Spotlight Interview: McConnell Heart Hospital at Riverside Methodist Hospital
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.
We currently are participating in a Cardiology Process Excellence initiative. Our cardiology team is focusing on inpatient preparedness, outpatient readiness, and general schedule reliability. This project has been successful in significantly reducing outpatient wait time as well as patients length of stay.
How are new employees oriented and trained at your facility?
All new personnel at Riverside Methodist Hospital receive a general hospital orientation. The RNs in the EP lab receive 12 weeks of orientation with a dedicated preceptor. Orientation begins in the non-invasive labs performing cardioversions, tilt table tests, and ICD checks. The remaining 10 weeks of orientation takes place in the invasive labs performing EP studies, ablations, and device implants. At the end of orientation, RNs are independent in scrubbing with our physicians, circulating, and documenting all aspects of our studies. A pocket EP guide is provided for all new EP nurses with doctor equipment preferences, set up and general procedural information. The education committee is currently working on an education book for the floor nurses to help them better understand the field of electrophysiology and what we do. We believe that this will better enable nurses to educate their patients and answer basic questions.
What types of continuing education opportunities are provided to staff members?
We frequently have inservices by device company representatives about their new devices, pacing concepts and programmer use. We send two staff members to the Heart Rhythm Society conference each year, and 4-6 staff members to other national conferences to continue our education and interact with other EP professionals. We also have several nurses trained to independently run the Biosense Webster CARTO mapping system. The EP MED recording system is a new system recently added to our lab. We currently have three systems. All of our staff is trained to use the recording system with five RN super users.
This coming October 2005, our lab is planning our first annual EP Symposium for Allied Health Professionals. The sessions will be given by our own physicians and staff members.
How is staff competency evaluated in your lab?
In addition to the inservices and conference opportunities, there are also annual departmental competencies and yearly staff performance reviews. The RNs on staff are required to perform annual conscious sedation competencies in accordance with hospital policy. Recently, our hospital-based competencies have been put online through The Riverside Corporate University. The EP lab competencies are completed yearly and involve hands-on ACT training, fluoroscopy, and basic technology.
Please describe one of the more interesting or bizarre cases that have come through your EP lab.
One of our more interesting cases involved a patient with recurrent ventricular fibrillation. Dr. Emile Daoud performed the case. The patient had an ICD and had received greater than 40 shocks in 48 hours prior to transfer to Riverside Hospital. The patient had no response to antiarrhythmic drugs. It was noted on the telemetry that each episode of VF was initiated by a unifocal PVC. Therefore, the plan was catheter ablation. Because of hemodynamic instability, the patient was placed on Cardiopulmonary Support prior to EPS. With successful mapping and radiofrequency ablation of the LV PVC, the patient had no further VF or ICD shocks for greater than two years.
How does your lab handle call time for staff members?
Our lab is in operation Monday through Friday from 7:00 am to 7:30 pm. We are closed on holidays and weekends. On a given day, we have 18-19 RNs scheduled to work across five invasive labs and three non-invasive labs. Four RNs are designated to have late call each evening. Late call is defined as staying, at most, two hours past your scheduled time in order to complete cases that may run past 7:30 pm. We do not have overnight or weekend call, and our RNs are scheduled to stay late on days that they are scheduled to work.
Does your lab use a third party for reprocessing?
We do not use a third party for reprocessing.
Approximately what percentage of your ablation procedures are done with cryo? What percentage is done with radiofrequency?
Approximately 99.9% of our ablation procedures are performed using radio-frequency ablation. We do not have cryoablation available in our department other than with investigational protocols.
What trends do you see emerging in the practice of electrophysiology?
We are finding that the future trends are more and more geared towards atrial fibrillation therapy. The final technique to cure atrial fibrillation is not here yet, but there is a lot of current research going across the nation and abroad.
According to one of our physicians, Dr. Raul Weiss, there is an infusion of technology that depends less on the operator. The finest example of this is the use of Sstereotaxis, in which the operator is basically a guided robot. Another area on the forefront is a genetic assessment for patients who are at risk for sudden cardiac death. Although there are no publications as of yet, there are several ongoing studies of which we are participants.
The area of heart failure is another field of interest. The trend here is looking for the narrow complex QRS patients with dysynchrony. They are looking specifically at non-responders to biventricular pacing, and trying to manipulate both V-V timing and AV delays.
Does your lab provide any educational or support programs for patients?
Our education committee is currently working on patient education materials for atrial fibrillation cases. There are many educational pamphlets available for patients and their family members in our waiting rooms. We have teaching pamphlets on every procedure that we currently perform. The RNs and doctors also review cases with the patients and answer questions as needed. We have a unique display case of the history of implantable devices with sample devices in our family waiting room.
Describe your city or general regional area. How does it differ from the rest of the U.S.?
Riverside Methodist Hospital is located in Columbus, Ohio. Columbus is a city of over 1.7 million people and continues to show incidence of cardiovascular disease on the rise, contrary to national trends. The Columbus market is highly competitive, with three major health systems all focusing on heart care services.
Riverside s market includes a 47-county region in Ohio, approximately 3.6 million individuals, and enjoys a network of affiliated regional hospitals and heart programs throughout the region accounting for more than 40% of the patient volume for heart procedures.
Please tell our readers what you consider unique or innovative about your EP lab and its staff.
The Riverside EP lab is unique in the fact that our invasive labs are staffed by an all RN staff. We are also equipped with staff and lab space to enable us to do a very large volume of cases as well as several complex cases within one day.
In addition, we are unique in our ability to schedule our cases in a timely fashion which allows patients to have procedures done without the wait time.
Our customer service team was innovative in developing a call back system to all of our outpatients post procedure. This allows patients to have any questions answered and provides a more personable service experience. This call back program has helped us to keep our patient satisfaction at a very high level.
We also have a Tenderhearts program for all outpatient cardiac procedures. The Tenderheart coordinators facilitate outpatient flow by helping to educate patients and families about procedures, direct people to and from our waiting area and consultation rooms, and updating our families about patient progress during procedures.
Lastly, all of our staff and physicians come from a unique background, which contributes to our lab being one of the highest regarded EP labs in the country.