Spotlight Interview: Riverside Methodist Hospital

Riverside Methodist Hospital, a 1,063-bed, private, not-for-profit hospital is a central Ohio health care leader. In 1999, Riverside ranked fifth in the United States for its number of patient admissions. Riverside remains the Columbus area market leader for Heart Services, Orthopedics and Maternity Services. The Arrhythmia Services Department at Riverside is the busiest and one of the most highly regarded EP programs in the country, offering state-of-the-art technology to address the needs of patients with heart rhythm abnormalities.

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

At Riverside, we have four dedicated invasive electrophysiology labs, and a fifth opening in the summer of 2002. We have two additional rooms for non-invasive procedures such as tilt table testing, external cardioversions and implantable cardioverter-defibrillator (ICD) testing. We have 32 staff members, including 28 registered nurses and 4 patient care technicians. Most of our nurses have critical care experience. We have an inventory manager, two inventory technicians and an administrative assistant. The electrophysiologists who utilize the lab are in private practice. The electrophysiology lab has a block scheduling system for the two physician groups who practice at Riverside. There are a total of seven full-time electrophysiologists.

What types of procedures are performed at your facility? Approximately how many are performed each week? What complications do you find during these procedures?

We do basic electrophysiology studies and radiofrequency ablations for many types of arrhythmias, including AVNRT, atrial flutter, atrial tachycardias, ventricular tachycardias, Wolff-Parkinson-White and atrial fibrillation. We implant cardiac pacemakers, ICDs and biventricular pacemakers and defibrillators. We utilize the laser for lead extractions and perform internal cardioversions. Along with the invasive procedures, we do non-invasive cases, including tilt table testing, external cardioversions, and ICD testing. In addition, we have a special focus on atrial fibrillation ablations. Dr. Emile Daoud performed the first LASSO mapping catheter-guided pulmonary vein isolation procedure in the United States at Riverside in November of 2000. Our physicians often use the transseptal approach to map and ablate left-sided tachycardias. We have many resources to assist with advanced mapping of arrhythmias including the Cordis Webster Biosense system, the QMS Basket and the Cardiac Pathways RPM system. We will be doing a trial with the Endocardial Solutions mapping system in April of 2002. In 2001, we performed 8,262 procedures in our lab, of which 5,160 were invasive. The remaining were non-invasive procedures, including holter monitoring and SAECG (signal average ecg) testing. The complication rate in our lab is well within the accepted national standards. We have a nurse outcomes manager assigned who collects key outcome data on all procedures. These data are routinely shared with and analyzed by our medical director, Dr. Steven Kalbfleisch, and presented in multidisciplinary team meetings.

How is your EP lab managed, and by whom?

The management team includes a nurse manager, an assistant nurse manager, and a clinical leader, who manages the flow of the lab on a daily basis.

Is the EP lab separate from the Cath lab? Are the employees cross-trained?

Our lab is completely separate from the cath lab and we are not cross-trained, although we are located in close proximity to one another.

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

All of the EP staff nurses are trained to assist in all procedures performed in the lab, both invasive and non-invasive. All staff nurses are expected to know how to operate all equipment and computer systems used during procedures. Certain nurses have undergone extra training for specialty technologies such as Biosense and Cardiac Pathways. Our patient care technicians have the responsibility to help set up patients and labs for procedures and to help nurses during non-invasive procedures.

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

Riverside is one of the top 10 sites in the country for research. In fact, at any given time we are involved in about 15 to 20 active research protocols. Because of that, we were the first center in the country to perform a LASSO mapping catheter-guided pulmonary vein isolation procedure to ablate focal atrial fibrillation and the second in the country to implant an epicardial biventricular pacemaker. We have been using new catheters in combination with mapping systems for ablation of arrhythmias.

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

The Riverside EP lab is filmless; our flouroscopy does not have cine capabilities.

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

All procedures are handled through our hospital s central scheduling system using the Encompass software. On a daily basis there are 3 to 4 physicians dedicated to EP procedures, so physician timeliness is not a problem. There are typically 3 registered nurses assigned to each invasive lab, so the turnover time between cases is usually 10 to 15 minutes.

What processes does your lab use for pulling sheaths post-diagnostic and interventional procedures? How does your lab handle hemostasis (i.e., manual or vascular closure devices, where do patients go, who is responsible)?

Most of our cases involve venous sheaths, which are pulled by the EP nurses, and manual pressure is held until hemostasis occurs. If a patient has an arterial sheath, he or she is taken to the cardiac cath lab holding area, where the sheath is pulled by holding area staff. Occasionally, a cath lab physician will come to the EP lab to place a closure device in a patient with an arterial sheath.

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

There is an inventory manager who oversees the supplies purchased for both the cath and EP labs. We also have an inventory supervisor and an inventory technician who handle only EP supplies. People Soft is used for inventory control and ordering. There is also a barcode scanning system, which is incorporated into the nursing charting system to keep track of items used during a case and for billing purposes.

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

In 1990, Riverside EP lab had only one physician and two nurses, and there were 145 cases done. In 2001, there were seven physicians, twenty-six nurses and 8,262 cases performed. In 2002, we will gain a fifth invasive EP lab and a holding area designated just for EP patients. Riverside Hospital is also currently constructing a dedicated heart hospital on the campus, due to open in the spring of 2004. In the new heart hospital, there will be six invasive EP labs, three non-invasive labs, a larger holding area, plus room for expansion in the future.

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

Most of the changes we have seen are related to the recent cuts in reimbursement. There has been increased pressure to contain the costs in the lab.

What measures has your EP lab implemented in order to cut or contain costs and improve efficiencies in patient throughput?

We have initiated a rounding nurse program in our lab to improve patient flow. One of our staff nurses comes in daily at 6:00 am to round on in-patients and ensure their readiness for procedures (i.e., a running IV, NPO, consent forms signed). This has definitely helped. Riverside also has a Tender Hearts program for all outpatient cardiac procedures. The Tender Hearts coordinators facilitate outpatient flow by helping to educate patients and families about procedures, direct people to and from waiting areas and update families about patient progress during lengthy procedures.

Does your EP lab compete for patients? Has your institution formed an alliance with others in the area?

Yes, Riverside competes with other Columbus area hospitals for EP patients. Our cardiology groups have formed allegiances with many smaller outside hospitals within about a 90 mile radius of Columbus, so many of our patients are from outlying areas.

Does your lab have an outpatient program?

There is a very large outpatient program in our lab; about one-third of our patients daily are outpatient. We have a Cardiac Diagnostic Care Unit (CDCU) where outpatients are checked in, have an H & P done, have an IV placed and wait for their procedure. The CDCU also receives patients post-procedure, and discharges them after their recovery period.

How are new employees oriented and trained at your facility? 

All new personnel at Riverside receive general hospital orientation. The RNs in the EP lab receive an 8- to 12-week orientation with another EP nurse. They are taught to know all procedures, equipment and computer systems. They are also taught surgical scrub techniques for device implants.

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

There are many opportunities for our staff. We frequently have in-services by pacemaker company representatives about new devices and their device programmers. Every year, we send 2-4 of our staff nurses to the NASPE/Bard conference. We send staff nurses to specialty technology training, such as the Cordis Webster Biosense system. We also send staff nurses to learn updates on current systems we use, such as the Prucka system. These continuing education opportunities are very important for our staff, since we are responsible for operating and troubleshooting systems during procedures.

How is staff competency evaluated?

Along with the in-services and training opportunities mentioned above, there are annual staff reviews. All of our staff have hands-on opportunities daily with all equipment.

Does your lab utilize any alternative therapies?

There are visual therapy ceiling tiles in our largest invasive labs. We also have personal stereos available for patients who request them or for patients that may not tolerate or desire chemical sedation.

How does your staff 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?

Our lab is open Monday through Friday from 7:00 am to 7:30 pm. There are two shifts in our lab, 7:00 am to 5:30 pm and 7:00 am to 7:30 pm. Generally, the staff nurses with more seniority work until 5:30 pm. We do not have any overnight or weekend call; however, we have a late call assigned daily to cover procedures that may run past 7:30 pm. There are generally 4 nurses assigned to late call daily, which works out to about 5 times a month.

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

The medical director of the EP lab attends a monthly meeting with our outcomes manager to review cases in which there were complications. Dr. John Hummel, one of the electrophysiologists, is the co-chair of the hospital s Continuous Process Improvement Team for Heart Services. There is also an EP work team composed of an EP physician, EP lab management, EP outcomes manager, representatives from the physicians office and from the nursing units in the hospital who frequently care for pre- and post-EP patients.

What trends do you see emerging in the practice of invasive cardiology?

Invasive cardiac electrophysiology seems to be headed towards expanded indications for both implantable devices and catheter ablations. There will be more empiric use of defibrillators. A greater utilization of biventricular pacing technology will be seen for chronic heart failure. Catheter ablation will have a greater role in the treatment and cure of atrial fibrillation.

For more information about Riverside Methodist Hospital, visit www.ohiohealth.com.