Email Discussion Group: April 2009

Readers, the hot topic this month is on the subject of late cases — it has definitely struck a chord with many — just look at all the responses! Take a look at the questions below and let us know if you can help answer any of them. You can respond by emailing us at eplabdigest@hotmail.com or also by visiting us at www.eplabdigest.com. Remember, when responding to the discussion group, don’t forget to let us know if you would like your name and/or location listed.

New Question:

Digital Case Storage We’d like to know what other labs are doing with all the digital media generated in their EP labs. We have cases stored on CD for Carto, EnSite and Prucka. Does anyone have a policy regarding how long this information needs to be kept, and what type of storage is being used? — Lauren A. Crooks, RN, Sisters of Charity Providence Hospital, Electrophysiology Lab, Columbia, SC (To reply to this question, please type “Digital Case Storage” in your subject line.) We are moving to a server that will accept all of the case information from both labs. This is not up and running yet. It is coming with our new EP lab recording system that was recently purchased. Once you have a report published in the patient’s medical record, I don’t know if you are legally bound to keep the case data. If you think about it, EPs are the only ones who would understand the data. We do keep the data basically for research purposes. — Dale R. Beatty, RN, MS, Manager, EP Lab, Northwestern Memorial Hospital, Chicago, IL

Under Discussion:

Late Cases We have a busy lab, and it seems to us that complicated cases are being added or done even at the later part of the day. I wanted to know if there are any labs out there that have a policy or standard regarding late cases that are being done or added on at a later part of the day, especially complex ones. Do you have a limit or cut-off with your cases per day? If so, may we take a look at your policy regarding this matter? — name withheld by request (To reply to this question, please type “Late Cases” in your subject line.) At Columbia, we have 4-7 "day RNs" that work 7am-7:30pm and 2-4 "night RNs" that work 10am-10:30pm. Since we do not cross-cover Cath, nor do we take call, we have to stay until cases are done. Having said that, as a rule we usually don't start cases after 7:30pm unless we are swamped. We have two rooms, so if both rooms run late, the day RNs rotate "staying late" if necessary. As for the complexity of the case, we generally will not start a complex case after 7pm. We perform 3-4 AF ablations a week, so the second case is usually a congenital AFL or an SVT. In rare cases we do three RFAs in one day. The third case is hardly ever a complex case, though, due to threat of staff fatigue. We usually will not have a "cut off" per se, but will base our decisions to add on complex RFAs based on the present schedule. Most complex RFAs are pre-scheduled anyway, and "the Chief" will give us fair warning of heavy days on the horizon. Also, the attending is required to buy dinner for the nurses for any case started after 7pm! — Edmund Donovan, Clinical Nurse II, New York Presbyterian Hospital-Columbia If someone comes up with an answer for this that won't upset everyone, it would be great. We have 3 docs that work in 2 different hospitals, and it all depends on where they start which hospital gets the late cases. I am the only EP nurse here, so frequently I am here at 6am to start a case with one doc, who then goes to the office only to have another doc come in and start an ablation at 4:30pm. UGH. — Name withheld by request Our lab has a general policy that no patients are to be put on the table after 6pm. There are many factors that have to be considered, though, and so there are occasional exceptions to that. Complicated cases are included in that general rule, but for those cases anesthesia coverage frequently comes into the mix as well. We currently are doing about half moderate sedation and half anesthesia (MAC and general), although that ratio fluctuates. Our issue is that we only have an anesthesia provider available until 5:30pm. That means that the case is supposed to done by 5:30pm (there is a little bit of wiggle room there, but not much). So if we have a complicated case that requires anesthesia coverage, and it will not be done by 5:30, it will most likely not be put on the table. If it is a sedation case (those are handled by our sedation RNs), that is another matter. We have a “call” team here everyday that stays until the cases get done, so staffing is not generally an issue. Sometimes, though, the physician will simply say that he/she does not want to start the case late in the day. Additionally, if the case is a lead extraction, we may not have an OR window until later in the day. If the leads have been in a long time, and the physician thinks it might be a long or especially difficult case, they may postpone it until they can get an earlier window, but that is not always the case. — Sue Deck, BS, RN, RCES We have two labs. Basic hour of operation is until 1730. We have one late shift that will keep a lab open until the cases are finished. We don’t have any hard and fast rule on how late cases can run. Our record is probably 1230am. This is rare for us, a couple times a year staying that late. — Dale R. Beatty, RN, MS, Manager, EP Lab, Northwestern Memorial Hospital, Chicago, IL Placing complex cases on as last case or adding a complex case at the end of the day has become a more common practice lately. We currently have no policy in regard to how late a physician can add a case on, despite multiple requests. A previous manager in our unit developed a grid that listed every procedure and the "approximate" length of the procedure in its entirety. Cases were then scheduled to fit into a 12-hour day; obviously exceptions would have to be made on occasion, but generally it gave the lab and physicians a format to operate by and lent some organization to what can be a very hectic and unpredictable schedule. Unfortunately, when that manager left, the scheduling grid apparently left too. We have been unable to locate a copy, and attempts to simply reproduce and re-instate this practice have been lost in frequent changes of management or just plain stalled. I suggest, as we are going to continue to press for in our unit, forming a committee to study and offer evidence-based approximation of procedure times followed by cooperation from the physicians in coordinating the placement of the cases on the schedule so as to facilitate an organized and smoothly run lab. Everyone knows that in healthcare, late cases are just part of it, the needs of the patient dictate the length of the day and rightly so. But it is also true that in most instances, the scheduling of the cases could be done in a more efficient manner. Is it fair to say that the late cases are usually the exception, not the rule? It seems that if late cases were the rule, a second shift would have been created. The above-mentioned scheduling procedure worked well; all sides have to be onboard, though. — name withheld by request Patient Care What suggestions can you offer in helping with patient care in the EP lab? For example, how do you help patients relax before an EP procedure? Also, what techniques do you use during procedures to make sure everything goes smoothly? (To reply to this question, please type “Patient Care” in your subject line.) EP and the Economy Has your EP lab been affected by this economic downturn? How is your EP lab staff managing? What changes, if any, are being made? (To reply to this question, please type “Economy” in your subject line.) Abandoned Leads New research reveals that abandoning a nonfunctioning lead in an ICD patient is safe and does not pose a clinically significant risk of complication. This study also suggests that lead extraction should be reserved for cases of system infection or when large numbers of leads have been abandoned. How does your lab handle the practice of abandoning leads? Is lead extraction always performed for lead malfunctions? (To reply to this question, please type “Abandoned Leads” in your subject line.)