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Spotlight Interview: Lahey Hospital and Medical Center
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EP LAB DIGEST. 2023;23(11):1,16-19.
When was the cardiac electrophysiology (EP) program started at your institution? By whom?
Fred Venditti, MD, started the EP program at Lahey in 1989. Bruce G Hook, MD, has been director of the arrhythmia service since 2012, and G Muqtada Chaudhry, MD, is director of the EP laboratories. Other faculty members include Jonathan Silver, MD; Matthew Reynolds, MD; Guy Kulbak, MD; and Paul Harnish, MD.
What drove the need to implement an EP program?
EP was still a relatively new field in 1989, but the Boston area was actively involved, with a number of academic EP programs open. Lahey Hospital had recently relocated from Boston to a new suburban facility in Burlington, Massachusetts, and the cardiology department was expanding.
What is the size of your EP lab facility? Has the EP lab recently expanded in size, or will it soon?
We historically have had 2 dedicated EP labs and 50% use of one of the cardiac catheterization laboratories. In September 2023, we opened a third dedicated EP lab. This was a unique build in that it started with 4 “modular” shells that were lifted by a huge crane onto the roof of the fourth floor. Once in place, the shells were attached together and a new lab was built inside (Figures 1-3).
Who manages your EP lab, and what is the mix of credentials and experience?
Arthur Oberheim, MA, BSN, RN, NE-BC, is the nurse manager of invasive cardiology. Karen Greene, RN, is the tertiary team lead of the EP laboratories and runs the Product Review meeting. Our staff training and experience includes registered nurses (RNs), radiologic technologists (RT[R]s), and cardiovascular technologists (CVTs) in the critical care/CV-intensive care unit (ICU), emergency department, progressive care unit level of care, and interventional radiology.
What is the number of staff members?
There are 16 RNs, 3 RT(R)s, 1 CVT, 4 EP fellows, and 6 attending physicians.
What types of procedures are performed at your facility?
We perform catheter ablations for atrial fibrillation (AF), atrial flutter (AFL), atrial tachycardia (AT), atrioventricular node, supraventricular tachycardia (SVT), Wolff-Parkinson-White syndrome, premature ventricular contractions (PVCs), and ventricular tachycardia (VT). We also perform left atrial appendage occlusion (LAAO), and implantation of pacemakers (PPMs) and implantable cardioverter-defibrillators (ICDs) (transvenous, leadless, biventricular, and subcutaneous). In addition, we perform lead extraction (90% are done in the EP laboratory) and have full cardiac surgical backup for high-risk cases.
Approximately how many catheter ablations (for all arrhythmias), device implants, lead extractions, and LAA closures are performed each week?
In a typical week, we perform about 15 AF ablations and 6-10 ablations for other arrhythmias. We perform about 15 device cases and 3-5 Watchman (Boston Scientific) implants per week.
What types of EP equipment are commonly used in the lab?
We have the WorkMate Claris System and stimulator (Abbott) in all 3 labs. Each lab is outfitted with 2 mapping systems, including the EnSite (Abbott), Rhythmia (Boston Scientific), and Carto (Biosense Webster, Inc, a Johnson & Johnson company) systems. For cardiac rhythm management (CRM) implants, we use Medtronic, Abbott, and Boston Scientific in 95% of cases.
What are some of the new technologies and techniques recently introduced in your lab? How have these changed the way procedures are performed?
We are participating in Boston Scientific’s ADVANTAGE AF Study for pulsed field ablation of persistent AF. We have also recently added the POLARx Cryoablation System (Boston Scientific) to our AF ablation portfolio. The Carto Optrell (Biosense Webster) and TactiFlex (Abbott) catheters were recently introduced to the lab, and we anticipate adding the Carto QDOT Micro catheter (Biosense Webster) in the next few weeks. The Optimizer (Impulse Dynamics) will also be available shortly. In LAAO, we have performed over 500 Watchman implants, including approximately 150 this past year. We have also participated in clinical trials with the Amplatzer Amulet LAA Occluder (Abbott) and CLAAS System (Conformal Medical) devices.
How is inventory managed in your EP laboratory?
Our inventory is managed through the Workday inventory managing system and overseen by our supply chain coordinator, Greg Hodsdon. Monthly product review meetings are held with the EP physicians, EP lab manager, and supply chain team to review new and/or unused supplies.
Tell us about your device clinic, including its staffing model.
The device clinic manages 3400 patients with implantable loop recorder, PPM, ICD, or CRT devices. We perform approximately 19,000 remote and in-office checks annually. The primary site is on the Burlington campus, with a support site at the Peabody campus. The lead pacemaker technician handles operations, with 3 additional technicians who support clinic visits. We outsource our remote monitoring, with onsite provider clinical interpretation and billing. We have a dedicated RN who triages alerts and manages one-week wound checks. There is a scheduler to manage calls and ensure appointments are booked appropriately. The technicians and RN work collaboratively with the allied professionals (APs) and physicians to ensure all alerts are managed. We have a team of APs and doctors who read reports on a daily basis. There is one physician assigned daily to review red alerts with the clinic staff.
Tell us what a typical day might be like in your EP laboratory.
A typical day starts at 7:00 AM with room setup and equipment check. At 7:30, we have a morning meeting in the control room to review the cases for the day with lab staff, advanced practice providers (APPs), fellows, and attendings. Our goal is to have the first patient in each room at 8:00. We generally have cases scheduled first with anesthesia, followed by moderate sedation cases. Our lab is staffed Monday through Friday, 7 AM-7 PM. We have a pre/post holding area with 16 beds that is open Monday-Friday, including overnight coverage Monday through Thursday. This is where both catheterization and EP patients are prepped for the procedure and recovered after. It also permits overnight stays and evening discharges.
Can you describe the extent and use of vascular closure devices at your lab? Tell us about your approach for same-day discharge.
We use Vascade (Haemonetics) closure devices for venous access, while arterial sheaths are closed with Perclose (Abbott). The goal is for every outpatient to go home the same day, depending on time/length of case and patient condition. Currently, about 90% of patients having elective procedures are discharged the same day, including AF ablation, Watchman, and CRM implants. Our same-day discharge program started prior to the pandemic in a limited fashion, but like many hospitals, after we reopened post-pandemic, there was a heightened interest. Many patients undergoing VT ablation and all patients having lead extraction are observed overnight.
Has your lab recently undergone a national accrediting inspection?
In 2019, we were the first EP laboratory in Massachusetts to receive accreditation by the American College of Cardiology (ACC). Our most recent reaccreditation was in June 2022.
How do you ensure timely case starts and patient turnover?
We ensure timely case starts by pulling equipment needed for cases ahead of time and completing room setup while cleaning.
How does your lab schedule team members for call?
We have 2 staff members on call every Saturday and Sunday from 8 AM-12 PM, primarily for urgent inpatient device implants. With our staffing, the call rotation runs roughly every 6 weeks. The on-call team is comprised of 2 RNs or 1 RN and 1 RT, and an EP fellow and EP attending. After-hours emergent temporary pacing wires are placed in the catheterization laboratory by the EP physicians and catheterization laboratory’s on-call team.
Do you have flexible or multiple shifts? How do you handle slow periods?
We have 10-hours shifts (7 AM-5:30 PM and 9 AM -7:30 PM) and 12-hour shifts (7 AM -7 PM). If there is downtime, which is rare, staff have time to work on their continuing education credits, clean and organize the lab, update inventory, and work on Champion roles. These Champion roles include ACC accreditation and the moderate sedation committee.
How are vendor visits managed?
Vendors for device implants and mapping cases are chosen by the attending physician. The scheduler will send an email invite at the time the procedure is scheduled. The EP charge nurse will notify the vendors the day before about timing. For add-on cases, vendors are notified by the EP charge nurse.
What are the best features of your EP laboratory’s layout or design?
The best feature of laboratory’s layout is that the stimulator and mappers are all in the room (not sitting in the control room). The control room is in the center of 2 labs, with the third lab in close proximity. The holding area is adjacent to the labs. This makes for quick patient transport from procedure room to recovery. The department as a whole is also adjacent to the cardiac PCU and cardiac care units.
What measures has your lab implemented to cut or contain costs?
Product review meetings are held monthly with the EP attendings, lab manager, and supply chain team to review supply costs and review products prior to adoption. Beth Israel Lahey Health System has a dedicated team reviewing CRM costs and contracts on a biannual basis to ensure we get the best pricing. Current contract terms for CRM devices are applied to all hospitals across the health system.
What quality control measures are practiced in your lab?
We meet quarterly with the attending physicians, lab staff, EP fellows, and APs to review procedure complications and implement best practices. One example is that after a case of local anesthetic toxicity, we reviewed weight-based dosing with the anesthesia pain service and now note maximum local anesthetic dose during time-out at the beginning of each case. This also resulted in a protocol for treating local anesthetic toxicity that is posted in the EP laboratories.
What works well in your laboratory for onboarding new team members?
Each new hire has a 3-month orientation period. Each month has a certain focus. For RNs, the first month is focused on moderate sedation, the second is on technical supplies and scrubbing, and the third month is focused on device implant and programming. Each hire is assigned 2 preceptors so that there can be consistency with the orientation process. Monthly check-ins are held with the new hire, preceptors, and tertiary team lead. New hires are given additional orientation time if needed.
What continuing education opportunities are provided for staff members?
Staff receive one education day per year. There are weekly opportunities, on Wednesdays, for in-services or additional education about topics staff are interested in learning more about or reviewing. On a rotating basis, 3 staff members attend the Heart Rhythm Society’s annual conference each year.
Discuss the role of mid-level practitioners in your lab.
The APPs evaluate patients pre and post procedure, see consults on the inpatient units, and practice in our outpatient arrhythmia and device clinics. They do not participate in laboratory procedures since we have an EP fellowship program and adequate coverage for virtually all cases. APPs are responsible for performing around 1000 cardioversions annually and all ILR implants.
Share a memorable case from your EP lab and how it was addressed.
A 22-year-old military soldier from Jordan was referred to us through our international office for treatment of recurrent AT with tachycardia-induced cardiomyopathy (ejection fraction [EF] of 15%) and heart failure. After 2 failed ablations in Jordan, we successfully mapped and ablated a LAA AT and his EF normalized within days. Unfortunately, he presented 2 weeks later with recurrent AT while at home. He came back and we mapped the same AT within the LAA. We treated him with a Lariat suture delivery device (SentreHeart), resulting in immediate termination of AT. He is now 8 years out from the procedure with no recurrence. He has maintained normal left ventricular function and is leading a normal life.
Does your lab use a third party for reprocessing or catheter recycling? How has it impacted your lab?
Ablation catheters, intracardiac echocardiography catheters, and steerable sheaths are reprocessed with Stryker. This has resulted in significant cost savings for the lab.
Does your lab perform conduction system pacing?
We started conduction system pacing with His bundle pacing about 5 years ago. Starting around 2021, we switched to left bundle branch pacing, and currently 80%-90% of all pacemaker implants are physiologic pacing systems. We use leads and devices from Medtronic, Boston Scientific, and Abbott for physiologic pacing. All 6 physicians implant physiologic pacing systems.
Tell us about your primary approach for LAAO.
We started Watchman implants in 2011 as part of the PREVAIL trial. After the Watchman received FDA approval in 2015, we were the first hospital in Massachusetts to implant the Watchman and have done more than 500 implants. Three attending physicians implant LAAO devices, and with continued growth, a fourth operator has just recently started training to implant the devices. We also have experience with the Amulet device and the investigational Conformal implant.
Does your program have a dedicated AF clinic and/or a dedicated lead extraction program?
Each of the attending physicians has a dedicated clinic day. Given the prevalence of AF, about 90% of patients seen in the outpatient clinic have a diagnosis of AF. Therefore, like many EP programs, our outpatient clinic is essentially an AF clinic. We have 5 dedicated outpatient APPs who see patients independently and also have shared visits with the physicians. Each fellow has one half day per week in the clinic. With this mix of providers in clinic, we are able to see about 40-50 new patients per week. Post-AF ablation patients are seen in clinic at 3 weeks by an APP, and then at 3 and 9 months by the attending physician.
Discuss your approach to risk factor modification for AF.
Patients are screened for symptoms of sleep apnea and referred for testing, as appropriate. We also discuss the importance of sustained 10% weight loss in overweight patients, management of hypertension and diabetes, and limiting alcohol intake to 3 or fewer drinks weekly. Referral to onsite medical weight loss clinic is available. The CHA2DS2-VASc score and need for anticoagulation is documented for each patient at every visit.
How does your EP laboratory handle radiation protection for physicians and staff?
Each staff member is provided with lead and a radiation tracking collar. Lead is evaluated for integrity once a year. There are 2 mobile lead shields in each room. Each procedure table has lead skirts and a torso lead shield that can be positioned for physician preference.
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?
Two of the 3 procedure rooms are equipped with updated fluoroscopy systems that provide lower radiation exposure than previous systems. Radiation tracking numbers are documented at the end of each procedure. Some physicians use techniques to reduce fluoroscopy times during cryoballoon ablation, such as pulmonary vein pressure measurement instead of contrast injection. Zero fluoroscopy ablation has been performed for SVT, AFL, and AF.
What are some of the dominant trends you see emerging in the practice of electrophysiology?
Zero fluoroscopy ablation is clearly an emerging area of interest. Patients, staff, and fellows in training are all deserving of experience and potential benefits with this technique. Physiologic pacing has emerged as a superior technique to traditional right ventricular endocardial pacing and may supplant traditional biventricular pacing at some point. Pulsed field ablation is the first new ablation technology since the cryoballoon and the excitement for this modality is palpable in most EP labs. Finally, the explosive growth of CRM implants and the increased lifespan of patients has put increased pressure on device clinics. Managing the longitudinal follow-up for CRM patients is a challenge that we all need to work on.
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 challenges or benefits do you associate with that?
We see more frequent detections of AF in patients wearing the Apple Watch and other personal heart rhythm devices. We have embraced this, as it allows patients to present earlier in the AF process, which has been shown to improve treatment outcomes. Telehealth visits, especially for elderly patients unable to easily leave their homes, started during the pandemic and have become quite popular. Patients have remote access to their charts, and the ability to communicate with the care team has exploded in popularity. Managing the number of remote patient queries will be a challenge for all of us to keep up with.
Describe your city or general regional area. How is it unique?
Burlington is a suburban community located 16 miles northwest of Boston, known for its high-tech businesses. There is a population of 26,377 and 23.8% of the local population was born outside of the US. Being outside the Boston city limit has an advantage in referral patterns for patients that prefer to avoid the congestion of the city. Many of our patients come from EP outreach clinics north and west of the hospital. We have quick access to major highways, including US-95.
What specific challenges does your hospital face given its unique geographic service area?
Boston is well-known for world-class medical care and teaching hospitals. As such, competition between the various hospitals can be intense at times. Being in New England, winter snowstorms can occasionally make travel to the hospital treacherous for our patients and staff.
Please tell our readers what you consider special about your EP lab and staff.
We truly are a team dedicated to helping our patients. We work very well with one another and share the same goal of providing individualized, exceptional care. We all come from different backgrounds and experience, which allows us to approach each case and patient with a well-rounded mindset. This dedication does not stop in the lab. We have a large EP support system throughout the hospital, both inpatient and clinic. Outside of the local community, we share our EP services on an international level. Project Pacer International is a nonprofit organization that was founded at Lahey Burlington in the 1980s. With Project Pacer, physicians and staff have travelled to developing areas around the world to provide cardiac intervention, including pacemaker and ICD implants as well as ablations. We also have a longstanding relationship with patients and physicians in Bermuda. This includes providing both medical and surgical services here at Lahey Burlington.
