Spotlight Interview: Korea University Anam Hospital

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

We have two EP labs. The electrophysiology program was started in 1993, and atrial fibrillation (AF) ablation was performed here for the first time in Korea in 1998. We are planning to add another EP lab and hybrid OR in the near future. 

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

We currently have a total of 18 team members in the EP lab, including four EP physicians, five EP fellows, six registered nurses, and three cardiovascular technicians. 

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? 

Our arrhythmia center provides comprehensive electrophysiologic care, including SVT ablation, complex arrhythmia ablation for AF and ventricular tachycardia, implantations of pacemakers and ICDs, and cardiac resynchronization therapy. LAA occlusion and lead extraction procedures are performed as well. 

We currently perform 800 ablations/year, including 350 AF ablations and 120 device implants/year. We perform approximately 6-7 AF ablations, 8-10 other ablations, and 2-3 implants each week. 

Who manages your EP lab?

Young-Hoon Kim, MD, PhD is the director of our EP lab. He is a globally well-known electrophysiologist in the field of AF ablation, and currently is the president of the Asia-Pacific Heart Rhythm Society. Hyun-Soo Lee, MPH, CEPS is a leader of the Korea Arrhythmia Allied Professionals, and Kyung-Jung Ko, RN manages our EP lab. They work together for staff orientation and education, equipment and supply selection, and to ensure appropriate staff assignments for various procedures.

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

The EP and cath labs have been separate since 2000. However, some of our RN staff members are cross-trained to work in both labs. Both labs share a day care center of 10 beds for pre- and post-procedural care. 

Do you have cross training inside the EP lab? 

No. RN staff members are trained to monitor, circulate, and sedate the patient. The technologists operate the stimulator and X-ray equipment, and scrub on occasion.

We realize that working as a team is extremely important in providing our patients with the best possible care. Therefore, we always work hard to maintain a strong teamwork environment in our EP lab.

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

We are a tertiary referral hospital affiliated with the Korea University Medical College.  

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

We most commonly utilize St. Jude Medical’s EnSite Velocity Cardiac Mapping System and Cool Flex irrigated tip ablation catheters for AF ablation in our lab. In addition, some of the equipment frequently used in our lab includes GE Healthcare’s CardioLab IT Hemodynamic and EP Recording System, the EP-4 and Bloom Cardiac Stimulators, Siemens/Biosense Webster’s ACUSON ICE catheters (navigation and non-navigation), and St. Jude Medical’s Swartz braided transseptal catheter sheaths, as well as diagnostic and ablation catheters from St. Jude Medical, Biosense Webster, and Boston Scientific.

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

We arrive at the hospital at 7 am, and prepare one or two rooms depending on case numbers. We usually have two or three AF ablations and SVT or device implantations per day. 

What imaging technology do you utilize? 

We use a 3D mapping system such as St. Jude Medical’s EnSite Velocity and Biosense Webster’s Carto for AF and ventricular arrhythmias. We utilize intracardiac echocardiography for ventricular arrhythmias originating from complex structures such as the coronary sinus, aortomitral continuity, and papillary muscle. Cardiac MR is performed to evaluate the scar distribution of the LA or LV. Rotational angiography is performed for left atrial 3D reconstruction using the Philips Allura FD10 angiography system.

What is your experience with MR conditional cardiac devices? 

For most cases, we implant Korean FDA-approved MRI conditional cardiac devices manufactured by Medtronic (Revo MRI SureScan pacing system) and BIOTRONIK (Evia pacemaker). We do not have adverse effects (e.g., significant increase in pacing threshold or change in lead impedance) under MRI (1.5 Tesla) with current pacemakers. 

Does your program utilize a cardiovascular information system (CVIS), picture archiving system (PACS), or cardiology picture archiving system (CPACS)?

Yes, a picture archiving system and cardiology picture archiving system are equipped in the Korea University Medical Center. 

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

We use the Google calendar. When operators decide on the procedure, they provide the patient’s identification to our dedicated nurse, and she arranges the schedule and uploads the schedule into Google calendar, which is shared with our EP doctors, nurses, and technicians.

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

We follow the Joint Commission International’s regulations for time out procedure and patient identifiers. All equipment is tested on a regular basis.   

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

The introduction of new equipment is decided on by physicians. To maintain adequate inventory, one of the EP nurses is responsible for checking it out within the EP lab. 

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

When a second EP room was opened three years ago, our patient volume, especially for AF, nearly doubled. To meet the expanded volume, a nurse and technician were recruited. 

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

In Korea, the expenditure is reimbursed by the National Health Insurance Corporation (NHIC). For example, NHIC guarantees AF ablation only two times. Therefore, we make the maximum effort to restore and maintain sinus rhythm under these limitations.

Have you developed a referral base?

As a tertiary referral hospital, patients are referred by primary and secondary institutes. However, many patients also visit our lab after finding us via the internet, public broadcast, or newspaper. 

In what ways has the EP lab contained costs or improved efficiencies in patient through-put? 

We have increased efficiency using the hospital reprocessing system. 

How are new employees oriented and trained at your facility?

We have a special program to train new employees. For three months, new employees observe procedures; after the training period, they perform procedures under a senior’s coaching for six months. If they meet expectations during the hands-on period, they will be signed off.  

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

Our lab encourages members to receive additional certification or licensing. There are regular educational opportunities and exams offered for each specialty. One technician and one nurse from our lab were the first people in Korea to pass the Registered Cardiac Electrophysiology Specialist (RCES) exam. 

How do you prevent staff burnout? In addition, do you practice any team-building exercises?

We currently have regular team building on a quarterly basis. Most of our team members also take part in an internal club for mountain climbing. 

Describe a particularly memorable case that has come through your EP lab. How was it addressed, and what lessons were learned from it?

We had a patient with suspected fascicular ventricular tachycardia (VT), which was interpreted from surface ECG. We performed an EP study and potential guided ablation; however, the VT was not terminated by ablation, even with enough power and duration. Therefore, we searched another site from which the clinical VT was originating. At last, we could finally terminate the VT by ablating the tip of the papillary muscle. However, it showed relatively narrow QRS, which could be observed during fascicular VT. Unlike an aortic approach through which we could terminate VT originating from the septal area or the base of the papillary muscle, we could more easily approach the tip of papillary muscle through transseptal puncture. The lesson learned was that when faced with confusing arrhythmias, one should try to explore their real origin as well as consider various ablation strategies.

How does your lab handle call time for staff members? 

We normally perform procedures five days a week; however, for emergencies we are available 24 hours a day, 7 days a week.   

Does your lab use a third party for reprocessing or catheter recycling?

No, our EP lab uses the hospital’s central reprocessing department, which is very efficient. 

Do you utilize both cryo and radiofrequency ablation in the lab?

We are not currently using cryo. Radiofrequency is used in 100 percent of our ablation cases.

Do you perform only adult EP procedures, or pediatric cases as well? 

Only adult EP procedures are performed at our facility.

What measures has your lab taken to reduce fluoroscopy time and minimize radiation exposure to physicians and staff?

We use the minimal fluoroscopy dose setting, and try to reduce fluoroscopy time using a 3D navigation system. Our hospital safety control team evaluates all team members for fluoroscopy exposure dose. Radiation exposure for our staff and physicians is monitored and reported every year. 

What are your thoughts on EHR systems? Does it improve your quality of care? 

The hospital has already adopted an EHR system, and most affairs are computer based. However, in EP lab, we still record the report by hand during the procedure, and type in a document after the procedure. The report is then scanned into the EHR system. These days, we are in the process of implementing an electronic-based recording registry, and once it starts, this work will be more convenient and we’ll have more rapid accessibility to record. 

How is outpatient cardiac monitoring managed?

The Device Clinic performs device follow-ups twice a week. This Device Clinic is run by a dedicated nurse, technician, and physician. These team members take charge of the interrogation, and doctors confirm the result and modify the settings as needed. Other monitoring, including 24-hour Holter monitors or 12-lead ECG testing, is generally based out of the physician practice, where the cardiac functional exam center performs these exams.

Describe your city or general regional area. 

Our center is located in Seoul, which is the capital, the largest metropolis, and business and financial hub of South Korea. The city’s highly developed infrastructure makes it convenient even for foreigners to use public transportation or access the internet. Seoul is surrounded by mountains, and the Han River flows through the center of the city. Since Korea has four distinct seasons, we can enjoy the different scenery and activities throughout the year. Also, our area has of lot of traditional and historic places. The Seoul metropolitan area contains four UNESCO World Heritage Sites: Changdeok Palace, Hwaseong Fortress, Jongmyo Shrine, and the Royal Tombs of the Joseon Dynasty. In contrast, Seoul is one of the most modern cities in the world. It is the center of the Korean Wave, which refers to the increase in popularity of South Korean culture, including K-dramas, K-pop, Korean traditional cuisine, and so on. Visit Seoul, South Korea!

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

Our EP lab was designed to be very large, making everyone’s job easier as well as providing patients with more comfort. We have a truly integrated EP team, and our primary goal is to provide superb EP procedures to appropriate patients. We are very proud of our good outcomes following complex procedures. Our main concerns are on patient safety, convenience, and satisfaction. We don’t care how early the first procedure starts or how late the last procedure ends. Everyone on our staff is hardworking, and we are always trying to learn more and adapt to using new technology.  

As one of the worldwide leading groups in the field of the EP, we’ve presented studies and shared our experience at many conferences. Also, since this is a teaching hospital, new trainees (including international fellows) visit our EP lab every year, and do their jobs well after finishing their training here, continuing to co-work with us when needed.