Spotlight Interview Update

When was the EP lab started at your institution? Before 1974: 5% 1975-1979: 3% 1980-1984: 13% 1985-1989: 27% 1990-1994: 27% 1995-1999: 16% 2000-2004: 6% 2005-present: 1% (Data N/A: 2%) Massachusetts General Hospital - October 2004: Dr. Jeremy Ruskin is the founder and director of the MGH Cardiac Arrhythmia Service and Clinical Electrophysiology Laboratory. Since its inception in 1978, this service has been dedicated to excellence in clinical care, the training of fellows in clinical cardiac electrophysiology, and research on the mechanisms of and innovative therapies for the treatment of cardiac arrhythmias.

Examples of procedures performed at your facility (besides EPS, ablations, and device implants): Tilt table testing: 54% Cardioversions: 38% Lead extractions: 35% 3D mapping: 34% Cryoablation: 20% NIPS: 17% Loop recorder implants: 17% Pediatric cases: 12% TEE: 6% SAECG: 5% Coliseum Medical Center - June 2007: Since we are a new EP lab, our electrophysiologists are starting with simpler procedures. To date, the majority of our cases have been AICDs, BiV ICDs, dual-chamber pacemakers, EP studies, atrial flutter and supraventricular ablations, and tilt table studies.

Approximately how many cases are performed each week? Procedures per week: 0-9: 4% 10-29: 50% 30-49: 31% 50-100: 15%

How many ablations? 0-5: 50% 6-11: 37.5% More than 12: 12.5%

How many device implants? 0-5: 15% 6-13: 54% 14-19: 23% More than 20: 8% Lancaster General Hospital - November 2004: We perform approximately 70 procedures per week, or just over 3,600 annually. About 60% of this volume comes from device implants, and the other 40% from EP studies and ablations.

Is the EP lab separate from the cath lab? Yes: 88% No / Combined: 12% St. Mary s Hospital Medical Center - April 2005: From 1987 to 2003, the EP lab was integrated in the cath lab. Theoretically, all cath lab staff were cross-oriented to EP; in reality, a small group did most of the EP work. In 2003, our dedicated EP lab opened. Cath and EP lab staff are no longer cross-trained for the most part. Cath lab staff is still responsible for device implants when needed. EP lab staff no longer takes cath lab call.

Have you developed a referral base? Yes: 99% No/data not available: 1% The University of Utah, Cardiac Electrophysiology Division - August 2007: Our referral basis extends to different states in the region, including Idaho, Nevada, Wyoming, Colorado, and northern and southern Utah. The atrial fibrillation program has greatly expanded our referral base by attracting patients from California as well as other states in the northwest, along with international referrals from countries as far as eastern Europe and the Middle East.

Outpatient procedures performed: EP studies: 31% Device generator changeouts: 31% Ablations: 28% TTT: 23% Event monitors/Loop recorders: 14% Cardioversions: 14% NIPS: 8% Device implants: 5% Rural outreach clinics: 3% Sinai-Grace Hospital - July 2005: Most of the EP procedures are performed on an outpatient basis. These include ICD placement for primary prophylaxis against sudden cardiac death, SVT ablations, and at least 75% of CRT cases. We utilize what we call a 23-hour admission, in which the patient reports on the day of admission, undergoes the procedure and spends the night in the hospital, and is discharged the following day.

What types of continuing education opportunities are offered to staff? Attendance at national meetings (e.g., HRS): 69% In-hospital meetings/conferences: 54% Vendor-sponsored in-services: 49% Participation in local/state/national professional organizations: 32% Web-based training: 9% Grand rounds: 3% Participation in medical committees: 2% William Beaumont Hospital - May 2007: Continuing education is encouraged and reimbursed by the hospital. Each year two to four nurses are sent to the Heart Rhythm Society s annual conference. Weekly, vendors provide short updates on product innovations. Staff are provided the opportunity to go to training and education seminars offered by industry. There are online education requirements that staff must complete on a yearly basis that are completed on the job. The department has weekly staff meetings that may include education topics regarding team development to updates on hospital initiatives.

Does your lab utilize any alternative therapies? No: 60% Yes: 40%

If answering yes, what types: Music: 37% Calm atmosphere: 11% Humor/Smile: 8% Visual therapy/guided imagery: 8% Touch therapy/massage: 8% Relaxation/breathing techniques: 6% Reiki: 6% Warming systems: 3% Mended Hearts volunteers: 3% Child life specialists: 3% Other: 7% Illinois Masonic Hospital - March 2003: We work with patients to relax during procedures, continually providing support and letting them know where we are in the procedure and what they can expect to feel, etc. We utilize relaxation-breathing techniques. However, we have found that what makes our patients feel most comfortable is the camaraderie they sense between the physicians and nurses, and they feel comforted by the fact that we are all so calm and confident in one another. Many of our patients have commented on this after the procedure is over. We also play the patient s choice of music before we begin anesthesia to help them relax. For the majority of our patients, having a nurse stand by them during the procedure, explaining to them what is going on and what they can expect to feel is comforting and usually enough to help them relax.

Does your lab have a formal call schedule for EP staff? No: 57% Yes: 43%

For Yes answers, these were some examples of call schedules: Required to work after hours until cases are completed: 61% One weekend per month and various weekdays: 18% A couple days every 6-12 weeks: 14% Saturday mornings as needed: 7% Riverside Methodist Hospital - May 2002: 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 four nurses assigned to late call daily, which works out to about five times a month.

Does your lab use a third party for reprocessing? No: 43% Yes: 57% Bay Medical Center - October 2005: Yes, we do. We reprocess several of the EP catheters, which generates a big savings.

What are your thoughts about non-EPs implanting ICDs? In Support: 21% Do Not Support: 79% Hershey Medical Center s Penn State Heart & Vascular Institute - March 2007: To implant an ICD takes skill and dexterity. Many non-EPs can learn the skill of implantation; however, implanting an ICD is only a small facet of patient care. What about programming, setting proper parameters, and administering appropriate anti-arrhythmic therapy? To me, it is continuity of care if my electrophysiologist implants the device and is there for more follow-up care if needed. Therefore, we do not train non-EPs for ICD implants.