Spotlight Interview: Temple University Hospital

Temple University Hospital (TUH), a 564-bed facility in North Philadelphia, is one of the region’s most respected academic medical centers. TUH is the chief clinical training site for Temple University School of Medicine, and, since its inception in 1891, has accrued a rich history in producing leaders in medicine, providing exceptional patient care, and contributing to the current state of medical knowledge in the basic, translational, and clinical research arenas. 

Under the leadership of John N. Kastanis, FACHE, President and CEO of TUH, and Dr. Larry Kaiser, the Dean of the Temple University School of Medicine and President and CEO of the Temple University Health System, our hospital is currently undergoing a massive transformation with an invigorating influx of world-class physicians. Dr. Daniel Edmundowicz, Chief of Cardiology, is spearheading and orchestrating the synchronous growth of all cardiovascular subspecialties, including cardiac electrophysiology.

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

This is an extraordinary time for the Temple EP program, and we are so grateful for the opportunity to share our rapidly evolving story with the EP Lab Digest^® readership! In recent years, the Temple University Hospital EP program had been staffed by three attending electrophysiologists, with most procedures being performed in one biplane EP lab. In September 2013, Dr. Joshua Cooper, FACC, FHRS was recruited as the Director of Cardiac Electrophysiology at Temple, which marked a new beginning in our EP program. With respect to the EP lab facilities, the existing EP lab had all of its technology updated or replaced, except for the biplane fluoroscopy system, and design and construction of two additional EP labs began. A brand-new single-plane EP lab will be complete in July 2014, and will be able to accommodate all EP procedures including complex ablations. Even more exciting is the new biplane EP lab/hybrid OR that will be open in late April 2014 and be used exclusively by the EP section. This biplane hybrid EP lab will also be outfitted with the full constellation of equipment and technology to permit all EP procedures, and will be the location of choice for laser lead extractions, epicardial VT ablations, other complex ablations, and hybrid procedures with the cardiothoracic surgical team. With regard to EP faculty, the current team of Dr. Joshua Cooper, Dr. Richard Greenberg, Dr. Bindi Shah, and Dr. George Yesenosky will be joined by Dr. Jeffrey Arkles and Dr. Chethan Gangireddy, who will be starting in July 2014, bringing the total to six attending electrophysiologists. With the doubling of faculty and tripling of the EP lab capacity, we expect our EP procedural volume to dramatically increase, accommodating the already rapidly expanding demand on both the device and ablation fronts.

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

We currently have six full-time EP staff members in the EP lab, including five RNs and one EP technologist. With the imminent addition of two new EP labs, we are currently actively recruiting and hiring additional experienced EP RNs and lab techs in order to concurrently staff and run the three EP labs every day.

What types of procedures are performed at your facility?

In the past, complex EP patients such as those amidst a VT storm had to be transferred to other institutions for management. However, with the addition of new EP faculty, additional EP labs, and the latest EP technologies, we have now become a full-service tertiary referral EP center that is ready and able to manage all EP conditions and accept all such patients from other facilities, no matter how complex the issue. We perform all device implantations including biventricular devices, subcutaneous ICDs, and the latest generation of implantable cardiac monitors. We perform all types of catheter ablations, including SVT, PVC, atrial fibrillation (AF), VT, PVC-induced VF ablations, and epicardial procedures. We will soon be performing left atrial appendage (LAA) closure procedures in a collaborative approach between the EP and interventional cardiology teams. Our cardiothoracic surgery colleagues have particular interest and expertise in arrhythmias as well as in advanced robotic surgical techniques; they perform stand-alone Maze procedures for AF and also collaborate with the EP team when needed in complex device and ablation procedures.

Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained?

Historically, the single Temple EP lab has operated under the umbrella of the cath lab, with one cath/EP lab manager, and with EP lab staff being routinely utilized in the cath lab when needed. With our recent increase in EP lab procedural volume, the introduction of more complex EP procedures, and the imminent opening of two additional EP labs, there is now a more clear demarcation between the EP and cath lab teams. While we may occasionally utilize a cath lab staff member to assist in the EP lab on a day we are understaffed, we have moved to a model of hiring EP-skilled RNs and techs on a per-diem basis when necessary. With the increase in acuity and complexity in our EP lab experience, it has become essential that all EP staff have specialty EP knowledge in order to maximize efficiency, effectiveness, and safety in all EP procedures. As we expand to three EP labs, we will almost certainly hire a separate EP lab manager to facilitate an organized and streamlined workflow.

Do you have cross training inside the EP lab? 

Yes, our EP lab team members are expected to understand and appreciate the various aspects of all EP procedures that are performed, from device implantations to lead extractions to ablation procedures. All EP lab staff are able to scrub/prep patients for device implantations, and all EP lab staff are trained to run the EP equipment that is used during EP studies and ablation procedures, including the radiofrequency ablation generator, cryoablation console, multi-channel pacing stimulator, and intracardiac electrogram recording system.

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

With respect to device implantation, we implant devices from all manufacturers, as deemed appropriate for each specific patient by the EP attending physician. A self-contained headlamp system is used by some physicians during device procedures for better device pocket illumination and visualization. Medtronic’s PEAK PlasmaBlade electrocautery system is routinely used for generator changes, lead revisions and device “upgrades” to minimize the risk for thermal injury to functional indwelling leads during device pocket dissection. For lead extraction procedures, we primarily use the Spectranetics laser sheath extraction system but also rely on fixed and rotational mechanical sheaths, and an array of femoral snares during more complex extractions. We use venoplasty techniques in the great veins and coronary vein system to manage venous stenosis, and prefer using a 6 mm x 40 mm noncompliant balloon system (compatible with 0.035” wire) for venoplasty in the subclavian and brachiocephalic vein systems. 

Each EP physician has her/his individual preferences when it comes to catheter ablation. Intracardiac echocardiography (phased-array platform) is routinely used during complex ablations to assist with anatomic definition and catheter positioning, as well as to facilitate transseptal puncture and monitor for complications. Three-dimensional electroanatomic mapping is used for all complex ablations such as AF, VT, and PVC ablation. The Biosense Webster CartoSound ICE/3D mapping integration platform is typically used for aortic cusp and papillary muscle PVC ablation. Cryoablation is typically used for parahisian accessory pathway or atrial tachycardia ablation, and is also frequently used for AV node reentry tachycardia ablation in young patients. We use 4 mm non-irrigated RF catheters for simple ablation such as WPW, and irrigated RF ablation is typically used for ablation of AF, atrial flutter, VT, and PVCs.

How is shift coverage managed? What are typical hours?

Our EP lab schedule is currently in flux as our clinical volume is rapidly growing in the expansion from one to three EP labs. For the moment, the EP lab staff manage their own daily coverage schedule, in consultation with the cath/EP lab manager, ensuring adequate staffing for the procedural volume each day. If a particular day’s staffing demand exceeds our ability to accommodate, EP-expert per diem RNs and/or techs are hired to fill the need. A typical day will start at 7am and end when the procedures for the day are done, which often extends into the evening hours. Our EP staff members can only be described as exceptional with respect to their unwavering dedication to our patients and their flexibility in accommodating whatever needs to be done each day. We plan to introduce a “late shift” in order to run one of the three EP labs into the evening hours each day to accommodate complex cases.

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

Until recently, there has been a dominance of device procedures and simple ablation procedures in our EP practice. In a single EP lab, we have routinely performed between four and six procedures in a day, between 8am and 6pm or so. Such procedures might include pacemaker and ICD implantations, generator changes, biventricular devices, SVT ablations, EP studies, and atrial flutter ablations. When laser lead extractions need to be done, these have typically been performed in a shared hybrid OR, in parallel with the procedures occurring in our EP lab. With the expansion of our procedural repertoire to include more complex ablations, some days are comprised of a simple procedure (device implant or simple ablation) and a complex procedure (AF or VT ablation), but we certainly have performed two complex ablations sequentially, as the situation demands. When our three EP labs are fully operational this summer, it is likely that one lab will be largely devoted to device cases and the other two labs, including our EP hybrid lab, will be used for ablation procedures and lead extractions. Given the unpredictable nature of complex ablation procedures, we expect to staff and operate one of our EP labs into the evening hours each day.

What new equipment, devices and/or products have been introduced at your lab lately? How has this changed the way you perform those procedures?

We are constantly on the lookout for new products and technologies to incorporate into our EP practice that improve effectiveness, safety, and efficiency of our procedures, as well as extend our therapeutic capabilities. In addition, as a training institution with a plan to offer educational courses in the near future, we strive to always be on the cutting edge of EP lab technology, including the incorporation of advanced data storage and broadcasting techniques. With regard to device procedures, the use of a head-mounted light source allows the implanting physician unparalleled visual access to the device pocket, which assists with safe lead dissection, device/lead positioning, and hemostasis. We also use TYRX’s AIGISrx Antibacterial Envelope in carefully selected cases to reduce pocket infections in these high-risk patients. Temple EP is now implanting Boston Scientific’s S-ICD System, which is an extremely valuable option for patients with venous access limitations, young patients with VF syndromes, congenital heart disease patients with right-to-left intracardiac shunting, and those with a high risk for endocarditis (hemodialysis patients). We are also utilizing Medtronic’s Reveal LINQ implantable cardiac monitor for patients with rare syncope and a negative initial evaluation, patients with cryptogenic stroke, and sometimes as a means to quantify the AF burden in patients. We are looking forward to imminently starting a LAA occlusion program, which will be an important option to reduce stroke risk in patients with AF who are not good candidates for long-term anticoagulation. 

In the lead extraction/management realm, our greatest development is the construction of a dedicated EP hybrid OR. This lab is located adjacent to the other operating rooms and can be instantly converted into a surgical suite, complete with cardiopulmonary bypass/perfusion capabilities, in the rare event that cardiothoracic surgical intervention is needed during laser lead extractions or other complex EP procedures. This hybrid EP lab will also be used for collaborative EP-surgical interventions whenever percutaneous catheter ablation alone does not suffice. 

In the AF realm, we routinely use general anesthesia, jet ventilation, intracardiac echocardiography, irrigated RF ablation, and the latest 3D mapping techniques to achieve high success rates and minimize the need for repeat procedures in patients with paroxysmal and persistent AF. We have already incorporated Biosense Webster’s Carto 3 MEM Software and VisiTag Module to improve our understanding of the arrhythmic substrate and ablation lesion formation, and are very much looking forward to using the new contact force catheter technology to further improve ablation efficacy and minimize complications. We are always highly cognizant of minimizing radiation exposure to the patient and EP staff, and utilize biplane fluoroscopy, collimation, low frame rates (3 frames/second), non-fluoroscopy imaging (ICE, 3D mapping), and other techniques to achieve the lowest radiation dose possible. To further reduce radiation dose we will be installing Biosense Webster’s CartoUnivu Module in our EP labs, which merges fluoroscopy with 3D electroanatomic mapping, further reducing “pedal on” time. 

Lastly, to facilitate teaching and real-time case broadcasting, we are installing in-handle cameras in our overhead operative lights as well as installing single-screen and broadcast solutions from Banyan Medical Systems in our EP labs. The latter will give us the ability to securely transmit full-resolution images via an Internet-based platform to be used for instantaneous off-site collaboration during a case, for off-line trainee teaching locally, or for live-case broadcasting in a symposium venue.

What is your experience with MR conditional cardiac devices? 

We implant devices from all companies and incorporate MR conditional device implantations into our procedural repertoire. We have anecdotally observed a higher rate of lead perforation and dislodgement in leads that have been specifically designed to be MR conditional, and are therefore pleased with the current progress in getting standard pacemaker leads tested and approved for use in the MRI environment. In addition, we are working to create a protocol for MRI imaging in patients whose pacemaker and ICD systems are not formally labeled as MR conditional. We feel that there are certain situations where MRI imaging is essential to a patient’s care, with no suitable alternative imaging modalities. In such patients, the risk/benefit balance may fall in favor of proceeding with MRI imaging as long as the patient partners with the health care team and agrees to the small risk of device and/or lead malfunction following exposure to the strong magnetic fields in the MRI environment.

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

Just as in our cardiac catheterization labs, our EP cine and stored fluoroscopy runs are automatically archived for review at any time. We are currently working to integrate our intracardiac echo systems into our echocardiography network to similarly allow for automatic archiving of all stored ICE images and video loops.

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

Our EP lab scheduling system is currently in flux due to the expansion as well as because of anticipated changes in the Temple University Hospital inpatient information system. At present, our EP administrative assistants work directly with our EP lab staff as well as with the Temple Access Center to create our daily schedule, prepare all pre-procedure documentation, and obtain insurance pre-authorization for the procedure and hospital inpatient or outpatient admission. With the imminent tripling of our EP lab capacity will come a much greater complexity in scheduling patients and ensuring all pre-procedure tasks are complete and in order. We are currently looking at different software solutions for the short term, but as our hospital will be implementing the inpatient EPIC system in the next one or two years, we anticipate that we will be using EPIC for procedure scheduling in the long run. 

Have you developed a referral base?

Yes, we have a rich referral base in the greater Philadelphia area and beyond, and the list of referring cardiologists, internists, and electrophysiologists continues to grow along with our program. While Temple University Hospital has a skilled marketing team, we have found that our most rewarding source of new referrals is via word-of-mouth praise from our satisfied patients. Customer satisfaction is paramount in our Temple EP program, and that starts from the very first time we interact with our new patients by telephone to set up an office visit. Our EP-knowledgeable administrative assistant staff frequently develop long-lasting relationships with our patients by providing compassionate and prompt assistance as soon as we receive the initial referral phone call or note. We schedule a very timely appointment and our expert outpatient EP team spends as much time as needed with each patient to educate them about their condition, review all treatment options, and reassure them that we will do everything possible to achieve the best possible outcome. Under the leadership of Rutuke Patel, PA-C, MSPAS, RCIS, our outpatient-associated professional team is second to none, and it is a testament to their knowledge and passion for their work that glowing patient testimonials come to our attention every week. The expert and attentive care that our EP attending physicians give each patient in the clinic setting solidifies the bond that patients feel when they get their EP care at Temple. There is nothing like the immediate relief from palpitation episodes, the improvement in heart failure symptoms, or the satisfaction of an outstanding cosmetic result after device implantation to prompt patients to refer their family and friends to our EP practice.

How do you ensure timely case starts and patient turnover?

The key to prompt starting times and patient turnover is a dedicated EP lab staff that works well together as a team and has the patients’ well-being as their first priority. When these ingredients are in place, everyone does whatever tasks are needed to move things forward. We are so incredibly proud of our Temple EP lab staff in every regard, including their professionalism, clinical skill, mutual respect, sense of humor, efficiency, and cohesiveness as a team. Simply put, we have never had a problem with prompt start times or rapid case turnovers. Cases are almost always ready to start before 8am, and turnover times of 15-20 minutes are routine. But we would be remiss if we did not acknowledge the extraordinary contributions by our colleagues in the department of anesthesia. We utilize CRNAs, anesthesiology residents, and attending anesthesiologists in most of our EP procedures, including use of general anesthesia for AF ablations, lead extractions and other complex procedures. It is only with seamless collaboration with anesthesia staff that prompt start times and rapid turnovers can be accomplished. It will be a new challenge to maintain our efficiency as we grow to three EP labs; to succeed, we will need to recruit EP lab staff who embody the same dedication, knowledge, and principles that are espoused by our current EP team members. The creation of a separate EP lab manager position will likely be necessary to maintain our current high level of performance.

Has your institution formed an alliance with others in the area?

Jeanes Hospital is part of the Temple University Health System, and Dr. George Yesenosky is the primary provider of EP services at that hospital.

How are new employees oriented and trained at your facility?

Orientation and training are done by our current EP lab staff as well as our EP attending faculty. As we currently work out of one EP lab, there is always ongoing teaching during every case. As we expand to three EP labs and grow our staff, we plan to create an educational curriculum to permit standardized teaching in a formal lecture series. In addition, we will primarily be looking to hire EP lab staff with years of experience, so that we can build upon an existing foundation.

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

A 45-year-old man had a history of inferior myocardial infarction but a relatively preserved LV ejection fraction of 50% in the past. He underwent routine stress echo testing for renewal of his commercial driver’s license and was found to have very frequent PVCs and runs of nonsustained VT that were completely asymptomatic, as well as a reduced LV ejection fraction of 35%. The morphology of his frequent ventricular ectopy suggested a possible origin from his inferior LV scar, and he was told by his cardiologist that he had progressive ischemic cardiomyopathy with scar-based reentrant VT and that he would need an ICD, lose his commercial driver’s license, and forfeit his career. In our EP lab he underwent LV and RV mapping and was discovered to have an idiopathic PVC/VT focus in an area of normal myocardium on the floor of his right ventricle, near the moderator band. After successful ablation, all ventricular ectopy disappeared and there was no inducible VT related to his small inferobasal LV scar. Therefore, he likely had a nonischemic PVC-induced cardiomyopathy unrelated to his coronary disease — we are waiting for a follow-up echocardiogram to verify that his LV function returns to his prior baseline. His case demonstrates the need to always have an open mind with respect to diagnosis, and that sometimes two different processes can be active in the same patient, especially when one of them is coronary artery disease that is so commonplace. In this instance, the recognition and treatment of a reversible cardiomyopathy will likely have major implications on the patient’s quality of life and career.

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

Cryoablation is used for most parahisian pathways and atrial tachycardias, as well as for many AV node reentry ablation procedures, particularly in younger patients. We have not yet incorporated cryoballoon techniques in our AF management, as our current use of RF ablation with advanced 3D mapping techniques, general anesthesia, and jet ventilation has given us excellent success rates with very few complications.

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

At the start of each procedure, we perform a fluoroscopy “time out” in order to implement all means to achieve the lowest possible radiation dose. Different angles of acceptable RAO and LAO camera positions are tested to find the angles with the lowest radiation dose. The flat panel detectors are lowered as close to the patient as possible. Collimation is used to eliminate unnecessary peripheral field radiation exposure. The lowest frame rate that achieves acceptable imaging is used (as low as 3 frames per second). Radiation shields are properly positioned to protect the EP physician and all staff in the room. Other imaging modalities (intracardiac echocardiography and 3D electroanatomic mapping) are used to maximum advantage to minimize the need for fluoroscopy. In our new hybrid EP lab, the Zero-Gravity system (CFI Medical Solutions) has been installed for maximal protection of the EP physician, especially during long procedures. In all three EP labs, we will be installing Biosense Webster’s CartoUnivu Module that registers the fluoroscopy image with the Carto 3 electroanatomic mapping system, which will further reduce the need for live fluoroscopy.

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

Outpatient device follow-up is exclusively done by our Temple EP staff, including our outpatient PAs, NPs, and RNs under attending EP supervision; we do not rely on industry representatives for scheduled device interrogation. We utilize remote device monitoring to reduce the number of trips to the office that patients must make, as well as to investigate patient symptoms and any other device concerns that occur between scheduled device interrogations. We will soon implement a PA/NP-run device clinic for routine device management, which will streamline our outpatient EP practice.

Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR)? 

Yes, an NCDR Data Registry form is completed for all ICD implantations.

How does your lab handle device recalls?

When a device or lead recall is announced, we obtain a list of affected patients from the vendor and contact each patient to schedule an individual counseling session. The decision to replace an advisory device and/or lead either immediately or at the time of battery depletion is individualized and must take into account multiple factors. Some of these factors include the risk and nature of the specific device/lead malfunction, the ability and timing to detect a malfunction before harm befalls the patient, pacemaker dependence of the patient, the incremental risk of intervention prior to the next scheduled device procedure (factoring in the expected time to the next generator change), the existing lead hardware in place, the patency of the ipsilateral subclavian vein, the patient’s comorbidities and anticipated longevity apart from arrhythmia-related diagnoses, the risk of malfunction of the new device or lead, and most importantly, the psychological factors and patient wishes after a full education and counseling session has taken place. The decision to proceed with lead extraction of an advisory lead is usually a completely separate matter from the decision of whether to replace that advisory lead, as a new lead can often be added without extracting the old one. Once all options for managing the device recall have been discussed, including the risks and benefits of each strategy, the physician and patient together will make the most appropriate decision for that specific clinical scenario.

Are you ACGME-approved for EP training? What are your thoughts on two-year EP programs?

Yes, we are approved for two EP fellowship positions, and we strongly feel that two years of EP training are necessary given the broad spectrum of EP clinical and procedural skills that must be acquired.

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

Words cannot express the pride that we feel for our Temple EP staff, including the lab staff, the outpatient staff, the inpatient staff, and the administrative staff. The common elements that are shared by all of them are a passion for patient care, mutual respect, a constant desire to achieve excellence, a strong loyalty to being part of the Temple family, and the realization that job satisfaction results primarily from the quality and character of the people with whom you work. It is our welcome challenge as we navigate a major growth phase in Temple EP to add team members who will continue the tradition of humble distinction that our current staff demonstrate. By recruiting new members to our EP team who emulate the role models we already have in place, our vision to grow into one of the dominant EP programs in the region will most certainly be realized. 

Attending EP Physicians:

• Joshua Cooper, MD
• Richard Greenberg, MD
• Bindi Shah, MD
• George Yesenosky, MD
• Jeffrey Arkles, MD
• Chethan Gangireddy, MD

EP Lab Staff:

• Sam Lark, EP lab technologist
• Jeanine Adgalane, RN
• Duwayne Dixon, RN
• John Salvatore, RN
• Joseph Mullins, RN
• Richard Kalman, RN

Inpatient NPs:

• Linda Madrak, CRNP
• Deborah Gleeson, CRNP

Outpatient PA and RNs:

• Rutuke Patel, PA-C
• Karen Heston, RN
• Deborah Whitley, RN

Administrative Assistants:

• Sandra Beale
• Delrine Randolph