So Far, So Fast and Ever Evolving: Loma Linda University Cardiac Electrophysiology Technology Program

“We have an innate desire to endlessly learn, grow and develop. We want to become more than what we already are. Once we yield to this inclination for continuous and never-ending improvement, we lead a life of endless accomplishments and satisfaction.” 

~ Chuck Gallozzi

It was a mere four years ago that Loma Linda University (LLU) introduced the Cardiac Electrophysiology Technologist (CEPT) program, aiming to meet a growing demand for clinical EP staff and provide patients with quality care in the cardiac EP lab.¹ Not only has the CEPT program met this goal, it has surpassed it. The program’s most recent accomplishment of achieving the Commission on Accreditation of Allied Health Education Programs (CAAHEP) accreditation has raised CEPT program expectations and prospects, as well as improved opportunities for those who never considered a career in cardiac EP. As of September 2013, student eligibility for Cardiovascular Credentialing International’s (CCI) Registered Cardiac Electrophysiology Specialist (RCES) certification became dependent upon program accreditation. Under CAAHEP accreditation, graduates of LLU’s CEPT program are eligible to sit for the RCES examination through CCI’s RCES4 qualification pathway. Although the accreditation process is intense and requires years of organization, planning, and follow-through, time and dedication to this endeavor is well worth it. The CEPT program was recognized by CAAHEP for substantial compliance with nationally established accreditation standards. The CEPT Advisory Board contributed to our CAAHEP accreditation success, as members including physicians, administration, nurses, vendors, CVTs, and current students and graduates of the program provided much needed perspective and insight as to how the program should “adjust its sails.” The feedback gained through this process allowed immediate action-oriented steps to ensure CAAHEP accreditation was achieved. The support and passion from our team, which was united in their efforts, has helped ensure the LLU CEPT program to succeed. 

Contributions

The Heart Rhythm Society (HRS) and International Board of Heart Rhythm Examiners (IBHRE) are guiding lights in the field of cardiac EP with regards to expert consensus guidelines and certifications, respectively. Last year, the CEPT program received the first college-based clinical EP program endorsement from the IBHRE.² From the CEPT program’s inception just four years prior, this is a major accomplishment that validated our program’s strides towards growth, demonstrating efforts are aligned with IBHRE’s mission.

IBHRE offers two certifications for allied professionals: 1) the Certification of Competency in Cardiac Electrophysiology for the Allied Professional (CEPS), and 2) Certification of Competency in Cardiac Rhythm Device Therapy for the Allied Professional (CCDS). Both IBHRE certifications are more desired in the academic and industry settings of cardiac EP. The CEPT program curriculum and competencies utilized the IBHRE exam matrix as one of its primary guidelines, and it is the model to which our CEPT students are trained. 

Another guiding light in the cardiac EP arena is CCI, whose vision is to be the recognized credentialing organization for Cardiovascular Technology and emerging medical professionals.³ CCI offers the RCES certification for allied professionals. The exam overview and matrix also contributed to the CEPT curriculum; in addition, its influence on the EP-specific clinical competencies greatly supported our CAAHEP accreditation efforts as well as improved chances for IBHRE endorsement. The addition of clinical hospital sites were also influenced by CCI matrices, as CEPT’s competencies are shared among clinical EP sites. CEPT faculty have served on the CCI RCES Examination Committee, contributing to the development, composition, analysis, and questions in examination content. RCES certification serves as a prominent EP-specific credential and will continue to be a step in the career ladder for students who wish to pursue clinical EP positions or move on to pursue additional certification and work in academic and industry settings. 

Program Developments

The CEPT program is now housed under Cardiopulmonary Science (CPS) instead of Radiation Technology (RT); both departments are located within the School of Allied Health Professions (SAHP) at LLU. Since this move, adjustments have been made to the structure, content, faculty, and selection of students within the program.

The CEPT program continues to have a certificate and associate track. Both are 12 months in duration; however, the certificate track now also consists of a new hospital-based hybrid option for current non-certified staff members in cardiac EP labs who wish to prepare didactically for board exams (RCES or CEPS). Candidates from other states who are interested in the program are encouraged to apply; some state legislations implement out-of-state fees, but this can be discussed upon review of the applicant’s location. The hospital-based hybrid track is one of the most exciting advancements of the CEPT program to date. Early on, the CEPT program catered to new allied health professionals who wanted to get into the cardiac EP lab or industry, but educational, competency, credentialing, and/or clinical needs of existing EP allied staff and their respective hospital-based programs were nonexistent. Thus, the CEPT program was modified to assess and account for the current education and skills of hospital-based EP allied professionals. Emphasis is placed on didactic education, while clinical competencies are achieved in one’s current lab. In essence, one uses his/her schedule to fulfill the clinical hours, with emphasis placed on specific cases (as they arise), to meet competencies each quarter. There is no need to rotate to labs outside of one’s work to complete the required 800 hours of clinical practicum; instead, the hospital staff’s occupational hours double as their clinical hours, unless absolutely necessary to meet accreditation guidelines. This year, in partnership with Hoag Memorial Hospital Presbyterian, the CEPT program piloted a beta endeavor referred to as a hospital-based hybrid program. This new approach for extending clinical EP education and training is showing great promise. 

Although the clinical obligations per academic year are the same for certificate and associate students, associate student applicants would not be eligible for the certificate track due to their lack of healthcare experience. The CEPT program has established clinical contracts with 12 labs in the southern California area, allowing student exposure to a variety of cases, technologies, and physician preferences. The sharing of information, knowledge, and expertise is a cornerstone to improving current practices in the EP lab. To support our clinical site, the CEPT program provides EP-related books to all clinical sites, encouraging education of lab personnel across the board.   

Additional coursework was added to the CEPT curriculum, centering on intracardiac electrogram interpretation. This course follows the existing rhythm recognition and 12-lead EKG interpretation courses, but focuses more on the electrical waveform variations seen specifically in the cardiac EP lab. To supplement this course and its specialized content, the CEPT program has teamed with VisibleEP, LLC to provide simulated mapping and electrograms, yielding kinesthetic learning in an interactive, virtual environment. The VisibleEP software compliments the CEPT course content and includes videos, modules, and quizzes to assess students’ comprehension and proficiency in each section. The addition of VisibleEP offers a unique set of educational tools for both instructors and students. Conveying the concepts of cardiac EP theory and concepts can be challenging, and borders on being considered abstract and theoretical. There are some good online learning entities; however, the VisibleEP software allows the honing of clinical EP skills without the expense and risk of a human patient (i.e., pacing functions, catheter manipulations, and tissue-modifying ablation). The CEPT program is currently integrating this application into the curriculum. 

It is worth noting that CEPT’s 60% hire rate is well above traditional allied health programs, which have an average of 35%. In fact, 100% of students who passed RCES boards were able to find employment after graduation from the CEPT program. Graduates have jumpstarted their careers in EP labs and industry, while some choose to continue their education in other programs. 

Leadership

The CEPT program is fortunate to have faculty with a plethora of experience, both in cardiac EP and other clinical areas. Alan Alipoon serves as director of the CEPT program; his experience as a respiratory care practitioner is of value, as the emergence of the cardiac EP specialty parallels the growth patterns seen years ago in respiratory care. Janelle Guerrero was hired as full-time faculty immediately upon completion from the CEPT program based on her previous experience in cardiac rehabilitation and exercise physiology. Her “insider’s prospective” as a graduate of the program provides students with a better sense of direction. The pioneering mavericks of our team, program co-founders Joe Giron and Peter McBride, continue to change the face of education in EP as we know it — their desire to share EP education with the world is inspirational. The addition of Dr. Ronald Lo as medical director to the CEPT program has brought additional credibility to the program. His relaxed and methodical approach to the specialty is irreplaceable during hands-on training with CEPT students, and his guidance, advice on curriculum, and superb training in cardiac EP are invaluable. One couldn’t proceed without mentioning the value of the chair of the CEPT Advisory Board, Trina Schneider; her experience, marketing abilities, and counsel have been invaluable during the last six months with our program. Collectively, the innovations, creativity, and perspective from CEPT faculty have brought more life into this program.

Future Program Advancements

Over the last four years, interest in RCES credentialing has increased, reflecting higher demand in the field and greater reimbursement for professionals who hold such credentials. According to CCI, the number of professionals with RCES credentials nationwide included 556 at the end of 2014.⁴ In 2011, the total was 303. As the demand for education in cardiac EP continues to rise, the CEPT program will play an important role in providing quality education for both the student without clinical lab familiarity and the hospital-based EP allied professional with a surplus of experience. In order to appeal to both candidate types, the LLU CEPT program has been developing several marketing opportunities, including an already established website and social media pages. Video projects of both educational and marketing value are underway as the CEPT program looks to spearhead the direction of education in the cardiac EP specialty. Outreach to the military has also provided substantial feedback of the need for specialized training in cardiac EP and other cardiovascular specialties. Military personnel who choose to apply to the LLU CEPT program and are accepted will be more marketable upon graduation, increasing the likelihood of job placement after life in the military. The end goal of veteran applicants is placement of those who serve in the military on a career path that is both challenging and inspiring. An additional program benefit is having two veterans as faculty members of the CEPT program, as they understand the challenges that face today’s military. 

The EP industry is poised for explosive growth in the next few years. As the population ages, EP will gain more popularity in the cardiovascular industry. According to the Centers for Disease Control and Prevention, total spending due to cardiovascular diseases is expected to reach $646 billion by 2015, and a staggering $1.2 trillion by 2030. The total number of atrial fibrillation patients in the U.S. is expected to reach 5.6 million by 2050.⁵

In light of these statistics, and with the advent of the Affordable Healthcare Act, healthcare delivery will continue to evolve and expand. Educational pathways and access need to evolve, if not in anticipation with healthcare policy changes, then in tandem. Only recently have allied professionals had access to formal clinical EP education and training; however, clinical EP training for physician extenders (e.g., nurse practitioners, physician assistants) has yet to be formally actualized. Programs like Loma Linda University, Pennsylvania College, and Sentara College have answered the call of hospitals, physicians, and industry to formally develop clinical programs for EP allied professionals. We are also now considering clinical EP education and training for physician extenders, as well as lengthening the current associate track of the CEPT program into a bachelor’s program. It is with hope that such endeavors will evolve before demand increases; however, funding is a major obstacle in program and professional expansion. Collaboration with industry reveals some opportunity for grant funding, use of equipment, training of students and faculty, as well as placement of graduates directly into the EP industry. Our program is also considering efforts to establish RCES/CEPS prep courses for those who are board eligible but need a refresher without extensive education commitments. 

Education: The Missing Link

There is a term being loosely used of late in some cardiac EP labs: lead RN/techs. Administration is keen on developing lead RN/techs, yet their role has not been clearly defined. What differentiates a lead RN/tech from those already working in the lab? They understand the science behind EP, and as a result, cases flow even more efficiently, improving patient safety and saving time during the case. The lead RN/techs are also engaged in events as the case unfolds, anticipating the needs of the electrophysiologist without relying on much direction. Since allied EP staff are a cornerstone to cohesion and flow, their education and understanding are necessary to have in a lab of high caliber. This academic year, Hoag Memorial Hospital Presbyterian sponsored two of their techs’ continuing education in CEPT’s hospital-based hybrid track. Next year, we anticipate the sponsorship of two additional RN/techs into the 2015 cohort. The feedback from administration, management, physicians, and staff in Hoag’s EP lab has been positive. According to Tom Lonergan, executive operations director of Hoag Heart and Vascular Institute, “We are fully supportive of the CEPT program at LLU. Having a program to give our employees a much better clinical and practical understanding of electrophysiology enhances their ability to provide the most optimal care of our arrhythmia patients. Arrhythmia is one of the significant growth areas of cardiovascular medicine. As the industry progresses, having staff that are trained and experts in the care of such arrhythmias will be critical to improving patient outcomes and providing care in the most efficient manner.”

Final Thoughts

The field of cardiac EP continues to have a certain level of experimentation; however, established practices are well in place. As such, it is important to institute quality accredited and standardized training of allied EP staff and not rely solely on the idea that on-the-job-training will suffice. Additionally, the demand side of this economic equation is not just associated with the growth of a target market, but also the competent resources available for quality EP professionals. Presently, all manufacturers that provide cardiac ablation products, as well as the medical facilities that provide those services, are only ablating approximately 10% of the population with access to healthcare and in need of cardiac ablation.⁶ The LLU CEPT program was born from the obvious supply and demand requirements, as well as from the frustration of medical industry hiring EP lab staff. In the past, many cardiovascular service line administrators voiced concern surrounding this issue, but accepted a certain level of attrition and feared it was a consequence of the beast. This is no longer the case. Investing in continuing education for staff improves morale across the board, as allied EP staff feel needed and become more loyal to their team. It also improves the education of all staff in the lab, as the physician spends more time educating the curious student and other staff lean in to listen. Most importantly, it improves the quality of the lab, as penalties of not having quality outcomes are most evident with the demands from the Affordable Healthcare Act. 

Loma Linda University’s CEPT program has open enrollment for the 2015-2016 academic year. Please visit the CEPT website below for more information, or contact Alan Alipoon, aalipoon@llu.edu or Janelle Guerrero jmguerrero@llu.edu, directly.

CEPT website: https://www.llu.edu/allied-health/sahp/cardio/cept.page

CEPT Facebook page: Facebook.com/LluCardiacElectrophysiology

CEPT LinkedIn group: https://www.linkedin.com/grp/home?gid=6810690

Disclosure: The authors have no conflicts of interest to report regarding the content herein.

References 

1. Giron J, Alipoon A. The New Cardiac Electrophysiology Technology Program (CEPT) for Allied Health Professionals. EP Lab Digest. 2011;11(1):26-27. 
2. Endorsed Programs and Products. International Board of Heart Rhythm Examiners (IBHRE). Available online at www.ibhre.org/Exam-Preparation/Endorsed-Programs-and-Products#axzz3WMUwi8bm. Accessed April 13, 2015.
3. About CCI. Cardiovascular Credentialing International (CCI). www.cci-online.org/content/about-cci-0. Accessed April 13, 2015.
4. 2014 Annual Report. Cardiovascular Credentialing International. www.cci-online.orghttps://s3.amazonaws.com/HMP/hmp_ln/imported/2014%20Annual%20Report-Final.pdf. Accessed April 13, 2015.
5. Chronic Disease Prevention and Health Promotion. Centers for Disease Control and Prevention (CDC). Published July 21, 2010. www.cdc.gov/chronicdisease/resources/publications/AAG/dhdsp.htm. Accessed April 13, 2015.
6. Kneeland PP, Fang MC. Trends in catheter ablation for atrial fibrillation in the United States. J Hosp Med. 2009;4(7):E1-5.
7. Go AS, Hylek EM, Phillips KA, et al. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA. 2001;285(18):2370-2375.