Spotlight Interview: Orlando Regional 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? Orlando Regional Medical Center has three dedicated EP labs. A fourth lab is scheduled to open in January 2008. After the new lab opens, reconstruction on an existing EP lab will begin. Once completed, we will have two single-plane Siemens labs and two Siemens biplane labs with the GE CardioLab IT monitoring systems. We have eight dedicated electrophysiologists, along with a few cardiologists and surgeons who perform implants in the EP lab. The staff consists of an EP lab nurse manager, EP lab supervisor, clinical quality assurance specialist, and educator. We have eight registered nurses (RNs), three radiologic technologists (RTs), four respiratory therapists (RRTs), three cardiovascular invasive specialists (RCIS s), one scrub technologist, two advanced clinical technologists, and one daily scheduler.

When was the EP lab started at your institution? The EP program initially started in 1988, with Dr. Marcus Hazday performing the first EP study in the Cath lab. In 1990, Dr. Hazday performed the first internal cardiac defibrillator implant in the OR. At that time, we were implanting permanent pacemakers in the Cath lab. In 1992, Dr. Aurelio Duran (now the Department Head of Cardiology and Electrophysiology) performed the first ablation in the Cath lab.

What types of procedures are performed at your facility? Procedures performed include EP studies (EPS) and ablations of tachycardias, including atrial fibrillation, AVNRT, atrial tachycardias, AVRT, atrial flutter, complex ventricular tachycardias, RVOTs, and accessory pathways. All complex ablations are performed using a 3D mapping system such as Carto (Biosense Webster Inc., a Johnson and Johnson company, Diamond Bar, California) or the EnSite NavX system (St. Jude Medical, St. Paul, Minnesota). We also implant permanent pacemakers, ICDs, biventricular devices and loop recorders.

What is the primary goal of your program (AF ablations, lead extractions, BiVs, etc.)? Our goal is to provide comprehensive electrophysiology services in a tertiary care center, serving a large geographical area.

Approximately how many are performed each week? We perform 45-50 procedures weekly.

Who manages your EP lab? Lisa Kearney, RN is our EP lab nurse manager and Aurelio Duran, MD is the medical director.

Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained? Yes, there is a separation of the Cardiology Interventional Platform at ORMC. While the EP program began in 1988, the EP lab department was developed in 1995, when the first dedicated EP lab was built. The EP staff members are dedicated to EP, and at this time, they do not cross-train to work in the Cath lab.

Do you have cross training inside the EP lab? What are the regulations in your state? Yes, we encourage cross training within the EP lab. All EP staff are cross-trained to monitor, run the Bloom stimulator, scrub, ablate, and perform 3D mapping, cryoablations, and intracardiac echocardiography (ICE). However, in our organization only the RNs can circulate and give sedation. All staff must maintain current BLS and ACLS certifications.

What new equipment, devices and/or products have been introduced at your lab lately? How has this changed the way you perform those procedures? Within the last two years we have upgraded all EP monitoring equipment to the GE CardioLab IT system. We have added the EnSite 3D mapping system by St. Jude Medical, Intracardiac Echocardiography by Boston Scientific, the AcuNav (ICE) Cypress by Siemens, the ThermoCool ablation system by Biosense Webster Inc., and cryoablation, as well as upgraded to the CartoMerge 3D mapping system by Biosense Webster Inc. The addition of this advanced technology has allowed us to perform more complex and challenging ablations and procedures. During our more complex ablations, we are also utilizing anesthesia for patient safety and as required by physicians.

Who handles your procedure scheduling? Do you use particular software? Future and elective EP case scheduling is processed by the business team, who utilizes the Tempus software program. Daily scheduling (for add-ons and emergencies) is handled by the EP scheduling coordinator and the EP lab supervisor within the EP department.

What type of quality control/quality assurance measures are practiced in your EP lab? We have performance improvement measures that are followed and tracked based on JCAHO National Patient Safety Goals and Core Measures, to include patient verification, ASA scores on charts prior to procedure start, and administration of IV antibiotics within one hour of device implant. All can be tracked through a database within our nursing reports. We can report complications and quality assurance issues, as well as track and maintain the CMS ICD Registry.

How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? Inventory is checked daily by the inventory supply technician who manages and orders any supplies needed for day-to-day operations. We have a quality control specialist who manages par levels, makes new item evaluations and determines purchasing. New items are presented to a New Products Committee through the Materials Management Department, which works on reviews and trials of new products.

Has your EP lab recently expanded in size and patient volume, or will it be in the near future? Our patient volumes have been on a steady increase over the last three years, leading to the need for an additional EP lab. This new lab will be completed in January 2008, bringing our total to four EP labs.

How has managed care affected your EP lab and the care it provides patients? We are specialized in not only providing EP services regionally, but also in meeting the needs of electrophysiologists who need advanced care for their patients.

Have you developed a referral base? Yes, over the past 15 years we have developed a regional reputation for providing advance electrophysiology care.

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? While providing excellent clinical care, our physicians are committed to improving efficiency throughout and are very involved with Materials Management in the process of bringing in new products and equipment. A value and financial analysis is completed and reviewed with physicians prior to the induction of new products. We have implemented (where applicable) standardization within the cardiology departments, which includes all the hospitals within the Orlando Healthcare System. We frequently take advantage of bulk purchasing and vendor contracts. We have standardized EPS and implant surgery packs and have developed physician protocols in the GE CardioLab IT system to ensure consistency and efficiency. Monthly staff meetings are also held to discuss any issues or ways in which to maintain and improve throughput. In addition, we recently opened a dedicated pre/post EP/Cath recovery unit where EP patients are prepped pre-procedure and recovered immediately post procedure. This unit has helped with proficiency and consistency in patient care, which is optimal for throughput and patient satisfaction. We meet regularly with the manager of the pre and post EP/Cath unit to maintain efficiencies in throughput.

What procedures do you perform on an outpatient basis? Tilt table studies, EP studies, device change-outs and some of our ablations are performed on an outpatient basis. The patient s history and response to the procedure are all assessed prior to discharge.

How are new employees oriented and trained at your facility? All new employees complete an EP orientation program designed by an RN and a CVT in the department. RNs and techs are placed with a preceptor for their entire orientation. RNs start in the circulator role; once competency is documented, they progress to other roles. Techs usually start orientation in the scrub role; once complete, they train at the monitor and stimulator. Consistency is maintained by assigning one preceptor for each position. We include both hand-on and classroom training, including both computerized programs and books. We stress the importance of reading, observing and asking questions to staff and physicians. We anticipate at least a year of training before new staff members perform more complex procedures.

What types of continuing education opportunities are provided to staff members? We attend EP conferences and have quarterly meetings with physicians presenting case studies, new techniques and new technology. We have wonderful vendor relationships and support, which includes various educational lectures per year that we can attend. Each year we also send four staff members to the Heart Rhythm Society s annual conference.

How is staff competency evaluated? Staff is evaluated yearly during Annual Clinical Review through written and practical testing. Staff skills stations with competency checks are performed by management and vendor support on all EP equipment. In-service training is scheduled when new procedures and new technologies are introduced. Staff is evaluated for competency prior to participating in those procedures. We are in the process of developing a technician clinical ladder to compensate staff members for knowledge base, years worked, degrees earned and certification in specialized areas.

How do you prevent staff burnout? With a cross-trained staff, we are able to rotate through various types of procedures and work among different staff daily. The staff takes turns covering late cases and completing cases. No weekends, holidays, or on-call is required.

How do you handle vendor visits to your department? Do you contract with vendors? Vendors are scheduled and are present for all pacemaker, ICD, and BiV device implants. We also schedule vendor support to be present for certain types of procedures or new technologies that may require the assistance of a company representative. All other vendors must have an appointment they are placed on the vendor calendar for the particular day of their appointment. We have a corporate vendor compliance packet that must be completed prior to the vendor being given a distinctive vendor badge.

Please describe one of the more interesting or bizarre cases that have come through your EP lab. Because our hospital covers such a wide variety of areas in central and coastal Florida, we do see our share of interesting cases. Many of these cases are along the lines of anatomical and conduction anomalies. Two cases in particular raised a few eyebrows. We did a technically challenging case involving a female patient with an SVT. She was highly symptomatic while in this arrhythmia, and had become refractory to medications. Upon initiation of the case she was found to have a left persistent inferior vena cava, which connected directly to the coronary sinus and drained into the right atrium. Once access was obtained via the internal jugular, she was induced with typical common AVNRT and underwent successful AVN modification with the guidance of Biosense Webster s Carto system. We also had a 43-year-old mother of three with recurrent palpitations, near-syncope and syncope for many months. Her initial evaluation included a normal EKG, echo and stress test. Tilt testing identified a neurally mediated form of syncope. Treatment with fluids, salt, and support stockings prevented her syncope, but she continued to experience palpitations, throat discomfort and dizziness. After beta blockers failed, she was brought to the EP lab and we identified two right-sided ectopic atrial tachycardias, inducible only with rapid atrial pacing and Isuprel. St. Jude Medical s EnSite 3D mapping system was used to map it to the superior portion of the crista terminalis a few millimeters from the SA node. The second was more inferior. Cryoablation was used to minimize permanent injury to the SA node and phrenic nerve. The dual AVN pathways were discovered along with typical AVNRT. The space between the His purkinje recordings on the His catheter was less than 1 cm from the coronary sinus ostium. Therefore, CryoCath and St. Jude Medical were used to decrease risk of permanent CHB. The slow pathway was successfully ablated using CryoCath. Her symptoms of palpitations and dizziness were corrected; however, over the next several months she experienced recurrent neck throat pounding with unifocal PVCs. After failure of beta blockers and calcium blocker therapy and declining antiarrythmic therapy, she was brought back to the EP lab. During the second EP study, we identified a single focus leading to the unifocal PVCs. It was mapped to the anterior portion of the RVOT near the boundary with the septum. This is often a thin area, so it is difficult to maintain stability, especially during frequent ventricular ectopy. Again, cryoablation along with St. Jude Medical s mapping system was used successfully to eliminate the fourth tachycardia focus in this young woman.

How does your lab handle call time for staff members? We do not have to take call.

Does your lab use a third party for reprocessing? Yes, we have had great success with reprocessing using Ascent Healthcare Solutions.

Approximately what percentage of your ablation procedures are done with cryo? What percentage is done with radiofrequency? We have two physicians that use cryoablation only for AVNRT cases. Our remaining physicians use cryoablation when appropriate.

Do you perform only adult EP procedures or do you also do pediatric cases? Is there cross training for pediatric cases? We will occasionally treat a teenaged patient, but we no longer perform pediatric cases. Pediatric cases are performed at our pediatric facility, Arnold Palmer Children s Hospital.

Do your nurses/techs participate in the follow up of pacemakers and ICDs? If so, how many device visits per week do they handle? Do you use any particular software for follow up? How many of your ICD/pacemaker patients require a doctor for their visits? We do not do any follow ups on pacemakers or defibrillators. However, some of the staff can do programming and checks if needed.

What trends do you see emerging in the practice of electrophysiology? How is your lab preparing for these future changes? Trends emerging in the practice of EP include increased treatment of atrial fibrillation and older, more ill patients with cardiomyopathy. We are enlarging the size of our EP lab, and have added many new technologies to support the needs of our patients.

What are your thoughts about non-EPs implanting ICDs? Do you train such individuals? At our institution, credentialing for ICD implants requires the physician be board-certified in Electrophysiology through ABIM.

When was your last JCAHO inspection? Our last inspection took place two years ago.

Are you ACGME-approved for EP training? What do you think about two-year EP programs? Although we are a teaching institution at this time, we do not provide a fellowship program in clinical electrophysiology.

Does your lab provide any educational or support programs for patients who may have additional questions or those who may be interested in support groups? We answer any questions the patient or family member may have at the time of the procedure, as well as provide them with written educational material. Orlando Regional Medical Center has an excellent Cardiac Rehabilitation Program for both inpatients and outpatients. We offer group Cardiac Education Classes two times a week for patients. We discuss risk factors for cardiac disease management, medications, and recovery from an MI, CHF, AFIB, post EPS ablation, ICD and/or pacemaker implantation. We cover all diagnoses of the class participants. We also offer a group CHF class three days a week for all patients who are diagnosed with or have a history of CHF and/or were implanted with a biventricular pacemaker or ICD. With an order from the physician, our inpatients can be seen one-on-one at any time for cardiac teaching with a cardiac rehab registered nurse. For our outpatients (with a cardiologist referral), we have a monitored exercise program that develops a personalized exercise program and provides continued education on risk factor modifications and lifestyle changes. This program helps to build a patient s stamina and self-confidence, and makes exercise a daily part of their life while monitoring blood pressure, heart rate and rhythm. We have a local and national chapter of Mended Hearts, which is a self-help support group organization for patients with heart conditions. It is also for families, friends and others.

Please tell our readers what you consider unique or innovative about your EP lab and staff. One of the unique aspects about our lab is the complexity of patients we treat. The physicians and staff members are aware of the high level of expertise required. This type of training requires a great deal of efficiency and at least three or more years of experience in the EP lab for each RN and technician. The physicians and staff work very closely to achieve this level of training. This collaboration has led to a very positive team spirit and individuals who have worked here for over a decade.