Spotlight Interview: Maine Medical Center

Maine Medical Center (MMC), recognized as a Best Regional Hospital by U.S. News and World Report for 2017-2018, is a complete health care resource for the people of Greater Portland and the entire state, as well as northern New England. Incorporated in 1868, MMC is the state’s largest medical center, licensed for 637 beds and employing nearly 7,500 people. MMC’s unique role as both a community hospital and referral center requires an unparalleled depth and breadth of services, including an active educational program and a world-class biomedical research center. As a nonprofit institution, MMC provides nearly 23 percent of all the charity care delivered in Maine.

Who manages your EP lab and program?

Dr. Andrew Corsello is the Medical Director of the EP lab, Jill Knutson, BSN, RN is the Electrophysiology Program Manager, Jonathan Czachor, RCIS is the Director of Cardiac Cath Services, and Megan Lowell, BSN, RN is the Nurse Manager of the EP lab.

What is the size of your EP lab facility? Has your EP lab recently expanded in size or patient volume, or will it be soon?

The Cardiovascular Institute at Maine Medical Center is currently home to 3 EP labs, with a fourth EP lab slated to undergo construction in spring 2018. We are also welcoming 3 new electrophysiologists to our team in late summer or early fall. Maine Medical Center has also recently been approved a certificate of need for a $512 million expansion featuring a new cardiovascular tower, which includes 4 state-of-the-art EP labs, 5 cath labs, and 10 ORs (including 4 hybrid). The new tower will also house patient rooms as well as a prep and recovery area specially designed to serve our patients.

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

The EP lab at Maine Medical Center is comprised of 15 staff members that are dedicated to EP. This includes 10 RNs, 2 CVTs, and 3 RT(R)s, as well as a number of per diem staff members.

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 performs a variety of procedures, including complex ablations. We implant permanent pacemakers, ICDs, loop recorders, the WATCHMAN device (Boston Scientific), the Micra TPS (Medtronic), MR conditional pacemakers, and subcutaneous ICDs (S-ICDs). We also perform cardioversions, TEE/cardio-versions, CRT, His bundle pacing, and Convergent procedures. Table 1 (in next column) shows the number of procedures performed yearly since 2015.

Are employees cross trained?

We have a swing team that is trained in both cath and EP. However, because of the high volume of complex cases, we maintain separate staff for our EP and cath labs.

Do you also have cross training inside the EP lab?

Our entire EP lab staff is cross trained throughout the EP lab to scrub, monitor, or circulate most cases. Some procedures, such as pediatric cases and WATCHMAN implants, have dedicated specialized staff.

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

Staff members generally work either a 9- or 10-hour shift four days per week. Coverage is typically staggered, with shifts running from 0630-1700, 0700-1730, or 0800-1730. There is a 24-hour service for any emergent procedures.

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

EP procedures are scheduled by the Maine Medical Partners – MaineHealth Cardiology Scarborough office, in conjunction with two administrative staff at MMC’s EP lab, using the EMR system EPIC.

How are new employees oriented and trained at your facility?

For 3-6 months, new staff is paired with one preceptor for each major role in the EP lab. This model has proven successful by decreasing staff burnout and providing new staff with a more well-rounded experience. Our Staff Development Coordinator sets up the learning plan for each new staff member and matches them with preceptors. A Learning Style Inventory is filled out by all current and new staff so learning styles and teaching styles are as appropriately matched as possible. We have a variety of didactic materials that are put into the new employee’s Competency-Based Orientation Tool, so they are learning theory alongside clinical knowledge and skills. The trainee and preceptor meet with the Staff Development Coordinator 2-3 times monthly to ensure their training is on track and meeting their needs.

What types of continuing education opportunities are provided to staff members? How do you prevent staff burnout?

Thursday mornings are dedicated to one-hour staff inservice training. We typically separate EP staff from the cath lab staff, considering their diverse educational needs. In addition, we provide inservices for soft skills and coping skills such as Professionalism, Compassion Fatigue, Mindfulness in Medicine, and Resilience. Staff members take turns rotating through out-of-state conferences such as the annual Heart Rhythm Society's scientific sessions. As Maine Medical Center is a teaching hospital, there are multiple opportunities for ongoing training and inservices at our institution, which are well attended by medical personnel from all over New England. Given our high volume and quality outcomes, we have close relationships with vendors who consistently provide educational opportunities both on and off campus. Finally, all members of the EP lab team are certified in BLS, ACLS, and PALS, which is taught by our qualified staff AHA instructor.

How is staff competency evaluated?

Our new EP staff utilizes a competency-based orientation tool that has checklists overviewing required competencies and tasks. New staff is not moved forward in their training and active participation in cases until they have demonstrated and documented competency. In addition, all EP staff members are evaluated annually during a 360-degree review, which includes input from their manager, peers, and physicians.

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

Of our 15 EP staff members, eight are currently RCES certified. Members of our EP staff are allotted a four-year window upon hire to pass the RCES exam. This certification also helps staff to climb the clinical ladder, which comes with significant benefits.

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

There are several committees at Maine Medical Center in which staff members can represent our EP team. Several of our staff are on these committees including the educational steering committee, quality committee, and the Key Performance Indicators committee.

How does your lab handle call time for staff members?

Currently, our EP lab does not require call. Our EP program utilizes a “late” team that consists of 2-3 staff members who stay late (after 1730) if cases are not completed. Our cath lab colleagues have a call team that is trained in temporary pacemakers should an emergent need arise.

What are your techniques for LAA occlusion? Do you have a primary approach?

As of the writing of this article, Maine Medical Center is the only hospital in the state implanting the WATCHMAN device. To date, we have implanted more than 50 WATCHMAN devices, and the outcomes have been excellent!

Is hybrid epicardial and endocardial ablation of atrial fibrillation performed at your institution?

Maine Medical Center offers hybrid Convergent ablation of persistent and long-standing persistent atrial fibrillation (AFib), and tailors the approach to the patient. Since starting our Convergent program, we’ve performed more than 50 Convergent hybrid procedures, and 89% of these patients have been in normal sinus rhythm at their one-year follow-up.

Do you treat only adult patients, or pediatric cases as well?

At Maine Medical Center, we have the only pediatric electrophysiologist in northern New England. As such, we are privileged to perform both pediatric and adult cases. Our pediatric cases are performed 1-2 times weekly and the lab is staffed by a dedicated specialty team.

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

The recent addition of a hybrid room in the cardiac suite of the OR advanced our complex ablations and laser lead extractions. Our approach to AFib in patients at high risk for recurrence is the Convergent procedure. We now perform this in one room, overlapping times with the surgeon. We've also been able to perform more complex lead extractions and re-implants with the support of a cardiac surgeon.

Another new change is the creation of a program allowing techs to close device pockets. This has further engaged the staff and been a complete win for the staff, patients, and physicians.

We also believe in the importance of specialization and the impact of volume on outcomes. Therefore, the current 6 adult EP physicians on staff have agreed to give up some procedures for the betterment of our patients. Of the advanced procedures, the following represent our sub-specialization:

• 4 out of 6 physicians perform AFib ablation
• 1 out of 6 physicians perform VT ablation
• 2 out of 6 physicians perform laser lead extraction
• 2 out of 6 physicians perform S-ICD implantations
• 1 out of 6 physicians perform WATCHMAN device implantations
• 2 out of 6 physicians perform Micra TPS implantations

Each of the physicians has 2-3 of these specializations. For example, the Micra TPS and S-ICD implantations are performed by the two physicians who chose to give up AFib ablation. Of note, our pediatric electrophysiologist on staff sees and performs procedures on all pediatric and adult congenital patients.

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

Managed care has had minimal impact on our practice. However, we have encountered inappropriate denials from carriers for implantable loop recorders and S-ICDs.

Have you developed a referral base?

Historically, our cardiology group has worked with hospitals and referring cardiologists to develop a regional systemic approach that serves the needs of a large part of southern and central Maine. As a result, we are able to maintain a fairly large EP program at Maine Medical Center with volumes that support advanced EP care. We provide EP services to over 60 cardiologists within this system. We provide on-site EP consultative services, device management clinics, and in some cases, perform basic device procedures at our system’s referral hospitals. We look forward to expanding access to our patients close to their homes. At the same time, we have worked with our marketing department to highlight new procedures such as the Convergent and WATCHMAN procedures.

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

Although many of our referrals come from within the MaineHealth system, we want to compete to provide advanced services to allow patients from Maine to stay within state for complex care. We do compete for basic EP patients in parts of our region that are close to other EP programs. We hope that our commitment to local EP clinics and the quality of our advanced EP program will help us build upon our market in those areas.

MaineHealth has 12 hospital-owned or affiliated hospitals. As the only EP lab for this system, we frequently see patients from other hospitals and have outpatient EP clinics in these communities. There are other EP programs in Maine, but there is little overlap in terms of competition for patients.

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

More than 95% are radiofrequency ablations.

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

Contact force has dramatically changed our procedures, and is used on the majority of atrial fibrillation and flutter procedures. It has allowed us to use minimal fluoroscopy as well as more precisely create linear lesions and wide pulmonary vein encircling lesions. The adoption of contact force and heavy reliance on impedance resulted in a change in our findings at the time of repeat AFib ablations — much of the time, the veins are already blocked when patients come back for repeat ablations. We also shifted toward PVI plus posterior wall isolation for the majority of persistent AFib ablations rather than PVI alone.

How do you use the NCDR Outcome Reports to drive QI initiatives at your facility?

We submit 100% of cases for patients undergoing either WATCHMAN or ICD implant to the NCDR registries. All cases are coded within two weeks of discharge. This allows the data abstractor to review opportunities for improvement with the EP medical director and EP attendings in real time for review and resubmission as needed. Registry results are shared with our entire EP team and administration on a quarterly basis.

Do you utilize lifestyle modification as therapy for your patients with atrial fibrillation?

Heavily. We screen aggressively for obesity, sleep apnea, and excess alcohol use, and then refer patients to a cardiac rehabilitation/lifestyle modification program for appropriate candidates prior to taking an invasive approach to management of their AFib.

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

We started Micra TPS implants during the first wave of rollout after FDA approval. The Micra pacer has been excellent for dialysis patients, after valve replacement for endocarditis, and after some laser lead extractions. As previously mentioned, MMC was the first hospital in the state to perform the Convergent procedure and, at the writing of this article, is the only hospital in the state implanting the WATCHMAN device.

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

We have seen a steady growth in laser lead extraction, AFib ablation, and VT ablation over the past few years. This year, we have two senior physicians becoming part time and three graduating EP fellows joining us in late summer/early fall, which will allow us to advance our VT, laser lead extraction, and AFib programs. These physicians are currently finishing training at Massachusetts General Hospital, Duke University Hospital, and the Cleveland Clinic; they will help us leap forward in the scope and quality of our advanced programs.

Is your EP lab currently involved in clinical research studies?

We have consistently been involved in landmark trials such as DAVID, SCD-HeFT, DAVID-II, MOST, BRIDGE, WRAP-IT, AFFIRM, and others. We're currently recruiting for ARTESiA, and will soon start recruiting for ASAP-TOO.

Are you ACGME-approved for EP training? What are your thoughts on two-year EP programs?

We have a general cardiology fellowship that just expanded to three fellows per year. We do not have an EP fellowship.

Most of us completed a two-year EP fellowship and agree that the current scope and depth needed to practice EP at a high level is better with a two-year fellowship.

Has your EP program achieved IAC accreditation, or does it plan to in the future?

Yes, we are assembling our application for IAC accreditation.

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

We have two mapping systems: CARTO (Biosense Webster, Inc., a Johnson & Johnson company), which we primarily use, and the EnSite NavX (Abbott). We also use the EP-4 Cardiac Stimulator (Abbott) and the CardioLab Recording System (GE Healthcare). Our ablation system is the SmartAblate System (Stockert/Biosense Webster, Inc., a Johnson & Johnson company). The ablation catheters we use are primarily the THERMOCOOL SMARTTOUCH catheter and 4 mm DecNav, F-type (Biosense Webster, Inc., a Johnson & Johnson company), and BLAZER (Boston Scientific). Our mapping only catheters for advanced ablations include the PENTARAY, LASSO, and DECANAV (Biosense Webster, Inc., a Johnson & Johnson company). We use diagnostic EP catheters from Abbott. We implant ICDs and pacemakers from Medtronic, Abbott, and Boston Scientific. Intracardiac echocardiography catheters used are the ACUSON AcuNav Ultrasound Catheter (Siemens Healthineers Global) and SOUNDSTAR Catheter (Biosense Webster, Inc., a Johnson & Johnson company).

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

EP inventory is managed in a couple of ways. We utilize an electronic replenishment system through our Offsite Distribution Center for high use catheters and supplies, as well as a manual process of ordering as needed for lower use items. For the low use supplies, we rely on a downloaded list from the McKesson monitoring system, which we run at the end of each day and then order accordingly.

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

We contract with Stryker Sustainability Solutions to reprocess diagnostic and ultrasound catheters. We also receive a rebate for reclaiming the platinum from catheter tips. The combination of these two initiatives results in an annual savings of approximately $700,000 for our institution.

How do you handle vendor visits to your department?

Our EP lab is closed to vendors unless there is a case-supported need. We do utilize vendors / clinical specialists for 3D mapping procedures. If an appointment is requested, it is vetted through the business manager and forwarded to the appropriate person (e.g., contract specialist, cath/EP business manager, EP director) depending on the nature of business.

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

Portland, Maine is a fantastic city that draws a unique group of patients, advanced practice providers, staff, and physicians. For some, the area seems too cold, too far, or too rural. For others, it's a dream place to live with breathtaking natural beauty, a friendly culture, and great restaurants, all within a two-hour drive from Boston, which has a collegial atmosphere and a strong patient-centered attitude.

Maine Medical Center is a 637-bed hospital that has the largest and most advanced cardiology program in northern New England, easily rivaling the programs in Boston, with whom we work closely. The physicians have a teaching and academic clinical appointment and outstanding partners. This structure allows us to concentrate on improvement and growth. Our lack of a competing system for EP in this catchment allows us to move forward in a way that is totally patient centered rather than competitive.

There are too many examples to be complete, but a few illustrative examples may help. All six EP physicians have an administrative role rather than having one physician perform administrative duties. Each hospital day starts with the physician going to the EP lab assigned to them, and running through all the cases for the day with the staff. The physicians then sit down for roughly 30 minutes to talk about each inpatient, so that a group decision is made on every complex case. The physicians have a strong bond of mutual respect, which allows our program to flourish.

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

We have a highly skilled and specialized staff that is instrumental in the success of our program. In addition, the physicians and staff have a wonderful rapport that allows them to speak openly about their experience and opinions, bettering our patient care.