Spotlight Interview: The Heart Rhythm Center at Deaconess Health Systems

What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab? The EP lab at The Heart Rhythm Center at Deaconess Health Systems consists of one dedicated EP lab at our main campus and one shared room (with the cath lab) at our Heart Hospital campus. Additionally, a new biplane EP lab was installed in the Heart Hospital at Deaconess Gateway that was operational as of June 2009. Also, we share a four-bed holding area with the main campus cath lab. We have three electrophysiologists, with an additional EP physician that joined the group in July 2009. We also have two EP physicians, Dr. Rimawi and Dr. Crevey, who perform some procedures in this EP lab from a different group. Our EP staff consists of three full-time RNs, one part-time RN, three full-time RTs, and one full-time RCIS/RCES. When was the EP lab started at your institution? The EP program at our main campus was initially started in July 1993 by Dr. Christine Gest, with the first dedicated EP lab in the area opening in the fall of 1994. The primary focus was on comprehensive electrophysiology and the implantation of non-thoracotomy ICDs. In 2003, Dr. Chandra Kumbar joined the EP lab and initiated our complex ablation program, including ablative treatment for atrial fibrillation (AF), atrial flutter, and ventricular tachycardia (VT). The first cryoablation in the state of Indiana was done at our main campus in May 2005. Dr. Ashwani Bedi joined us from Mayo Clinic in 2006 and was first in the region to start a laser lead extraction program in 2007. In January 2007, the shared EP lab at our Heart Hospital campus was opened. What types of procedures are performed at your facility? Approximately how many are performed each week? We perform implantations of permanent pacemakers and intracardiac defibrillators, including biventricular devices. Comprehensive diagnostic and interventional electrophysiology procedures, including supraventricular tachycardias (SVTs), atrial fibrillation, atrial flutter and ventricular tachycardia ablations, are performed using the Carto (Biosense Webster, Inc., a Johnson & Johnson company, Diamond Bar, CA) and EnSite (St. Jude Medical, St. Paul, MN) systems. We also do laser lead extractions. Recently, our physicians have begun performing epicardial ablations partnering with our cardiovascular surgeons. We currently perform between 13 to 18 EP procedures per week. What is the primary goal of your program? Our primary goal is to offer comprehensive electrophysiology services to our patients and the community. The ultimate goal is to gain recognition as an EP center of excellence. Who manages your EP lab? Ashwani Bedi, MD is our EP lab Medical Director, and Mr. Curt Webb is our Department Director. Mrs. Karen Fox is the Cath Lab Manager, also responsible for the EP lab. The day-to-day operations of the EP lab are the responsibility of our EP charge person, and are rotated between three staff members. Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained? Yes, we have dedicated EP staff. Some EP staff are cross-trained in the cath lab. Some of them take call on weekends. This arrangement has been going on since 1998. Do you have cross training inside the EP lab? What are the regulations in your state? New EP staff members go through a three- to six-month orientation and training process. Physicians are also actively involved in teaching of EP staff. Nurses are the only ones who can give medications. Radiological technicians operate the x-ray equipment. All other staff members have a State Health Department limited Cardiac Catheterization Certificate, which allows them to move the x-ray table and C-arm only. 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 upgraded our AcuNav (Siemens Medical Solutions, Malvern, PA) to SoundStar technology (Biosense Webster, Inc., a Johnson & Johnson company) at both campuses in the summer of 2008. Our new dedicated EP lab at the Heart Hospital has a new Philips biplane x-ray system. Who handles your procedure scheduling? Do you use particular software? We have a secretary for the cath lab who handles the EP scheduling using Apollo CardioSchedule (LUMEDX, Oakland, CA), in a collaborative effort with our EP physicians’ office staff. What type of quality control/quality assurance measures are practiced in your EP lab? Fluoroscopy times and radiation doses are monitored and reported for every procedure. Conscious sedation audits are done on all patients sedated by the nursing staff. We also do laser standards (check off), time outs prior to procedure, and routine equipment checks and maintenance. How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? Our inventory is checked on a weekly basis by two EP staff members, and supplies are ordered as needed through a Lawson supply system. All supplies are kept in locked cabinets at night. All new equipment purchases are done through our purchasing department after it has gone through the budget process. Has your EP lab recently expanded in size and patient volume, or will it be in the near future? Our EP program expanded in June 2009 with the opening of a new dedicated EP lab in our Heart Hospital campus, going from one and a half labs to two and a half EP labs in all. In July 2009, our program also added another EP physician. How has managed care affected your EP lab and the care it provides patients? Within the EP lab we have not felt a lot of change with managed care. The EP physicians continue to see a busy patient schedule. Have you developed a referral base? Yes. Heartcare, a joint program of Deaconess Hospital and The Heart Group, operates over 20 satellite offices in the Tri-State region. These offices are located in southern Illinois, northwestern Kentucky, and southern Indiana. Nearly a third of our patients come from areas outside Evansville. We also get referrals from regional cardiology practices from nearby cities. 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 have a Value Analysis Team that meets monthly to discuss new supplies needed as well as supply cost management. Every January, a complete inventory is done and a list of supplies due to expire in that year is made. The list is updated periodically and posted in the lab. Physicians also actively participate in cost savings. Does your EP lab compete for patients? Has your institution formed an alliance with others in the area? Yes, there is one other lab in town. Our lab is the busiest in town, with a full line of technology required in today’s EP world as well as very knowledgeable staff. No alliance has been formed with any other institution in the area. What procedures do you perform on an outpatient basis? In addition, what EP procedures are generally only considered inpatient? Usually all the implants are done as outpatient or as observation status. Post-ICD checks (NIPS) and generator replacements are performed on an outpatient basis. Most of the complicated ablations such as VT and AF ablations are done as inpatient. New device implants and post-ablation patients stay overnight for monitoring purposes. How are new employees oriented and trained at your facility? New members joining our electrophysiology team must first attend the required hospital orientation. Upon arrival to the EP lab, a 12-week orientation and preceptorship is tailored to meet each new hire’s needs and expectations. We feel that it takes at least one year to fully train a new or existing member on the monitor, stimulator and mapping systems. Most of the training is done on the job with different staff, depending on the tasks. What types of continuing education opportunities are provided to staff members? Physicians actively engage in discussing the cases and the review of literature. Monthly EP education sessions are arranged as permitted. Device and catheter reps also provide in-services from time to time and at our annual skills day fair. We try to send two staff members to the Heart Rhythm Society’s scientific sessions every year. How is staff competency evaluated? We perform annual skills day for all EP staff, including hospital and safety competencies. Annual peer evaluations are done on all EP staff members. All EP staff is required to be BLS and ACLS certified. How do you prevent staff burnout? In addition, do you practice any team-building exercises? The staff has scheduled late days each week. We all work as a team and make sure people are getting off at decent hours, and at the same time, if we have late cases, they are taken care of in a timely manner. Most of us have scheduled days off in any particular week. We are also huge believers in family time, and try to honor that whenever possible. What committees, if any, are staff members asked to serve on in your lab? The EP staff participates on the Educational and Professional committee, Quality Council, Practice Council/ Policies, and Nursing/Retention Recruiting committee. How do you handle vendor visits to your department? Do you contract with vendors? All vendors are required to sign in upon entering the department. All vendor contracts are handled through our purchasing department. Does your lab utilize any alternative therapies to help patient in the EP lab? We do use music therapy on request by patients. Please describe one of the more interesting or bizarre cases that have come through your EP lab. What lessons did you learn from it? Many of our patients are memorable to the staff for a variety of reasons. From the bald-headed guy with a tattoo on the back of his head of a man pushing a lawn mower (this attracted a lot of attention from the staff) to the young lady we coded for four hours for electromechanical dissociation or PEA. She eventually went to surgery and was placed on a biventricular assist device. After a couple of awake post-op days, she was transferred for possible heart transplant. You need to always be prepared for the worst, because you never know what’s going to happen or when. How does your lab handle call time for staff members? How often is each staff member on call? How frequently do they have to come in, on average? Is there a particular mix of credentials needed for each call team? Call for our EP lab is staying late to finish the scheduled cases for that day. We require four staff members to be on call (or stay late) every night. Two of those staff members are required to be RNs, one staff member is required to operate the CardioLab (GE Healthcare, Chalfont St. Giles, UK), stimulator and mapping systems and one staff member must be able to scrub. The call schedule gets rotated, so staff are usually on call two to three days per week. Does your lab use a third party for reprocessing? We did initially, but the physicians were disappointed with the condition and performance of the returned catheters, so we discontinued the program. Approximately what percentage of your ablation procedures are done with cryo? What percentage is done with radiofrequency? Approximately 12% of our ablations are done with cryo, mainly for AVNRT. About 88% of our ablations are done with radiofrequency systems, both Stockert and EPT. Do you perform only adult EP procedures or do you also do pediatric cases? Is there cross training for pediatric cases? We do mainly adult EP procedures. We have one EP physician who has performed cases on a few mid-teenage patients. No additional cross training was needed. What measures has your lab taken to minimize radiation exposure to physicians and staff? Our fluoroscopy has been upgraded to allow 7.5 fps. We also use the RADPAD (Worldwide Innovations & Technologies, Inc., Overland Park, KS) radiation protection products on all ablation procedures and have lead skirt barriers on both sides of the table. In addition, we have lead upper shields on both sides of the patient and a roll around lead shield. In addition, we follow the ALARA (As Low As Reasonably Achievable) guidelines. Do your nurses/techs participate in the follow up of pacemakers and ICDs? No. What are some of the dominant trends you see emerging in the practice of electrophysiology? How is your lab preparing for these future changes? We are seeing some trends in our electrophysiology lab with the increased use of cryoablations for SVTs and ThermoCool (Biosense Webster, Inc., a Johnson & Johnson company) catheter ablations for AF ablations. What are your thoughts about non-EPs implanting ICDs? Do you train such individuals? Well-trained cardiologists may be competent to perform ICD implants, especially if they have fulfilled the HRS requirements. We do not train non-EP physicians. What about device recalls? How has your lab handled these? We have treated patients with recalled devices as per established guidelines. The patients are monitored through the EP physician’s office. Is your lab doing web-based/transtelephonic device follow-up? No. The physician practices provide this independently. Is your EP lab currently involved in any clinical research studies or special projects? Which ones? Yes, we have been involved in several device studies. Currently we have a couple of active studies going on. This is mainly done through physician offices, but with hospital IRB approval. When was your last inspection by the Joint Commission? We are no longer inspected by the Joint Commission; we are now reviewed by the Healthcare Facilities Accreditation Program (HFAP) under Requirements for Healthcare Facilities. 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? The EP staff does not provide any educational material to patients. This is handled by the physician offices, device reps, admitting unit, and/or the EP nurse practitioners. Currently the EP lab does not have a device support group, although we have had one in the past. Give an example of a difficult problem or challenge your lab has faced. How it was addressed? Approximately one year ago, we had two staff members end up on the injured list and eventually left the EP lab. That left the EP lab very short staffed. We had staff that worked five days a week, gave up vacation time, worked late hours, gave up family time, and basically worked together as a team to get the work done. Cross training had to be quickly jump started, along with recruiting for new EP staff. Describe your city or general regional area. Evansville is a city of approximately 121,500 and sits in the southwest corner of Indiana. We serve patients coming from all over the tri-state area, and the draw is close to one million people. Please tell our readers what you consider unique or innovative about your EP lab and staff. Our EP lab staff is a mix of awesome professionals who demonstrate each day how important our patients are. We work with excellent physicians who are well trained, knowledgeable, and above all, respect our talents and dedication to electrophysiology. The EP staff is impressive as a working team, supporting each other in and out of the lab. 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