Spotlight Interview: Northwestern Memorial Hospital

As one of the country’s premier academic medical center hospitals, Northwestern Memorial Hospital (NMH) serves as the primary teaching hospital for Northwestern University Feinberg School of Medicine in downtown Chicago, Illinois. The hospital is committed to the advancement of healthcare through clinical innovation, medical education and scientific research. The medical staff represents virtually every specialty and is comprised of more than 1,600 affiliated physicians who also serve as faculty members of the Feinberg School. Northwestern was ranked #1 in Chicago and #17 nationally in Cardiology and Heart Surgery by U.S. News & World Report in 2012.

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

Northwestern Memorial Hospital has two dedicated EP labs, which were constructed in 2007 and are separate but adjacent to three cath labs, as well as a third EP lab that is under construction and is expected to open in Fall 2012.

What is the mix of credentials at your lab?

We have eight nurses, three cardiac ablation specialists, two operation coordinators, and one administrative assistant:

• Dale Beatty, BSN, MS
• Jesselyn Cacho, BSN
• Audrey Cole, BSN
• Lisa Forstall, BSN
• Diane Fort, BSN
• Tricia Geroulis, RN
• Joy Halsted, BSN
• Stephanie Markko, BSN
• Sara Mullins, BSN
• Nicole Cook, BSN
• Erika Elganzouri, BSN, MSN, MBA
• Byron Rollins, cardiac ablation specialist
• Greg Shade, cardiac ablation specialist, clinical engineer
• Kevin Walker, MS cardiac ablation specialist
• Lynda Perez, administrative assistant

We also have eight board-certified cardiac electrophysiologists and four EP fellows:

EP Attendings:

• Brad Knight, MD, Director of Cardiac EP, Director of EP Fellowship Program
• Rishi Arora, MD, Director of Experimental EP
• Alex Chicos, MD, Assistant Professor of Medicine
• Jeffrey Goldberger, MD, Director of EP Research
• Leonard Ilkhanoff, MD, Director of Inherited Arrhythmia Program
• Susan Kim, MD, Director of Device Clinic
• Albert Lin, MD, Associate Director of Cardiac EP/Director of EP, Northwest Community Hospital
• Rod Passman, MD, Associate Director of Cardiac EP/Director of AF Center

EP Fellows:

• Prashant Bhave, MD
• Evan Giedrimas, MD
• Taral Patel, MD
• Sharon Shen, MD

When was the EP lab started at your institution?

The modern EP program was started by Dr. Richard Kehoe in the 1980s. Dr. Alan Kadish took over as the director of the program in 1990 after moving from the University of Michigan. Dr. Kadish handed over the reigns as director of the EP lab to Dr. Jeffrey Goldberger after he rose to the position of Associate Chief of Cardiology. After Dr. Kadish left in 2009 to become the president of the Touro College and University System in New York, Dr. Bradley Knight was recruited from the University of Chicago to assume the EP directorship in October 2009.

What types of procedures are performed at your facility?

The entire range of electrophysiology procedures, including catheter ablation and device implantation, are performed at Northwestern. Our focus has been on interventional procedures for challenging and complex heart rhythm disorders, including ablation procedures for patients who have had failed procedures at other institutions, epicardial ablation, and left atrial arrhythmias following prior ablation or surgery. We recently performed the first left atrial appendage occlusion procedure in Illinois using the new LARIATs snare-based suture system (SentreHEART, Redwood City, CA) that requires a combined transseptal and epicardial approach. We are also involved in several investigational procedures. We were one of the top enrolling centers in the totally subcutaneous implantable defibrillator IDE study (Cameron Health, Inc.), and are continuing to enroll patients in the LAPTOP-HF trial (St. Jude Medical), which involves implantation of a transvenous lead with a left atrial pressure transducer.

Approximately how many procedures are performed each week?

Northwestern is the largest academic heart rhythm program in Illinois, with a large-scale community outreach program. There has been marked growth in interventional EP lab procedures over the past three years. We perform about 25 invasive procedures at Northwestern Memorial Hospital per week. However, our heart rhythm physicians also provide a full spectrum of EP procedures and services at several other regional Chicagoland hospitals, including Northwestern Lake Forest Hospital in Lake Forest, Northwest Community Hospital in Arlington Heights, and Hinsdale/La Grange Hospitals, which are part of the Adventist hospital system in the western suburbs.

What is the primary goal of your program?

Our primary goal is to provide compassionate, high-quality, evidence-based care for patients with heart rhythm disorders to improve our patients’ quality of life and longevity. Our focus has been on the management of complex heart rhythm disorders using a tailored interventional approach.

Who manages your EP lab?

Dr. Bradley Knight is our Medical Director, John Ernst is our EP Lab Manager, and Susan Campbell is the Director of Operations.

Are employees cross-trained?

No, although some of our nurses do have previous cath lab experience.

Do you have cross training inside the EP lab?

Yes. Although the model is based primarily on having nurses manage the patient and technicians manage the equipment, our nurses are cross trained and are often very involved in the technical aspects of the procedure, including the prep and setup as well as interfacing with the recording system during the procedure. Our nurses also scrub in for device implants.

What are the regulations in your state?

Illinois is a certificate of need state.

What new equipment, devices and/or products have been introduced at your lab lately?

Both labs have a Prucka recording system (GE Healthcare, Waukesha, WI) and a Bloom stimulator (Fischer Medical Technologies, Broomfield, CO). The third EP lab will be similar, with the exception of having a biplane Philips fluoroscopy system (Philips Healthcare, Andover, MA).

Regarding mapping systems, we have Carto 3 mapping systems (Biosense Webster, Inc., a Johnson & Johnson company, Diamond Bar, CA) in both of our EP labs. We also have the NavX system (St. Jude Medical, St. Paul, MN), which is portable and can be moved to either lab, and are planning to acquire a second NavX system in the near future as part of the third EP lab construction.

We were the first in the world to use the NRG^™ RF Transseptal Needle (Baylis Medical, Montreal, QC, Canada), and use it for most transseptal procedures now. We were early adopters of cryoballoon technology for atrial fibrillation (AF) ablation, and were the first hospital in Illinois to perform the left atrial appendage occlusion using the LARIAT^® (SentreHEART) device.

We have a Siemens ultrasound console (Siemens Medical Solutions USA, Malvern, PA) for intracardiac echo and another machine that we share with the cath lab. We recently moved a small portable echo machine into the EP lab as well, so that we can perform urgent surface echocardiograms in the event of a possible pericardial effusion or tamponade.

How has this changed the way you perform those procedures?

The availability of up-to-date, cutting-edge imaging and ablation technology has allowed us to push the envelope from a invasive procedural standpoint.

Have you recently upgraded your imaging technology?

We have two relatively new biplane Siemens imaging systems in each of our EP labs. One of our two EP labs also has Stereotaxis technology (Stereotaxis, St. Louis, MO) installed.

Who handles your procedure scheduling? Is a particular software used?

The nurse clinicians in the cardiology clinic perform scheduling of our outpatients. The operations coordinator in the EP lab collaborates with the nurse clinicians and with the inpatient service to ensure that the scheduling is complete and that all testing, lab work and education is performed. Cerner software (Cerner Corporation, Kansas City, MO) is used.

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

We have an institutional, prospectively maintained AF ablation database and quarterly quality reports that include the ACC-NCDR^™ National Registry. We have yearly competencies that the staff must also complete. Equipment is updated on a regular basis, and preventative maintenance is performed.

How is inventory managed at your EP lab?

We work with our materials management department to manage our inventory. We recently switched from manual ordering to using RFID to handle the inventory.

Who handles the purchasing of equipment and supplies?

Northwestern OR inventory management handles the purchasing of equipment and supplies.

How has your EP lab recently expanded in size and patient volume?

With marked growth in interventional EP lab procedures over the past three years, the staff have handled the increased volume well. Although our third EP lab is still under construction, we have handled the additional volume by expanding our hours of staffing and moving simple devices to the OR or cath lab when possible.

Is your EP lab part of a separate heart hospital?

Yes, the EP program is part of the Northwestern Bluhm Cardiovascular Center.

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

The primary effect of managed care has been restrictions placed on patients who are often unable to seek care outside their network.

Have you developed a referral base?

Yes, Northwestern Memorial Hospital is a primary referral center in Chicago for patients with heart rhythm disorders. Our physicians feel that clinical expertise, high-quality care, and close personal communication with referring physicians are critical components to creating and maintaining a referral base. One challenge has been the merging of local physician groups with hospital systems. Once a physician group becomes part of a hospital system, it makes it difficult for them to refer patients outside their system.

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

Reducing costs is a constant mission. We have recently implemented electronic inventory and expanded reprocessing systems to reduce costs. We also renegotiated our implantable device contracts in 2011.

In what ways have you improved efficiencies in patient through-put?

A key has been the creation of a full-time operations coordinator. The responsibilities of this nurse include working with the nurse clinicians, EP physicians, anesthesia, and consulting services to improve patient scheduling, start times, lab turnaround, and workflow.

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

The Chicago market is very competitive. We feel that the expertise of our heart rhythm team and physicians makes our services highly competitive in the region. Northwestern also recently purchased Lake Forest Hospital, and is in the process of vetting other potential acquisition opportunities. Our physicians have independently branched out to provide EP services to regional hospitals as described above.

How are new employees oriented and trained at your facility?

There is a three-month orientation process. Each new employee is evaluated, and if the need for additional orientation is needed, we do provide that time.

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

Each year, Northwestern Memorial Hospital will send some of the staff to the annual Heart Rhythm conference. We also have nurses attending the CVN review course. Northwestern Memorial Hospital is dedicated to providing educational opportunities to our staff. In addition to our regular local didactic conferences such as Cardiology Grand Rounds, this summer our Cardiology Division, under the direction of Dr. Clyde Yancy, held its first annual Cardiovascular and Cardiac Surgery Symposium, with a target audience that included our EP staff and nurses.

How is staff competency evaluated?

We perform annual competencies. Each staff member is responsible to perform a self-evaluation; we also do peer evaluations, and then the staff member will meet with our manager, John Ernst.

How do you prevent staff burnout?

We offer staff members opportunities to grow in their career. They are offered opportunities to attend classes/conferences and grand rounds during the work day. Our scheduling coordinator works with the staff to provide a flexible schedule that meets each staff member’s needs: some staff work three 12-hour shifts, some work four 10-hour shifts. We are closed on the weekend and do not take call.

Do you practice any team-building exercises?

We have frequent in-service opportunities outside of the hospital, and our physicians have had staff recognition events at their homes.

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

Examples include the Invasive Cardiology Nurse Quality and Patient Safety, Nursing Practice, Nursing Informatics and Technology, Nursing Research, Professional and Transplant Services, and Best People Committees.

How do you handle vendor visits to your department?

Vendors schedule appointments with the operations coordinator, and the hospital uses Reptrax to ensure security.

Do you contract with vendors?

All vendor contracts with the hospital are managed by our Purchasing Department.

Describe a particularly memorable case or event in your EP lab.

On February 2, 2011, there was a powerful and historic blizzard that hit the Chicago metropolitan area. The storm brought heavy snowfall, totaling 20.2 inches. The storm prompted some of the staff to stay in the hospital to accommodate emergency procedures. Despite being short staffed in the EP lab, with many of our physicians stranded in their vehicles in record snow drifts, we managed to have a team successfully perform a VT ablation on an inpatient who was admitted with repeated AICD firings.

This year we also performed the first LARIAT^® left atrial appendage closure in Chicago. The process was interesting in that it involved both epicardial and transseptal access, yet remained minimally invasive. The case was successfully completed by Drs. Knight and Lin, and the patient is doing well in follow up. Likewise, we recently implanted our first left atrial pressure monitor as part of the LAPTOP-HF trial. It was interesting to implant a left atrial lead from femoral vein access, and then the lead transferred by snare to the superior subclavicular device pocket.

The EP team has learned to pull together to accomplish our common goal of providing the best patient care. We support each other and our patients to provide a unique environment for our team and our patients.

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?

We do not take call. We staff both rooms until 19:30. We have two late nurses daily that are required to stay until our procedures are completed. Each member of the team is responsible for two late days a week. We have two nurses and one technician who are required to stay late.

Does your lab use a third party for reprocessing? How has it impacted your lab?

Yes, we currently use Stryker. We have seen a large cost savings with little downside. We have moved toward reprocessing using the maximum turns for each catheter as permitted by law.

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

We rarely perform focal cryoablation. This has been reserved for high-risk anteroseptal accessory pathways, and rare slow AV nodal pathways. However, we have moved aggressively toward the use of the cryoballoon for ablation of paroxysmal AF. A majority of our AF ablation procedures for patients with paroxysmal AF involve the use of the cryoballoon. An analysis of our first 50 cases showed a 30-minute reduction in procedure time with no increase in fluoroscopy time or major complications.

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

We only perform EP procedures in patients over age 16 at Northwestern Memorial Hospital. One of our physicians, Dr. Rishi Arora, has a particular interest and a lot of experience treating adult patients with congenital heart disease.

Lurie Children’s Hospital, which is affiliated with Northwestern, has just moved from Lincoln Park to downtown next to our hospital. Dr. Knight and Arora are planning to obtain privileges at Children’s Hospital so that they can collaborate more easily with our outstanding pediatric cardiac electrophysiologists.

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

Several efforts have been made to reduce our radiation exposure in the EP lab over the past couple of years. Efforts have included working repeatedly with our imaging representatives to lower the dose and frame rate of our system. We have also begun to regularly use a RADPAD^® protection shield (Worldwide Innovations & Technologies, Inc., Kansas City, KS) after consultation with our hospital radiation safety officer. We are hopeful that significant advances in imaging systems will allow us to install a fluoroscopy system in our new EP lab, which will greatly reduce the radiation exposure not only to our staff, but also to our patients.

Do your nurses/techs participate in the follow up of pacemakers and ICDs?

Our lab contacts each patient 48 to 72 hours post procedure to follow up with how the patient is feeling. The nurse clinicians are responsible for wound check and follow up of patients.

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?

We see approximately 85 patients in our device clinic per week. We use the Medtronic Paceart^® System (Medtronic, Minneapolis, MN), and are in the process of upgrading our Paceart and EPIC systems to better integrate the two systems. A majority of our device patients are managed by our device nurses who are supported by the electrophysiologist who is running an adjacent heart rhythm clinic.

What are some of the dominant trends you see emerging in the practice of EP? How is your lab preparing for these future changes?

The trends in the practice of EP include an increase in the complexity of procedures such as complex ablations and implantation of more complex devices. This will lead to more cases requiring anesthesia support. We are preparing for this by having our anesthesia colleagues provide input on our new EP lab.

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

We make every effort to contact and inform all affected patients once we learn of a device recall and make the process as smooth as possible for them.

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

Yes, there are about 40 remote follow-up and 70 TTM per week, and we are continuously moving in the direction of enrolling more patients in remote monitoring.

What other clinical research studies is your EP lab currently involved in?

In addition to the trials mentioned above, we are also currently involved in the EchoCRT trial, and we are the top enrolling center in the CRYSTAL-AF study, which is examining the use of ILRs for cryptogenic stroke.

Are you ACGME-approved for EP training?

Our fellowship training program is ACGME approved. Our EP fellowship transitioned this year from an 18-month clinical requirement to a 24-month clinical requirement.

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?

We have multiple sources of educational material for our patients. We have some handouts that were tailored for our patients at Northwestern, and we commonly refer patients to both the recently improved Patient Information link at www.hrsonline.org as well as to our Health Learning Resource Center in the hospital.

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

Chicago is the largest city in Illinois and the third most populous city in the United States. The city has approximately 2.7 million residents. Its metropolitan area, sometimes called “Chicagoland,” is the third largest in the United States, with an estimated 9.8 million people. Chicago is the county seat of Cook County, although a small portion also extends into DuPage County.

The Chicago campus of Northwestern University includes the Feinberg School of Medicine; Northwestern Memorial Hospital, which is ranked as the best hospital in the Chicago metropolitan area by U.S. News & World Report for 2011-2012; the Rehabilitation Institute of Chicago, which is ranked the best U.S. rehabilitation hospital by U.S. News & World Report; the Prentice Women’s Hospital; and the new Ann & Robert H. Lurie Children’s Hospital of Chicago.

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

Although we have state-of-the-art facilities, the strength of our EP program is our people. We have a large group of highly-experienced, academic, interventionally-minded electrophysiologists with diverse clinical and research interests, who are supported by the finest nursing and technical staff to deliver customized interventional EP procedures to patients with all types of heart rhythm disorders.

We also reach out to our communities to promote heart health awareness (e.g., Mended Hearts, the Zoe Foundation, etc.).

We have developed an innovative callback system for prompt follow up of our patients after their procedures. As a result of these initiatives, our EP lab team was awarded the trophy for the Best Patient Satisfaction twice (so far) this year.

For more information, please visit:
www.nmh.org