Spotlight Interview: The Ohio State University’s Richard M. Ross Heart Hospital

When was the EP lab started at your institution? What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab? Has your EP lab recently expanded in size and patient volume, or will it be in the near future?

The EP lab at the Ohio State University was initially started in 1972 by Dr. Stephen Schaal, with a primary focus on diagnostic electrophysiology studies. In the late 1980s, transvenous ICD implants were introduced into our EP lab. In 1988, the Ohio State University performed the first RF ablation in central Ohio. Over the past several decades the lab has grown steadily, but as the science of electrophysiology has developed therapeutic ablation and device therapy, the EP section has grown more rapidly in the past several years. Since 2006, there have been numerous changes in the electrophysiology service. For example, the EP staff has been increased by 5 electrophysiologists and other numerous staff members to support the newly renovated and expanded electrophysiology laboratories. In addition, we’ve opened a new unit that is solely dedicated to the care of patients with arrhythmias.

Even with this recent growth, further expansion is on the way. In July 2008, the Ohio State University’s Richard M. Ross Heart Hospital opened 2 additional patient care floors utilizing the universal bed model already in use on the other floors of the hospital. This expansion added 60 inpatient beds, 30 of which will be dedicated to the electrophysiology service. Nurses on the new EP unit are specifically trained to care for all aspects of EP and arrhythmia management, regardless of the extent of their acuity. The EP lab currently consists of 5 invasive suites and one non-invasive lab for tilt table testing, cardioversions, and defibrillator testing therapies. Since completion of the inpatient unit at the Ross Heart Hospital, another phase of expansion will soon begin with the construction of 3 additional invasive labs and a 10-bed EP holding and observation area. The electrophysiology section is made up of 9 board-certified electrophysiologists. The EP program also uniquely benefits from the assistance of a Level III trained heart failure physician who is certified to implant devices. There are also 2 EP fellows; our EP fellowship program has expanded to 2 EP fellows per year, for a 2-year program. The EP lab staff consists of a nurse manager, 29 RNs, 3 cardiovascular technicians, 2 radiologic technicians, 2 cardiovascular service associates, and an administrative assistant. The inpatient 30-bed EP unit is staffed by 7 nurse practitioners, a nurse manager, 2 assistant nurse managers, 50 RNs, and 29 support staff members. The members of the Ambulatory Care Unit consist of 4 RNs and 3 staff members. The specialized Antiarrhythmic Clinic is dedicated to managing patients who are prescribed amiodarone and other potentially toxic antiarrhythmic medications; it is staffed with a pharmacist and 2 staff members. Another section of our electrophysiology service is the Cardiac Rhythm Device Service, which assists with the management of patients with implantable devices. This service is managed by 6 RNs and 8 staff members. The EP Research section manages over 20 clinical trials and is made up of 4 RNs and a research coordinator.

What types of procedures are performed at your facility? What is the primary goal of your program?

The philosophy of the Ross Heart Hospital EP program is to offer the latest advances in technology to provide personalized and specialized patient care. To this end, we participate in numerous clinical trials and are early adopters and users of advanced therapies.

With a group of 10 physicians who vary in their primary focus, we are able to better serve our community and outlying areas in all aspects of EP. We completed over 5,000 invasive and non-invasive procedures in 2007. We perform diagnostic procedures and ablations (using both radiofrequency and cryo energies); last year we completed over 400 atrial fibrillation ablations. We use 3D mapping systems, such as EnSite, Carto, and CartoSound, and assisted navigation with Stereotaxis. We treat many congenital abnormalities and ablate complex SVTs and ventricular arrhythmias. Recently, our physicians have begun performing epicardial ablations. We also have a large focus on biventricular pacing for cardiac resynchronization therapy, as well as complex extractions, using both laser and manual sheaths.

Who manages your EP lab?

Glen Plants, RN, BSN was hired at the time of our expansion, to manage the process and staff within the lab.

What procedures do you perform on an outpatient basis?

Approximately 60% of our cases enter the hospital as an outpatient. Procedures that would allow patients to return home the same day are diagnostic electrophysiology studies, device generator replacements, and some ablation procedures such as SVT. Most other outpatients are typically monitored for approximately 24 hours.

Have you developed a referral base? Has your institution formed an alliance with others in the area?

Patients are routinely referred to us from the entire state of Ohio as well as from neighboring states such as West Virginia, Pennsylvania, Kentucky, Michigan, and even Florida. We have cultivated an extensive referral base, in part related to the geographic position of Columbus, but also due to the efforts of the EP staff to provide their expertise to other sites. The Ohio State University is a tertiary referral center for many hospitals in the southeastern part of the state. Also, the EP section supports over 8 outreach clinics, which are operated in a cooperative nature with affiliated hospitals. Oftentimes, device implants and low-risk EP procedures are performed at these outreach centers by the OSU electrophysiologists. We believe this is advantageous for the patient and their family, for the local institution, and for the electrophysiologist.

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

A full complement of technologies is essential in order for the Ross Heart Hospitals EP program to manage any particular patient need and to provide a safe and successful therapy for any arrhythmia. Some of these changes and advances have allowed us to evolve our scope of practice to meet the needs of our patient population. In the past two years, we have opened our Stereotaxis lab, allowing remote catheter manipulation via magnetic guidance. This in turn reduces the amount of fluoroscopy exposure that the patient and medical staff receive. We have also recently started using Biosense Webster’s CartoSound Module, which allows a real-time intracardiac ultrasound image to provide a 3D map of the left atrium for the ablation of atrial fibrillation. Using this software allows the physicians to make a full 3D map of the left atrium prior to performing a transseptal puncture. Also available is ultrasound imaging for intracardiac echocardiography, cryoablation, and radiofrequency probe for transseptal puncture. Most recently, the EP lab has added epicardial ablation. In addition to our non-powered, electrosurgical and laser sheath extractions, we have recently begun using Cook Medical’s Evolution and Evolution Shorty Mechanical Dilator Sheath sets, which are rotationally powered and designed to navigate through dense fibrous or calcified tissue.

What complications do you find during these procedures?

The most critical complications we might encounter are pericardial tamponade and respiratory compromise. Although these do not occur often, we have developed a system within our lab for the initiation of our emergency response. This includes staff and supply allocation, as well as contacting ancillary services such as anesthesia and CT surgery. Another complication can be related to infections. We have an EP committee that focuses on infection control. This committee, in collaboration with the Infectious Disease Section, has created standards of practice from the hospital and the Association of Perioperative Registered Nurses (AORN) policy to continue to keep our infection rates minimal (<1%).

Do your nurses/techs participate in the follow up of pacemakers and ICDs? If so, how many device visits per week do they handle?

The EP lab staff does not participate in the direct follow up of pacemaker/ICD patients. We have an independent Cardiac Rhythm Device Service, which includes 14 staff members who are assigned on a daily rotation between the outpatient clinic and inpatient services. Inpatient services include ER and OR consultations, device interrogation and reprogramming, and discharge teaching and wound care for the newly implanted device patients. The average patient case load is approximately 40 patients per day, with our outreach clinics seeing up to 90 patients per day. Our Paceart database has information on over 14,000 patients. The Cardiac Rhythm Device Services also handles remote transmissions for device follow up and troubleshooting. They currently have approximately 1,000 patients enrolled in remote device monitoring.

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

The research team is involved in numerous multi-site and investigator-initiated studies; they work collaboratively with the EP lab, Device Services and Heart Failure and Outpatient Arrhythmia Clinics. The RNs on the research team are responsible for screening and identifying patients for study entry, teaching, chart review, and data collection and follow up throughout the duration of the clinical trial. Research at the Ohio State University’s Ross Heart Hospital focuses on 2 areas: device therapy for heart failure, and ablation therapies for atrial fibrillation and ventricular tachycardia. We currently have 21 active trials, including those on balloon-based therapies (such as from CardioFocus and ProRhythm) and others on curative ablation of atrial fibrillation such as TTOP AF (Ablation Frontiers is the sponsor) and CABANA (which is now closed to enrollment). Device trials include FREEDOM, RISK, Chronicle ICD, FIX-HF-5 and RESPONSE-HF. The FIX-HF-5 and Chronicle ICD trials are managed by the heart failure coordinators. One unique study in particular is PROTECT AF, which involves percutaneously deploying a device (WATCHMAN® device) that occludes the left atrial appendage; this study is also now closed to enrollment.

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

The EP and cath labs are located in the same area, but are run as two separate entities, including separate staff, for nearly 30 years. Our staff is not cross-trained to the cath lab. With our high volumes and complex cases, we have focused on the education and expertise of our staff to be solely devoted to electrophysiology.

Who handles your procedure scheduling?

The process of getting a patient into the lab is a collaborative effort. For outpatients, the heart schedulers initiate the process. All inpatients are evaluated by one of our electrophysiologists, who then contacts our pre-EP nurses, who arrange the procedure. Our 2 pre-EP nurses carefully screen the patient to be certain that the initial workup and proper pre-op testing, labs, and imaging studies have been completed and are available to the lab at the time of the procedure. Once on the schedule, the daily charge nurse assigns patients to particular labs and manages the flow of patients throughout the day.

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

We have many committees within our lab that are filled on a volunteer basis: • Members of our Shared Leadership committee are elected for 6-month rotations to evaluate and represent the needs of our staff. Regular meetings are held with the physicians, EP lab manager, director of nursing, and many ancillary services that work toward promoting safe and efficient patient care within our EP lab. • The Education Committee evaluates staff educational needs and integrates learning opportunities to meet particular needs of each staff member. • Our Infectious Disease committee works in collaboration with the hospital Infectious Disease Team, Environmental Services, and AORN to create a set of guidelines to practice within the EP lab. • There is a Room Design committee that collaborates to increase our overall efficiency within the lab by creating and maintaining consistencies between the lab suites. • Due to the high level of acuity that we care for in our EP lab, we have created an Emergency Response committee to assess any complications that can occur intraoperatively. We have also implemented a process to assure prompt response to any emergency by using resources and equipment from within the department, as well as enlisted the assistance of ancillary services, such as anesthesia and CT surgery, when necessary. • We have a committee that focuses on Scheduling as well as an Activities Committee that coordinates activities to build camaraderie. • Finally, there is a team that works toward maintaining our Magnet status within our department.

How do you prevent staff burnout?

Our Scheduling Committee works diligently to provide flexibility and time off requests for staff; there is also a rotation system for ‘on call’ and designated ‘late scheduling’ that facilitate staff to plan ahead for personal commitments. Our Activity Committee arranges activities for the staff to participate in outside of the hospital, such as our annual holiday party and summer mud volleyball tournament.

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

At the Ohio State University, we have the backing and support of our department, as well as our union, OSUNO, to pursue educational opportunities and independent studies. This May, five staff members attended the HRS conference in San Francisco. Every Wednesday, the EP section hosts an educational conference that all staff is encouraged to attend. In addition, we have regular postings for conferences and educational forums. Our Scheduling Committee works to accommodate staff requests for everyone’s learning needs. There is a yearly Ross Heart Hospital competency fair that must be completed by all staff. In addition to having in-services on supplies and therapies used in the lab, our Education Committee has implemented the “EP Blitz,” which is a day-long educational opportunity providing vendor support on use and troubleshooting of all equipment used within the lab.

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 6-12 week orientation and preceptorship is tailored to meet each new hire’s needs and expectations.

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

Incoming inventory and purchasing is managed by two cardiovascular service associates who maintain $2-3M worth of stock per month. The clinical/bedside team is responsible for inventory of the supplies used during a particular case. This is all maintained through the use of a materials management program called Q-sight.

Does your lab use a third party for reprocessing?

No, any products that are introduced into the body are single-use only (i.e., diagnostic/therapeutic ablation catheters and intracardiac ultrasound equipment). Please tell our readers what you consider unique or innovative about your EP lab and staff. The Ross Heart Hospital EP section and our patients are so fortunate to have a total of 166 health care personnel dedicated to the subspecialty of managing and curing arrhythmias.

Figure 2. Front Row: Dr. Macy Smith; Dr. Mahmoud Houmsse; Dr. Doron Menachemi; Dr. Ayesha Hasan; Dr. Steve Kalbfleisch; Bruce West, RN; Laura Dochstader, CVT; Kelly Withrow, RN; Tracy Schwartz, RN; Kandie Brantley, RN; Craig Adams, RN; Cheryl Gysegem, RN; Rob Lock, RT; Connie Smith, RN; Dr. David Hart; Janie Haas, RN; Dr. John Hummel; Dr. Charles Love. Top Row: Greg Brumfield, RT; Tanya Holuczak, RN; Amy Teagarden, RN; Dr. Ralph Augostini; Duane Dallman, RN; Lynn Reade, RN; Dawn Clark, RN; Trisha Morris, CVT; Maranda Durant; Sarah Jacobs, RN; Katie Williams, RN; Lori Sindledecker, RN.

Figure 3. Melissa Cribbs, RN; Tim Brigner, RN; Mary Wourms, RN; Nathan Ricker; Angela Bowman, RN; Kari Dunham, CVT; Jill Gibson, RN; Glen Plants, RN, Nurse Manager; Mary Wilson, RN; Linda Paxton, RN, Director of Nursing; Julie Lyons, RN; Larry Oliver.

Figure 4. Dr. Stephen Schaal.

Figure 5. Dr. Ashish Gangasani, Dr. Emile Daoud, Dr. Zhenguo Liu, and Dr. Raul Weiss.

Figure 6. Kim Bructo, RN, Marsha Colahan, RN, and Sandy Campbell, RN.