Spotlight Interview: Concord Hospital

What is the size of your EP lab facility? When was the EP program started at your institution?

Nestled on a hillside in the Capital Region of New Hampshire is Concord Hospital. Established in 1953 as a community not-for-profit hospital, Concord Hospital has grown to be a 295-bed licensed facility. 

Medical Director Dr. Adam Chodosh, a board-certified electrophysiologist, opened our electrophysiology lab in the spring of 2011. Dr. Clayton Jones, also a board-certified electrophysiologist, joined Concord Hospital in 2016 in response to the growing demand for electrophysiology services in our area. Concord Hospital currently has 2 EP/cath labs, and we are excited to open a third lab suite in early fall 2016. 

What is the number of staff members? What is the mix of credentials at your lab?

Concord Hospital’s EP lab is comprised of 15 highly trained staff members with varied backgrounds. There is a dedicated prep and recovery area staffed by 3 RNs. In addition, there are 6 RNs and 6 cardiovascular technologists who rotate between the EP and cath labs. Our staff credentials include CCRNs, RCISs, an RCES, RT(R)s, and EMTs. There is a robust cardiac education program in the hospital in which staff routinely participate. All staff members are required to obtain RCIS certification within 2 years of employment, and the RCES credential is strongly encouraged.    

What types of procedures are performed at your facility? Approximately how many catheter ablations (for all arrhythmias), ICD implants, and pacemaker implants are performed each week? 

The EP lab is focused on providing a wide variety of complex yet minimally invasive procedures in a well-equipped setting. These procedures include EP studies to determine and diagnose arrhythmias, as well as ablations for atrial flutter, atrial fibrillation, atrial tachycardia, SVT, and ventricular tachycardia. Implantable pacemakers, defibrillators, biventricular devices for resynchronization therapy, and lead extractions are also performed. Plans are taking shape to begin WATCHMAN (Boston Scientific) implants and Convergent procedure (AtriCure) programs with the expansion of our third EP/cath lab suite. 

Is the EP lab separate from the cath lab? Are employees cross-trained?

The EP lab and catheterization lab are not separate at this time, thus enabling a team approach. Staff is initially trained to be competent in the cardiac cath lab upon hire, then cross-trained to EP lab procedures. 

What type of hospital is your EP program a part of? 

Concord Hospital’s electrophysiology program belongs to a community-based, not-for-profit organization, with 2,603 full-time employees. 

What types of EP equipment are most commonly used in the lab? 

We use Philips and GE Healthcare for fluoroscopy, the WorkMate Recording system (St. Jude Medical), and the EnSite mapping system (St. Jude Medical). We use ablation catheters such as the FlexAbility and TactiCath (St. Jude Medical), Blazer catheter (Boston Scientific), SF catheter (Biosense Webster, Inc., a Johnson & Johnson company), and the cryoballoon (Medtronic). We use the ViewFlex (St. Jude Medical) for intracardiac echo. For pacer/defib implants, we use Boston Scientific, St. Jude Medical, and Medtronic. 

How is shift coverage managed? What are typical hours (not including call time)?

Staff members generally work 9-hour shifts, four days a week from 7:30 am – 5 pm, with rotating days off. Some staff members rotate to work three 12-hour shifts from 7:00 am – 7:30 pm to accommodate any EP cases that extend into evening hours. 

Tell us what a typical day might be like in your EP lab.

Our day typically begins with prep and recovery. Our nurses arrive at 6 am, and patients shortly afterward. A bustle of activity ensues over the next hour and a half in order to prepare the patient, during which time the patient is prepped for the procedure and any additional questions regarding the procedure are answered. Patients are introduced to the EP and anesthesia teams, and a physician-patient discussion of plan of care takes place. Each day in the lab has a different dynamic; however, in general, 1-2 ablations per day are scheduled along with 1-2 device implants, depending on the complexity and length of the procedures.

What new technology has been recently added to the EP lab? How have these technologies changed the way you perform procedures?

Recently, the addition of Medtronic’s cryoballoon has changed the dynamic and the treatment of atrial fibrillation, as it has had increased efficiency and outcomes have been superior. St. Jude Medical’s TactiCath has offered us enhanced contact force technology.

What types of cardiac mapping systems do you utilize? 

We use St. Jude Medical’s EnSite mapping system, and are in the process of evaluating the cost benefits of purchasing Biosense Webster’s CARTO system.

What imaging technology do you utilize?

We currently use Philips for fluoroscopy and intracardiac ICE. When performing atrial fibrillation ablations, we employ cardiac MRI and cardiac CT in conjunction with St. Jude Medical’s EnSite mapping system to evaluate a patient’s vascular and cardiac anatomy.

Do you implant MR conditional pacemakers or ICDs? What about subcutaneous or leadless devices?

We do implant MR conditional pacemakers and ICDs. We currently do not implant leadless or subcutaneous devices, but are in the process of training for these.

Who handles your procedure scheduling? Do they use particular software? 

Procedures are scheduled through the physician’s office using the McKesson central scheduling management system. We have a designated secretary within our department to ensure accuracy  in procedure scheduling. In our cardiology practice, there is a procedural nurse who organizes the patient’s chart using a checklist, which includes all laboratory work, updated history and physicals, physician orders, and notifying vendors.

How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies?

We use the Logi-D system to manage inventory. The system uses tags to signal which inventory is low based on par levels, and these tags are then placed on a centrally located board to signal the need to reorder. Other items are tagged with a RFID tag, and when used, it is placed into a special receptacle that tracks items for reorder. We also use Stryker for our repossessing needs. Each week we receive a list of products that can be reordered, and we order products as needed.

Tell us more about your upcoming expansion. 

Yes, we are in the process of building a new EP/cath lab suite. The lab will be used as a crossover lab that will allow us to adapt to the needs of the department for EP, catheterization, and peripheral procedures. This addition is much needed as we add new EP procedures, incorporate the volume of an additional electrophysiologist, and continue to see higher volumes of cardiac caths and interventions. 

Have you developed a referral base?

We are a regional tertiary care center and have developed relationships with 7 community hospitals, which now regularly refer patients. 

In what ways have you helped to cut/contain costs and improve efficiencies in the lab?

Contracts are tenaciously negotiated in order to minimize expenditures related to devices and equipment. We use Stryker to reprocess the majority of our EP catheters, which has led to significant savings. To ensure quality and streamline processes, Concord Hospital has a Clinical Quality Value Analysis committee that analyzes and researches ways to adapt to the changing marketplace of hospital-based care.

How do you ensure timely case starts and patient turnover?

Ensuring timely case starts is a carefully coordinated process. Patients arrive one and a half hours prior to procedures to allow the opportunity for assessment by the RN and preparation of the patient, all while allowing ample time for patient interview by the electrophysiologist and/or the anesthesiologist. The electrophysiology team arrives 30 minutes prior to patient start time to assemble and arrange for all equipment necessary for the first case of the day. 

How are new employees oriented and trained at your facility?

Every new employee is assigned a preceptor. A series of competencies based upon standards of care are completed, including through computer-based learning modules. There is a concentrated effort by Concord Hospital educators to present applicable cardiovascular classes and symposiums to gauge and ensure that staff members are proficient.

What types of continuing education opportunities are provided to staff members?

Multiple continuing education avenues are presented to staff and encompass applicable topics. This includes hospital-based education on cardiac studies, pharmacology, basic and advanced EKG interpretation, pacemaker/device education, and a yearly cardiac symposium. Vendor education sessions are included, and involve a vendor-based program of educating staff on how to use specific devices and/or equipment as well as demonstrate hands-on proficiency. For the past two years, some staff members have been given the opportunity to attend the Heart Rhythm Society’s annual scientific sessions, which has been a significant boost in our continuing education achievement. Our physicians show a vested interest in staff capabilities by choosing a tracing prior to cases and assisting staff with identifying the rhythm through problem solving. Post-procedure case debriefings are performed for difficult cases.

How is staff competency evaluated?

Staff members have competencies that are signed off by their preceptor. If a staff member is not competent in a particular area, then they are offered more training and given the chance to understand and get signed off on the competency. The lab keeps a competency log, and a staff member is assigned to each competency to make sure all staff members are kept competent with all equipment and procedures in the lab.

Have members of your staff taken the registry exam for the Registered Cardiac Electrophysiology Specialist (RCES)? Does staff receive an incentive bonus or a raise upon passing the exam?

We have one staff member, Paul Hackett, who has received his RCES. He is a ‘veteran’ in our department, and has been here since our cardiac program’s beginning in 1989. Staff members do not receive a bonus or raise as an incentive to take the exam; however, the exam is paid for and educational materials are provided.

How do you prevent staff burnout? Do you also practice any team-building exercises?

Our EP/cath lab team has an extraordinary relationship. We are a close-knit group that works very well together. We try to plan monthly dinners or relax together outside of the work environment. Many of us love to hike, and make plans routinely in the summer and fall months. Teamwork is essential in what we do here, and we have an outstanding, dedicated team.

What committees, if any, are staff members asked to serve on in your lab?

Concord Hospital has several committees that our team is part of. There are representatives from our department on the following committees: Radiation Safety, Quality Value Analysis, Medication Safety, Cardiovascular Collaborative, and STEMI.

How do you handle vendor visits to your department? Do you contract with vendors?

Vendors have to schedule appointments and sign into vendor tracks in the main lobby, where they are assigned a badge.

Does your lab utilize any alternative therapies to help patients in the EP lab? 

The patient is encouraged to choose the music they would like to listen to during their procedure. Patients are given warm blankets, and there is a concentrated effort on positioning. Our staff members are compassionate and soothing in order to make patients feel at ease during their procedures. 

Describe a particularly memorable case from your EP lab and how it was addressed.

A recent pulmonary vein isolation cryo case stands out, because the patient had congenital atresia of the right superior vena cava with a persistent left superior vena cava. Dr. Chodosh was unable to pace the diaphragm from the SVC due to the congenital atresia, so he used a catheter and manipulated it around the coronary sinus, and was able to achieve diaphragmatic stimulation. He published this technique in the HeartRhythm journal (https://bit.ly/2chfjlO). 

How does your lab handle call time for staff members? 

We do not have a call team for EP, but we do have a cardiac catheterization team on call 24/7. This call team consists of 3 staff members and an interventionist. Both EP/cath lab staff members are required to take cath lab call every fourth weekend and one night per week. 

Approximately what percentage of ablation procedures are done with cryo vs radiofrequency?

Since Concord Hospital does proportionally more atrial fibrillation ablations, we use roughly 60% cryo and 40% RF.

Does your lab use contact force sensing technology during radiofrequency ablation of atrial fibrillation?

Yes, we use the TactiCath catheter (St. Jude Medical), which employs contact force sensing technology for pulmonary vein isolation for atrial fibrillation. 

What other innovative EP techniques are being utilized in your lab? 

Currently, we are the only hospital in New Hampshire that performs lead extraction procedures.

Do you perform only adult EP procedures or do you also do pediatric cases? 

We only perform adult procedures at Concord Hospital.

What measures has your lab taken to reduce fluoroscopy time? In addition, what types of radiation protective shielding and technology does your lab use?

We use many measures to ensure we are using the ALARA principle. For example, we use: 

• Pulse fluoroscopy at 7.5 f/s and low detail
• RADPAD (Worldwide Innovations & Technologies) to reduce scatter
• Personalized dosimeters that are checked monthly
• 3D mapping
• Ultrasound
• Lead glasses
• Additional lead attachments for the shield
• Hanging lead shields

What are your methods for device infection prophylaxis?

Thankfully, our infection rate is exceedingly low. Patients are given a surgical scrub solution, chlorhexidine. They are instructed to wash their chest for 3 days prior to the procedure with the scrub solution. When they arrive to the EP/cath prep area, they are clipped (if applicable) and the scrub solution is applied again. Patients are also given antibiotics prior to the incision, and a neomycin/polymyxin irrigation solution is used to irrigate the device pocket before it is closed. A sterile dressing is applied. The patient then follows up in one week post procedure for a wound check by a device nurse in the cardiology office.

What are some of the dominant trends you see emerging in the practice of electrophysiology? 

Evolving technologies such as three-dimensional electroanatomic mapping, contact force technology, the cryoballoon, and quad leads, are making EP procedures faster, safer, more predictable, and are leading to better outcomes.

How does your lab handle device recalls?

Vendors follow a notification process regarding affected patients, and then our electrophysiologists develop a patient care plan.

How is outpatient cardiac monitoring managed?

We have 2 dedicated device nurses who monitor daily remote transmissions. We currently follow approximately 2000 devices and see patients in 2 different device clinics. Cardiac nurse practitioners as well as electrophysiologists and cardiologists provide daily supervision. We use Paceart (Medtronic) for our device data management. We currently contract out with CardioNet for all outpatient telemetry and monitoring. 

How is coding and coding education handled in your lab? How is your lab dealing with the transition to ICD-10?

Our lab works in coordination with our coding department, in which we have a designated coder who is up-to-date with ICD-10 and provides feedback as necessary to maintain quality.

Is your EP lab currently involved in clinical research studies? Which ones?

We participate in a Northern New England EP lab registry, currently collecting procedural data as well as outcome data among 3 local institutions. We expect to eventually publish data. We participate in a primary prevention ICD trial through Indiana University, and have published case reports.

Does your hospital offer a cardiac device support group for patients? 

Yes, we have biannual device support groups. They are well attended and well received. We cover a variety of topics and have multidisciplinary participation including local social workers, psychologists, heart failure nurses, electrophysiologists, and device nurses. 

Describe your city or general regional area. How is it unique from the rest of the U.S.?

The state of New Hampshire is unique in so many ways. The amazing White Mountains, Lakes Region, and beautiful Seacoast Region are located here. There is also no sales tax. On April 12, 1934, the highest wind speed recorded in the U.S. at ground level was in New Hampshire at Mt. Washington; the winds were three times as fast as most hurricanes (231 miles per hour). Winter conditions on the summit of Mt. Washington can also rival those of Mt. Everest!

Please tell our readers what you consider special about your EP lab and staff.

Concord Hospital’s electrophysiology staff is passionate about the care we provide to our patients. Our team’s excellence springs from multiple medical professions bringing different skills and knowledge to our lab. Each and every one of our physicians is supportive and committed to educating staff, keeping us up to date on cutting-edge technology. The staff here is a very close family; not only do we work together, we also spend time with each hiking, camping, and enjoying other recreational pursuits.