Spotlight Interview: MidMichigan Medical Center – Midland

When was the EP program started at your institution? Is the EP lab separate from the cath lab?

The EP lab was created in 2007, and we also added a second lab in 2018. Since its inception, the EP lab has always been separate from the cath lab. We have dedicated EP lab staff.

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

Three midlevel nurse practitioners in the practice respond to consultations and cover inpatient services / outpatient clinics. They work collaboratively with our 4 dedicated device nurses, 3 medical assistants, and 3 schedulers.

Electrophysiologists include Dr. Islam, Dr. Opesanmi Esan, and Dr. Michael Mellana. Our team also includes certified nurse anesthetists.

What types of procedures are performed at your facility?

Our robust device implantation program includes pacemaker, CRT, defibrillator, and loop recorder implants. Over the years, our lab has added subcutaneous defibrillator implants, MR-conditional pacemakers and ICD implants, and Reveal LINQ Insertable Cardiac Monitor (Medtronic) implants. We have recently completed our 100th WATCHMAN device (Boston Scientific) implantation for left atrial appendage occlusion.

A complete laser lead extraction program was created in 2015, allowing all devices and related leads to be extracted here.

On the ablation side, over half of our patients receive treatment for atrial fibrillation. The rest is a mix between atrial flutters, AVNRTs, atrial tachycardias, premature ventricular contractions,
and ventricular tachycardias.

Approximately how many catheter ablations (for all arrhythmias), ICD implants, and pacemaker implants are performed each year?

Approximately 300 ablations and 700 device implantations are performed annually.

Who manages your EP lab?

Our cardiovascular service line director, Sunita Vadakath, oversees and coordinates the different departments to maximize efficiency. Our catheterization lab supervisor, Rebecca Boyce, RN, and our EP lab coordinator, Karron Aultman, RN, work together tirelessly to coordinate all of our cases and make sure the day runs smoothly. Nicole Desham, RN is our office manager.

What type of hospital is your EP program a part of?

MidMichigan Health is a community hospital. It continues to grow and merge with other hospitals in the area.

What types of EP equipment are most commonly used in the lab?

We utilize diagnostic and ablation catheters from Abbott, and implant various devices by Abbott, Boston Scientific, and Medtronic. Our mapping system was recently upgraded to the EnSite Precision Cardiac Mapping System (Abbott). We plan to purchase another mapping system in the first quarter of 2019.

We also use the ACUSON AcuNav Ultrasound Catheter (Siemens Healthineers) for each complex arrhythmia case, alongside traditional fluoroscopy.

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

A typical day in the EP lab begins with an atrial fibrillation ablation case, followed by other ablation cases. In the afternoons, we perform device (e.g., ICD, pacemaker, CRT, or ICM) implantations and cardioversions.

Who handles your procedure scheduling? Do they use particular software?

Our EP schedulers, who recently switched to the EPIC software, work with central scheduling to schedule cases.

What type of quality control and assurance measures are practiced in your EP lab?

We do standard safety checks of the equipment each morning, and biomedical performs scheduled maintenance checks as well.

Has your EP lab recently expanded in size and patient volume?

Yes, MidMichigan Medical Center - Midland is slated to open a Heart and Vascular Center in 2020, as part of its commitment to excellence and its determination to be the leader in cardiovascular care in the area. This facility will be state of the art, and bring all the different facets of cardiovascular care (cardiology, structural heart diseases, electrophysiology, vascular surgery, and cardiothoracic surgery) together in one location, providing a streamlined experience for patients.

Does your lab use a third party for reprocessing?

Yes, we utilize Stryker for reprocessing of catheters.

How do you ensure timely case starts and patient turnover?

Our staff is fairly efficient and takes great pride in their work. However, case starts and turnover can be a challenging issue, especially when anesthesia is involved in cases.

How are new employees oriented and trained at your facility?

There is a 3-month orientation period during which new employees train with a senior member in all areas of the lab.

Do you also practice any team-building exercises?

Yes, we are a close-knit group, so we try to plan activities together outside of the hospital/work environment.

Does your lab utilize any alternative therapies to help patients in the EP lab?

We routinely play music in the lab to create a relaxed environment.

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

We are an RF-only lab at this point, but we do plan to add cryo in the next year.

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

NOACs have simplified management of these complex patients. Nonetheless, bleeding risk remains an issue, and patients always prefer to safely discontinue anticoagulation whenever possible.

What measures has your lab taken to reduce fluoroscopy time?

We rely on three-dimensional mapping more than fluoro during our cases. We also use a groin shield.

What are your thoughts on EHR systems? Does it improve your quality of care?

EHR does provide everything in one place. It can be a useful reminder for quality measures as well. EHR has increased the amount of time the physician spends doing charting.

Is your EP lab currently involved in clinical research studies? Which trials?

We have participated in several research studies over the years. We were one of the sites involved in the LAPTOP-HF trial, which evaluated a left atrial pressure monitoring system. We have participated in many lead, device, and drug trials as well, including the SCORE Registry and MPP Trial. We are currently taking part in the ARTESiA trial.

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

I am very proud of our EP lab staff. They are hardworking and always advocate for patients. They take an interest in learning and have grown into mature thinkers, which I think is an essential characteristic for any successful EP lab program.