks idea

In 1993, the Medical Center was upgrading its cardiology data management system to the GE Medical Systems MUSE® system. A series of technological advances, including moving to a PC-based strategy, made the system much faster, easier to use, and more productive than its predecessor.

Much of the time we spent on ECGs was in the cardiology department, editing and processing the tracings and reports, said Ann Bonner, RRT, director of Pulmonary Services. We saw a real opportunity to increase efficiencies in this area and reduce the number of personnel needed to do this job, due to the advantages of the new system.

Once we started that train of thought, we began to see the possibilities for reorganizing the entire ECG service delivery mechanism. Respiratory therapists had already assumed the ECG duties on the night shift when the department was closed, so we said, "why can't everyone do it?"

The Pulmonary Department was receiving complaints from caregivers on the floor that ECG services were not as accessible as needed, according to Stanley. This helped convince us that the best people to put in charge of the service were those in a position of direct patient care.

By training these people to schedule and administer ECGs, we gave them more flexibility in coordinating their patients' care versus having to be responsive to the schedule of an outside department," she said.
 

Training is important

This became the core group of "mini-experts," according to Bonner. It was their responsibility to learn ECGs as well as they could, and then become the trainers for the other people on their floor. They also would be available to assist in performing the studies.

The first step in training was to upgrade and increase the medical center's ECG cart inventory in order to place a cart on every floor. JFK selected GE Medical System's exercise testing system.

The new carts offer the latest in menu-driven operator interfaces which simplify use and help people get comfortable with the hardware more quickly, according to Bonner. "This was important, because it allowed trainers to spend more time on good lead placement, which is critical to doing quality ECGs," she said.

Another benefit of the new carts is that they provide enough memory to store a day's worth of ECGs. Each morning at 5:30 a.m., a cardiac technician collects the ECGs for input into the cardiology data management system.

A collection protocol was established to review the quality of the tracings at the cart prior to transmitting them to the MUSE system. Those judged too poor to use are redone.

"In this way, we can provide a double check of our quality," Bonner said. "We had to accommodate the learning curve issues regarding ECG performance of the cross-trained staff."

The ECG staff was reduced to 2.99 FTE positions as cardiac technicians. In this new role, the technicians effectively "complete the loop" between the ECG data gathering and the information management. In addition to collecting and checking the studies, they also download the data into the MUSE system, process the information and coordinate it with the first previous study, if available.
 

"Once people understand that we must do business differently to succeed, they embrace the opportunity to make themselves more valuable."

This information is given to the physician panel for overreads, which the technicians then transcribe into the permanent electronic record. From there, confirmed ECG printouts and results are delivered to the nursing units for posting.

The cardiac technicians also have been cross-trained to apply Holter monitors and scan studies, perform stress tests, and provide signal average ECGs. In addition, they serve as a hospital-wide resource for education and training.

"Our strategy is to make every member of the medical center's workforce as valuable as they can be," says Lucy Dwyer, R.N., director of Cardiac Rehabilitation and Diagnostics. "In addition to developing a broader range of employable skills, we've seen people respond very well."

Stanley agrees, "Medical professionals need to be flexible and adapt to new ways of providing care to remain effective. Once people understand that we must do business differently to succeed, they embrace the opportunity to make themselves more valuable. We're willing to invest in our staff to acquire those extra skills," she said.

JFK becomes the prototype for Columbia

"We can help take away much of the downtime associated with making such a decision, simply by sharing this information," Stanley said. "It is important to measure results and share these 'best practices' to help make the whole system stronger."

Looking ahead, JFK Medical Center is integrating its cardiology management database with a system that permits Emergency Services personnel to access complete cardiology patient histories and ECG waveforms as part of its Chest Pain Emergency Center and the new Columbia Chest Pain Network.

Columbia institutions are aiming to significantly reduce the time it takes to treat acute myocardial infarctions, Stanley said. This includes investing in 12-lead ECG capabilities for field emergency personnel, who can transmit diagnostic tracings prior to the patient reaching the medical center. These can be compared to any previous studies in the patient’s file on the MUSE system.