Spotlight Interview: Bridgeport Hospital

What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab?

We presently have two rooms dedicated to electrophysiology procedures. These include an EP lab and a lab for device implants. We are currently in the process of constructing a new EP lab. Our Arrhythmia Service of 11 members includes 4 attending physicians, 1 nurse practitioner, 3 registered nurses (one dedicated to research studies), 1 surgical technician, 1 RCIS, and 1 secretary. Cardiology fellows rotate through the EP Service facilities, but our institution does not sponsor an EP fellowship.

When was the EP lab started at your institution?

The EP lab opened in July 1992. It was the first such facility in Fairfield County. Since its inception, the lab has been directed by Dr. Craig McPherson, the current Director of Cardiac Electrophysiology.

What types of procedures are performed at your facility? Approximately how many are performed each week?

We perform an average of 10–15 cases per week. These include EP studies, device implants (including biventricular devices) and cardiac ablations. We were the first institution in Fairfield County to perform ablations for atrial fibrillation (the first such procedure was performed by Dr. Robert Winslow) and are presently the only site performing such complex procedures in lower Fairfield County. Dr. Murali Chiravuri and Dr. Joseph Tiano also perform these procedures. In June 2010, Dr. McPherson performed the first MRI-compatible pacer implant in the state, under a compassionate use protocol, in a woman with exercise-induced infra-nodal heart block and a cavernous sinus brain aneurysm that requires periodic follow-up by MRI. This February, Dr. Winslow implanted the first such device in the state of Connecticut after its clinical release by the FDA.

Who manages your EP lab?

Our lab is managed by Dawn Nair, DNP, APRN-BC, who is the Manager of Invasive and Noninvasive Cardiology. The Electrophysiology Peer Review Committee oversees policies and quality assurance aspects of the EP service. This committee meets monthly to discuss lab policies and procedures and review all complications or adverse outcomes related to lab procedures. Additionally, the EP lab participates in the Cardiac Quality Team, which meets monthly to discuss quality and the JCAHO metrics.

Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained?

The EP lab has been separate from the cath lab since its inception. The EP nurses are dedicated to the EP lab, but our technicians are cross trained to the cath lab, and at times, cover that facility. Also, some of the cath lab team nurses and technicians are cross trained for EP.

Have you recently upgraded your imaging technology? How has this changed the way you perform procedures?

We are presently replacing our EP lab to enhance its capabilities. The new facility will contain a Siemens biplane fluoroscopy camera (an upgrade from our present single-plane unit) equipped with the ability to perform 3D reconstruction of left atrial geometry via contrast injection. This will obviate the need to perform an MRI or CT scan prior to AF ablations. The biplane imaging will facilitate LV electrode placement during biventricular implants as well as catheter placement during complex ablations. As part of the new lab upgrade, our St. Jude Medical computerized mapping system and our Siemens ACUSON X300 intracardiac echo system will be integrated into the hardware. Finally, the new unit has hardware and software elements designed to minimize radiation exposure. We anticipate that the new lab equipment will facilitate the performance of procedures, enhancing patient safety and improving lab throughput.

Who handles your procedure scheduling? Do they use particular software?

The Heart Institute at our hospital employs one person who schedules all outpatient procedures, including those of the EP Service. All inpatient procedures are scheduled directly with the EP nurse working in the lab on that particular day. All procedures are entered into the CARE scheduling system, which was custom designed for Bridgeport Hospital.

What type of quality control/quality assurance measures are practiced in your EP lab?

In addition to the dedicated Electrophysiology Peer Review Committee that oversees all aspects of quality assurance for the EP lab, all members of the lab staff, from physicians to technicians, are fully credentialed for the roles they fulfill.

How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies?

The EP staff work closely with the Cardiac Systems Coordinator to manage inventory within the EP and cath labs. The team continually evaluates actual usage to determine appropriate inventory levels. New products are evaluated by a committee to determine clinical utility and cost. For capital purchases, a business plan is created and brought to administration for approval. Equipment is purchased through an upgrade from an old system to a new system. However, as a lab we take the time to research and find the best equipment suited for the lab with an objective on cost.

Have you developed a referral base?

Since 1992, our EP Service has served as a tertiary referral center for southern Connecticut. In 2011, this was formally established through the formation of The Connecticut Cardiac Arrhythmia Center of the Heart Institute at Bridgeport Hospital, which was developed to facilitate physician and patient self-referral to our institution.

What types of continuing education opportunities are provided to staff members?

Although institutional resources are limited, some funding is made available by the hospital and through research grants to support members of the staff to periodically attend regional and national educational and scientific sessions. This is especially true when staff members are presenting papers or lectures at such meetings. In addition, all are encouraged to seek out learning sessions on their own, including attendance at local, regional and national meetings. Finally, the hospital does have a tuition assistance program for members of the nursing staff who pursue studies at local universities to enhance their educational credentials.

How is staff competency evaluated?

All staff members are required to complete annual competency tests, and RNs must complete conscious sedation competency yearly.

How do you handle vendor visits to your department? Do you contract with vendors?

Vendor visits are scheduled by appointment only. In order to gain access to the hospital, all vendors must register with Vendormate. We contract with vendors as part of the Yale New Haven Health System. 

Describe a particularly memorable or bizarre case that has come through your EP lab. What lessons did you learn from it?

Last year, we managed a patient whose laboratory experience changed our approach to conscious sedation. He was a 45-year-old man of average build who worked as an executive and suffered from AV node reentry tachycardia. After suffering some breakthrough SVT episodes on medication, he elected to undergo what his physician and the lab staff all felt would be a fairly routine AV node slow pathway ablation. During the pre-study interview, he reported no past difficulty with sleeping or snoring. The baseline EP study confirmed the diagnosis. As the ablation proceeded, however, the patient started to become restless and agitated. He was noted to suffer periods of apnea, during which his oxygen saturation would fall to 55% and from which he would emerge with loud snoring and violent thrashing. It became unsafe to deliver all the RF lesions that were needed as the area requiring RF delivery was close to his AV node (SVT had persisted after more distant lesions had been delivered). The procedure had to be aborted, even though some SVT was still occurring. After the procedure, when we again asked this normal sized, non-obese man if he had any history of snoring or sleeping difficulty, he replied that he did not. His wife burst out laughing and reported that, “I kick him several times a night so that he’ll quiet down.” She frequently observed him having apnea spells during his sleep. Although these frightened her earlier in their marriage, over the years she “got used to them.” We recommended that the patient speak to his primary physician about undergoing a formal sleep study. Since then, we ask about sleep-disordered breathing in all of our patients (and their bed partners), irrespective of their body build, especially those who are likely to need more prolonged periods of sedation. If patients are being treated for sleep apnea with breathing masks, they are asked to meet with a member of our Respiratory Therapy staff, who provide them with CPAP or BiPAP machines for their EP procedure. Since we have adopted this policy, we have not had any occurrences similar to the patient described in this vignette.

How does your lab handle call time for staff members?

Unlike their peers in the cath lab, the EP lab staff members are not required to take off-hours call. However, the staff does work flexible schedules in order to accommodate the needs of our patients and physicians. This includes running the lab into the early evenings on some days, while starting a little later on others.

Does your lab use a third party for reprocessing?

We have been reprocessing pacing electrodes since the EP lab first opened in 1992. This helps control expenses, and we have never noticed this to impact the quality or safety of our procedures.

What measures has your lab taken to minimize radiation exposure to physicians and staff?

Our lab uses table skirts and shields mounted from the ceiling to help decrease radiation scatter. Nurses sit behind a radiation screen when fluoroscopy is performed. All physicians and staff members wear dosimeters that are monitored by the Staff Physicist at our hospital. If increased radiation exposure is detected, the affected individual is not allowed to work in the lab for a period of time. Fortunately, this has never occurred. Our new lab will have digital acquisition technology and pulsed fluoroscopy, which will further reduce radiation exposure during interventional procedures.

Do your nurses/techs participate in the follow-up of pacemakers and ICDs?

In general, routine device follow-up is performed in the office of the implanting physician. The offices of Drs. Chiravuri, Winslow and Tiano are staffed by dedicated nurse practitioners who assist with device interrogation and programming. Urgent device analysis in hospitalized patients is performed by the EP physicians, the cardiology fellows and nurse practitioners at The Heart Institute. Dr. McPherson, who is based at Bridgeport Hospital, follows his patients in the Pacemaker & ICD Clinic. The clinic is staffed by Cathy Wright, APRN, and Dr. McPherson. Cardiology fellows rotate through the clinic as part of their training. Cathy heads our program to provide peri-operative device interrogation and reprogramming in the operating room and procedure suites of the hospital. Web-based and transtelephonic device follow-up are becoming increasingly utilized in all device clinics.

What are some of the dominant trends you see emerging in the practice of electrophysiology? How is your lab preparing for these future changes?

One clear trend is increased utilization of ablation therapy, particularly for treatment of atrial fibrillation. Part of our response to this has been to upgrade our primary EP lab, as described above. In addition, Dr. Tiano was recently recruited to increase our complement of EP physicians trained in the performance of complex ablation procedures. Finally, Dr. Chiravuri is teaming with our Director of Cardiothoracic Surgery, Dr. M. Clive Robinson, to learn to perform the hybrid procedure. This new procedure combines a minimally invasive epicardial approach by the cardiothoracic surgeon, with catheter-based endocardial approaches by the electrophysiologist, in an effort to improve ablation outcomes in patients with persistent atrial fibrillation. We hope to begin performing this procedure in the near future.

Another trend in electrophysiology, as in all of medicine, is an increase in patient self-referral via the Internet and self-education via social networks. Part of our response to this was to establish The Connecticut Cardiac Arrhythmia Center, one feature of which is a dedicated telephone line through which patients may ask questions regarding potential arrhythmia symptoms and by which their referral to electrophysiologists may be facilitated. Links to the center have been created through Facebook and Twitter. Recently, our hospital developed a video campaign that was posted on YouTube. Designed to educate the lay public about atrial fibrillation, it is entitled, “Do you have rhythm” (interested readers can visit “https://www.youtube.com/watch?v=zzhOxJpzky8”).

What about device recalls? How has your lab handled these?

Device recalls are handled through the offices of the implanting physicians, not directly through the EP lab.

Is your EP lab currently involved in any clinical research studies or special projects? Which ones?

Our arrhythmia service has participated in several multi-center studies, including MUSTT, INTRINSIC RV, SHIELD, RE-LY, ARISTOTLE and the MADIT-CRT trials. We will be participating in the MADIT-RAID trial.

Are you ACGME-approved for EP training?

Bridgeport Hospital, which is affiliated with Yale University, sponsors ACGME-accredited fellowships in Cardiovascular Diseases and Interventional Cardiology, but not in Cardiac Electrophysiology. Dr. McPherson is the Director of the Cardiology Fellowship.

Does your staff provide any educational materials for patients who may have additional questions about their condition/procedure? In addition, does your hospital or staff have a device support group?

All of our patients are discharged with written instructions about their procedures and devices; this includes a combination of educational materials written by staff members and information provided by the device manufacturers. The Yale New Haven Health System is presently migrating to the Epic electronic medical record system, which will be used at all its inpatient and outpatient facilities (including member physician practices). Among its many advantages, Epic will allow all patient education materials to be standardized and available electronically for both printing and direct transmittal to patients via fax or email.

Our hospital does not sponsor a specific device support group; however, the hospital’s general cardiac patient support group, Heart Beats, Inc., is organized by, and welcomes, former cardiac patients (from any hospital), their families and friends, and all others interested in topics related to heart disease. Since 1981, Heart Beats’ educational programs have been conducted by leading local and national cardiovascular experts as well as other qualified professionals in the healthcare field. These programs focus on all aspects of cardiovascular care, including prevention, cardiac interventions, lifestyle modifications and diet. Heart Beats lectures are held quarterly at the hospital and support groups are held monthly. In addition, Heart Beats members visit current cardiac patients to provide encouragement and emotional support. The group also funds the purchase of Sir Koff-A-Lot teddy bears, which are used by patients to reduce discomfort when they sneeze or cough during recovery from surgery.

Describe your city or general regional area. How does it differ from the rest of the U.S.?

We are located in a unique geographical location. Bridgeport itself is an urban center and its residents have diverse ethnic and cultural backgrounds. Twenty miles to our northeast, in New Haven, is Yale University, with which we are affiliated. This provides our patients and staff access to the educational and clinical resources of a major academic medical center. Many of our physicians and students work and learn at both institutions. The training programs in Emergency Medicine, Surgery and Pediatrics are fully integrated with Yale. In addition, Yale faculty members provide many educational sessions at our hospital. Between Bridgeport and the New York state line lies one of the most affluent areas in the United States, encompassing the upscale communities of Greenwich, Darien, New Canaan, Wilton, Weston, Westport and Fairfield. As a result of this rather unique geography, Bridgeport Hospital serves a patient population that is remarkably diverse in its ethnicity, social fabric and financial status. This makes working here a challenging, invigorating and rewarding personal experience for all of our staff.

Please tell our readers what you consider unique or innovative about your EP lab and staff.

We are a relatively small, close-knit group who work well together. We share the burden of scheduling to make sure that each patient has a comfortable experience during their procedure. Our physicians assist each other to improve arrhythmia care in the EP lab and in our community. This collegial atmosphere has resulted in the creation of a successful arrhythmia program that has led the way in the local community for over two decades.

For more information, please visit www.bridgeporthospital.org/