Spotlight Interview: Fletcher Allen Health Care

What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab? The Arrhythmia Service at Fletcher Allen Health Care (FAHC) includes 4 academic physicians, one private practice physician, two nurse practitioners, 1 clinical fellow, several research fellows, 7 lab staff (all RNs), 2 pacemaker clinic RNs, 2 ablation clinic RNs, and one advanced practice RN who works exclusively in the ablation lab. When was the EP lab started at your institution? The EP service at FAHC was originally started by Dr. Arthur Levy in 1976; at that time, EP procedures were conducted in the cardiac catheterization laboratory. A dedicated electrophysiology lab was started in the early 1990s by Dr. Mark Capeless. The ablation and device programs were significantly expanded in 2002 with the addition of Dr. Spector and Dr. Lustgarten, at which point a second EP lab was opened. We now run two full-time laboratories: a biplane ablation laboratory and a dedicated operating room for device implantation. What types of procedures are performed at your facility? Approximately how many are performed each week? Over 1,000 EP procedures per year are performed at our facility. Approximately 600 device procedures (pacemakers, ICDs, biventricular devices and direct His bundle pacemakers) and about 350 ablation procedures, including ablation for atrial fibrillation, atrial tachycardia, ventricular and supraventricular tachycardia, are performed. Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained? The ablation lab is located within the cath lab suite; however, the EP lab functions completely independently (with its own physicians and nurses). In 2005 we moved the device lab into the OR for improved sterility. We now have a dedicated device implant lab that is staffed exclusively by EP nurses. Nurses are not crossed-trained with the cath lab, although we do help our neighbors out from time to time. All EP nurses rotate between the device and ablation lab. Who handles your procedure scheduling? Do you use particular software? There is a dedicated EP lab scheduler who works with the clinic nurses to schedule all outpatient procedures. All inpatient procedures are scheduled through the EP lab nurse of the day. All EP procedures are scheduled using IDX Imagecast software (GE Healthcare, Waukesha, WI). What type of quality control/quality assurance measures are practiced in your EP lab? Julie Eastman, RN, who is one of our dedicated staff nurses, splits her time between staffing the lab and acting as the quality assurance nurse. She reviews all intra-procedural or post-procedure complications. Data collection and documentation exceeds Joint Commission standards. All complications are discussed among the entire service at our monthly QA meeting, which is led by the EP QA director, Dr. Mark Capeless. How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? One of the EP nurses works actively with material management to maintain inventory within the EP lab. Close attention to changes in usage patterns allows us to maintain a tight inventory. The addition of new products is discussed between the nurses and physicians with consideration for utility and cost. The nurse then brings products to the attention of purchasing for price negotiation with venders. For large purchases, a business plan is initiated and presented to administration. 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? In addition to aggressive vender negotiation and use of strategies such as bulk purchasing and catheter reprocessing, the lab participates in a recycling program. In terms of improving efficacy, the lab staff has actively worked to achieve on-time starts and to minimize turnover time. The hospital has recently changed over to an electronic medical record (EMR), which allows us to gather history, lab values, EKGs and other test results prior to patient arrival. How do you prevent staff burnout? In addition, do you practice any team-building exercises? The staff regularly participates in team-building discussions and activities outside of the lab. How do you handle vendor visits to your department? Unless they are present to provide product support during a case, vendors are seen by appointment only. Does your lab utilize any alternative therapies? We frequently utilize music within the lab environment as a means of relaxation for both patients and staff. Our patients are encouraged to select the music they’d like to hear. 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 do not have an on-call schedule for the EP nurses. The lab runs from 7 am to 5:30 pm, five days a week. It is not unusual for procedures to run late, in which case the staff rotates who stays late. On rare occasions we have performed urgent ventricular tachycardia ablations and pacemakers on the weekend; however, any weekend calls are voluntary. Does your lab use a third party for reprocessing? How has it impacted your lab? We do use third party reprocessing. Although this has occasionally caused some fluctuation in inventory, we have realized tremendous savings as a result of reprocessing catheters. Do you perform only adult EP procedures or do you also do pediatric cases? Is there cross training for pediatric cases? We perform EP procedures on patients from ages 13 and up. What measures has your lab taken to minimize radiation exposure to physicians and staff? Like all labs we are conscious of and use appropriate measures to minimize radiation exposure, including protective gear, maximizing distance and minimizing fluoroscopy time. With the use of three-dimensional mapping, we have decreased fluoroscopy time for many ablation cases. Do your nurses/techs participate in the follow up of pacemakers and ICDs? If so, how many device visits per week do they handle? Do you use any particular software for follow up? How many of your ICD/pacemaker patients require a doctor for their visits? The device clinic is located off site and is run by dedicated nurses. The EP staff nurses perform all post-operative, emergency department and in-hospital device checks. We also frequently see patients with mobility problems who have come to the medical center to see other providers. All device checks are documented in a Paceart system database (Medtronic, Minneapolis, MN) as well the hospital’s EMR. Is your lab doing web-based/transtelephonic device follow-up? The pacemaker clinic routinely uses web-based/transtelephonic transmissions for follow-up. This is quite useful to both the patients and staff, as we provide service to patients in rural areas (up to 3 hours’ drive from the hospital campus). Transtelephonic device checks are performed between outreach clinic visits. Web-based/transtelephonic transmissions have become a valuable resource for remotely troubleshooting device problems. Is your EP lab currently involved in any clinical research studies or special projects? The lab is currently involved in a few pre- and post-market device trials as well as investigator-initiated studies, including direct His bundle pacing and analysis of complex electrograms for mapping of atrial fibrillation. Are you ACGME-approved for EP training? What do you think about 2-year EP programs? We have an ACGME-approved EP fellowship training program. We feel that due to its complexity, clinical EP training now requires 2 years of fellowship. We also offer research training in electrophysiology. We have initiated a combined research/clinical track for training of fellows interested in a research/academic career. This is a 5-year program in which fellows have nearly 2 years of dedicated research time, perform the ACGME-required general cardiology rotations and then 2 years of clinical EP training. Do you provide any educational materials for EP patients who may have additional questions about their condition/procedure, or does your hospital or lab staff have a device support group? Outpatients receive both written and verbal pre-op instructions. All patients receive written discharge instructs, which are reviewed prior to discharge. In addition, all patients are given time to discuss their condition and treatment options with their provider prior to and after undergoing any procedures. For those patients seeking additional information, the hospital website has information about arrhythmia and treatments, including educational videos we’ve recorded for patient information (https://www.fletcherallen.org/services/heart_health/multimedia_gallery/video_gallery/videos_heart_health.html). Patients who undergo device implantation are given additional written and verbal instruction by an EP staff nurse at the time of post implant device check. For more information, please visit: https://www.fletcherallen.org/