Spotlight Interview: Virginia Mason Medical Center

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

Virginia Mason Medical Center (VMMC) is a 284-bed urban hospital located in downtown Seattle, Washington. VMMC has two dedicated full-service EP labs, with two full-time electrophysiologists in a group of nine cardiologists. The Director of the Electrophysiology and Arrhythmia Services is Dr. Christopher Fellows, who started the EP lab at VMMC in the 1980s. Dr. Michael Belz joined the service in 2000. Our EP staff is partially separated into an outpatient group (clinic) and the EP lab staff (hospital), with some overlap. The EP lab is staffed by three full-time RNs, two per diem RNs, and a surgical scrub tech. A part-time RN has been recently hired. There are two ARNPs, who split their time between the EP lab and the clinic. Both are NASPE-HRS certified in cardiac electrophysiology. Two RNs and a LPN run the Device Clinic. In addition, there is a full-time RN and a full-time LPN; they handle all research projects for the Cardiology Section.

When was the EP lab started at your institution?

The EP lab was opened in the Spring of 1986. When the EP lab at VMMC first opened, it was one of two in the area. Our patient population largely comes from VMMC s clinics, Group Health and Pacific Medical. Our physicians see patients three days a month at outlining clinics within the state and in Alaska.

What types of procedures are performed at your facility? Approximately what percentage of your ablation procedures are done with cryo? What percentage is done with radiofrequency? Do you perform only adult EP procedures or do you do pediatric cases as well?

Our patient population is typically adult, although we do take care of the occasional older teenager.

Approximately how many are performed each week? What complications do you find during these procedures?

We do anywhere from 20-50 procedures per week. In 2003, we did 907 procedures, and for the first six months of this year, we have done 885 procedures. Complications are rare, with only ten major complications in 2003 that required intervention or cessation of the procedure. These included lead dislodgement, preumothorax, cardiac tamponade, stroke, heart block and respiratory failure. One of our complications resulted in a significant change of practice. Formerly, we recommended stopping warfarin four days prior to device implants. Unfortunately, one of our patients with chronic atrial fibrillation suffered a stroke the day after ICD testing converted his atrial fibrillation to sinus rhythm. Now we perform device implants, as has been reported elsewhere, without stopping anticoagulation.

Who manages your EP lab?

The lead RN is responsible for the day to day running of the EP lab. The Clinical Specialist is responsible for coordinating the efforts of the EP lab, the Cath lab, and the Pre/Post Procedure Unit (PCU), in providing the most comprehensive care for our patients. The clinic Electrophysiology CSR does scheduling of all procedures in the lab.

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 in the aspect that each area has its own dedicated staff. Both areas are located in the Cardiovascular Imaging and Intervention Center of the Medical Center. There is the opportunity for staff to be cross trained if they so desire, and most of the staff have done so. Many of the EP lab s staff started out in the Cath lab. Their extensive Cath lab experience allows us to do occasional coronary angiograms prior to a complex ablation.

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

All the RNs are trained to monitor, set up, scrub and do basic running of the mapping and ablation systems. The tech can do all except monitor the patient. The ARNPs are responsible for the placing of the sheaths and catheters, plus dictating the procedures. Both are capable of running all the mapping/ablation systems.

What are some of the new equipment, devices and products introduced at your lab lately? How has this changed the way you perform those procedures?

We rely heavily on the PRUCKA (GE Healthcare, Waukesha, Wisconsin) and CARTO (Biosense Webster Inc., Diamond Bar, California) systems for most of our mapping/ablation procedures. We have been using the Biosense Webster CARTO system for a while now. This has cut down the amount of time and supplies required for doing transeptal, EAT and atrial flutter ablations. At this time, we are looking to upgrade the system with the Biosense Webster CARTO Sync/Merge system. The Acuson AcuNav (Siemens Medical Solutions, Malvern, Pennsylvania) intracardiac ultrasound is used for our transeptal punctures. Recently we acquired and are in the process of learning the Endocardial Solutions system. We are interested in Stereotaxis, but have not yet decided on the need for it.

Is your EP lab filmless, or does it plan to become filmless in the foreseeable future?

Both of our labs are filmless.

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

The Clinic Electrophysiology CSR does the scheduling of procedures in the EP lab. She is responsible for both the physicians clinic schedules and the EP lab schedule. All schedules for the EP and Cath labs are located in the hospital-based scheduling computer system. This allows all areas (Office, PCU, EP, Cath) and all staff involved to see at a glance who and what type of procedure is scheduled. The two physicians split their days, with them either being scheduled in the EP lab or in the clinic. This allows a physician to always be available to do a procedure or to see a patient in the hospital or clinic.

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

The lead RN manages inventory by doing daily counts. Orders are placed through purchasing and then delivered within one or two days. The decision to purchase new equipment is a joint decision made by the Cardiology Manager, Purchasing/Contracting, and the Electrophysiology physicians.

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

In August 2003, a second EP lab was opened to handle increasing volumes. Prior to this, the staff were working 12-16 hour shifts every weekday. Procedures are staggered using both labs so that the ARNP can start in one lab while the physician finishes in the other. The physician is able to move directly from one procedure to another, thus allowing us to be more efficient and to increase the number of procedures done within a normally scheduled day.

What measures has your EP lab implemented in order to cut or contain costs?

Our hospital has a Lean Policy. All departments are held responsible to be cost efficient at all times. Recently we took a look at what supplies we had in stock and what was actually being used. Based on this, we were able to eliminate supplies that we seldom used. We elected to use two companies for most of our supplies. With the assistance of our purchasing and contracting departments, we were able to lower the cost of the supplies needed. Bulk purchases were made on higher cost items. A third party does reprocess certain supplies.

What procedures do you perform on an outpatient basis?

We perform most of our procedures on an outpatient basis, and have been sending our elective device implants and routine ablations (SVT, atrial flutter, and normal heart ventricular tachycardias) home the same day as their procedure. This has been partially a result of managed care concerns, but the primary motivation has been patent preference and a lack of complications with early discharge. Biventricular device implants, ablations for atrial fibrillation or ischemic ventricular tachycardias, and AV node ablation/pacer implants will usually spend one night in the PCU.

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?

Our EP staff is highly dedicated to providing the highest care for our patents. All work as a collaborative group to move cases as quickly as possible through the lab, without sacrificing safe care of our patients. The staff is very flexible in the hours they work. Start time is staggered, with the greatest number of staff available from 08:00-15:00. Closing time is when the last case scheduled is completed. Call for the Electrophysiology Department consists of device interrogation for newly hospitalized/ER patients and for patients going to the OR. After hours weekday call is done by the Device Clinic RNs and by the ARNPs. Weekend call is done by the EP lab RNs for the rare pacemaker implant in addition to device interrogations. At any given time, there is only one staff member on call. If a pacemaker needs to be implanted on the weekend, a second staff member is called to assist. The vendor for the device to be implanted is always involved in the surgery.

How are new employees oriented and trained at your facility? How is staff competency evaluated? What types of continuing education opportunities are provided to staff members?

Training for new staff is based on their past experience. Typically, training is three to six months. Recently, a new staff position has been developed within the EP and Cath labs to facilitate new staff orientation and continuing education. All mandatory hospital training (BCLS, IVCS, Mock Code, etc.) and competency criteria must be met within a designated time period. Checklists are the major tools used for this process. Training manuals and other resources are readily available to staff. Within six months, all RN staff must be ACLS-certified. There are funds available to allow our staff to attend NASPE-HRS or one other major conference or forum per year. The staff member is then expected to share the knowledge he/she gains through a presentation.