East Carolina Heart Institute at Pitt County Memorial Hospital

What is the size of your EP lab facility and number of staff members? Our EP lab consists of 1 bi-plane Philips lab and 2 single-plane Philips labs, a Tilt room, and the pacemaker clinic. We also share a Philips bi-plane cath lab when a fourth lab is needed; this lab is equipped to perform cath or EP procedures. We have six electrophysiologists who are a mix of private and academic physicians. One of our six EP physicians is a pediatric electrophysiologist. We employ 7 RNs (8 including a manager), 10.5 CVTs, and a technical assistant. What is the mix of credentials at your lab? All nurses are RNs. All CVTs are RTs, except one who is a respiratory therapist, who is cross-trained to function as an RT. Our technical assistant has a certification as a nurse aide II (care partner). When was the EP lab started at your institution? Our first EP lab was established in 1987 by Drs. Rehan Mahmud, electrophysiologist, and Dr. William Reeves, chief of cardiology at the time. Dr. Harry DeAntonio is our current chief of cardiology, and Dr. David Frazier is our EP lab medical director. What types of procedures are performed at your facility? We perform pacemaker, ICD, BiV ICD and BiV pacemaker implantations, EP studies, loop recorder implants/explants, device change-outs, all types of ablations (including atrial fibrillation [AF]), advanced 3D mapping with EnSite systems, ICE procedures with Boston Scientific’s iLab system and Siemens Acuson, tilt table studies, modified temporary pacemakers, and SAECGs. We use both radiofrequency and cryo for our ablations. Eventually, we will add the TandemHeart procedure to our list (training will start soon). Cardioversions and ICD tests are done at bedside; these are not routinely performed in the EP lab. Approximately how many are performed each week? Last year our volume was 1,751 patients/2,432 procedures, which averages out to ~34 patients/48 procedures per week. What is the primary goal of your program? As a regional EP referral center for 29 counties, our goal is to offer a full complement of dysrhythmia treatment services to patients across the life cycle. We perform a mix of device and ablation procedures based on patient need. Some electrophysiologists also collaborate with cardiac surgeons for optimal treatment approaches. Who manages your EP lab? Shannon Abbott, RN is the manager of the EP lab and echo lab. Formerly a staff nurse and supervisor of the cath lab, she has worked with cardiac patients for nearly 20 years. A dedicated charge person handles daily operations in the EP lab. Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained? Yes, the EP lab is separate from the cath lab. The two departments have been separate since the beginning of each of these programs. Many EP staff transferred from the cath lab in the past, but they are not presently cross-trained to work in the cath lab. Do you have cross training inside the EP lab? What are the regulations in your state? Most RNs are able to circulate any case. At present, only one RN is able to scrub devices. CVTs cannot perform RN functions in our lab. Only RNs document in the patient’s electronic medical record and administer medications. Only RNs are allowed to administer medications in our hospital. RNs must remain with patients who are monitored (in the room and during transport). What new equipment, devices and/or products have been introduced at your lab lately? How has this changed the way you perform those procedures? The newest equipment/procedure that has been initiated in our EP lab is the TandemHeart. We are in the training process and will soon begin supporting high-risk, complex ablations with this product. The TandemHeart should allow us to perform higher risk ablations with less risk of adverse complications. Who handles your procedure scheduling? Do you use particular software? Our hospital has a centralized scheduling system. Physician office staff fax or call patient information to Patient Scheduling, and the patients are placed on our computerized schedule. Our hospital uses Cadence, which is part of EPIC. What type of quality control/quality assurance measures are practiced in your EP lab? Measures practiced in our lab include labeling of bowls/syringes on and off the sterile field, patient identification and timeout checks before procedures, lead apron checks, dosimeter readings/high fluoro times. We also track, report, and look for solutions to infection issues (which are very rare). How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? Supplies (catheters, cables, sutures, etc.) are ordered through Pyxis supply stations. Devices are handled manually between the manager and vendors. Devices/leads are bought as bulk purchases or are paid for at the end of each month. A dedicated CVT oversees the supplies in the Pyxis stations and handles back-orders, etc. The manager handles purchasing of devices, leads, and equipment. Has your EP lab recently expanded in size and patient volume, or will it be in the near future? Our patient volume has been stable and relatively flat the last two years. Is your EP lab part of a separate “heart hospital”? Yes, in January 2009, we moved into our new East Carolina Heart Institute at Pitt County Memorial Hospital (PCMH), which is connected to the main hospital. We moved our newest single-plane lab over to our new area and obtained a new single-plane and a bi-plane lab. How has managed care affected your EP lab and the care it provides patients? We remain committed to providing safe, patient-centered care. Managed care has prompted us to routinely seek opportunities to control supply and device expenses. Have you developed a referral base? PCMH, part of an eight-hospital network of University Health Systems of Eastern Carolina (UHS), provides EP services for the entire system. We also serve as an EP referral center for the 29 counties of eastern North Carolina. What measures has your EP lab implemented in order to cut or contain costs? We participate in resterilization programs, competitive pricing programs and bulk purchasing options, as well as use Pyxis supply to assist with inventory management and track expiration dates. In addition, in what ways have you improved efficiencies in patient through-put? We work closely with physicians, their office schedulers, and our Cardiovascular Outpatient Unit to plan the order of patients each day and minimize patient wait times. Does your EP lab compete for patients? Has your institution formed an alliance with others in the area? PCMH serves as a referral center for all of eastern North Carolina; other regional programs are within 60-90 minutes from us. We are part of an eight-hospital system; we own, lease or manage all of these facilities. How are new employees oriented and trained at your facility? After new employees complete general hospital orientation, they are assigned a preceptor in the EP lab. Experienced nurses typically need six weeks of orientation. Due to the highly technical duties of the CVTs, their orientation is approximately six months. What types of continuing education opportunities are provided to staff members? Staff participate in hospital in-services and continuing education programs, as well as training provided by physicians and vendors. How is staff competency evaluated? Staff competency is evaluated during and at the end of orientation. Staff are checked for competency with equipment, policies, and procedures on an as-needed or annual basis. All EP staff members are required to complete BLS, ACLS, and PALS courses every two years. How do you prevent staff burnout? We promote a healthy work environment by relieving staff during lengthy cases, and equitably rotating scheduled late days. Teamwork is promoted as well as positive attitudes and humor. Do you practice any team-building exercises? We enjoy occasional group dinners to celebrate special events and participate in an annual holiday social. We have also held a softball game and holiday parties with other cardiac units. What committees, if any, are staff members asked to serve on in your lab? EP lab staff members serve on many hospital and unit committees, such as patient satisfaction, nursing congress, staff advisory, patient safety, recruitment and retention, unit educator, quality initiatives, and the peer interview committees. Several EP staff also serve as ACLS and BLS instructors. How do you handle vendor visits to your department? Do you contract with vendors? Vendors are present for every procedure involving a device (e.g., new implants, change-outs, lead revisions, etc.). Other vendor visits are by appointment only. Yes, our product purchases are based on pricing agreements approved by our material services and legal departments. Does your lab utilize any alternative therapies? Yes, some physicians use music during procedures. Describe a particularly memorable or bizarre case that has come through your EP lab. What lessons did you learn from it? We performed an extremely complex ventricular tachycardia ablation on a very sick patient who was on high doses of antiarrhythmics, who had received multiple ICD shocks for several days. This lengthy affair involved various catheters and multiple ablation burns with short runs of VT, but in the end, the ventricular tachycardia was terminated. The patient did not require a single shock throughout the entire procedure. He actually was discharged home shortly thereafter. 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? Our EP lab does not use a call schedule. We have two late teams stay to finish the day’s caseload. Volunteer teams are used for the rare weekend or holiday cases. There are three staff members for each case/procedure, with at least one RN and one CVT present. Does your lab use a third party for reprocessing? How has it impacted your lab? We have recently started reprocessing our diagnostic and ICE catheters with an outside vendor. We use in-house reprocessing for our cables and surgical instruments. These efforts have resulted in less expense cost. Approximately what percentage of your ablation procedures are done with cryo? What percentage is done with radiofrequency? Most of our cases are done with radiofrequency ablation (~90 percent). Only about 10 percent of cases are done with cryo. We often use cryo when we are working close to the AV node. Cryo is also used more frequently in our pediatric cases than adult cases. How many pediatric cases on average do you perform? Is there cross training for pediatric cases? We perform both adult and pediatric EP studies, ablations, and device implants. We performed about 60 pediatric cases last year. All EP staff are trained to help with pediatric procedures. All EP staff complete a PALS course every two years. What measures has your lab taken to minimize radiation exposure to physicians and staff? Fluoro is kept on “low-dose” and catheter signals are used during ablations instead of fluoro whenever possible. Physicians may use the RADPAD® (Worldwide Innovations & Technologies, Inc.) on lengthy procedures as needed. Each staff person and physician wears his or her own lead apron. Lead shields and glasses are available for staff to use as well. 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? Yes, our RRT/CVT staff conducts an in-hospital pacemaker clinic and interrogates pacemakers and loop recorders/ICMs. ICD follow-up is done in the physicians’ offices. We see 30-40 patients per week in the pacemaker clinic. We have a Medtronic Paceart® System for device follow-up in our clinic. Clinic pacemaker patients are tested and reports are forwarded to the patient’s physician for sign-off. Our medical director also oversees the pacemaker clinic daily. There is a physician in close proximity if needed. What trends do you see emerging in the practice of electrophysiology? How is your lab preparing for these future changes? The most dominant trends we see are AF ablations and CRT device implants. We will be upgrading our 3D mapping system to the newest version and our cryo consoles have been upgraded to accept the cryoballoon (when it is released for use). We are hopeful both of these measures will increase safety and decrease procedure time for AF ablations. We continually work with our vendors to decrease pricing for CRT devices so we can reduce patient costs. What are your thoughts about non-EPs implanting ICDs? Do you train such individuals? Only EP physicians implant ICDs in our labs, as they have the proper training to implant, program, and provide proper follow-up for these complex devices. We do not provide training to non-EP physicians to implant ICDs. What about device recalls? How has your lab handled these? Vendors promptly notify us about recalls. The physicians, our risk management and finance departments are informed, and appropriate actions are taken based on the physicians’ and/or the device company’s recommendations. We follow the guidelines as instructed and pull product from our shelves, return product, perform device change-outs, provide credits, etc. Is your lab doing web-based/ transtelephonic device follow-up? We are in the beginning stages of performing follow-ups with St. Jude Medical’s Merlin.net and Medtronic’s CareLink. Is your EP lab currently involved in any clinical research studies or special projects? Our EP lab is not currently involved in any research studies. Are you ACGME-approved for EP training? Presently, we are not ACGME-approved for EP training. 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? Patients receive discharge and other post-procedure information in the unit from which they are discharged. Currently, there is no in-hospital pacemaker or ICD support group. Give an example of a difficult problem or challenge your lab has faced. How it was addressed? Scheduling is one of our biggest challenges (e.g., when MDs compete for lab time). This is accentuated by lengthy EP procedures. EP shares a fourth lab with the cath lab when needed. Describe your city or general regional area. How does it differ from the rest of the U.S.? PCMH is located in Greenville, North Carolina. Greenville has a population of about 84,000 residents and is considered a “college town” due to the East Carolina University campus downtown. Our hospital was once surrounded by tobacco farms, but is now dominated by physicians’ offices, banks, and apartments. PCMH is the flagship hospital for University Health Systems of Eastern Carolina (which owns, leases or manages eight other hospitals) and is the third-largest hospital in North Carolina. PCMH is an 861-bed, private/not-for-profit, level 1 trauma center that serves 29 counties in North Carolina. We are a referral center for patients from the borders of Virginia to South Carolina and from Raleigh to the coast. Most of these counties would be considered very rural. PCMH serves as the teaching hospital for the Brody School of Medicine at East Carolina University. PCMH is a teaching site for medical students and residents, nurses, and other health professionals. At PCMH, we serve both private and academic physicians. Research and education are a huge part of our hospital’s mission. There are more than 800 physicians and 1,600 nurses at PCMH. We see about 39,000 inpatients and 266,000 outpatients per year. More than 3,800 babies were born here last year. Some of our most recent awards include: Working Mother magazine awards PCMH as a top 100 job site for working mothers, PCMH is on the list for “Most Wired” hospitals, certified stroke center, accredited chest pain center, Joint Commission accredited hospital, accredited rehabilitation facilities, and our echocardiology department is accredited in adult echo, adult stress testing, adult TEE, and pediatric echo. PCMH will also be applying for Magnet certification later this year. In addition to its numerous ground transport vehicles, PCMH’s EastCare has three air flight ambulances to transport critical patients by air. Please tell our readers what you consider unique or innovative about your EP lab and staff. Our EP lab staff is a well-trained, extremely intelligent team who are impressively dedicated to their professions and their department. They are compassionate not only with their patients, but also with each other. We work with skilled physicians who are experts in the field of electrophysiology, and strive for safe, quality outcomes for our patients. Our EP lab staff and physicians are truly incredible people who are committed to providing incredible care … every day. For more information, please visit www.eastcarolinaheartinstitute.com/