Creating a Blueprint for EP Service Expansion: Experience From St. Luke’s

As the only Idaho-based, not-for-profit health system, St. Luke’s Health System has been a part of the communities we serve since 1902. Each St. Luke’s Health System hospital is nationally recognized for excellence in patient care, and St. Luke’s Regional Medical Center’s EP services are consistently rated among the best in the country. For the fifth consecutive year, St. Luke’s was ranked in the 50 Top Cardiovascular Hospitals by Truven Health Analytics; St. Luke’s was also ranked by Healthgrades as one of America’s 100 Best Hospitals for the specialty of Cardiac Care. Additionally, St. Luke’s received the 2015 Healthgrades Outstanding Patient Experience Award, and is a three-time Magnet designee by the American Nurses Credentialing Center as a Magnet Recognition Program. 

With the population in Boise and the surrounding areas expected to nearly double in the next 15 years, St. Luke’s plans to modernize and expand its medical center in Boise to meet the health care needs of the local and regional areas. This Boise “Master Plan” includes a new heart hospital. High-quality healthcare, state-of-the-art technology and facilities, and high-caliber medical professionals are what the people of the Boise and surrounding communities deserve. St. Luke’s Regional Medical Center is already at or near capacity. Our first and foremost priority is the needs of our patients. The heart hospital is a “Master Plan” we are proud to continue working toward; plans for the heart hospital included an expansion of our electrophysiology services. 

“Prescription for Change” is a term coined by the president and CEO of St. Luke’s Health System, Dr. David C. Pate. This term can also be used to describe the electrophysiology services within St. Luke’s Heart Hospital, since the blueprint for the heart hospital is to develop our rapidly growing EP service line. St. Luke’s is community owned and operated, and as the need for expanding cardiovascular services and new technology has grown, so has the need to expand our electrophysiology services. EP services originated inside the St. Luke’s Regional Medical Center’s cardiac cath lab in 1991, with device implantation being the primary procedure performed. Since that time, a standalone EP lab was constructed and new procedures were added. In 2013, St. Luke’s recognized the EP lab was at 64.6% utilization most days and 79.25% on other days. At the same time, we were facing an increasing trend of atrial fibrillation cases, the need for new technology, and ablations with cardiovascular studies. With engaged physicians and administration working together, a strategic assessment of the electrophysiology program was conducted and an aggressive strategic plan was developed. Careful consideration was taken into account regarding the patient experience, financial support, and value of the procedures added to the communities we serve.  

Plans for The Heart Rhythm Center

The strategic plan for the Heart Rhythm Center included adding an EP lab, electrophysiologist, and advanced technologies and procedures. A dedicated Heart Rhythm Center was needed to enable our electrophysiologists to centralize the outpatient care of patients to one convenient location. The center opened in December 2013. It was the start of the blueprint to build on a growing program that was needed to serve the people of the surrounding Boise communities. It is a comprehensive service that includes close monitoring of a patient’s before and after treatment, as well as procedures such as tilt testing, device interrogation, and regular follow-up care.

A New EP Lab

The need for another EP lab was reviewed by administration, physicians, and staff. St. Luke’s Regional Medical Center and St. Luke’s Meridian Medical Center had a total of six labs. Of those six labs, only one was a designated EP lab, and another underutilized cath lab was used intermittently for device implants and storage. This underutilized lab did not add financial value to the organization. The first option was to expand EP services to the Meridian facility; however, this was not an economical choice for the program. The alternative option was to more frequently use the underutilized cath lab for EP procedures. Initially, that was the agreed-upon decision. The underutilized cath lab room was converted into an EP procedure room, and supplies and equipment were added to resemble the first EP lab. In the first year of developing and implementing this plan, procedures such as ablations, catheter-based therapies for atrial arrhythmias, device implantations, 3D electroanatomical mapping, and intracardiac echocardiography were performed. However, this lab soon became a shared lab for diagnostic and interventional pediatric cardiovascular procedures — it was not a feasible combination for procedures that required anesthesia resources. Cases were lengthy and the procedures consistently overlapped on the schedule, causing delays for procedures that followed one another. Understanding the delay for the procedures or continuing with a lab that was not to its full functionality, the decision was made to reassess the need for a new lab. In 2014, St. Luke’s administration and physicians made the decision to purchase a new EP lab. In November 2014, the new EP lab opened (Figure 1).

Adding an Electrophysiologist

While determining the need for a new EP lab, an assessment was also being made for an additional EP physician. Again, with the population of our communities growing at a significant rate, patients were on a waiting list for various EP procedures. Building a program with highly skilled physicians is a task that Dr. Marshall Priest, Executive Medical Director at St. Luke’s Heart, and David Bishop, Administrator at St. Luke’s Heart, take pride in. Developing an aggressive and strategic plan for a strong electrophysiology program included assessing skill sets and expertise in additional EP procedures. Although advanced technologies and procedures were at the forefront of providing a better patient experience and growing the program, Dr. Priest also wanted the cardiologists, surgeons, nurses, and other caregivers to have great relationships with patients, St. Luke’s leadership, and partners in the community. It was important to maintain a similar level of like-minded peers and attract exceptional physicians that could build a quality program. The electrophysiology lab was no different. In September 2014, Drs. Marcos Daccarett, Danny Noonan, and Mindy Marks were joined by Dr. Joshua Mozes (Figures 2 and 3). Together, they have initiated a rigorous protocol for atrial fibrillation ablation and other EP procedures that have far exceeded the expectations of patient care and treatment. 

The Need for Advanced Technology

Included in our strategic plan to expand EP services and improve the quality of the patient experience meant that our scope of practice needed to feature more advanced technologies as well. Ablations for all types of supraventricular arrhythmias as well as ventricular arrhythmias, including ventricular tachycardia of both ischemic and non-ischemic etiologies, were already being performed in the EP lab. Additionally, catheter-based therapy for all atrial arrhythmias (including right and left atrial flutter), as well as ablation of paroxysmal and persistent atrial fibrillation, were a part of patient care. Implantation of devices, such as pacemakers and defibrillators as well as loop recorders, was also being performed. 

More advanced services were also added, including 3D electroanatomical mapping, intracardiac echocardiography, and different ablation technologies such as open and closed irrigation radiofrequency ablation. In the last year, we began utilizing an insertable loop recorder that does not require anesthesia and can be injected into the patient with its preloaded functionality. This monitor allows patients to be discharged within minutes of the procedure. We have also recently introduced an advanced mapping system that allows for more detailed and clearer signals. In addition, because of our center’s rigorous protocol for atrial fibrillation ablation, none of St. Luke’s patients have experienced a stroke as a result of an ablation procedure. It is our goal to continue this quality accomplishment by also implementing a new device called the WATCHMAN Left Atrial Appendage Closure Device (Boston Scientific), which is used for patients with atrial fibrillation who are at risk for stroke from embolization of a blood clot from the left atrial appendage. 

Final Thoughts

The goal for expanding St. Luke’s EP services was to provide a comprehensive program. This was accomplished through the quality of work from our physicians, nurses, and administration. Creating a successful EP program is not just about the lab itself — it also means having highly skilled techs and nurses that work in close collaboration with the physicians, hiring physicians who go beyond their passion of medicine, and ensuring the most advanced technologies are available to the patient. It is part of the blueprint for a total patient experience.