Spotlight Interview: Walter Reed Army Medical Center

What types of procedures are performed at your facility? Approximately how many are performed each week? What complications do you find during these procedures? Joan: The cardiac catheterization lab performs diagnostic and interventional coronary procedures to include angioplasty, stenting, rotational atherectomy, directional coronary atherectomy, the Cardioseal atrial septal closure device, peripheral and carotid artery stenting, and Angiojet. The electrophysiology lab performs EP studies and radiofrequency (RF) ablations on AVNRT, atrial flutter, AVRT, ectopic atrial tachycardias, and ventricular tachycardia. We also implant cardiac pacemakers and implantable cardioverter defibrillators. The only pediatric cardiac electrophysiologist in the armed services is assigned to WRAMC, so we also perform many pediatric EP studies and RF ablations as well. In a typical week, we will perform three to four EP/RF ablations, and two to three device implants.

How is your EP lab managed, and by whom? Albert: A non-commissioned officer, who is a RCIS, manages our cardiac catheterization/EP lab. For most EP cases and device implants, a core group of two RCIS and one nurse is assigned to those cases.

Is the EP lab separate from the Cath lab? Are employees cross-trained? Albert: The EP and cardiac catheterization labs coexist in one location. However, our EP monitoring system is hardwired into one lab. All EP studies are done in this lab. Device implants are done in any available room. All employees are cross-trained to be proficient in any procedure performed in our lab. New employees are exposed to every procedure that we perform. Every employee in the cath lab is able to prepare a patient for an EP study. Only those who show a strong interest in electrophysiology are trained to operate the stimulator and monitoring system.

Do you have cross-training inside the EP lab? What are the regulations in your state? Joan: All employees in our EP lab are cross-trained for maximum efficiency. There is no differentiation between the nurse and tech role.

What are some of the new equipment, devices, and products introduced at your lab lately? Joan: We recently purchased the CARTO (Biosense Webster, Diamond Bar, California) electroanatomic mapping system. This system has been very useful in the ablation of atrial flutter and ectopic atrial tachycardias. We are in the process of acquiring intracardiac echocardiography. Our labs were completely renovated two years ago; our equipment is now all new and state of the art.

Is your EP lab filmless, or does it plan to become filmless in the foreseeable future? Joan: Since the renovations two years ago, we are now completely filmless.

Who handles your procedure scheduling? Do you use particular software? How do you handle physician timeliness? Joan: We have two dedicated EP days in the lab for outpatient EP procedures. Our electrophysiologists are hospital-based and don t have any other scheduled duties on those days, which eliminates any scheduling conflicts or issues with physician timeliness. Inpatient EP procedures and device implants are done any day of the week, and those cases are given priority in the EP lab. All scheduling is done on our hospital network that has a proprietary scheduling system.

What processes does your lab use for pulling sheaths post- diagnostic and interventional procedures? Albert: The physician who performs the procedure will pull the sheath on the table immediately after the procedure. Arterial lines placed during diagnostic cardiac catheterization cases are pulled by the cardiology fellow assisting the staff physician. The arterial lines are normally pulled in the post-procedure observation area.

How does your lab handle hemostasis (i.e., manual or vascular closure devices, where do patients go, and who is responsible)? Albert: All of our hemostasis is achieved using manual pressure. After the procedure, outpatients are returned to our cardiovascular short stay and observation clinic for post-procedure observation. Inpatients from the coronary care or cardiac step down ward are returned to their original room post-procedure. Inpatients from other wards are sent to the post-anesthesia care unit.

How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? Joan: For commonly used, high- volume items, we use the Omni-Cell system, which allows our logistics department to monitor and replenish our stock. The non-commissioned officer in charge of inventory control orders specialty items on an as-needed basis. Orders are processed by our logistics and contracting departments.

Has your EP lab recently expanded in size and patient volume, or will it be in the near future? Joan: Since the renovation of our cardiac catheterization laboratory two years ago, we have seen a forty-three percent increase in patient volume. In the EP lab, we are projecting a thirty-eight percent increase in procedures.

How has managed care affected your EP lab and the care it provides patients? Joan: Because of managed care, all health care institutions have changed the way they purchase supplies and manage inventory. At WRAMC, we have managed to do this through innovative contracts with suppliers with no deleterious effect on patient outcomes.

What measures has your EP lab implemented in order to cut or contain costs and improve efficiencies in the patient through-put? Joan: By using the Omni-cell inventory control system, we have been better able to control our inventory and avoid stockpiling expensive equipment. This reduces the risk of inventory loss due to expiration or the equipment becoming obsolete.

Does your EP lab compete for patients? Has your institution formed an alliance with others in the area? Albert: We are one of two military medical centers in the Military District of Washington that perform electrophysiology studies. We work together to exchange ideas, advice, and equipment in order to provide the best care possible to all eligible patients.

Does your lab have an outpatient program? Joan: In 1996, the cardiology service at WRAMC implemented the Cardiac Short Stay and Observation Center (CSSOC) to handle all outpatients who are treated in the cardiac cath lab (this includes EPS, elective pacemaker implantations, cardiac catheterizations, and peripheral vascular procedures). Registered nurses, licensed practical nurses, and nurse assistants from the cardiac step-down unit staff the CSSOC. The outpatients are case managed pre-and post-procedure by a cardiology service nurse.

How are new employees oriented and trained at your facility? Albert: All new personnel at WRAMC receive a general orientation to the facility. Employees assigned to the cath lab are given a unit specific orientation, which includes a familiarization with all procedures and equipment.

What type of continuing education opportunities are provided to staff members? Albert: The U.S. Army requires all soldiers to participate in weekly Sergeant's time training. During these sessions, a staff member presents a class on a cath lab or military-oriented subject. Civilian employees often attend these sessions. Representatives from various suppliers often come to our facility and give in-service presentations. Staff members are also given time to attend conferences of their choosing.

How is staff competency evaluated? Albert: All job titles in the cath lab have a competency checklist and employee skills are re-evaluated annually.

Does your lab utilize any alternative therapies? Joan: There is no formal alternative therapy program at WRAMC, but we do encourage our patients to bring in their favorite music to help alleviate pre-procedure anxiety.

How does your lab 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? Albert: Due to contracting issues that have yet to be resolved, only military technicians pull call in the WRAMC cath lab. Due to staff shortages, the four military trained RCIS s are on call every other day and every other weekend. Call-ins to the EP service are rare, but the coronary angiography side of the house does see its share of call-ins. The call team is required to stay in the cath lab until all procedures are complete. All technicians are expected to maintain a full schedule the next day regardless of call-ins. This arrangement is less than ideal, and steps are being taken to allow civilian employees to take call. As non-commissioned officers in the U.S. Army, the technicians do whatever is required to accomplish the mission.

What type of quality control/quality assurance measures are practiced in your EP lab? Joan: All physicians who perform procedures at the WRAMC cath lab participate in quarterly multi-disciplinary quality improvement meetings. Daily quality control checks are performed in the cath lab on the Avoximeter, HRACT machine, IABP, and crash carts.

What trends do you see emerging in the practice of invasive cardiology? Joan: We expect to see an increase in advanced interventional procedures such as brachytherapy within the next several years. We expect to be implementing brachytherapy at WRAMC within the next six months. In the electrophysiology lab, we expect to see an increase in the use of electroanatomic mapping systems and intra-cardiac echocardiography. These are just a few examples of the highly technical route that invasive cardiology is beginning to follow. We believe that cath labs will continue to demand a higher level of technical competence from their staff in order to successfully utilize the emerging technologies.

Does your lab undergo any sort of inspection? How often does this occur? Joan and Albert: Every three years, we undergo a JCAHO inspection, as well as numerous in-house inspections at regular intervals. In September, the College of American Pathologists is coming to our lab to conduct their bi-annual inspection of our ancillary laboratory quality control program. In addition, we undergo a quarterly safety inspection and periodic unannounced visits from various disciplines within the hospital.

Please tell our readers what you consider unique or innovate about your EP lab and its staff. Joan and Albert: The population that our EP service treats represents a broad cross-section of our society from all parts of the United States and Europe. Our staff members also reflect the diversity of geography and ethnicity in the military. Our patient population is generally younger than that of other labs, with 32% of our EP patient population under the age of 21 and only 35% of our patients over the age of 65. In other labs in the United States, 85% of all cases involve AVNRT; at WRAMC, only 13% of our patients present with AVNRT. We are also unique in that we are a showcase lab for Phillips Medical Systems, so we are visited by representatives of cath labs from all over the U.S. Additionally, we are frequently visited by high-ranking military and federal government officials, as well as foreign dignitaries. The most unique aspect of our lab is that we are one of only two electrophysiology labs in the world where the staff is required to wear black berets to work (the other is Brooke Army Medical Center at Fort Sam in Houston, Texas.)

Is there a problem or challenge your lab has faced? How it was addressed? Joan and Albert: Historically, we are faced with a challenge of yearly turnover of staff due to military moves and separations. We have dealt with this challenge by implementing a rigorous staff competency evaluation program to ensure that staff members are fully competent. Additionally, all military staff members are trained at the same institution, so there is a continuity of skill level when new staff members arrive. Currently, because of military downsizing and separations, we are integrating more civilian staff members into our team. This transition in staff makeup has resulted in cultural and attitude changes in the daily operations at our cath lab. One ameliorating factor in this problem is the fact that most civilian staff members are either retired or ex-military.