John Muir/ Mt. Diablo Health System

What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab? The John Muir/Mt. Diablo Health System includes two acute care hospitals. John Muir Medical Center is a 321-bed acute care facility located in Walnut Creek, California, that is designated as the only trauma center for Contra Costa County and portions of Solano County. Recognized as one of the region's premier healthcare providers, areas of specialty include high-risk obstetrics, orthopedics, neurosciences and cardiac care. Mt. Diablo Medical Center is a 259-bed acute care facility located in Concord, California that serves Contra Costa and southern Solano counties. The medical center has long been recognized as a preeminent center for cardiac care, including open-heart surgery and interventional cardiology. The new John Muir/Mt. Diablo Cardiac Rhythm Center (CRC) is located at the John Muir Campus. The recently renovated EP lab is approximately 800 square feet, and was developed to diagnose and treat heart rhythm disorders. Diagnostic and interventional cardiac rhythm procedures, device implants and arrhythmia surgeries are also done at the Mt. Diablo Campus. The CRC brings together a group of leading cardiac electrophysiologists, interventional cardiologists and cardiovascular surgeons. These physicians lead a team of specially trained health care professionals including registered nurses, radiology technologists, cardiovascular technologists and a clinical nurse specialist. The Angio/Cardiac Cath/EP (ACE) department employs a total of 24 RNs, 14 RTs, 3 CVTs, 1 Nursing Assistant, 1 Inventory Manager, 1 Angio Tech Assistant and a Scheduling Coordinator. All employees rotate through the EP labs, but there is a core group of RNs and CVTs who have received specialized training in EP procedures. Several of the employees have specialized certification in invasive cardiology, including NASPExAM Testamurs, Certified Radiology Nurses, CCRNs, Certified Neuroscience RNs, a Certified Vascular Interventional Tech, a Certified Interventional Cardiac Tech, MSN and BSN prepared RNs. Specialty certification is encouraged and rewarded with an annual bonus. Each procedure is staffed with a minimum of two RNs, an RT, and a CVT. All of the EP MDs are board certified or board eligible. The team supports six electrophysiologists from two groups. When was the EP lab started at your institution? The EP program began in 1992 with two electrophysiologists performing only diagnostic EP studies. From 1996-1999, the program expanded and was able to offer radiofrequency (RF) ablation therapy as well as device implants in the EP lab. Today, we perform the full spectrum of diagnostic and interventional rhythm procedures. What types of procedures are performed at your facility? We perform diagnostic electrophysiology studies, intracardiac echocardiography, T-wave alternans testing, and radiofrequency catheter ablation for treatment of AVNRT, AT, VT, atrial flutter, WPW and atrial fibrillation. Left-heart access is performed using either a transseptal or retrograde approach, depending on physician preference. Permanent pacemakers, loop recorders, implantable defibrillators, as well as cardiac resynchronization devices are implanted in our facility. We have participated in several cardiac device and lead trials, including CONTAK RENEWAL Decrease HF, Easy Trak 2, Easy Trak 4, Glideline studies, VITALITY ICD trial (Guidant), Vibrant study (Vitatron), Block HF, MASTER trial (Medtronic, Inc.), and RARE registry (St. Jude Medical). JMMDHS was the number one implanting facility for both the VITALITY ICD and CONTAK RENEWAL Decrease HF trials. Approximately how many procedures are performed each week? The JMMDHS performs an average of 30 Cardiac Rhythm procedures weekly, including 7 EP studies, 6 ablations, 2 three-dimensional (3D) mapping procedures, 10 pacemaker procedures, and 5 ICD procedures. What complications do you find during these procedures? We track major and minor procedural and post procedural complications that may result from device implants and EP/ablation procedures. Following review of the literature and HRS standards, we were able to develop a comprehensive monitoring program for CQI and Peer Review processes. Post procedural complications are identified through chart review and the hospital s MIDAS system. All complications are entered into the CardioLab DMS system. From here monthly complication reports can be generated and are then referred to the Quality Management Department for peer review. The quality indicator summary is reviewed quarterly at department-specific medical staff meetings. Our complication rates are below the established benchmarks. Who manages your lab? The Cardiac Rhythm Center is managed by Lisa Tisdale, RN, MS, CNS, in close collaboration with the CRC Medical Director, Dr. Carleton Nibley, the managers of the cardiac cath labs, Donna Kosch, RN, BSN (John Muir campus), Cuco Garcia, RT (Mt. Diablo campus), and Margaret Simor, RN, BSN, CRN, Director of Clinical Operations, Cardiovascular Service Line for John Muir/Mt. Diablo Health System. The health system is currently recruiting for a cross-campus director of the Cath Labs. Is the EP lab separate from the cath lab? The CRC is part of the Angio/Cardiac Cath/EP (ACE) department, which is comprised of three procedure rooms at each campus, for a total of two EP labs and four angio/cardiac cath labs. Are employees cross-trained? All staff members rotate into the EP lab. There is a core group of staff with additional specialized training on the CardioLab, stimulator, RF ablation units and mapping systems. Do you have cross training inside the EP lab? What are the regulations in your state? In California, Title 22 outlines the scope of practice for RNs and RTs. To the fullest extent allowed by the law, the staff is cross trained, allowing for more flexibility with staffing and greater staff satisfaction. The RNs, CVTs and RTs can scrub, circulate, and operate the Bloom stimulator and the CardioLab monitor, but only RNs can administer medications, monitor and assess the patient. RTs are the only ones that can operate the fluoroscopy equipment. What are some of the new equipment, devices and products introduced at your lab lately? The recent renovation of the CRC included installation of all new equipment, everything from the Toshiba Digital Fluoroscopy equipment, Pyxis inventory management system, upgraded GE ComboLab and two new 3D mapping systems. The Biosense Webster CARTO XP and the ESI Mapping System with NavX were installed during the room renovation, creating a dedicated, state-of-the-art EP suite. It was a challenge to train our staff on all this new technology in a short period of time. However, the staff truly excelled, and now less than six months later, they are proficient in the use of the new equipment. How has this changed the way you perform those procedures? The electrophysiologists are utilizing the 3D mapping systems more often for complex arrhythmia mapping, which has resulted in shorter procedure times and the ability to offer more complex ablations to these challenging patients who otherwise might have had to leave the community for treatment. The Pxyis system has streamlined not only the inventory management but also procedural set up. By creating "pick lists," physician s catheter and equipment preferences are highlighted in the Pyxis, allowing the staff to quickly identify and access the supplies necessary for a particular procedure. With the separate control room, the ability to communicate with team members is essential. The use of a wireless intercom system has facilitated clear, accurate communication among the team members. The circulating RN, MD and RT wear belt packs and wireless headsets, while those team members in the control room use the hardwired headsets. This allows for clear accurate communication during routine and emergency situations without disturbing the patients. Who handles your procedure scheduling? Do you use particular software? How do you handle physician timeliness? There is a dedicated person in the department that schedules all the procedures in the department. The PDS scheduling system is being implemented at JMMC at this time. At the MDMC campus, the scheduling for the Angio/Cath/EP labs is done through the surgery department using Orbit Surgery Scheduling software. The surgery department communicates the daily schedule electronically. Add-on procedures and transfer patients are communicated verbally. A CRC Scheduling worksheet was developed to facilitate scheduling and coordinating support for complex EP procedures. The form provides a method to document requests and confirmation of clinical support for specialized equipment, for example, 3D mapping procedures. Fortunately, physician timeliness has not been an issue in the EP lab. However, we document reasons for a delay in the case start time in the CardioLab, which includes late physician arrival or equipment failure these are reviewed on a quarterly basis. Our first case is scheduled to start at 7:00 A.M., and our EP MDs are often early. What type of quality control measures are practiced in your EP lab? Quality control checks on the equipment in the procedure rooms are performed on a daily basis by the staff, while the Biomed department tracks and performs the preventative maintenance. Daily checks include the imaging equipment, defibrillators, emergency equipment and the ACT machines. What type of quality assurance measures are practiced in your EP lab? Quality and outcomes are an important focus within our Cardiac Rhythm Center. Cardiac rhythm procedures, outcomes and complications data is collected electronically within the GE CardioLab and DMS system. We have the support of three full-time clinical outcomes and application support analysts, Nicole Blalock, Julie Bokinskie and Cathy Alvernaz, in the department who are able to query data and generate monthly reports which summarize type and volume of procedures. Procedures by physician are reported in addition to complications. How is inventory managed at your EP lab? Each campus has an individual assigned, Anna Borden and Kim Rice, who manages the inventory for the EP lab on a daily basis. The Pxyis supply management system, located in each of the EP labs, tracks inventory and automatically sends a list of supplies to the materials management department for reordering. Who handles the purchasing of equipment and supplies? A purchasing agent for our department assists with vendor contracts and pricing for catheters, supplies and devices. Capital equipment items are identified, researched, and prioritized with input from the director, staff and electrophysiologists. Has your EP lab recently expanded in size and patient volume, or will it be in the near future? The majority of the complex rhythm procedures, including the 3D mapping cases and all the atrial fibrillation ablations, are now performed at the John Muir campus. Device implants, routine EP studies and ablations are also performed at the Mt. Diablo campus. With the opening of the Cardiac Rhythm Center and marketing within the community, the volume has increased significantly for atrial fibrillation ablation (69%), 3D mapping (30%) and device implants (3%) in Q1-2 2005 compared with the Q1-2 of 2004. We are expecting to see an increase in volume with the expansion of the atrial fibrillation program, expanded device indications and increasing awareness within the community and among the referring physicians in the area. How has managed care affected your EP lab and the care it provides patients? Although reimbursement, cost containment and effectiveness are key elements of a successful rhythm center, our goal is to provide state-of-the-art care in a cost-effective manner to our patients treated in the CRC. Managed care in California has been a way of life for many years. The health system is supportive of providing the most advanced rhythm treatment available, which we can do by working closely with our physicians, vendors, and materials management to achieve cost effectiveness. 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? The purchasing department works very closely with the CRC to negotiate pricing with our vendors. Our CRC patients are admitted directly to the cath lab "Bay," a four-bed pre-post recovery unit. Our RNs admit and prepare patients for their procedures, as well as pull sheaths and discharge patients home or hold until inpatient beds are available. Does your EP lab compete for patients? Has your institution formed an alliance with others in the area? Within the East Bay area, there are competing EP programs. The Cardiac Rhythm Center is able to offer patients leading-edge technology and expertise that may not be available at the other local EP programs. We do not have a formal alliance with other hospitals in the area, but because we have the ability to treat complex arrhythmias, many patients are transferred or referred to our facility. We are located within 60 miles of two large university hospitals, but our goal is to provide state-of-the-art care for patients within their own community. What procedures do you perform on an outpatient basis? Each patient is assessed prior to the decision to admit or discharge home. Patients are admitted and discharged the same day for a variety of procedures. These include device generator changes, loop recorder implants, diagnostic EP studies, and most ablation procedures. Atrial fibrillation ablation and other complex ablation procedures as well as device implant patients typically stay one night in the hospital. How are new employees oriented and trained at your facility? New employees are teamed with a primary and secondary preceptor, usually an RN and RT, for at least three months. The orientation program is individualized depending on previous experience and could be extended if necessary. Employees are oriented and trained in all areas: cardiac cath, angio and electrophysiology. In addition, all employees attend the hospital orientation. What types of continuing education opportunities are provided to staff members? We have a variety of educational opportunities for the staff. Last winter, the managers presented a six-week EP boot camp covering basic EP training. In addition, we have ongoing presentations from the EP MDs on staff, from the vendors, and from the clinical support staff. Last March, the Health System and HRS co-sponsored a two-day Wine Country Arrhythmia Symposium in Sonoma, California, which has now become an annual event. It is coming up March 31 to April 2, 2006. How is staff competency evaluated? Every quarter the staff is required to complete competency packets with a post test on a variety of topics including anatomy and physiology, aseptic technique, medications, and radiation safety. Staff also is required to demonstrate competency on all cath lab equipment. Peer evaluations are completed annually. How do you handle vendor visits to your department? Vendors are scheduled in the EP lab on a limited basis with prior approval from the department manager. Clinical support for 3D mapping procedures and device implants are scheduled and confirmed prior to the procedure. Does your lab utilize any alternative therapies? We play music in the EP lab for our patients. We have an extensive CD collection in the department, so we can offer a wide selection of music to make our patients feel more comfortable. In addition, our "Mended Hearts" volunteers provide emotional support for our patients and families undergoing procedures. These volunteers have had procedures in the EP or cath lab. How does your lab handle call time for staff members? How often is each staff member on call? Is there a particular mix of credentials needed for each call team? There is no special call for EP procedures, but there is an on-call team for the department. Our hours of operation are 7 A.M. - 5 P.M. After 5 P.M., late cases or emergency add-ons are staffed by the on-call crew. We try and schedule our EP procedures to start prior to 3 P.M., so that the on-call team is available by 5 P.M. for emergency cardiac, stroke or trauma patients. The staff are assigned 1 weekend/month and 1-2 evenings/week on a rotational basis. The more senior staff have first chance for extra on-call hours. We stay late on an average of 3-4 evenings/week, usually for cases added on or emergencies; the weekends also tend to be busy with cases on both Saturday and Sunday. Does your lab use a third party for reprocessing? No. Approximately what percentage of your procedures are done with cryo? What percentage are done with radiofrequency? One hundred percent of cases are done with RF ablation. Do you perform only adult EP procedures, or do you also do pediatric cases? Is there cross training for pediatric cases? We perform procedures on adolescents, ages 13 years or older. What trends do you see emerging in the practice of electrophysiology? The EP MDs are performing atrial fibrillation ablation procedures now more than ever. We are expecting an increase in the ICD volume with the expanded indications. More of our procedures are utilizing the advanced 3D mapping systems with CT image integration. Is your EP lab currently involved in any clinical trials or special projects? Yes, we are currently participating in two trials, Easy Trak 4 and the MASTER trial. Does your lab undergo a JCAHO? Yes. In fact, we recently had an unannounced validation survey which went very well. The inspector commented the Health System obviously has a culture of "continuous JCAHO readiness." 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 Health System is currently developing the Cardiac Rhythm Center section of the web site to provide patients, community members, staff and physicians with information on diagnosis and treatment of arrhythmias (www.johnmuirmtdiablo.com). Preprocedural information is being developed for the web site as well. Written materials are provided for all the device implant patients upon discharge. Many of our CRT patients participate in the cardiac rehab program. Give an example of a difficult problem or challenge your lab has faced. How was it addressed? The shortage of trained staff is always challenging in the EP area. We have been able to provide additional coverage by floating staff between the two campuses. We try and recruit new grads from the RT program in the area. The Health System has many perks for experienced staff to enhance retention. Many of our nurses have been employed in the department for more than 20 years. Bed availability in the hospital can be a problem. The Bay will hold patients until beds become available, and during high census, outpatient procedures are limited to seven per day. Describe your city or general regional area. How does it differ from the rest of the U.S.? John Muir and Mt. Diablo are both located within Contra Costa County, which is home to more than 1 million people. The population in Contra Costa County is expected to increase by another 6% by 2010. John Muir campus is located in Walnut Creek, California, with a population of 83,932; the Mt. Diablo campus is in Concord, California, with a population of 128,486 people. Our Health System provides exceptional care and access to advanced medical care to almost 1 million people who live in our service area. We are close to two world famous university medical centers, but our patients are able to access state-of-the-art cardiac rhythm care within their own community at the Cardiac Rhythm Center. Please tell our readers what you consider unique or innovative about your EP lab and its staff. The Cardiac Rhythm Center has brought together some of the Bay Area s finest cardiac electrophysiologists and provided them with state-of-the-art cardiac electrophysiology equipment. Virtually everything needed to provide the best outcomes for patients with cardiac rhythm disorders is now available in one place. Focusing our arrhythmia treatment efforts in the Cardiac Rhythm Center has allowed our staff to work collaboratively as a team, bringing the very best technologists, nurses and physicians together in a state-of-the-art facility. We recognize that the best way to treat rhythm disorders is by creating an environment designed and equipped solely for this purpose.