St. Peter's Hospital

In this interview, this dedicated EP lab takes time to remember Dr. Brian McGovern, who was involved with starting the program in 1990.

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

The electrophysiology lab at St. Peter s Hospital has one dedicated EP lab and one dedicated implant procedure suite. The two main physicians are board-certified in clinical cardiac electrophysiology. Our team consists of three full-time registered nurses, two part-time registered nurses, two per diem registered nurses, one full-time cardiovascular technician, and one part-time cardiovascular technician. All of our clinical backgrounds are in cardiac critical care or medical cardiology. We are all ACLS-certified, and the nurses are credentialed in conscious sedation.

When was the EP lab started at your institution?

Dr. Brian McGovern from Massachusetts General Hospital started Northeast Arrhythmia Associates, which is part of Albany Associates in Cardiology, in 1990. At that time, patients had to leave the area to have EP procedures done. St. Peter s and Massachusetts General Hospitals formed an alliance to develop the EP program here in Albany, New York. Dr. McGovern was instrumental in bringing the program up to the level of excellence it continues to be. Dr. McGovern and Dr. Ross Brooks started coming to St. Peter s Hospital from Boston to see patients in the office, and complete procedures such as EP studies and radiofrequency ablations (RFAs). In 1994, Dr. Guillermo Sosa-Suarez, our current EP service director, became the full-time electrophysiology partner at St. Peter s Hospital, associated with Albany Associates in Cardiology. Dr. Ian Santoro came here in 2001 as a full-time electrophysiologist with Capital Cardiology Associates, another large cardiology group that practices in the area.

What types of procedures are performed at your facility?

Electrophysiology services provided at St. Peter s Hospital include tilt table testing, cardioversion, diagnostic electrophysiology studies, ablations (including atrial flutter and fibrillation, and ventricular tachycardia [VT]), implantable cardioverter defibrillator (ICD) and pacemaker implants, including biventricular device implants for heart failure, NIPS and ICD checks. Laser lead extractions are done in the operating room by one of the cardiothoracic surgeons who specialize in this procedure. Patients from other hospitals and other physician practices in the area are referred to St. Peter s EP Department for all of these procedures. We are also involved in research protocols.

Approximately how many are performed each week?

Each week our procedures include: 6-7 ablations; 6-8 EP studies; 5-8 ICD implants; 3-5 PPM implants; 2-3 biventricular devices; 20-25 ICD checks.

What complications do you find during these procedures?

We experience a small number of complications that are common to our procedures, but our complication rate is well within national standards. Complications rarely occur during the procedure. After the procedures, the patients are closely monitored. All complications are tracked to identify any system or practitioner trend, and/or opportunities to improve our care delivery.

How is your EP lab managed, and by whom?

A nurse manager and the invasive cardiology manager are responsible for the overall managing of the EP lab and staff, as well as the cath lab. There is a team leader/clinical care coordinator that works full time in the EP lab who coordinates the schedule, staffing and the flow of the procedures, and has input on evaluations.

Is the EP lab separate from the cath lab? For how long? Are employees cross-trained?

The EP lab is separate from the cardiac cath lab, but they are located next to each other. Although the lab manager is the same, staff members are separate. However, we work together to provide optimal care to all the patients. Currently, we are not cross-trained with the cath lab or they with us, although we help each other out as needed with minor things such as pre-assessment, monitoring a patient in the holding area or transporting patients back to their rooms. If there is ever an emergency situation, we all are very flexible in being wherever is needed. Initially, it was the cath lab staff who cross-trained and developed the EP lab at St. Peter s, but since 1991, the EP lab has had a dedicated staff.

Do you have cross training inside the EP lab? What are the regulations in your state?

All of the EP lab staff is cross-trained throughout the Cardiology Department, with the exception of the cath lab as mentioned above. All of the nurses are cross-trained to cover in areas such as nuclear medicine stress testing, cardiac rehab, and TEEs. All EP staff are cross-trained to work in all the different types of cases. Nurses are cross-trained as well to scrub for implant cases and assist with the technical role in the EPS/RFA procedures. All EP staff are trained to use all of the computer equipment, specialty technologies, and device programmers. Each of the physicians we work with have nurse practitioners that follow their patients for the usual preparation for EP cases, such as follow-up teaching, reviewing labs and writing orders, and making follow-up appointments.

What are some of the new equipment, devices and products introduced at your lab lately?

We have a full array of EP lab systems, including the CARTO (Biosense Webster, Inc., Diamond Bar, California) advanced mapping of complex arrhythmias, Prucka (GE Medical Systems, Waukesha, Wisconsin) for the diagnostic and procedure recording system, BLOOM (Fischer Imaging, Denver, Colorado) electrical stimulator, and the Medtronic Atakr, Stockert and EPT ablation systems (Medtronic, Inc., Minneapolis, Minnesota).

How has this changed the way you perform those procedures?

The CARTO system has facilitated the electrophysiologists with better mapping and ablation of the more complex rhythms. The Prucka is our updated recording system. The ablation systems are equally up to date with the advances in technology, although they all do the same thing.

Who handles your procedure scheduling? Do you use a particular software? How do you handle physician timeliness?

The team leader, along with the two main cardiac group transfer centers and EP/cath lab secretaries, coordinate the EP schedule. The team leader coordinates with anesthesia for implants, NIPS procedures, and cardioversions. It can be challenging to coordinate the procedures at times, but for the most part, things have a way of working out. We use a computerized scheduling system, which is very easy to learn and update. Physician timeliness is not usually a problem; we just keep beeping them on their pagers until they come for the case (which does not happen too often). Their offices are not far from the hospital, and they are usually rounding in the hospital on the days they have procedures.

How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? Our senior cardiovascular technician orders and maintains all of our inventory and stock. This is a huge task, and it is done extremely well; he is very budget conscientious. EP catheters, connectors and any accessories needed for cases are also ordered and maintained. For bigger purchases of equipment such as monitors, EP systems, or tables, they proceed through the usual process through the departmental requests and capital budgets.

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

Over the next year, the EP lab will be expanding to include another dedicated EP lab/implant suite. St. Peter s Hospital is planning a major renovation project over the next 10 years. The facility will be renovating the operating room and the critical care areas over the next three years. In the five- to 10-year phase, the EP and cath labs will be in a brand new building with a more dedicated space.

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

We are doing more outpatient procedures, and the physician groups work closely with the health insurance companies to keep them informed and educate them in all areas of electrophysiology.

Does your EP lab compete for patients? Has your institution formed an alliance with others in the area? There are four major hospitals within a 15-mile radius (including a Veterans Adminstration [VA] hospital) that all have busy EP labs. The competition mainly involves physician and patient preference, pertaining to which hospital they prefer. All of the cardiology practices have privileges at the institutions, and have at least one electrophysiologist that works in the EP lab, with the exception to the VA hospital (which has their own group). They have formed alliances within their practice groups to maintain a high standard of patient care, and refer to each other as needed for the more complicated cases. St. Peter s Hospital has joined alliances with Champlain Valley Physician s Hospital Medical Center in Plattsburgh, New York, Benedictine Hospital in Kingston, New York, Glens Falls Hospital, and Saratoga Hospital, to provide services both in the EP and cath labs for patients that live farther away. We treat patients from as far north as Plattsburgh, west of Utica, east of Vermont and western Massachusetts, and south of Kingston.

Does your lab have an outpatient program?

We have a large outpatient ICD follow-up clinic. We complete 20-25 ICD checks per week.

How are new employees oriented and trained at your facility?

Each new employee is oriented slowly. We focus on the tasks and expand when the person is ready. The orientation can last three to six months or longer, until the person is comfortable with each type of procedure. For the nurse, conscious sedation is a major role that is taken very seriously and evaluated carefully.

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

We try to send two or three staff members to NASPE each year. Our cardiology department is very supportive of sending us to continuing education seminars and classes that are offered locally as well as around the country. We also have departmental inservices included with the cath lab on topics of interest as well. In addition, we are supported by a Clinical Nurse Specialist.

How is staff competency evaluated?

We have competency checklists individualized for the EP lab staff that is completed yearly. We also have routine yearly evaluations with our supervisors. In addition, there is a conscious sedation competency evaluation and an OR competency evaluation that we follow as our standard of care for implant cases.

Does your lab utilize any alternative therapies?

We do not currently have these therapies in our EP lab, but the cath lab is participating in a Reiki research project along with their use of conscious sedation. Complimentary therapies such as massage are used in our cardiac rehabilitation program.

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? Do they still maintain a full schedule the next day if they had to come in the night before? Is there a particular mix of credentials needed for each call team?

Currently, there is no on-call time for the EP lab. We usually can accommodate the physicians scheduled cases, as well as the add-ons that may arise throughout the regular working day. Occasionally there are cases that may need to be done after the planned cases, which may become a long day for us. Those that can stay try to come in a little later the next day. Something more emergent like a temporary pacing wire is done in the critical care areas or ER by their staff. A pacemaker can always be done in the operating room on the weekend if necessary.

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

We have a nurse who collects and maintains outcome data on all of our high-volume procedures and as needed. There are quarterly quality assurance meetings attended by staff, and quarterly reports are distributed to staff and physicians for review as well. These reports are analyzed and carefully reviewed by our program director. We monitor outcomes, length of stay (LOS), and complications. We participate in National Patient Safety Goal enforcement and are implementing new Fire Safety Protocols.

What trends do you see emerging in the practice of electrophysiology?

Some of the trends we see emerging include more biventricular device (both pacemaker and ICD) implants and, with the addition of the CARTO system, many more ablation procedures.

Does your lab undergo a JCAHO inspection?

We have regular inspections set up by JCAHO.

Is there a specific problem or challenge your lab has faced? How it was addressed?

One problem is the usual challenge of limited space, but that should improve over the next few years. Staffing, at times, can be an issue for our group (covering vacations, call-ins, or add-on cases). We have a very flexible staff who are always very accommodating and willing to do whatever is necessary to complete a full case load, while providing the most optimal care for the patients. We have recently looked at a work week of four 10-hour days and the like, for more flexible hours and to maintain staff satisfaction.

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 an abundance of patient education for all types of procedures. The ICD patients have a large support group that two of our nurses facilitate four times a year, including a summer picnic. Approximately 40-150 patients attend the meetings, depending on topics of interest or the season. The patients who attend the meetings regularly are in the process of taking over running the meetings and facilitating the group activities with our full support. There is also an ICD support group newsletter which is sent to over 750 patients that coincides with the meetings. One of our beloved, Dr. McGovern, had been working with Dr. Sosa-Suarez to develop a local chapter of his Atrial Fibrillation Foundation in Albany, New York. We are in the planning stages to carry on his work and dedication to patient education, along with Massachusetts General Hospital, which is the main foundation. Dr. McGovern was a great patient advocate for teaching, education, and patient referral, while providing and maintaining the highest level of patient care. Sadly and respectfully, we are carrying on with his intentions.

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

We pride ourselves on a phrase we have learned through our hospital s People Centered Teams education classes: There is no I in team. We try our very best every day to work together to accomplish our goal, which is to provide the safest quality of care to a very special group of patients. I read something in another facility s Spotlight Interview about spending more time at work in the EP lab than they do with their own family and friends. That rings true for us as well. We try to respect each other and give each other space as well. It is the only way to get through the long days and enjoy the normal ones.

Tell us about Dr. McGovern.

We all miss Dr. McGovern very much. Our hearts remain sad that he is no longer with us, but we all cherish the memories we have of him. We want to continue providing the best care for our patients in his honor. Dr. McGovern was a great patient advocate, and we strive to maintain the high level of patient care and patient education for all of our patients that he expected. Dr. McGovern came out to St. Peter s Hospital every Wednesday, and that continues to be our favorite day, but something always seems to be missing. Brian made us feel that all was right in the world, even when it wasn't. We miss his sense of humor, funny stories, speedy walk, his wonderful laugh, his endearing stories about his family, and especially his presence in our lives. Dr. McGovern loved his patients, and many of them have fond memories as well. He made us all feel important and a part of his life. We will never forget him and his dear family.