St. John Hospital and Medical Center, founded in 1952, is a 607-bed teaching hospital in Detroit, Michigan. It is one of the leading providers of adult open-heart surgery in the state, and was recently named one of the top 100 Cardiovascular Hospitals in the country. It is also the largest acute care provider and the only designated Emergency Trauma Center on Detroit’s east side. Currently building a second EP lab suite, see how this busy EP lab manages their day-to-day concerns through teamwork and communication.

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 one dedicated clinical electrophysiology suite, which includes one laboratory, a room for tilt table testing, and a patient recovery area (where we also perform external cardioversions and ICD testing). In addition, given our high volume, we frequently use one of the cardiac catheterization laboratories for surgical procedures (pacemaker and ICD implantations). There are four staff electrophysiologists at our institution: Dr. Luis A. Pires, Lab Director; Dr. Matthew A. Flemming; Dr. Aaron B. Hesselson; and Dr. Sohail A. Hassan. Our physicians, three of whom are board-certified in clinical cardiac electrophysiology, have been at our institution anywhere from one to nine years.

Our laboratory staff consists of one cardiovascular technician, five registered nurses (one of whom, Katrina Johnson, serves as our research coordinator) and one secretary. All of our nurses are trained and experienced in administering conscious sedation. Except for one nurse, our staff members have been working in our laboratory anywhere from two to ten years.

When was the EP lab started at your institution?
Our laboratory has been operational since 1993.

Photo 1

From left to right (standing): Keith Clark, Lab Technician; Dr. Luis Pires, Lab Director; Meredith Burkhard, RN; Dr. Aaron Hesselson; Kelly Humphrey, RN, Charge Nurse; Katrina Johnson, RN, Research Coordiantor; Dr. Sohail Hassan; Dr. Matthew Flemming. (Sitting): Debra Steffen, Lab Secretary; Karen Sison, RN; Erica Brenckle, RN.

What types of procedures are performed at your facility?
We perform a variety of procedures ranging from simple electrophysiologic studies to device implantations and complex catheter ablation procedures,including ablation of "focal" atrial fibrillation.

Approximately how many are performed each week? What complications do you find during these procedures?
We perform, on average, 30 procedures per week (approximately 1,600 procedures per year), including 220 catheter ablations, 450 ICD placements (180 biventricular devices) and 300 pacemaker implantations. An additional 120 pacemaker implantations are performed in the operating room per year in our center. In addition, we perform between 450 and 500 tilt table tests per year.

In general, due to uncompromising diligence from our physicians and laboratory staff, we have had very low complication rates in our laboratory.

How is your EP lab managed, and by whom?
Our laboratory is managed by Judith Olcese, RN, who is the Manager of the cardiac catheterization laboratory, and the laboratory's Medical Director, Luis A. Pires, MD. The day-to-day operation of the laboratory is carried out by the charge nurse, Kelly Humphrey, whose responsibilities include: staffing, staff continuing education and efficient patient flow. Moreover, the laboratory’s chief technician, Keith Clark, is responsible for procurement of all necessary diagnostic and therapeutic tools and equipment needed in the laboratory.

Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained?
Yes, the EP laboratory has been independent of the catheterization laboratory since 1994. Some of the cath lab nurses are cross-trained to assist in the EP laboratory, and play a vital role given our expanding patient volume. On the other hand, our lab staff works exclusively in the EP lab.

Do you have cross-training inside the EP lab? What are the regulations in your state?
Yes, we provide cross-training for cath lab nurses who have demonstrated certain aptitude for EP lab procedures. We are not aware of any specific state regulations pertaining to this issue.

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?
In addition to recent upgrading of our Prucka system (GE Medical Systems, Milwaukee, Wisconsin), our laboratory is equipped with a variety of diagnostic mapping tools including CARTO (Biosense Webster, Diamond Bar, California), QMS (Boston Scientific, Natick, Massachusetts), and the latest EPT RF generator XP (for large-tip ablation catheters) (Boston Scientific). We are also in the process of purchasing equipment to perform laser-guided lead extractions.

Photo 2

Dr. Pires supervising a cardiology fellow during ICD implantation.

Is your EP lab filmless, or does it plan to become filmless in the foreseeable future?
Yes, we rely on digital imaging technology.

Who handles your procedure scheduling? Do you use a particular software? How do you handle physician timeliness?
Procedure scheduling is handled by our tireless secretary, Debra Steffen. We use a hospital-wide computer scheduling software (Omniserve, McKessonHBOC, Minneapolis, Minnesota). Given our ever-expanding volume and the use of a single lab, we make every effort to be as efficient as possible. We allocate "block times" on specific days based on physician group affiliations; this approach facilitates our being to able to perform a large number of procedures in a single lab.

How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies?
Our inventory and equipment purchasing is handled by the laboratory's chief technician, Keith Clark. Mr. Clark relies heavily on a cost-effective approach, including the use of "bulk buys" to further reduce cost.

Has your EP lab recently expanded in size and patient volume, or will it be in the near future?
We are in the process of building a second dedicated EP laboratory. Our patient volume has been increasing, on average, by 15 to20 percent per year.

Has managed care affected your EP lab and the care it provides patients?
Yes, to some extent. We encounter occasional patients who are not permitted to have their procedures done at our facility for insurance purposes, although we make every effort to accommodate as many of these patients as possible.

What measures has your EP lab implemented in order to cut or contain costs and improve efficiencies in patient through-put?
We have initiated an inventory program that ensures cost-effective purchasing. Specifically, we rely heavily on the use of "bulk buys" with vendors, particularly with respect to pacemaker and ICD procurement.

Does your EP lab compete for patients? Has your institution formed an alliance with others in the area?
Yes, absolutely. Our lab is one of several laboratories in the southeastern Michigan region, but our referral pool encompasses a far greater portion of the state. Our staff electrophysiologists also work and perform procedures at several other local hospitals.

Photo 3

Kelly Humphrey, RN, interrogating a patient’s ICD.

Does your lab have an outpatient program?
Although the hospital does not have a specific outpatient EP program, each of the physicians group works diligently to insure state-of-the-art patient follow-up (e.g., ICD support group) and access to pertinent information (e.g. website). Moreover, we make great effort to increase and maintain referring physicians’ awareness about the latest treatment options available in the area of arrhythmia management. We find this useful since about half of our procedures are elective outpatient cases.

How are new employees oriented and trained at your facility?
All new employees undergo an intense, three-month long training under the direction of the lab’s charge nurse, in addition to close monitoring for up to 12 months.

What type of continuing education opportunities are provided to staff members?
Each year, at least one or more of our nurses and technicians attend NASPE, as well as other educational (e.g., industry-sponsored) events. Also, time permitting, our staff are encouraged to attend in-hospital EP/ECG conferences for cardiology fellows and medical house staff.

How is staff competency evaluated?
Staff competency is assessed semi-annually by the lab manager, with occasional input from the EP Lab Director, Dr. Pires, and the other attending electrophysiologists.

Does your lab utilize any alternative therapies?
Not specifically, although our physicians try very hard to keep up with new and innovative approaches to diagnose and treat our patients with a variety of cardiac arrhythmias.

Photo 4

Dr. Pires reviewing a case with a fellow, Dr. Matthew Sevensma, and Keith Clark, Lab Technician.

Have you had any interesting or bizarre cases come through your EP lab?
Yes we have. I think it is due largely to our fairly high volume of patients and a myriad of procedures performed in our laboratory.

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?
Kelly Humphrey, the lab’s charge nurse, handles the call schedule. Each day there are two staff members on call to cover late cases past 17:30 hours (but rarely past 20:00 hours), plus half a day on Saturdays (for very rare cases). Yes, the staff is expected to maintain a full working schedule the day after call — and often do so gracefully.

What type of quality control/quality assurance measures are practiced in your EP lab?
We regularly evaluate the functioning of our equipment and closely monitor complications in our laboratory. Furthermore, to assure an efficient flow of cases in/out of the laboratory, we pay close attention to procedure lengths and turnover between cases.

What trends do you see emerging in the practice of invasive cardiology?
We have experienced considerable growth in our program, especially in the past two years, and suspect that we will see further increase in the number of procedures in our laboratory.

Does your lab undergo any sort of inspection? How often does this occur?
Our laboratory undergoes inspection by the JCAHO every other year, and to date we have not had any major issues. In addition, we rigorously test and maintain proper functioning of our equipment in the laboratory.

Photo 5

Katrina Johnson, RN, Research Coordinator.

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. In addition to their duties in the laboratory, our staff plays an important role in patient/family education both pre- and post-procedure. This is done in conjunction with each electrophysiologist’s private Advanced Practice Nurse.

Is there a problem or challenge your lab has faced? How it was addressed?
Yes. Our major problem has been the constraint of having to accommodate a relatively large and increasing volume of procedures in a single laboratory. We are hoping to solve the problem with the construction of our second EP laboratory.

Is your lab currently involved in any clinical trials or special projects?
Yes, we are currently involved in several clinical trials, ranging from cardiac resynchronization therapy (e.g., RHYTHM-ICD, PAVE, COMPANION), innovative ICD follow-up (Home monitoring technology, Vitality DS), and lead analysis (Glideline XR). Additionally, we are each involved with several institution-based investigations in various areas of clinical electrophysiology.

Please tell our readers what you consider unique or innovate about your EP lab and its staff.
We have a collegial and collaborative working environment, and each of us strives for an uncompromising goal: good care of our patients and efficient delivery of services for our referring physicians. Despite a busy clinical service in a private-practice setting, each of our physicians remains committed to research and teaching (including cardiology fellows from within our institution and other local programs). Dr. Pires has published several peer-reviewed articles in the past few years, and Dr. Hesselson recently authored a well-received book: Simplified Interpretation of Pacemaker ECGs.

Is there anything else you would like to add?
Our team-oriented approach allows us to do a lot (increasing procedure volume) with limited resources (a single EP laboratory).

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