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UCLA Arrhythmia Center Team: left-right: Shelly Cote RN NP, David Cesario MD PhD, K. Shivkumar MD PhD, Maria Hardie RN NP and Sen Ji MD PhD

There are two state-of-the art EP labs at the UCLA Cardiac Arrhythmia Center, which aim to serve as a resource for patients in the Los Angeles area. These labs allow for complex ablation work and include an implant lab for devices. In addition, they offer intra-cardiac echocardiography for guiding procedures, invasive hemodynamic monitoring and support for complex ablation procedures, and intra-operative ablations in the cardiac ORs where they are pioneering robotic and minimally invasive approaches to non-pharmacological management of arrhythmias.

What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab?
We have two EP (ablation) labs and one implant lab. There are 5 RNs and 4 techs that help with staffing these labs. We have three adult EP attendings and one pediatric EP attending. We also have two nurse practitioners in our group.

When was the EP lab started at your institution?
The program was started in the mid 1980s.

What types of procedures are performed at your facility? Approximately how many are performed each week? What complications do you find during these procedures?
Complex catheter ablation cases (including ventricular tachycardia, atrial fibrillation, complex congenital), pericardial mapping and ablations are also done. We have a busy implant program with several CRT implants a week. In addition to this, we have a steady stream of EPS, AVNRT, pacemakers and regular ICDs. Fortunately, we have had a low rate of complications (major and minor < 1.5%). Typical issues we track include pocket hematomas, pneumothorax, infection, and tamponade.

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Dr. Issac Wiener.

How is your EP lab managed, and by whom?
We have a full-time nurse manager who coordinates the lab staff. All medical issues (privileges, QA, QI, etc.) are handled by myself.

Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained?
The EP lab is separate from the cath lab. However, employees are cross-trained.

What are some of the new equipment, devices and products introduced at your lab lately? How has this changed the way you perform those procedures?
We have several mapping systems — virtually all the products for mapping and catheter ablation that are available today. We are a regional referral center for complex ablations and failed ablations, which has required extensive training of staff.

Is your EP lab filmless, or does it plan to become filmless in the foreseeable future?
We are a filmless lab, with digital archiving.

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Dr. Kevin Shannon.

Who handles your procedure scheduling? Do you use a particular software? How do you handle physician timeliness?
We have an administrative assistant who handles this using Microsoft Outlook.

How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies?
We have a common administrative coordinator who does this for the cath and EP labs.

Has your EP lab recently expanded in size and patient volume, or will it be in the near future?
We have seen a tremendous growth in EP cases (especially the complex cases) due to strong support of our community in greater Los Angeles.

How has managed care affected your EP lab and the care it provides patients?
We serve an area that has extensive managed care presence. However, this trend is on the decline in Southern California, and we anticipate that this will not adversely affect care in the future.

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Inside the EP lab.

What measures has your EP lab implemented in order to cut or contain costs and improve efficiencies in patient through-put?
We have monthly administrative meetings that have hospital administrative people and lab staff in attendance. This has helped us to understand our true costs, and we have a mechanism of “value analysis” for new EP products.

Does your EP lab compete for patients? Has your institution formed an alliance with others in the area?
Fortunately, we have been seen as a true resource to the community and have not had to compete for patients in the traditional sense. About 30–40% of cases at the UCLA Cardiac Arrhythmia Center are referred to us by other electrophysiologists. We are constantly providing CME courses and have electrophysiologists visit our lab to spend time during cases for a direct observation experience. This has created a tremendous amount of goodwill in the community we serve.

Does your lab have an outpatient program?
We have an outpatient clinic that focuses on the following specialized programs:

       • Atrial Fibrillation Program: Focusing on all aspects of ablation for atrial fibrillation and complex atrial tachycardias including focal ablations, linear ablations, etc.
       • Percutaneous Epicardial Ablation Program: This is a new approach that is being used for ablation of ventricular tachycardias and previously failed accessory pathway ablations.
       • Heart Failure Device Program: Bi-ventricular pacing/ICD program, complex ablations.
       • Adult Congenital Heart Disease: Ablation of complex macro reentrant tachycardias in patients with ACHD.
       • Lead Extractions: A dedicated program for lead extractions in collaboration with Cardiac Surgery Service has been established.
       • Intra-Operative Ablations: The David Geffen School of Medicine at UCLA has a nationally renowned cardiac surgical team and our service complements their efforts.

How are new employees oriented and trained at your facility?
Our manager has a comprehensive program for orientation, and we provide clinical updates to our staff as well.

What type of continuing education opportunities are provided to staff members?
Our staff is invited to all our conferences and some even participate in clinical research. All staff are encouraged and supported to attend meetings such as NASPE and AHA.

How is staff competency evaluated?
The senior EP nurses do this on a continuing basis.

Does your lab utilize any alternative therapies?
No.

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EP lab (Erik Ascencio RT, Drs Shivkumar and Cesario and Dr. Valderrabano (right panel).

Have you had any interesting or bizarre cases come through your EP lab?
Too many to list here! However, some include transseptal puncture of the septum via the left subclavian for LV endocardial lead implant for a patient in cardiogenic shock, and complex congenital cases such as Fontan’s and VT ablations come to mind.

How does your lab handle call time for staff members? How often is each staff member on call? How frequently do they have to come in, on average? Do they still maintain a full schedule the next day if they had to come in the night before? Is there a particular mix of credentials needed for each call team?
There are established university guidelines for call time. Staff members are on call once in 4–5 days. They come in about 20% of the time. However, sometimes they stay late to help with overflow cases. Currently they come in the next day to work, although the manager tries to rearrange the schedule to help with this issue.

What type of quality control/quality assurance measures are practiced in your EP lab?
We have bi-monthly QA and QI meetings. We discuss minor and major complications in-depth for lab improvement.

What trends do you see emerging in the practice of invasive cardiology?
Interventional EP is becoming a field that has more in common with minimally invasive cardiac surgery than interventional cardiology! The future looks to be exciting.

Does your lab undergo any sort of inspection? How often does this occur?
There are a series of inspections mandated by JCAHO and local hospital policy. This is done at least once a year, and there are standard preventive maintenance measures for the labs and equipment.

Does your lab provide any educational or support programs for patients who may have additional questions or those who may be interested in support groups?
Yes, our nurse practitioners are developing a website for patient FAQs.

Is there a problem or challenge your lab has faced? How it was addressed?
Our biggest challenge has been training cath lab and EP lab staff to learn each other’s tricks of the trade and help with our quartenary care EP program. We now have a cadre of people who can deal with diverse procedures from transseptals, epicardial mapping, lead extractions to instituting cardiopulmonary bypass for ablations.

Is your lab currently involved in any clinical trials or special projects?
Yes, we are participating in several clinical trials (internal and multicenter). Some of these are RHYTHM-ICD, COMPASS, DETECT-SVT. We also have several protocols in the pipeline for catheter ablation and bi-ventricular devices.

Please tell our readers what you consider unique or innovate about your EP lab and its staff.
We have developed our program to be a regional resource for cardiac electrophysiology. Currently, we are one of the few centers in the country that routinely perform complex ablations (epicardial mapping ablation, operative mapping and complex congenital ablations) on a regular basis. We hope to serve practitioners and groups who want to help UCLA’s evolution in this area.

If you would like more information, please go to the website of the UCLA Cardiac Arrhythmia Center: http://www.cardiology.med.ucla.edu/cardiology/arrhythmia/home.htm