Spotlight Interview: Central Washington Hospital

Central Washington Hospital is the major medical center serving an area of more than 12,000 square miles in north central Washington. Located in the heart of Washington, we provide a comprehensive range of primary and specialized care services with rural outreach to multiple communities.

When was the EP program started at your institution? By whom?

Device implants and right-sided ablations have been performed here for a number of years. With the arrival of Dr. Roy Lin, we performed our first complex left atrial ablation in 2017.

Since then, we have added many firsts, including ventricular tachycardia ablation, His bundle pacing, leadless pacemaker implants, and fluoroless ablation.

What is the size of your EP lab facility?

We have three labs in total: a designated EP lab, cardiac catheterization lab, and interventional radiology (IR) lab.

What is the number of staff members? What is the mix of credentials at your lab?

We have 32 employees in our combined EP, cath, and IR labs. This includes 11 techs (CVT/RT) and 12 nurses (RN/BSN/RCIS). There are two administrative assistants managing scheduling and purchasing for our interventional labs. We have four interventional cardiologists, three interventional radiologists, and one electrophysiologist. In our device clinic, we have designated EP staff, including two registered nurses and two medical assistants.

What types of procedures are performed at your facility? What types of complex ablations are performed?

We perform all device implantations, as well as His bundle pacing and leadless pacemaker implants. We also perform all forms of ablations, including for SVT, right atrial flutter, atrial fibrillation, left atrial flutter, PVC, and ventricular tachycardia.

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

It varies week to week, with an average of four ablations and nine device implants each week. In 2018, we performed approximately 350 EP procedures (150 ablation-related and 200 device-related cases). That is more than a 20% increase in volume compared to the year prior, with anticipated continued increase.

What percentage of your lab’s device implants use MR conditional pacemakers or ICDs? What percentage of implants use subcutaneous or leadless devices?

We predominately use MR conditional devices, with 10% being leadless and 20% of ICD implants being subcutaneous.

Who manages your EP lab?

Ashleigh Zutter, RN, BSN is our inpatient cardiac services manager. Kirsten Snyder, CVT is our EP lab technician/supervisor. Roy Lin, MD is our director of EP services.

Are employees cross trained?

Our staff are uniquely cross trained in EP, cath, and IR.

What types of EP equipment are most commonly used in the lab? What imaging technology do you utilize?

We utilize the EnSite Precision Cardiac Mapping System (Abbott), RHYTHMIA HDx Mapping System (Boston Scientific), Arctic Front Advance Cryoballoon and CryoConsole (Medtronic), LABSYSTEM PRO EP Recording System (Boston Scientific), and ViewMate Z Ultrasound (Abbott).

What new initiatives or technologies have recently been added to the EP lab, and how have they changed the way you perform procedures?

Our first addition was the use of headphones in the lab, which has dramatically improved communication between all team members. Headphone use has helped to engage every staff member during the procedure as well as facilitate on-the-job learning of EP procedures. We’ve subsequently introduced the EnSite Precision Cardiac Mapping System with the use of the TactiCath Quartz, and later with the TactiCath Contact Force Ablation Catheter, Sensor Enabled (Abbott), which has eased our transition to perform fluoroless ablations. In addition, we utilize the ORION high-resolution mapping catheter (Boston Scientific) along with our RHYTHMIA HDx Mapping System for some of our atrial tachycardia ablations.

How is shift coverage managed? How does your lab handle call?

We have 8- and 10-hour shifts. Calls are once per week and every fifth weekend covering cardiac, EP, and IR services.

Who handles procedural scheduling?

The administrative assistant at the lab location and the medical assistant in the clinic handles scheduling via Epic software.

Have you developed a referral base?

We have developed a collegial relationship with referring clinics across four different counties. We provide support through telephone consultation and educational conferences.

In what ways have you cut or contained costs and improved efficiencies in the lab and device clinic?

We have reduced waste using PAR levels to prevent expired products, and we reprocess when possible.

How are new employees oriented and trained at your facility?

New employees are paired with a seasoned EP tech or RN until they are comfortable. They are also assessed utilizing competency sheets.

What types of continuing education opportunities are provided to staff? How many of your staff members attend medical conferences each year?

Staff members are encouraged to attend national conferences and educational courses. Annually, two to three staff members per year attend the Heart Rhythm Society’s Annual Scientific Sessions.

What growing pains or learning curves has your lab experienced over the years?

As the complexity of our procedures has increased, one of the challenges we experienced was staff competency for EP procedures. Therefore, we have emphasized appreciation of the fundamentals of electrophysiology, and have taken advantage of any teachable moments during cases. Formal lectures for our staff pertaining to the intricacy of EP procedures are also provided by Dr. Lin and our mapping representatives David Hutsell (Boston Scientific) and Chris Lewchuk (Abbott).

How do you prevent staff burnout and turnover? What approaches do you use for team building?

We encourage everyone to be oriented and rotate through the different disciplines, including the EP lab. We also have regular staff outings and events.

How do you handle vendor visits to your department?

Vendor visits must be pre-approved and scheduled ahead of time.

Approximately what percentage of ablation procedures are done with cryo vs radiofrequency?

We perform approximately 30% of our ablations using the cryoballoon.

What are your thoughts on the use of NOACs in patients with non-valvular atrial fibrillation?

We encourage the use of NOACs for our patients with non-valvular atrial fibrillation. We work diligently with their insurance and industry to help alleviate cost. In some cases, our institute also provides assistance via our compassionate care program.

Do you utilize lifestyle modification as therapy for your patients with atrial fibrillation?

We emphasize the importance of lifestyle modification, including weight loss and alcohol reduction. Assessment and/or treatment for sleep apnea is strongly encouraged for each of our patients.

What percentage of cases are done without fluoro? What approaches has your lab taken to reduce fluoroscopy time?

We perform most of our ablations with minimal or zero fluoroscopy. This is accomplished through three-dimensional electroanatomic mapping and intracardiac echocardiography. During device implants, we routinely use frame rates of 7.5 frames per second or lower. To protect our anesthesia colleagues, they are reminded to remain behind their portable leaded acrylic shield to maximize their distance from the radiation source, and to wear a lead apron and thyroid shield.

What are your methods for device infection prophylaxis?

The majority of our device implants are performed on an outpatient basis. Pre-procedural Hibiclens wash and antibiotic prophylaxis are implemented. Intra-procedure use of antibiotic flush and the TYRX Absorbable Antibacterial Envelope (Medtronic) are used for high-risk patients. A predominate number of our patients receiving device implants are discharged the same day.

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

We have very low complication rates for our device and ablation procedures. QI initiatives have been important in tracking outcomes and identifying areas for improvement.

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

We foresee advances in physiologic and leadless pacing technology. Mapping and therapeutic catheters will also continue to become faster and safer. This is what makes our field exciting, and it is imperative for us to evolve and adapt with evidence-supported advancements.

Do you utilize remote monitoring of CIEDs? What clinical and economic benefits have you seen?

Given our large service area, we utilize remote monitoring for the majority of our patients whenever possible. Those without the ability to connect remotely due to their rural location meet with our dedicated device nurses, who travel to outreach clinics to provide device services.

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

Central Washington Hospital is uniquely situated in the heart of Washington state, surrounded by the beautiful Cascade Mountains. We are the main hospital of Confluence Health, an integrated, rural healthcare delivery system and the major provider of healthcare to people of this region. According to the CMS database, the state of Washington has one of the highest prevalences of atrial fibrillation.

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

We understand the challenges of rural healthcare, and strive to provide the highest quality comprehensive care to a catchment area of over 250,000 people. We are uniquely located to provide comprehensive EP care to a region where the nearest EP facility is another three hours away.

What is considered historic about your EP program or hospital? Has your program or hospital recently experienced any “firsts”?

There have been many firsts in the last two years of our EP program, including our first left atrial ablation, PVC/VT ablation, His bundle pacing, leadless pacemaker implant, and fluoroless ablation cases. We also introduced cryoablation technology to this region.

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

We have an amazing group of techs and nurses that provide outstanding patient care. They come to work daily with enthusiasm, and have made great strides to advance arrhythmic care here in north central Washington. 

For more information, please visit www.confluencehealth.org