University of Rochester Medical Center at Strong Memorial Hospital

What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab?

We have two electrophysiology labs (both with fixed x-ray systems, one biplane, and one single plane), divided by a control room. We share an 18-bed pre/post area with the cath lab. Tilt tests, cardioversions, and non-invasive EP studies are performed in a dedicated holding room. We have 10 RNs. (Eight are full-time and two are part-time). We all have nursing backgrounds in cardiology or critical care. We have four EP attending physicians and one dedicated EP fellow (with three fellows coming in July 2003). There is a heart pavilion within the hospital, and a dedicated floor specializing in the treatment of cardiovascular patients and cardiac transplantation. Patients are also placed in other telemetry units as needed.

When was the EP lab started at your institution?

The Electrophysiology program was established in 1982 by Dr. Thomas Rahilly. However, he died in an automobile accident in 1983; the program continued from that time under the supervision of Dr. Toshio Akiyama, and then by Dr. James Daubert in 1992. Catheter ablation procedures were begun between 1992-1993. Procedures were performed in the Cardiac Catheterization Laboratory (with ICD implants in the operating room) until the first dedicated EP Lab opened in 1996. A second shared lab was added in 1999. Two brand new dedicated EP Labs opened in 2003.

What types of procedures are performed at your facility? Approximately how many are performed each week?

The University of Rochester is the major center for cardiology clinical research studies. In the past, we have been involved in the Companion and Miracle Studies, as well as the MADIT I and II trials. Dr. Arthur Moss, who is a UR faculty member and primary investigator in MADIT II, has provided the criteria to implant implantable cardioverter-defibrillators (ICDs) in patients that previously would not have been candidates. Our laboratory and the EP service have been actively involved in invasive and non-invasive trials investigating issues on long QT syndrome, arrhythmogenic right ventricular dysplasia, inheritable arrhythmias, prevention of sudden cardiac death, as well as evaluation of new implantable devices, antiarrhythmic medications and interventional EP catheters with funding sources from the National Institutes of Health, Guidant, Medtronic and St. Jude Corporations. Annually we perform:

ICDs: 200 non-biventricular (154 dual and 55 single)

Cardiac resynchronization therapy/BiV: 100 BiV (65 BiV ICDs, 40 BiV pacers)

Pacemakers: 300 pacemakers

Implantable loop recorders: 25

EPS: 300/year

RFAs of ventricular and atria arrhythmias: 260

Lead extraction: 50-100/year

NIPS: 50/year

Cardioversions: 150/year

Tilt table procedures: 100/year

Complication rates are tracked carefully by EP Lab nurses and physicians, and reviewed quarterly at QA meetings. Atrioventricular (AV) block requiring a pacemaker is below 0.5% for ablations, and infection rates are below 1% for device implants.

Who manages your EP lab?

The EP Service Director is James P. Daubert, MD, and the Associate Director is David Huang, MD. The EP lab is also managed by Nurse Manager Dawn Urquhart, RN, MS, who also manages the cardiac cath lab and the step down unit, as this enhances our continuity of care. Molly Coonan, RCVT, is the lead EP technician.

Is the EP lab separate from the cath lab?

The cath and EP rooms are operationally separate, but share the same geographic location.

Do you have cross training inside the EP lab?

The technical (mapping, etc.) work is performed exclusively by two RCVTs. The role of the nurses is to circulate, administer medication and perform patient care. Regulations are that RNs are responsible for conscious sedation, medication administration, assessment intervention and defibrillation. Cath lab and EP nurses do not cross train in the labs, but do work together in the pre-post area.

What new equipment, devices and/or products have been introduced at your lab lately? How has this changed the way you perform those procedures?

For extractions we have a Spectranetics laser, as well as Cook/electrosurgical extraction equipment. Our monitoring system is GE/Prucka, and we have the 3-dimensional mapping systems from Biosense and ESI. This has allowed us to do more complex procedures with greater accuracy and efficiency, resulting in improved patient cure rates and outcomes.

Is your EP lab filmless?

Yes we are filmless and archived.

Who handles your procedure scheduling? Do they use particular software?

We have a scheduling office with three full-time employees who schedule procedures for the EP and Cath Lab. Scheduling is done via a hospital-wide system which has demographic information. Our procedure and outpatient reports are done in a database written in 4D by one of our cardiology attendings, Dr. Karl Schwarz, and this software is used in Echo, Cath and many other cardiology sections. The EP component was designed by Dr. Schwarz and the EP attendings. We are anticipating using the program for scheduling, as well as billing, very soon. Regarding physician timeliness, we try to balance elective with inpatient and emergency cases. We utilize a secure text paging system for MD timeliness and communication within the unit and hospital.

How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies?

Our inventory is managed during the case by a computer inventory management system (Touch scan/ESI) for billing purposes; RNs scan items as they are used. We have three full-time inventory control staff for both EP and cath labs who are involved in ordering, receiving, price negotiation and cost analysis and work directly with the vendors along with our purchasing department.

Has your EP lab recently expanded in size and patient volume, or will it be in the near future?

With this relocation we have expanded to two rooms, and our volume has increased 18% in the past year.

How has managed care affected your EP lab and the care it provides patients?

Our community has an aggressive managed care organization and our market is such that we compete with other hospitals. We receive many referrals from other geographic regions for EP procedures.

What measures has your EP lab implemented in order to cut or contain costs? In addition, in what ways have you improved efficiencies in patient through-put?

We have a computer-based inventory system (TS 2000) that partners with purchasing to achieve complete pricing contracts with our vendors. We utilize consignment whenever possible.

Does your EP lab compete for patients? Has your institution formed an alliance with others in the area?

Within our community we compete with other hospitals, including one other EP program in Rochester; however, throughout upstate New York patients are referred to us for certain procedures.

Does your lab have an outpatient program?

Our doctors and NPs travel to rural centers to outreach clinics to oversee an aggressive outpatient schedule.

How are new employees oriented and trained at your facility?

We utilize a comprehensive training orientation for new hires consisting of 1:1 preceptorship and six weeks of hands on training. If hires are new to the University of Rochester, our nursing practice has an orientation to complete in addition to training in the EP lab. Nursing staff are often broken in by the attendings who try to make our work day pleasurable by infecting us with their sometimes corny senses of humor. During one procedure, Dr. Daubert was placing the new sweet tip lead in a patient, while a new nurse was helping. After explaining how the tip secreted a sugary substance, he innocently asked the nurse if the patient was diabetic. The nurse, putting it together, scrambled through the chart and said she was; then, dutifully stated her last BG. Seeing a golden opportunity, Dr Daubert ordered to get the insulin ready! As he continued to screw in the lead, the nurse, standing at the bedside with insulin and glucometer in hand, broke into laughter, realizing he had been had. He passed initiation!

What types of continuing education opportunities are provided to staff members?

We partner with our vendors for in-services on everything, from new devices to how to use a programmer; we use Medtronic, Guidant and St. Jude. We also have the opportunity to go to NASPE annually, as well as opportunities to attend grand rounds with attendings and fellows on new and different cases.

How is staff competency evaluated?

During orientation, we have specific competencies for all procedures. There are more generic in-house competency that staff must also complete.

Does your lab utilize any alternative therapies to help patients in the EP lab?

An individual plan of care is developed prior to the procedure by the primary nurse and the patient. Nurses identify patient concerns during pre-procedure assessment, and are able to offer individualized therapies based on patient needs. This may include visual imagery, i.e., a scenic mural of the city of Rochester that surrounds the labs, a choice of music, positioning, and the comfort of being surrounded by confident and competent staff.

Describe a particularly memorable or bizarre case that has come through your EP lab.

We had a patient with 2 sinus and AV nodes in for radiofrequency ablation (RFA). We managed to do a successful ablation. While doing a BiV/pacer, we discovered our patient had a persistent left SVC; this system was successfully implanted. Another case involved a patient in for AVNRT and we found he had a bystander Maheim bypass tract. A patient complaining of syncope episodes was referred for a tilt table test, and stated that only certain conditions brought on the symptoms. Our dedicated staff would go to any lengths to set about replicating these conditions as closely as possible. While the test was in progress with the patient hooked up to various monitors and equipment, strapped to the table and tilted at sixty degrees the primary nurse, the attending physician and patient were observed by another staff member to all be sipping ice-cold coca colas! Contrary to the patient s claim, this did not induce syncope in any of them.

How does your lab handle call time for staff members? How often is each staff member on call? How frequently do they have to come in, on average? Is there a particular mix of credentials needed for each call team?

Each staff member is on call once every 8 weeks. However, case volume is such that case operations extend late into the evening at times, and each day two nurses are assigned to stay until all procedures are completed. The nurse is expected back at his/her scheduled time the following day.

What type of quality control/quality assurance measures are practiced in your lab?

Quality control is a managed program that is unit- and hospital-wide. There are specific accountability guidelines for incident reporting, and there are regularly scheduled quality assurance meetings. What are some of the trends you see emerging in the practice of electrophysiology? More indications for devices, therefore busier. Our in-house patients are sicker, and we are starting to see patients coming down from the ICUs. Our BiVs are showing a 75-80% symptomatic improvement.

When was your last inspection by JCAHO?

There is the JCAHO every three years. We also have ongoing inspection for health and infection control and radiation safety.

Does your staff provide any educational materials for patients who may have additional questions about their condition/procedure?

Patients are seen in clinic by nurse practitioners prior to procedures. During this visit patients obtain a complete understanding of their disease process, information regarding options for treatment, risks and benefits of each, and written materials. Ample opportunity is given for patients to have all their questions and concerns addressed at this time. At discharge, patients are provided an instruction sheet pertaining to their procedure and encouraged to call the clinic with questions or problems. Two weeks later, patients begin a series of follow-up visits. Previously, in the earlier days of ICDs, we had an active ICD support group. In addition, our CHF and general cardiology groups have patient support groups.

Give an example of a difficult problem or challenge your lab has faced. How it was addressed?

There have been no major problems, the small day-to-day challenges are addressed quickly and overcome. However, some of the challenges we face are that our volume is increasing, there are higher technology costs, we are adapting to our new labs, and there continues to be challenges with decreased revenue from payers. Finally, we are also dealing with recruitment and retaining staff.

Please tell our readers what you consider unique or innovative about your EP lab and staff.

All staff (EP, Cath and all the support staff) work well together! Fridays are fun Fridays: we all wear the same tie-dye shirts, bring in our favorite foods, and throughout the day gather in the break room to relax, eat and enjoy each other's company.