New Electrophysiology Educational Internship Program

Unlike cardiovascular technology, which can recruit staff from schools nationwide and has a nationally recognized credentialing program, the Registered Cardiovascular Interventional Specialist (RCIS), in place, electrophysiology has neither. In order to be better able to staff the electrophysiology (EP) lab and train electrophysiology technologists, Lancaster General Hospital (LGH) in Lancaster, Pennsylvania has designed and implemented a unique educational training program, an EP Internship, for electrophysiology technologists. Lancaster General Hospital is a 518-bed community hospital situated in south-central Pennsylvania, and is also a designated level II trauma center. Lancaster General is the only hospital in the region to have achieved Magnet status for nursing, as designated by the American Nurses Credentialing Center, and has been ranked as one of the top 100 hospitals in the US for five out of the last six years. Additionally, Lancaster General has been named one of the 50 best hospitals in the US for cardiovascular care byUS News and World Report for both 2004 and 2005, and is the only hospital in the region to have achieved this honor. Lancaster General is allied with the Lancaster General School of Nursing and the Lancaster General College, offering diploma/certificate and associate degree programs in nursing, cardiovascular technology, radiological technology, diagnostic sonography, nuclear medicine and surgical technology. The hospital also has a nationally recognized family practice residency program, which was created in 1969 and has graduated 399 residents. The electrophysiology laboratory at Lancaster General is one of the busiest centers on the East Coast, performing over 3,600 procedures annually, including diagnostic and interventional EP studies and pacemaker and implantable cardioverter-defibrillator (ICD) implants. The hospital actively participates in research, and was one of the first centers in the country to perform biventricular pacemaker and ICD implants. LGH recently completed installation of a new bi-plane electrophysiology suite, and the addition of a second bi-plane lab is scheduled for January 2006, which will bring the total number of electrophysiology suites to five. Historically, EP staff education and training was done on the job (OJT) according to a leveling system already in place. The leveling system consisted of departmental education training and testing that determined the staff member's level of clinical knowledge and expertise. Under the leveling system, a new staff member was designated as a Level I tech, and over a two-year period received education and training in order to advance to a Level II status. The Level II staff member was required to demonstrate clinical competency in the following areas: Scrub and perform stimulation protocols for: 1 wire ventricular study 3 wire syncope study 4 wire supraventricular tachycardia (SVT) study. Record for: (including data work-up and medication protocols if needed) 1 wire (ventricular) study 3 wire syncope study 4 wire SVT study - AV Nodal Re-entrant Tachycardia (AVNRT) Record for an AVNRT ablation (all stimulation protocols, watch screen and monitor rhythm, and data work-up) Record for an atrial flutter ablation (all stimulation protocols, watch screen and monitor rhythm, and data work-up) Scrub for pacemaker and ICD insertions/revisions (this was before the advent of the biventricular (Bi-V) insertion). In addition to the required clinical competencies, the Level II tech was required to pass the written Level II exam, which was created by the senior electrophysiology staff and EP physicians. The Level II exam tested the technologist on basic EP theory, pharmacology, anatomy and physiology, SVTs and atrial flutter, pacemaker and ICD function, ablation theory, and electrogram recognition. There was no formal educational program or training, but staff members attended courses offered by the North American Society of Pacing and Electrophysiology (or NASPE; now known as the Heart Rhythm Society [HRS]), the American College of Cardiology (Heart House), Medtronic, Inc., St. Jude Medical, Inc., Guidant Corporation, Biosense Webster, Inc., Endocardial Solutions, GE Medical Systems, and the University of Oklahoma Health Sciences Center Electrophysiology Lab, as well as hospital-based educational seminars offered by senior EP techs and cardiologists. The availability of off-site education and training, along with the wealth of training offered by physicians and senior technologists, coupled with physician expectations, and the small size of the lab resulted in a core group of well trained staff. Within a relatively short period of time, a majority of the staff successfully challenged both the EP and Pacing NASPExAM® for associated professionals. Due to their high level of knowledge and expertise, staff members were heavily recruited by the electrophysiology industry, resulting in high staff turnover. This high turnover, combined with advances in technology and procedure volume, left the hospital with a multitude of issues, including: Suboptimal staffing (novice staff, high turnover, vacant positions) No dedicated clinical supervisor in position An average of 76.5 hours of overtime per week by staff. Low staff morale Procedure cancellation rate of 38% Procedure scheduling delays of 1012 weeks Physicians dissatisfied with slow pace of lab/staff Inordinate use of agency staff to supplement staffing These challenging issues were ample evidence that the electrophysiology department urgently required reorganization if the program was to be successful. Within two years, a full-time director, clinical educational coordinator, educator for the EP internship, and clinical supervisor were in place, and the medical leadership and medical director roles were redefined. Currently, six electrophysiologists provide services from three different cardiology groups. Staffing is a mixture of RNs and technologists, with RNs providing moderate sedation and technologists carrying out the other procedural roles (scrub, record and circulate). All technologists are expected to prep patients for all procedures, and are trained to perform all stimulation protocols, follow and expedite medication protocols in conjunction with stimulation protocols, and provide data work-up for physician interpretation. The technologists are required to be proficient on the Cardiolab recording system, and be familiar with and operate the 3-D mapping systems (Biosense Webster, Inc. and ESI), and the intracardiac ultrasound system (GE Aspen). The physicians also rely on the staff members to assist with equipment selection for all procedures performed in the lab. Selected technologists have also been trained to insert venous and arterial sheaths and place wires for diagnostic EP procedures, and all staff members are qualified to close pacemaker/ICD incisions. The technologists and nurses in the lab are viewed as an extension of the physician performing the procedure, and they are all an integral part of the care and treatment of our patients. In order to maintain this high level of lab functioning, it became evident that a new educational process was needed in order to hire and retain EP lab staff, and the EP Internship program was born. In place of the traditional OJT, new EP staff members undergo 22 weeks of intense didactic education in combination with clinical rotations in the EP lab. All interns must achieve at least an 85% on all written exams, and must be signed off on a core group of clinical competencies. The internship begins with hospital and departmental orientation followed by the Intro to Electrophysiology lecture. The didactic portion of the program is highly specific to EP, and is a combination of lectures and case studies provided by several instructors. Lecture topics include mechanisms of arrhythmias, ventricular and supraventricular tachycardias, electrogram recognition and case studies, stimulation and medication protocols used at LGH, and interventional therapies, including radiofrequency and cryoablation and cardiac devices. Clinical rotations are interspersed with lectures, and an attempt is made to merge clinical experience with lecture topics. After completing the 22-week intensive portion of the program, the interns have up to an additional six months to complete the required clinical competencies and be signed-off by the Medical Director. At that time, the intern becomes a Level I EP Tech and has up to 12 months to successfully challenge an EP Core Knowledge Exam. After passing the core knowledge exam, the tech advances to Level II, the minimum required for employment. Techs may remain at Level II, or choose to participate in the EP Clinical Ladder program and advance to Level III or IV. All EP techs are encouraged to challenge at least the NASPExAM® in EP. Passage of either the EP or Pacing exam is required to advance to Level IV. Many of the instructors in the Internship are EP staff members; however, we also utilize staff from other departments (biomedical engineering, non-invasive cardiology), and outside sources such as Medtronic, Inc. and local physicians offices, for lectures and clinical rotations. The interns have class four mornings per week for 4.5 hours, followed by 1 hour of study time and then a clinical rotation for the rest of the day. There is one full day of clinical per week. The interns are assigned a clinical preceptor for the duration of program and work exclusively with that person on a daily basis. Departmental and hospital competencies are also included in the curriculum and are incorporated into the lectures and clinical experience. For example, the airway management and the ABG competency are included in the pulmonary A & P/ airway lectures and the pharmacology competency is built into the pharmacology lecture. Written tests and clinical validations at the end of the classes document the competencies and are repeated annually. The last on-the-job-training staff member was hired in September 2003. At the same time, four nurses were recruited to provide moderate sedation during procedures. In January 2004, we started recruiting for the first EP internship class. Our prerequisites for acceptance into the internship included any of the following: prior EP experience, RCIS with interventional experience, RN with recent critical care experience, Physician Assistant training, or Certified Nurse Practitioner status. The first interns completed their didactic education in June of 2004 and completed the required clinical competencies by June 2005. In the fall of 2004, two existing staff members started a modified internship (didactic content only) and two new employees started the full internship in January of 2005. Of the six interns that have completed the didactic portion of the program, 83% have successfully passed the written final examination, and 50% have completed the clinical competency requirements and have been validated by the Medical Director. The other 50% completed the didactic portion less than six months ago, and are still working on completing their clinical competencies. As of this writing, one of the interns has successfully challenged the associated professionals NASPExAM for pacing, and two interns will be challenging the associated professionals NASPExAM® in EP in May 2006. The remaining interns will have until May of 2007 to challenge the NASPExAM®. The EP Internship has definitely benefited the EP program at Lancaster General, turning out six highly functioning and valuable EP techs. The success of the program has not come without some degree of difficulty, though. The program is extremely intense, and presents a very large amount of information in a comparatively short time frame. The final exam is especially challenging, covering the entire curriculum, and has a first-time passing rate for the final comprehensive exam of approximately 40%. Those who were unsuccessful on the first try received an average grade of 77% (approximately a C+ according to most accepted grade scales). The need for frequent remediation and retesting, along with the frustration and feedback of the graduates and staff, resulted in a re-evaluation of the program's structure and content. We are currently reviewing the program's content and time frame, and are considering expanding the program to 1 year. Under the new format, the first third of the program would have more didactic instruction and less clinical time, the middle third would have equal parts clinical and didactic instruction, and the final third would be entirely clinical. The curriculum originally included 80 hours of basic and advanced pacemaker classes, provided by Medtronic, Inc.; those classes have been replaced with on-site instruction. Independent study and class presentations have also been added. Based on the feedback from Internship graduates, scheduling of classes and clinical has been adjusted in order to allow the interns to be in the clinical setting for the entire day. The graduates also suggested that instead of having one clinical preceptor for the entire program, several should be utilized, in order to give the interns a more well-rounded clinical experience. To address this issue, at the start of the program, each intern will be assigned a clinical instructor, a primary preceptor and a mentor. The mentor will be available to assist not only with educational questions, but can also address issues concerning the work environment or difficulties with peers. The preceptor will be responsible for teaching in the clinical setting, and the clinical instructor will be an educational resource at the beginning of the clinical rotations, and available for signing off clinical skills at the end of the clinical rotations. The mentor will help the intern bring the whole picture together, while the preceptor and clinical instructor offer clinical guidance and support. In trying to determine if our selection process was a problem, we have discovered that the prerequisites for acceptance into the internship appear to have little bearing on the interns'written test scores. However, clinical evaluations did uncover different strengths and weaknesses that seem to be dependent on the intern's clinical background. Those with diagnostic and/or interventional cath lab experience were more comfortable in the scrub rotation and easily learned to manipulate EP wires and other procedure-related equipment. Those with OR experience had little difficulty with the sterile environment; however, manipulating wires and learning to operate EP equipment required more training. Registered nurses and paramedics required additional time in the role of scrub tech in order to master the sterile environment and equipment manipulation. Interestingly, prior EP experience did not appear to be particularly beneficial, as the test scores and clinical performance of interns with a background in EP were no better than those who had no EP experience. We also closely scrutinized the final exam, which was the original leveling exam. As a result, several ambiguous and/or poorly written questions were deleted, along with several that seemed to have little bearing on electrophysiology or were beyond the scope of the material presented in the Internship. The revised final examination has been evaluated and validated by a selected team of staff members with varying levels of knowledge and experience, and does a better job of evaluating what the interns have learned. The expectation of the Internship was that it would decrease the time required for OJT (formerly, at least two years), and produce educated and competent technologists capable of passing the NASPExAM® in a specific area within two years. To date, six employees have participated in the Internship. Test scores have been mixed, but clinical performance has generally been excellent. One graduate has successfully passed the NASPExAM® in Pacing, and two more plan to do so. The training and education provided in the Internship is difficult and intense, and has decreased the OJT training time from two years to one; however, to date the quality of the training has not yet been objectively validated. It is also evident that the selection of candidates cannot be based solely upon credentials or past medical experience, but that motivation and desire to learn are the driving forces behind a successful electrophysiology technologist.