Spotlight Interview: Nebraska Heart Hospital

What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab?

At the Nebraska Heart Hospital (NHH), there are 2 electrophysiology labs staffed with 4 dedicated EP staff members. Our EP team members include a mix of RCIS, RT (CV), and RNs.

When was the EP lab started at your institution?

The Nebraska Heart Hospital opened in May of 2003. Services at the Heart Hospital include 3 cardiology catheterization laboratories, 2 of which are set up to accommodate electrophysiology procedures. Having two procedural labs enables an efficient turnaround, providing staff and physicians dedicated time to patient care.

What types of procedures are performed at your facility?

The Nebraska Heart Hospital performs all types of ablations, EP diagnostic procedures, device implantation including biventricular pacemakers and ICDs, and laser lead extractions.

What is the primary goal of your program (AF ablations, lead extractions, BiVs, etc.)?

Our physicians are focused on all EP procedures that fulfill our patient's individual care, from complex VT ablations to implantation of biventricular devices for the management of congestive heart failure. Due to the diverse medical and interventional therapies available, each patient's care plan is individualized to best meet their needs.

Approximately how many are performed each week? What complications do you find during these procedures?

On average, we perform 20-30 EP procedures per week, which include all device implants and all types of ablations.

Who manages your EP lab?

Our Cath Lab Team Leader, Jackie Mendoza, RN, manages the EP lab. Jackie works with physicians and staff to identify efficient strategies, which contributes to superior outcomes for patients.

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

The EP lab is not separate from the cath lab. All staff are cross-trained to circulate and scrub EP procedures, excluding the EP recording. There are four staff who are trained to record all EP and ablation procedures.

Do you have cross training inside the EP lab? What are the regulations in your state?

All staff are cross-trained for EP procedures. The state of Nebraska allows institutions to govern who can administer conscious sedation, and all hospitals in Nebraska mandate that only RNs give conscious 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 are a test lab for Siemens' new EP software with the ability to integrate the whole hospital's electronic medical records (EMR) and demographics in the EP system. This will give us the ability to standardize reports and have the free flow of data back and forth from the hospital system to the EP system, which creates greater efficiency in the lab. The endpoint would be billing and materials management to be seamlessly completed with little human interaction, and eventually, inventory ordered electronically.

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

We have a scheduler that manages the cath and EP lab's schedules, with the Cath Lab Team Leader overseeing the schedule. Our staff are scheduled for stacked shifts Monday through Friday with rotating evening/night/weekend call.

What types of quality control/quality assurance measures are practiced in your EP lab?

Our current initiative focuses on tracking and preventing infection, maintaining the CMS device registry, and monitoring sedation administration and complications. Providing a multidisciplinary team approach to patient-centered care is the focus of our organization.

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

We have an inventory coordinator who manages our inventory. The Cath Lab Team Leader purchases equipment.

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

As we are a new hospital, our patient volumes are continually on the rise.

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

Being a relatively young organization, we have not noticed the effects of managed care as many other hospitals have experienced. Managed care, PPOs, CMS (Medicare), and like-centered organizations are all we have known since our doors have opened.

Have you developed a referral base?

Patients in our EP service are referred through consults from general cardiologists as well as from primary care (Family Practice and Internal Medicine) physicians. The Hospital benefits from its sister company, which provides services through a network of seven offices and outreach clinics to more than 40 communities.

What measures has your EP lab implemented in order to cut or contain costs?

The implementation of product standardization provides pricing incentive from participating vendors. We use just in time inventory management to control cost of on-hand inventory.

In addition, in what ways have you improved efficiencies in patient throughput?

There is no difference between types of patients that we treat in our EP lab compared to other hospitals this is how we do it at NHH. We are breaking ground on integrating the hospital's Health Information Management (HIM) system with EP and cath lab procedures. This has allowed us to implement quick turnaround times between procedures to maximize staff and procedure room utilization. These measures allow patients to return to their rooms quicker and therefore to be dismissed in a timely fashion. In turn, we can care for more patients in our facility while decreasing their length of stay.

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

There are 2 other facilities in our city that provide similar services. However, through our physician practice organization and reputation for outcomes, the Nebraska Heart Hospital maintains a high volume, resulting in a strong program.

What procedures do you perform on an outpatient basis?

Device exchanges and some EP/ablation procedures are performed on an outpatient basis, providing that these patients meet the dismissal criteria mandated by Heart Hospital physicians.

How are new employees oriented and trained at your facility?

New cath lab staff members participate in hospital orientation for new employees, and then undergo department orientation, which is individually tailored using a mentor.

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

We send 2 staff members annually to the HRS meeting. This past year, we offered a two-day course at our facility offered by Order and Disorder in the Cardiac Rhythm, Beyond the Basics. This course offered CEUs for participants, and was extended to all EP staff in the Omaha-Lincoln metro area. Nebraska Heart Hospital also offered a Triggers and Tracing in-service for staff.

How is staff competency evaluated?

We perform a series of annual competencies in which all employees are mandated to participate. These competencies are peer-reviewed and self-tested.

How do you prevent staff burnout?

The cath and EP lab employees are afforded the opportunity to change the hours of their shifts if needed, and to flex between 8- and 10-hour shifts weekly. We self-schedule our on-call days by having four different call groups. One person from each group takes call every night; our employees schedule their days around their personal schedules. Those that like extra call have ample opportunity to take as much as they want, and those who like as few days of call as possible find this need fulfilled as well.

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

We have staff members on the Safety Committee, the Infection Control Committee, a Pharmaceutical Error Prevention Committee, and various other committees as the opportunities present themselves. By participating in various forums, staff gain an ownership in the different processes that affect their day-to-day responsibilities.

How do you handle vendor visits to your department? Do you contract with vendors?

Unless a vendor is required to be there for a procedure, we only allow vendors in our department if they scheduled a time in advance. Vendors have to check in at the front desk of our hospital and receive a vendor ID badge. We do contract with several vendors for our EP and ablation catheters and for our devices and lead systems.

Does your lab utilize any alternative therapies?

Our lab does not use alternative therapies at this time.

How does your lab handle call time for staff members? How often is each staff member on call? How frequently do they have to come in, on average? Is there a particular mix of credentials needed for each call team?

Our employees take call on a rotational basis and for all cath lab procedures, not just EP procedures. Each staff member makes their own call schedule; we have four different teams, and one person from each team is required to be on call every night. The teams decide amongst themselves how the call is divided. Two of the teams are comprised of RNs so that we have two nurses on call most nights, and one team is comprised of the dedicated EP staff members, thus enabling us to have an EP person on call every night as well. Our call team frequently stays after hours to finish the cases for the day. Our call team occasionally is called in the middle of the night, and the call team also performs anywhere from 3 to 10 procedures over the weekends. Our staff members take call in addition to their regularly scheduled full-time hours.

Does your lab use a third party for reprocessing?

We do use a third party for reprocessing of all of our EP and ablation cables and any of our EP catheters that are not steerable, or in other words, not on a handle.

Approximately what percentage of your ablation procedures is done with cryo? What percentage is done with radiofrequency?

We are currently not using cryoablation therapies, although our physicians have expressed an interest; however, it is something we are planning for future use. One hundred percent of our ablations are done with radiofrequency, as well as utilization of some saline-cooled systems like Chilli (Boston Scientific) for some procedures.

Do you perform only adult EP procedures or do you also do pediatric cases? Is there cross training for pediatric cases?

We do mostly adult EP procedures, but occasionally we see cases of young adults in the 14- to 18-year-old range. We do not perform any procedures on patients with congenital heart disease at this time.

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?

The Nebraska Heart Institute has a Pacemaker and Arrhythmia Clinic that performs all follow-up for pacemakers and ICDs. As part of our staff EP training, we do send our employees to out-of-state clinics where they receive hands-on training from our industry representatives for device checks and troubleshooting devices for problems. Our Pacer Clinic uses Paceart software (Medtronic) for its patient registry. Most patients come to the clinic for routine checks without the physician being present. However, the physician is still in the clinic at the same time and is immediately available for any questions that may arise.

What trends do you see emerging in the practice of electrophysiology? How is your lab preparing for these future changes?

We see more device implants for congestive heart failure management as well as implanting the biventricular devices earlier in this disease process. We also see more patients scheduled for pulmonary vein and linear or Pappone techniques in managing paroxysmal and chronic atrial fibrillation. We are looking into the efficacy of treatment options such as cryotherapy technology in our ablation procedures. Also, we see technologies such as three-dimensional mapping becoming more routine in our EP practice. To stay ahead of the cure, we send staff members for additional training in these technologies and procedures.

What are your thoughts about non-EPs implanting ICDs? Do you train such individuals?

We have several cardiologists and cardiovascular surgeons who routinely implant pacemakers, and would consider training them to implant ICDs. However, at this time, we have no plans to train non-EP physicians for implanting ICDs and biventricular devices.

What about device recalls? How has your lab handled these?

Our vendors have been very generous in offering our physicians the freedom to choose what is best for patients when a device has been recalled. We have electively replaced most of these devices in our practice.

Is your lab doing web-based/transtelephonic device follow-up?

Our lab does not perform these services; however, the NHI Pacemaker and Arrhythmia Clinic does offer follow-up for devices.

Is your EP lab currently involved in any clinical research studies or special projects? Which ones?

We are currently involved in St. Jude Medical's RETHINK Trial for patients with congestive heart failure and narrow QRS. We also are involved in the MADIT-III trial through Boston Scientific.

When was your last JCAHO inspection?

We have not undergone JCAHO accreditation as of yet; we are not required to do so. We have undergone both state and CMS accreditation, which are considered far more vigorous then JCAHO. Many hospitals opt for JCAHO accreditation rather than undergo the CMS accreditation, as CMS recognizes JCAHO as an alternative.

Does your lab provide any educational or support programs for patients who may have additional questions or those who may be interested in support groups?

Nebraska Heart Hospital and Nebraska Heart Institute provide educational support and support groups for patients who have an interest.

Give an example of a difficult problem or challenge your lab has faced. How it was addressed?

Building an EP lab from the ground up as a new hospital has been a challenge in and of itself. Keeping EP-trained personnel has proved itself to be quite a challenge as well. Employees with EP experience are in high demand, and this speaks volumes about the individuals and the programs from which they arise. We have lost employees to industry; therefore, we are in the process of creating a career ladder within our department to keep the interest of our EP staff members within our organization.

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

Our city has a population of 230,000 people; we draw our patients from around the state of Nebraska and Midwest region, which is largely a rural farming community. Nebraska Heart Institute has strategically located clinics around the state for patient convenience.

Please tell our readers what you consider unique or innovative about your EP lab and staff.

Our cath and EP lab staff are highly motivated individuals who put patients and their families first and foremost. Our employees are keyed into minimizing waste and improving patient outcomes. Our staff is highly unique in that we not only record all EP and ablation procedures, we create the physician's procedure report before the patient even leaves our procedure room. This holds true for all cath lab procedures. Reports and images are available at bedside immediately following the procedure. Nebraska Heart Hospital is the first of its kind in that we have forged a unique partnership with Siemens Medical to create a truly digital system complete with electronic medical records.