Spotlight Interview: Caritas St. Elizabeth`s 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? The Arrhythmia Service at Caritas St. Elizabeth s Medical Center is comprised of two state-of-the-art EP labs. Our staff of four electrophysiologists, two EP fellows, one cardiology fellow, one physician assistant, ten registered nurses, three radiology technologists, one engineer, a lab assistant, one secretary and one scheduling coordinator moved into this new space from a single outdated lab in the spring of 2005. We also have an affiliated device clinic that is run by two experienced nurse practitioners. We have two Philips labs, one of which features the first in the world integration of Stereotaxis with the advanced Philips imaging system. When was the EP lab started at your institution? The EP service at Caritas St. Elizabeth s Medical Center was initiated in 1989 by the arrival of Dr. Charles Haffajee. Ablation procedures were originally performed using direct current from a standard external defibrillator machine and were performed in an old cath lab. Device implants were initially performed by a surgeon until 1992, when the first ICD was implanted in the EP lab by Dr. Haffajee. We now have a full complement of four attending electrophysiologists. The EP fellowship program started in 1994 and was increased to two fellows last year. What types of procedures are performed at your facility? In addition to traditional ablation procedures for AVNRT, AVRT, atrial flutter, atrial tachycardias, RVOT and complex ventricular tachycardias, we perform atrial fibrillation ablations using both manual and remote magnetic navigation. We also perform permanent pacemaker, ICD, cardiac resynchronization and loop recorder implants. Defibrillator testing, tilt table testing and cardioversions are also a part of our curriculum. Diagnostic EP studies and catheter ablations are guided by Carto 3D or EnSite NavX mapping systems. For atrial fibrillation ablations, advanced three-dimensional imaging (Philips) is used in collaboration with CT overlay. This imaging breakthrough provides the ability to overlay a three-dimensional rotational angiogram or CT replica of the left atrium upon a corresponding live fluoroscopic image. We were among the first EP laboratories in the world to test and enhance this technology, which is now available for clinical use. What is the primary goal of your program (AF ablations, lead extractions, BiVs, etc.)? We perform catheter ablation and implant procedures covering the whole spectrum of an EP laboratory in a tertiary care setting. A specific area of interest for our lab is real-time anatomical cardiac imaging during atrial fibrillation ablations for the purpose of decreasing radiation exposure and improving procedural efficiency. Approximately how many are performed each week? What complications do you find during these procedures? We perform an average of 15 invasive and 10 noninvasive procedures weekly and generally have complication rates well below the national averages in all areas. Who manages your EP lab? Our lab is under the direction of Charles Haffajee, MD, and day-to-day management is governed by senior nursing staff including Sarah Patton, RN, Jean Connolly, RN, and Kathleen Familetto, RN. Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained? The EP lab is completely separate from the cath lab this has been the case since 1992. Although many of our nurses have prior cath lab experience, they are not crosstrained for that work environment. Do you have cross training inside the EP lab? What are the regulations in your state? The majority of our EP lab staff are crosstrained to perform any role necessary for all EP procedures, with the exception of bedside echocardiograms, for which we consult our echo team. Conscious sedation is administered by RNs only, and all of our staff are BLS- and ACLS-certified as mandated by the state. What new equipment, devices and/or products have been introduced at your lab lately? How has this changed the way you perform those procedures? All of our EP monitoring equipment mapping and ablation systems were new in 2005. The addition of Stereotaxis and Philips imaging technology has been our most important enhancement. The latest advancement featuring an overlay of three-dimensional rotational angiography or a CT image upon live fluoroscopy is most exciting. Who handles your procedure scheduling? Do you use particular software? Our coordinator, Roseann Vescio, schedules all procedures in our lab and the cath lab via the IDX scheduling system. Add-on cases are called directly into our laboratory and handled by our secretary, Aimee Belton. What type of quality control/quality assurance measures are practiced in your EP lab? We are compliant with JCAHO National Patient Safety Goals and Core Measures in our laboratory. This includes preprocedural ASA evaluations, patient and verification measures and magnetic screening. How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? All inventory management is entered into our Philips/Witt database. Our chief radiology technician, Tammee Sweck, handles the responsibility of inventory purchases and restocking. At our weekly EP meetings, materials management and new product trials are discussed and delegated to the appropriate staff. Capital equipment repair and troubleshooting is handled through our Clinical Engineering department, who also manages support contracts with our vendors. Has your EP lab recently expanded in size and patient volume, or will it be in the near future? Our EP lab expansion occurred in 2005; we currently have no plans to add more labs. Our volume, however, remains steady and we anticipate an upward trend to continue for next year. How has managed care affected your EP lab and the care it provides patients? Managed care has helped to improve our operational efficiency but has not affected our status as a center of excellence in the cardiology community. Have you developed a referral base? Our referral base is comprehensive as we are the flagship institution within the five-hospital Caritas Christi network. Our reputation also gives us the opportunity to care for patients referred out of the network from central and Southern Massachusetts and Rhode Island. 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? Through direct collaboration between the EP physicians, our chief radiology technician and the nurse managers, cost-effective measures for equipment orders and bulk purchase programs are analyzed at our weekly staff meetings. In the laboratory, pre-programmed ablation protocols optimize procedure duration to facilitate patient through-put and minimize radiation exposure to patients and staff. For implants, operative equipment is prepackaged, which further improves efficiency. What procedures do you perform on an outpatient basis? Most of our diagnostic EP procedures, elective ablations and device generator changes are performed as outpatient procedures. Our holding area procedures include DC cardioversions, ICD defibrillator threshold testing and tilt table testing. How are new employees oriented and trained at your facility? The typical training process for EP allied staff consists of a six-week orientation in which a trainee is paired with a preceptor who guides the trainee through EP protocols and procedures. Prior to orientation, the trainee is given a comprehensive, evidence-based manual that he/she uses as a reference for standard operating procedures. Once a week, the trainee, preceptor and nurse educator meet to evaluate achievement of objectives and to individualize training. The entire EP lab staff participates in this process by assuming responsibility for providing the trainee with the necessary tools to be successful as a full-time staff member. What types of continuing education opportunities are provided to staff members? We have one staff meeting per week on a rotating schedule that provides one educational session per month for the EP allied staff. These sessions are usually interactive cases presented by the EP fellow. In addition, all staff members are given opportunities through our device vendors to attend outside educational seminars. We also provide opportunities for a number of staff to attend the annual Heart Rhythm Society meeting. How is staff competency evaluated? There are multiple competency programs provided by our nursing education department to provide individualized benchmarks for our staff. Most of these computerized applications are designed to emphasize strengths and accomplish objectives in areas where help is needed. How do you prevent staff burnout? We are fortunate to be in a field of cardiology that provides a wide array of patients, and therefore, procedures. This diversity gives our staff the opportunity to rotate through all types of procedures, which helps to keep everyone fresh. In addition, no weekend or holiday call is required. How do you handle vendor visits to your department? Do you contract with vendors? All vendors in our institution are required to register in administration and to wear visible time-stamped badges once they have stepped into the building. We contract for bulk purchases with many of our vendors, and our involvement in clinical trials also helps to cut patient costs. Company representatives are present for all implants. Please describe one of the more interesting or bizarre cases that have come through your EP lab. We cared for a patient originally from Albania residing in the Boston area over the past decade who had undergone BiV/ICD implant at our facility in 2003. He had originally presented with a well-established non-ischemic cardiomyopathy prior to implant with NYHA Class III heart failure symptoms accompanying an EF of 20%. The patient experienced dramatic improvement in his symptoms over the ensuing year such that he was able to travel back to Albania to visit family. While there, the patient consumed some traditional meals that included goat's milk and meat. He presented nearly two years later with symptoms of bacterial endocarditis and blood cultures growing the rare bacteria Brucella melitensis, likely from his goat product exposure. We performed an extensive literature search and were unable to find any case reports of Brucella endocarditis with BiV/ICD. The device and leads were extracted with surgical backup without complications, and his postoperative echocardiogram revealed an EF that had improved to 50%. The bacteria was sensitive to gentamicin and doxycycline and the patient was successfully treated from an infectious disease standpoint. However, the dilemma we faced was whether or not to reimplant his device given his improved EF and resolution of heart failure. We performed an EP study, which was negative, and then elected to watch him closely. To date, he has not required a new device or heart failure therapy and his EF remains the same. We are currently hopeful that this unprecedented case will be published in the literature. How does your lab handle call time for staff members? Our staff does not take call. Does your lab use a third party for reprocessing? Yes, we are contracted with SterileMed Inc. Approximately what percentage of your ablation procedures are done with cryo? What percentage is done with radiofrequency? All ablation procedures performed in our laboratory are done with radiofrequency. Do you perform only adult EP procedures or do you also do pediatric cases? Is there cross training for pediatric cases? Our lab is primarily an adult EP lab; therefore, pediatric crosstraining is not an issue. 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? The nurses in our EP lab do almost all inpatient device follow-up and interrogation in collaboration with either the PA, a fellow or an attending physician. Our part-time nurse practitioners run the outpatient device clinic in our cardiology department with cross coverage from the EP nurses during vacation times. We use multiple vendor-supported device databases for patient tracking, including St. Jude Medical s Housecall Plus, Home Monitoring, Medtronic s CareLink and Boston Scientific s LATITUDE. Routine outpatient device follow-ups do not usually require physician supervision, but physician office visits are often coupled with an add-on device check for patient convenience. What trends do you see emerging in the practice of electrophysiology? How is your lab preparing for these future changes? We are definitely seeing an upward trend in referrals for atrial fibrillation ablations, which drives our desire to optimize current imaging techniques and improve the efficiency and safety of these procedures. What are your thoughts about non-EPs implanting ICDs? Our hospital and the associated network require board-certified electrophysiologists to perform implants. When was your last JCAHO inspection? Our last inspection took place in early November. Are you ACGME-approved for EP training? What do you think about two-year EP programs? We are approved for two EP fellows in addition to our regular academic general cardiology fellowship program. 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? Our EP staff provides comprehensive education to patients and their families before and after every procedure. We also provide counseling through our in-house Cardiac Rehabilitation Program, where other cardiac disease management risk factors and treatment plans are reinforced. Please tell our readers what you consider unique or innovative about your EP lab and staff. One of the biggest compliments we receive from patients is our staff's ability to minimize procedural anxiety through careful explanation and listening skills.These attributes, coupled with technical expertise and a spirit of collaboration, make our EP lab uniquely meaningful to our patients and staff. For more information, please visit: www.semc.org