Spotlight Interview: Pulse Heart Institute at MultiCare Deaconess Hospital

Please share some background information about your electrophysiology (EP) program, including when it was first started at your institution.

In the mid 1980s, Dr Charles Swerdlow, along with cardiac surgeons Dr Bill Coleman and Dr Sam Selinger, first brought EP services to Deaconess Medical Center, starting with mapping and surgical ablation for ventricular tachycardia (VT) and Wolff-Parkinson-White syndrome. This was subsequently done in partnership with cardiac surgeon Dr Vern Holbert as well. A few years later, Dr Don Chilson performed the first implantable cardioverter-defibrillator (ICD) implant in the operating room at Deaconess Medical Center.

Spokane became a regional leader in ablation with the work of Dr Chilson and Dr Harold Goldberg, who arrived in Spokane in 1988.

In 1989, Drs Chilson and Goldberg performed the first ablation at Deaconess Medical Center in Spokane to modify the atrioventricular (AV) node for AV node reentry, carrying out direct-current shock ablation on the fast pathway. The potential for AV block was avoided, and the case was published in Circulation,¹ along with a series of cases from the University of California, San Francisco (UCSF). In 1990, Dr Ron Grunwald and Dr Goldberg performed AV node modification, the first such surgery in Spokane and one of the first performed nationwide. In 1991, Dr Goldberg performed ablation of the right bundle branch for the treatment of bundle branch reentrant tachycardia. The case was published in the Journal of the American College of Cardiology,² along with a series of EP cases from UCSF. Also in 1991, the first His bundle ablation in Spokane was performed to treat ICD shocks in a patient, with atrial fibrillation (AF) as a cause of ICD shock; in this case, a rise in this patient’s heart rate often resulted in ICD discharge due to limited rate programmability. Prior to 1993, ICDs were implanted via open chest procedures, with shocking patches sewn directly onto the heart and epicardial pacing leads used to record the heart rate. Dr Chilson was a primary investigator in the Endotak trial to investigate the safety and efficacy of a transvenous defibrillating system. Dr Chilson also developed a unique catheter for mapping known as the basket catheter.

In 1992, Dr Goldberg implanted an ICD in a patient with sudden cardiac arrest due to Chagas disease; this likely represented one of the first cases in the world to use an ICD implant for this condition, which is prominent in South America. In 1993, Dr Michael Kwasman performed the first atrial flutter ablation in Spokane. In 1996, Dr Bryan Fuhs was the first in Spokane to refer magnetic resonance imaging to a patient with a pacemaker, the safety of which was later demonstrated.

Seminal trials such as the CABG Patch Trial, which was published in the New England Journal of Medicine (NEJM) by Dr J. Thomas Bigger in 1997,³ were carried out in Spokane with Dr Goldberg as a primary investigator. Dr Chilson was a primary investigator in the landmark SCD-HeFT trial, which was published in the NEJM by Dr Gust Bardy et al⁴ in 2005 and demonstrated the benefit of ICDs in primary prevention of sudden death.

EP procedures were traditionally a part of the cath lab service at Deaconess. Due to increased volume over time, there was a need to create a specialized EP team. In the early 2000s, under the leadership of Drs Goldberg and Chilson, EP services were separated from the cath lab and a specialized EP team was created.

In 2016, MultiCare acquired the Deaconess Medical Center, Valley Medical Center, and Rockwood Clinics. Since acquisition, the Pulse Heart Institute (a MultiCare business unit) has increased community access to arrhythmia services by adding 3 electrophysiologists, an additional EP procedure room at Deaconess, and an EP lab at Valley Medical Center.

What is the size of your EP lab facility? Tell us about the recent expansion as well.

Our EP lab is located on the fourth floor of the Pulse Heart Institute at Deaconess Medical Center. On this floor, there is a dedicated EP lab and a second multipurpose lab that is predominately used for EP. The rooms are large and spacious. This floor also contains the admit/recovery unit and 5 procedure rooms, including the primary EP lab, a second EP/neuro room, 2 cath labs, and 1 vascular/hybrid room.

Within the last year, the Pulse Heart Institute built a multipurpose cath/EP lab at Valley Medical Center in Spokane Valley to increase access for our patients throughout the region. EP services expanded from only pacer implants to implantations of all devices as well as basic EP studies and ablations.

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

The entire lab has 9 procedural RNs and 20 technologists, as well as other support staff that help with ordering and handling supplies. There is a mix of RCIS and RT credentials in the lab. The EP lab rotates 9 procedural nurses and 6 dedicated RCIS techs for EP procedures. Additionally, we have 4 RNs who serve as nurse navigators for the EP program, along with a dedicated advanced registered nurse practitioner (ARNP) and physician assistant (PA-C).

Deaconess and Valley Hospitals are also beneficiaries of Spokane Community College’s Invasive Cardiovascular Technology (ICT) Program. MultiCare has a long-standing partnership with the college, including that one of the primary instructors is a valued member of the Deaconess cath lab. This pipeline has helped build and sustain technical talent in our cath labs in the Spokane region. The ICT program at Spokane Community College has been around for approximately 40 years.

What types of procedures are performed at your facility?

Deaconess has a well-established device program, including implantations for permanent pacemakers, leadless pacemakers (Micra TPS, Medtronic), ICDs, subcutaneous ICDs, cardiac resynchronization therapy  devices, and physiologic pacing. Ablation services are offered, including for supraventricular tachycardia, premature ventricular contractions, and VT. Services such as cryoablation (balloon and focal) as well as irrigated and nonirrigated ablation for AF are also offered.

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

Approximately 10-14 ablations and 8-12 device implants are performed each week. We perform 5-6 Watchman device (Boston Scientific) procedures per month.

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

We currently use CardioLab (GE Healthcare) for monitoring and are planning to implement LabSystem Pro (Boston Scientific). Our stimulators are from Micropace. For mapping, we use both the Carto 3 (Biosense Webster, Inc, a Johnson & Johnson company) and EnSite Precision (Abbott) systems. We use an array of diagnostic and therapeutic catheters from Abbott and Biosense Webster. We use the Arctic Front (Medtronic) for cryoablation. For visualization, we use the SoundStar Ultrasound (Biosense Webster) or ViewFlex Xtra ICE (Abbott) catheter, and the Acuson S2000 (Siemens). For transseptal punctures, we utilize either a BRK (Abbott) or NRG (Baylis Medical) needle.

Who manages your EP lab?

Brian Watson is the manager of Cardiovascular Services, with oversight of procedural operations for cath, EP, and interventional radiology (IR).

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

Our device clinic operates out of 3 main locations: Spokane, Spokane Valley, and North Spokane. We also provide device support to our outreach clinics throughout Eastern Washington and Eastern Oregon.

The dedicated team consists of talented lead techs, device techs, remote techs, schedulers, and monitor techs.

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

In the early stages of the pandemic, the limiting factor in the hospital setting was personal protective equipment (PPE). Early in 2020, we had to get very creative with securing PPE and making sure we had adequate resources for our cases. We shifted heavily to virtual visits for those patients that could accommodate telemedicine, as well as pushed for same-day discharges whenever possible and when safe to do so. In the lab, we have made specific changes to target our ability to send patients home the same day. We have accomplished this by using closure devices to shorten time. As a result, approximately 90%-95% of our EP patients at Deaconess are now discharged same day.

How do you ensure timely case starts and patient turnover?

We have found communication and appropriate staffing are the biggest factors in keeping the day on schedule. Constant measurement and analysis of our turnaround times are imperative to steady improvement.

We are very focused on operational efficiency in the EP lab, especially regarding room turnaround time. In 2021, Deaconess had the best EP turnaround times in the MultiCare system. Our physicians and team are committed to this goal, and plan on continuing this in 2022.

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

The team begins daily at 6:30 AM, performing a final check of the schedule and verifying all resources are lined up and available. At this point, it is all about making the proper adjustments to the ever-changing flow of the cath and EP labs. From a staffing perspective, the EP techs set up, monitor, scrub, tear down, and manage turnover. Patients are then admitted to the Cardiovascular Admit Recovery Unit, which is a separate nursing unit that both prepares patients for procedures and recovers them until discharge. Our amazing cath/EP lab RNs work with preprocedural nursing staff to get the patient ready for the case, manage the patient during the case, and transfer the patient to the postprocedural area. There is continuous collaboration to keep all the different departments on task. Most days are completed by 5 PM. All staff work four 10-hour shifts.

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

Moving to reprocessed supplies as well as having strong partnerships with our vendors has helped us create value within our EP lab. We are also working strategically to increase procedural volumes by educating referring physicians, transitioning tilt studies to EP clinic visits, adding an AF clinic, and expanding the number of EP procedure rooms.

Tell us more about your use of reprocessing and how it has impacted your lab.

We use 2 vendors, Innovative Health and Sterilmed (a Johnson & Johnson company), for reprocessing. We process catheter cables through our central processing. Initiating this process was initially a challenge, as getting staff educated on which item went to which vendor took a while. However, it’s going much more smoothly now. We have also been very happy with the quality of our reprocessed catheters.

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

Although there are specific credentialing resources available to staff, we rely heavily on our vendors for continuing education. MultiCare also offers tuition reimbursement for staff seeking more formal education options. All lab staff have $500/year to spend on continuing education. Medical conferences are usually attended on a rotation. COVID-19 has restricted conferences and travel, but we hope to begin attending conferences again in the future.

Tell us about your primary approach for LAA occlusion.

We utilize the Watchman device for percutaneous LAA closures. We perform the procedure in much the same way as we would for any other left atrial access—with a single fixed curve sheath and NRG needle.

What approaches has your lab taken to reduce fluoroscopy time?

During ablations, our electrophysiologists primarily use ultrasound and mapping, with only a tap on the fluoro pedal before transseptal puncture. During device implants, we utilize shielding and the Radpad (Worldwide Innovations & Technologies, Inc) to help reduce exposure.

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

Currently, Siemens provides quality checks during preventive maintenance visits. Once a year, a physicist comes in to perform third-party checks for radiation safety.

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

EP’s evolution into a mostly same-day outpatient service allows for larger institutions to help smaller and more rural institutions treat their patient populations. We see the industry continuing to move in this direction and expect to see a gradual shift of these procedures into surgery centers.

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

We are a regional health care facility providing service to a large rural community. Spokane has many of the benefits of a large city, but within 15-20 minutes, you can be deep in the country. We are fortunate to have many beautiful lakes and mountain ranges nearby. Many people move to the area for hiking, fishing, and hunting. We are also home of the Gonzaga Bulldogs, one of the best college basketball teams in the country, year in and year out.

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

Del Reiber, lead EP tech, describes it best: “I’ve been working at Deaconess and doing supplemental work for other hospitals for almost 30 years. This is really the first time I have seen all the pieces of the program come together, with the same goal of providing the best patient experience, while still providing a fun and positive work environment.” 

References

1. Epstein LM, Scheinman MM, Langberg JJ, et al. Percutaneous catheter modification of the atrioventricular node. A potential cure for atrioventricular nodal reentrant tachycardia. Circulation. 1989;80(4):757-768. doi:10.1161/01.cir.80.4.757

2. Cohen TJ, Chien WW, Lurie KG, et al. Radiofrequency catheter ablation for treatment of bundle branch reentrant ventricular tachycardia: results and long-term follow-up. J Am Coll Cardiol. 1991;18(7):1767-1773. doi:10.1016/0735-1097(91)90519-f

3. Bigger JT Jr. Prophylactic use of implanted cardiac defibrillators in patients at high risk for ventricular arrhythmias after coronary-artery bypass graft surgery. Coronary Artery Bypass Graft (CABG) Patch Trial Investigators. N Engl J Med. 1997;337(22):1569-1575. doi:10.1056/NEJM199711273372201

4. Bardy GH, Lee KL, Mark DB, et al. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med. 2005;352(3):225-237. doi:10.1056/NEJMoa043399