Spotlight Interview: Eisenhower Medical Center

What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab?

The EP lab has two rooms, 1 active, with four staff members. There are three RNs and one scrub tech.

When was the EP lab started at your institution?

Andrew Rubin, MD started the lab at Eisenhower Medical Center in 1994.

What types of procedures are performed at your facility?

Our procedures consist of implants of BiVs, ICDs, and pacemakers, as well as AV node ablations, atrial flutter, bypass tract, WPW, and SVT and VT ablations. We are currently preparing for atrial fibrillation ablations this fall.

Approximately how many are performed each week? What complications do you find during these procedures?

We perform approximately 20 cases a week, which does not include elective cardioversions, tilt table testing, or non-invasive EP procedures (NIPS). We have rare complications of lead dislodgement and hematomas. The lab is below the national standard of infection rates for devices.

Who manages your EP lab?

Sharon Duncan, RN is our clinical supervisor.

Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained?

The lab is independent; it has been freestanding from the cath lab since 1997.

Do you have cross training inside the EP lab? What are the regulations in your state?

The RNs are cross-trained in the lab to work the EP stimulator system, to perform conscious sedation, and to circulate and scrub cases.

What new equipment, devices and/or products have been introduced at your lab lately? How has this changed the way you perform those procedures?

Recent equipment added to the lab includes the Endocardial Solutions (St. Jude Medical) mapping system, new delivery systems for BiV/ICD implants, and our intracardiac echocardiography (ICE) machine. The constant change in device requirements and standards has increased the number of ICD and BiV/ICD implants. The use of non-contact mapping has decreased the length of our cases. We have two electrophysiologists and eight cardiologists who implant pacers. Our electrophysiologists and staff have been involved with a Brady training program for the last ten months for California cardiologists wishing to learn implant procedures. We are currently looking into expanding our program to other states.

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

We have a central scheduling department that utilizes Pathways Healthcare Scheduling System by McKesson. The scheduling team also works closely with our supervisor. All add-on cases are handled through the supervisor and the EP lab staff. We keep close contact with our physicians about scheduling issues or any events that may alter the schedule.

What type of quality control/quality assurance measures are practiced in your EP lab?

Our quality assurance measures consist of monitoring infection rate, turnover time, and conscious sedation.

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

The EP lab staff manages inventory, and the supervisor purchases supplies and equipment.

Has your EP lab recently expanded in size and patient volume, or will it be in the near future?

Our volume has gradually increased due to growth of population in the Coachella Valley. The most marked increase has been the BiV/ICDs. This growth will continue to affect the number of cases we perform.

How has managed care affected your EP lab and the care it provides patients?

Managed care has affected the lab at a low rate. Our base population is 70 - 80% Medicare patients.

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 utilize bulk purchase options for devices to contain cost. We also open supplies as needed, and do a lot of price comparisons.

Does your EP lab compete for patients? Has your institution formed an alliance with others in the area?

Our lab does not have to compete for patients since we are the only full-time, dedicated EP lab in the Coachella Valley.

What procedures do you perform on an outpatient basis?

On an outpatient level, we perform generator changes, EP studies, and uncomplicated ablations. Selective new device implants also are considered for outpatient status. We utilize a Special Procedure Unit for cardioversions, tilt table testing, and occasional NIPS procedures.

How are new employees oriented and trained at your facility?

New employees are partnered with experienced EP employees; the length of training is based on an as needed basis. Each job is thoroughly taught and evaluated before moving on to another job area in the EP lab (i.e., giving moderate sedation, circulating a surgery, operating the EP lab system and stimulator, and scrubbing surgeries and procedures).

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

Continuing education for the lab is offered via an annual hospital skills day. We offer an annual electrophysiology symposium, which is sponsored by Bard EP. Our staff attends the annual Heart Rhythm Society meeting, as well as other ongoing device company in-services. The staff and physicians review cases or have internal educational meetings.

How is staff competency evaluated?

Staff competency is observed on an ongoing basis, with new procedures evaluated yearly. Yearly evaluations are done by the supervisor with goals for the next year.

How do you handle vendor visits to your department?

Vendors are present for device implants; other reps make appointments through our clinical supervisor.

Does your lab utilize any alternative therapies?

Our lab prides itself in our vast collection of music and our stereo system. We ask patients if they have a favorite type of music; that allows the patient to mentally drift with the adjunct of moderate sedation.

Please describe one of the more interesting or bizarre cases that have come through your EP lab.

One bizarre case that took place in our lab was of a young female patient status post endocarditis with valve replacement surgery, that developed into heart block intra-op. A pacemaker was implanted utilizing epicardial leads. Post-op, the patient had an episode of ventricular fibrillation, requiring a return visit to the EP lab for an upgrade to an ICD. After numerous surgeries, this young lady was discharged in good condition and extremely thankful that new technology continues to develop.

How does your lab handle call time for staff members? How often is each staff member on call?

The staff is only on call from 6am until 2:30pm during days that no cases are scheduled. That phenomenon is extremely rare. We do not work on weekends or holidays.

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

We only perform procedures on patients older than 14 years old.

Does your lab provide surgical backup for procedures (such as biventricular implants)?

Surgery will place epicardial leads for unsuccessful BiV/ICD implants, and will assist in implants if extensive subcutaneous tunneling is required.

What trends do you see emerging in the practice of electrophysiology?

Some of the exciting trends we think are emerging in the field of EP include advanced techniques of atrial fibrillation ablations and remote monitoring of heart rhythm devices.

When was your last JCAHO inspection?

We are surveyed by JCAHO, which can be done at any time.

Does your lab provide any educational or support programs for patients who may have additional questions or those who may be interested in support groups?

Education is given to patients on an individual basis, with plenty of materials given about post-op care. They are educated in the EP physician outpatient clinic, which has extensive Web sites and literature information.

Give an example of a difficult problem or challenge your lab has faced. How it was addressed?

A difficult challenge for the lab is providing flexible hours to accommodate cases for physicians versus limited staffing resources.

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

Coachella Valley is the region surrounding the city of Palm Springs, California. Our valley's growth rate is approximately 52 new residents per day. The expected population by the year 2010 is estimated at over 800,000, with a moderate number of patients that live here six to eight months per year.

Please tell our readers what you consider unique or innovative about your EP lab and staff.

The employees of the EP lab know and work very well with our electrophysiologists, Dr. Andrew Rubin and Dr. Leon Feldman. It makes for a pleasant working environment that is nice to come to every day. As we are not a large academic center, we may have an easier direct communication link to the hospital administration, who always support our EP lab program and its growth.

For more information about Eisenhower Medical Center, please visit www.emc.org.