Spotlight Interview: Stamford Hospital

Stamford Health is a not-for-profit healthcare system in lower Fairfield County. The system provides inpatient, outpatient, and ambulatory services through Stamford Hospital, a 305-bed acute care tertiary hospital; Stamford Health Medical Group, a partnership of primary and specialty care physicians; Stamford Hospital Foundation; and a diverse and growing number of retail and ambulatory locations across the region. Stamford Health is affiliated with the New York-Presbyterian Healthcare System and is a major teaching affiliate of the Columbia University College of Physicians and Surgeons. 

Stamford Health earned the Planetree Distinction Award for Leadership and Innovation in Patient-Centered Care, placing it among only seven of the 350 Planetree facilities in the world recognized with the honor.

At Stamford Health, care is directed beyond simply treating disease or injury, to consideration of the entire person and his or her physical, emotional, and spiritual needs, as well as those of their families and caregivers. This creates an environment where taking care of people involves providing the best care across the entire continuum — from prevention and wellness to diagnosis and treatment to ongoing support.

When was the EP program started at your institution? 

Stamford Hospital has had an EP program within our cardiovascular suite for many years. Our initial focus was mostly on device implants and non-complex ablations. Our current director of electrophysiology, Dr. Sandhya Dhruvakumar, came to Stamford Hospital in 2013. At that time, we began to expand our program.

What is the size of your EP lab facility? Has your EP lab recently expanded in size or patient volume? 

Stamford Hospital’s EP volume has been steadily increasing, and we are consistently exceeding our yearly expected procedure volume. For example, last year (FY15) our budgeted procedural volume was 322 cases, and we actually did 365 cases. 

To accommodate the increasing volume, we have basically doubled our staffing and have begun the process of cross training some cardiac cath lab staff to circulate in complex ablation procedures. We currently have four dedicated EP RNs and two dedicated EP technologists.

The physical department has also expanded and will be expanding again in the next year. We originally shared a procedural room with the cardiac cath lab, but as our volume grew, we needed our own dedicated space. In spring of 2013, Stamford Hospital began construction on a dedicated EP biplane lab. In May 2014, our new state-of-the-art electrophysiology suite opened. We use this room for all ablation cases. However, our volume is still exceeding what we can do in one room, so our device implant volume spills over into our other cardiac cath lab and into the hybrid OR. We will be expanding again in September 2016 when we move into our brand-new hospital facility. The cardiovascular suite will include a biplane room for electrophysiology, a cardiac cath lab, a hybrid procedure lab, and a shell lab that can be finished based on growth and need.

Approximately what percentage of ablation procedures are done with cryo versus radiofrequency?

For FY14-15, we did 20-25% cryoablations vs 75-80% radiofrequency ablations. In FY16 to date, we have completed 68% cryoablations vs 32% radiofrequency ablations.

Who manages your EP lab?

Perry Burgess is the nurse manager, Belen Camacho is our clinical coordinator, and Michael Lutka is the lead EP technologist.

Are employees cross-trained?

Our current cardiovascular suite includes electrophysiology, cardiac cath, non-invasive cardiology, and interventional radiology, as well as holding and recovery for this combined patient population. We have a primary EP staff pool, but many of the staff members are also cross trained to work in cath and interventional radiology. All nursing staff are trained for device cases.

Do you have cross training inside the EP lab?

The EP nurses and technologists are cross trained to use the CardioLab Recording System (GE Healthcare) and Bloom stimulator (Fischer Medical Technologies). In the near future, nurses and technologists will cross train in various aspects of the procedures. At the current time, only technologists scrub in for EP cases. 

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

Stamford is a community and academic hospital. We are a not-for-profit teaching hospital serving Stamford and the surrounding area. Stamford Hospital is an affiliate of NewYork-Presbyterian Healthcare System. We also are a teaching affiliate of the Columbia University College of Physicians and Surgeons. However, we do not have fellows in the EP lab.

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

The lab uses a large variety of equipment. Brands such as Medtronic, St. Jude Medical, Boston Scientific, Terumo, Biosense Webster, and Merit Medical are some of the high-usage products.

How is shift coverage managed? What are typical hours (not including call time)?

The EP lab is staffed with both 10-hour shifts and 13-hour shifts Monday through Friday. The 10-hour shifts run 7:00am-5:00pm. The 13-hour shifts run from 7:00am-8:00pm. Weekday call is assigned based on staffing necessity and to cover vacation time. However, the departmental expectation is that the EP staff stays to finish all EP cases.

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

The first EP patient arrives at 6:30am. They are prepped by two EP nurses or an EP nurse and a nurse assigned to holding for the day. Patient prep includes a physical assessment, drawing necessary blood work, obtaining intravenous access, and a doing a pre-procedure EKG. Next, the patient will meet with the physician, anesthesiologist/CRNA, and physician assistant or nurse practitioner. Each one of these team members explains their role and what the patient can expect throughout their stay with us. Simultaneously, the other EP RN and the EP technologist set up the lab and prepare for the patient’s arrival. 

The family members are escorted to the waiting area at the time the patient is moved into the EP suite. While in the procedural room, the patient is attached to EKG monitors, mapping patches, grounding pads, and defibrillator pads. Depending on the procedural type, some patients get an arterial line and a Foley catheter. Next, the patient is positioned using protective methods to allow the most ergonomic comfort due to extended procedural times. At this point, some patients are intubated, but many of our patients receive total intravenous anesthesia (TIVA).

The procedural team consists of a physician, two to three EP nurses, a technologist, an anesthesia provider, and a representative from the mapping or cryoablation company. The team works together to eradicate the arrhythmia while keeping the patient safe. Open communication and strong teamwork is the key to this process. 

When the procedure is over, the patient is awakened and assessed. The sheaths are removed by the procedural team and manual pressure is held to obtain hemostasis. The patient is recovered by an EP RN in the cardiovascular lab recovery area. At that time, the procedural team splits, and one nurse recovers while the other two procedural RNs move into the room with the next patient. The EP patient is either discharged or transferred to an inpatient room, depending on the type of procedure they had done. 

What new technology has been recently added to the EP lab? How have these technologies changed the way you perform procedures?

We recently added the EnSite Mapping System (St. Jude Medical) to our lab. This system allows for mapping without a magnet. By adding EnSite to our lab, we can now use a variety of catheters. We have found that this has helped us save in our overall procedural costs.

What types of cardiac mapping systems do you utilize?

Stamford Hospital currently utilizes Biosense Webster’s CARTO^® system and St. Jude Medical’s EnSite Mapping System.

What imaging technology do you utilize?

A GE biplane system is used as well as intracardiac echo. Some physicians use a CT scan in conjunction.

Do you implant MR-conditional pacemakers or ICDs? What about subcutaneous or leadless devices?

Yes, we use MR-conditional devices (PPMs, ICDs). We also utilize the subcutaneous ICD and Medtronic’s Reveal LINQ ICM. 

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

We have two procedural schedulers that manage both EP and cath procedures. We work closely with physicians’ offices to ensure a seamless transition from community to hospital care. Our scheduling is done using MEDITECH software.

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

Measures practiced in our lab include: fluoroscopy time monitoring analysis, fluoroscopy dose monitoring analysis, contrast use analysis, first case start time, room turnaround, antibiotic start times, and pre and post neurologic assessments. 

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

Supplies are ordered based on the doctors’ preference and use per case. Michael Lutka, our lead technologist, orders equipment and supplies. However, all staff play a role following up on supply needs and communication with technologists.

Have you developed a referral base?

Doctors refer patients to our electrophysiology physicians. Dr. Dhruvakumar and Dr. Shuaib Latif are part of Stamford Health’s Medical Group; Dr. John Novella, Dr. Michael Pittaro, and Dr. Joseph Tiano are part of Cardiology Physicians of Fairfield County.

We also obtain referrals from a large number of community-based medical facilities and other hospitals in the state.

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

Stamford Hospital competes with other NYC hospitals, since we are so closely located to the New York border. We also compete with hospitals located in Bridgeport and New Haven. However, Stamford Hospital works hard to stay ahead of the curve when it comes to technology. For example, Stamford Hospital was the first in Fairfield County to perform cryoballoon ablations and use biplane fluoroscopy.

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

Some of the ways we’ve accomplished this is through data collection projects and through structured equipment purchasing (bulk purchases, recycling). 

How do you ensure timely case starts and patient turnover?

A detailed pre-procedure phone call is completed a minimum of one to three days before the scheduled case. This information is entered into our system ahead of time. This practice helps to identify possible complications or pre-procedure conflicts. As a result, this practice also cuts down on the need to cancel procedures on the day of the case.

We start bringing patients in at 6:30am to improve first case start times. We also track how long each procedure takes, so that cases can be more appropriately scheduled. 

We have streamlined procedural handoff and room turnaround, and have also collaborated with anesthesia to streamline the recovery process.

How are new employees oriented and trained at your facility?

New hospital employees go through the hospital orientation process. This focuses on Stamford Hospital’s mission, belief system, and standards of excellence. 

Next, new employees begin a departmental orientation process. All new employees receive their own competency-based orientation (CBO) binder, which contains departmental skill-based CBOs. These CBOs are used to check off skills as they are mastered during the orientation process. In addition, weekly orientation goals are set by the preceptor, and progress towards these goals is discussed on a weekly basis with the new employee, preceptor, and nurse manager or clinical coordinator. 

All employees on orientation are paired with a primary preceptor, who they follow throughout the orientation process. For EP nurses, orientation begins in the holding and recovery area, and continues in the procedural specialty area. Orientation for EP technologists is structured the same way, except that technologists do not train in holding and recovery, so they skip that step.

Interdepartmental cross training is available for anyone who is interested in training. It is structured around the employee’s specific needs and previous skill set.

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

We have MD-facilitated education time built into our schedule. The entire EP department attended clinical education offered by Healthworks, Inc. We have frequent vendor-facilitated continuing education opportunities. We offer college tuition reimbursement. There is also a clinical ladder for nurses.

How is staff competency evaluated?

It is evaluated through open communication meetings, peer review, hands-on skill competency testing, computer-based (and unit-specific) required tests and training, and a yearly mandatory skills day that involves a review of equipment through hands-on stations.

Have members of your staff taken the registry exam for the Registered Cardiac Electrophysiology Specialist (RCES)? Does staff receive an incentive bonus or raise upon passing the exam?

All of the EP staff members either have a certification, are working towards certification, or are enrolled in a continuing education program. Our long-term departmental goal is to transition toward RCES certification.

• Michael Lutka, RT(R) is currently working toward RCIS/RCES certification.
• Nicola Donnelly, RN is currently working towards CVN certification.
• Leigha DeFeo, RN is currently enrolled in a BSN program.
• Kyna Henrici, RN is currently enrolled in a MSN program.
• Sandy Sharoh, RN completed CCRN re-certification. 

How do you prevent staff burnout? Do you also practice any team-building exercises?

Stamford Hospital’s EP team is a very close-knit group. We support one another, and treat each other like family. Despite how fast we are growing and expanding, we really try to work together to come up with the best way to cover all of the cases while maintaining a work/life balance. Additionally, we are all flexible when it comes to scheduling, and we look at each week as a team to decide what the best staffing model will be. We also try to be proactive and use EP staff meetings to discuss challenges and plan for future changes. We have a monthly support group provided by chaplain services. This support group is informal, and gives the staff the ability to discuss challenges and difficulties at work. 

How do you handle vendor visits to your department? 

Stamford Hospital does maintain various vendor contracts as well as educational visits. Vendors are required to check in.

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

Stamford Hospital’s EP lab staff will discuss music preference with patients. We also have noise reduction practices and blanket warmers.

As a Planetree-designated hospital, our approach to patient-centered care is holistic and encourages healing in all dimensions — mind, body, and spirit.

How does your lab handle call time for staff members? 

Non-restricted call pay is paid for nurses and techs who take call from home on the weekdays. When called in, staff gets paid at an increased hourly rate. There are no scheduled weekend cases.

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

We currently use Stryker and Biosense Webster. Since we recently started the program, data is not yet sufficient at this time to determine cost savings.

Does your lab use contact force sensing technology during radiofrequency ablation of atrial fibrillation?

Yes, we use the THERMOCOOL SMARTTOUCH^® Catheter and CARTO^® System (Biosense Webster, Inc., and Johnson & Johnson company), and the TactiCath ablation catheter with the EnSite system (St. Jude Medical).

Is hybrid epicardial and endocardial ablation of atrial fibrillation performed at your institution?

Yes, we perform Convergent atrial fibrillation ablation at Stamford Hospital for patients that meet the criteria.

What measures has your lab taken to reduce fluoroscopy time? In addition, what types of radiation protective shielding and technology does your lab use?

• GE settings (lower dose options) 
• Biplane
• Other imaging (ICE, mapping systems)
• 3D mapping
• Personal lead and dosimeter monitoring for all procedural staff
• Lead glasses for staff at the table
• Zero gravity for the doctor
• Freestanding rolling glass shield
• Additional lead apron attachments for the table
• Room lock
• Extension tubing on lines to allow more distance with medication administration.

What are your methods for device infection prophylaxis?

We utilize a bacitracin pocket wash, the TYRX^™ Antibacterial Envelope (Medtronic TYRX), and surgical scrub and asepsis. We also follow guidelines from the Association of periOperative Registered Nurses. Practices for surgical attire include having the staff change at work and wearing caps, shoe covers, and masks in the procedure area.

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

Post calls are done for patients who go home the same day. Nurses call and make sure the patient has a follow-up appointment. Staff also asks a list of questions pertinent to the procedure and care. Continued care is then trended towards the doctor offices. Other patients who are transferred to hospital specialty areas will receive discharge instructions from the unit. These patients will follow-up with their doctor after discharge.

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

The electronic medical record is helpful. It allows accessibility to chart information by multiple users in different areas. Computerized documentation is more legible, and therefore, less errors occur. Popup reminders aid in the prevention of missing yet necessary patient care tasks.

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

Trends include using less fluoroscopy and more ICE-guided procedures to help decrease radiation exposure, as well as increased use of cryo technology vs RF.

How does your lab handle device recalls?

Any remaining recalled product is removed from the supply area. The device company sends memos and keeps track of patient implant information. The company will also directly contact the doctors’ offices as well as patients.

How is outpatient cardiac monitoring managed?

This process is managed through each patient’s doctor’s office. This collaborative process between doctor and hospital occurs upon data analysis.

Does your heart rhythm service offer patients with a suspected inherited arrhythmia a referral to cardiovascular genetics clinic?

Yes, doctors refer to other disciplines.

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

Stamford is just outside the greater New York area. Stamford is home to numerous large corporations, including Fortune 500 companies. Stamford is the largest financial district in the New York metropolitan area outside of New York City itself. Stamford is an affluent, highly educated community. As the third largest city in the state, the hospital caters to a large and culturally diverse patient population.

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

We work exceptionally well as a team — we help each other in any way necessary. We have a shared responsibility to assist in all care regardless of designated role, within the scope of practice. We always look for ways to learn and grow as a team. We have a high level of mutual respect for each other and for our patients.