Spotlight Interview: Chattanooga Heart Institute at Memorial

© 2023 HMP Global. All Rights Reserved.

Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of EP Lab Digest or HMP Global, their employees, and affiliates. 

EP LAB DIGEST. 2023;23(6):1,12-14.

When was the cardiac electrophysiology (EP) program started at your institution? By whom?

In 1993, Dr David Salerno moved from Minneapolis to Chattanooga to start the EP program at CHI Memorial.

What drove the need to implement an EP program?

With no EP programs in Chattanooga, there was a growing need in the community for EP services. We became the first EP program in Chattanooga in 1993. Importantly, continuity has been maintained since those initial days, with overlapping personnel at each stage. Two team members who started the program over 30 years ago are still working in the lab today!

What is the size of your EP lab facility? Has the EP lab recently expanded in size?

The department began operations in an existing cardiac catheterization laboratory but quickly grew with 2 dedicated rooms. In June 2014, we moved into our newly constructed space in the Guerry Heart and Vascular Center, with 2 EP labs and a shelled space. We now have 3 dedicated EP labs, with the last one completed in 2019. For our new space, we built the department in 2 pods: one cath lab pod of 4 labs and one EP pod with 3 labs, plus a peripheral lab. The approximate square footage is 850 square feet.

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

Tina Mathis, BSN, RN, has been our cath and EP lab manager for the last 2 years. Previously, she was a cardiovascular service line director in California and now has more than 8 years of leadership experience. There is a dyad relationship with the administration and physician leaders. Jill Brown, RT(R), is our EP team lead. She has 26 years of EP experience (22 years at CHI Memorial). She facilitates the daily flow of patients in the EP labs, communicates coverage needs with representatives, ensures inventory is on hand for cases, and communicates with physicians, advanced practice nurses, the charge nurse, and schedulers.

What is the number of staff members?

We have 11 dedicated EP team members with many years of experience. The team includes registered nurses (RNs) and radiologic technologists (RTs), some who are certified registered cardiac electrophysiology specialists (RCES), that support our 5 dedicated electrophysiologists.

What types of procedures are performed at your facility?

We perform EP studies, ablations (atrial fibrillation [AF], supraventricular tachycardia [SVT], ventricular tachycardia [VT]), left atrial appendage closure (LAAO) procedures (Watchman device, Boston Scientific), laser lead extractions, and device implants, including leadless pacemakers, physiologic pacing with His bundle and left bundle branch area pacing, and biventricular implantable cardioverter- defibrillators (ICDs), pacemakers, and implantable loop recorders.

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

We perform approximately 15 ablations and 20 device implants each week. Our LAAO program recently started and is growing; this year, we are on track to complete 75 cases.

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

We use the Carto mapping system (Biosense Webster, Inc, a Johnson & Johnson company), CardioLab Hemodynamic Recording System (GE Healthcare), and Micropace stimulator. We use the following catheters for ablations: SmartTouch SF, Pentaray, Soundstar ultrasound, and Vizigo (all Biosense Webster).

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

We recently obtained a Vivid S70N Dimension ultrasound system (GE Healthcare), which has great imaging capabilities for access and intracardiac echocardiography (ICE).

How is inventory managed at your EP lab?

We use the WaveMark Inventory Management System (Cardinal Health). This system uses barcodes to decrement inventory and charge patients, as well as notifies our supply chain to reorder supplies.

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

Patients are seen in the office at the Chattanooga Heart Institute. The device clinic, which is overseen by EP physicians, is staffed with 9 RNs and manages more than 7000 patients.

How has the COVID-19 pandemic impacted your EP lab, hospital, or practice?

Like most facilities, our volumes plummeted during the COVID-19 pandemic, given the elective nature of the EP field. Over time, we have built back to pre-COVID volumes.

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

We commonly use a figure-of-8 stitch for venous closure and Perclose (Abbott) for arterial closure. Many of our patients are discharged on the same day for ablation cases. More than 90% of device implants/replacements are also discharged the same day.

How do you ensure timely case starts and patient turnover?

Reduced staffing, lab availability, and the desire for a streamlined patient process led us to undergo an EP lab efficiency project in 2022. We looked at the process from the preprocedural area and worked with anesthesia colleagues. Ventilation strategies were adjusted. Over several months, factors such as start times, various points of the procedure, and room turnover were all analyzed for means of improvement. These efforts resulted in a 20-minute improvement in start time and 46% reduction in room turnover times. We continue to assess for improvement and the gains have been durable. While efficiency is key, safety, effectiveness, and comfort are our 3 main goals, with safety always being the most important. We ensure this through experienced staff, protocols, and communication.

How does your lab schedule team members for call?

There is no call for the EP team. We have a late team assigned each day who will stay to complete cases as needed.

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

We have 10-hour shifts from 7 AM to 5 PM. When it is slower, we offer to float to other areas as available and have a low census “go list” (which usually has plenty of volunteers). Additionally, low census days are available for staff to get into the drawing for a day off. If they win the drawing, they choose whether or not to use the paid time off. When we see volume fluctuations, we plan ahead as much as possible. We try to keep a late team here until 4 PM to stay productive.

How do you handle vendor visits?

Representatives sign into Vendormate and change into scrubs to support cases. We appreciate our vendor support.

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

We have large rooms that are located in the same pod with our internal central supply storage, which is easily accessible to all EP labs. The new lab, completed in 2014, was designed with EP nurse and physician input at each stage. Additionally, from a customer service perspective, patients and families are greeted upon arrival, and families are updated throughout the case by a designated staff member. At the end of the case, the physician meets with the family in a private consultation room to discuss the case findings and next steps.

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

We use SterilMed, a Johnson & Johnson company, to help decrease supply costs. We use WaveMark for our inventory management system, which helps us keep the correct par levels and expirations at a minimum.

What quality control measures are practiced in your lab?

Bimonthly meetings involve the EP physicians, surgeons, EP staff, infection control, pharmacy, supply chain, and quality department. Data from the National Cardiovascular Data Registry are analyzed and trends are discussed. Hospital metrics involving EP are also followed. Device infections are discussed as well as any known issues in the hospital. n

Samuel O Jones IV, MD, MPH, FACC, FHRS

Chattanooga, Tennessee

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

We have an extensive training and orientation program. Each new hire cross-trains to all roles, including circulator, scrub, monitor, and fluoroscopy. Once those skills are mastered, they are cross-trained on the stimulator.

What continuing education opportunities are provided for staff members?

We have vendor in-services and online modules from Biosense Webster through Johnson & Johnson. RCES and RN specialty certification prep and certification reimbursement are available for the team.

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

Advanced practice providers consult with patients for appropriate procedures and assist with scheduling procedures. They are an integral part of the team, especially with patient teaching and communication between patients and physicians. Additionally, they complete pre- and post-operative orders and provide care as needed to patients.

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

We use SterilMed, which has helped to cut cost on supplies.

Tell us about your primary approach for LAAO.

In 2021, our institution was named a LAAO Center of Excellence for our national health care system, CommonSpirit Health. We use a multidisciplinary approach to help achieve the best outcomes for our patients. We use an echocardiographer in every case and find this input invaluable.

Does your program have a dedicated AF clinic?

We have an AF observation unit. The mission of this unit is to perform rapid evaluation and restoration of sinus rhythm when appropriate, which includes medications and cardioversions, if indicated. Patients are then discharged to follow up with an EP appointment or preferred cardiologist.

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

We all wear appropriate lead, including eyewear. There is additional shielding on the tables as well as portable lead shielding, and the monitoring stations inside the room are behind lead glass shielding. We monitor our dosimetry reporting and report exposure that has exceeded limits. For lead extractions, we manage short-term extractions (<1 year) in the EP lab. More complex lead extractions are completed in the hybrid lab with surgical backup.

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

We have increased use of ICE and 3-dimensional mapping systems. Many cases, including AF ablations, are performed with low fluoroscopy, while some SVT and atrial flutter cases use no fluoroscopy.

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

Emerging trends in EP include pulsed field ablations, physiologic pacing, and same-day discharge.

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 are the associated challenges or benefits?

Use of digital health and wearables has increased. We encourage our patients to bring this data to the clinic. Overall, it has been beneficial, but it must be utilized in the correct way. One challenge is that the data is occasionally incorrect and that may increase patient anxiety. It also creates a significant amount of data that is not easily reimbursed when being reviewed.

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

With the nation’s fastest internet, Chattanooga is known as “Gig City,” which brings many tech-oriented people nearby. We have a rapidly growing community that includes a university town. With the nearby lakes, rivers, and mountains, there are also plenty of opportunities for outdoor activities.

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

We have 2 competing hospitals within a 5-mile radius. We strive to ensure excellent patient care, patient outcomes, and customer service to keep patients in our system.

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

We have a seasoned and skilled team with over 171 years of combined EP experience. This includes 2 team members who have been here since the program began in 1993. The long tenure of employees is typical, as we have a great team and an excellent place to work. Because of the geography of our city, staff have choices for employment, so our retention efforts remain competitive. Our team community is strong and feels like family, which also helps retain our talented and skilled staff. Many have worked at other facilities in the past and enjoy the work, team dynamics, and morale of our EP lab, and plan to continue to call it home. That makes us happy and proud! 

For more information, please visit:

Facebook - @CHIMemorial

Twitter - @CHI_Memorial

LinkedIn - @CHI-Memorial

---

At CHI Memorial, we are very proud to have been recognized by the following organizations for our quality, safety, and patient experience:

Leapfrog Top General Hospital and Leapfrog Fall 2022

• One of 32 general hospitals to receive the distinction

• CHI Memorial Chattanooga received an “A” grade

• 101 Best Hospitals for Bariatric Surgery

CMS Star Rating 2022

• Only health system in region to receive 5 of 5 stars

• Sixth time receiving 4 stars or higher

Fortune/Merative 15 Top Health Systems

• Selection based on top performance in care, efficiency, and community value

US News & World Report 2022-2023

• Eighth straight year named a Best Regional Hospital

Healthgrades

• Patient Safety Excellence Award recognizing CHI Memorial Hospital’s Chattanooga and Hixson hospitals as top 10% in nation

Top Cardiology Hospital

•  1 of 2 in Tennessee and 1 of 103 in the nation, among 4500 hospitals

Chattanooga Times Free Press’s Best of the Best 2022

• Best Hospital - 14th year; Best Emergency Department - 12th year.

• Best Healthcare Employer

NRC Health 2022

• Recognized in 2022 as a Top 100 hospital for Consumer Loyalty