Spotlight Interview: Sanford Heart Center-Fargo

Sanford Heart Center in Fargo, North Dakota, is an advanced health care facility that is dedicated to the work of health and healing through exceptional care, innovation, and discovery. Care is centered around prevention, diagnosis, and advanced treatment of cardiovascular disease in patients. We provide cardiovascular services to patients within a tristate (North Dakota, western Minnesota, and South Dakota), 300-mile radius across the upper Midwest. 

We have three highly trained electrophysiologists along with a highly trained team of nurses, cardiovascular technologists, cardiologists, and cardiovascular surgeons. The hospital has five cardiac cath labs, two of which are dedicated to electrophysiology. 

At Sanford Heart Center-Fargo, our patients have access to advanced treatments and technologies. Our promise to patients is that we will deliver a flawless experience that inspires.

What is the size of your EP lab facility? When was the EP lab started at your institution? 

Sanford Medical Center Fargo is a 583-bed facility. The EP lab was started in 1995. We have two dedicated EP labs and an additional lab that can be used for EP and other procedures. 

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

We have approximately 40 staff members in our lab. Our team consists of radiology technologists, RCES’s, RCIS’s, and registered nurses.

What types of procedures are performed at your facility? 

We perform pulmonary vein isolations; VT, SVT, and atrial flutter ablations; laser lead extractions; pacemaker, ICD, CRT-D, and loop recorder implantations; tilt table testing; and left atrial appendage closures. 

Approximately how many catheter ablations (for all arrhythmias), ICD implants, and pacemaker implants are performed each week? 

We perform more than 420 ablations per year, more than 600 device implants, and more than 45 laser lead extractions per year. We average more than 20 EP procedures per week.

Who manages your EP lab? 

The EP lab is managed by Jana Hart, RN, BSN, in collaboration with Paul Burud, RN, BSN, MSSL, the Director of Cardiovascular Services. Jana has been part of the Sanford Heart Center team for 13 years, and Paul has been part of the team for 5 years.

Is there cross-training between the cath and EP labs, or inside the EP lab? 

Employees are cross trained to provide care in both the EP and cath labs. Staff is also cross trained and rotate through different roles within the EP lab, such as scrubbing, recording, and running the Prucka system and Bloom stimulator.

What type of hospital is your EP program a part of? 

We are a community hospital in a rural setting, providing EP services in the tri-state region.

What types of EP equipment is most commonly used in the lab? 

The most commonly used equipment in the EP lab includes cryoballoon ablation with the Arctic Front (Medtronic), 3D mapping with EnSite Velocity (St. Jude Medical), as well as use of the Prucka recording system (GE Healthcare) and Bloom stimulator (Fischer Medical Technologies).

How is shift coverage managed? What are typical hours? 

Our hours of operation are from 7 a.m. to 5:30 p.m.; this is covered with 10-hour shifts.

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

For a patient procedure, the patient arrives to our Day Unit where they are prepared for their procedure and have their pre-anesthesia assessment completed. The EP rooms are set up and all safety checks of equipment are done prior to the patient arrival into the lab. After the patient is prepped and room checks are complete, the patient comes to the lab for further preparation of the procedure. The procedure is performed. The physician speaks with family post-procedure and completes post-procedure orders. The patient is then transferred to the PACU or Observation Unit. We average approximately 5 cases a day. 

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

We continue to introduce new technologies and procedures as they become available in the United States. The most recent technologies are the DoseAware real-time radiation badges (Philips), cryoablation using the Freezor MAX and Freezor Xtra (Medtronic), an additional 3D mapping system, and subcutaneous ICD implantation. 

How has this changed the way you perform those procedures? 

Three-dimensional mapping and use of the cryoballoon have reduced fluoroscopy time along with radiation exposure. DoseAware gives us real-time exposure doses to staff and patients during the procedure, assisting with reduction in radiation exposure.

What imaging technology do you utilize? 

We have two Siemens biplane rooms and one Philips biplane room.

What is your experience with MR conditional cardiac devices? 

We have seen an increase in the utilization of MRI devices. Prior to implanting, work was done with the MRI safety committee drawing up protocols and algorithms for device identification and follow-up. This information is based on the FDA and manufacturers’ guidelines. 

Does your program utilize a cardiovascular information system (CVIS), picture archiving system (PACS), or cardiology picture archiving system (CPACS)? 

We use Cardiology PACS integrated with Cardiology through the Cardiology DMS, which maintains a systematic retrieval and archiving system.

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

We have a cath lab service area assistant who handles our procedure scheduling, which is done using Epic Cadence scheduling software. 

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

We measure complications, length of stay, fluoroscopy time, and Press Ganey Scores. All are tracked through the quality improvement department in conjunction with the ICD Registry.

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

Inventory is managed through a barcoding process built within the CardioLab System (GE Healthcare) that is managed through the Cardiology DMS application. We also utilize a two-bin system for minor supplies used on a daily basis. This is a process that is managed by Supply Chain Management. Our cath lab manager and director, along with Supply Chain Management, handle purchasing of equipment and supplies. 

Has your EP lab recently expanded in size and patient volume? 

We have steadily increased our patient volumes and will continue to adapt the service to meet the needs of the EP patient population.

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

We have shifted many patients from an inpatient hospital status to an observation or outpatient status with same-day discharge.

In what ways have you helped to cut/contain costs and improve efficiencies in the lab? 

We have standardized processes, along with product. Product standardization is very important since it reduces inventory and overall costs. We work very closely with our physician partners when decisions are made about products and utilization. We also monitor all of our wasted products and evaluate how to reduce waste.

How does your lab communicate necessary information to staff? 

We hold daily huddles and routine department meetings, as well as communicate by e-mail.

How do you ensure timely case starts and patient turnover? 

We coordinate staff and physician schedules with the daily schedule. We monitor daily patient arrival and departure times in and out of our lab. As a result of daily monitoring, we are able to identify trends quickly and adjust as needed. 

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

There are additional hospitals in the area that provide EP services as well. We have built alliances with many healthcare providers and organizations in the region. In addition, we have established referral relationships with these hospitals and providers, of which their patients are able to receive EP services we offer that are not available at their location. 

How are new employees oriented and trained at your facility? 

New employees are assigned a primary preceptor who provides direct training. They have a competency checklist that needs to be completed prior to performing skills independently.

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

Staff members attend our annual competency skills fair and are also given the opportunity to attend a cardiovascular symposium. Education for new procedures and products that are being introduced into the lab is provided as needed. 

How is staff competency evaluated? 

Staff competency is evaluated through initial competencies and ongoing yearly competencies.

Do you encourage your clinical staff members to take the registry exam for Registered Cardiac Electrophysiology Specialist (RCES)? How many members of your lab have taken the exam? Does staff receive an incentive bonus or raise upon passing the exam? 

Yes, we encourage staff members to take the RCES exam. We have a physician who conducts weekly education sessions to prepare staff to take the exam. We currently have three RCES’s. Staff who take the exam are moved to a different job classification, which results in a pay differential.

How do you prevent staff burnout? In addition, do you practice any team-building exercises? 

To prevent burnout, we have staff cross trained so that they are able to rotate through the EP labs as well as cath labs. In an effort to promote staff and physician satisfaction, we hold debriefing sessions as needed after procedures with staff and physicians.

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

Staff members attend the Nurse Senate and Chest Pain Committee meetings.

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

Yes, we contract with vendors for supplies. Vendors need to make appointments and check in, provide identification, and adhere to the standards of the hospital vendor policy. 

Does your lab utilize any alternative therapies to help patients in the EP lab? 

We utilize music in the labs as an alternative therapy to help relax patients during procedure preparation.

Describe a particularly memorable case that has come through your EP lab. How was it addressed, and what lessons were learned from it? 

We treated a patient that presented with an occluded superior vena cava who had been evaluated at two prior hospitals. The patient was pacemaker dependent with a failing pacing lead. We were able to extract the over 20-year-old lead successfully with re-implantation of a new lead. 

Another patient was evaluated and found to have severe valvular heart disease in addition to persistent atrial fibrillation. With a collaborative effort between our cardiothoracic surgeon and electrophysiologist, we were able to restore normal sinus rhythm and resolve  her valvular heart disease. The patient has regained her quality of life following the staged procedures.

How does your lab handle call time for staff members? Does your lab use a third party for reprocessing or catheter recycling? How has it impacted your lab? 

Yes, we reprocess some of our diagnostic catheters and recycle others that cannot be reprocessed. As a result, we have seen a positive impact on the lab.

How many of your ablation procedures are done with cryo? How many are done with radiofrequency? 

Approximately half are completed with cryoablation and about half are done with radiofrequency. All PVIs are first performed with cryoballoon, and with radiofrequency ablation if necessary to achieve pulmonary vein isolation.

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

In addition to implementing DoseAware for real-time exposure, we have an internal physics department that works directly with the physicians to maximize image quality while focusing on dose reduction to patients and staff.

What are your methods for infection prevention (eg, during device implants, etc.)? 

We focus on yearly competencies with staff to educate and eliminate any infections. In addition, we require proper attire to be worn by staff at all times, including sterile scrubs and bouffant hats.

What innovative EP techniques are being utilized in your lab? 

Innovative EP techniques being utilized in our lab include LAA with the LARIAT Suture Delivery Device (SentreHEART, Inc.), epicardial VT ablations, PVIs, and laser lead extractions.

Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) or any other outside data collection registry? 

Yes, we are part of the ICD Registry.

How do you use the NCDR Outcome Reports to drive QI initiatives at your facility?

At Sanford Heart Center, we track trends and review the data. We collaborate with our Office of Continuous Improvement to implement performance improvement projects that improve patient outcomes and enhance quality care.

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

This standard of care has had a positive impact on the patients we serve. We are able to have all patient information securely available electronically, and it is easily accessible. EHR systems improve quality of care by making orders clear and legible for all health care team members. Furthermore, EHR systems allow information to be readily available and allow us to easily track and trend patient data. We are able to utilize best practice alerts and hard stops to assure we are not missing any important medications or orders.

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

Dominant trends we see emerging in EP include performing less initial ICD implants, more treatments for atrial fibrillation, and more laser lead extractions.

How does your lab handle device recalls? 

Each patient is notified as recommended, and proper management of recall is followed based on the FDA recommendations.

How is outpatient cardiac monitoring managed? 

Outpatient cardiac monitoring is managed through the Heart Center’s Pacemaker Arrhythmia Clinic.

How is coding and coding education handled in your lab? 

Coding and coding education is handled through Sanford Health’s coding department.

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

Yes, we are currently involved in the  SIELLO Clinical Study,  the Protego DF4 Post Approval Registry, , the Left Atrial Pressure Monitoring to Optimize Heart Failure Therapy Study (LAPTOP-HF),   the Quadripolar Pacing Post Approval Study, the Attain Performa Quadripolar Lead Clinical Study, and the Product Surveillance Registry Base (PSR).

Are you ACGME-approved for EP training? 

No, we are not an academic training center.

Does your hospital offer a cardiac device support group for patients? 

Yes, our hospital holds an annual community symposium called Confident Living With a Defibrillator. This is a free educational opportunity to the public that provides support and education to patients living in the community with devices. 

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

The population of Fargo and the surrounding area is 120,000. Our area is different from many parts of the United States because it is in a rural setting, and patients come to receive care from more than 300 miles away.

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

Our team is extremely dedicated to providing quality care. We have a highly engaged team that is eager to learn, along with a dedicated team of physicians who enjoy teaching and introducing new technologies and techniques into our lab to better serve our patients.