Spotlight Interview: The Clement J. Zablocki VA Medical Center

The Clement J. Zablocki Veterans Affairs (VA) Medical Center is located on 125 acres on the western edge of Milwaukee and part of the VA Integrated Services Network 12. The 196-bed medical center delivers primary, secondary, and tertiary medical care, and provides more than 857,000 visits annually through an extensive outpatient program. The mission of the Zablocki VA Medical Center is to honor American veterans by providing exceptional health care that improves their health and well-being.

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

Electrophysiology services began here in 1999 by Dr. James Roth.

This was expanded upon with the arrival of Dr. Dalip Singh (Division Chief) and Dr. Hakan Paydak when a cardiac mapping system and laser lead extraction were added to the lab. Currently, our electrophysiology team is led by Dr. Singh, Dr. Evgueni Fayn, and Dr. Jalaj Garg.

What is the size of your EP lab facility? Is an expansion planned?

We have one dedicated EP lab, one swing lab (for device implants), and a holding area. We plan on upgrading another lab to a hybrid OR, which could potentially be used for left atrial appendage occlusion and lead extractions, by 2022. We haven’t yet performed left atrial appendage occlusion, as we are waiting for funding approval from the Department of Veterans Affairs.

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

We have an all-RN lab staff, with 5 full-time positions and 3 EP lab technicians (who all are cross-trained in EP and cath). Our department is also supported by 3 full-time advanced practice nurses (APNs).

What types of procedures are performed at your facility?

We perform device implantation (including leadless pacemakers and subcutaneous ICDs), lead extraction, diagnostic EP studies, epicardial and endocardial ablation (pulmonary vein isolation, posterior wall, superior vena cava (SVC) isolation, alcohol ablation for the vein of Marshall, premature ventricular contraction/ventricular tachycardia [VT] ablation, supraventricular tachycardias [SVT], and AV node), and cardioversions. In 2020-2021, we performed approximately 300 complex atrial fibrillation (AF) ablations, 300 device implants, 100 VT ablations, and 100 laser lead extractions. Our lead extraction program is jointly run by Dr. Singh and Dr. G. Hossein Almassi (cardiothoracic surgeon), who have performed approximately 1000 lead extractions.

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

We use the Prucka recording system (GE) with a Bloom stimulator (Fischer Medical). We have one Carto 3 mapping system (Biosense Webster, Inc., a Johnson & Johnson company). We utilize intracardiac echocardiography (ICE) for transseptal punctures with SoundStar (Biosense Webster) catheters. For device implants, we utilize cardiovascular implantable electronic devices (CIEDs) from Abbott, Biotronik, Boston Scientific, and Medtronic. For the past three years, we have been doing His bundle pacing. For complex VT ablation, we routinely use advanced cardiac imaging with MRI to evaluate the arrhythmic substrate and selectively use the Impella (Abiomed) for circulatory support. We just did our first implant of the remedē System (Respicardia), which is a new technology used to treat patients with central sleep apnea.

Who manages your EP lab?

The program manager is Stefanie M. Shierk, MSN, RN, CCRN. She oversees the day-to-day lab operations, including department staffing, budget, and new catheters/equipment.

Shannon Miller and Ingra Wesby are our dedicated care coordinator RNs, who handle all aspects of scheduling, from patient contact and instructions to insurance coverage and post-procedural follow-up appointments.

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

The device clinic has 2000 active patients, and is staffed by a team that includes EP physicians, nurse practitioners, device nurses, and technicians. Duties include remote interrogations, in-person checks (i.e., wound checks), and non-MRI-conditional CIED programming and supervision for MRI scans. We provide device clinic coverage to other areas in Wisconsin (Green Bay) as well as out of state (two locations in Illinois, one in Michigan, and one in Iowa), with satellite clinics in which the device RN drives to these locations and a physician is there for every visit on a video link. A unique feature of our practice is that a physician oversees every device check in the clinic (usually 25 patients a day), with 2 nurses assisting and interrogating devices. Another nurse performs remote monitoring and is also tasked with ensuring the quality of our remote monitoring.

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

Like many other labs during the COVID-19 pandemic, we encountered challenges ensuring patients received the care they needed. There was a decline in elective procedures in 2020 due to the pandemic, but since January 2021, we have returned to our baseline in the EP lab. All patients have a COVID-19 screening test up to 3-5 days pre-procedure, and patients who have had COVID-19 are scheduled according to CDC guidelines. During the pandemic, we began doing outpatient atrial flutter and SVT ablations as well as single- and dual-chamber device implants, and we have continued this practice. Additionally, we have performed multiple urgent cases on COVID-19 patients by following guidelines for safety from the Centers for Disease Control and Prevention (CDC).

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

We use anesthesia for all of our ablation procedures. This has significantly improved the flow of cases in our lab. Previously, we discovered add-on cases that needed anesthesia were difficult to perform since we did not have dedicated anesthesia staffing. With our current model, we have improved the efficiency and safety of our EP cases.

With an excellent support team from Biosense Webster (led by Christopher Kajfosz, Clinical Account Specialist, and Randy Hampton, Territory Manager), we have been able to perform complex AF and VT ablations, thus reducing the procedure time and increasing the weekly number of cases. In addition, we are also approved for the Carto 3 System V7 and Carto Prime Module upgrade, which will allow us to perform simultaneous mapping that we believe is instrumental in patients with multiple premature ventricular contraction (PVC) morphologies.

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

Our staff arrives at 5:30 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. The patient arrives in the lab at 6:30 AM and we stick before 7 AM for the first case of the day. We typically perform one complex ablation per day (either AF or VT ablation), along with SVT ablation or device implantation and cardioversions. Depending on the number of add-on cases, we typically end around 4:30 PM.

How do you ensure timely case starts and patient turnover?

This is something that we struggled with in the past. We always began our first cases on time, but any add-on cases could delay us by an additional 15 minutes over our standard turnover time. This was often due to patients not being consented, the IV not being placed in the correct arm, or not prepping patients on the floor, resulting in a slight delay. With a stick time before 7 AM (consenting all outpatients in the clinic and inpatients the night before), it’s a breeze. We have strong APNs 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.

Do you utilize a same-day discharge approach for AF ablation cases?

Most patients undergoing device implantation or right-sided ablation are discharged the same day; however, patients undergoing complex ablation procedures stay overnight. For all patients scheduled for same-day discharge, we perform vascular access site checks in six hours and ambulation for one hour before discharge. All device patients also undergo wound and device check before discharge, with early follow-up in the device clinic at 1 week and 4 weeks.

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

One of the best features of our layout is the state-of-the-art lab design and support from the Department of Veterans Affairs, which enables us to provide the best medical care to veterans. Also, the close proximity of the cardiac/cardiothoracic surgery intensive care unit (ICU) and inpatient unit facilitates easy communication between staff and physicians, especially during complex cases. In addition, we have significant cardiothoracic surgery support (Dr. Almassi). We have a biplane fluoroscopy system in the lab, but rarely use the second arm.

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

There is regular in-service training provided by industry to train staff members on new and advanced procedures. Any unusual measures, findings, or complications during procedures are typically followed by a briefing session between the physician and staff. It may also be reviewed by medical directors for further action. In addition, it is optional for EP staff to attend and participate in weekly EP fellow teaching conferences and research conferences. There are funds to support EP lab technicians to attend the American College of Cardiology (ACC), American Heart Association (AHA), or Heart Rhythm Society (HRS) scientific sessions each year. This year, our star APNP, Judith Fox, was awarded travel grant support from the HRS. In addition, all nurses and EP techs participate in complex case discussions and electrogram analysis during procedures.

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

Last year, there was a male patient that presented to the ER with VT storm. Because of frequent ICD therapies, he was scheduled for VT ablation; however, en route to his scheduled ablation, he received multiple device shocks. He was taken by EMS to the nearest hospital, which was 50 miles away. At that point, an emergent ambulance transfer was arranged to our facility for urgent VT ablation. Our EP lab and anesthesia staff were available and on hand to help. At that moment, the most crucial task was performing this procedure and caring for the patient. Our dedicated teams smoothly arranged the transfer and made the ablation possible, saving the patient’s life. These are the moments when the care provided by our staff is truly appreciated.

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

We order in bulk when possible, and participate in a metal recycling program. Catheters are not resterilized.

Does your program have a dedicated AF clinic?

AF patients are seen in our regular EP clinic. Patients seen in the clinic are offered a comprehensive approach to their arrhythmia care, including various therapeutic options, risk factor management, and lifestyle modification. In addition, we partner with a dedicated cardiology sleep specialist as well as a weight management and metabolism clinic. We also work with our colleagues in cardiology to care for our patients with heart failure and valvular heart disease.

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

Our lab transitioned several years ago to the use of limited fluoroscopy for ablation procedures. We are currently performing 90% of our ablation cases without fluoroscopy, while the rest use a frame rate of 1-3 frames/sec (by default if the need arises). The main steps we have employed have been in the workflow of our ablations, specifically AF procedures. We use ICE to visualize the catheter in the SVC and watch it drop to engage the fossa ovalis. Transseptal access is then obtained using a wire and cautery approach via the NRG Transseptal Needle (Baylis Medical) under direct intracardiac ultrasound guidance. We also routinely draw sound contours of the left atrium, left ventricle, and surrounding structures.

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

We use radiation badges, mobile and hanging lead shields, and the RADPAD (Worldwide Innovations & Technologies, Inc.). A radiation safety officer maintains and monitors badge levels. We have scheduled preventative maintenance on all of our equipment and perform an annual scan of our lead to look for integrity issues.

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

We are using force-sensing catheters with irrigated ablation catheters. We have also recently adopted vein of Marshall alcohol ablation for persistent atrial fibrillation. We find there is a quicker adoption of non-pharmacological therapies such as ablation. As the only VA referral center in the tristate area, our staff are pioneers in lead extraction. We have removed over 200 Sprint Fidelis leads (about 150 of which were at first generator change), helping to avoid future inappropriate shocks from fractures.

In addition, one of the enduring trends in electrophysiology has always been innovation and the introduction of new technologies. AF continues to be the main challenge in EP, both because of its complex pathophysiology and increasing incidence. With the advent of pulsed field ablation, there will be a significant shift towards AF ablation, overcoming the potential long-term side effects of antiarrhythmic drugs.

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

We routinely use wearable technologies such as smartwatch technology, the KardiaMobile (AliveCor) device, or wearable patch monitors to detect atrial and ventricular arrhythmias, and to monitor treatment success (especially after ablations). We also try to scan the ECGs from smartwatches into each patient’s electronic medical record if possible. However, as of now, we do not encourage patients to buy such devices.

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

Milwaukee is the largest city in Wisconsin and the fifth-largest city in the Midwestern United States. Milwaukee is considered one of the most ethnically and culturally diverse cities in the U.S. Milwaukee is home to Summerfest, one of the largest music festivals in the world. The city is also home to 2 major professional sports teams, the Bucks and the Brewers. In addition, Milwaukee is a popular destination for activities such as sailing, windsurfing, kitesurfing, ethnic dining, and cultural festivals (Milwaukee is often referred to as the City of Festivals).¹

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

What makes our program special is our commitment to teamwork and patient care. Our team is a fun, cohesive, and competent group who are extremely dedicated to providing top-notch medical care to our veterans. Our team is dedicated, hardworking, and continually rises to meet daily challenges. It’s a privilege to work alongside them. They make my job more fun, and they set a high bar for excellence that we try to exceed together every single day. 

Reference

1. Milwaukee. Wikipedia. Accessed December 6, 2021. Available at https://en.wikipedia.org/wiki/Milwaukee