Spotlight Interview: MUSC Children's Hospital

What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab? The Pediatric Arrhythmia Service at MUSC has one fully dedicated digital bi-plane Philips cath lab, and one procedure room where we do pacemaker evaluations, tilts and other minor procedures. We also have a "Same Day" area where minor procedures requiring sedations can be performed. There are two pediatric electrophysiologist (Drs. Saul and Blaufox), one fellow, two arrhythmia nurse specialists and three EP/CVT techs, as well as a secretary and manager, all dedicated to the arrhythmia service. There are also three nurses and two X-ray techs who cross-cover EP and all other pediatric cath lab procedures. When was the EP lab started at your institution? The lab was opened by the pediatric EP pioneer Dr. Paul Gillette in 1984. It was one of the first pediatric EP labs in the world. Dr. Phil Saul, who performed the first pediatric radiofrequency (RF) ablation for WPW with his partner Ed Walsh in 1990 at the Children s Hospital in Boston, has been the director since 1997. More than 1,500 ablations have been performed since the first case at MUSC in 1991. What types of procedures are performed at your facility? The full range of EP procedures seen in adult labs are performed here, just fewer. We do tilt tests, cardioversions, pacing and ICD implants, NIPS, trans-esophageal and intracardiac diagnostic EP studies, 3D mapping using both CARTO and EnSite systems, catheter ablations using standard RF, cooled-tip RF, larger tip high-powered RF, and cryoenergy. Pediatric patients also have the full range of arrhythmias, including common forms of SVT, atrial reentry, ventricular tachycardia, and even atrial fibrillation. They just occur in different distributions than is seen in adults. Approximately how many are performed each week? What complications do you find during these procedures? About 3-5 per week in total, including 120 or so ablations per year. We never have complications! Just kidding, I wish that were true. Seriously though, one difference between the care of adults and children is that children tend to have less serious conditions as a group, allowing us to focus more strongly on safety than efficacy compared to adults. Nonetheless, in more than 500 cases over the last seven years, we have had a greater than 99% acute success rate for attempted SVT ablations, with only two major complications, one AV block and one coronary occlusion in an infant. Who manages your EP lab? Dr. Saul is the Medical Director of the Arrhythmia Service, Dr. Blaufox is in charge of devices and the clinic, and Lisa McKellar is the hospital manager. Is the EP lab separate from the cath lab? Are employees cross-trained? The lab is a dedicated EP lab, but is in the same area as and immediately adjacent to a second pediatric cath lab which is used primarily for hemodynamic and interventional procedures. Both labs are set up to do all types of pediatric studies if necessary. All the EP/cath lab staff are cross-trained for general pediatric caths as well. Do you have cross training inside the EP lab? What are the regulations in your state? Only nurses can give drugs and perform conscious sedation. The EP technologists are all CVTs, and some of the RTs and RNs also run the EP equipment. For flexibility, everyone is trained to operate the RF and cryoablation generators. 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 were the first pediatric EP lab in the US to have both the CARTO and EnSite 3D mapping systems. For the most complex cases in patients with post-operative congenital heart disease, we will often use both systems together, with the Navistar catheter simultaneously serving as the mapping catheter for the EnSite system. The systems are complimentary, with EnSite providing a rapid map, and CARTO providing highly detailed electro-anatomy. Our lab performed a cryoablation procedure the same week the CryoCath system was approved by the FDA. We now use cryoablation for all AVNRT and septal pathway ablations, particularly liking the excellent safety profile around the AV node. The EPT large-tip 100-watt RF ablation system has been a real plus for atrial reentry ablations in late post-operative congenital heart patients. Who handles your procedure scheduling? Do you use a particular software? How do you handle physician timeliness? Brenda Haldi, the Service secretary, handles all scheduling. The software package, CardioIMS, is a centralized medical records management system, designed by Camtronics, specifically for pediatric cardiology data management. All Cardiology Division staff have web-based access to the system. Physicians who are repeatedly late are beaten, but never severely. What types of quality assurance measures are practiced in your EP lab? Prior to every case, a checklist is performed, confirming the presence of consent, history, physical and that the correct procedure is being done on the correct patient. As required by JCAHO, we always use a minimum of two patient identifiers. Our nurses perform an independent double check on all meds before administration. Staff must demonstrate working knowledge of all equipment through annual competencies. How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? The cath lab coordinator and a CVT have been assigned the dual responsibility to maintain supplies. We also occasionally "trade" supplies and catheters with the adult EP lab at MUSC when inventories require it. Capital equipment is evaluated by the staff and physicians, but purchased through a request by our division manager to the capital budget process of the hospital. Has your EP lab recently expanded in size and patient volume, or will it be in the near future? A single dedicated EP lab, which we have had the luxury of for about five years now, is generally adequate for even the largest pediatric EP program, and has allowed us to grow 5 to 10% per year. Up until a year ago, our growing adult service used the pediatric lab two days a week while awaiting the completion of new facilities, limiting the peds service a little. However, we again have plenty of capacity for patient volume growth. How has managed care affected your EP lab and the care it provides patients? Very little. Managed care has minimal penetration in the South Carolina market, and we have a strong bargaining position for children s services in our region. What measures has your EP lab implemented in order to cut or contain costs? On-hand inventory has been greatly reduced, utilizing par supply levels. When possible, similar items have been consolidated to a single vendor. We also participate in hospital-wide initiatives to reduce costs through reprocessing, single-vendor contracts, and the implementation and tracking of supplies through Pyxis. How are new employees oriented and trained at your facility? All new employees go through a three-day hospital-wide orientation, followed by department orientation and finally job specific orientation. Generally, the length of the job-specific training depends on the position and the individual s experience. Because of cross-training for multiple roles in EP and congenital heart caths, "training" can often take well over a year. Given this long process, we work hard to keep our staff who have demonstrated full competencies. What types of continuing education opportunities are provided to staff members? The daily interaction with the faculty and EP fellow is an important means of education. Staff also often attend regularly scheduled in house conferences. Industry-based training courses are utilized routinely when new equipment is installed or new staff need training. We also work to send staff to HRS and other EP-focused national, regional and local meetings. In fact, the Arrhythmia Service is hosting the Third Charleston Symposium on Interventional Pediatric Electrophysiology at Kiawah Island May 1-3 this year, and all staff will be invited to attend. How is staff competency evaluated? Demonstration of specific task competencies is evaluated annually through a checklist process in which each staff member is evaluated by another staff member. Despite being colleagues, the staff take judging each other very seriously. The hospital has computerized annual training as well. Please describe one of the more interesting or bizarre cases that have come through your EP lab. Patients with complex congenital heart disease often have complex and difficult-to-manage arrhythmias. Perhaps the most difficult case we have managed was that of a four-month-old 4.7 kg baby boy with partially repaired congenital heart disease and multiple types of VT. After having arrhythmia surgery on the RV outflow tract and being the smallest child in the world at the time to have an ICD implanted, he continued to have incessantly recurrent LV fascicular VT, requiring 70 shocks and over 400 ATPs over a two-week period. We finally took him to the lab in the middle of the night and successfully ablated his VT using a retrograde aortic approach to the LV. Although we had to leave him with complete AV block, he never had VT again, and his ICD was replaced with a standard dual-chamber pacemaker. We have also done an emergency case in a 12-year-old boy with tachycardia-induced myopathy who was on ECMO during the cath. We successfully ablated an ectopic right atrial focus, leading to eventual complete recovery. How does your lab handle call time for staff members? There are three call teams covering EP and all other pediatric cath lab procedures. Each team consists of a CVT, a RN, and a RT. The staff rotates on a three-week schedule. Does your lab use a third party for reprocessing? Yes, we use third-party reprocessing for diagnostic EP catheters and Nellcor SPO2 sensors. Ablation catheters are not approved for reprocessing at this time. Approximately what percentage of your ablation procedures are done with cryo? What percentage is done with radiofrequency? Our focus on safety led us to be one of the very first adopters of cryo technology. We went through the learning curve for AV node modification and septal pathways, which account for about 50% of our cases, and now use cryo exclusively for those cases. We also attempt to use cryo in virtually all the smallest patients, regardless of substrate. The rest are RF: standard, cooled tip or large tip high power. What trends do you see emerging in the practice of electrophysiology? Over the next 10 years, two avenues of advancement are likely. On the one hand, technological improvements in every area will continue to occur, particularly as we gain the routine ability to merge anatomically accurate 3D images and electrical mapping information. When one combines the 3D data with remote stereotactic navigation, much of the technological puzzle will be solved. However, a second area related to understanding the biological underpinnings of why arrhythmias actually occur may be more important. We should be able to eventually manipulate the biology to actually correct the abnormality, which will have a tremendous impact on our patient care. For instance, stem cells are already being used to replenish damaged myocardium. It won t be long before we can biologically manipulate cardiac conduction as well. Does your lab provide any educational or support programs for patients? In our case, we are typically educating the parents, rather than the patient. We have two pediatric arrhythmia nurse specialists, Amy Simmons and Patty Hussey, who send out information to all families with scheduled procedures and provide as much detail as they would like. Also, all device patients are familiarized with the implanted devices in advance, and trained in the management issues they need to know about. The nurses visit the families with an hourly update during all cases as well. Describe your city or general regional area. How does it differ from the rest of the U.S.? Charleston is a historic and beautiful coastal city of about 500,000 surrounded by marsh and beach. Although we are geographically eccentric in South Carolina, MUSC is the only pediatric surgical and catheterization program serving the four million people in the state. The most unique feature of our region is a closely integrated working relationship between all the pediatric cardiologists in the state, known as The Children s Heart Program of South Carolina. Please tell our readers what you consider unique or innovative about your EP lab and its staff. Like many labs, we are proud of our technical accomplishments, and are often the very first to utilize a new technology that may serve our patients better, such as cryoablation or 3D mapping. However, the very best part of our lab is that like the rest of the MUSC Children s Hospital, we are all about kids. We love taking care of the kids and their families and do everything we can to make their experience at MUSC as pleasant as it can be. We try to keep it light hearted, even if it means getting a little silly at times. One of the best examples is how we often end unequivocally successful cases, joining Dr. Saul in a rousing rendition of the Gilligan's Island theme song. It s really a catchy tune and when we sing it, we know we ve done well! Sometimes A Teddy Bear s Picnic serves as a substitute: If you go out in the woods today, you re in for a big surprise, If you go out in the woods today, you d better go in disguise, For every bear the ever there was, will gather there for certain because, Today s the day the Teddy bears have their picnic!