Emory Crawford Long Hospital

The electrophysiology department at Emory Crawford Long Hospital in Atlanta, Georgia, holds a series of very important firsts. In 1987, Dr. Paul Walter inserted the first implantable defibrillator in Georgia. In 1997, Drs. David DeLurgio, Jonathan Langberg, and Angel Leon performed the state's first implantation of a biventricular pacemaker designed to resynchronize the beating of the ventricles. In addition, in 2001, Dr. Leon performed the world's first implantation of the Medtronic InSync cardiac resynchronization therapy system following its FDA approval. In this month s spotlight interview, Dr. DeLurgio describes how this innovative EP lab stays so successful. Our EP facility consists of two dedicated full-time electrophysiology labs and one part-time lab, also configured for cardiac catheterization and coronary/peripheral interventions. We also have direct access to a state-of-the-art cardiac observation area for pre- and post-procedure monitoring and for procedures that do not require patient instrumentation. We have four full-time EP staff members, and use cath lab cross-trainees as needed. Three of our staff members are RNs, and one is a registered technologist in radiography (RTR). A dedicated EP lab was opened in 1993 under the direction of Dr. Angel Leon. Since that time, we have relocated and expanded greatly in case volume, staffing and complexity of procedures. All procedures are performed by one of three Emory Crawford Long Hospital attending physicians (Drs. David B. De Lurgio, Angel R. Leon and Fernando V. Mera). A wide mix of cases is typical. With regard to devices, standard pacemakers and implantable defibrillators are still an important caseload, but in recent years resynchronization devices have become a significant portion of what we do. We are a regional referral center for lead extraction; therefore, we also perform a significant number of laser sheath extraction procedures. Catheter work, in addition to EP studies, includes ablation procedures for supraventricular tachycardias (SVT), atrial flutter, atrial fibrillation and ventricular tachycardia (VT). Device procedures make up approximately 65% of our volume. We perform an average of eight resynchronization procedures per week, and these are almost always ICDs. SVT ablation continues to represent a steady flow of cases, with a growing number of atrial fibrillation cases. All told, approximately 2,000 cases are performed annually. Complications are monitored carefully for quality control. The number one complication with device cases is pocket hematoma. Infection rates are less than one percent, due to strict adherence to OR sterility guidelines. Pericardial tamponade has remained a rare, but memorable, occurrence. All cases are performed under conscious sedation. With sicker congestive heart failure (CHF) patients now a routine presence in the lab, I was very concerned that respiratory and hemodynamic complications would increase. We introduced end-tidal CO2 monitoring approximately two years ago, and I believe this has contributed to a very low incidence of sedation-related complications. Catheter-related complications are very low. We perform all of our own transseptal procedures for left heart ablations. In the last year, there have been two transseptal-related adverse events. The EP lab is managed by Dr. Johnathan Langberg, and the cath lab is managed by Dr. Ziyad Ghazzal. A Level IV RN manages patient flow for the cath/EP area, and one of the RNs in the EP lab is a Level IV manager. I am the medical director for the EP labs, and the cath labs have a medical director as well. Our cath/EP area consists of five cath labs and two EP labs (the fifth cath lab is shared between cath and EP as needed). Adjacent are twenty cardiac observation beds with a central monitoring area. We have always had the EP and cath labs in the same area. We find that this facilitates patient management pre- and post-procedure, speeds turnover time, and permits ready access to cross-trained cath lab staff as needed during breaks or in overtime situations. Our staff is fully cross-trained so that all employees can perform all tasks. Our staff tends to rotate responsibilities during the day to lessen the possibility of fatigue. Our state requires all personnel to be credentialed, but the type of credentials needed may vary. The addition of new mapping systems such as Constellation (Boston Scientific, Natick, Massachusetts), ESI with NavX ® (Endocardial Solutions, Inc., St. Paul, Minnesota) and LocaLisa ® (Medtronic, Minneapolis, Minnesota) has resulted in more complex ablation cases and has added an education responsibility to our staff. In addition, we are typically involved in several device trials at any one time. This exposes our lab and our staff to many pre-market products and protocols that may alter the normal case flow. Since our labs are separate from the cath labs, we have never used film. More recently, we have taken advantage of digital technology to archive interesting cases and create teaching files. Our office handles scheduling and pre-certification. Close contact with the EP lab is required to assure a manageable schedule and to avoid conflicts in physician availability. We use 4D software for case scheduling. Our lab is somewhat unique in that it is closed with respect to attending physicians. We are hospital-based faculty of the Emory University School of Medicine. Our offices are near the EP labs, and our clinic and travel schedules are coordinated to assure availability and timeliness. We track all outcomes. A nurse compiles quarterly outcomes reports, and we attend a regularly scheduled morbidity and mortality conference. Conscious sedation variances are reported and analyzed. After routine EP studies and ablations, venous sheaths are pulled in the lab before the patient is transferred to a gurney. Arterial sheaths are sealed in the lab using commercially available sealing devices. Patients with multiple venous sheaths who were heparinized have their sheaths removed in the cardiac observation area when the ACT has fallen to an acceptable level. If such a patient is admitted (in atrial fibrillation ablation patients), their floor nurse will pull the sheaths in their hospital room. We handle the majority of cases in the lab, since non-heparinized patients with venous sheaths require only a brief manual compression period. Arterial sheaths are sealed in the lab by the physician and monitored by the nurse in the cardiac observation area or on the hospital floor. Heparinized patients with multiple venous sheaths usually have the lines pulled in the cardiac observation area where they are monitored prior to discharge. Patients who are admitted become the responsibility of the floor nurse. As the EP lab director, the purchasing of capital equipment is my responsibility. This is done in conjunction with the hospital s cath/EP lab director. A designated inventory manager (RN) handles the inventory for the entire cath/EP area. We maintain a par level of inventory. In July 2002 we moved into new cath and EP labs, expanding from two to five labs. We also greatly enlarged our cardiac observation area, allowing us to shift noninvasive procedures out of the EP lab. This has facilitated continuous growth in case volume at Crawford Long Hospital. Emory Crawford Long Hospital (in conjunction with Emory University Hospital) negotiates managed care contracts on our behalf. Patients in managed care plans require pre-certification prior to their procedure to ensure payment, and this has increased our office staff responsibilities. Beyond this, however, it is rare that a patient cannot receive care in our lab. The cardiac observation area has had a great impact on lab efficiency. Since each patient is in a private room with telemetry, oxygen, and suction, we use this area to perform conscious sedation procedures that do not require instrumentation. Consequently, all cardioversions, noninvasive programmed stimulation, chronic ICD defibrillation testing, and tilt table tests can be performed without utilizing time in the EP lab. In the lab, we use competitive purchasing and the leverage of our large volume to control equipment costs. We also limit catheter counts for routine EP studies and ablations. We have opted against a resterilization program for designated single-use EP products to avoid potential liability. Atlanta is a competitive market with regard to all of cardiology. We market ourselves as the most comprehensive EP service regionally, but we do not engage in direct competitive practices with others in the area. The EP community is fairly cohesive. This is exemplified by the recent formation of the Metro Atlanta Pacing Society, a regional EP society that meets semi-annually to discuss interesting topics and cases. Standard EP studies and ablations are performed on an outpatient basis. Patients are typically discharged after a three-hour holding period in the cardiac observation area. Device patients and atrial fibrillation ablation patients are routinely admitted. All new employees are brought in through our preceptor program where they receive on-the-job training by our staff. We provide direct training in areas of EP, and we use industry as a valuable source of training on specific equipment and devices. We encourage the staff to attend all Metro Atlanta Pacing Society meetings, one national meeting (either NASPE, AHA, or ACC), and a regional meeting if possible. We provide funding to cover expenses and adjust our schedule to make this possible. We also utilize industry-sponsored activities such as clinical investigation coordinators meetings and pacing school to fill in any gaps in education. All staff members are required to recertify annually with the hospital on equipment and protocols and to maintain their licensure. In addition, annual self-evaluations and evaluations by the cath/EP manager are performed. Our labs are equipped with CD players and a stereo sound system to create a relaxing atmosphere. We do not use any other alternative methods. I never cease to be amazed at the variety and complexity of cases we see. Recently, we evaluated a young male referred after aborted sudden cardiac death. We ended up diagnosing myotonic muscular dystrophy and treating the patient with a defibrillator. Call time is generally taken two to three days per week, and the call team consists of an RN and an RTR. The call team stays until the work is done, but there is no call back or weekend work in our EP lab. The next day schedule is not affected by the call schedule. Reprocessing is performed by the hospital. This results in quick turnover time on pacer/ICD trays and resterilized cables. We do not reprocess EP catheters. EP procedures and indications have grown rapidly in recent years, and I expect many labs to increase their EP presence as we have. The days of cath and EP labs sharing the same space are rapidly disappearing. Opportunities for RNs and RTRs are now commonplace. We subject ourselves to annual JCAHO accreditation, as well as annual radiation safety inspections. General safety inspections are performed at random intervals by the hospital. We have an Arrhythmia Center that provides teaching for post-pacemaker and post-ICD implant patients. The Arrhythmia Center is our base for chronic device follow-up, and our nurses there run a quarterly ICD support group. Our website is also an excellent source of information, and we subscribe to commercially available written materials to supplement our education aims. It seems like there is a crisis every day, but these are usually small issues that are easily resolved. I have learned that being flexible and reasonable with my staff goes a long way toward maintaining a good working environment. I also try to involve the entire staff in any decision-making that may affect their workload. Our group has performed approximately 1,200 biventricular cases, and just when I think I have seen everything, something new comes along. We participate in numerous clinical trials, and therefore have become familiar with most products that are available or under study. It is my opinion that nearly all the products out there are acceptable. What makes the difference, though, is a rapid assessment of obstacles during a difficult case, so that the approach can be adjusted in a timely manner. This avoids prolonged cases that not only tax the physician but also the patient and staff. We often use tools typically found in cath labs, such as various guidewires and diagnostic catheters (IMA, MP, left Amplatz), to assist with coronary sinus and or coronary venous cannulation. We are deeply involved in physician education. Our labs are equipped with high-definition digital robotic cameras with direct connections to two on-site auditoriums. Up to 150 people may watch and interact with physicians on-site during live case demonstrations, and with the addition of satellite communications, we have transmitted case demonstrations to sites all over the world. None of this is possible without an interested and willing complement of nurses and techs.