Spotlight Interview: Heart Hospital of New Mexico at Lovelace Medical Center

When was the EP program created?

The EP program was created in 1972 by Dr. Barry Ramo.

What is the size of your EP lab facility?

There are currently 2 dedicated EP rooms and 1 swing room we can use for device implants. We plan on upgrading this room in 2021 to provide 3 dedicated EP rooms.

Tell us about your EP lab staff.

We have 12 dedicated EP staff, as well as other cath lab staff that are cross trained to help with devices, including RNs, RT(R), and paramedics.

What types of procedures are performed at your facility?

We perform all EP procedures in our lab: ablations (atrial fibrillation, atrial flutter, ventricular tachycardia, supraventricular tachycardia), His bundle pacing, pacemaker and implantable defibrillator implantations, lead extractions, and left atrial appendage (LAA) closures (WATCHMAN [Boston Scientific] and LARIAT [SentreHEART] device). We are also involved in numerous EP-related research trials. In January 2021, we did our first remedē System implants (Respicardia), which is a new technology used to treat patients with central sleep apnea.

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

We perform an average of 37 EP procedures every week.

What type of EP equipment is most commonly used in the lab?

We use 2 primary device manufacturers: Abbott and Medtronic. Most of our ablations are performed with the CARTO mapping system (Biosense Webster, Inc., a Johnson & Johnson company), and we typically use CARTO catheters (SMARTTOUCH, SMARTTOUCH SF, and PENTARAY) for our ablations. Our lab also has a mobile EnSite mapping system (Abbott) that we use on occasion. Our recording system is also an Abbott system. In addition, we have a robotic navigation system (Stereotaxis) that we use for most of our ventricular tachycardia ablation procedures.

Who manages your EP lab?

Our lab is managed by a director, manager, and lead techs for each modality. Lead staff members are responsible for special orders, management of inventory, and repairs/replacement of equipment.

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

Our device clinic is staffed with 3 RNs, 3 device techs, and 2 monitor techs. One nurse manages the device clinic and oversees daily operations. Another nurse performs remote monitoring for our heart failure patients and is also tasked with ensuring quality of our remote monitoring. A third nurse splits her time between heart failure and device management. Two device technicians perform our in-office clinic checks, and another technician assists with remote monitoring of our patients with pacemakers, implantable loop recorders, and defibrillators.

In what ways has the COVID-19 pandemic impacted your hospital, EP lab, or practice?

Like many other labs during the COVID-19 pandemic, we have encountered challenges ensuring patients receive the care they need. We adjusted staffing schedules as well as developed a comprehensive case rationale documentation process to score the acuity relating to resource allocation and the critical nature of the procedure preoperatively. Lovelace Medical Center also participated in community outreach to encourage patients to get the cardiac care they need.

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

We recently decided to use anesthesia for all of our ablation procedures. We have hired 3 full-time certified nurse anesthetists to assist with our EP cases. This has significantly improved the flow of cases in our lab. Previously, we would discover add-on cases that needed anesthesia were difficult to perform, since we did not have dedicated anesthesia staffing. Moreover, we can now seamlessly transition from moderate sedation to general anesthesia if the situation arises intraoperatively. With this current model, we have discussed improved efficiency and safety in our EP cases.

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

Our staff arrives at 6:30 AM to set up for the first case of the day as well as to review the case, supplies, and equipment needs with the physician and CRNA. We perform our scheduled outpatient cases as the first case, with any add-on patients to follow. We typically do a combination of 8 ablations and devices per day, with cases starting at 7:30 AM. Depending on the number of add-on cases, we typically end around 6:30 PM.

How do you ensure timely case starts and patient turnover?

This is something we struggle with, and I think it is the same for all labs. We start our first cases on time, but any add-on cases usually can delay us by an additional 15 minutes over our standard turnover time. This can often be due to patients not being consented, the IV not being placed in the correct arm, or not prepping patients on the floor, which results in a slight delay. We have strong APPs who round on all of our inpatients and who are excellent facilitators that communicate to the lab what type of procedure needs to be performed on patients. The ability to have someone rounding and communicating the needs of the patients has been invaluable for improving throughput.

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

One of the best features of our layout is the close proximity of our 2 EP labs, which are directly right next door to each other. This facilitates easy communication between staff and physicians, especially during difficult cases.

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

In the device clinic, we brought in all of the remote transmissions to the clinic. This has enabled us to increase revenue as well as improve patient quality and satisfaction.

What types of continuing education opportunities are provided to staff? What options for continuing education are available to your mid-career staff?

We started our EP education series several years ago. The purpose is to provide CEUs for our hospital and clinic-based staff. The educational sessions are presented by our physicians. We also offer a monthly journal club, grand rounds, and annual updates in current concepts.

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

The times when you see the true reflection of the quality of the EP lab and staff are usually during the most difficult of cases. I remember there was a case last year on the eve before a major holiday. There was a young patient who had cardiomyopathy and needed a biventricular ICD. It was an extremely difficult case given the patient’s anatomy. At one point, all the EP physicians were in the lab troubleshooting and discussing options to be able to successfully complete the procedure. The EP lab staff were all available and on hand to help. In that moment, the most important thing was performing this procedure and helping the patient on the table. The possibility of missing time with family given the holiday was not at the forefront of anyone’s mind. These are the moments when you truly appreciate the care provided by our staff.

Does your lab use a third party for reprocessing or catheter recycling?

During the past year, we have researched the benefits of reprocessing catheters. Currently, we are in communication with a third-party vendor for the reprocessing of our catheters.

Does your lab perform His bundle pacing?

Yes, for the past 3 years, we have been a His bundle pacing training site for physicians across the country.

Tell us about your primary approach for LAA occlusion.

The primary method we use is the WATCHMAN device. We typically have 2 days a month where an operator has several scheduled. We have also started implanting the LARIAT as part of a research study and registry.

Does your program have a dedicated atrial fibrillation clinic?

We do have a dedicated atrial fibrillation clinic. We started this clinic about 18 months ago. The goal is to ensure patients have direct and easy access to EP providers.

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

A little over 2 years ago, we started transitioning to performing our ablation cases without fluoroscopy. For over 95% of our ablation cases, all 5 EP physicians no longer put on lead. The main steps we have employed have been in the workflow of our ablations, specifically atrial fibrillation procedures. We use intracardiac echocardiography to visualize the catheter in the SVC and watch it move down to the septum. We also routinely obtain sound contours of the left atrium and surrounding structures. Transseptal access is obtained using a wire and cautery approach under direct visualization on intracardiac ultrasound.

How do you manage radiation quality checks of the imaging equipment?

We have scheduled preventative maintenance on all of our equipment, and scan our lead once a year to look for integrity issues.

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

One of the trends in electrophysiology has always been innovation and the introduction of newer technologies or practices. Our lab transitioned to the use of limited fluoroscopy in the management of ablations several years ago. Recent trends have primarily been associated with identifying new methods for implantation of physiologic pacemakers. Our lab and physicians have been pioneers in this particular field. We also frequently evaluate new technologies for performing atrial fibrillation ablations as well as LAA closures.

How do you utilize digital tools or wearable technologies in your treatment strategies?

We primarily use digital tools and wearable technologies in the outpatient setting for diagnosing arrhythmia. We use a wearable patch as an event monitor for patients; our patients are amazed by this technology, and compare it to prior monitors that had wires. We also encourage patients to use other wearable devices (smartwatches, mobile cardiac telemetry monitors, etc.) to assist in the diagnosis and management of their arrhythmias.

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

We are located in Albuquerque, New Mexico. This puts us in a unique situation, as New Mexico has limited healthcare resources. We are privileged to care for patients not only from New Mexico, but from all over the southwest region.

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

The main challenge for our patients is access to care. Electrophysiology services are primarily offered in Albuquerque. This means that we often have patients from hundreds of miles away who need our services. This can pose an issue with delay in care, as patients are apprehensive about traveling for care even though it is needed.

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

Our physicians have been blessed by the quality of our EP nursing and technician staff. They all have many years of experience in the EP lab — some have been working in electrophysiology for over 20 years. This affords a plethora of experience, both from a historical perspective as well as from the knowledge of the tools we use. Because of this, it is routine for some of our EP lab staff to bring up helpful suggestions during cases, especially during complex cases. Our lab staff collaborate with our physicians, which significantly improves the quality of patient care.