Spotlight Interview: University of Maryland Medical Center (UMMC)

What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab? The UMMC EP lab consists of two clinical laboratories a single and a biplane lab, along with a three-bay holding area. It also has a dedicated research laboratory. There are five attendings, three EP fellows and up to three research fellows. The UMMC EP lab is an all-RN staff, with nine dedicated laboratory and two research nurses. When was the EP lab started at your institution? UMMC EP lab was started in 1989, and the range of services continues to grow. What types of procedures are performed at your facility? The UMMC provides comprehensive electrophysiological services with detailed arrhythmia evaluation, tilt table testing, and cardioversions. In regards to devices, we perform implantation of pacemakers, defibrillators, and BiV devices, along with lead extractions. We have extensive experience with diagnostic EP studies, radiofrequency (RF) and cryoablations of SVT, prominently atrial fibrillation as well as ventricular tachycardia including endocardial and epicardial approaches. What is the primary goal of your program (AF ablations, lead extractions, BiVs, etc.)? One of our main focuses is on RF ablations, especially for atrial fibrillation (AF) and ventricular tachycardia. Approximately how many are performed each week? What complications do you find during these procedures? The lab on average has five cases per day, with at least one or two cases being an ablation. Complications are rare less than 1% with hematomas after device implantations being the most common. Who manages your EP lab? Dr. Stephen Shorofsky is the Director, and Deborah Nolan Reilly, RN, MS is the lab supervisor. Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained? Initially, the EP lab was in the same wing as the cardiac cath lab, but always had a dedicated lab and staff. In 1995, the EP lab moved to a separate wing from the cardiac cath lab in the north hospital. What new equipment, devices and/or products have been introduced at your lab lately? How has this changed the way you perform those procedures? We recently have added St. Jude Medical s EnSite/NavX system with the Fusion module. We acquired a Siemens Acuson for further integration with our Carto platform (CartoSound). One of the biggest changes has come with the addition of a Hansen Medical unit (Sensei Robotic Catheter System), which allows us a remote performance of our atrial fibrillation cases. Who handles your procedure scheduling? Do you use particular software? Scheduling is coordinated by a dedicated Heart Center staff member, Stephanie Lockett, in close collaboration with the attendings. What type of quality control/quality assurance measures are practiced in your EP lab? Quality control is promoted by the use of Pathways for implants, ablations and electrophysiology studies. These protocols help to provide consistency for patients pre/intra/post-op care. We use a variety of measures for quality assurance, in particular, follow-up phone calls to insure patient satisfaction along with a patient survey. Databases help to monitor the incidence of infection, moderate sedation complications, and amiodarone follow-up and compliance. How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? Inventory is manually monitored using a par level system. A physical inventory is done biannually in June and December. The purchasing of supplies is overseen by the EP lab supervisor and the hospital s Procurement and Contract Office, though it is based on physician input and preference. 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? Measures used to cut or contain costs include a just in time inventory with minimal par levels along with standardization of EP supplies. UMMC belongs to a consortium, which helps to maintain lower costs, and is actively involved with the hospital s Procurement and Contracting Office during negotiations. Having dedicated personnel in key roles has helped to alleviate delays, cancellations, and general stumbling blocks that in the past have slowed or even stopped the flow of patients. Our dedicated Heart Center personnel coordinate the outpatient scheduling and interface with the insurance companies and doctors offices to obtain all the necessary information prior to the patient admission. An assigned nurse provides pre-op instructions and reviews blood work a week prior to the procedure to insure that laboratory results are within an acceptable range. What procedures do you perform on an outpatient basis? Most of our cases can be done on an outpatient basis; this includes DFT testing, tilts, cardioversions, generator changes, and most ablations. How are new employees oriented and trained at your facility? New staff members are assigned to a preceptor for a period of 3-4 months. They attend company classes on ICDs, PPMs, and programmers, along with hospital classes on moderate sedation. Further information is provided to the new employee through books, articles, DVDs and a didactic weekly morning conference meeting. There is another three-month rotation through our Device Clinic with an assigned preceptor/mentor. What types of continuing education opportunities are provided to staff members? On a rotating basis, two staff members are able to attend the HRS conference, and one staff member is able to attend the SASEAP conference annually. The remainder of staff are allowed five conference days per year. The hospital provides RNs with a $500 reimbursement for conferences, membership dues, and/or journals or books. How is staff competency evaluated? Annually competencies must be maintained. All RN are ACLS- and BLS-certified. How do you prevent staff burnout? We encourage staff to use their vacation and personal leave time in order to rejuvenate themselves. We have them attend conferences and also rotate staff out of the lab to allow ‘desk time to work on their projects. We provide them with as few scheduling constraints as possible while still maintaining patient flow. We also do activities that are not work related but encourage a ‘team spirit , such as our book club and karaoke night. What committees, if any, are staff members asked to serve on in your lab? The UMMC s new staffing model encourages all nurses to participate in hospital committees. The EP lab personnel has or is on the following committees: Moderate Sedation; Internal Review Board (IRB) for new research protocols; Patient and Family Education; Safety; Nurse Council; Nursing Trends; and the Ethics Committee. Several nurses from the EP lab were also members of the Guidant/Boston Scientific Advisory Board. How do you handle vendor visits to your department? Do you contract with vendors? Vendors are encouraged to set up appointments with the EP lab secretaries. If this is not done, meeting with them is not guaranteed but done on availability. Please describe one of the more interesting or bizarre cases that has come through your EP lab. A 54-year-old patient was referred for VT; endocardial voltage mapping showed no myocardial scar. However, as we have extensive experience using cardiac imaging to guide complex ablations, we performed a PET/CT that demonstrated an epicardial scar. An epicardial ablation guided by PET/CT significantly reduced the VT burden. After a recurrence of arrhythmia several months later, we used our close collaboration with our cardiac surgeons during a mitral valve replacement to successfully perform an additional epicardial cryoablation of the scar. The patient has now been VT-free for >1 year. 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? Is there a particular mix of credentials needed for each call team? There is no call time, other than the day after Thanksgiving, and this is done on a volunteer basis. The labs are covered weekdays until the cases are done, usually at 18:00. A call list exists for rare emergencies. Does your lab use a third party for reprocessing? Yes, we use Ascent Healthcare, but we are trending away from resterilization since the cost savings has been dwindling over the past few years. Catheter vendors have been more aggressive in providing us with better pricing, though. Approximately what percentage of your ablation procedures are done with cryo? What percentage is done with radiofrequency? Most ablations are performed with radiofrequency. Septal pathways or septal tachycardias, especially in the pediatric population, are performed with cryo. Some of our investigator-initiated research protocols also involve cryoablations. Do you perform only adult EP procedures or do you also do pediatric cases? Is there cross training for pediatric cases? Dr. Mubadda A. Salim is UMMC s pediatric electrophysiologist. Approximately 20 cases per year are brought up to the adult EP lab. Pediatric anesthesia is used for these cases; adult EP fellows scrub in and the adult EP attendings act as resources. RN staff are used only as circulators. 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 Device Clinic is held every Wednesday from Noon to 4:30pm. Staff rotate through the clinic, where about 20-25 patients are seen. All patients in the clinic are examined by a physician. Patients can also come to our SDA (same day area), where their devices are interrogated. To improve patient care, we have initiated remote follow-up in 2007 using the LATITUDE and CareLink systems. We are also currently adding Biotronik s remote follow-up. Our current remote follow-up volume is approximately 25 per month, and the number is increasing each month. What trends do you see emerging in the practice of electrophysiology? How is your lab preparing for these future changes? An increasing number of devices are implanted in the private sector in the United States. This allows the academic centers to further focus on complex ablations such as for atrial fibrillation and ventricular tachycardia. We have state-of-the-art EP equipment with two fully current mapping systems (Carto, EnSite) with the most recent software for image integration or ultrasound guidance. We are currently integrating Hansen Medical s remote catheter system into this workflow. A close collaboration with our industrial partners allows us to develop new software and hardware application to facilitate complex ablations. What are your thoughts about non-EPs implanting ICDs? Do you train such individuals? We currently do not train non-EP physicians. What about device recalls? How has your lab handled these? EP lab personnel see to it that the companies have contacted all patients at risk; then a certified letter is sent to the patient s last known address. Follow-up phone calls and clinic charts are flagged, so that all staff is aware of the necessary steps needed to be taken. Is your lab doing web-based/transtelephonic device follow-up? We started enrolling patients in remote follow-up in 2007. We are presently following approximately 150 patients, with that number growing. We are using CareLink, LATITUDE, and Biotronik (within the next month). Is your EP lab currently involved in any clinical research studies or special projects? Which ones? We have a very active academic research program in our EP division, with up to three research fellows (one is just leaving, two new ones are coming), which are supported by national research grants. Some of our main focuses are facilitating complex ablations such as ventricular tachycardia by integration of PET, CT, or MRI; development of real-time imaging strategies; and automatic vector detection for guidance of VT ablation sites. We also collaborate in a variety of investigator-initiated research initiatives with other academic centers regarding genotyping and sudden cardiac death. In addition, we participate in a wide range of clinical research studies concerning novel devices, device programming, risk stratification and heart failure applications. New research protocols, including remote catheter control, are also currently being developed. Are you ACGME-approved for EP training? What do you think about two-year EP programs? Our program is ACGME approved. We feel that two years of clinical training is necessary for a comprehensive and complete training, despite the ABIM s requirement of only one year in order to sit for the board examination. 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 had a monthly support group from 1990 until 2000, but the need has significantly decreased. Now have an annual luncheon with guest speaker. Give an example of a difficult problem or challenge your lab has faced. How it was addressed? In the initial phase coordination, TEEs in the early morning prior to our atrial fibrillation ablations have been difficult. The newly acquired Acuson ultrasound allows our attendings to perform TEEs prior to cardioversions and ablations. Describe your city or general regional area. How does it differ from the rest of the U.S.? UMMC is located in a large, metropolitan region with well-established referral patterns. This is similar to other large cities with university-based training programs. Please tell our readers what you consider unique or innovative about your EP lab and staff. We have a very innovative research program, and have played a pivotal role in research regarding biphasic defibrillators and waveforms. Currently, we have a focus on using PET/CT and MRI to define scar substrate to facilitate complex VT ablations as well as developing novel real-time imaging approaches such as real-time CT. We are also investigating automatic vector guidance to further increase our ablation success. Our current collaboration with Hansen also enables us to combine our ongoing research with remote catheter control. UMMC has an excellent collaboration with industry partners to bring these concepts from the bench to the bedside and to develop clinical products out of research ideas. For more information, please visit: https://www.umm.edu/