University of Iowa Hospitals

We have two dedicated clinical electrophysiology laboratories. One is generally regarded as our "device" laboratory, in which we implant pacemakers and defibrillators including biventricular devices. In this lab, we occasionally perform "NIPS" and other rather straightforward procedures. In our other larger (1,200 square feet) laboratory, we perform more complex electrophysiology studies, device implants, and all ablations. This laboratory has biplane capabilities, and is where all complex (CARTO and ESI) mapping procedures are completed. There is a separate pediatric EP/cardiac catheterization laboratory. A separate area (an adjacent recovery room) is used for tilt table testing. The tilts are generally performed by our team of Advanced Registered Nurse Practitioners, who also take care of the majority of our patients after procedures. Lead extractions are generally performed in the operating room. There are three adult EP faculty at the University of Iowa: Dr. Brian Olshansky, Director; Dr. Pamela Nerheim, who completed her cardiology and electrophysiology fellowships at the University of Iowa (and who has a background in nursing); and Dr. James Martins, who is also Chief of Cardiology at the Iowa City Veterans Administration Hospital. There is one invasive pediatric EP faculty: Dr. Ian Law. We collaborate with him on select cases. In addition, we have one EP fellow a year. Our EP fellows sometimes overlap a year performing research as part of their general cardiology fellowship. This year, Dr. Hongsheng Guo is working with us. Our program is popular with fellows, and presently one-half of the general cardiology fellowship program has an interest is pursuing a career in EP. The fellowship was one of the first approved and has successfully trained many electrophysiologists, all of whom have successfully passed the certification exam. Our nursing staff and radiographers include personnel who cross train from the cardiac catheterization laboratory. They are highly trained in electrophysiology and cardiac catheterization procedures. Our nursing staff has become a strong asset of our laboratory. The cross training has provided new expertise, as many of the staff have a background in interventional stent and angioplasty work. Several radiographers and nurses are RCIS-certified and participate in more complex device implants, providing us with a specific advantage of instrumenting the coronary sinus during biventricular cases with speed and low risk to the patients. Our staff is also capable of closing device pockets. Frank Eischens is the Manager of the Adult Cardiac Cath and EP Labs, and Darin Hochstetler is the Assistant Nurse Manager. Renee Bender is the Nurse Coordinator for the Adult Electrophysiology service. She coordinates the procedure and clinic visit scheduling with the faculty and with the procedure lab personnel. She follows our outpatients carefully, and provides extensive patient and family education. We feel that our team approach gives each member an ownership of the work rewarded by increased responsibility. Drs. Martins and Olshansky are board-certified (and re-certified) cardiac electrophysiologists. Dr. Nerheim is board eligible for EP. Frank Eischens has a technical and nursing background and is a Testamur of NASPE AP/EP, as well as RCIS certified. He has been involved with cardiac electrophysiology for over six years. Three of our radiographers are RCIS certified. All of our nurses who administer conscious sedation have been trained and are certified by the hospital. Tom Drews is a fully trained, NASPE-certified pacer/defibrillator technician with a BSEE. Dr. Olshansky and Dr. Martins have been certified in deep sedation. The laboratory has been running consistently for over 23 years. During that time, several EP faculty have come and gone. As such, the volume and case mix of the laboratory has fluctuated over the years. Over the past 3 years, since Dr. Olshansky has joined the laboratory, the volume has grown and the complexity of the procedures has changed. We perform everything from simple electrophysiology studies, device implantations including biventricular implants, to simple and complex ablation procedures. We are seeing a great increase in the number of procedures in our atrial fibrillation ablation program. Our technique is to attempt to isolate all the pulmonary veins. We have tried several approaches, including ESI and CARTO. Generally, we have found using Lasso catheters and a double trans-septal technique to be the best. Intracardiac echo is scheduled to arrive in the next several months and our plan is to work closely with our echo colleagues (Dr. Richard Kerber) in this regard. An animal laboratory allows investigation of innovative therapies and techniques. We perform over 600 procedures each year. This includes over 150 ablation procedures, over 100 ICD implantations and over 100 pacemaker implants. Our ablations include: accessory pathways (still relatively common in Iowa), AVNRTs, atrial tachycardias, idiopathic VT and VT in structural heart disease (for those who are resistant to medications) and focal pulmonary vein atrial fibrillation ablations. Most of the complex congenital heart disease ablations are for atrial arrhythmias and are performed by Dr. Law. We see a mix of some of the most complex cases in the state and from neighboring states as we are a tertiary care referral center. We do not routinely find complications during our procedures. After the arrival of Dr. Olshansky, and with reorganization, there was a change in protocols, procedures and nursing faculty. With the present staff, the procedures are performed efficiently, effectively and with low risk of complications. We have not had a major complication over the past years with the present staffing but have had rare pneumothoraces, rare device infections and occasional hematomas. Many complications are extremely low due to preventative measures such as infusing intravenous fluid through venous sheaths to avoid deep vein thromboses. As many of our patients come from a long distance, we watch our patients overnight after an ablation or device implant. Frank Eischens, RN, Chief Clinical Technologist, and Darin Hochstetler, RN, Assistant Nurse Manager, and the EP Program Director Dr. Olshansky, manage the EP lab. Mr. Frank Eischens manages the lab. His position includes maintaining our laboratory in a cost-effective manner, insuring efficient patient flow, organizing personnel for the procedures, efficiently scheduling patients, overseeing conscious sedation, maintaining credentials of all of our staff members, making sure equipment is in working order, negotiating costs of equipment for the laboratory and for patients, becoming involved with state-of-the-art equipment and its use in our laboratory. Yes, the laboratory is separate from but adjacent to the cardiac catheterization laboratory. It is conveniently located to all nursing staff and EP faculty members. This has been the case for over 20 years. Yes. Due to the unpredictability of scheduling needs, we have gone to a fully cross-trained system. The crossed-trained staff enjoys the variety in their work and each staff has chosen a type of EP role with which they are particularly pleased. The concept that all our employees are cross-trained is relatively new (less than one year). It has worked out well, in fact, better than having a dedicated EP staff. Cross-training offers a distinct advantage for a device implantation as the staff technically trained in cardiac catheterization procedures is highly competent in venous access and placement of leads in unusual positions (based on their experience with angioplasty procedures). Our nursing and radiographer staff performs the following: 1) starts IV lines; 2) places catheters; 3) closes device (pacemakers, ICDs) pockets; 3) removes lines; 4) runs the stimulator; 5) runs our ablation equipment; and 6) operates complex mapping equipment including CARTO and ESI. There are weekly conferences with the nursing staff and Dr. Olshansky to discuss issues in the laboratory and to become educated in EP issues. Dr. Olshansky and Mr. Eischens collaborate to ensure that the nurses and radiographers have the expertise to perform all procedures. There are no regulations from the state, but we have identified areas of expert knowledge and skill that are expected to perform EP procedures. Critical Practice Competancies are evaluated annually to assure that the staff participating in the various procedures have an optimal level of skill. What are some of the new equipment, devices and products introduced at your lab lately? We are about to completely revamp our main EP laboratory. We will be getting new state of the art Siemens radiography equipment. We may be upgrading our Prucka equipment (we have a prototype network based system now). Within a few months, we will be installing Stereotaxis equipment. The approach offered is to direct catheters and leads to places unreachable with manual catheter movement. With Stereotaxis, catheters are placed magnetically and robotically. One of the innovators of this technology is the Chief of Neurosurgery at University of Iowa, Dr. Mathew Howard. This equipment may help facilitate atrial fibrillation ablations, place coronary since leads and perform linear ablations for atrial fibrillation. We work in collaboration with our cardiovascular surgeons. They have had an interest in MAZE procedures, but we have started an atrial fibrillation ablations in the OR with AFx radiofrequency ablation probes. We are presently not using any innovative energy sources for ablation in the laboratory such as cryoablation, although we have had a Stockert Generator in our laboratory. We expect that the capabilities of the Stereotaxis equipment may have a major impact on how we perform cases. Presently, our EP laboratory is not filmless. We do have methods to store digitally images and in the PRUCKA system. When the Siemens equipment arrives, we will be filmless. Frank Eischens and Darin Hochstetler arrange the schedule. The goal is to be highly efficient during the day so that few, if any, cases need to be performed at night. Generally, both laboratories are in use during the day. With cross training and job sharing, we have an ample number of nurses to perform procedures, and there is little "down-time". Scheduling is performed using Microsoft Outlook. Procedures generally start between 7:30-8:00 am. Consent is obtained by the faculty at the initial visit or by the EP fellow or a nurse practitioner. The fellows and the nursing staff place lines. The faculty is expected to oversee these issues and to be present as needed for critical portions of the procedure. Frank and Darin manage the inventory. Frank has been critically involved in negotiating costs for devices and catheters. Our goal is to be cost effective, but not at the expense of patient care. It has expanded in volume and will likely expand more in the near future. Presently, we do not perform many "MADIT II" implant due to concerns about reimbursement and staffing issues. We expect this to be resolved in t the next several months. Dr. Nerheim has a process improvement grant to track patients who would fit "MADIT II" criteria but are not presently being referred to us or getting ICD implants. In addition, with the results of the COMPANION Trial now reported, we are receiving more referrals from our heart failure colleagues for bi-ventricular device implants. Changes in insurance/hospital affiliation have had a significant impact on our referrals. Much of these issues are out of our hands. We try to minimize the unnecessary use of multiple catheters. We have negotiated with the device companies and the catheter companies for good prices. We have become more cognizant of the need to perform procedures efficiently. We run two laboratories (and with our second Prucka system which is portable even use one of the catheterization laboratories, and the recovery room) for other procedures. We minimize overtime use of the laboratory. We have nurse practitioners ("attending directed service") to manage our overnight patients. They write the history and the physical examination when the patient arrives. They follow and discharge the patient under the supervision of the attending electrophysiologist. Absolutely. Several electrophysiologists practice in the general area, and we do compete for the same patients in a friendly way. Iowa City has a total population less than 60,000, but being a tertiary care center we have a much larger referral base than the immediate surrounding area. We have tried to develop a collaborative relationship with the electrophysiologists in the state. We have established an Iowa EP society that attracts electrophysiologists from the surrounding area to hear visiting experts speak on select EP topics. We provide outreach services to several institutions in the state and have provided such services in Illinois. We are in the process of expanding our outreach services to help other communities in the state that could benefit from EP expertise. Yes it does. We perform some of our procedures on an outpatient basis. Our outpatient EP clinic at the University of Iowa sees over 1,600 patients/year. We provide outpatient outreach clinics. We follow some devices trans-telephonically throughout the state. We have a strong commitment to education in our EP lab on all levels. All faculty members and our trained nursing staff provide didactic teaching and "on-the-job training" in the laboratory. We have several weekly conferences to review cases on all levels. These include conferences for the fellows, for the faculty and for the nurses and radiographers. As stated, we have several conferences. Our nurses and radiographers also attend the ACC and NASPE conferences. We have recently started formal continuing education to involve not only lab staff, but clinic and inpatient nursing staff as well. After training, competency is determined by assessments from the faculty and from Darin and Frank. Yes it does. Dr. Olshansky has a specific interest in alternative therapies. Generally, these therapies are used for patients with benign palpitations, syncope and risk reduction. Dr. Olshansky has employed the use of an energy healer for young patients with "POTS" and those with neurocardiogenic syncope. Several herbal therapies have also been employed for these patients. Dr. Olshansky is involved in an ongoing study with the Maharishi University in Fairfield, Iowa to evaluate the use of an Ayurvedic medicine approach to reversal of arteriosclerosis, in combination with meditation. In terms of innovative alternative technological therapies, we have a cautious approach to new technology. Dr. Olshansky often takes a "blue collar" approach to ablations: more is not always better. Successful ablations can often be accomplished with standard recording systems and routine ablation equipment. Yes. As we remain a tertiary referral center for the state, we get to see some of the most complex cases. Many of the issues, however, involved more than just the arrhythmia problems. Frank Eischens arranges the call time and overtime. There is an on-call schedule for the staff members mainly for the catheterization laboratory. Rarely for EP. If there is a need for a temporary pacemaker, they may need to come in. The faculty and the fellows take care of most of the evening problems and utilize our operating room for evening and on-call device implants. In addition to minimizing EP staff call, this also serves to give our cardiovascular surgery fellows an opportunity to participate in device implants. It is dependent upon patient care needs. The call team staff would be the first to be released from work the following day, when staffing permits. Yes. As it is rare for the on-call team to be faced with an EP problem, though, there is no particular expertise needed for the on-call team. We routinely evaluate the complications in our laboratory and the functioning of our equipment. Further, we assess the length of time of the cases and the problems with select cases. These are discussed with Frank and Dr. Olshansky. If there is a substantial issue, this is raised for all faculty members, fellows and staff. More procedures, less reimbursement, greater need for efficiency, less involvement in OR procedures, greater use of the EP laboratory, greater use of procedures to treat arrhythmias, more need for qualified nursing and technical staff in the EP laboratory greater expertise of the members of the EP team, greater need for teamwork. Our lab has completed a JCAHO inspection in the fall of 2001. We perform our own equipment inspections on a schedule that varies according to the type of equipment. Each piece of equipment in the lab has a routine preventative maintenance schedule. Our older radiological equipment required servicing regularly. JCAHO performs accreditation visits every three years. Absolutely. Much of this has been developed in house and is provided by our Nurse Coordinator, Renee. We also provide other educational material from web sites and from published educational pamphlets. We act as a referral center for the state. We also have an online "virtual hospital" that provides educational material regarding arrhythmia management. Yes. We are in a financial crunch, and so a main challenge has been to innovate and develop as well as provide excellent care in a cost-effective manner. Yes. Dr. Olshansky has just developed a multicenter trial to evaluate the use of DDDR (with AV search hysteresis) versus VVI ICDs. This "Intrinsic RV" Trial will begin over the summer. It will involve 1,400 patients and 100 sites. It is sponsored by Guidant. We have been involved in the 3,830-lead study with Medtronic and otherwise are involved with several clinical trials (TOVA SCD-HeFT and others). We are about to start several locally driven clinical trials involving patients with syncope and patients are risk of sudden cardiac death. We are eager to begin investigation with Stereotaxis equipment. We have a collaborative environment that works. The members of the team are committed to develop a strong relationship for excellence in patient care. There are many checks and balances not present in other laboratories. All aspects of patient care in EP are formalized with specific protocols for each procedure and for conscious sedation. We have made an effort to make sure that every aspect of patient care flows effectively and includes all needed components.