Spotlight Interview: Penrose-St. Francis Cardiovascular Center

The EP laboratories are a significant part of the Penrose-St. Francis Cardiovascular Center. Overall, the Vascular Center of Colorado (VCC) is approximately 20,000 square feet in size, and has five invasive procedure rooms, two of which are dedicated to EP procedures. The facility is located in Colorado Springs and is a referral center for southern Colorado and the Rocky Mountain region, especially for atrial fibrillation ablation and excimer laser lead removal procedures.

Our electrophysiology service provides state-of-the-art technology for the diagnosis and treatment of arrhythmias through catheter ablation and device implants.

The atrial fibrillation program is one of the most active and successful in the western United States for treatment of this common and debilitating rhythm problem. Our center also includes a Cardiac Device Clinic that supports approximately 3,000 patients. We perform significantly more complex cases than most other centers of our size, and our rates of adverse events are far below regional and national averages.

Our EP laboratory is proud of the fact that all our clinical personnel are either certified or are pursuing certification from the International Board of Heart Rhythm Examiners (IBHRE). This demonstrates our commitment to clinical excellence and best outcomes from the physicians, nurses, and technicians. 

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

The Penrose-St. Francis Cardiovascular Center has two dedicated EP labs and a Pacer Clinic. Pacemaker/ICD implants and replacements are also performed in the cath labs. The EP staff is comprised of six registered nurses, one radiology technologist, one cardiovascular technologist, and three cardiopulmonary technologists.

When was the EP lab established?

Dr. Barber established the EP lab in April 1993 with one full-time and two part-time staff.  Dr. Nath joined the group in 1996, and Dr. Cole joined the group in 2004.

What types of procedures are performed at your facility? Approximately how many are performed per week?

The EP lab at the VCC performs the full spectrum of EP procedures. Ablation procedures include treatment of atrial fibrillation, ventricular tachycardia, epicardial arrhythmias, atrial tachycardia, and atrial flutter ablations. Implants include biventricular devices, ICDs, pacemakers, and implantable loop recorders. The EP staff also assists in laser lead extractions in the operating room. On average, our EP labs perform approximately 20 cases per week.

What is the primary goal of your program?

We are a balanced program. All the EP physicians have expertise in device implants as well as in all types of ablations.

Who manages your lab?

The EP labs are managed by Erin Kiesling, RN, CEPS, Clinical Lead, Michael Eglinton, Clinical Coordinator, and Christopher Cole, MD, Medical Director of the EP lab. Business leadership and administrative management is provided by Cardiac Partners.

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

All team members of our EP lab have been fully trained to scrub and operate the EP recording systems, stimulator, and ablation generators. All members of our staff have successfully completed ACLS training; however, only RNs certified in conscious sedation are able to administer sedative drugs. Our hospital takes a more restrictive view than state law permits.

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

Sina Connor, RN, CEPS manages our inventory using the inventory module portion of our hemodynamic monitor system. PAR levels are developed, and routine items are ordered and re-stocked daily. As a business that is independent of the hospital, our dedicated staff and physicians are very involved in selecting, ordering, receiving, and stocking supplies. Vendor negotiations are handled by the EP lead, Clinical Coordinator and/or Cardiac Partners, depending on the products and costs.

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

Approximately five years ago, the EP lab moved into new facilities that included a dedicated lab as well as a swing lab for less complex ablations and device implants. We anticipate within the next 12–18 months a new “hybrid” lab will be completed. This will allow for performance of combined surgical/catheter-based AF ablation as well as for other complex ablations.

Is your EP lab part of a separate “heart hospital”?

Our lab is located within the hospital, but is actually an independent entity that is managed by both the hospital and our physicians in a joint venture approach. Cardiac Partners developed and manages the independent entity.

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

Colorado Springs has a significant managed care population (approximately 30–35%). The EP lab is very efficient in terms of supplies or implantable device costs, room time, and turnover times. We have not run into economic barriers that reduce or prohibit care to patients, and we are able to provide care to all patients unrelated to their insurance status or ability to pay.

Have you developed a referral base?

Our physicians staff a number of outreach clinics throughout rural Colorado in addition to their presence within Colorado Springs. All of this provides a very broad and extensive base for EP referrals. Large volumes of specialty services such as a-fib ablations and laser lead extractions have created a specialized referral base.

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

As discussed above, our EP lab is part of a hospital/physician joint venture. As such, the physicians are very involved in negotiations with our various suppliers and distributors. Their input and direct involvement has helped save significant amounts of money for supplies and implantable devices. Cardiac Partners and its CPLink cardiovascular database software provides valuable feedback to the physicians, and allows us to accurately measure and report: costs per case; cost per physician; room time; room turnover time; on time starts; and, related per case cost measures.

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

There are two competitive hospital systems in Colorado Springs. We enjoy a good working relationship with the other system, and recognize that patient care comes first.

How are new employees oriented and trained at your facility?

Upon completion of the hospital orientation, the new employee enters the lab and is assigned a preceptor to provide guidance and education. A comprehensive skills checklist was created to evaluate a new employee’s skill set and their progress.

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

Our lab prides itself on the many educational opportunities provided to its staff. Our lab has many continuing education opportunities, including a semi-annual skills fair, a library with training materials, personal study time, and internal IBHRE prep classes taught by our electrophysiologists. IBHRE test fees are paid for by the company, and a bonus is awarded to the employee upon certification. Staff members are encouraged to attend many outside conferences and educational opportunities at the company’s expense. For example, three staff members attended HRS in Boston in May. Five out of eight lab staff members are IBHRE certified. Our three newest staff members are currently preparing for their IBHRE certification. 

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

We perform only adult EP procedures, with the rare exception of a young adult.

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

Staff has annual radiation training by a physicist. Each piece of lead is cataloged and inspected annually. Our Radiation Safety Officer tracks our exposure monthly. We use Mavig (Siemens) radiation shields, Infab lead aprons (Infab Corporation), thyroid collars, and MicroLite leaded eyewear (AttenuTech). Low-dose radiation settings on the x-ray equipment are used as often as possible.

Approximately what percentage of your ablation procedures are done with cryo and what percentage with radiofrequency energy?

While we have the ability to perform cryoablation at our facility, our physicians use RF 95% percent of the time.

What innovative EP techniques are being utilized in your lab?

Our labs are equipped with advanced 3D contact and noncontact mapping systems. We frequently use St. Jude Medical’s EnSite Velocity system including NavX and Array mapping. Biosense Webster’s Carto 3 mapping system is also frequently used incorporating the CartoSound and CartoMerge software. These 3D mapping systems provide innovative technology-driven treatment of complex arrhythmias. We provide state-of-the-art equipment and technology to our patients in order to be competitive with any hospital or university/teaching institution.

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

Electrophysiology does not have an ablation registry similar to the NCDR^® CathPCI Registry^®; this should be developed and implemented. In the future it will be all about outcomes, complications and cost efficiency. Quality metrics will determine future reimbursement in all areas of medicine, and EP is no exception. Being able to provide excellent results in a safe and cost-effective environment will be the drivers in maintaining high levels of consumer satisfaction and optimal insurer reimbursement. Our physicians already have initiated metrics for the staff including routine performance reviews. Frequent educational opportunities at state-of-the-art courses provide support and encouragement for all staff to achieve Testamur status with the Heart Rhythm Society by taking the IBHRE examination.

What are your thoughts about non-EPs implanting ICDs?

At our institution EP Board Certification is required to implant defibrillators. 

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

Our device clinic works in collaboration with cardiac device companies. An alert is created in the database after a device recall is announced, and at-risk patients are identified. They are then monitored continually for any issues and brought in for evaluation as needed.

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

Yes, our Device Clinic does both Web-based and transtelephonic device follow up, averaging about 10 remote monitoring follow ups per day.

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

We have been and will continue to be involved in investigative trials. Our focus has predominantly been in either ablation trials (AF, AFl, and VT) or both pre- and post-release device trials. Our nurses have presented some of our research results at previous HRS meetings.

Are you ACGME-approved for EP training? What do you think about two-year EP programs?

We are not an approved site for post-graduate EP training as we are a private hospital without university affiliation. Our volumes are adequate that should an opportunity arise, training of fellows would be a possibility. Our doctors strongly believe that an EP fellowship should be at least two years if a person wishes to provide all aspects of electrophysiology care (complex ablations, device implants, device follow up, etc.).

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

Our most difficult challenge has been recruiting and retaining enough well-trained staff to handle workloads. Having an EP lead working hand in hand with our cath lab lead and Clinical Coordinator often allows us to place “overflow” cases (predominantly simple device implants) in rooms other than the EP labs. This enhances our patient flow and limits the need for staff overtime.

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

We are not a teaching hospital and do not have fellows to assist our physicians with procedures. As such, the staff often functions in the “fellow role” scrubbing as the first assist on all EP and device implant cases. Our physicians provide training, education and oversight such that the EP staff are expected to be cross trained and able to assume all roles in the lab including monitor duties (running the stimulator, etc.), assisting (scrubbing, obtaining venous access, etc.) and circulating the cases. This is done on a rotational basis such that all staff may remain engaged and involved. We feel this is unique to our lab and provides the best opportunities for educational experiences.