Spotlight Interview: Kaweah Delta 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? At Kaweah Delta Medical Center, we work in one EP lab and occasionally in one of three cath labs. Our staff includes an EP physician, three full-time RNs, and one full-time EP tech.

When was the EP lab started at your institution? The EP program at Kaweah Delta Medical Center began in July 2007 with the arrival of Dr. Sukhvinder (Sukh) Bhajal.

What types of procedures are performed at your facility? Ablations by Dr. Sukh Bhajal include supraventricular tachycardia, ventricular tachycardia, atrial flutter, atrial fibrillation, and AV node. Device implants include pacemakers, loop recorders, ICDs, and biventricular devices. Dr. Bhajal also performs lead extractions.

Approximately how many are performed each week? What complications do you find during these procedures? We perform 12–15 procedures weekly. We have had two pericardial effusions in the last two years. Who manages your EP lab? The EP lab is managed by Dr. Sukh Bhajal.

Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained? Yes, the EP lab has a dedicated staff separate from the cath lab staff. This began a year after the program started, when a dedicated EP lab was built. Staff members are not usually cross-trained from the EP lab to the cath lab; however, there are a few staff members with both cath and EP lab experience who will occasionally work in both labs.

Do you have cross training inside the EP lab? What are the regulations in your state? All RNs are trained to perform each task in the lab, and the EP tech does everything except sedation.

What new equipment, devices and/or products have been introduced at your lab lately? How has this changed the way you perform those procedures? We utilize the Carto mapping system (Biosense Webster, Inc., a Johnson & Johnson company, Diamond Bar, CA), GE Prucka (GE Healthcare, Waukesha, WI), Siemens fluoroscopy (Siemens, Malvern, PA), laser lead extraction system (Spectranetics, Colorado Springs, CO), and Sequoia ICE imaging (Siemens). The newest advances in EP technology allow us to do procedures more efficiently and with greater precision.

Who handles your procedure scheduling? Do you use particular software? Outpatient procedures are scheduled by a service that coordinates with Dr. Bhajal’s office, and inpatient procedures are scheduled directly by Dr. Bhajal.

What type of quality control/quality assurance measures are practiced in your EP lab? We monitor our program by the 2009 Joint Commission patient safety standard, use a pre-op checklist, and the Pyxis (Cardinal Health, Dublin, OH) computerized medication administration system. The department monitors safety issues, radiation exposure, and expiration dates on all products.

How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? The inventory is currently managed and purchased by the EP tech. We are constantly looking for new ways to save money, especially as our volume continues to grow.

Has your EP lab recently expanded in size and patient volume, or will it be in the near future? After the addition of the new EP lab last year, our volume and efficiency have both increased significantly. Since patients in this area were unaware of many of the services an electrophysiologist can provide, the initial volume was low, but now through Dr. Bhajal’s efforts to educate physicians on the benefits of ablation and device therapy, the volume has grown exponentially.

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 use the minimum number of catheters necessary, and we use third party reprocessing for our ICE catheters. A major way we can cut costs with all implanting physicians is using the appropriate device for the appropriate patient (i.e., not using a high-end pacemaker for a patient who has complete heart block or atrial fibrillation).

How are new employees oriented and trained at your facility? New employees undergo a six-week preceptorship under a seasoned employee in his or her field. After the six weeks, the employees begin to work independently with close supervision.

What types of continuing education opportunities are provided to staff members? Kaweah Delta’s EP lab staff attends the Heart Rhythm Society meeting each year as well as other regional programs offered through either the hospital or industry, so they may continue honing their skills and keep abreast of the newest advances in the EP world.

How is staff competency evaluated? Dr. Bhajal evaluates the EP lab staff based on their performance.

How do you prevent staff burnout? In addition, do you practice any team-building exercises? EP staff members work 3 days a week and are not required to take call, which prevents burnout. We definitely work long hours on the days we are in the lab, but knowing there is no pager to carry is a great advantage. The EP lab staff has frequent social gatherings where team building is practiced.

What committees, if any, are staff members asked to serve on in your lab? The EP nurses are active in the Magnet Program, which was developed by the American Nurses Credentialing Center (ANCC) to recognize health care organizations that provide nursing excellence. The program also provides a vehicle for disseminating successful nursing practices and strategies.

How do you handle vendor visits to your department? Kaweah Delta Medical Center has a check-in policy where vendors are required to get a badge and check in only for their scheduled appointments.

Does your lab utilize any alternative therapies? No.

How does your lab handle call time for staff members? The EP lab staff is not required to take call because of the long hours they put in during the 3 days that they are in the lab.

Does your lab use a third party for reprocessing? Yes, we use third party reprocessing for our ICE catheters, which helps save money.

Approximately what percentage of your ablation procedures are done with cryo? What percentage is done with radiofrequency? One hundred percent of ablations are done with radiofrequency in our lab.

Do you perform only adult EP procedures or do you also do pediatric cases? Is there cross training for pediatric cases? The majority of our patients are adults, but Dr. Bhajal is trained in both adult and pediatric EP procedures.

What measures has your lab taken to minimize radiation exposure to physicians and staff? We abide by ALARA recommendations pertaining to shielding, time and distance.

Do your nurses/techs participate in the follow up of pacemakers and ICDs? The device vendors are responsible for all of the device follow-up at Kaweah Delta Medical Center.

What trends do you see emerging in the practice of electrophysiology? How is your lab preparing for these future changes? There is an increase in atrial fibrillation ablations, as well as an increase in lead extractions. Our volume is steadily increasing in each of these procedures.

When was your last inspection by the Joint Commission? Our last review was in 2008.

Give an example of a difficult problem or challenge your lab has faced. How it was addressed? When the program first started in June 2007, there was not a dedicated EP lab, so we were constantly struggling for lab time. In July 2008, a dedicated EP lab was opened to address this problem, and it has made things much more efficient.

Describe your city or general regional area. How does it differ from the rest of the U.S.? Visalia, California is a community of 120,000 people located in Tulare County, in the heart of the Central Valley. It is about 3 hours north of Los Angeles, and about 3 hours south of the San Francisco Bay Area. Our community is largely agriculturally-based economically. We are also an area with a large indigent population due to the agriculture work environment. Our air quality is poor, and that is another factor that impacts the health of our community. Having more than a 51% Hispanic population, we also see a high percentage of our population with diabetes.

Please tell our readers what you consider unique or innovative about your EP lab and staff. The EP lab was started from the ground up with new staff, because there was no EP service in the area prior to Dr. Bhajal. Within one year from the opening of the lab, we were performing more than 500 procedures annually.

For more information, please visit: www.kaweahdelta.org