Spotlight Interview: UNC Health Care

What types of procedures are performed at your facility? Approximately how many catheter ablations (for all arrhythmias), ICD implants, and pacemaker implants are performed? 

We perform all types of device implants, including pacemakers, ICDs, BiVs (ICDs and pacemakers), and loop recorders. Ablations performed include those for atrial fibrillation (endocardial), ventricular tachycardia (endocardial and epicardial), PVCs, complex and non-complex SVTs, and Convergent procedures. Other procedures we perform include tilt table tests, cardioversions, and EP studies.

We do approximately 700 ablation cases and 500 device cases per year.

What is your number of staff members, and what is their mix of credentials?

We have 11 staff members, including RNs, RTs, and RCIS’s. We have five EP attending physicians and one full-time EP fellow.

What is the size of your EP lab facility? 

There are three designated EP labs at UNC Health Care.

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

We use three mapping systems in our lab, including Biosense Webster’s Carto System, St. Jude Medical’s EnSite Velocity System, and Boston Scientific’s Rhythmia Mapping System.

We implant devices by BIOTRONIK, Boston Scientific, Medtronic, and St. Jude Medical.

For ablations, we use both standard RF and cryo catheters, as well as catheters such as Boston Scientific’s IntellaMap Orion Mapping Catheter and St. Jude Medical’s EnSite Array Catheter. We also utilize contact mapping/force sensing catheters such as Biosense Webster’s ThermoCool SmartTouch catheter and St. Jude Medical’s TactiCath Quartz Contact Force Ablation Catheter.

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

The UNC Health Care System is an academic medical center and a non-profit integrated health care system owned by the state of North Carolina. It exists to further the teaching mission of the University of North Carolina and to provide state-of-the-art patient care.

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

At UNC Health Care, our day in EP starts at 7:00 am. Staff assignments are made the night before to fulfill designated roles and responsibilities among the staff. Staff assignments are unique with regards to roles, in that all members are cross-trained to scrub and circulate. Other staff members with more experience are assigned to mapping and utilizing the stimulator under the auspice of a physician. The circulating role for ablation cases involves assisting our holding pre-procedural area in preparing the patient; for device cases, the sedation nurse assists with this. On arrival to work, staff assumes their roles and each lab is checked off and readied for the procedure. We use a multidisciplinary approach through EP physicians, Anesthesia, OR staff for Convergent procedures, EP staff, and holding staff to adequately meet patient needs.

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

• Our EP lab has a designated lead nurse and lead tech to facilitate compliance and functioning of the EP labs and staff, as well as serve on the Leadership committee with lab management.
• Quarterly quality meetings are held to review clinical outcomes and develop quality improvement plans.
• Designated EP staff members provide education to other departments regarding post-procedural care of EP patients.
• Several staff members serve on hospital committees such as Radiation and Safety, Diversity, and Professional Development.
• Designated staff members are responsible for ensuring completion of the ICD Registry.
• All staff members participate in huddles and staff meetings.
• All staff members attend weekly EP educational conferences given by EP attending physicians.
• Additional EP education is provided by EP attending physicians to provide tutorial case reviews of interesting cases performed in our EP lab.
• Designated individuals provide inventory control and maintenance of lab equipment. 
• All staff work together to facilitate a safe, clean, and sterile environment for procedures.
• The lead nurse assists in writing policies and procedures pertinent to the EP lab.
• Thank you cards, procedural brochures, and educational information handouts are provided to patients and families.
• Monthly EP education is provided to staff to reinforce EP concepts.
• Environmental services are utilized to terminally clean our labs to enhance sterility of procedures. 

How do you ensure timely case starts and patient turnover?

Communication and teamwork are essential in ensuring excellence in patient care, appropriate start times, and adequate lab turnover times. 

The UNC EP lab operates under the guidance of a lead nurse and lead tech. The role of the lead nurse is to handle administrative tasks such as patient scheduling and staff assignments, serve as a liaison between board runner and procedure rooms, and manage flow of patient care outside the procedure rooms. The lead tech helps to ensure adequate patient care and flow from within the procedure rooms, troubleshoot equipment, manage and purchase inventory, proctor staff, and handle other administrative tasks. Together, the lead nurse and lead tech reinforce adequate case start times and room turnover times.

We also have assigned Environmental Service Staff to facilitate room turnover times.

How are new employees oriented and trained at your facility?

• We have a structured EP lab orientation program for all new EP technologists and nurses. This includes:
• Basic competencies such as but not limited to performing 12-lead EKGs with rhythm interpretation, identification of intracardiac rhythms, IV assessment skills, venous and arterial sheath pulls, connectology with all mapping systems, radiation safety, etc.
• Definition of individual roles within the EP lab, such as the circulator, scrub person, and sedation nurse.
• Review of policies and procedures.
• Orientation to pre- and post-procedural care.
• Familiarity with equipment and respective procedures.
• Online learning modules pertinent to the EP lab, such as radiation safety and conscious sedation.

Weekly meetings with leadership staff provide a basis to assess progress, provide feedback, and determine goals. Our overall goal is to have nurses and technologists gain expertise in both simple and complex procedures in order to function independently. 

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

• Music therapy: Our EP labs are equipped with iPod speaker systems. Since an EP lab can be intimidating for many patients, we encourage music therapy to help them relax and feel more at ease. We even take patient music requests.
• Distraction techniques: We had a young pediatric patient receiving a pacemaker who brought her favorite teddy bear the day of her procedure. During the procedure, one of our nurses had an idea to implant a pacemaker in the little girl’s teddy bear to help assimilate and comfort her during the process of the procedure. After obtaining permission from the parents, two of our nurses worked together to find an unused, outdated pacemaker and proceeded to sew the device into the teddy bear as well as mend other tattered areas of a well-loved bear. After the procedure, the little girl was informed her favorite stuffed animal also required a pacemaker and was presented with her new and improved teddy bear. She broke out in a big smile and immediately touched the teddy bear’s boo-boo and then her own.
• Lighting: Our labs are equipped with full color spectrum LED lighting to help reduce patient stress. 

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

Cardiac tamponade is a rare occurrence in our EP lab. However, it is an associated risk with AF ablation procedures. Anytime there is an occurrence in our EP lab, our approach is to debrief to help identify ways we could improve patient care and enhance learning. During one of our recent AF procedures, a patient went into cardiac tamponade. As a result, we identified certain factors we felt could be improved upon. Our lead nurse developed an algorithm for cardiac tamponade to ensure better patient outcomes and enhance quality of care. The information garnered was shared at staff meetings, huddles, and subsequent educational sessions.

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

We perform both adult and pediatric EP procedures. We train our staff to function in both adult and pediatric procedures. PALS-certified staff and Pediatric Anesthesia personnel manage pediatric cases.

What innovative EP techniques are being utilized in your lab? 

Some of the innovative techniques being used in our lab include left atrial appendage occlusion devices, hybrid procedures, 3D mapping systems, Catheter Robotics’ Amigo Remote Catheter System, Boston Scientific’s S-ICD System, the CardioMEMS HF System (St. Jude Medical), and cryoablation therapy from Medtronic.

Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) or any other outside data collection registry?

Yes, we use the ACC-NCDR.

How do you use the NCDR Outcome Reports to drive QI initiatives at your facility?

We review clinical data at our quarterly quality meetings to drive change. Our multidisciplinary team develops plans and metrics to monitor performance.

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

Yes, we are ACGME-approved for EP training. Our goal is to assist our fellows to become independent practitioners proficient in electrophysiology. Thus, we support two-year EP programs and feel they should be mandated because there is too much to learn in one year. The end result is an EP practitioner capable of facing all contingencies in clinical practice.

Is your EP lab currently involved in clinical research studies? Which ones?

Yes, our EP lab participates in device research studies such as the NAVIGATE Clinical Study and the Evera MRI Clinical Trial. The ablation research studies we participate in include the CABANA Trial, ZERO AF, and Ablate-NCS.

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

At UNC Hospitals, we use an electronic medical record system known as EPIC, which puts essential patient information into one consolidated medical record with shared access across numerous medical facilities. This provides a user-friendly system and improves quality of patient care. In addition, EPIC provides a direct link for patients to access their medical records and communicate more effectively with physicians and other health care providers.

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

Chapel Hill, North Carolina was rated by Newsmax magazine as #3 of the top 25 most uniquely American cities and towns. We feel Newsmax magazine describes Chapel Hill best by stating, “This college town has all the culture of a big city and some of the best educational institutions in the country. And it’s long been on the map as the so-called ‘Research Triangle,’ along with nearby Raleigh and Durham. Although you may not head to Chapel Hill expecting a foodie’s getaway, travelers get exactly that with what Bon Appétit recently dubbed it “the foodiest small town in America.”¹ 

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

What makes our EP lab and staff unique is a dual thought process. First, we employ diversity. We embrace a global way of thinking, utilizing the unique skill sets and experiences of our staff to foster a patient-centered care environment. We feel our team is our most important asset. Secondly, we have a sense of pride and commitment in obtaining dedicated solutions to each individual patient. n

Reference

1. Newsmax Magazine Rates the Top 25 Most Uniquely American Cities And Towns. Newsmax. Available online at https://www.newsmax.com/Slideshows/Newsmax-Magazine-Rates-the-Top-25-Most-Uniquely-Am/97791/3--Chapel-Hill,-N-C-/4/. Accessed June 9, 2015.