Spotlight Interview Update: El Camino Health

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EP LAB DIGEST. 2024;24(4):1,14-17.

When was the electrophysiology (EP) program started, and by whom?

The EP program was started in July 2008 when Bing Liem, MD, joined El Camino Health. With decades of experience as a Stanford EP attending, Dr Liem was instrumental in championing and developing this program throughout its infancy. 

What drove the need to implement an EP program?

El Camino Health was assuming leadership in health care in the region, hence the need to provide comprehensive service for the community. Prior to starting this program, patients were transferred to regional academic centers if they required an ablation.

What is the size of your EP facility? 

We currently have 2 dedicated EP  rooms. One of these rooms has undergone renovation, while the other is in the process. After completion, both rooms will have all EP equipment hardwired on booms. The size of each laboratory is 600 square feet. Our total square footage after renovation will not increase but will be reformatted for optimal space to allow for current and future technologies. 

Who manages your EP laboratory, and what is the mix of credentials and experience?

Evy Nitzany has been the EP program manager for the past 8 years. Our EP medical director is Shaun Cho, MD. Our trained staff have a mixture of credentials including registered technologist (RT), cardiac interventional (CI) technologist, vascular interventional (VI) technologist, registered nurse (RN), critical care registered nurse (CCRN), registered cardiovascular invasive specialist (RCIS), registered cardiac electrophysiology specialist (RCES), and certified electrophysiology specialist (CEPS). Experience varies from 0-25 years. 

What is the number of staff members? 

Our EP laboratory is unique in the sense that we are part of a larger catheterization laboratory that performs diverse procedures across multiple modalities (cardiac catheterization, structural, EP, neuro, interventional radiology [IR], peripheral, etc). We require staff to rotate through all service lines (including EP) and function at a basic level, which entails scrubbing, monitoring, and circulating. The total number of staff who rotate through these rooms is approximately 40. However, staff have the option to train at a higher level in EP, which consists of connecting EP equipment, troubleshooting, and operating the GE recording system and stimulator throughout ablation procedures. This core group of trained individuals currently stands at 10 clinical staff members.    

What types of procedures are performed at your facility? 

We perform a wide range of EP ablations and cardiac rhythm management procedures. Our 6 operators perform ablations for paroxysmal, persistent, longstanding persistent atrial fibrillation (AF), convergent AF, atrial tachycardia, accessory pathways, atrioventricular nodal reentrant tachycardia, typical/atypical flutter, atrioventricular junction, idiopathic/ischemic ventricular tachycardia (VT), EP studies, and VT induction studies. Our operators also perform implants and generator changes for pacemakers, implantable cardioverter-defibrillators (ICDs), subcutaneous ICDs (S-ICDs), cardiac resynchronization therapy devices, leadless pacemakers, implantable loop recorders, conduction system pacing, and laser and mechanical lead extraction. The only procedure that is not performed at El Camino Health is epicardial VT ablation.

Approximately how many catheter ablations, device implants, and lead extractions are performed each week? 

On a weekly basis, we average 11.6 ablations, 10.8 device implants, 0.2 lead extractions, and 1.4 Watchman (Boston Scientific) device procedures. 

What types of EP equipment are commonly used in the laboratory? 

The mapping systems we currently use are the Carto 3 (Biosense Webster, Inc, a Johnson & Johnson company) and EnSite X (Abbott) systems. We use the CardioLab AltiX BT21 recording system (GE) and Micropace stimulator. We also have a CryoConsole Cardiac Cryoablation System (Medtronic) that we use for focal ablation. For radiofrequency (RF) ablation, we use the QDOT Micro (Biosense Webster), ThermoCool SmartTouch SF (Biosense Webster), and TactiFlex Ablation (Abbott) catheters. For diagnostic catheters, we use the Octaray (Biosense Webster), Optrell (Biosense Webster), and Advisor HD Grid mapping catheter, Sensor Enabled (Abbott). We use the Vivid S70 ultrasound machine (GE). The ultrasound catheters used with this system include the NuVision (Biosense Webster), Soundstar (Biosense Webster), and ACUSON AcuNav catheters (Biosense Webster).

What are some of the new technologies and techniques recently introduced in your laboratory? How have these changed the way procedures are performed?

Recently, our operators have switched to using the ensoETM (Attune Medical) esophageal cooling device during AF ablation. With this new device, we are constantly cooling the esophagus at 4⁰ C and can focus on creating an uninterrupted contiguous lesion along the posterior wall in the left atrium (LA) without the worry of creating a thermal burn in the esophagus. This technology has significantly reduced procedural time for our AF ablations as well as reduced the likelihood of esophageal injury.  
 
How is inventory managed in your EP laboratory?

We control our inventory through the WaveMark Solution (Cardinal Health), which is managed by 2 dedicated inventory coordinators. Under this system, which uses radiofrequency identification (RFID), all our supplies are automatically reordered as they are being scanned throughout procedures. The EP program manager and clinical staff work closely with the inventory coordinators to adjust periodic automatic replacement (PAR) levels based off usage to reduce any excess or expiring supplies found in the storage room. 

Does your program have a device clinic?

We do not currently have a device clinic at the hospital. Most of our physicians are either independent practitioners or belong to physician groups and follow up with the patients in their respective clinics. 

Tell us what a typical day is like in your EP laboratory.

A typical day would consist of both EP rooms running in conjunction with a mixture of ablation and device cases. We usually start the day with our more logistically complex cases that require more resources such as transesophageal echocardiogram (TEE)/anesthesia/operating room (OR) back. An example would be an AF ablation or laser lead extraction. As the day progresses, we move onto our less complex cases, such as atrial flutter ablations. Device cases typically fill the last portion of the day.

Can you describe the extent and use of vascular closure devices in your laboratory? Tell us about your approach for same-day discharge (SDD). 

Our current approach for vascular closure is with the use of the Vascade closure device (Haemonetics). This device has provided us with great success in achieving rapid hemostasis with a low complication rate for our EP patients compared with our previous approach of manual compression. 

Furthermore, this device has allowed for a shorter bed rest time, which greatly contributes to the comfort of our patients, especially those who have back problems or difficulty urinating while lying flat. Additionally, since patients are ambulating much sooner post procedure, many are able to be discharged the same day. Our SDD cases are elective and currently include some of our ablations, ICD/pacemaker device implants, and Watchman procedures. The physician will determine if the patient is a suitable candidate for SDD and the nursing staff will follow our SDD procedure, which includes nursing assessment requirements in place. Finally, patients who have SDD receive a follow-up phone call the next day. 

Has your laboratory recently undergone a national accrediting inspection?

Yes, we have undergone national accreditation for our EP and cardiac catheterization laboratory through the American College of Cardiology. The completion of these 2 accreditations allowed us to achieve HeartCARE Center designation in August 2023. El Camino Health is currently one of only 4 hospitals in California to earn this distinction. As the first heart program in the Bay Area to achieve this recognition, it demonstrates that El Camino Health provides leading-edge cardiovascular care and superior results that are among the best of all area hospitals.   
Obtaining this distinction was a year-long journey of learning, collaboration, and process enhancements between hospital departments, physicians, and administration. 

How do you ensure timely case starts and patient turnover?

Staff document metrics such as in-room time, stick time, out of room time, and turnover time. Any delays are recorded as well. These metrics are reviewed monthly by management to ensure everything is functioning at an optimal level. If there are any consistent outliers, management performs a process improvement to resolve the issues. Turnover is always a work in progress, but we have reduced this time by having 2 environmental service workers help with turning over our 6 catheterization laboratory rooms. Also, a nurse and tech assist with turnover by pulling supplies or getting the next patient on the table and patched, keeping the daily flow on schedule.

How does your laboratory schedule team members for call?

Call time is based off a 4-week schedule and equally distributed among the clinic staff.

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

The majority of staff have 10-hour shifts from 7:00-5:30. After 5:30, there are 2 call teams for cardiac and IR. Generally, EP cases do not go beyond 5:30, but in the rare cases they do, one of the call teams will be assigned to complete the procedure. 
During slow periods, staff is assigned different projects to help the department such as performing outdates on supplies, completing mandatory compliance modules, or education modules, etc.

How are vendor visits managed?

All vendors must be enrolled with Vendormate before they can be allowed into our facility. For vendors that clinically support our EP procedures, we inform them of the schedule the week prior to ensure they arrive for the appropriate cases. For sales reps who do not support procedures and are selling us new product, we have a policy that those supplies must undergo vetting by the value analysis committee prior to being sold in the hospital. 

What are the best features of your EP laboratory’s layout or design?

The best feature of our layout is that we have all our mapping system and EP equipment hardwired on booms in our EP laboratories. This convenience reduces the time required for rolling large pieces of equipment in and out of rooms; it also helps minimize any wear and tear on those machines.
 
What measures has your laboratory implemented to cut or contain costs?
The largest cost saver for our program has been through purchasing most of our disposables reprocessed through third-party companies. This has led to huge cost savings, equating to over a million dollars in annual savings. Furthermore, we are in the process of sterilizing some of our disposable cables in house, which will provide additional cost savings for our program. Another big cost saver for us was through entering service contract agreements with Biosense Webster, Abbott, and GE. Not only did this cover the cost of preventative maintenance and repair/replacement of faulty equipment, it also enabled us to get the latest hardware and software upgrades at no additional cost. This way, we could always stay at the cutting edge of technology while keeping costs low. Finally, we are members of the HealthTrust Performance Group, which has enabled us to contain costs by taking advantage of national contracts that have already been negotiated for all their members.

What quality control measures are practiced in your laboratory?

We have a radiation safety officer who oversees radiation exposure for staff and physicians. Also, we have an infection prevention workgroup that focuses on continuous improvement of the infection prevention processes. The group works closely with departmental management and has implemented several process changes, including correct site prep education, procedure room traffic management, and a surgical site infection prevention checklist that is completed prior to each device procedure requiring an incision. The checklist assists the team in tracking to ensure all the preprocedural prep, antibiotics, and correct prep techniques were used. The checklist also includes intraprocedural infection prevention steps such as irrigation prior to incision closure and if postprocedural aseptic dressing procedures were completed. 
We also participate in the National Cardiovascular Data Registry (NCDR) AF Ablation Registry as well as other cardiovascular registries, which help us closely monitor procedural outcomes and benchmark against other facilities providing the same types of procedures.

Finally, another quality control measure we practice is biannual preventative maintenance on all our EP equipment. We work closely with clinical engineering and vendors to complete these tasks. 

What works well for your laboratory for onboarding new team members?

Our EP education is divided into basic and advanced levels. We expect all staff members to function on a basic level to circulate or monitor if they are an RN and scrub alongside the physician if they are an RT. We group the trainee with a seasoned clinical staff member who will mentor them through their onboarding process in EP. This period also helps to solidify the workflow among our different operators and mapping systems. This process typically takes a minimum of 4-6 weeks before they can be signed off. For team members who have a strong grasp of the basic level in EP and want to further their skill level, we offer them the advanced level training, which is a structured approach. We start with connectology and basic troubleshooting of equipment while also having them shadow the more experienced core EP staff members who are operating the recording system and stimulator. We later progress to hands-on training of operating the stimulator and recording system for basic EP cases such as AF ablations. Over time, we get them involved in more challenging EP cases such as flutters to EP studies to supraventricular tachycardias to VTs. To further facilitate their foundation, we provide staff with didactic resources such as books, weekend classes hosted by vendors, and online EP courses through Springboard Healthcare.  

What continuing education opportunities are provided for staff members?

Continuing education units provided to our core group in EP include online courses through Springboard Healthcare, classes hosted by vendors on weekends, conferences such as the Heart Rhythm Society’s annual scientific sessions, and hospital education modules. 

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

The nurse practitioners (NPs) in our laboratory provide a huge service to both patients and physicians. Their main responsibilities include providing education to patients prior to admission to discuss the procedure and medications, as well as answering any questions after the case. They also help offset physician workload by entering the H&P, pre- and postoperative orders, and discharge summaries into Epic. Furthermore, NPs round on the patients pre- and postprocedure as well as see patients in the outpatient clinic. Some of our NPs also perform cardioversions and answer triage/RN concerns from the cardiac unit to help alleviate time for physicians.

Share a memorable case from your EP laboratory and how it was addressed.

As a high-volume AF center, we frequently perform redo AF ablations, including atypical LA flutters. Circuits oftentimes are perimitral, which may pose certain challenges and limitations during endocardial ablation. In one such case, we struggled to achieve flutter termination despite extensive mitral isthmus ablation. The anterior approach (extending from the LA roof to the anterolateral mitral annulus) was unsuccessful, while a prominent distal coronary sinus (CS) limited the success of a traditional posterolateral line. Encouraged by emerging data and our early experience with vein of Marshall (VOM) ethanol ablation, we decided to attempt this technique for this atypical flutter. The CS and VOM were cannulated and the balloon inflated. Upon the first injection of 1 cc of ethanol, we noticed a significant slowing of the tachycardia cycle length by about 30 ms. After the second 1 cc injection, the tachycardia terminated, and the patient was back in sinus. This exemplified a clear epicardial connection for this perimitral flutter and the potential success this technique of ethanol ablation for the VOM may offer. Our physicians are innovative and dynamic in the sense that they are constantly looking to improve patient care by implementing new tools and techniques into their practice.  

Tell us more about your use of a third party for reprocessing or catheter recycling. How has it impacted your laboratory?

The 2 companies we currently utilize for third-party reprocessing are Stryker and Sterilmed. Using these companies has positively impacted our laboratory, not only for appropriate disposing of EP cables and catheters that may otherwise end up in a landfill, but also in terms of cost containment. We have helped save the hospital over $1 million. With the platinum tips that these companies collect from our catheters, we earn an additional quarterly rebate.  

Does your laboratory perform conduction system pacing?

Over the past year and a half, most of our operators have migrated towards conduction system pacing, specifically left bundle pacing, which seems to be the dominant alternative to right ventricular pacing. Although there is still a lot of data to be collected regarding this new approach, the outcomes seem positive for the patients who are experiencing stable/improved ejection fraction as well as a reduction in cardiomyopathy. 

Tell us about your primary approach for left atrial appendage occlusion (LAAO).

Focus on stroke risk mitigation is a priority for our AF patients. Nearly all AF patients with CHA2DS2-VASc scores >2 are considered to be LAAO candidates if there are any safety issues or other compliance barriers to long-term anticoagulation. We have traditionally chosen the Watchman FLX (Boston Scientific) as our default strategy for these patients. Select patients for whom the LAA anatomy is deemed unsuitable are offered the Amulet (Abbott). Intraprocedural imaging has been one of the strengths lending to our success. Our team includes a dedicated cardiologist with expansive experience providing expert TEE imaging throughout the procedure. This has catalyzed our move away from preprocedural imaging, minimizing extra visits and exposure, and improving the patient experience, which has been meaningful in the wake of the COVID-19 pandemic. We have also continued to evolve in this regard by introducing emerging techniques including intracardiac echocardiography (ICE) and 4-dimensional ICE. 

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

As a community hospital, El Camino Health does not employ their own physicians; instead, doctors are mostly part of larger group practices such as Palo Alto Medical Foundation. There is no need currently to have an AF clinic at our hospital since the patients are seen in the clinics belonging to these larger group practices. 

With <10 cases annually, we do not have a dedicated lead extraction program; however, our proximity to the OR and the availability of their staff has made it very suitable to perform complex cases that require OR backup. Our physicians perform both laser lead and mechanical lead extractions.  

Discuss your approach to risk factor modification for AF. 

Risk factor modification for AF is a very important aspect of our practice. Risk factors such as obesity, sleep apnea, or alcohol use are all contributing lifestyle factors for the eventual development of AF, as well as to potentially improve the success rates of any other therapies. Our physicians have increasingly worked with weight loss clinics and sleep clinics to get patients screened for potential therapies. Other comorbid conditions such as hypertension or structural disease are addressed rigorously as well. We are fortunate to work in a highly integrated comprehensive clinic; in this setting, our services are aligned, allowing physicians to quickly access them for patients.

How does your EP laboratory handle radiation protection for physicians and staff?

All clinical staff and operators wear a dosimeter badge. The clinical staff, vendors, and anesthesiologist in the room all wear lead, while the operator utilizes the Zero-Gravity (Biotronik) suspended radiation protection system. This has significantly benefited some of our doctors who have experienced chronic back pain from heavy lead apron. 

What approaches has your laboratory taken to reduce fluoroscopy time? What percentage of cases are done without fluoroscopy? How do you record fluoroscopy times and dosages?

We recently purchased the Azurion image-guided therapy system (Philips), which has provided us with high-quality imaging while emitting a significantly lower x-ray dose. The field of EP in general has seen a rapid advancement in both 3-dimensional (3D) mapping systems and ICE technologies. Our laboratory has certainly experienced this shift in reliance on these tools; as a result, we have seen a significant reduction in the use of x-ray and computed tomography imaging. About 16% of cases are performed completely without fluoroscopy in our laboratory. We record fluoroscopy time using McKesson; however, we are transitioning to Epic Cupid in the coming months. 

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

EP is truly a dynamic field that is constantly innovating and improving through new emerging technologies and techniques. Many of these trends have been implemented in our program. The current buzz in EP is pulsed field ablation. We are looking at purchasing one of these systems but have not yet made a final decision. It will be interesting to see the full impact this technology has in EP.

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?  

Digital health and wearable technologies have an increasing role in the modern EP practice. All our physicians routinely encourage patients to use either an Apple Watch or device such as the KardiaMobile (AliveCor) to document their heart rhythm whenever there is a symptom, and certainly as a way of surveillance for any recurrent AF post ablation. These are very useful techniques to reassure patients about the presence or absence of rhythm abnormalities when they do feel symptoms, though often they do need to be reviewed. The automated detection of AF by the Apple Watch is potentially very useful, though the experience and data are still quite early. Our physicians also have a tremendous number of device patients on remote monitoring, which is clearly an important aspect of digital health that really helps to extend the continuum of chronic care management.

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

There are a number of well-regarded health care facilities in our area, which makes it very competitive. Being in the heart of Silicon Valley also provides quick access to all the latest and greatest advances such as smartwatches to monitor heart rate or rhythm. Our highly educated patient population is focused on personal health and quick to report any heart rhythm irregularities to their physicians. Although we have a wide mixture of demographics, the general vicinity of our hospital is fairly affluent (being in the heart of Silicon Valley), and we have a fairly large aging population. 

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

One of the specific challenges our hospital is facing is hardwiring the continuum of care after discharge. The various service providers and entities use different information and data platforms, which can make information sharing, in a protected health information compliant way, a challenge. 

Another challenge is the “corporate practice of medicine” in California. We are constantly developing and maintaining positive relationships between administration and physicians, since they are not employed by the hospital, to continue our high quality of care. Communication channels must be open since our hospital works with so many different physician practices.

Our biggest challenge, however, is hiring skilled professionals with EP experience. The Bay Area has a notoriously high cost of living, and all hospitals in this area are encountering this same challenge of hiring or maintaining trained staff who are willing to endure these high costs, even with extremely competitive compensation rates.  

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

Our program safety is our top priority and we take pride in our low complication rate. Our physicians have decades of experience, and many of them have trained at some of the top institutions in the country. Our EP physicians work well with each other and collaborate with other specialties to allow for the highest level of care for patients. Staff experience varies widely, but we all work well together to onboard new staff and ensure none of the team members ever struggle during procedures. We provide as many resources as possible so that all members on our team feel successful in their understanding of EP and confident in the level of care they provide to the patient. Our team is focused on standardizing and optimizing our workflows while minimizing any unnecessary practices. Our management team also works in unison with the needs of the staff as well as the physicians. Those needs may vary, from acquiring new pieces of EP equipment to implementing new clinical workflows. As a department, we all work together to create a successful program. We work alongside the Heart and Vascular Institute to roll out new initiatives and maintain the NCDR cardiovascular registries, which help closely monitor patient procedural outcomes and benchmark with other facilities providing similar procedures. This outcome data is just one of many tools we use to help continuously improve our high-quality patient care.