Tufts-New England Medical Center, Cardiac Arrhythmia Center

Tufts-New England Medical Center (NEMC), located in Boston, Massachusetts, has long been considered one of the best in clinical care. Their electrophysiologists provide access to the newest advances in antiarrhythmic drugs, ICDs, pacemakers and ablation techniques through a wide range of therapeutic trials. The Cardiac Arrhythmia Center currently houses three EP labs; they are also building a fourth lab that is scheduled to be finished in May 2004. Keep reading to find out about the other innovations and projects going on at Tufts-NEMC.

What is the size of your EP lab facility and the number of staff members? What is the mix of credentials at your lab? Currently we have three labs, including one used primarily for devices, one for radiofrequency ablations (RFAs), and one room where smaller procedures are done (i.e., implantable cardioverter defibrillator [ICD] testing, cardioversions, and tilt table testing). By May of 2004, we will have a new procedure room for device and EP studies. We staff one RN and one CVT per patient, with a staff total of four RNs and four CVTs in our lab. The labs are in a 10,000-square-foot Cardiac Arrhythmia Center. We provide comprehensive outpatient evaluation for patients with heart rhythm disorders. We have dedicated rooms for pacemaker (PM) and ICD evaluation, outpatient evaluation and management (E & M), and a transtelephonic monitoring center. Overall, staff in the Cardiac Arrhythmia Center include seven full-time and three part-time RNs, six technicians, four secretaries, a business manager, three EP fellows and five staff electrophysiologists.

When was the EP lab started at your institution? It was started in 1983, and the space was shared with our Cardiac Cath Lab. By 1984, we had a dedicated EP lab room.

What types of procedures are performed at your facility? We perform ICD and PM implantation, RFAs (i.e. for atrial flutter, atrial fibrillation, right- and left-sided supraventricular tachycardias [SVTs], atrioventricular [AV] nodes, ventricular tachycardias), implantable loop recordings, primary EP studies, tilt table testing, cardioversions, ICD testing, biventricular PPMs and ICDs.

Approximately how many are performed each week? What complications do you find during these procedures? Per week we perform a minimum of 10 devices, five RFAs, and 10 EP studies, plus the additional cases listed above. Complications are carefully monitored, varying upon the complexity of the procedure and status of the patient.

Who manages your EP lab? Management occurs collaboratively amongst the director of the Arrhythmia Center, an assistant nurse manager within the lab, and a business manager.

Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained? The EP lab is separate from the cath lab; it has been this way since 1984. Employees are not cross-trained due to this separation.

What are some of the new equipment, devices and products introduced at your EP lab lately? How has this changed the way you perform those procedures? Some of the new advancements in our lab include electroanatomical mapping for radiofrequency ablations utilizing the Carto XP (Biosense Webster Inc., Diamond Bar, California) and an upgraded BARD LabSystem Duo (Bard, Murray Hill, New Jersey). These improvements have decreased procedure time, thus increasing our volume.

Is your EP lab filmless, or does it plan to become filmless in the foreseeable future? All labs are filmless and use digital imaging.

Who handles your procedure scheduling? Procedure scheduling occurs the evening prior and then are re-evaluated during morning rounds. An EP fellow and attending electrophysiologist staff all cases.

What type of quality control/assurance measures are practiced in your EP lab? All machines are Q.A. d per JCAHO guidelines.

How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? EP materials are ordered by a CVT (i.e. general stock and catheters). All other implantable merchandise is on a consignment basis with our selected vendors.

How has managed care affected your EP lab and the care it provides patients? All patients are reviewed from an insurance standpoint and precertified prior to 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? RN and CVT staffing has been staggered throughout the course of the day, thus decreasing on the amount of overtime. Our institution is actively reviewing means of cost containment for our lab. Patient turnover has improved by getting patients to the lab while the previous case is being completed.

Does your EP lab compete for patients? Has your institution formed an alliance with others in the area? No alliances have been formed; however, referring MDs do make referrals based upon previous care provided by our EP attendings.

What procedures do you perform on an outpatient basis? All procedures are performed on an outpatient basis.

How are new employees oriented and trained at your facility? New EP employees undergo a general two-day hospital training, followed by an extensive six-week training orientation role in our lab.

What types of continuing education opportunities are provided to staff members? RN staff is provided with CEU credentialing. Staff are encouraged to attend local and national meetings. The NASPE meetings also serve as a major source of continuing education.

How is staff competency evaluated? An annual review is performed on all staff employees.

How do you handle vendor visits to your department? Vendor visits occur without scheduled appointments unless specific topics need to be discussed in a meeting fashion.

Does your lab utilize any alternative therapies? No alternative therapies are utilized.

Please describe one of the more interesting or bizarre cases that have come through your EP lab. Complex right- and left-sided atrial arrhythmias can be very interesting to map using our Carto system. Biventricular coronary sinus lead placement can also become challenging.

How does your lab handle call time for staff members? Scheduling occurs Monday through Friday, with no on-call time needed.

Does your lab use a third party for reprocessing? No. All of our catheters are single-use only.

Approximately what percentage of your ablation procedures are done with cryo? What about radiofrequency? We are currently in the process of obtaining cryo technology; otherwise, all cases are completed with radiofrequency.

Do you perform only adult EP procedures or do you also do pediatric cases? Both pediatric and adult cases are completed here.

Does your lab provide surgical backup for procedures (such as biventricular implants)? Our lab works closely with our OR for surgical back-up (if needed). This is routinely obtained for lead extractions but not for biventricular implants.

What trends do you see emerging in the practice of electrophysiology? Due to recent studies, we have seen a dramatic increase in our ICD implants. Atrial fibrillation RFAs have also been increased due to the advances in safety and success.

Is your EP lab currently involved in any clinical trials or special projects? We have been actively involved with a wide range of clinical trials, including most of the recent important ICD trials evaluating the role of the ICD in the prevention of sudden cardiac death. In addition to prior participation in the CABG Patch, MADIT II and DEFINITE trials, we have participated in trials evaluating triggers of ventricular arrhythmias, the role of fish oil in the reduction of ventricular arrhythmias, and the role of the ICD in the prevention of sudden death in patients with hypertrophic cardiomyopathy. We are currently involved in a number of trials, including a NIH study of arrhythmogenic right ventricular dysplasia and a study of optimal RV-LV stimulation in biventricular pacing. We have over 240 peer-reviewed research manuscripts and as many abstracts based on work from our electrophysiology lab.

Does your lab undergo a JCAHO inspection? We just recently completed our JCAHO inspection without any incidents reported.

Does your lab provide any educational or support programs for patients who may have additional questions or those who may be interested in support groups? We have established an ICD support group to create a support network for this patient population. It meets approximately every 3-4 months with a noted speaker to address current topics and concerns.

Describe your city or general regional area. How does it differ from the rest of the U.S.? Boston continues to be a strong medical community that draws patients from throughout the Northeast region for their care. There are unique challenges to the geographic area, including a high market penetrance of managed care. There are also three medical schools and seven other EP labs in the immediate geographic area. Despite the fact that our hospital is one-third the size of three of our competitors, our procedure volumes are comparable.

Give an example of a difficult problem or challenge your lab has faced. How it was addressed? In this respect, one of our greatest challenges has been to maintain clinical referrals and lab volume. Based on excellent outcomes, individualized patient-focused clinical care, and communication with referring MDs, we have done extremely well in a very competitive environment.

Please tell our readers what you consider unique or innovate about your EP lab and its staff. Our lab staff provides a multitude of RN and CVT backgrounds, which only enhances the care that is provided for our patients. We work with a great team perspective. Most importantly, patient safety and procedure success, in that order, is always our primary focus!