Analysis Of Charges And Complications Of Permanent Pacemaker Implantation In The Cardiac Catheterization Laboratory Versus The Operating Room - Brief Article

AORN Journal, August, 2001 by Victoria M. Steelman

ANALYSIS OF CHARGES AND COMPLICATIONS OF PERMANENT PACEMAKER IMPLANTATION IN THE CARDIAC CATHETERIZATION LABORATORY VERSUS THE OPERATING ROOM

K H Yamamura et al Pacing & Clinical Electrophysiology Vol 22 (December 1999) 1820-1824

Perioperative nursing has expanded well beyond the traditional walls of an OR suite. During the past two decades, the trend toward implanting permanent pacemakers in cardiac catheterization laboratories (CCLs) has increased. Perioperative nurses may question whether it is as safe and cost-effective to perform these procedures in the CCL compared to the OR. The purpose of this study was to evaluate simultaneously cost, length of hospitalization, and complications between patients receiving pacemakers implanted in the OR by surgeons and those receiving pacemakers implanted in the CCL by electrophysiologists.

Methods. The sample in this study consisted of 254 patients consecutively undergoing implantation of permanent pacemakers during a two-year period. These implantations occurred in the OR (122 subjects) or the CCL (132 subjects) in a single hospital setting. All patients were older than 16 years of age. The average age of participants in the two groups was similar--a mean age of 64 +/- 21 years in the OR group versus a mean age of 65 +/- 17 years in the CCL group. The indication for the procedure and type of pacemaker implanted also were similar among patients in both groups. Dual chamber pacemakers were implanted in the majority of participants (78% of OR participants, 73% of CCL participants).

Results. The average hospital charge for pacemaker implantation in this study was significantly higher in the OR group ($5,464 +/- $1,670) than the CCL group ($2,682 +/- $8) (P [is less than] .001). The cost of the leads and pacemakers were identical and were not included in this analysis. Physicians' fees also were not included.

The average hospital stay did not differ between the two groups; however, the preprocedure length of stay was significantly lower in the CCL group (3.16 +/- 12.4 days) compared to the OR group (5.65 +/- 9.54 days) (P [is less than] .05). Complications were minimal in both groups, and no significant differences were found between groups.

Discussion. This study provides interesting information, even though it has two serious limitations. First, the outcome of cost was determined by hospital charges. Costs and hospital charges are not the same and should not be equated when performing a cost analysis. The findings also have limited generalizability because only one setting was used. Even with these limitations, however, the authors should be applauded for critically evaluating the cost-effectiveness of the care provided in their setting. We clearly can gain information that may identify opportunities for perioperative nurses in other settings.

The cost savings associated with performing pacemaker implantation in the CCL were dramatic. The average charge of implanting a pacemaker in the OR was roughly twice as much as in the CCL. The variability in charges among subjects in the OR group also was much greater than those in the CCL. The streamlined processes involved in performing a series of similar procedures may contribute to these lower charges and variations. One may conclude that there is a potential for cost savings in other settings.

The preprocedural lengths of stay (LOS) were shorter in the CCL group. The reason for the shorter LOS provides valuable information. The researchers speculate that procedures were scheduled more easily with less waiting time in the CCL than in the OR. This may be tree in other hospitals as well.

In this study, pacemaker implantations were performed in a CCL by nonsurgeons with no increase in complications. This demonstrates that it is possible to perform these procedures in a CCL with patient outcomes similar to those achieved in the OR; however, each hospital is a unique environment with different abilities among surgeons, cardiologists, and nursing staff members. We cannot assume this result would occur in another setting. When implanting pacemakers, the standard of care needs to be the same in the CCL as in the OR. When this standard is achieved, there is an opportunity for safe, cost-effective pacemaker implantation in the CCL. The cost savings to the institution is likely to be significant.

Perioperative implications. The movement of surgical procedures to settings outside the OR will continue as we search for cost-effective ways to provide safe patient care. According to the article, more than 50% of permanent pacemakers currently are implanted in CCLs; therefore, an opportunity for cost savings exists in many hospital settings. Each setting is different, however, and any proposed change should be evaluated thoroughly by a multidisciplinary team that includes perioperative nurses. If the decision is made to begin performing these procedures in the CCL, every attempt should be made to provide the same standard of care as in the OR. Perioperative staff members and educators should take steps to ensure this occurs, including sharing standards, educating CCL staff members, assessing their competency, and evaluating patient outcomes.