Spotlight Interview: Oklahoma 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? Oklahoma Heart Hospital (OHH) provides state-of-the-art diagnostic and invasive procedures in our EP lab with three physician electrophysiologists, two radiology technologists and four specialized cardiovascular registered nurses. When was the EP lab started at your institution? Our EP lab opened in August of 2002 with the opening of the Oklahoma Heart Hospital. At that time the EP lab started with a staff of one EP tech, two RNs and one RT. The first Carto (Biosense Webster Inc.) procedure was performed in October of 2002, while the first transeptal procedure was done in June of 2003. Our first robotics procedure was performed in February of 2008. What types of procedures are performed at your facility? The EP lab at Oklahoma Heart Hospital implants several types of devices such as loop recorders, pacemakers, ICDs and BiV ICDs, as well as upgrades ICDs to BiVs and extracts implanted devices. Our lab provides diagnostic EP studies, ablations of the AV node, AVNRT, AVRT, Carto-assisted sinus node, atrial tachycardia, VT, atrial flutter ablations and CartoSound, and Hansen Medical robotics-assisted ablations for atrial fibrillation (AF). Approximately how many are performed each week? Our EP lab is one of the most active programs in the region. We perform approximately 8-10 EP studies with ablations, and 4-6 AF ablations. There are also approximately 3-5 pacemaker implants, 6-8 ICD implants, and 4-6 BiV ICD implants performed by EP physicians in the cath lab and EP lab combined. What is the primary goal of your program? The primary goal of the electrophysiology program at Oklahoma Heart Hospital is to provide state-of-the-art EP studies, ablations and device implants for the heart health of our community, state and region. A key aspect of achieving that goal is to have a flexible leadership that is proactive and agile in both responding to changes in the medical environment and the need for new technical advances while maintaining a safe environment for patients and staff. Who manages your EP lab? The overarching philosophy at Oklahoma Heart Hospital is to bring together the best and most experienced staff of cardiovascular specialists, nurses and technicians and give them the tools to do their best work under a strategically thin administration. Suzanne Charbeneau, RN is the Director of Surgery, Cath and EP labs; Debbie Flynn, RN is the Cath Lab Manager. Both provide support, direction and promote an open-door policy. Their management style allows the EP lab to be essentially self-managed and self-directed with an emphasis on encouraging teamwork and individual interaction and input. Under this management model the EP lab coordinator is a position that rotates weekly, giving more employees management opportunities to take the general basic responsibility of the lab. Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained? The original design of the Oklahoma Heart Hospital strategically and physically included separation between the EP and cath labs because of their different functions and staffing needs. There remains some elements of shared management between the two lab teams. Most of the EP lab staff has had previous cath lab experience, which provides crucial experience for the lab, the physicians and new staff. Do you have cross training inside the EP lab? What are the regulations in your state? The management philosophy at the Oklahoma Heart Hospital creates a positive environment for each RT and RN staff member be cross-trained in all aspects of the EP lab, so that there is greater depth in each position. Each individual is trained how to conduct EP studies, scrub during EP procedures and device implantation, set up and maintain the EP MedSystems as well as Biosense Webster’s Carto equipment, and document the progress of the procedure in the lab recording system. The only restriction in cross training is in the administration of medications. An RN or physician must provide medications for conscious sedation or other medical needs. Neither cath lab staff nor EP lab staff is allowed to initiate sheath access for any procedure. What new equipment, devices and/or products have been introduced at your lab lately? How has this changed the way you perform those procedures? The Oklahoma Heart Hospital has a history of quickly adopting new advances in cardiovascular care with the latest technology. The hospital has demonstrated flexibility and agility in streamlining the process of acquiring new equipment when medical evidence supports the swift acquisition. The EP lab has been the beneficiary of this rapid evidenced-based philosophy of acquiring new technology. Biosense Webster’s CoolFlow technology was introduced in our lab in February 2007. Hansen Medical’s Sensei Robotic Catheter System was installed and has been in use since February 2008. Biosense Webster’s CartoSound was installed in June of 2008 and was initially used in August of 2008. Hansen Medical’s robotic system has proved to be a stable catheter platform for ablation procedures, especially for AF ablations. Biosense Webster’s CartoSound has provided ultrasound images of the left atrium and pulmonary veins, and assists in more accurate anatomy for AF ablations in the left atrium. The stable placement of the CS lead has improved since the introduction and use of Medtronic’s StarFix CS Lead as an alternative for BiV ICD implants. Who handles your procedure scheduling? Do you use particular software? The cath lab’s scheduling staff provides our day-to-day procedure scheduling. Any added procedures during the day are at the discretion of the cath lab manager or director. We have a standing commitment to never delay procedures for scheduled in-house patients to the next day. The scheduling staff does not use any special software other than software associated with Cerner. What type of quality control/quality assurance measures are practiced in your EP lab? Oklahoma Heart Hospital opened as the first all-digital hospital in Oklahoma and in the nation. All data is generated by computer input and is maintained on a secure system. All patient events are recorded within the electronic medical record system, providing reports and statistical variations in the facility’s goals. The EP lab follows Joint Commission and CLIA standards. For most problems, the FOCUS and PDCA models are implemented. How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? The EP lab’s immediate inventory is tracked by documentation of use in the procedure monitoring system. The inventory staff reorders supplies per par levels. EP lab RTs physically check the inventory par levels each month for discrepancies. Items that are not charged for a procedure, such as minor and reusable equipment, are ordered through our inventory staff as needed. The cath lab manager or director handles all contracts and large item purchases. Has your EP lab recently expanded in size and patient volume, or will it be in the near future? The demand for cardiovascular services in general and electrophysiology procedures specifically at Oklahoma Heart Hospital have risen dramatically in the past few years. As a result, plans are in process to enlarge the EP lab. This will allow the relocation of the bulk of EP MedSystems (now St. Jude Medical) and Biosense Webster’s Carto equipment out of the procedure room and into the expanded control booth. We are also continually increasing in patient volume in the EP and cath labs. Oklahoma Heart Hospital is a stand-alone heart hospital, a separate physical facility from Mercy Hospital but a part of the Mercy Health System of Oklahoma. How has managed care affected your EP lab and the care it provides patients? The philosophy of Oklahoma Heart Hospital is to provide the best care for each patient that enters the door regardless of provider status. Have you developed a referral base? A major element in the success of the Oklahoma Heart Hospital is the strategic partnership between the hospital and Oklahoma Cardiovascular Associates (OCA) — Oklahoma’s largest cardiovascular physician group. This pre-existing network of cardiovascular specialists and their 40 rural Oklahoma clinics provided an immediate referral base for the hospital and EP lab. OHH and OCA are associated with the Mercy Health System, providing another vital referral base. 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? We continually balance the commitment to best patient outcomes with the need for innovative technical advancements that will stand the test of time. Technical products that don’t meet those standards are not purchased. The Oklahoma Heart Hospital was physician designed from the foundation up to streamline the patient’s movement through the facility. The design has also brought other efficiencies in staffing and patient flow. Post-procedural patients are either returned to their outpatient room or are transferred to an assigned inpatient room. All AF ablation patients are taken to the Recovery Room to verify post-procedure stability, and then are sent to an assigned inpatient room. Does your EP lab compete for patients? Has your institution formed an alliance with others in the area? There are three other EP labs in Oklahoma City: The University of Oklahoma Health Sciences Center, associated with OU Medical School and recognized as a leader in the combination of adult and pediatric EP studies, also provides statewide community care as well as physician training. The OU EP lab has 3D Carto and Stereotaxis AXIOM capability. Midwest City Regional Hospital has an EP lab capable of procedures that feature 3D Carto and Hansen Medical’s Robotics Sytem. Integris Baptist Medical Center of Oklahoma has an EP lab capable of procedures using 3D Carto. What percentage of procedures are performed on an outpatient basis? In addition, what EP procedures are generally only considered inpatient? Over 97% of all patients are admitted through Oklahoma Heart Hospital’s Outpatient Department. All patients scheduled to receive new devices are admitted to the hospital after their procedure for an overnight stay, as are patients receiving atrial fibrillation and AV node ablation procedures. Few patients are admitted to the hospital prior to a procedure unless the patient is transferred from another facility. Those patients traveling a long distance for an elective procedure are provided with a hotel room at a discounted rate. How are new employees oriented and trained at your facility? New employees attend a week of hospital orientation and then continue the process in their specific area with a preceptor. The cath and EP labs provide continuous orientation with a cath lab or EP lab preceptor. What types of continuing education opportunities are provided to staff members? The facility uses EP MedSystems (now St. Jude Medical) and Biosense Webster’s Professional Education training personnel for onsite EP or equipment training. Offsite training expenses are reimbursed upon completion of the program. How is staff competency evaluated? EP staff members and preceptors evaluate and record the competency of new EP staff during their orientation and training. The cath lab manager annually evaluates cath and EP staff competency. How do you prevent staff burnout? Our 6 EP staff members have every weekend off without call. Five staff members work 40 hours a week in 4 days, which permits their fifth day of the week as a day off. Four of the 5 staff members are scheduled one weekend a month as a 4-day weekend. It is also recognized that each RN or RT is important. They are encouraged to express his or her ideas about procedural or patient needs and to work with each other to obtain appropriate results. What committees, if any, are staff members asked to serve on in your lab? We have one EP RN that participates on an Education Committee. For the remaining staff, procedural time constraints and the number of procedures scheduled as well as the staff size does not permit committee attendance. How do you handle vendor visits to your department? Do you contract with vendors? Vendors are encouraged to arrange a time for visits with the cath lab manager in order to visit the EP lab. The EP lab contracts with most vendors for devices and catheters. Does your lab utilize any alternative therapies to help patients in the EP lab (e.g., music guided imagery techniques, etc.)? We provide a positive attitude and reinforcement to the patient. Most of all, we listen. Most of the patients appreciate our attempt with laughter as we interact with them. We provide music per patient preference as well as staff preference. Overall, we attempt to give the patient a quiet procedure without any extra stress load from either noise or levels of conversation. Describe a particularly memorable or bizarre case that has come through your EP lab. What lessons did you learn from it? A very memorable procedure happened a few years ago during a WPW procedure. The physician began mapping with EP MedSystems (St. Jude Medical) and an ablation catheter. After unsuccessfully ablating an area associated with WPW, the physician then decided to change to Biosense Webster’s 3D Carto mapping system. After setting up and connecting the Carto and Stockert equipment with EP MedSystems, the 3D mapping was begun. After mapping for a few minutes, the physician began to burn at one specific spot. During the first and only burn, the surface leads showing the classic delta wave changed to normal. Post-procedure testing did not produce a WPW tracing. It was impressive. How does your lab handle call time for staff members? How frequently do they have to come in, on average? Is there a particular mix of credentials needed for each call team? The EP lab staff do not routinely take call. The only call we are requested to be available is the day after Thanksgiving, during Christmas Eve, and on New Year’s Eve during the day. The EP call team consists of three members with at least one RN. Sometimes the team will consist of three RNs. Does your lab use a third party for reprocessing? No. Approximately what percentage of your ablation procedures are done with cryo? What percentage is done with radiofrequency? No cryo is used, only radiofrequency is used on all ablations. Do you perform only adult EP procedures or do you also do pediatric cases? Is there cross training for pediatric cases? We primarily provide appropriate EP procedures for adults, but have had patients as young as 12. What measures has your lab taken to minimize radiation exposure to physicians and staff? The EP lab has strict procedures to minimize radiation exposure to the staff and patients. Staff must always use lead table aprons, wear lead aprons, and use the time, distance and shielding formula to reduce exposure. During long procedures, the Fluoro Pulse rate is reduced for the added safety of the patient. We have a required annual radiation presentation for all cath and EP lab 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? Because of the strategic alliance between Oklahoma Heart Hospital and Oklahoma Cardiovascular Associates, onsite clinics are available for patient follow-up. Each physician or their PA or NP provides the follow-up in clinic. The pacemaker/ICD reps are well respected and are always available for the clinics. However, most of the continual device follow-up has shifted to the Internet with the use of Medtronic’s CareLink. What are some of the dominant trends you see emerging in the practice of electrophysiology? How is your lab preparing for these future changes? The EP procedures are becoming more complex at smaller facilities. The increased demand for services among older patients and patients with complicated health issues are impacting the system. The need for more sophisticated equipment and software to aid in diagnostic and invasive EP procedures is well known. What are your thoughts about non-EPs implanting ICDs? Do you train such individuals? We have several non-EP physicians that implant pacemakers and have started to implant ICDs. These physicians are trained cardiovascular surgeons who have experience implanting apical leads for BiV ICDs. What about device recalls? How has your lab handled these? Device recalls are followed by the physician, office staff and device company representatives. All device recalls are discussed among them, and the status of that particular device is determined. The EP lab is involved if the device must be replanted. Is your lab doing web-based/transtelephonic device follow-up? The EP physician, office staff, and representatives have utilized the Medtronic web-based CareLink system since it has been available. Is your EP lab currently involved in any clinical research studies or special projects? Which ones? There are several research studies that are currently taking place at Oklahoma Heart Hospital, but only a few involve EP: • The REDUCE HF trial with Medtronic began in June of 2006 involving an ICD and the Chronicle pressure lead. • The BLOCK HF trial with Medtronic also started in 2006 and is ongoing. This involves RV pacing compared to BiV pacing in patients with heart block. When was your last inspection by the Joint Commission? Our last inspection was in April 2008. Are you ACGME-approved for EP training? No. 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? Oklahoma Heart Hospital and Oklahoma Cardiovascular Associates’ physician offices have educational materials specifically related to the patient’s inquiries. Our hospital-wide computer system provides information that can be printed out and given to the patient. Our hospital has appropriate informational TV programs about devices and procedures available for the patient or family to watch. The patient is encouraged to watch an appropriate program prior to their intended procedure to familiarize them and their family with the procedure and terminology. Oklahoma Heart Hospital’s device support group is led by one of our EP physicians. We also have a psychologist on staff dedicated to addressing the mental health aspect of patient cardiac care. Give an example of a difficult problem or challenge your lab has faced. How it was addressed? We recently had several post-AF patients develop post-procedural hemodynamic instability and subnormal temperature. These conditions were documented after the patients were transferred to their room. Because we were unaware of the situation that was occurring, we did not consider any changes in our procedure. However, after we became aware of the problem, we developed a plan to monitor the patient’s core temperature as well as to keep the patient warmer. We now use a Foley catheter with a temperature probe during AF procedures to monitor the patient's core temperature. We now also use the Bair Hugger® therapy heating blanket (Arizant Healthcare Inc.) under the patient. In addition to these changes, all of our AF ablation patients are now transferred to PACU for observation first and then to their room. Describe your city or general regional area. How does it differ from the rest of the U.S.? Oklahoma has a rich Native American history. Once referred to as Indian Territory, the land was eventually named Oklahoma, which is Choctaw for Red Man. Because of the 1886 Land Run and because of land claims made before the start of the Run, the state’s nickname became to be known as “Sooners” due to those early claims. The state capital, Oklahoma City, sits in the middle of the state. In this central region, the topography transitions from foothills with rivers and trees and tall grass in Eastern Oklahoma to rolling flat lands with short grass in Western Oklahoma. Because of Oklahoma’s numerous lakes, this state is reported to have more shoreline than is along the East Coast and Gulf Coast combined (though the claim is often contested). The infamous parking meter was invented and installed in Oklahoma City in 1935 to solve a parking problem. The Port of Catoosa on the Arkansas River is near Tulsa, Oklahoma and is considered a viable shipping port in the nation’s interior. Oklahoma City also hosts a rowing team south of downtown on the Oklahoma River. Oklahoma Medical Research Foundation near the OU Medical Center campus has researched and developed various solutions to medical problems. Our state capital has an active oil well on the capital grounds, where before statehood a forest of oil derricks testified to an oil boom. Oklahoma City has revitalized the downtown sector of the city since the Oklahoma City bombing with a new entertainment district called Bricktown, attracting high-caliber events and the new NBA team Thunder. National touring concerts and theatre attractions regularly book in Oklahoma City to sellout crowds. The home of the Oklahoma University Sooners is 30 minutes south in Norman, and the home of the Oklahoma State Cowboys is 20 minutes north in Stillwater. Stillwater is also the home of Eskimo Joes. Trout fishing is a sport in Eastern and Central Oklahoma rivers and lakes, while Striper Bass fishing and Bass Fishing Tournaments are a growing industry on the 74,686 acres of Lake Texoma in Southern Oklahoma and Northern Texas. Please tell our readers what you consider unique or innovative about your EP lab and staff. Our EP lab is small but efficient. Each staff member works collaboratively to complete the day, solve problems, or even take on necessary responsibility. Each staff member is aggressive in learning any new task or meeting any challenge, to the point that most of our staff can work independently. All staff are able to perform without assistance on our EP MedSystems and Carto equipment. Three of our staff have held supervisory positions at previous facilities. Everyone is experienced in cath lab situations. In 2006 our EP lab produced a live hour-long Internet broadcast of a BiV ICD implant. At the end of the hour, the device and leads were in place, tested, and the pocket closed. Oklahoma Heart Hospital has won a number of awards including the prestigious Press Ganey Summit Award for patient satisfaction four years in a row; the Department of Health & Human Services - LifeShare Medal of Honor (only specialty hospital in U.S. to receive award); Total Benchmark - Top Acute Care Hospital; American Academy of Critical Care Nursing AACN – Beacon Award for Excellence in Critical Care; Oklahoma Foundation for Medical Quality OFMQ – Top Performing Hospital in Quality (large hospital) and the Oklahoma Nurses Association ONA – Excellence in the Workplace & Friends of Nurses. Oklahoma Heart Hospital is pro-active in meeting the needs of the state and community. While other hospitals demand a high patient load for nurses and ancillary staff, Oklahoma Heart Hospital has drastically reduced the number of patients assigned to any one nurse, committed to a maximum of 4:1 patient-to-nurse ratio and in critical care a 1:1 ratio 24/7. Every patient that has passed through the EP lab is impressed with the attention and efficiency from everyone they meet in the hospital. For more information, please visit: www.okheart.com