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Spotlight Interview: Johns Hopkins Heart and Vascular Institute
The physicians and staff of the Johns Hopkins Heart and Vascular Institute work diligently around the clock to provide the highest quality of comprehensive care and the most cutting-edge treatments for their patients. The cardiovascular and electrophysiology 
laboratories at The Johns Hopkins Hospital consist of 11 procedural suites — five dedicated cardiovascular suites and six dedicated electrophysiology suites, one of which is noninvasive and one of which is a cardiac MRI suite. Both electrophysiology and cardiovascular service lines have Operating Room hybrid procedure suites
These hybrid labs provide a mutually conducive environment for complex procedures.
In April 2012, the Johns Hopkins Heart and Vascular Institute moved into its new location (https://tinyurl.com/mgl3g39) in the Sheikh Zayed Tower. The Institute includes cardiology, cardiac surgery, vascular surgery, and imaging services. Previously, these services were located on different floors and sometimes in different buildings on our historic campus. The move was an unprecedented task that required years of forethought and planning.
The Johns Hopkins Arrhythmia Service began in the early 1970s with three goals in mind:
- To provide leading-edge clinical care for patients;
- To conduct research to determine the cause of arrhythmias and to develop therapies for patients who have arrhythmia-associated medical problems;
- To train the next generation of thought leaders in arrhythmia management.
As the first such service in Maryland and one of the first in the United States, the Johns Hopkins Arrhythmia Service rapidly took on a leadership role. An early success was the development and use of the first implantable cardioverter defibrillator. In 1980, Levi 
Watkins implanted the first automatic implantable cardioverter defibrillator — invented by Michel Mirowski and Morton Mower — in a patient at The Johns Hopkins Hospital who had experienced numerous episodes of life-threatening arrhythmias.
What is the goal of your lab?
The goal of the Johns Hopkins electrophysiology lab is to provide our patients and customers with optimal treatment options performed by world-renowned physicians. The lab strives to provide patients with timely and accurate diagnoses and therapies. As an academic institution, we are also committed to teaching future generations of academic and clinical electrophysiologists.
Tell us about the size of your electrophysiology lab facility. How many staff members are there? What is the mix of credentials at your lab?
When we moved to our new clinical space, we expanded our service line from 2.5 dedicated invasive procedure rooms to four dedicated invasive procedural suites, plus one noninvasive room. We also added a 1.5T cardiac MRI scanner to be used for MRI-guided ablations in the near future.
Our staff includes 14 radiologic technologists and 11 nurses. The majority of radiologic technologists have earned their advanced certifications (CI, CV, RCIS, RCES). Many nurses have earned their cardiac vascular and critical care certifications as well.
Who manages your lab?
Due to the larger than average size of our workforce, we have a separate nurse manager and radiologic technologist manager. Christina Staten is the radiologic technologist manager and Kim Sweitzer is the nurse manager.
We are honored to be led by our medical director, Hugh Calkins, the immediate past president of the Heart Rhythm Society. He has published over 450 articles in prestigious journals and is renowned for his contributions to the field of electrophysiology. Most notable are his contributions to the fields of arrhythmogenic right ventricular dysplasia (cardiomyopathy), atrial fibrillation, and catheter ablation. He is dedicated to fostering an environment of academic and clinical excellence here at Johns Hopkins.
Additionally, we have a dedicated inventory manager, Kelly Hagin. All clinical managers report to Kevin Hsu, the administrative director of invasive cardiac services.
Have you recently upgraded your imaging technology?
Two Philips biplane rooms were purchased for our expansion into the new clinical building. These rooms are equipped with FlexVision 56-inch monitors (Philips) and Carto 3 mapping systems (Biosense Webster, Inc., a Johnson & Johnson company). The other two rooms are equipped with biplane GE imaging equipment that was repurposed from our old clinical space.
All four electrophysiology labs have 3D mapping capabilities, doubling Johns Hopkins’ capacity to perform complex ablations. Currently, we utilize the Stereotaxis Odyssey archival system to store data from all imaging modalities used during a case — ultrasound, X-ray, 3D mapping, electrograms, and event logs. We utilize the captured data for daily conferences and academic discussions. Large screens and audiovisual upgrades will allow for the future broadcasting of procedures, which will provide learning opportunities for medical students, fellows, and junior faculty across Johns Hopkins campuses.
Our hybrid suite functions as an electrophysiology lab or cardiac operating room as needed. This capability allows for a greater flexibility of treatments based on the needs of our patients. We most often utilize our electrophysiology hybrid room for lead 
extractions that can require emergent surgical intervention. We also perform the LARIAT (SentreHEART, Inc.) appendage occlusion procedure in the electrophysiology hybrid room.
What types of procedures are performed at your facility? Approximately how many are performed each week?
We perform an average of 60 device cases (implants and extractions) and 110 ablations per month. Our endocardial and epicardial ablations include SVT, idiopathic and ischemic VT, and atrial fibrillation ablations. We also perform cardioversions and tilt table tests in our noninvasive procedure room.
At Johns Hopkins, we work with national and international teams to care for patients and conduct research. Our Arrhythmogenic Right Ventricular Dysplasia (Cardiomyopathy) Program, which was founded 15 years ago, has emerged as the leading program in the United States. Each year, several hundred patients travel to Baltimore to be evaluated and/or treated for cardiomyopathy. During their one- to two-day visit to Baltimore, they undergo a comprehensive evaluation for cardiomyopathy and are also seen by a 
genetic counselor who specializes in this condition. We currently perform epicardial VT ablation procedures for arrhythmogenic right ventricular dysplasia on a weekly basis.
Other major areas of research and clinical interest include magnetic resonance imaging to facilitate electrophysiology procedures. Our program played a pioneering role in the approach of using MI-based scar to guide VT ablation procedures. Another area in which we played a pioneering role is demonstrating the safety of performing magnetic resonance imaging in patients with implanted devices. Henry Halperin and Saman Nazarian have led the MRI program and the work on MRI screening and device scanning.
Jane Crosson is our dedicated pediatric electrophysiologist; she performs electrophysiology studies and ablations on our pediatric patient population. Crosson is the director of the Pediatric Electrophysiology Service and co-director of the Adult Congenital Heart Disease Program at Johns Hopkins.
Does Johns Hopkins have an electrophysiology fellowship training program?
The Johns Hopkins electrophysiology fellowship program, directed by Ronald Berger, is a two-year track, with three fellows in each year. We have trained over 50 electrophysiology fellows in the past 20 years, many of whom are electrophysiology directors at 
their respective institutions. In the Johns Hopkins electrophysiology program, all invasive cases are staffed by a dedicated electrophysiology fellow working side by side with a member of the electrophysiology faculty. Fellows also participate in and lead clinical research projects in the electrophysiology labs.
How is inventory managed at your lab? Who handles the purchasing of equipment and supplies?
Kelly Hagin is our inventory manager. She has a team of dedicated electrophysiology inventory specialists who meet the various demands of our department. They oversee supply usage of assigned procedure rooms and storerooms, perform visual inspection of supplies for proper rotation of inventory using the First In, First Out model, perform supply cycle counts to eliminate discrepancies, and collaborate with clinical staff on a daily basis to address supply needs.
Capital equipment is purchased through a collaborative effort between clinical leadership, physician leadership, and materials management. Disposable supplies are purchased through the SAP program. All supplies are managed via SAP with minimal par levels and maximum stock needed. When the manufacturer’s barcode is scanned during a procedure, the supply is automatically removed from inventory and reordered if it meets the minimal stocking criteria.
What measures has your lab implemented in order to cut or contain costs?
Our physicians actively participate with hospital administration and the corporate purchasing department in cost reduction initiatives. The team has been focused on formulating new contract negotiation strategies, developing actionable performance data and supplying benchmarking data, and aligning a product selection process across the Johns Hopkins Health System. The team was able to achieve more than $3.5 million in savings over the past three years on supplies while maintaining an 85 percent room utilization rate and a 14 percent volume growth from 2011 to 2013.
Additionally, for over six years, our lab has successfully utilized third-party companies (Stryker Sustainability Solutions and SterilMed) for electrophysiology catheter reprocessing. This program was vetted through a multidisciplinary team that included purchasing/supply chain, electrophysiology lab faculty leadership, infection control, legal, compliance, clinical engineering, and the clinical staff. Reports of cost savings, landfill reduction, and utilization are provided regularly by the company representatives. Our main campus’ success has prompted our Johns Hopkins affiliate campuses to follow suit. 
Have you developed a referral base?
Our electrophysiology program is world-renowned, especially for complex ablations, which results in many international referrals. Many patients hear about our electrophysiology service by word of mouth or via the internet. We also receive referrals from our network of Johns Hopkins cardiologists, other local cardiologists, and cardiologists in surrounding states. We continue to build our referral base via high-quality care, excellent patient satisfaction, and a focus on patient-centered care.
How are new employees oriented and trained at your facility?
All nurses are required to have two years of intensive care unit experience prior to being considered for a position in our lab. Currently, newly hired nurses must complete a nine-week orientation period; they are paired with a primary/secondary preceptor team. Hybrid nurses who cover both electrophysiology and cardiovascular rooms complete a rigorous 13-week orientation.
Many of our radiologic technologists are hired directly from our schools of medical imaging with no prior special procedure experience. As a return on our investment, they are required to sign a three-year service payback agreement. Radiologic technologists are paired with a set of experienced preceptors for a challenging and very thorough 90-day onboarding/orientation process.
Is the electrophysiology lab separate from the cardiovascular lab? Are employees cross-trained?
Due to the size of our lab and staff, as well as the specialized nature of our procedures, we operate as two separate organizational units. However, all staff members are encouraged to learn and grow professionally. Several of our electrophysiology radiologic technologists currently cover cardiovascular shifts several days per week. They also help to fill “call shifts” as needed. There are currently four hybrid electrophysiology and cardiovascular cross-trained nurses that rotate weekly to both areas of the lab.
How is staff competency evaluated?
Various skills are evaluated for competency on an annual basis. Competencies may be mandated by the state, the hospital or by our department. Our primary focus for competencies is on learning new skills or equipment, “hot topic” processes or procedures, and high-acuity, low-incidence scenarios. One unique opportunity offered by our department is a full advanced cardiovascular/basic life support course taught by members of our own unit. We feel that practicing critical scenarios together as a team helps us to perform more proficiently in times of duress.
Additionally, as part of each employee’s annual evaluation, he or she is expected to provide one to two in-services per year — depending on his or her job title and years of experience — to their coworkers. This practice helps to facilitate and promote an environment that endorses continuous education and growth.
What types of continuing education opportunities are provided to staff members?
Weekly in-services (12 CE credits annually) pertaining to a variety of clinical applications are provided for the clinical team. Staff members are encouraged to attend company-sponsored weekend workshops for device management and electrophysiology didactic lectures to further their exposure and knowledge of electrophysiology theory and practical clinical applications.
Our lab’s administrator is willing to fund travel to conferences offering appropriate clinical education. Staff members are given the opportunity to attend the annual Heart Rhythm Society’s conference on a rotational basis. Staff members who attend conferences are required to give a 30- to 45-minute presentation on an interesting and clinically relevant topic upon their return.
Are you ACGME-approved for electrophysiology training?
We are ACGME-accredited. Fellows spend 24 months in the Johns Hopkins Clinical Cardiac Electrophysiology Training Program to achieve excellence in all areas of arrhythmia management. Our fellows develop expertise in the diagnosis, treatment, and management of arrhythmia disorders. The program fellows participate in all facets of the Johns Hopkins Arrhythmia Service. They interact with arrhythmia patients in both inpatient and outpatient settings. Fellows are given the opportunity to assume responsibility for both acutely and chronically ill patients. A two-year electrophysiology fellowship is essential to fully develop the skills needed to independently practice as a board-certified electrophysiologist.
Do you participate in any registries or studies?
We currently participate in the ICD Registry along with numerous multicenter trials, including RAID, CABANA, and the CardioFocus laser ablation trial.
How does your lab handle vendors/visitors?
The Johns Hopkins Health System Corporation, in response to the Joint Commission recommendations, has engaged the services of Vendormate to credential and assist in monitoring vendor representatives who provide services to the Johns Hopkins Health System. Vendormate is a Web-based system that enables Johns Hopkins to upload new or revised policies, requirements (medical or educational), and any other notification to vendors via a Vendormate e-blast. This system requires vendors to read and acknowledge any notification within a two-week window.
