Spotlight Interview: Northwestern Memorial Hospital

When was the EP program started at your institution? By whom?

The modern EP program was started by Dr. Richard Kehoe in the 1980s. Dr. Alan Kadish took over as the director of the program in 1990 after moving from the University of Michigan. Dr. Kadish handed over the reigns as director of the EP lab to Dr. Jeffrey Goldberger after he rose to the position of Associate Chief of Cardiology. After Dr. Kadish left in 2009 to become the President of the Touro College and University System in New York, Dr. Bradley Knight was recruited from the University of Chicago to assume the EP directorship role in October 2009.

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

We have 3 EP labs with biplane fluoroscopy and all of the equipment needed to perform complex EP procedures, as well as a smaller adjacent room used for cardioversions, implantable monitors, and tilt table testing. Lead extractions are performed in a hybrid operating room one floor below the EP labs. We have future plans for a hybrid lab shared with the Cath lab.

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

The lab staff consists of 9 RNs with a variety of backgrounds including EP/Cath lab, Critical Care, OR, and ER, with two-thirds of our nursing staff holding specialty certifications. Additionally, there are 3 ablation specialists and a clinical engineer.

We have 8 full-time EP faculty at Northwestern Memorial (NM) and 4 EP fellows. We also have an advanced practice nurse (APN) who independently performs cardioversions and places implantable loop recorders (ILRs), as well as an APN who manages cardiac implantable electronic devices (CIEDs) for patients undergoing MRIs and helps run the inpatient EP consult service. Our outpatient EP team consists of 4 EP nurses and 3 EP APNs, and a fully staffed device clinic.

What types of procedures are performed at your facility?

We perform the full spectrum of interventional and investigational EP procedures at NM, including radiofrequency (RF) and cryo ablations, device (pacemaker, ICD, CRT, and subcutaneous ICD) implants, Micra transcatheter pacing system (Medtronic) implants, WATCHMAN (Boston Scientific) procedures, lead extractions, tilt table testing, and ILR insertions.

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

We perform approximately 15 EP procedures including catheter ablations, 15 device procedures including generator changes and implantable monitors, 1 lead extraction case, and 1-2 left atrial appendage closure (LAAC) procedures per week.

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

We use the EnSite NavX (Abbott), CARTO (Biosense Webster, Inc., a Johnson & Johnson company) and the KODEX-EPD (Philips) cardiac mapping systems. We utilize cryoballoon catheters (Medtronic), THERMOCOOL SMARTTOUCH catheters (Biosense Webster), and the TactiCath Ablation Catheter (Abbott). We use devices from Abbott, Boston Scientific, BIOTRONIK, and Medtronic. In addition, we use the Bloom EP stimulator (Fischer Medical) and CardioLab system (GE).

Who manages your EP lab?

This is a collaborative effort between our Medical Director (Dr. Knight), our Clinical Coordinator (Joel Galam), and our Clinical Nurse Manager (Andrea Stone).

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

Our device clinic follows approximately 5000 patients with pacemakers, defibrillators, and ILRs. Patients are followed both remotely and in person. Pacemaker and defibrillator patients are checked remotely every 91 days and seen in person once a year. ILR patients are checked remotely every 31 days. Device clinic staff also reprograms devices pre- and post-surgery when necessary during normal clinic hours. The clinic is staffed Monday through Friday from 7:00 am until 5:00 pm. Staff includes 3 full-time nurses, 1 part-time nurse, 2 device technicians, and 1 patient liaison.

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

In the early months of the pandemic, our lab devised a schedule for the staff to minimize exposure to each other by dividing into 3 groups. Each group was assigned to specific days in the lab. This method not only prevented a communal spread should one staff member contract COVID, but it freed up staff on their non-lab days to help out in different capacities, either in the COVID ICU providing primary nursing care, the COVID testing drive-up swabbing patients for COVID, the COVID line calling patients who have tested positive, or working security throughout the hospital to ensure people are in the right place. Our physicians took on placing central and arterial lines in the COVID ICU. To free up resources, we limited our cases and focused mainly on generator changes, urgent device implants, and highly symptomatic patients needing ablations. We avoided anything requiring a transseptal puncture or overnight stay, and tried to focus on cases using moderate sedation, allowing anesthesia availability to help cover needs in the COVID ICU. Clinic appointments were primarily done via telemedicine, and the MyChart EMR patient portal was utilized to submit photos for incision checks.

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

We are always looking to improve our procedural outcomes both in terms of efficacy and patient safety. To that effect, we are participating in a number of clinical trials and lab initiatives to try to achieve these goals. While the focus is often on outcomes with novel ablation, implantable device, and structural (LAA occlusion) technologies, we try to have an equal emphasis on patient safety. One example is our attempt to prevent extracardiac complications of atrial fibrillation (AF) ablation with esophageal temperature monitoring depending on the ablation technology (RF vs cryo ablation) to try and improve patient safety and hopefully improve outcomes. We also participate in the American Heart Association’s Get With The Guidelines-AFIB registry. Our complication rate for AF ablation procedures is half the national average compared to our peers.

Tell us what a typical day might look like in the EP lab.

Our EP lab staff and EP fellows arrive at 6:30-7:00 am to set up for the first case in each lab, discuss the procedure with patients, and review the case, supplies, and equipment needed. This is followed by didactic lectures or in-service conferences prior to starting our first cases at 8:00 am. We first perform our scheduled outpatient cases, followed by any add-on inpatient cases. We typically do a combination of 6-9 ablations and device implants per day. At the end of the day, we will review cases for the next day to ensure all necessary pre-procedure testing or medications have been arranged.

Is a same-day discharge approach utilized for AF ablation cases?

We have not pursued same-day discharge for AF ablation procedures. At present, all of our AF ablation patients stay overnight in our specialized post-cardiac intervention recovery area.

How do you ensure timely case starts and patient turnover?

Tracking delays on first cases has helped to narrow down the reasons why a delay occurs; we are then able to come up with solutions. For example, we noticed a trend of delays waiting on lab results, so we modified the workflow by having patients come in prior to their procedure for lab work, and this modification has eliminated delays related to lab results. We continue to monitor reasons for delays and adjust our routine as necessary. We also begin gathering supplies at the end of each day for cases taking place the next morning.

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

Our labs are set up with our nurses positioned at the head of the bed behind a lead screen, where they can monitor the patient’s vital signs while being able to see the patient and converse with them. Because our EP labs were built at different times, the layouts are variable. The optimal layout seems to have a separate control room positioned at the foot of the fluoroscopy table, where the recording systems, mapping systems, and stimulators are located. Voice-activated microphones are utilized for coordination of care between the procedure room and control room.

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

In the lab, we have installed new inventory control cabinets to help maintain costs. We are able to track our supplies as they arrive in the facility and maintain a par level based on usage. As supply levels fall, it triggers an order to be placed. The goal is to track inventory and prevent loss or expiration of costly supplies. Significant savings have also been made through reprocessing and minimizing the number of catheters used in each case.

What types of continuing education opportunities are provided to staff?

There are many opportunities available for continuing education for EP staff. Our Bluhm Cardiovascular Institute (BCVI) hosts the annual Catheter and Surgical Therapies for Atrial Fibrillation (CAST-AF) conference, where our physicians provide educational updates with international faculty. Our EP lab staff attend (in person during non-COVID times), and CEUs are available. There are many opportunities for learning through different vendors such as Biosense Webster, Boston Scientific, and Abbott; these are currently virtual, but we are hoping for the return to in person. There is also Medtronic Academy for extra learning and CEUs. In addition, our Education Coordinator has organized many in-services for us from vendors such as Baylis Medical and Spectranetics.

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

Ordinarily, phrenic nerve pacing is done at high output via a deflectable decapolar catheter positioned in the high posterolateral superior vena cava. In one case, our monitoring system was not functioning, giving us no way to pace through the system. In order to circumvent this malfunction, we disconnected the pins of our decapolar catheter from the pinbox and then connected the pins corresponding to the two most distal electrodes of the catheter to a standard temporary external pacemaker box. The most distal pin was used as our anode, and the more proximal pin was used as our cathode. Pacing was set to a VVI mode at 60 beats per minute with an output of 20 mA, which was successful in pacing the distal electrodes of the decapolar catheter, resulting in consistent and vigorous phrenic nerve capture.

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

We use Medline ReNewal to reprocess the majority of our catheters (eg, ICE, CS, quads). In 2020, we saw a savings of almost $350,000. We expect our savings to increase, as there are plans to expand the process to include additional products.

Does your lab perform His bundle pacing?

Our EP lab adopted physiologic pacing early due to the perceived benefits of utilizing the native His-Purkinje system rather than direct myocardial stimulation. Nowadays, the technique has become a mainstay in our EP lab. We consider it for both bradycardia pacing as well as cardiac resynchronization therapy. We have published our novel findings with physiologic pacing and participated in clinical trials evaluating its efficacy for cardiac resynchronization therapy. We routinely consider its use for all patients that will have a high burden of ventricular pacing and other clinical scenarios where we think the patient will benefit.

Tell us about your primary approach for LAA occlusion.

Our primary approach to LAAC is implantation of the WATCHMAN FLX device (Boston Scientific) and the LARIAT system (AtriCure). We are active in clinical trials, including CATALYST (Amulet device, Abbott), CHAMPION-AF (WATCHMAN FLX), and aMAZE CAP (LARIAT). We currently perform LAAC under general anesthesia with TEE guidance, and are evaluating implantation of LAA plugs under sedation and with intracardiac echocardiography.

Does your program have a dedicated AF clinic, or have plans to implement one?

We have recently hired a nurse as an AF Coordinator. She is helping us develop protocols for identifying patients who are good candidates for LAAC and catheter ablation, and she is trying to streamline the referral process. We also have initiated an AF care pathway where patients with newly diagnosed AF are seen within a week in our EP clinic by one of our EP nurse practitioners.

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

To reduce fluoroscopy and improve outcomes, we use ultrasound for femoral vascular access and to confirm wire positioning. Intracardiac echocardiography (ICE) and tactile feedback are used to ease advancement of wires and catheters. We utilize 3D electromagnetic mapping systems, such as CARTO and NavX, along with force-sensing catheters. We rely on intracardiac signals, ICE, or even alligator clips on the wires to track guidewire positioning. Some attendings utilize a fluoroless approach with all SVT, typical flutter, PVC, and ventricular tachycardia ablations, as well as left atrial RF ablations. If the patient has a CIED (pacemaker or ICD), we tend to use minimal fluoro to assess lead/catheter interaction.

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

In addition to daily checks by one of the radiology technologist resource coordinators for the EP and Cath lab, preventative maintenance is performed routinely by Siemens and Philips. All staff also wear badges that are monitored and exchanged monthly by our radiation safety department. We are provided reports monthly as to our exposure levels, and all of the staff lead is routinely inspected for damages. We have 3 fluoro settings in each EP lab, and start off procedures with the lowest exposure settings.

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

We see the following trends happening in EP: anticipated growth in AF ablation and LAAC, alternative energy sources such as ultra-low cryo ablation and electroporation, more focus on procedural efficiency and cost reduction efforts, more efforts at fluoro reduction, early discharge after procedures, more telemedicine, a continued shift in control and decision making from physicians to hospital administrators, more virtual educational programs, and greater roles for APNs in EP.

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

These tools are indispensable to the practice of EP. We use digital heath to diagnose arrhythmias in patients with symptoms such as palpitations. We also use wearable technology to document AF burden and the efficacy of rhythm control strategies.

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

We face a unique challenge in Chicago, where there is a fragmented healthcare market and intense competition. The highest volume centers account for a minority of the overall cases.

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

We are geographically challenged due to our downtown location by Lake Michigan, resulting in problems caused by traffic, expensive parking, and limited access to public transportation. Traffic has been better during the pandemic, but fewer people are living and working near the hospital. We anticipate that the growing network of NM hospitals and telemedicine will help address these issues.

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

Our EP lab staff is comprised of varied backgrounds and experiences, and we utilize our strengths as we continue to grow. We were all challenged in different ways by the pandemic, and yet we were able to come together as a group and draw strength from each other to get through all of the challenges. As we began to resume normal operations, we had a backlog of patients. However, we pulled together through the summer, and recorded the highest caseloads ever in the months of June and July! We even volunteered to come in on Saturdays to help get the patients the care they needed sooner. Through it all, our patient satisfaction scores are the best they have ever been, and this speaks volumes about our amazing staff.