Spotlight Interview: MedStar Health Cardiac Electrophysiology

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EP LAB DIGEST. 2023;23(4):1,14-17.

When was the cardiac electrophysiology (EP) program started at your institution and by whom?

MedStar's EP program was launched by Dr Edward Platia in 1985 at MedStar Washington Hospital Center (MWHC) in the nation’s capital. He remains our charismatic emeritus physician whose upbeat energy continues to inspire the program.

What drove the need to implement an EP program?

EP was a nascent field in the mid 1980s and MedStar's program has evolved with the growth of this rapidly developing specialty.

What is the size of your EP lab facility? Has the EP lab recently expanded in size?

As of March 2023, MWHC has 6 full-service EP labs plus 4 additional labs for noninvasive cases such as cardioversions and head-up tilt table testing.

Our integrated patient care suite incorporates these 4 noninvasive labs to offer 15 bays for preprocedure and postprocedure care. Our most recent EP laboratory was completed this month and has been named the MedStar Health Heart Rhythm Innovation Center, a large, hybrid-capable EP lab with a built-in 27-seat viewing auditorium and multimedia broadcasting system. We call the space our “EP Lab of the Future” because we aspire for it to be a high-impact training and education center to help move the field forward.

Who manages you EP lab, and what is the mix of credentials and experience?

Our health system’s Physician Executive Director of Cardiac Electrophysiology is Zayd Eldadah, MD, PhD. Our cardiovascular technologist (CVT) program manager is Alex Ayalew, BSc, MA, RCES, and our assistant nursing director is Simone Payne, RN, BSN, MSA. Our EP Lab Regional Administrative Director is Bonnie Bosler, RN, BSN, MSA, CCRN-K. Our CVTs have registered cardiovascular invasive specialist (RCIS) and/or registered cardiac electrophysiology specialist (RCES) certification. Many of our registered nurses (RNs) also have additional nursing certifications.

What is the number of staff members?

Our physician team includes 18 cardiac electrophysiologists plus 2 EP fellows who regularly perform cases at MWHC. They are supported by 12 CVTs, 22 RNs, 1 nurse navigator, 1 medical office assistant, and 2 patient care technicians, along with our CVT program manager, assistant nursing director, and regional administrative director. We continue to assess needs, and we have opened additional CVT and RN positions to support our recently expanded procedure and patient care space, plus continually meeting needs associated with continued growth. We utilize agencies to support staffing as needed.

What types of procedures are performed at your facility?

We perform the full spectrum of procedural cardiac EP, including endocardial and epicardial catheter ablation to treat arrhythmias such as supraventricular tachycardia, ventricular tachycardia (VT), atrial flutter, and atrial fibrillation (AF). We also have a deep and continual collaboration with our cardiac surgical team, with which we partner to perform epicardial ablations and hybrid procedures for inappropriate sinus tachycardia, AF, and lead extractions, for example. Additional procedures include left atrial appendage (LAA) closure, His bundle pacing (HBP), left bundle branch area pacing (LBBAP), tilt table testing, cardioversions, and of course, device implantations (loop recorders, pacemakers, implantable cardioverter-defibrillators, subcutaneous defibrillators, leadless pacemakers (Aveir [Abbott] and Micra [Medtronic]), the remedē^® System [Respicardia/ZOLL Medical], and Barostim [CVRx]).

Approximately how many ablations (for all arrhythmias), device implants, lead extractions, and LAA closures are performed each week?

The case load varies; however, the lab typically performs 50 ablations, 25 device implants, 1-2 laser lead extractions, and 4-8 LAA closures per week.

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

Our EP equipment includes the Carto 3. v7.2 system (Biosense Webster, Inc, a Johnson & Johnson company), EnSite Precision and EnSite X (Abbott), SmartAblate (Biosense Webster), EnSite Amplifier and Ampere generator (Abbott), Maestro 4000 Radiofrequency Ablation System (Boston Scientific), CryoConsole Cardiac Cryoablation System (Medtronic), Centricity Cardio Workflow and amplifier systems (GE Healthcare), MicroPace Stimulator (GE Healthcare), EP-4 Cardiac Stimulator (Abbott), Sonosite Ultrasound (Fujifilm Sonosite), Acuson P500 Ultrasound System (Siemens Healthineers), Vivid Ultrasound (GE Healthcare), Zonare (Abbott), Octaray Mapping Catheter (Biosense Webster, Inc), SmartAblate (Biosense Webster, Inc), PentaRay catheter (Biosense Webster), EnSite catheter (Abbott), Advisor HD Grid, Sensor Enabled (Abbott), TactiCath Ablation Catheter, Sensor Enabled (Abbott), and Arctic Front Advance Pro Cardiac Cryoablation Catheters (Medtronic). Our fluoroscopy systems include both Philips and Siemens units.

What are some of the new equipment, devices, and products recently introduced at your lab? How have they changed the way you perform procedures?

New equipment includes the Carto v7.2 system (Biosense Webster), EnSite X (Abbott), Octaray Mapping Catheter (Biosense Webster), Vascade MVP System (Haemonetics), RF Transseptal System (Baylis Medical), and SafeCross Transeptal System (East End Medical). Using the new transseptal systems, our physicians enjoy better visualization with less fluoroscopy and reduced transseptal procedure times.

How is inventory managed at your EP lab?

Our supply chain team manages all inventory and orders supplies based on par levels.

Tell us about your device clinic, including its staffing model.

An integral part of the ambulatory Heart Rhythm Clinic, the device clinic at MWHC is a robust practice supported by 2 RNs, 2 CVTs, and several administrative support associates. In 2022, over 1600 patients were seen in person, and over 6500 remote encounters were performed. We are currently transitioning our entire patient population to a new remote management platform.

How did the COVID-19 pandemic impact your EP lab, hospital, or practice?

The pandemic changed so much in our lives. However, aside from a few months of reduced EP lab volume, it did not dramatically alter the activity, growth, or expansion of our program. It taught us to be leaner, more thoughtful, and more appreciative of all the good that is around us. From an operational perspective, we operated 3 labs per day and after cancelling the lowest urgency cases. Once we resumed normal operations, the caseload immediately grew. We now have to create blocks of time to accommodate inpatient add-on patients.

How do you ensure timely case starts and patient turnover?

A terrific nurse navigator reviews every day’s patients to ensure they are clinically ready. This includes confirmation that appropriate lab work and test results are on hand, followed by a preprocedural phone call to answer questions. We have implemented a 0715 preprocedural case huddle with the patient, electrophysiologist, anesthesiologist, certified registered nurse anesthetist/anesthesiologist assistant, CVT, and EP nurse to ensure that everyone involved in the case understands the plan of care. After the team huddle, the patient enters the room at 0730. The lab assigns float CVTs and RNs to assist with lab turnover while the primary team hands off in the recovery area.

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

The EP preprocedure and postprocedure suite opens at 0600, and scheduled outpatients start arriving between 0615-0630. Physicians arrive at 0700-0710, and the patient huddle with the team takes place at 0715 to complete all introductions, answer questions, and review the plan of care for the patient and their family members. Our current daily case average for cases is 16, which includes scheduled outpatients and inpatient add-ons. CVTs arrive at 0700 and are scheduled until 1700, with a few assigned to “late stays” to assist with completing the last cases. The intent is for the EP department to close by 1930, but with inpatient add-ons, this can vary throughout the week. Professionalism means focusing on the quality of care at every level, including starting and ending on time.

Is your lab using same-day discharge?

A majority of our procedural patients are discharged the same day. With our new vertical care area built into the EP preprocedure and postprocedure suite, we are now able to offer a “one-stop” experience for patients and their families by caring for them from start to finish without reliance on postprocedure recovery elsewhere in the hospital.

Can you describe the extent and use of vascular closure devices in your lab?

Femoral venous accesses with 6 to 14 French (F) sheaths and femoral arterial accesses with 7F sheaths and smaller are closed using the Vascade MVP system. Groin punctures beyond 16F are closed using Perclose (Abbott).

How does your lab schedule team members for call?

The lab currently operates on a Monday through Friday schedule with staff scheduled from 0600-1930 daily. Each day, there are “late stay” staff (CVTs and RNs) designated to support cases that may end after normal hours and/or emergency cases that will run late.

Do you have flexible or multiple shifts? How do you handle slow periods?

RNs provide coverage from 0600-1930; they are assigned 10-hour or 12-hour shifts. CVTs provide coverage from 0700-1730 and are currently scheduled for 10-hour shifts, but we are currently looking at 12-hour options. Slow periods are evaluated and associates are “flexed” if overstaffed.

How do you handle vendor visits?

We have excellent professional relationships with our vendor partners, who support patient care delivery in the procedure room and thereafter. MedStar uses Green Security to manage sign ins and sign outs by vendors in the hospital.

What are the best features of your EP lab’s layout and design?

The geographic contiguity of every component of the heart rhythm service line at MWHC is an enormous strength. Having all procedural, ambulatory, and administrative personnel in the same place, including clinical and administrative leadership, lab associates, our MWHC-based ambulatory center and device clinic teams, our EP advanced practice providers (APPs), and those who support our new training and education center, makes for work days that are energetic, efficient, highly collaborative, and extremely enjoyable.

Do staff members enjoy any specific perks?

Yes, we offer EP-specific education, including a spring retreat for all EP staff and support staff, environmental services, supply chain, and others who support EP daily operations. Educational benefits are offered through the hospital to support furthering education. MedStar Health offers an enormous array of employee benefits that make it a highly competitive health care employer.

What measures has your lab implemented in order to cut or contain costs?

We use a process for value analysis to review new requests for products and equipment. This process involves the physician champion requesting the product and a dedicated in-house expert leading a collaborative economic and clinical assessment. After approval, the product is subject to subsequent price negotiation to ensure maximal savings.

How are new team members onboarded?

We have partnered with CHART Healthcare Academy to enhance our onboarding/orientation structure. In addition to providing a better training system, we are now able to support continuing education (CE) for RNs and CVTs. This program is a 6-week coaching/mentoring program to cultivate advanced skills and augment the development our associates achieve on the job. Communication styles are studied, including how to provide high-quality feedback and create a healthy culture among staff. Regina Kiefer, RT(CV), RCES, RCIS, provides monthly education days and one-on-one coaching to build staff confidence. Consistently positive results have been demonstrated after the first 6 months of hire for all new EP staff. The CHART platform supports new and advanced team members through community channels and advanced coaching, which has served as an excellent resource for the team as a whole and especially our staff working toward EP credentialing. We are also provided access to virtual monthly EP Pro courses with more live coaching as well as a dashboard look at each associate’s progress. This program has been a game-changer for training, education, and advancing our service line.

What other CE opportunities are provided for staff members?

MedStar supports associates’ participation in educational activities both within the health system and outside it. These include in-services with CE credit, our EP core curriculum and annual MedStar Heart Rhythm symposia, education through CHART Healthcare Academy, as well as regional and national conferences. Staff also have an opportunity to use allotted funds ($10K per a year for RNs, $4K per year for CVTs) for educational degrees (CVTs are unionized through the Service Employees International Union, and RNs are unionized through National Nurses United).

Discuss the role of mid-level practitioners in your lab.

Under the supervision of our EP physicians, our EP-specialized APPs support elective procedures by documenting the history and physical examination, placing orders, and assessing each patient to ensure that medications/labs are appropriate and no further diagnostic tests are needed. After the procedure, the APP either discharges the patient from our care suite, or less commonly, admits the patient to a hospital bed for overnight observation or more advanced care. The APPs assist the EP physicians in seeing and managing inpatient hospital consultations and arranging for EP procedures as necessary, including orders, diagnostic tests, and patient education. There are currently 10 APPs that support our EP program at MWHC.

Describe a memorable case from your EP lab and how was it addressed.

One particularly memorable case involved an elderly man whom we recently treated for long-standing persistent AF. He had been plagued by years of deteriorating quality of life because of his arrhythmia and had to abandon golfing, yard work, and many other activities that he loved. He found us after being dismissed by other hospitals and practitioners who considered his AF to be too intractable to be corrected. Last year, he underwent a convergent ablation procedure as part of our EP cardiac surgery hybrid program, and he is now in stable sinus rhythm, back on the golf course, living life to the fullest, and—according to his wife—happier and more active than he has been in 10 years. Stories like his make our life’s work indescribably rewarding—and a deep honor and privilege.

Does your lab use a third party for reprocessing or catheter recycling? How has it impacted you lab?

Yes, we have been working with Innovative Health since 2020. In FY22, we were able to save over $1 million, waste divert 2,592 lbs, and reduce CO₂ emissions by 10,373 lbs.

Tell us about your approach to HBP and LBBP.

Yes, we are pleased to offer multiple complementary approaches to resynchronize hearts and improve symptoms, including both conduction system pacing such as LBBAP, as well as biventricular pacing. We also have been able to offer our patients (along with our physicians and EP fellows) the unique talents of Seth Worley, MD, who has created an entire line of unique tools and techniques to place left ventricular pacing leads in patients who may have been unable to experience effective cardiac resynchronization by standard methods.

Tell us about your primary approach for LAA closure.

LAA closure therapy continues to play an important role in select AF patients. As new generations of LAA closure devices come to market, we expect more of our patients will benefit from a reduced risk of bleeding and continued protection from stroke. Our team at MWHC has among the highest volume LAA closure programs in the country.

Does your program have a dedicated AF clinic and/or a dedicated lead extraction program?

AF is the central diagnosis in modern cardiac EP, increasingly as our population ages. We have been fortunate to build an AF Center of Excellence administered from the 24 ambulatory sites throughout our region that constitute the MedStar Health EP outpatient service. Our regional extraction center is based at MWHC and is a special example of the power of collaboration to safeguard our patients and optimize outcomes. Extractions for all lead systems greater than 12 months from implant are scheduled with a dedicated cardiac surgical support team in the room and a designated cardiac surgeon in-house is available to intervene when needed. Two highly experienced EP physicians, Athanasios Thomaides, MD, and Cyrus Hadadi, MD, head the MWHC lead extraction program. High-volume, focused training, state-of-the-art equipment, plus a robust and thoughtfully structured rescue mechanism, are hallmarks of our program, which attracts referrals from long distances and has thankfully built an excellent track record of safety and effectiveness.

What approaches has your lab taken to reduce fluoroscopy time?

Reducing fluoroscopy time benefits everyone, especially patients and providers. With recent advances in 3-dimensional electroanatomic mapping, along with image integration, we are performing more cases with zero (or minimal) fluoroscopy. However, fluoroscopy cannot be abandoned completely, as we are an academic training center and must use fluoroscopy to educate trainees, promote safe procedures, and validate nonfluoroscopic data.

What are some of the trends you see emerging in the practice of EP?

Emerging trends in EP include leadless pacing, pulsed field ablation, noninvasive ablation, and smarter strategies for arrhythmia prevention.

How do you use digital health and wearable technologies in your treatment strategies? Have you seen an increase in the number of patients using digital health technologies? What are the associated challenges or benefits?

The digital health revolution has arguably touched the EP field more so than many other specialties, primarily because of the rapid proliferation of wearable heart monitors (eg, Kardia [AliveCor] and Apple Watch). We definitely see more data from these technologies, which can enhance patient engagement, promote good follow-up in the arrhythmia clinic, and facilitate diagnosis and treatment. The challenge of data overload remains a prime concern, but thankfully, we have not yet experienced the much-feared data deluge that was once forecast.

Describe your city or general regional area. How is it unique?

The Baltimore-Washington metropolitan area is home to over 10 million people and it continues to grow. It is anchored by government, but also by numerous other economic engines that confer stability and desirability. As the region’s largest health system, MedStar Health has the honor and responsibility of delivering ethical, humane, evidence-based, and cutting-edge health care to all of our area’s diverse communities.

What specific challenges does your hospital face given its unique geographic service area?

MedStar Health is a nonprofit health system that serves as a care safety net for a large and diverse population, including numerous underprivileged communities in the Baltimore and Washington, DC, metropolitan areas. As such, our overarching challenge is providing best-in-class care to all of our patients, regardless of their financial capability or insurance coverage. This means having to work smart, be cost-efficient, minimize waste, and find creative ways to grow and expand when the resources to do so are not limitless.

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

The MedStar EP team is an extraordinary group of professionals. First and foremost, they are all caregivers. They are genuinely committed to our patients’ well-being and to providing the most technologically advanced care that is delivered safely, compassionately, and comfortably. They embody the ideal of lifelong learning and demonstrate daily that being a world-class EP caregiver means dedication, being on top of your game, staying current, always growing, finding resourceful solutions, respecting and supporting your teammates, and never forgetting that promoting our patients’ best interest is our top priority.