Spotlight Interview: Atrium Health Wake Forest Baptist Hospital

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EP LAB DIGEST. 2023;23(10):1,12-15.

When was the cardiac electrophysiology (EP) program started at your institution, and by whom?

The EP laboratory at North Carolina Baptist is credited to be started by Wesley Kenneth Haisty, MD. In the mid 1980s, as great progress was being made in the field of diagnostic EP studies, Dr Haisty hired David Fitzgerald, MD, who trained as a fellow under Warren “Sonny” Jackman, MD, to help start an EP program. In August 1989, Dr Fitzgerald convinced the hospital to acquire investigational radiofrequency (RF) ablation equipment. In 1991, US Food & Drug Administration (FDA) approval was released for RF ablation and Dr Fitzgerald completed the first RF ablation of an accessory pathway in North Carolina. These procedures were completed in the cardiac catheterization laboratory 2 days per week during off-hours.

In 1992, Tony Simmons, MD, was hired from the Cleveland Clinic and the EP lab we currently inhabit was built. At that time, there were 2 holding rooms, 2 procedure rooms, and a room for tilt table testing and cardioversions. Dr Simmons oversaw the device program in the EP lab, with eventual expansions into implantable cardioverter-defibrillator (ICD) implantations, lead extractions, and cardiac resynchronization therapy. The expansions allowed for the department to grow and begin the EP fellowship training program in 1991.

Alongside these physicians, Carol Westmoreland, RN, and Mary Isaacs, RN, are credited as having a major role in building the EP program.

There are currently 6 EP faculty: Patrick Whalen, MD; Tony Simmons, MD; Prashant Bhave, MD; Natalie Bradford, MD; Ghanshyam Shantha, MD, MPH; and Patrick Kozak, MD.

Current holding room staff include Andrea Seckman, RT(R) (CV) (ARRT); Cheryl Bailey, BSN, RN; Amy Kendrick, BSN, RN; Lorri Dodson, CNA II; and Abby Wood, CNA II.

Our lab staff consists of Diane Marion, RT(R); Lee Anne West, RN; Kristine Santiago, BSN, RN; Ashley Graham, RT(R)(CI), RCIS; Natasha Sells, BSN, RN, PCCN, RCES; Oliver Gibson, BSN, RN; Mallory Finn, RN; Leah York, RCIS; Nancy Carter, RN; Mary Swaim, BSN, RN, PCCN; Tamie Berry, ASRT; Kelly Oliver, RT(R); Emily Bare, RT(R); Janet Romero, RN; Coltin Greer, BSN, RN, CCRN; and Christine Weisensel, BSN, RN.

What drove the need to implement an EP program?

The need for an EP program was generated by the large number of patients with arrhythmias requiring pacemakers and ablations. With the lack of available time slots in the cardiac catheterization laboratory, creating a separate EP lab became essential for patient care.

What is the size of your EP lab facility? Has the EP lab recently expanded in size, or will it soon?

Our EP lab in its current state has 4 procedure rooms and 4 holding bays. The smallest room (Lab 1) is used for cardioversions, loop monitor implants, and single-/dual-chamber pacemakers/ICD implants. The other 3 rooms are fully functioning labs that can support most of our cases. Our hybrid lab (Lab 4) houses most of our most complex cases (laser lead extractions, epicardial ventricular tachycardia [VT] ablations, and convergent/hybrid ablations with cardiothoracic [CT] surgery). Our lab has not been expanded in some time, but we are renovating Lab 2 and hope to expand Lab 1 in the near future to create a fully functioning procedure space.

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

Our manager, Misty Alford, MSN, RN, RCIS, is new to our EP lab. She brings 25 years of nursing experience ranging from cardiac catheterization, EP, prep/recovery, structural heart, intensive care unit/telemetry, and interventional radiology (IR). About half of her time in nursing has been in a leadership role.

Our assistant nurse manager, Malissa Tickle, BSN, RN, started here as a nurse in the EP lab in 2006. She was then promoted to assistant manager in 2017. Malissa does most of the behind-the-scenes work managing account charges, chart audits, staffing/time keeping, and many other tasks.

Andrea Seckman, RT(R)(CV)(ARRT), is our EP lab coordinator. Andrea oversees staff room assignments, managing the schedule and the flow of patients in and out of the EP lab, among other responsibilities. Andrea also functions as a holding room staff member before procedures. Andrea brings years of experience to the EP lab. She started her career in 1987 in the radiology department, then transitioned to IR, and then to EP.

What is the number of staff members?

Our lab consists of 6 EP attending physicians, 2 EP fellows, 1 nurse manager, 1 assistant nurse manager, 1 coordinator, 2 holding room nurses, 2 CNA II, 2 advanced practice providers (APPs), and 16 in-lab staff members. Credentials include registered nurses (RN), registered radiologic technologists (RT[R]), and registered cardiovascular invasive specialists (RCIS). Experience in the EP lab varies from 30 years to less than a year.

What types of procedures are performed at your facility?

We have the full breadth of EP procedures in our lab. We perform cardioversions, implantable loop recorder (ILR) implants, pacemaker/ICDs (single- and dual-chamber, biventricular [BiV], and conduction system pacing), RF ablation (supraventricular tachycardia [SVT], atrial fibrillation [AF], PVC, VT – endo/epi with/without hemodynamic support), cryoablation (cryoballoon pulmonary vein isolation [PVI] and focal cryotherapy), left atrial appendage (LAA) occlusion, leadless pacemakers (Medtronic and Abbott), hybrid ablations with CT surgery (AF, inappropriate sinus tachycardia), and laser lead extractions.

We have been at the forefront of emerging technologies, most recently participating in IDE trials for Abbott’s dual-chamber leadless pacing system and Biosense Webster’s pulsed field ablation system.

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

Our EP lab performs approximately 80 catheter ablations, 10 LAA closures, 70 implants (including ILRs), and 10 laser lead extractions per month.

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

For implantable devices (pacemakers/ICDs), we use primarily Abbott, Biotronik, Boston Scientific, and Medtronic. When completing most ablations, we typically use the Carto (Biosense Webster, Inc, a Johnson & Johnson company) mapping system. We also have capabilities to use the EnSite (Abbott) and Rhythmia (Boston Scientific) mapping systems as needed.

For intracardiac electrogram recordings and pacing, we use the LabSystem Pro EP Recording System (Boston Scientific) and EP-4 Cardiac Stimulator (Abbott).

The most used catheters in this lab are the SmartTouch SF (D/F curve), DecaNav, and OctaRay (all Biosense Webster) catheters. The most common sheaths that are used are the 8.5 French SLO sheath (Abbott), Vizigo sheath (Biosense Webster), and the VersaCross RF transseptal solution (Baylis Medical).

What are some of the new equipment, devices, and products recently introduced at your lab? How have they changed the way you perform procedures?

The newest mapping catheters in our lab are the OctaRay and Optrell (Biosense Webster). Our lab also recently started using the ensoETM (Attune Medical), which provides esophageal protection by cooling the esophagus during ablation procedures involving the LA posterior wall. Another new piece of equipment used is the ClearLight noninvasive arterial monitoring system (Edwards Lifesciences). This provides beat-by-beat blood pressures similar to an invasive arterial line with a small pressure cuff on the patient’s finger.

Newer catheters and the increasing processing power of mapping systems have improved the efficiency of map creation. The esophageal cooling balloon has made posterior wall isolation safer for patients while also making the procedure faster and allowing for zero/low fluoroscopy cases. The noninvasive arterial line has saved time by obviating the need for an invasive arterial line for most procedures. It also lowers the risk of arterial injury by not having to place an invasive line.

How is inventory managed at your EP lab?

Our inventory is managed by Ian Potts. He currently utilizes Q-Site and CORE Connect (Atrium Health) for inventory levels and ordering.

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

Our device clinic is comprised of 3 device specialists and a nurse. The device clinic manages approximately 5000 patients. Receipt and formatting of remote monitor reports is outsourced to a third party (CV Remote Solutions), who also assists with monitoring alert notifications and sending notifications to staff as needed. We have 3 cardiac device technicians who work at multiple locations, aligning with EP physician clinics when possible. We utilize a full electronic workflow using ScottCare interface with Epic. We also have one device nurse (RN) and one dedicated device scheduler at this time.

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

An average day in our lab is typically very busy. We start our day with outpatients and/or emergent add-ons. After outpatients are completed, we move on to nonemergent add-on cases. The types of cases vary day by day due to the case load and providers available in the lab. A typical day might have 5 cardioversions, 3 device implants, an SVT ablation, atrial flutter (AFL) ablation, and 3 AF ablations.

Can you describe the extent and use of vascular closure devices at your lab? Is your lab using same-day discharge?

Our EP lab currently uses both the Perclose (Abbott) and Vascade (Haemonetics) closure devices. This technology has allowed us to achieve same-day discharge for most of our ablations.

Has your lab recently gone through a national accrediting inspection?

We underwent a virtual Joint Commission Survey in 2021.

How do you ensure timely case starts and patient turnover?

Turnover times are a topic of discussion at staff meetings. To ensure timely case starts, our first patients of the day check into our holding room area around 0600. This gives in-room lab staff time to get rooms ready and communicate with the anesthesia team with the goal of having a 0730 in-room time. Once in the room, the EP lab staff and anesthesia team work collaboratively around the patient for maximum efficiency. For ablations, providers use Perclose (Abbott), Vascade (Haemonetics), or a figure-of-8 suture for quick turnover at the end of the case.

How does your lab schedule team members for call?

This EP lab does not currently have a call team. We schedule our late days a month in advance. Urgent overnight EP procedures, such as temporary pacing wires, are done at the bedside in the coronary care unit.

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

We currently have 3 shifts: an 8-hour (0700-1530), 10-hour (0700-1730), and 12-hour (0630-1900) shift. We do not typically have a lot of slow periods, but if we do, we use that time for staff education/training, in-services, and inventory management.

How do you handle vendor visits?

Vendor representatives use the Reptrax system to sign in and out.

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

The rooms are close in proximity to each other. The holding room is located inside the lab, only steps away from the procedure rooms. Our inventory rooms are also located inside the lab for quick and easy access to supplies.

Do staff members have any little or big perks that you would like to share?

One perk (that may or may not be a perk depending on who you ask) is that we recently began offering 12-hour shifts to those who prefer them.

Another perk is that we recently added an EP clinical ladder. The staff have steps on the ladder they can complete or become proficient in to move up the ladder for increased responsibility and pay.

What measures has your lab implemented to cut or contain costs?

QSight (Owens & Minor) is used to help maintain PAR levels. QSight provides a notification of expiring items and gives PAR level numbers. The PAR numbers help prevent over-ordering of supplies to help maintain the budget. We also use Stryker to reprocess eligible catheters.

What quality control measures are practiced in your lab?

Our lab has monthly staff meetings on what we are doing well and what areas can be improved upon (such as turnover times and lab efficiency). We also have a quarterly morbidity and mortality conference with staff, EP fellows, and EP faculty to discuss cases that resulted in an unwanted outcome; we collectively brainstorm what can be done to prevent such incidents from happening again.

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

New staff members are paired with a primary preceptor for a minimum of 12 weeks. During this period, the new team member will learn the basics on how to function in the EP lab, including how to document, circulate, and scrub most ablations and single-/dual-chamber devices. As they grow in their EP career, more complex tasks are added (eg, how to use the recording system, scrub a BiV, and perform laser lead extractions). They can either go back to their primary preceptor for one-on-one training for more complex procedures or choose another staff member if preferred.

What continuing education opportunities are provided for staff members?

Our lab offers the Johnson & Johnson Institute learning platform as well as Medtronic Academy. We also have regularly scheduled in-services on new equipment or refreshers on equipment currently used every day in the lab. We also offer reimbursement for staff members wanting to obtain their registered cardiac electrophysiology specialist (RCES) certification.

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

We have 2 APPs in our lab: Gillian Winter, FNP-C, MSN, and Sarah Mikac, PA-C. Both play a huge role in our day-to-day operations. They complete most consenting, history and physical notes/updates, cardioversions, loop monitor implants, some device pocket closures, and manage case schedules and/or conflicts, among many other tasks. Without the APPs, lab efficiency diminishes greatly. They are a great asset to the team and a pleasure to work with.

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

The most recent memorable case was an AF ablation with Dr Elijah Beaty, a faculty member who recently transitioned to an affiliate hospital. The patient originally came to the lab for a cryoablation. During initial catheter placement, the patient was noted to have an interrupted inferior vena cava. Therefore, the cryoablation case was aborted. Due to the patient’s drug-refractory, symptomatic AF, Dr Beaty arranged for the patient to return for a repeat attempt at ablation, this time with a planned right internal jugular (IJ) approach for transseptal access to the LA.

This case was the first IJ transseptal at Wake Forest Baptist Hospital. This case also involved multiple disciplines, including structural imaging for transesophageal echocardiography and interventional cardiology for aseptal ballooning. With an atypical set of tools and a team approach, transseptal access was achieved with a short Agilis steerable sheath (Abbott) and RF ablation (PVI) was performed without complications. At follow-up, the patient is doing well and has had no complaints.

Does your lab use a third party for reprocessing or catheter recycling? How has it impacted your lab?

We use Stryker and Sterilmed, Inc (a Johnson & Johnson company) for third-party reprocessing. Stryker reprocesses catheters from all vendors, while Sterilmed only reprocesses single-use devices  from Johnson & Johnson. Reprocessing catheters saves the lab money and decreases the amount of waste sent to landfills.

Does your lab perform conduction system pacing?

His bundle pacing has more or less been phased out of our lab. We do currently use left bundle branch area pacing (LBBAP) quite frequently. Most of our dual-chamber pacemakers are now implanted with an attempt at LBBAP pacing. LBBAP is also a great backup option for BiV implants where coronary sinus anatomy is not suitable.

Tell us about your primary approach for LAA occlusion.

We primarily use the Watchman device (Boston Scientific), and a multidisciplinary approach is used for all Watchman implants. Our Watchman coordinators work with the patients, implanting physicians, company representatives, structural imaging team, and EP schedulers.

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

The EP department started a dedicated AF clinic approximately one year ago. It was created to meet the increasing demand of patients needing to be seen by a provider in a timely manner. With this new clinic, any patient with a newly diagnosed atrial arrhythmia can be seen by an APP or provider within a few weeks.

We do not have a dedicated lead extraction program coordinator. However, we currently have 4 EP doctors who perform laser lead extractions. All the staff are trained on laser lead extractions and our CT surgery staff are also trained and available for laser lead extraction cases.

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

All staff wear lead aprons and a personnel dosimeter. The dosimeter is changed monthly. All radiation reports are sent to our manager.

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

Our lab uses catheters that can be quickly visualized on the mapping system to better direct catheters in the heart and minimize use of fluoroscopy. Providers also utilize intracardiac echocardiography during cases to minimize the use of fluoroscopy.

All EP faculty routinely perform most SVTs and right AFLs with minimal or no fluoroscopy. The availability of the VersaCross Pigtail RF wire (Baylis Medical) and esophageal cooling balloon has enabled us to perform more AF ablations without fluoroscopy. The first zero-fluoroscopy AF case in our lab was performed by Dr Natalie Bradford.

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

Our lab has rapidly changed to incorporate the implantation of LBBAP leads. We implant them routinely and are happy with their safety profile and clinical efficacy.

We are excited to have pulsed field ablation available to us for AF ablation. This technology holds the promise of enabling more efficient procedures while greatly reducing the threat of esophageal and phrenic nerve injury.

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 have seen an increased number of patients using wearable technologies. Most of our current patients use an Apple Watch or the Kardia (AliveCor). The Kardia is a good option for arrhythmia monitoring post ablation. However, we find there are some patients who are anxious and check their heart rhythm frequently—these frequent checks subsequently generate a high volume of messages to providers.

We are looking forward to participating in the REACT-AF trial, which uses a smartwatch for AF monitoring in patients with known AF who are maintained on a direct oral anticoagulant (DOAC). This trial is examining the safety and efficacy of using wearable technology to monitor for AF and titrate DOAC use based on recent AF history.  

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

We are in the Piedmont region of North Carolina. We are within hours of mountains and beaches. Winston-Salem is unique for its multiple areas for hiking, local breweries, and wineries. The home of the Innovation Quarter, Wake Forest University, and Wake Forest Medical School, Winston-Salem has transformed itself from a tobacco town into a hub for higher education, medicine, and technology.

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

As a Level 1 Trauma Center, our hospital accepts many patients from the western part of the state as well as some patients from Virginia. Patients typically have multiple chronic conditions and often present as severely ill. The need for EP procedures continues to rise while our footprint and resources remain fixed. Our lab does its best to accommodate all patients in a timely manner.

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

Our EP lab is special because it is a teaching facility. This means we encounter students, residents, and fellows of all kinds. With many health care professionals rotating through our lab, our providers can teach all things EP. It also allows us to participate in upcoming EP technologies via our research program. We get to evaluate new technologies and potentially bring more advancements to EP, improving care for our patients.

Our lab is also special because of our EP doctors, who are knowledgeable, caring, and personable. They always put their patients first and provide the best care possible. Our doctors also care about the staff. They are like family and there is a mutual trust. The relationship between provider and staff is strong.

Finally, our lab is special because of our staff. All our team members come with different health care backgrounds and experience. We are a mixed team of nurses and technicians. Sometimes we see each other more than our families! We are truly the family away from our family and we take care of each other.