Medical Center Hospital

What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab? We have one EP lab that is in a department with three other labs — two cardiac labs and one special procedures lab. We currently have five RNs who do EP and two fully trained technicians.

When was the EP lab started at your institution? We opened the EP lab in 1999, in an old cath lab, with one electrophysiologist on staff.

What types of procedures are performed at your facility? Procedures performed here include ICD and PPM implants, EP studies, tilt table studies, cardioversions, and ablations (for AVNRT, atrial flutter, PVCs, PACs, and WPW). We do transseptal ablations, but do not ablate atrial fibrillation.

Approximately how many are performed each week? What is your complication rate? We do approximately 10 implant procedures per week. We may do one or two ablations scattered throughout a month. What is interesting from our viewpoint (and we haven’t yet seen this in EP Lab Digest) is that our primary ablationist is a traveling electrophysiologist who flies in once or twice a month from Austin, Texas. He sees patients in the clinic in the morning, and we start in the EP lab as soon as possible after lunch. On our “EP” days, we will do anywhere from three to six ablations. The latest we have finished is 8:30 pm. We have not had any major complications post ablation.

What is the primary goal of your program (AF ablations, lead extractions, BiVs, etc.)? Our primary volume is in implants at this time, but it is our goal to increase our ablation volume and increase our technology as our program grows.

Who manages your EP lab? The EP lab staff are cath lab staff — especially for implants. When we do ablations, we have staff from the cath lab, as well as other staff who have been promoted to other positions in the Center for Heart Disease, but continue to keep their involvement in the EP lab. For this reason, we currently have our CCU Director and Directional Director staffing the electrophysiology lab. EP is so specialized that we loathe letting anyone walk away from it completely. All of the staff ultimately report to the Divisional Director of the Center for Heart Disease who was also the founding nurse in the EP lab.

Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained? The EP lab is not really separate from the cath lab staff — regular cath lab staff do implants. However, when we do ablations, we pull our specialized staff from across the Center for Heart Disease. We look to cath lab staff for those that have the aptitude and interest for doing EP, and cross-train them.

What new equipment, devices and/or products have been introduced at your lab lately? How has this changed the way you perform those procedures? We primarily use IBI and St. Jude Medical catheters as well as the EPT 1000 ablation module. Once we have a steady and healthy ablation volume, we would like to introduce new technology such as a system for mapping and ablating atrial fibrillation. We upgraded our GE ComboLabs (hemodynamic/EP monitoring) to the latest version this year.

Who handles your procedure scheduling? Do you use particular software? The OR scheduling staff schedules all procedures for the cath lab as well as EP. However, for ablations, the trained staff are notified of the procedures.

What type of quality control/quality assurance measures are practiced in your EP lab? Our EP data is reported to Goodroe and we receive quarterly reports that benchmark our productivity and outcomes against other labs doing roughly the same amount of business as we do and also compare us to national benchmarks. We keep a close eye on our morbidities and mortalities, and cases may be referred to our Cardiology Peer Review for non-punitive discussion and review.

How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? For our ablation procedures, we keep track of the sheaths and catheters we use and our inventory coordinator, B.J. Gold, RTR (CVT), replaces what we used and increases our par level if need be. All of our pacemaker and ICD inventory is on consignment and our pricing is capitated. By capitated, we mean that all devices are assigned a category (e.g., premium dual chamber, standard dual chamber, and basic dual chamber). We then assign a price to each category, and pay the same price for each device in that category, regardless of the vendor. If the vendor wants to use the device in our facility, they have to accept our pricing. This is a big switch from the usual pattern of the vendor giving a list price and the hospital trying to negotiate the price down from there. We set the price and then offer them the opportunity to either do business with us or not do business — it is their choice. Therefore, we let everyone play in the sandbox, so long as they play by our rules! Interestingly enough, all four CRM vendors in our area accepted the pricing contract.

Has your EP lab recently expanded in size and patient volume, or will it be in the near future? In addition, is your EP lab part of a separate “heart hospital”? Our ablation volume has been on the rise for the last couple of years thanks to Dr. Jason Zagrodzky’s monthly clinics and procedure days. Our pacemaker and ICD implant volumes have grown about 10 percent over the past year, done by our surgeons Dr. Kirit Patel, Dr. Allan Leshnower, and Dr. Joseph Suchareih, interventional cardiologists Dr. Nam Kim and Dr. Raja Naidu, and our local electrophysiologist Dr. Shmuel Inbar. Our goal is to keep increasing our ablation volume. We’d be thrilled if our EP lab was kept busy with ablations on a daily basis, rather than once or twice a month.

Have you developed a referral base? Several of our cardiologists in the area refer patients for ablation on a regular basis. Therefore, we’ve seen our monthly ablation volumes grow as well as seen an increase in physician referrals.

What measures has your EP lab implemented in order to cut or contain costs? In addition, in what ways have you improved efficiencies in patient through-put? We negotiate the price we pay for our catheters. More importantly, we focus on accurately turning in our charges for EP patients in order to optimize our reimbursement. However, we also try to stay updated with new products.

Does your EP lab compete for patients? Has your institution formed an alliance with others in the area? Medical Center Hospital has the only EP lab in our area. The nearest EP lab is about 150 miles from here. Therefore, we do not have a lot of competition for EP patients.

What procedures do you perform on an outpatient basis? In addition, what EP procedures are generally only considered inpatient? Most of our patient population start as outpatients. Admission to the hospital is done on a case-by-case basis.

How are new employees oriented and trained at your facility? New employees are oriented and precepted by experienced employees who exhibit the qualities that we want to cultivate among our staff. It is not uncommon for a new employee to spend time with more than one preceptor; this way they can observe exemplary nursing practice and model their own practice after it.

What types of continuing education opportunities are provided to staff members? Staff members are encouraged to pursue continuing education. Many of our EP lab staff members have attended educational classes such as Order and Disorder and St. Jude Medical’s Fundamentals of EP.

How is staff competency evaluated? Our staff undergo a yearly peer evaluation. Everyone on the team is welcome to contribute to the evaluation of a staff member’s job performance.

How do you prevent staff burnout? In addition, do you practice any team-building exercises? We try to have fun at work every day. When it’s time to work, staff are professional...but we keep it light. Also, the Department Director’s office is always open for anybody that needs to talk.

What committees, if any, are staff members asked to serve on in your lab? Staff members are encouraged to be active in our hospital community; therefore, they are welcome to serve on committees in which they have an interest or where they have been asked to serve. Some of the committees that staff members currently serve on are Core Indicators Team for AMI, Customer Satisfaction, and the Nurse Practice Council.

How do you handle vendor visits to your department? Do you contract with vendors? Vendors must go through a formal process with our hospital before they can visit our department. In-services and education must be scheduled in advance. We are tolerant and appreciative of vendor visits to our lab as long as patient care is never interrupted.

Does your lab utilize any alternative therapies to help patients in the lab (e.g., music, guided imagery techniques, etc.)? No; I guess we’re old fashioned that way. We talk to our patients and reassure them when they are anxious, as well as provide moderate sedation to keep them comfortable whenever necessary. We do honor patients’ requests and tastes in music.

Please describe one of the more interesting or bizarre cases that have come through your EP lab. What lessons did you learn from it? We had a 28-year-old patient come through the lab with terrible AV node function. When we were hooking up the patient, he told us he had been electrocuted as a child. While doing the EP study, the electrophysiologist was quite mystified as to why the AV node function was so terrible in such a young patient. We finally asked if the childhood electrocution could be the reason. The electrophysiologist was quite perturbed by this information (he prides himself on the completeness of his history taking) and exclaimed “he never told me he was electrocuted..but then again, I guess I didn’t ask!”

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? We don’t have a separate call schedule for EP. If there is an implant after hours or on weekends/holidays, the cath lab call crew comes in to do it. It is common for the call crew to come in on the weekends to do an implant so the patients won’t have to stay in the hospital all weekend waiting on a pacemaker. There is a backup call crew for cardiac emergencies. Every staff member takes an average of nine call days per month.

What percentage is done with radiofrequency? All of our ablation cases are done with radiofrequency energy.

Do you perform only adult EP procedures or do you also do pediatric cases? We do only adult and young adult cases.

What measures has your lab taken to minimize radiation exposure to physicians and staff? We have lead screens available for staff in the room (which is much appreciated by the anesthesiologists). Our ablation module and stimulator are in a control room separated from the procedure room by leaded glass. We all wear lead, of course, and are careful to practice time, distance and shielding in order to minimize exposure. Every staff member is fitted for their own lead and protective eye gear.

Do your nurses/techs participate in the follow up of pacemakers and ICDs? No, follow-up is done in physicians’ offices.

What trends do you see emerging in the practice of electrophysiology? How is your lab preparing for these future changes? We are advertising Dr. Jason Zagrodzky’s visits to our hospital to all cardiologists in the community, so he can obtain more referrals. We constantly promote education for our staff and provide training for those who are interested, and of course we read EP Lab Digest to keep updated on the latest changes. We would very much like to increase our EP volume and acquire new technologies.

What are your thoughts about non-EPs implanting ICDs? Do you train such individuals? We have mostly non-EPs implanting ICDs, so to us, it’s a way of life.

Is your lab doing web-based/transtelephonic device follow-up? Not currently, although some of our physicians do transtelephonic device follow-up from their offices. Patients can live up to 300 miles away, in which case the transtelephonic technology becomes very important.

Is your EP lab involved in any clinical research or special projects? Not at the moment, although we do participate in the ACC-NCDR ICD Registry.

When was your last inspection by the Joint Commission? Our last inspection was two years ago. Our window is now open for another inspection.

Are you ACGME-approved for EP training? What do you think about two-year EP programs? No, we have no experience with two-year EP programs. The remoteness of our region has necessitated that we train our own EP nurses.

Does your lab provide any educational or support programs for patients? We do provide educational materials. We do not have a follow-up group, but the company representatives are responsible for next-day follow-up.

Give an example of a difficult problem or challenge your lab has faced. How it was addressed? Having trained and involved staff has been the biggest challenge. We have learned that it is better to have fewer expert EP nurses than to force cross training. When we attempted to force cross training, staff were not engaged. We switched to finding individuals with the aptitude for EP and have had a much better experience. At this point, we look forward to our ablation days. Staff plan their vacations so that they don’t miss those days.

Describe your city or general regional area. How does it differ from the rest of the U.S.? We have a huge referral area — 17 counties — and some of those counties are bigger than Rhode Island! We are largely rural, and have a mix of Caucasian and Hispanic patients. The major industry is oil-related, so right now we are experiencing an economic boom while much of the nation is suffering from economic downturn. MCH is a hospital district, which means that we are the “community hospital” for Ector County, but we also serve 17 regional counties in two states. MCH is a designated Level III Trauma Center for this region, and has two helicopters that serve the region. We are also the home of the “Mojo.” The Friday Night Lights book was based in Odessa, Texas. John Lambert, RTR, played for Mojo in 1989.

Please tell our readers what you consider unique or innovative about your EP lab and staff. We started our EP lab with one nurse who did all the procedures alone, with just the physician for support. This included sedating the patient and running the stimulator. It was two years before we acquired a second helping hand. When our new Center for Heart Disease opened in 2002, we moved to our current facility, and for the first time we were formally combined with the cath lab. It continued to be a struggle to have staff in the EP lab. About two years ago, when Dr. Zagrodzky started coming, we began focusing on training EP staff. We’ve come a long way. We now have five nurses who can do EP and two technicians who are excellent in the EP lab.

For more information, please visit www.mchodessa.com.