Spotlight Interview: Mayo Clinic

What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab? We operate 5-6 EP labs per day, and have a separate non-invasive room for tilt table studies and any ICD follow-up examinations that require DFT testing. Along with our lab facilities, we operate the Heart Rhythm Center, which includes our Implantable Device Clinic, Arrhythmia Clinic, Atrial Fibrillation Clinic, Long QT/Inherited Arrhythmia Clinic, Pediatric and Adolescent Arrhythmia Clinic, and Syncope Clinic.

When was the EP lab started at your institution? Our laboratory was started in 1972; the first case was for arrhythmia mapping during open-heart surgery.

What types of procedures are performed at your facility? With year-to-date volumes available through September 2008, we are projecting to perform over 850 ablations, which includes over 400 PVI and 95 ventricular tachycardia ablations. We are estimating 500 ICD implants and 750 pacemaker implants.

What is the primary goal of your program? The primary mission of the Mayo Clinic is that the needs of the patient come first. Our specialty practice of the Heart Rhythm Services (HRS) follows that same vision; we provide cardiac arrhythmia patients with compassionate and expert care, with access to effective and state-of-the-art treatment. The Mayo Clinic has three shields that it serves: clinical practice, research, and education; time and effort are dedicated to all three shields.

Who manages your EP lab? The EP lab is managed under the overall integrated practice of the Heart Rhythm Services, which includes the procedure lab, HRS hospital services, the ECG lab practice, and the cardiovascular monitoring unit.

Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained? The EP lab is separate from the cath lab; it was initially developed as a separate practice. However, we do share the same building space and integrate for the prep/recovery room, information technology, lab office practice, and appointment scheduling. Staff is cross-trained between the lab, hospital, and clinic practice within the HRS. Staff cross-train between the cath lab and HRS for sedation, but otherwise focus on individual specialties.

Do you have cross training inside the EP lab? We cross-train with certain job functions, such as 3-D mapping and the operating of specialty equipment.

What are the regulations in your state? CRNAs or nursing personnel provide sedation per state guidelines. There are many unit-specific protocols and guidelines that have also been developed internally by Mayo experts in the field.

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 are currently trialing Hansen Medical’s Sensei Robotic Catheter System. New technology is continuously being incorporated into our practice, so change and advancements are constantly occurring.

Who handles your procedure scheduling? Do you have a preferred software? Multiple individuals, from schedulers to secretaries to the technician supervisor, handle procedural scheduling. Regarding software, we share an integrated system developed at Mayo for the cardiac cath lab and HRS.

What type of quality control/quality assurance measures are practiced in your EP lab? We track our long-term ablation outcomes for patients on a yearly basis. We also track procedural complications such as lead dislodgement, infection, pseudoaneurysm, hematoma, etc.

How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? We have a dedicated supplies chain management staff person, located in the cardiac lab, who provides an overview of inventory management. The cardiac cath lab has a dedicated individual that operates the day-to-day functions, and HRS is attempting to move towards a similar model. Most of our supplies are on automatic reorder based on supply usage. Par levels need to be adjusted periodically to deal with changes in usage patterns.

Has your EP lab recently expanded in size or patient volume, or do you expect it to in the near future? The practice typically grows by 10-15% in volume each year. We expect this to continue in the future. We are seeing the biggest growth in ablation and ICD implants.

Have you developed a referral base? We work directly with many different practices in the region as well as across the country. This is one of our keys to success.

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? Two of the most important items are cost containment/reductions of supplies and cross-training staff for various roles. We have held multiple Six Sigma / LEAN retreats on topics such as materials management, procedure scheduling, and ablation patient flow. These retreats feature key members from all the various disciplines involved in the practice, with the goal to improve the future state.

Does your EP lab compete for patients? Mayo is an integrated practice, so we do not compete internally. However, externally there is always competition, so you continuously need to evolve to remain competitive.

What procedures do you perform on an outpatient basis? In addition, what EP procedures are generally only considered inpatient? All ablations and new implants are considered inpatient. Device pack changes, EP studies, ICD DFT testing, and tilt table studies are done on an outpatient basis.

How are new employees oriented and trained at your facility? We have a formal orientation program for nurses and new RCIS staff. The length of orientation is based on completion of competency requirements and individual needs assessments.

What types of continuing education opportunities are provided to staff members? HRS staff attend core curriculum (unit-specific) classes each Monday, during which different topics are covered with various physician speakers providing the lecture. Other weekly or monthly opportunities include basic to intermediate EP and ablation education, implantable device tracings review, and morbidity and mortality cases, along with institutional opportunities.

How is staff competency evaluated? There are core Mayo Clinic competencies, such as emergency preparedness and infection control, that are required as an institution. Other competencies are job-specific to the work unit and are carried out annually.

How do you prevent staff burnout? Due to the specialization of the EP lab, burnout with staff is a constant challenge. The HRS practice continues to grow rapidly during a time in which incremental staff is the hardest to approve. It is hard to keep ahead of this situation. The key is to continually reinforce to staff that they make a positive impact in patients’ lives. You cannot do that enough.

Do you practice any team-building exercises? The best team-building exercise that can be done is to be committed to an integrated practice where all staff are important members and have a say in how to best meet the needs of the patient. Our staff also attended a Foster & Hicks presentation on mutual respect in the workplace.

What committees, if any, are staff members asked to serve on in your lab? Various committees include ablation practice, device practice, HRS operations, education, staffing and scheduling.

How do you handle vendor visits to your department? All vendors need to check in at the CV lab office prior to going into the specialty practice, and are expected to have an appointment prior to this. We have very specific criteria at Mayo related to vendor visits.

Do you contract with vendors? We do not. Our staff is trained to perform device implants, device follow-up, and operation of various specialty equipment. Vendors are present when new equipment is introduced into the practice, but only for a specified time.

Does your lab utilize any alternative therapies? We do use music therapy on request.

How does your lab handle call time for staff members? Call consists of device patient follow-up programming, rotated between all device nurses. However, there is no specific lab call at this time.

Does your lab use a third party for reprocessing? We do use a third party for some of the specialty catheter items.

Approximately what percentage of your ablation procedures is done with cryo? In addition, what percentage is done with radiofrequency? Only 1-2% of procedures are done with cryo. The rest (98-99%) are performed with radiofrequency.

Do you perform only adult EP procedures or do you also do pediatric cases? Is there cross training for pediatric cases? We perform procedures on all ages, including pediatrics. Cross training is done with staff for pediatric cases, and we also have a pediatric electrophysiologist on staff at Mayo.

What measures has your lab taken to minimize radiation exposure to physicians and staff? We are currently replacing the existing fluoro systems with new technology, which decreases radiation significantly. We have decreased frame speed rate as well. Procedure room redesigns are also helping to decrease dosing to staff.

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? Our device nurses rotate between the clinic and hospital. We currently follow approximately 15,000 patients with implantable devices. The nurses see approximately 400/week, between remote follow-ups and in clinics. We have created our own software program for this. There are two physicians that staff the Heart Rhythm Center who are able to intervene if abnormalities are found. Physicians only need to see patients when abnormalities are found.

What trends do you see emerging in the practice of electrophysiology? How is your lab preparing for these future changes? The treatment of atrial fibrillation continues to advance, and the needs for this population continue to develop. Our approach to atrial fibrillation is more comprehensive; we work with patients to help modify their risks to conditions such as sleep apnea, obesity, and hypertension, as well as make sure they receive the appropriate procedure and medication treatment.

What about device recalls? How has your lab handled these? We have a comprehensive approach when dealing with recalls. When a recall or advisory occurs, a meeting is called that includes key stakeholders in the process. This includes physicians from all Mayo sites, administration, materials management, lab and clinical leadership, legal, nursing, and office operations. Correspondence letters and frequently asked questions are drafted and sent to the patient via certified mail. Phone calls to each patient are also placed. Patients are brought into the Heart Rhythm Center for consultation and then can make an informed decision on how to best proceed based on their individual situation.

Is your lab doing web-based/transtelephonic device follow-up? Yes. This type of follow-up is seen very positively by our patients. This system started more than 15 years ago.

When was your last inspection by the Joint Commission? The hospital just completed the inspection this summer, and we are expecting them to review the clinic at any time.

Are you ACGME-approved for EP training? What do you think about two-year EP programs? Yes, and due to the complexity of the practice, you can see that there are benefits of a two-year program.

Does your staff provide any educational materials for patients who may have additional questions about their condition/procedure? In addition, does your hospital or lab staff have a device support group? Mayo Clinic helps us create our own educational materials that are specific to our practice. The nurses on our floor also share in education for our patients. In addition, we have our own support group as well as a coordinator for this endeavor.

Describe your city or general regional area. How does it differ from the rest of the U.S.? Rochester is a city of approximately 100,000. The Mayo Clinic has over 32,000 employees, so we are dependent on patients coming from all over the United States and abroad to support the large group practice. Our staff understand the mission statement regarding “the needs of the patient come first,” and that we need to continuously enhance our performance in every facet of the practice.

Please tell our readers what you consider unique or innovative about your EP lab and staff. We are currently in a four-phase improvement of identifying patients at risk for sudden cardiac death. We are working with our colleagues in cardiovascular diseases, internal medicine, administration, the quality office, systems and procedures, information technology, Mayo communications, education, nursing, and many other work groups within the Mayo practice. Our goal is to identify at-risk patients real-time while they are within the clinic or hospital setting, and that a discussion regarding SCA is documented in the electronic medical record.

For more information, please visit www.mayoclinic.org.