Spotlight Interview: United's John Nasseff Heart Hospital

What is the size of your EP lab facility and number of staff? We have two dedicated electrophysiology rooms.

One is a biplane room that is used for ablations and device implants. The second is a single-plane room, used primarily for device implants and lead extractions, although we can perform simple ablations in this room as well, due to having ESI systems in both rooms. We also have the possibility of doing device implants in any of the four coronary rooms, since all of our rooms have surgical capabilities. There are nine CVTs and thirteen RNs (including full and part-time). Everyone is rotated into coronary procedures as well as EP.

What is the mix of credentials?

The EP lab staffs CVTs and RNs. The CVT group consists of two RCIS, one CVT, one exercise physiologist, two paramedics, one surgical technologist, and two nursing assistants.

When was the EP lab started at your institution?

The EP program was started in the 1980s by Dr. Granrud, who did both EP and coronary angiography. In 1990, the first full-time electrophysiologist was hired. Today there are five full-time electrophysiologists practicing at the John Nasseff Heart Hospital: Dr. Pierce Vatterott, Dr. David Dunbar, Dr. Greg Granud, Dr. Stuart Adler, and Dr. R. Dent Underwood.

What types of procedure are performed at your facility?

Procedures performed include lead extraction, ablation (including atrial fibrillation, ventricular tachycardia, SVT, and atrial flutter; we either use NavX or EnSite Balloon for 3D mapping), and pacemakers and ICDs (including biventricular devices). In addition, tilt table studies and cardioversions are performed in the Same Day Interventional Unit (SDIU). Cardiac Echo has its own area of the heart hospital.

Approximately how may are procedures are performed each week?

Devices range from 10-20 per week. We do three ablations each week on average. The lead extractions are more sporadic. For example, in 2003, we did 60 lead extractions.

What complications do you find during these procedures?

When we first started left-sided EnSite and atrial fibrillation ablation, we saw an increase in tamponade. After possible causes were discussed, it was thought it could be a combination of Isuprel infusion, heparin, and 6 French (Fr) catheters. We switched to 5 Fr softer tip diagnostic catheters in the HRA and RV locations, and our incidence of tamponade decreased.

Who manages your EP lab?

The EP Lab manager also manages the cath and echo labs. The EP coordinator works directly with the staff and physicians facilitating orientation, training staff/physicians on new equipment, and promoting communication between physicians, staff, and management. The Nurse Educator updates our policies and procedures, facilitates orientation, and works with vendors to schedule inservices. The CV Lab coordinator runs operations of the CV/EP lab by creating room assignments for staff and assigning each procedure to a specific suite. She also makes the staff schedule.

Is the EP lab separate from the cath lab?

No, but not all of the staff works in EP. The radiology techs primarily work in coronary and peripheral procedures.

Are employees cross-trained?

All EP lab staff are expected to be competent in coronary procedures.

Do you have cross training inside the EP lab?

The CVTs primarily do all the scrubbing, sheath insertions, circulating, and suturing. We have a few RNs and RTs that have learned to scrub devices. CVT and Radiology Techs do not give sedation RNs only.

What are the regulations in your state?

Conscious sedation needs to be given by an RN. We use CRNAs and anesthesiologists for our ICD checks and cardioversions. The RNs in the EP lab do not administer Diprovan or Brevital.

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

The newest is CryoCath; ESI is always improving its software, and we are currently looking at upgrading or replacing our Bard monitoring system. Stereotaxis has been discussed as a future possibility. Our new Philips imaging systems allows us to lower our fluoro pulse rate down to 7.5 pulses per second, reducing patient radiation exposure.

How has this changed the way you perform those procedures?

We use cryoablation primarily for slow pathway modifications. The procedure tends to take a little longer, but cryo s reversibility has proven itself on more than one occasion.

Who handles your procedure scheduling? Do you use a particular software?

The John Nasseff Heart Hospital schedulers plan for the CV Lab, EP Lab, Echo Lab, outpatient tilt table studies, and cardioversions. The procedures are entered into Surgiserve in the scheduling office, and automatically transferred to NaviCare each morning.

What types of quality control measures are practiced in your EP lab?

Our BioMed department performs routine preventive maintenance. All lab test devices are QA ed according to CAP regulations.

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

A lot of inventory is par leveled and maintained by materials management. The EP Coordinator handles the ordering of the rest of the inventory. All implantable devices are consigned and supplied by the company representatives.

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

Our second dedicated EP room just opened in November 2003. There are no plans of future expansion at this time.

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

We are part of Allina Health System, which has been very aggressive in getting competitive pricing for implantable devices based on volume. Contracts vary, but are usually renegotiated every two years.

In what ways have you improved efficiencies in patient through-put?

Outpatients can be admitted directly to the SDIU, which is part of the John Nasseff Heart Hospital. There they are prepped for their procedure. In-patients can be transferred to the SDIU before their procedure to make sure the patient is prepped and everything is in order for their procedure. The SDIU will hold patients while they wait for a bed to be assigned to them, have sheaths pulled, or to monitor outpatients before they are discharged. The comfort of the patients families was also taken in consideration of the design of the SDIU. It is easily accessible to the waiting area and has two private consultation rooms where the family can meet with the physician.

What procedures do you perform on an outpatient basis?

On an outpatient basis, we perform non-invasive cardioversions, tilt table studies, echos, pacemaker/ICD generator changes, and most ablations.

How are new employees oriented and trained at your facility?

Management oversees orientation. We try and place new staff with the same preceptor every day for consistency. Weekly reviews are given during the first 90 days of orientation to identify areas to focus on.

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

We send staff to the Heart Rhythm Society meeting when funds are available. We are trained by vendors when new equipment is purchased. In addition, we have a weekly EP conference in which the physicians discuss difficult or interesting procedures.

How is staff competency evaluated?

Competency is evaluated by a yearly review, or more frequently if needed. The EP Coordinator works as a regular staff CVT, so he is usually aware of any issues if they occur.

How do you handle vendor visits to your department?

By appointment only.

Does your lab utilize any alternative therapies?

No.

Please describe one of the more interesting or bizarre cases that have come through your EP lab.

We have had cases of orthodromic tachycardia with intermittent LBBB, Mahaim fiber ablation, and attempted CS cannulation of LV lead placement in a patient with a left-sided SVC. Overall, there are too many bizarre lead extractions to discuss!

How does your lab handle call time for staff members?

Weekend call time is divided equally at the beginning of the year. Weekday call is assigned two weeks to one month in advance. How often is each staff member on call? CVTs are on call approximately every sixth weekend, and one to two nights during the week. This is for both EP and Acute MI call.

How frequently do they have to come in, on average?

We will do approximately one weekend pacemaker implant per month. We stay late to finish procedures on weekdays, two to three times per week.

Is there a particular mix of credentials needed for each call team?

We always have one RN, one RT, and one CVT on call. We also have a fourth call person, who can be any of the modalities.

Does your lab use a third party for reprocessing?

We currently use SterilMed, but Allina Health System is evaluating the top three reprocessors. The goal is for all campuses to use the same reprocessor, maximizing savings.

Approximately what percentage of your ablation procedures is done with cryo? What percentage is done with radiofrequency?

Approximately 40% are done with cryo, and 60% are done with RF.

Do you perform only adult EP procedures or do you also do pediatric cases?

Yes, all adults. In the past, we performed pediatric lead extractions by special request. We continue to do so only on a case-by-case basis.

Is there cross training for pediatric cases?

When we do a pediatric lead extraction case, leaders from children's surgery, pediatric ICU, and EP meet before the case. Since our nurses aren't PALS-certified, a nurse from the neighboring children s hospital will be in the room during the procedure. A pediatric surgeon is on standby, as well as surgical staff with all appropriate equipment. The patient is typed and crossed beforehand.

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

Biventricular devices are becoming easier. We predict an increase in biventricular device implants.

Is your EP lab currently involved in any clinical trials or projects?

Yes, we are enrolled in the Pocket Protector evaluation of using D-Stat flowable in device pockets, SAFARI, SAVE PACE, and FULL RHYTHM. The private practice physician s group (St. Paul Heart Clinic) has their own research staff. The patients are educated and consented through the St. Paul Heart Clinic. They then work with the EP lab staff to ensure everything needed for the study is ready for the procedure. They usually attend the procedures to make sure that all data is recorded correctly.

Does you lab undergo a JCAHO inspection?

Yes.

Does your lab provide any educational or support programs for patients who may have additional questions or for those who may be interested in support groups?

The physician's office at the St. Paul Heart Clinic handles all of the preprocedure education, as well as any follow-up questions the patients might have.

Give an example of a difficult problem or challenge your lab has faced. How it was addressed?

We have had issues with anesthesia coverage for our ICD checks. The physicians had several meetings with the anesthesia department. Problems in communication and scheduling were identified. The problems seem to have been resolved.

Describe your city or general regional area. How does it differ from the rest of the U.S?

St. Paul has a diverse population of approximately 300,000. We service patients from Wisconsin, outstate Minnesota, the Dakotas, as well as our immediate surrounding area. St. Paul is unique in that it is a larger city, yet has a small-town feel.

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

We have a diverse staff with different educational backgrounds. Everyone has different skills that they bring and can be shared with the rest of us. There are two OR rooms next to the cath lab. All our cath/EP rooms are surgically compatible. Our physicians are active in the training of the EP staff. They are always open to questions and genuinely want the staff to be involved in the procedures. Lastly, we are particularly proud of our lead extraction program, and the team approach taken during these higher risk procedures.