Use of a Shared Staffing Model for Cardiovascular Procedures, Including Left Atrial Appendage Occlusion

In January 2023, the structural heart program at the University of North Carolina (UNC) Health Rex completed its 500th left atrial appendage occlusion (LAAO), a minimally invasive procedure for patients with atrial fibrillation (AF) that reduces the risk of stroke and bleeding. UNC Health Rex is one of 14 hospitals in the UNC Health system serving patients across North Carolina. In this article, we discuss the unique shared staffing model for our cardiovascular procedures, including for LAAO cases.

Program History and Structure

Cardiac catheterization, electrophysiology (EP), and peripheral vascular (PV) labs generate a large percentage of the revenue stream in a health care system and represent 3 of the largest capital investments in a hospital’s budgetary expenditures. There has been much evolution in cath, EP, and PV over the past 20 years.

Previously, only diagnostic cardiac caths, right-sided procedures, pacemaker implantations, and ST-elevation myocardial infarction (STEMI) cases were performed in the cath and EP labs. Occasionally, there would be a peripheral vascular case in the form of a suspected renal artery stenosis, possible aortogram, or limited EP study. For smaller programs, it was also likely that cath, EP, or PV procedures took place in the same room with a fully cross-trained team. However, as EP procedures became more complex and new therapies for cath, EP, and PV became available, it was increasingly difficult for teams to obtain and maintain the level of expertise needed to work in a progressive combination cath/EP/PV environment. Today, many invasive heart and vascular labs operate in a collaborative hybrid setting to meet the diverse and complex needs of their patients.

At the Heart & Vascular Program at UNC Health Rex, we recognized the need to evolve, adapt, and grow as minimally invasive options became available through cutting-edge technology and research. While other cardiovascular programs house their hybrid programs within the operating room, UNC Health Rex decided early on to bring these procedures into state-of-the-art hybrid procedure rooms.

As plans were finalized for the North Carolina Heart & Vascular Hospital at UNC Health Rex, we first needed to ensure that infrastructure was in place for additional physician support and staffing. One of the first steps was to create a full-service PV program in 2008. With additional training and education for our cath lab teams as well as the acquisition of physicians with expertise in PV disease and limb salvage, we have become one of the country’s busiest and most complex PV programs. This program provides patients and teams with the unique benefit of having cardiologists and vascular surgeons work in a collaborative environment in the same shared space. The result is better care through real-time consults and a broader level of expertise.

In 2010, we experienced the merger of 2 cardiology groups that ultimately led to double-digit volume growth for 4 consecutive years. During that time, the team expanded from approximately 20 to 75 employees, including new positions for anesthesia techs and cath lab assistants in cath and EP. A cath lab assistant role was created to help increase efficiency by decreasing room turnover times and create a pool of potential cardiovascular specialist candidates. To be eligible for hire, candidates must be a certified paramedic and have a 2-year degree that would make them eligible to sit for the registered cardiovascular invasive specialist examination after 2 years.

As the cath lab began performing hybrid cases in both the structural heart and PV departments, the EP lab began developing an AF ablation program in 2012. The EP program is now comprised of 4 labs, including 3 ablation labs and 1 implant lab. There are 7 electrophysiologists and 3 implanting cardiologists that perform procedures at UNC Health Rex. Approximately 2500 procedures are performed each year.

This variety of new services offered required a substantial commitment from anesthesia to support the cases. Extensive training and education for the teams was also needed. The first transcatheter aortic valve replacements, endovascular aneurysm repairs, and AF ablations at UNC Health Rex were all performed in 2012. We also added a helipad in 2014, which resulted in a 73% increase in STEMIs over the next 3 years. In 2015, our cath and PV labs began operating 7 days a week, with one team on site each day to reduce the time to procedures. The addition of a weekend shift resulted in satisfaction for not only staff, patients, and their families, but also a substantial reduction in nonemergent callbacks and unnecessary overtime.

LAAO Program

As the AF ablation program grew, there was also a need for additional alternatives to blood thinners. Creation of an LAAO program helped to address that. The program started with 2 operators, Dr. Willis Wu (interventional cardiologist) and Dr. Sid Shah (EP), and has expanded to include the addition of electrophysiologists Dr. Geoffrey Lewis and Dr. Joseph Bumgarner.

Dr. Wu’s approach to LAAO includes first obtaining access using vascular ultrasound for imaging guidance as well as a micropuncture needle and catheter. These techniques are used to reduce the rate of vascular complications. Once access is gained with the needle, heparin is given intravenously at a dose of 90 units/kg bolus, followed by a drip at 23 units/kg/h. The rationale for giving the bolus dose of heparin with vascular access instead of after septal crossing is to reduce the incidence of cardiac thrombus as well as to increase efficiency. An Amplatz extra-stiff wire (Cook Medical) is then used to place a 16 French sheath into the right femoral vein; this sheath allows translation of torque with the delivery sheath, especially in obese patients. Through this sheath, a SLO catheter (Abbott Vascular) is directed into the superior vena cava. Echocardiographic guidance is used to perform transseptal puncture. Once transseptal puncture is performed, left atrial (LA) pressure is measured to ensure a pressure of 12 mmHg. Underfilling or overfilling of the LA may render measurements of the appendage to be discrepant with prior measurements. The SLO catheter is then ideally directed into the left upper pulmonary vein. This is irrelevant if using a ProTrack Pigtail Wire (Baylis Medical). Next, a .035-inch Amplatz extra-stiff wire is directed into the left upper pulmonary vein, and using this wire as a rail, the Watchman delivery sheath (Boston Scientific) is advanced into the LA. Using a straight pigtail catheter, the delivery sheath is advanced into the LAA and angiography is performed. Device size selection is made, and using fluoroscopic and echocardiographic guidance, the Watchman device is then deployed. Specific criteria are used to ensure proper placement and that device embolization will not occur. This includes ensuring that position is at the level of the circumflex coronary artery and not (significantly) protruding into the LA, adequate tug test, appropriate sizing with compression of the device, and no or minimal peri-device leak. Once these criteria are met, the device is released. Transesophageal echocardiogram is then used to ensure there is no migration of the device and no change in peri-device leak. The sheath is removed from the LA. Careful interrogation of the septum is performed to evaluate whether the septal defect needs to be closed. Finally, protamine is given. Hemostasis is achieved using a figure-of-8 stitch as well as manual pressure.

The cath lab staff, in collaboration with EP, performed the first LAAO procedure in September 2016. A combination team comprised of one cardiologist and one electrophysiologist was used early in our experience. Having a blended team offered greater flexibility in where LAAO procedures can be performed, including our hybrid, cath, and EP labs, using different combinations of staffing. One nurse is required and a 3- to 4-person team is used (usually 2 nurses and 2 cardiovascular specialists) to allow for lunch breaks and efficient room turnover as well as to ensure optimal workflow and patient throughput.

Every Thursday, we have a WebEx meeting with members of the Heart & Vascular leadership, preprocedural and postprocedural area staff, cath and EP lab managers, scheduling team, and anesthesia staff to look at the next week’s cases and confirm staffing, labs to be used, and any other issues. On a day that EP is running 3 ablation labs and 1 implant lab, lead extraction in the hybrid lab, and LAAO cases, the EP lab might only provide a cardiovascular specialist to scrub for the electrophysiologist performing the LAAO procedure. On a day when the cath lab call team was in overnight and the cath lab is short-staffed, the EP lab might staff the entire LAAO procedure. Our teams have learned to work well together and in any combination. This collaboration between the cath and EP labs has offered flexibility and the ability to spread work across departments so that one department does not have to shoulder all the burden when a stressful staffing situation occurs. The staffing model aligns with our organizational goal of one great team and has formed a bridge between 2 departments that often work in silos.

While there were some small learning curves in the beginning, such as the use of manifolds and documentation details, blending of the teams was seamless, and is still the model that we use today. Just as our previous cases required collaboration with anesthesia, LAAO cases also required a close working relationship with the echocardiography department. In addition, appropriate education regarding radiation safety and personal protective equipment was provided.

With our flexible staffing model and increase in LAAO, we soon reached our 100th case. With continued focus on the growth of the department in the form of outreach work on the part of our physicians and leadership, we were then at 200 cases. Working with anesthesia to obtain additional resources allowed us to expand the growth of the department and was an instrumental step in helping reduce patient wait time to have LAAO procedures completed. This helped us reach 300 LAAO completed procedures at UNC Health Rex. Doubling the physician pool that performed LAAO procedures gave our program another boost in growth and helped us serve our patient population, which expands beyond Wake County and the Triangle Area. We are now able to serve Johnston County as well as across the eastern portion of our state and beyond. The opening of Rex Holly Springs Hospital has allowed us to tap into yet another growth stream. We have now surpassed 500 LAAO procedures at UNC Health Rex. At each milestone, we take a moment for celebration with our teams. We feel it is important to share these celebrations with our teams to recognize the support and education provided by our product representatives.

About UNC Health Rex

UNC Health Rex participates in the National Cardiovascular Data Registry’s (NCDR) LAAO Registry, which assesses real-world procedural outcomes, short and long-term safety, comparative effectiveness, and cost effectiveness. With the NCDR LAAO Registry, UNC Health Rex maintains an A rating for proportion of successful LAAO procedures, among many other data-driven metrics.

UNC Health Rex has received many other quality-driven accolades as well. UNC Health Rex received a 5-star rating for quality of care from the Centers for Medicare and Medicaid Services (CMS). We were designated as a Magnet hospital for the fourth consecutive time in 2021, putting UNC Health Rex in an elite group of the top 2 percent of hospitals in the nation. Additionally, UNC Health Rex is one of 7 hospitals with Magnet designation, a CMS 5-Star rating, and a Leapfrog “A” safety grade (which the organization has received every grading cycle since 2012). We have also received the Press Ganey Guardian of Excellence Award for 3 years in a row. UNC Health Rex has received the American College of Cardiology’s NCDR Chest Pain/Myocardial Infarction Registry Platinum Plus Performance Achievement Award and Chest Pain Center Accreditation. We have also received Advanced Thrombectomy-Capable Stroke Center certification from The Joint Commission. In US News & World Report’s Best Hospitals list for 2021-2022, UNC Health Rex was one of 11 hospitals nationwide rated as “high performing” in 17 procedures and conditions. Additionally, we were named this year as one of the “Best Hospitals for Nurses to Work” by NurseJournal.

Summary

The key factors to sustainability when adding additional cardiovascular procedures in an already complex and high-acuity environment are flexibility, training and education, commitment from all ancillary-supporting departments, and regular peer review of cases. These can be achieved through extensive quality programs and a continuous performance improvement mindset.

As UNC Health Rex continues to grow its cardiovascular, structural heart, and PV programs, we will continue to experience staffing challenges. There is a shortage of health care personnel in the United States as a continuing result of the COVID-19 pandemic. Nurses and cardiovascular specialists have left to take higher paying travel assignments, while others have exited health care altogether. To remain competitive in this climate, organizations must be creative about staffing to attract talent. At UNC Health Rex, we believe our shared staffing model used in LAAO procedures will help us continue to recognize and implement sustainable growth models in the future as we move toward 600 LAAO procedures and beyond. 

Disclosures: The authors report no conflicts of interest  regarding the content herein.