Email Discussion Group: January 2010

Many of you have responded to the discussion group via our new online site at https://eplabdigest.com/ discussion-questions. See below for a sampling of recent activity.

New Question:

Cable Disorganization Our lab has an abundance of cables that often becomes tangled and inevitably damaged. Last week, damaged cable resulted in an intraprocedure delay of over 1 hour. Our Biomedical Engineers have authorized our department to contact a third party vendor for consultation. Has anyone had similar issues, and if so, how did you correct the problem? Does anyone know of a vendor that services this type of problem? — anonymous When responding to this question, please use “Cable Disorganization” in your subject line or visit “https://eplabdigest.com/discussion/Cable-Disorganization”

Under Discussion:

Distinguishing Block What are your tips for distinguishing between second-degree atrioventricular block type 1 and 2? — name withheld by request My tip for distinguishing between second-degree AV block, Mobitz type 1 and 2 on the surface electrogram is to pay close attention to the PR interval. If the PR interval varies with an occasional dropped QRS, it is type 1 or commonly referred to as Wenckebach. Specifically, the PR interval lengthens with each beat until it is blocked and does not conduct through to the ventricle. This is shown on the surface electrogram as a dropped beat. After the dropped QRS complex, the PR interval resets and the cycle repeats. In second-degree, type 2 there will be more P waves than QRS complexes. However, the PR interval for those beats that a QRS follows a P wave, the PR interval will remain constant and unchanged. The ratio of P waves (atrial activation) to QRS complexes (ventricular activation) is expressed as a ratio. This ratio may be constant or variable. Example: If a surface electrogram displays two P waves for every QRS complex and the PR interval is always the same, the rhythm would be second-degree AV block type 2 with 2:1 conduction. — D. Passey, RCIS, RCES * Editor’s note: To see accompanying images to this response, please visit: “https://eplabdigest.com/discussion-questions” AF Ablations Two physician groups at our hospital have recently recruited AF docs. We do not currently have an AF program in our EP lab. Plans have been made to purchase an ESI (St. Jude Medical) mapping system, and we use EP MedSystems. Does anyone have suggestions or a guide on how we should go about training our staff? The biggest part of learning is the plan; any help would be appreciated, especially orientation timelines, classes that would be helpful and/or books that could be helpful for the beginner staff. We currently do more simple ablations (i.e., atrial flutter, SVT, WPW). — anonymous I currently work at a facility that does AF ablations. I am a registered nurse. We use ESI and have EP MedSystems. (We also use Carto.) We trained ourselves and have maintained a standard AF set up, so I cannot guide on training lengths; speak to ESI and EP MedSystems and see what classes they can provide. Standard AF set up: Patient prep: NavX pads, NPO after midnight. The odd case is done under anesthesia. Defib pads on everyone, 12-lead EKG, hemodynamic monitoring, 2 peripheral IV, 20g minimum, one for IV heparin and one for sedation (we do all fibrillations under conscious sedation), Foley urinary catheter (for very long cases), start with a nasal cannula oxygen but have a 100% mask available, grounding pad to right scapula and abdomen. Table prep: 3-4 sheaths depending on what the doctors want: minimum of 3, 6Fr for a CS catheter, two 8Fr, will be exchanged over to transseptal sheaths. Heparinized saline, contrast, and normal saline for fluid. Two pressure tubings, transseptal needle, two transseptal sheaths (we use the Bard Channel FX, and they also have great training classes), Toray wire. As far as pulmonary vein catheters, we use Bard's Orbiter PV and also Biosense Webster's Lasso (both are 20 poles). The other catheter is an ablation of choice...we use ThermoCool (NaviStar/Carto) and with ESI we use the Chilli II. Expect a long procedure, we do ACT monitoring every 20 minutes, run our ACT's 275-300. Post-procedure echo is a standard for us, to R/O effusion. Sheaths are removed for an ACT of 180 or less; patient is on bedrest a minimum of four hours after sheath removal, and the patient is admitted to our Interim Coronary Care Unit post procedure. I hope this is helpful. — D. Acorn ICD Patient Protocol I am looking for information and policy and procedures regarding handling of patients in the gastroenterology lab who have implantable cardiac devices, particularly ICDs. Are company reps being called in, or does the staff use magnets to pause the ICD? Any information would greatly be appreciated. — name withheld by request First consult your hospital policy and procedure. Since the OR usually has an existing policy, start with understanding what is current at your facility. Then be sure your staff receives the appropriate education including Magnet use and the therapies involved when a device rep or appropriate hospital staff member is called. My choice is always Magnet use if possible. — B. Trollinger, RN, RCIS, FSICP Scope of Practice I am looking for a detailed "Scope of Practice" for the EP/cath lab. I do have the scope of practice offered on the SICP website. — John J. Simon III, MBA RT (CV) RCC The scope of practice for your lab will depend on several variables, including state law (nurse practice acts and the like), hospital policies, physician expectations and comfort levels, and the experience level of your staff. In our institution, our techs function at a very high level. We are a mid-sized community hospital and do not have fellows on staff, so our techs perform many duties that fellows usually perform at academic institutions. This includes things like closing pockets, inserting arterial and venous sheaths, inserting diagnostic catheters, watching and calling screens, operating the stimulator box, operating Carto/ESI (with and without company reps present) and working up data. Of course, not all the techs perform all those functions, and no one does anything without adequate experience and extensive training, and everything is done under the auspices of the physicians. In addition, many staff members have IBHRE certification and/or RCES credentialing (or are planning to) and we are now requiring all new hires to achieve RCES credentialing within two years of hire. The majority of our techs have completed our EP Internship (a six-month didactic and clinical orientation), during which they were trained to perform at the level expected in our lab. Everyone is not an expert at everything, and some have special areas of interest and/or expertise. If you have fellows on staff, that will most likely limit what your techs can do. Also, some states have regulations allowing only x-ray techs to operate x-ray machinery. Hospital policies may also restrict what techs can do. And if you have a lot of inexperienced people, they are not going to be able to function much above a fairly basic level until they have a year or so of full-time employment in the lab, regardless of what the scope of practice says they can do. So, long story short, the scope of practice for one lab may be very different than the scope of practice in another. It is fine to spell out minimum knowledge/experience requirements, but in reality, there are many variables that impact what EP techs know and how they practice. — name withheld by request Startup Policies & Procedures Our hospital is planning to start an EP program. I am interested in corresponding with EP lab coordinators willing to share information and/or basic policies and procedures in relation to startup efforts. The EP lab is set up, but has been on standby while an EP physician is being sought. Given the possibility of an accelerated startup, I am reaching out for resources and information. Although I have a number of years’ experience in EP, I have been out of the specialty a few years. I will welcome the input and exchange once again with other EP professionals. — T. Trahan, RT(R), Florida I just recently came into a lab and started an EP program. I was 'gifted' with 3D mapping systems and catheters that the hospital had bought 18 months before when they originally tried for an EP program. However, my hospital has been very willing to take my suggestions on what further equipment and supplies to purchase. If you are the only EP person there and need to do basic training, often the EP supply companies can give inservices. I will assume you have an empty room and supply closet. You will need biplane x-ray. You can do it without biplane, but I feel it limits your level of complexity for cases. More radiation and time per case. To start, use one brand of catheters for diagnostics (a,h,v) as this limits expense of maintaining two different inventories, and eventually just one brand will be principally utilized anyway. Select a generator that is the most flexible and can grow with your program. I recommend 100 watt. You won't use high watt often, but it’s there when you need it. Call and see if Bard or Prucka or Bloom will come to you with a loaner or if you can go to them to evaluate. My docs seem to have strong opinions on the selection of recording systems and could impact your practice. Have an idea of how long a procedure lasts, make sure the docs agree. Factor in turnaround time. Use OR standards for sterility. Good luck. Remember, the things you do now will be the reason they do them later. — R. Bennett, RT(R)