Spotlight Interview: John Muir Health Cardiac Rhythm Center
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EP LAB DIGEST. 2023;23(8):1,18-20.
When was the cardiac electrophysiology (EP) program started at your institution? By whom?
The Cardiac Rhythm Center at John Muir Health was started in 2004 to address the increasing complexity and range of EP services that we were providing at that time. The program was supported by our hospital administration, and Carleton Nibley, MD, was the first appointed medical director.
What drove the need to implement a cardiac EP program?
With the rapid expansion of ablation services to include atrial fibrillation (AF) ablation, the Cardiac Rhythm Center at John Muir Health required a programmatic approach to optimize safety and efficiency.
We began by selecting a program manager and physician medical director, both with extensive clinical cardiac EP experience, and then recruiting and training a team of nurses and technologists with a passion for EP.
We included after-hours training for our team, which was provided by our electrophysiologists. We also recognized the importance of creating a state-of-the-art space dedicated to our arrhythmia work, especially our increasingly complex ablation cases, so we designed and constructed a clinical laboratory that incorporated added space for specialized equipment and high-resolution, large-format monitors, as well as wireless communication and unobstructed viewing between operators and the control room.
What is the size of your EP lab facility? Has the EP lab recently expanded in size, or will it soon?
We have 2 rooms designated for EP in our department. The Cardiovascular Institute, which houses 5 cardiac catheterization labs, was built in 2010. Of the 5 labs, our EP labs are two of the largest, at approximately 800 square feet each.
Who manages your EP lab, and what is the mix of credentials and experience?
Scott Neal is John Muir Health’s program manager for the Cardiac Rhythm Center. Scott has 25 years of EP, 3-dimensional (3D) mapping, and teaching experience. Scott worked in the 3D mapping industry for 12 years as a clinical instructor, clinical mapper, and territory manager before coming to John Muir Health. He has certification from the International Board of Heart Rhythm Examiners (IBHRE) and is a registered cardiac electrophysiology specialist (RCES), and was on the Cardiovascular Credentialing International’s RCES exam writing team for many years.
Our lab is staffed with mix of RNs, x-ray technicians, and cardiovascular technologists (CVTs), all with clinical EP training and experience. Several members of our EP team have been in this field for more than 10 years and bring experience from other facilities, which helps keep us on the cutting edge and always growing.
What is the number of staff members?
Our standard staffing for ablation cases is 4 staff members, including 1 x-ray technician, 1 or 2 RNs (a CVT will often replace the second RN), and Scott for mapping. With Scott’s 3D mapping experience, we rarely need to rely on industry help.
What types of procedures are performed at your facility?
We do all procedures here at John Muir Health with the exception of epicardial ablations. Our current case mix is approximately 50% AF ablations and approximately 35% typical and atypical flutters (AFL), with the remainder being a mix of supraventricular tachycardia (SVT), ventricular tachycardia, and atrioventricular node ablations. We also perform lead extractions, left atrial appendage occlusion (LAAO) implants, and all cardiovascular implantable electronic devices including leadless pacemakers, subcutaneous implantable cardioverter-defibrillators, cardiac resynchronization therapy pacemakers and defibrillators, and loop recorders.
Approximately how many catheter ablations (for all arrhythmias), device implants, lead extractions, and LAA closures are performed each week?
In an average week, we perform approximately 12-14 ablations, 13-15 device implants, 3 LAAOs, and 1-2 lead extractions.
What types of EP equipment are most commonly used in the lab?
We use mostly EP catheters from Abbott (Duodeca, Inquiry, Advisor HD Grid Mapping Catheter, Sensor Enabled, Agilis deflectable sheath, TactiCath Ablation Catheter, etc), except for the occasional use of the Radia XT Steerable Catheter (Boston Scientific) for the coronary sinus (CS). About 90% of our AF ablations are performed using the Arctic Front cryoballoon and Achieve Advance Mapping Catheter (Medtronic). For intracardiac echocardiography (ICE), we primarily use a ViewFlex Xtra ICE Catheter (Abbott) and ultrasound machine (Zonare). For 3D mapping and radiofrequency (RF) ablation, we currently use only Abbott technology. Use of Abbott’s Advisor HD Grid Mapping Catheter and omnipolar mapping in association with their TactiCath ablation system has given us some great results on complex cases.
Both of our EP labs are equipped with the EnSite X 3D system (Abbott), Ampere RF ablation generator (Abbott), and Arctic Front (Medtronic). We have found that using the Arctic Front cryoballoon and Achieve mapping catheter with the EnSite system has provided great results through dramatically shortened case times and minimized use of x-ray.
Our EP recording system is currently the CardioLab (GE HealthCare); however, we are preparing to install the WorkMate Claris System (Abbott) and Merge Hemo (Merge Healthcare). We still use the Bloom Stimulator (Fischer Medical) for all our pacing.
What are some of the new equipment, devices, and products introduced in your lab? How have they changed the way procedures are performed?
Successful mapping and ablation of scar-mediated tachyarrhythmias has dramatically improved with the addition of both the Advisor HD Grid and omnipolar mapping. This technology, used in association with the TactiCath ablation catheter, has shortened our case times and increased our success rates for these complex procedures.
How is inventory managed at your EP lab?
We are fortunate to have our own materials management employee devoted to the catheterization and EP labs. This employee, along with some dedicated staff members, control all our inventory. Inventory management and reordering of new products are done through the BD Pyxis SupplyStation System (Becton Dickinson), which is managed by the materials management team. We have specialized EP personnel who have been trained to help manage the supplies in each room.
How has the COVID-19 pandemic impacted your EP lab, hospital, or practice?
The biggest impact of the COVID-19 pandemic has been the financial toll on our health system due to the cancellation of elective procedures, increased demand for supplies and personal protective equipment, and the emotional impact on staff and physicians. Our EP volume was impacted by the need to cancel cases and patients who waited longer for care. On a positive note, we saw an increase in same-day discharges (SDD), which for appropriate patients reduces costs and improves patient satisfaction.
Tell us what a typical day is like in your EP lab.
An average day at John Muir Health EP would include 2-3 ablations. We typically try to combine a couple of AF ablations with an SVT, AFL, or device implant. In our second lab, there is a combination of ablation and device cases, or an LAAO implant, device implant, and/or lead extraction.
Can you describe the extent and use of vascular closure devices at your lab? Is your lab using SDD?
When beds were at a premium during the pandemic, we employed the use of vascular closure devices to speed up the recovery and discharge process. Currently, we are using closure devices on many of our patients, but not all are being discharged same day. At this time, we are selective about who might be a good candidate for SDD and which patients should stay overnight.
How do you ensure timely case starts and patient turnover?
We are constantly monitoring on-time starts for all our first cases. We feel that the first case is the one case we can always control, so if we start late on that case, then we are often behind for the rest of the day. When we first started tracking on-time starts, we found that when we were late, it was on average a 16-minute delay. After drilling down and adjusting protocols to the statistics, we have dropped that to an average of 6 minutes if a case is late.
We have also worked hard to shorten turnover times. Together with our environmental services personnel, we have developed a procedure that usually puts us around the 25- to 30-minute mark. There is always room for improvement, but we have worked hard to get our times down to this mark and are pleased, but not necessarily satisfied.
How does your lab schedule team members for call?
Since many of our EP lab staff are also staff members in the catheterization lab, many of our staff take call. With our department having 5 procedure rooms, we are a big lab and quite busy. We have 2 call teams, one that is 24 hours and the other that is on call until midnight. This second team allows for many of our EP staff to be on call for late cases that take place in the EP lab.
Do you have flexible or multiple shifts? How do you handle slow periods?
At this time, we only have a 10-hour shift that starts at 0630 and ends at 1700. During slow times in the lab, our staff goes to other rooms to ensure all staffers have received their breaks, offer an extra hand if needed in complex cases, or complete competencies required by the hospital.
How do you handle vendor visits?
We are vendor-friendly lab. We recognize that many of our vendors offer specialized knowledge about the case or products that we may not have, and welcome their assistance. Cardiac device implant vendors are called in by the physician groups doing the implants, and 3D mapping vendors are called in by our EP manager when he cannot map them himself or if there are simultaneous cases. All other vendors go through our catheterization lab materials management manager to ensure we do not have multiple vendors onsite on the same day or on a day that we would not need them.
What measures has your lab implemented to cut or contain costs?
We have put together a committee with our material management team to manage new products. This helps ensure we are receiving competitive pricing on not only new products, but also evaluating the products we are currently using to compare pricing with the national average. We also look at competitor products if we are unable to achieve better pricing from a current device vendor. This committee, known as the SEARCH committee, meets every month.
We also currently reprocess all our mapping connector cables and ICE catheters. Used catheters are sent back for platinum recycling. We receive quarterly checks at market price for the platinum. We use Stryker to reprocess our EP cables and ICE catheters only. We have saved approximately $400k annually by reprocessing these items.
What works well for your lab for onboarding new team members?
When implementing new staff members into the EP lab, we have 2 proctors (1 registered nurse [RN] and 1 EP technician) who we use to teach all new staff. We have a set program that all new employees must go through before working on their own.
We expect all our EP staff to be able to pace, record, and understand all the EGMs. The RNs teach their specific responsibilities in the room, including assisting anesthesia, prepping the patient, managing activated clotting time and heparin doses, etc, as well as helping to run the RF generators and cryoconsole. Our technician teaches all the pacing and recording, including prepping the mapping system and ultrasound units, and also helps to run the generators and console.
What continuing education opportunities are provided for staff members?
We have a fund just for educational events, such as courses through the Heart Rhythm Society, promotional conferences offered by vendors, or local teaching institutions that offer courses. All employees are encouraged to attend meetings throughout the year to advance their education.
Discuss the role of mid-level practitioners in your lab.
We do not have any mid-levels dedicated to our EP department. The cath lab has physician assistants who the hospital employs for helping with pre-op orders, discharging patients, and assisting in noninvasive cardiology procedures and valve clinics.
Describe a particularly memorable case from your EP lab and how it was addressed.
After a post modified left atrial anterior line ablation for atypical AFL, we had difficulty getting the CS catheter out distally to pace near the line for determination of bidirectional block. We tried to slip in a second catheter across the transseptal site, but due to a redundant septum, we had difficulty with that as well. Not wanting to do a second transseptal puncture across the septum, we decided to do a quick map with the Advisor HD Grid using omnipolar mapping. This technology can show wavefront directional flow, and using this technology, we could quickly tell we had bidirectional block across the entire line by using the directional arrows. Both sides showed arrows going up to the ablation line from both the lateral and septal, but never through it.
We learned after this case that using this technology was a novel way to determine bidirectional block across ablation lines without having to map the entire chamber. Mapping points from 5-10 different sites on both sides of the line is all it takes to determine block, thus shortening total case time as well as saving time in the left atrium.
Tell us about your primary approach for LAAO.
LAAO implants are performed by an interventional cardiologist and 2 of our electrophysiologists. The approach used by all our implanters is a team effort between the implanter and echocardiography physician. We use a combination of transesophageal echocardiography (TEE) and fluoroscopy to measure the LAA ostium, choose the size of the device, and guide it for proper placement. TEE is then used again to ensure a proper fit and complete occlusion.
Does your program have a dedicated lead extraction program or AF clinic?
We are proud of our lead extraction program. We have a dedicated laser lead extraction team that is unlike the other programs in the area. Our program not only includes specialized EP staff and physicians, but there is also a dedicated cardiac surgeon who scrubs in and assists with cases. Along with the cardiovascular surgeon, there are 3 members from our heart surgery team, a perfusionist, and a cardiovascular anesthesiologist in the room at the ready.
We do not currently have a dedicated AF clinic; however, the John Muir Health Cardiovascular Medical Group, which consists of 31 cardiologists, 3 of whom are electrophysiologists, has a dedicated EP office and runs their own AF and device clinics.
How does your EP lab handle radiation protection for physicians and staff?
We have the Zero-Gravity system (Biotronik) at our sister hospital; the physicians are conscientious about their radiation times and work hard to use 3D mapping and ICE to help minimize times.
What approaches has your lab taken to reduce fluoroscopy time? What percentage of cases are done without fluoroscopy? How do you record fluoroscopy times/dosages?
We use 3D mapping for all our ablation cases and ICE on many to help minimize radiation dosages. We do not necessarily focus on zero fluoroscopy during our ablation cases, as we believe it is still a useful tool. We just use it very sparingly.
What are some of the dominant trends you see emerging in EP?
High-definition directional mapping has made a real impact on how we map and ablate scar-mediated tachycardias. The use of omnipolar mapping and the directional information we receive has helped us diagnose bidirectional block across lines that otherwise would have been difficult to do without 2 different catheters. This can now be performed with the Advisor HD Grid and only takes a couple of minutes of mapping to determine.
Describe your city or general regional area. How is it unique?
John Muir Health is a not-for-profit health care organization located east of San Francisco, serving patients in the Contra Costa, Eastern Alameda, and Southern Solano Counties. Our 2 acute care medical centers are located in Concord and Walnut Creek, and are supported by a network of more than 1000 primary care and specialty physicians. Being in the San Francisco Bay area, we serve a large and diverse population. We are fortunate to also have an excellent reputation and strong community support.
What challenges does your hospital face given its geographic service area?
Approximately 30% of our community residents are members of Kaiser Permanente, which precludes these patients from receiving care at our hospitals, except for emergency services. We have also experienced an increase in Medi-Cal and uninsured patients in our community over the past several years. Unfortunately, Medi-Cal payments do not cover the cost of care.
Please tell our readers what you consider special about your EP lab and staff.
We have a very strong team environment in our labs, with the understanding that no individual person will know or have the ability to do everything in the lab, but together we do. When we work together as a team, our skill sets overlap and nothing falls through the cracks. What makes us unique is the fact that we rarely use vendor assistance in our cases. Our lab can function independently and does not require mapping or cryo assistance with any of our ablation cases.
