Email Discussion Group: July 2008

New Question: Protocol for Tilt Table Study I recently encountered a superior manager who halted all tilt studies unless the physician was at the bedside. Prior to this we were performing these exams while the MD was in the lab, within close proximity, and not directly watching the patient. We are only tilting the patient on a table and if they do not respond to an 80-degree tilt in 15 minutes, we spray nitro under the tongue. The worst that has happened is they have gone asystole [during which time] we place them at zero degrees, give fluids, or at the worst-case scenario, give atropine. They immediately respond. Are there any rules which state that the physician must be directly at the patient’s bedside? Are the nurses not qualified to do this if the physician is not within arm’s length? — name withheld by request (To reply to this question, please type “Protocol for Tilt Table Study” in your subject line.) We do our TTT with Isuprel. There is a nurse and an ARNP in the room during the procedure, and the ordering doctor is in the hospital at the time of the procedure. Hope this helps. — Alison D. Swarens Yes, physicians need to be present with tilt table studies. Nurse Practitioners may also observe these tests in our hospitals. Our policy is the providers need to be present. There have been deaths due to tilt table tests. — name withheld by request Under Discussion: Operators Do other EP labs have both nurses and RTs operate the EnSite ablation computers and the diagnosis EKG computers (like Bard), or are these usually operated by just the RTs? — name withheld by request (To reply to this question, please type “Operators” in your subject line.) In our labs we have just one CVT, but all the staff is cross trained to do all the functions including mapping and operating Prucka. — Salwa Beheiry, RN, CCRN, Director, EP Services We are an equal opportunity lab. Our nurses and techs scrub, run the programmers, Bard, Carto, the Micropace system, the CryoCath and the Stockert and Thermocool systems. The only thing they do that I, as a tech, cannot do is give medications. We did this because it allows the nurses to participate as a part of the team, not only as the “keeper of the drugs.” This gives them the additional opportunities to learn other roles within the lab. This only occurs in our EP lab. — C. Gehin, RT(R), RCIS, RCES I have worked at two hospitals with EP labs. The first hospital encouraged every member of the EP team to become familiar with the equipment. They did ultimately have two RCIS's who are learning the Carto system. The RN, RTR, RRT, RCIS, EMT, and CVT are all included as team members trained to work in EP and cath labs. This includes working with Prucka and the set up of all equipment. When there aren't any EP procedures, the EP lab does cath lab procedures. My current hospital has a designated EP team. Currently the team has RNs and scrub techs. Everyone can set up the equipment, but the RNs operate the Prucka, EnSite, and Carto. The EP team has a goal of all members being able to operate all of the equipment. I am one of the team members still learning. Both hospitals limit the administration of medication including sedation to RNs. Both hospitals allowed the entire team to be trained in the ablation equipment. — B. Trollinger, RN, RCIS, FSICP Mobile EP Labs I was wondering if anyone is aware of any functioning mobile EP labs? I have found little information on mobile electrophysiology laboratories. I am specifically wondering how one is set up, the cost to run a mobile lab, funding for the lab, and how staffing works for this type of facility. — name withheld by request (To reply to this question, please type “Mobile EP Labs” in your subject line.) Conscious Sedation The discussion of “moderate sedation” or conscious sedation has been the subject of a lot of discussion in our lab. We are supposed to be sedating moderately, but we often find the physicians pushing for deeper sedation for DFTs. Currently we do not use CRNAs or anesthesia for this purpose; the RNs in the lab maintain adequate sedation levels. I've recently been researching “procedural sedation” to see if that would better describe what we do as opposed to moderate sedation. I continuously am searching for standards of practice for sedation in EP labs, particularly for long cases and DFTs. Any discussion would be helpful. — Jill, RN (To reply to this question, please type “Conscious Sedation” in your subject line.) EP Schools I was wondering if someone can let me know if there are any EP schools other than the Carnegie Institute in Troy, Michigan? I live in upstate New York. — Ross Scardino (To reply to this question, please type “EP Schools” in your subject line.) Diastolic Time Indices I am a cardiology fellow at the University of Utah. My question is why aren’t abnormal phonocardiographic indices such as pre-atrial diastolic time and accelerated atrial diastolic time in heart failure used? Is the shortened diastolic time due solely to the abnormal systolic time intervals (prolonged EMD)? — Osman Ahmed, MD, University of Utah, Salt Lake City, UT (To reply to this question, please type “Diastolic Time Indices” in your subject line.) Hands-on Training Are there any symposiums or classes available in the United States that provide hands-on EP training? — Heather Vardon, Aurora BayCare Medical Center, Green Bay, WI (To reply to this question, please type “Hands-on Training” in your subject line.) Refurbishing Costs How much does Ascent charge to refurbish an AcuNav catheter? — name withheld by request (To reply to this question, please type “Refurbishing Costs” in your subject line.) Pause on ECG I want to learn about indications of pacing in patients with ventricular pause more than three seconds according to evidence-based medicine. Is it logical or not to choose >3 seconds? — name withheld by request (To reply to this question, please type “Pause on ECG” in your subject line.) RCES Exam Have any readers taken the new RCES exam offered by CCI? What are your thoughts on the exam? Was the suggested reading list helpful in your exam preparation? Can you specify any resources to study from in addition to CCI's reading list? Do you have suggestions for preparing for the exam? — Toinette Trahan, RT(R) (To reply to this question, please type “RCES Exam” in your subject line.) Corvert At our facility and surrounding area hospitals, there has been a debate about the use of Corvert to chemically convert patients from atrial fibrillation to sinus rhythm without the presence of a physician. At our facility, our current practice is to give the drug in the presence of “trained professionals.” We interpret this as: in the presence of someone who is ACLS certified. We recently had an ACLS-certified professional refuse to give the drug without a physician present. What is the practice at your facility regarding chemical cardioversions? From my own experience, I have worked at the facility for five years and have given the drug several times without a physician present. I do feel comfortable doing this and often help other professionals administer the drug when they are not comfortable giving it. — Lisa Decker, RN, BSN, Genesis Medical Center, Davenport, IA (To reply to this question, please type “Corvert” in your subject line.)