Spotlight Interview: UCLA Cardiac Arrhythmia Center/Ronald Reagan UCLA Medical Center

What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab?

   Our facility has six labs, four of which are EP capable, and one has Stereotaxis.We have 25 clinical lab staff members, including 13 RNs, 10 RTs, and 2 CVTs.There two NPs and 10 EP physicians in our group, soon to increase to twelve.

When was the EP lab started at your institution?

   Our program was started in 1985. In 2002, Dr. Shivkumar was recruited to UCLA; we were organized as the UCLA Cardiac Arrhythmia Center and developed distinct EP programs. These include AF and VT ablation, epicardial ablation, and adult congenital ablation. We have a laser lead extraction program and an intraoperative mapping and ablation program with our colleagues in cardiac surgery.

What types of procedures are performed at your facility?

   Procedures performed at the Ronald Reagan UCLA Medical Center include electrophysiology studies, radiofrequency ablation, cryoablation, surgical ablation, epicardial mapping and ablations, and implantations of automatic implantable cardioverter defibrillators (ICDs), temporary and permanent pacemakers, and biventricular pacemakers and defibrillators. We also perform intracardiac ultrasound, atrial septal defect occlusions, intra-aortic balloon pump insertion, pericardiocentesis, and cardioversions. We average 40 EP studies, 40 device implants, and approximately 40 ablation monthly.

What is the primary goal of your program?

   Our program is multifaceted; we look for growth in all the emerging EP technologies and in the growing EP market. Our primary focus is on advanced catheter ablation.

Who manages your EP lab?

   Erick Ascencio, RT(R) (CI), is the operations manager for interventional cardiology, and Liza Vitturi, RN, MA, is the administrative nurse II for interventional cardiology. A daily charge/team leader position is assigned to nurses and technologists on a rotating basis.

Is the EP lab separate from the cath lab?

   No.

Are employees cross-trained?

About 50 percent of employees work in EP and cath. Staff interested in learning EP is given the opportunity to cross train.

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 recently added a Stereotaxis lab, which helps reduce our use of fluoroscopy. Additionally, we have purchased a lead cabin to reduce flouroscopic exposure for the operator and lab staff, as we are dedicated to complex ablations.A wireless headset intercom system has also been purchased to facilitate communication for a calmer environment.

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

   Our administrative staff use a web-based scheduling request form. Once requests are reviewed, they are entered into our GE Centricity^®/IDX system (GE Healthcare,Waukesha,WI).

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

   Quality assurance measures include conscious sedation outcomes. We also do bi-weekly PI/QI meetings with detailed case review as needed. Yearly competencies are mandatory for all staff.

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

   We use OptiFlex (Omnicell, Mountain View, CA) to track our supply PAR levels and reorder automatically.    Supplies are purchased by the manager after approval of the hospital’s value analysis committee. Equipment purchases must be approved by the director and associate director of cardiology services.

Has your EP lab recently expanded in size and patient volume, or will it be in the near future?

   Our labs increased from three EP-capable labs to four in July 2008. Procedure volume has increased by approximately 25 percent. We are seeing the national trend toward increasing EP cases and increasing outpatient versus inpatient cases.

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

   We provide the highest quality care for our EP patients, regardless of their financial/insurance status. We follow the CMS regulations closely for our cases, and we aim to meet all managed care and regulatory requirements by reviewing these on a regular basis.

Have you developed a referral base?

   Yes, our physicians have relationships with community primary care physicians (PCPs) as well as relationships developed through our outreach efforts.

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 process excellence/process improvement group that works on a daily basis to analyze all our supply, quality and supply management issues. We keep an ongoing published dashboard of our work.

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

   We have relationships and/or alliances with physicians and groups in the immediate and extended (regional, national, and international) community.

How are new employees oriented and trained at your facility?

   If staff meets the qualifications to work in our labs, we provide on-site detailed EP training. We buddy well-trained and expert staff with new staff members until we feel they are competent enough to work on their own.

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

   UCLA offers many continuing education opportunities. Staff are also encouraged to attend symposia related to their field of expertise in addition to weekly fellow conferences. We will again host the California Heart Rhythm Symposium, a two-day conference devoted to recent advances in translational and clinical electrophysiology, taking place in Santa Monica, California, on October 1-2, 2010. We look forward to welcoming our physician, associated professional and industry colleagues to this meeting.

How is staff competency evaluated?

   Competencies are evaluated yearly by observation, checklists and performance evaluations.

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

   We are a busy laboratory at a major academic center. Our cases are interesting and complex, and our staff knows to expect long hours while at the same time provide alert, confident, and competent care. We are very nurturing and encouraging to all our staff, and we always listen and act on concerns in a timely fashion. We meet regularly and involve the entire team in our process improvement initiatives.

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

   Committees include Performance Improvement, the Sedation Committee, and the Quality Improvement/Quality Assurance Committee.

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

Vendor visits are made and managed through Erick Ascencio, RT(R) (CI).Device representatives obtain identification badges to access the cath lab.

Does your lab utilize any alternative therapies?

   No. Most cases in our EP labs are performed under sedation, with members of the anesthesia staff present.

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?

   We do not have a call team for EP, only for STEMI procedures. This team also covers emergency EP procedures.    The call team includes one RN and two techs. One of the techs must be an RT.The nurses sedate and circulate, and the techs scrub assist and monitor.    They average one weekday per week and one weekend a month.The call team is activated about seven times a month.

Does your lab use a third party for reprocessing?

   No.

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

   Approximately 99% of our ablation cases are done with radiofrequency, with 1% being cryo.

Do you perform only adult EP procedures or do you also do pediatric cases? Is there cross training for pediatric cases?

   Yes, we also do pediatric electrophysiology cases. Cross training is provided to staff interested in this population. In addition, we have an advanced catheter ablation program for adults with congenital heart disease, and we actively pursue research in this area.

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

   All staff has personal protective lead and film badges. Staff that scrub and assist use lead eyewear. We also recently purchased a CATHPAX (Anthem Medical) lead booth for physicians to use.

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

   We have a dedicated pacemaker clinic where patients are followed up by advanced practice nurses and highly skilled laboratory technicians.

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 see an increase in complex ablation procedures and an increased use of new technology for safety and efficacy. We are preparing by providing constant education.

What are your thoughts about non-EPs implanting ICDs? Do you train such individuals?

   We do not train non-EPs for implanting ICDs. We do not have a basis for forming an opinion on that issue.

What about device recalls? How has your lab handled these?

   We are guided by Heart Rhythm Society and vendor recommendations in the event of a recall. Our Pacer/ICD clinic director and nurse manager review all recalls and discuss the implications with each patient individually.

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

   We have been involved in the TTOP trial, a study involving specialized bipolar radiofrequency catheters for the treatment of persistent atrial fibrillation. In addition, we are a core laboratory for the DETERMINE trial, a study enrolling patients with myocardial scar documented on MRI, EF>35% with randomization to ICD versus conventional therapy. We will also be a center for the CEASE-VT trial, one of the first trials comparing ventricular tachycardia ablation with antiarrhythmic therapy in patients receiving ICD therapy.

Are you ACGME-approved for EP training? What do you think about two-year EP programs?

   Yes. Two years may be needed based on the complexity of cases today, especially for fellows who wish to gain full competence in AF and VT ablation.

Does your lab provide any educational or support programs for patients who may have additional questions?

   The nurse practitioners in our EP group have special expertise in this area. During initial consultative visits, all patients receive an information packet that includes a description of their procedure, therapeutic options, and informed consent forms.

Give an example of a difficult problem or challenge your lab has faced. How it was addressed?

   The transition from our old facility to the new medical center was a tremendous challenge. In July 2008, we moved from our old hospital to a completely new hospital. The transition was a very good learning experience; we learned it is a must to work closely with your supply and equipment vendors. Planning inservice training for new equipment was a challenge while having to still operate in the old facility and send staff to the new facility for training.

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

   We are in Southern California, where there is a hub of numerous mid-sized hospitals serving all sectors.We are surrounded by many excellent institutions. However, our goals and concerns revolve only around best patient outcomes.

Please tell our readers what you consider unique or innovative about your EP lab and staff.

   We are a great team and we function as the ‘Bruins.’We have been fortunate to be at the forefront of several innovations in EP. Our motto is from the John Wooden ‘rules’:“We deeply care about what is correct and not who is correct” and “The star of the team is the team.” For more information, please visit: https://arrhythmia.ucla.edu/