Spotlight Interview: McConnell Heart Hospital at Riverside Methodist Hospital

Dr. Steven Kalbfleisch (seated). From left to right: Dr. Emile Daoud, Dr. John Hummel, and Dr. Eugene Fu.
From left to right: Cristi McMullen, RN, Susan Stewart, RN, Paul Piontkowski, RN, Cheryl Culberson, RN, and Amy Wagoner, RN.
Group photo, left to right: Marilyn Hockman Administrative Assistant, Angela Derauoux, PCT, Jodi Sucharski, RN, Julie Lyons, RN, Meredith Mehlman, RN. Back row, left to right: Kay Boddie, RN, Clare El''Geroushi, RN, Renee Cain, RN, Gayle Nichol, RN, Harol
Back row, from left to right: Wendy Sullivan, RN, Steve Haghiri, RN, Cathy Thomas, RN, and Sarah Jacobs, RN. Front row: Jay Barnes, RN and Barb Price, RN.
Dr. Allan Nichols (left), and Dr. Aysha Arshad.
Dr. Raul Weiss at the x-ray control desk.
From left to right: Monte DeLisi, PCT, Dr. Ralph Augostini, Jamie Miller, PCt.

What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab?

Our electrophysiology department consists of five dedicated invasive labs and three non-invasive labs. We have a sixth lab, which remains shelled for development at a later date. We have a total of 37 registered nurses, four patient care technicians, two inventory specialists, and a unit secretary on staff. Our nurses come from areas including open-heart recovery, ICU/CCU, the emergency room, and cardiac step-down. Each of them brings a unique skill set. We also have a biomedical engineer on staff, who is responsible for the daily maintenance and troubleshooting of our equipment.

We moved into our new McConnell Heart Hospital at Riverside in July of 2004. We have two private practice physician groups with whom we work: there are a total of five full-time electrophysiologists from MidOhio Cardiology and Vascular Consultants, and three electrophysiologists from Arrhythmia and Cardiovascular Consultants.

When was the EP lab started at your institution?

The EP department was started in 1990 by Dr. Allan Nichols of Arrhythmia and Cardiovascular Consultants at Riverside Methodist Hospital. It consisted of one lab shared with the cardiac catheterization lab, with two nurses working together in the department. Dr. Steven Kalbfleisch was the first MidOhio Cardiology and Cardiovascular Consultants electrophysiologist to join the RMH team in July of 1993. Dr. Kalbfleisch brought with him transvenous defibrillation systems and the ability to perform cardiac ablation therapy. In his first year with Riverside Hospital, volume increased from 200 to over 800 cases annually. The department has since grown in size to five invasive labs, three non-invasive labs, and eight physicians. Lab space is shared between the two physician groups.

What types of procedures are performed at your facility? Approximately how many are performed each week? What complications do you find during these procedures?

On an average day, we perform between 35-40 cases. Annually, we perform over 9,000 procedures, of which 5,800 are invasive. Our non-invasive case mix includes tilt table testing, cardioversions, SAECGs, and ICD checks. On the invasive side, we do quite a number of different procedures. We perform basic EP studies, radiofrequency ablations, and ICD and pacemaker implants, including biventricular devices. We utilize the CARTO (Biosense Webster), LocaLisa, and ESI mapping systems for our more advanced mapping cases. We have several physicians who perform laser lead revisions and extractions using the Spectranetics laser system.

We have a special focus on atrial fibrillation ablations and the technology surrounding this developing area. Dr. Emile Daoud performed the first LASSO mapping catheter guided pulmonary vein isolation procedure in the United States in November of 2000. Our physicians frequently utilize the transseptal approach to both map and ablate left-sided tachycardias.

Our complications rate is well within the accepted national standards.

Who manages your EP lab?

Our department is managed by a department manager, Cathy Thomas, RN and an assistant nurse manager, Becky McHolm, RN, BSN. We also have two clinical leaders, Julie Gurney, RN, BSN and Jay Barnes, RN who manage our daily schedule. Heather Connelly, RN, BSN is our dedicated department clinical educator.

Dr. Steven Kalbfleisch is the Medical Director of the EP lab, and Dr. John Hummel is the current Chief of Cardiology for Riverside Methodist Hospital.

Is the EP lab separate from the cath lab? Are employees cross-trained?

Our EP lab is completely separate from the cath lab; however, we are located in close proximity to one another. In addition, our employees are not cross-trained to work in the cath lab.

Do you have cross training inside the EP lab? What are the regulations in your state?

All of our EP nurses are trained to assist in all procedures performed in our lab, both invasive and non-invasive. It is the goal during their three-month orientation to cover all procedures that can be performed in our lab. All of our staff nurses are expected to know how to operate all equipment and computer systems that can be used during procedures. Several of our nurses have become "superusers" for certain pieces of equipment. Four nurses have undergone specialty training from Biosense Webster on the CARTO 3-D mapping system which is utilized by our physicians in our lab for atrial fibrillation, VT, and atrial tachycardia ablations.

Our patient care technicians are trained to assist in our non-invasive labs, to transport patients, to perform signal average ECGs, and to help get our invasive labs prepared for cases on a daily basis.

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?

Riverside Methodist Hospital is one of the top 10 sites in the nation for research. At any given time, we can be involved in 15-20 active research protocols.

MidOhio Cardiology founded a private, not-for-profit research foundation called The MidWest Cardiology Research Foundation (MWCRF) in 1988. In 1993, the scope of MWCRF expanded to accept investigational trials in electrophysiology with the use of the first nonthoracotomy implantable defibrillator and radiofrequency catheter ablation for curative therapy of cardiac arrhythmias. The EP physician director for the foundation is Emile Daoud, MD. Through MWCRF, the electrophysiologists have coordinated independent clinical trials, which facilitate an understanding of how to best manage patient care issues that are first noted in clinical practice.

Riverside Methodist Hospital was the first center in the country to use a circular mapping catheter (LASSO) for curative therapy for atrial fibrillation. We were the second in the country to implant an epicardial biventricular pacemaker, and the first in Ohio and only one of three centers in the U.S. to use cryoablation for atrial fibrillation. Our physicians are continuously invited to review and modify protocols for national studies before they are sent to the FDA.

The relationship between the hospital, physicians and the research foundation is completely independent. No financial incentive is provided to the electrophysiologists for organizing research trials or for enrolling patients. Under this type of structure, the sole motivation for patient enrollment is to provide the most advanced technology to optimize patient care.

Trials currently being conducted in the EP lab are TRENDS, ICE CRT, and Fibrillar. We are also excited to be involved in the WATCHMAN trial for which Dr. Steven Kalbfleisch is the co-primary investigator at this site. This is a United States Phase I trial, with the first patient being enrolled at our facility. The WATCHMAN trial compares the use of an implantable device verses coumadin therapy. The device is designed to close the orifice of the left atrial appendage, where clots from atrial fibrillation are thought to originate.

Who handles your procedure scheduling? Do you use a particular software? How do you handle physician timeliness?

We utilize TEMPUS program software to schedule our patients for their procedures, and scheduling is handled one of two ways. Procedures can be scheduled by central scheduling or by the physicians offices themselves. Recently, we worked with our physician offices to develop physician web scheduling, which enables the office scheduler s direct access to TEMPUS software without having to go through central scheduling. This has improved the accuracy of our schedule.

On a daily basis, we have 3-4 electrophysiologists available for performing procedures; therefore, physician timeliness is not an issue. On average, we have three RNs scheduled in each invasive lab and two dedicated housekeepers, so our lab turnover time is kept to a minimum.

What types of quality assurance measures are practiced in your EP lab?

Our Arrhythmia Services Clinical outcomes manager, Mary Beth O Connor, RN, BSN, MSN tracks key metrics for our department. Her findings are analyzed and shared on a monthly basis to each of our eight physicians.

Monthly reporting of Quality Outcome Indicators include device infection within 90 days of implant, pneumothorax requiring chest tube, tamponade, respiratory compromise requiring intervention, bleeding, and in-lab mortality. Data is presented by case and in a control chart format that shows rolling 12-month data to the physicians, unit managers, and with the Quality Specialist for peer review. Aggregate data is shared with the EP lab staff and the Heart Services Line Continuous Process Improvement Council. Compared to the outcomes noted in the literature, Riverside EP lab outcomes are at or below benchmark.

Our data is utilized to identify opportunities for improvement and to develop action plans.

How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies?

We have an inventory manager who oversees both the cardiac catheterization lab and the EP inventory rooms. We also have an inventory supervisor and technician who handle our EP supplies. Our management team works closely with the inventory supervisor when purchasing EP supplies. All large equipment purchase decisions are made by the department managers with input from our medical director, Dr. Steven Kalbfleisch.

The People Soft computer program is used for inventory control and ordering. We also have a device closet in our department, where all implantable devices and leads are kept.

Has your EP lab recently expanded in size and patient volume, or will it be in the near future?

Recently, we moved from our Riverside Methodist home into our new McConnell Heart Hospital. In July of 2004, we opened our new area that is equipped with five state-of-the-art invasive labs. Each lab is equipped with flat-panel OMEGA x-ray system technology and advanced EP recording systems. Two of our invasive labs have biplane fluoroscopy. Our new area also has three non-invasive procedural labs where cardioversions, ICD checks, and tilt table tests are performed. We have a sixth invasive lab which is shelled for development in the near future.

Our EP lab staff has grown substantially over the past three years in response to our expanding volume and growing number of complex procedures where patient acuity is high. Last year, we performed a total of over 9,000 EP procedures.

How has managed care affected your EP lab and the care it provides patients?

Managed care directly affects our reimbursement and the bottom line, but it does not, nor will it ever, affect the care that we provide our patients. We treat each patient in the same manner without regard to their insurance carrier.

As an organization, we are very concerned with the increasing costs of leading-edge technology, and have worked diligently with our physicians, materials management, and our vendors to accomplish the best pricing options possible.

What measures has your EP lab implemented in order to cut or contain costs?

We created a rounding position four years ago in order to facilitate inpatient flow to the lab. We utilize a sticker and barcode scanning system, which is also incorporated into our nursing charting system to keep track of items used during cases. Our lab inventory is monitored closely, and this has enabled us to contain costs. We frequently negotiate with all of our vendors in order ensure competitive pricing on all equipment.

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