Spotlight Interview: The Mount Sinai Hospital

Founded in 1852, The Mount Sinai Hospital is a 1,171-bed, tertiary-care teaching facility acclaimed internationally for excellence in clinical care and ranked 8th nationally for Cardiology and Heart Surgery by U.S. News & World Report. The division of cardiology is led by Valentin Fuster, MD, PhD. 

The electrophysiology lab at The Mount Sinai Hospital was started in 1985 by Professor J. Anthony Gomes, a currently active member of the EP faculty. In 2009, Vivek Y. Reddy, MD and his team were recruited to Mount Sinai. Vivek Y. Reddy, MD is currently the Director of Cardiac Arrhythmia Services for Mount Sinai Health System as well as the Leona M. and Harry B. Helmsley Charitable Trust Professor of Medicine in Cardiac Electrophysiology at the Icahn School of Medicine at Mount Sinai.

Srinivas Dukkipati, MD is Co-Director of Cardiac Arrhythmia Services and Director of the Electrophysiology Lab. Patients seek treatment for heart rhythm disorders at Mount Sinai because of its clinical expertise, leadership in the field of electrophysiology, innovative research, and the latest therapies being tested in clinical trials. The arrhythmia group is a multidisciplinary team that serves patients from around the world and strives to move the field forward.

What is the size of your EP lab facility? 

We have 3 dedicated cardiac EP lab rooms. Each room is fully equipped for performance of EP studies, catheter mapping and ablation of arrhythmias, and device implants. We share a 15-bed holding/recovery area with the cardiac catheterization lab. For lead extractions, we make use of an operating room outside the EP lab with cardiac surgery backup. 

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

The EP lab includes 8 full-time faculty, 5 clinical fellows, 2 research fellows, and a 25-member team of RNs, cardiovascular technologists (CVTs), and support staff. All RNs hold Bachelor’s degrees, and two RNs (including the clinical nurse manager) hold Doctorates in Nursing Practice. Caroline Austin-Mattison, DNP, FNP-BC is the Clinical Nurse Manager, and Sonia Zabala, RN, MPA is the Senior Director of Nursing, Mount Sinai Heart.

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? 

On average, we perform 20-25 catheter ablations, 4-6 ICD implants/generator changes, and 8-12 pacemaker implants/generator changes a week. 

Is your EP lab currently involved in clinical research studies? Which ones?

The EP Clinical Research Group (ECRG) is comprised of 9 dedicated, full-time research professionals and led by Betsy Ellsworth, MSN, ANP. We have over 40 active studies, and one-third of these were initiated by Mount Sinai EPs. Indeed, the EP group is performing 10 cutting-edge clinical trials requiring investigational device exemptions (IDEs) from the FDA.

Are you ACGME-approved for EP training? What are your thoughts on 2-year EP programs?

As of July 2017, we have an ACGME-approved 2-year EP program, which currently includes 5 fellows. Since 2009, we have strongly felt that 2 years are essential to develop the skills necessary for the range of conditions and treatments involved in EP today. 

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

The EP lab opens daily at 7 am. RNs work flex shifts: 7 am to 7:30 pm, 9:30 AM to 10 pm, or 11 am to 11:30 pm. CVTs work 7 am to 3 pm, 2 pm to 10 pm, or 3 to 11 pm. PCAs work 6 am to 2 pm, or 2 pm to 10 pm. There is no on-call coverage.

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

The EP lab team meets each day at 7:30 am to review the inpatient consult list and post-procedure patients. In each room, there are usually 3-5 cases scheduled, and these include any combination of ablations and devices. Several days a week, there are early morning conferences, including cardiology grand rounds, clinical case conferences, and electrogram review sessions. Throughout the day, there is frequent interaction in the EP lab between team members as cases are performed, and the common control room space promotes the sharing of interesting findings. We are always prepared for the add-on case late in the day, especially the emergency pacemakers that seem to occur on Friday night!

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

Several recently added technologies have focused on improving safety. For instance, we have introduced the pressure-sensing EpiAccess Needle (EpiEP, Inc.) to assist with epicardial access. Also, we have made frequent use of the DV8 Retractor (Manual Surgical Sciences), an esophageal deviation balloon, to avoid esophageal injury during ablation for atrial fibrillation (AF) procedures. 

What types of cardiac mapping systems do you utilize? 

We utilize a wide variety of mapping systems, and in the past year, these have included CARTO (Biosense Webster, Inc., a Johnson & Johnson company), EnSite NavX (Abbott), the Rhythmia Mapping System (Boston Scientific), CardioInsight Noninvasive 3D Mapping System (Medtronic), and the Topera Solution (Abbott EP). We anticipate using a few more new mapping systems this year (in IDE studies).

What imaging technology do you utilize?

We make regular use of ultrasound guidance to obtain femoral access for our ablation procedures. We use intracardiac echocardiography for every atrial fibrillation and ventricular tachycardia ablation. Pre-procedural CT scans are acquired for AF ablation, and in the past year, we have made more use of CT scans to identify areas with significant wall thinning prior to ventricular tachycardia ablations. 

Do you implant MR conditional pacemakers or ICDs? What about subcutaneous or leadless devices?

We have implanted MR conditional pacemakers and ICDs from each vendor as they have been released. We were a site in the FDA clinical trials for both the subcutaneous defibrillator and the leadless pacemaker (Mount Sinai was the lead site for the leadless pacer FDA trial). We are also an active enrolling site for the PRAETORIAN (PRospective, rAndomizEd comparison of subcuTaneOus and tRansvenous ImplANtable cardioverter defibrillator therapy) trial. 

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

Procedure scheduling is handled by the EP scheduling coordinator, and bookings are entered into Encapture scheduling software (Imagine Solutions). 

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

We have quarterly quality assurance meetings, during which the faculty and fellows meet with the nurse manager and the cardiologist director of quality assurance for Mount Sinai Heart to review any serious adverse events that occurred in the EP lab. 

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

Managed care has resulted in our hospital being especially proactive in obtaining pre-authorization for elective procedures. Also, we have been incentivized to reduce cost-inefficiencies associated with our delivery of care by entering procurement contracts across the Mount Sinai Health System. 

Have you developed a referral base?

Our referral base is mainly local/regional, but we also receive frequent referrals from other states as well as international referrals. 

How do you ensure timely case starts and patient turnover?

Outpatients are called the night before their procedure and asked to arrive at the hospital two hours ahead of time; preoperative laboratory studies and 12-lead EKGs are completed on the day of the procedure. Informed consent and evaluation by cardiac anesthesia and electrophysiology are performed in a timely manner. Inpatients are usually brought to the EP lab at least 15 minutes prior to the first case or before the end of previously scheduled cases. The charge nurse and clinical nurse manager ensure that all patients are prepped and brought in the EP rooms by 8 am. Potential barriers are promptly handled by the clinical nurse manager and/or attending physician to avoid any delays. Frequent updating of the patient tracking system and nurse manager rounding help ensure timely room turnover. 

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

The Mount Sinai Health System includes partner hospitals such as Mount Sinai Beth Israel, Mount Sinai St. Luke’s, and Mount Sinai Roosevelt. Although the institution is very large, we continually compete with numerous other systems in the New York area. This drives us to improve our level of service to patients and to incorporate the latest techniques and technology to improve outcomes. 

How are new employees oriented and trained at your facility?

RNs receive two full weeks of hospital orientation as well as four to eight weeks of lab orientation tailored to staff needs. Each RN is required to take a critical care course, and experienced critical care RNs have the opportunity to take the critical care examination. CVTs undergo a 6-month orientation period, the first 3 of which involve a mentored learning process.

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

For the nursing staff, there is tuition reimbursement of up to 13 credits for continuing education, and time is provided for up to 5 conference days. Mount Sinai is a Magnet facility, and all RNs are encouraged to obtain certification in their specialty areas. For CVTs, Mount Sinai provides intensive on-the-job training for those with healthcare experience; after two years of successful employment, they are encouraged to sit for CVT certification.

How is staff competency evaluated?

The hospital system provides annual online modules for training of all staff. A nurse educator works closely with the clinical nurse manager to ensure that staff members are current with any required testing and hands-on training for the lab. The manager does annual evaluations of RNs, CVTs, and PCAs, and the staff members are also provided an opportunity for self-evaluation.

How do you prevent staff burnout? Do you also practice any team-building exercises?

Weekly meetings are held, during which staff members are encouraged to verbalize any lab issues that require improvement. Such issues are addressed promptly or escalated to senior leadership as necessary. The EP lab manager utilizes per diem staff, travelers, and all resources to ensure adequate staffing, as this could be the number one factor for burnout. The staff members also have the opportunity to work with the Mount Sinai Talent Development and Learning team, who perform one-on-one interviews as well as develop programs to encourage teamwork and cohesiveness.

Describe a particularly memorable case from your EP lab and how it was addressed.

Every other year, we host the International Symposium on Ventricular Arrhythmias in New York, and for the 11th annual symposium in 2016, there was a live broadcast of three simultaneous ablations from our lab: two for ventricular tachycardia, and one for frequent premature ventricular complexes. The staff arrived very early to make sure all the equipment was ready, and there was a great deal of coordination involving every member of the team. Most important, the patients all had the courage to be part of the broadcast. 

How frequently are ablation procedures performed using cryo?

Approximately 5-10% of our AF procedures are done with cryoenergy. Otherwise, we use radiofrequency or laser energy. 

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

We use contact force sensing catheters (either from Biosense Webster or Abbott) for most catheter ablation procedures for atrial fibrillation. 

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

We do not perform hybrid ablation of AF at this time, because we are not convinced that the outcomes are superior to that achieved by us with catheters. Of course, we are open to revisiting this as more evidence develops. 

What are your thoughts on the use of the new oral anticoagulants (NOACs) in patients with non-valvular atrial fibrillation? 

We believe that NOACs are the primary therapy that should be used for stroke prevention in the majority of our AF patients. 

Do you perform only adult EP procedures, or do you also do pediatric cases? 

We also perform ablation cases in pediatric patients. In particular, we have a large experience with ablation in adult patients with corrected congenital heart disease (e.g., Fontan, Mustard, or Senning procedures). 

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

We use the WATCHMAN device (Boston Scientific), and less frequently (because of the lack of insurance coverage), the LARIAT Suture Delivery Device (SentreHEART, Inc.) for LAA occlusion. More recently, we have used the AMPLATZER Amulet Occluder (Abbott) in the setting of an FDA clinical trial. 

Do you participate in the left atrial appendage (LAA) occlusion registry? 

Yes. In addition, we have our own IRB-approved LAA Closure registry.

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

For scar-related refractory ventricular tachycardia, we are using novel ablation approaches such as bipolar RF ablation for deep intramural VTs, and alcohol ablation for septal VTs. If the VTs are of epicardial origin, we use pericardial access techniques for these arrhythmias; if the patient has an obliterated pericardium (e.g., from prior cardiac surgery), we work with our cardiac surgeons who can free up the pericardial space using a subxiphoid window to allow us to perform epicardial ablation. For atrial fibrillation, we are using a number of ablation technologies, including the CardioFocus laser balloon for pulmonary vein isolation, and will soon be starting FDA IDE clinical trials with innovative ablation catheters such as novel RF balloon technologies and robotically-driven collimated ultrasound technology. We are also using various rotor mapping technologies for persistent AF ablation (including Topera/Abbott and CardioInsight), and will soon be using several other novel mapping technologies in IDE trials. For complex atypical atrial flutters (AFL), in addition to high-density mapping technologies such as the Rhythmia system (Boston Scientific), we also utilize alcohol injection into the vein of Marshall to address otherwise recalcitrant mitral isthmus flutters. Another innovative technique is the use of transhepatic access in individuals without femoral venous access to the heart because of either a congenitally absent IVC or a chronically occluded IVC. In these patients, we have employed the transhepatic access to perform AF ablation, AFL ablation, and ablation of complex atrial tachycardias in corrected congenital heart disease.

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

Dr. Marie-Noelle Langan, Director of Electrophysiology Operations, has led initiatives to maximize the efficiency of documentation. We use the EHR (Epic) to schedule procedures and efficiently alert the team, including the scheduling coordinators, NPs, and physicians, about planned equipment to be used, clinical alerts, and potential clinical protocols that might apply for patients. We use EMR lists to ensure good follow-up at discharge from the hospital. Centralizing telephone conversations has decreased our medical errors and improved efficiency. The use of Epic ‘smartphrases’ helps remind providers about issues that should be addressed when calls are triaged so that remote information can be gathered prior to talking with the patient. Although it takes a fair bit of work at the initiation, it decreases work downstream.

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

Recent work has emerged about the importance of obstructive sleep apnea in atrial arrhythmia, and we frequently screen our patients with atrial fibrillation for this condition. We are also focusing more on improving our mapping and ablation techniques for atrial fibrillation beyond pulmonary vein isolation, using novel mapping algorithms. 

How does your lab handle device recalls?

Patients with devices are labeled in our system and can thus be identified easily. Generally, a recall will be associated with a list from the company as well. Most of our patients are also followed with remote monitoring. We develop a letter and a standardized template/smartphrase response to make calls to rapidly clarify the issue to the patient, and suggest that they make an appointment to discuss. The list is triaged based on risk, and the higher risk patients are the first to be addressed. We make note of the patients on the scheduling system and on the remote monitoring list, so all phone calls can be directed with this in mind.

How is outpatient cardiac monitoring managed?

We have developed a comprehensive system managed by the MAs, NPs, and MDs. This includes a printing system with documentation of the type of transmission (alert versus patient-initiated versus a routing visit), use of anticoagulation, and planned follow-up. This facilitates rapid decision-making regarding the need for telephone calls. Patients are tracked to ensure that they are connected with remote monitoring, and we follow up on all appointments with a strict “no-show” routine to ensure connectivity. Epic is used to formulate a list for all implant procedures to ensure that patients are transmitting successfully at discharge. We have created a patient pamphlet with information, including billing issues. We have smartphrases to document conversations regarding the utility of the remote when the device is wireless. 

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

New York City and its surroundings are home to multiple academic medical centers, but there is also a great demand for effective treatment of arrhythmia disorders, most of all, atrial fibrillation. Patients travel to New York from locations around the world to seek the latest medical advances, and people in the area come from all different walks of life. New York is also a wonderful and challenging place to live and work. Most of us commute from the surrounding communities, and for some of us, the ride to work can take as long as two hours. However, we are proud to be part of an effective and innovative team and hospital system. 

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

Our lab is characterized by a sense of professionalism in every team member, dedication to the highest level of patient care, and great camaraderie among the EP technicians, nurses, patient care assistants, and physicians. It is a highly effective and innovative environment. We are a close-knit group, and each day in the EP lab is a new experience. There is great variety on a daily basis, and rarely is there a dull moment. 

Disclosure: Dr Reddy serves as a consultant to, and receives grant support from Boston Scientific, the manufacturer of the Watchman device.