In the February 2006 edition of EP Lab Digest, we featured an article that outlined Lancaster General Hospital’s new EP Internship program. In this month’s issue, author Andrea Hostetter, BS, RN shows you how your EP lab can grow and improve by focusing on five main categories. This a summary article from a presentation to the Alliance for Cardiovascular Professionals (ACVP) in Atlanta, Georgia on March 10, 2006. The ACVP is an organization that aims to meet the needs of all cardiovascular and pulmonary providers, declare standards, and promote recognition of the cardiovascular profession.

Background
       Lancaster General Hospital (LGH) in Lancaster, Pennsylvania, is a busy 588-bed community hospital located in south-central Pennsylvania. LGH is a non-profit, Level II trauma center. The cardiology program at LGH is extremely robust with a very assertive team of cardiologists, electrophysiologists and staff. This program did well in spite of minimal organization and structure.
       LGH is experiencing unprecedented growth and is strategically planning for the future of health care in this county. Current plans address the issues not only from the bricks and mortar perspective, but also focus on reviewing and revising the process of care and patient flow to improve efficiency and through-put. The census on any given day can be 104%, meaning we have reached maximum bed capacity and surpassed our ability to place patients (both direct and EMD admissions) into inpatient beds.
       Following the resignation of the EP department manager in 2003, I agreed to take over as the Director of the EP Department on a temporary basis. I came to the position with 13 years of experience as the critical care nursing director, and based on my nursing experience, it was clear that monitoring and outcomes needed to be identified and tracked, and expenses brought under control. At the time, it seemed like an impossible task. Now, three years later, we have established a family of believers that EP can attain lofty goals.
       Internally, the hospital uses a standardized system for goal setting and prioritizing initiatives — the Pursuit of Excellence. Every idea, initiative, or suggestion is placed into one of the following five categories for evaluation purposes: People, Growth, Finance, Quality, and Service. The purpose of this article is to show how the EP department at LGH has used this system to grow and improve.

Table 1. Outcome monitoring.

- Outcome Monitor: 2003: Case cancellation: 38% Anesthesia utilization: 50% Sedation variances: 17% Device infection rate: 3% Outpatient queue 8–12 weeks 2006: Case cancellation: 2% Anesthesia utilization: 27% Sedation variances: 0% (5 months in a row) Device infection rate: 0.05% Outpatient queue: 2 weeks (up to 4 weeks for PVI)

People
       Finding the right people for the job was the first task at hand. In January 2003, it was clear that there were not enough hands-on workers with a solid foundation of EP knowledge and experience to get the job done. Even the management structure was thin. There was a working EP supervisor reporting to the Manager of the cath lab, thirteen EP tech FTEs, four sedation RN FTEs, and one support person to help stock rooms and turn over patients. There was one senior level tech (as denoted by status on the clinical ladder), but no senior RNs. There were no minimum hiring criteria in place, and staff turnover and vacancy were 38% and 25%, respectively. It appeared that the ability to move the team ahead and give them what they needed was little more than a pipe dream. While we were working internally to educate staff and achieve a common body of knowledge, I was also looking outside for just the right individuals.
       At the time, all of our staff education and training was “on-the-job training.” Agency staffing was rarely utilized, but in order to support the current staff and get them up to speed, we needed additional people just so we could get the cases done. I worked with a local agency that had several EP techs on staff who had previously worked at LGH. Over the next two years, the department of EP expensed in excess of $250,000 in agency costs to get the staff to the required level of functioning for our lab. At the same time, a new educator, an RN, was brought on board to develop continuing education strategies, and the internship program educator was hired to develop a training module for new employees. In addition, a paid EP medical director position was established, with specific and measurable performance outcome criteria for the physician. Dr. Douglas Gohn, with the Heart Group, is the director in this position.

Figure 1.

EP Lab Organizational Structure in 2003.

       We also implemented four core strategies: 1) formal, standardized interviewing/hiring processes; 2) minimum educational/experience employment standards; 3) a management/resource structure that was capable of supporting what needed to be done; and 4) decentralization of the decision-making process to a “core group” of staff members (the precursor to the development of a professional practice model for the EP lab). As a result, the turnover rate has decreased to about 3% for 2006 and no real staff vacancies exist.
       Interviewing viable candidates took on a whole new dimension as we embarked on a major marketing and recruitment campaign. We placed ads in local and regional newspapers as well as other well-known and respected venues such as EP Lab Digest to recruit qualified and motivated individuals. Interviewing candidates is now a process. Viable candidates are screened by the cardiology recruiter, followed by a phone interview with the Director. The next step, which is mandatory regardless of previous education or experience, is a day of shadowing in the lab. This step is frequently the make-or-break point in the process; we have a very busy, very fast-paced lab, and our techs frequently function as Fellows. Shadowing gives the candidate a taste of what the job entails, and also gives our staff a chance to interact with and evaluate the candidate. If the candidate is still interested after the shadowing experience, and if the EP staff is in agreement, there is a final formal interview with the EP medical director and the core group. It has proven to be a good process, resulting in good employees who fit into our lab environment.

Figure 2.

Figure 2. EP Lab Organizational Structure in 2006.

Growth
       In 2003, EP cases were performed in two cath labs that were 8–10 years old. There was one biplane room and one single-plane room. Two other procedure rooms with portable C-arms were the primary rooms for pacemaker/ICD implants. The largest functioning room was approximately 450 square feet. The renovation/ replacement plan was developed with major staff and physician input. To date, two new GE biplane rooms, both > 900 square feet, are operational, and a new flat-panel, single-plane GE room will be operation by July 1, 2006. A fourth room renovation has been budgeted in for fiscal year 2007.
       In addition to the changes in the physical plant, two new service line initiatives are included in the long-term development plan. The first initiative is the atrial fibrillation collaborative. This initiative is being developed in collaboration with the cardiothoracic surgeons in order to develop a treatment algorithm (medical, ablative, or surgical) that can be used to direct care for patients with atrial fibrillation. The second initiative is the Bi-V (biventricular) program for patients and physicians outside of the normal LGH catchment area. The hospital is working with a major device vendor to bring physicians to Lancaster for left ventricular lead placement training so that patients in other areas of the country can receive this life-changing technology. Dr. Seth Worley of The Heart Group has extensive experience in this area of practice and has developed/is developing catheters that expedite coronary sinus lead placement.

Finance
       In 2003, the EP case volume at LGH was 2,900 procedures, with about a 50/50 split between device and EP procedures. In total, $39 million was made in generated revenue. The hospital had signed a three-year contract with a major vendor for very aggressive pricing. In return, LGH agreed to implant the said vendor’s devices in 80% of our patients. Although a device contract was in place, compliance was not monitored or enforced. As a result, physicians implanted a multitude of devices manufactured by a multitude of vendors, which proved to be very costly for the hospital.
       In 2005, case volume had increased by 8% to 3,200 procedures, and revenue had increased by 87%, to $73 million. With the renegotiation of the contract looming, all implanting physicians were invited to be a part of the process to determine the best practice for LGH (contract vs. no contract, current vendor vs. a different vendor). After several meetings, presentations by three major vendors, and much discussion, the physicians unanimously agreed to continue with the current contract. Monthly utilization by physician is documented and reported to individual implanters and the Medical Director. Compliance with the device contract, which is heavily weighted to high-end devices, had also dramatically improved, to greater than 90%.

Quality and Service
       Outcomes and benchmarking are not easily attainable for EP, other than what EP labs internally monitor. LGH began to monitor and track outcomes that we felt were important early on in the process. One of the first concrete changes was the implementation of a new orientation process for EP technologists. New employees now go through an EP Internship with two parts: 22 weeks of didactic education and clinical training, followed by up to six months spent completing a group of required core clinical competencies. To date, the internship has “graduated” six highly functioning EP techs, and another will complete the program this month. Experienced technologists are encouraged to participate in the EP Tech Clinical Ladder, which encourages and rewards self-improvement and a high level of practice.
       Seven sedation nurses currently provide moderate sedation for approximately 70–75% of all cases performed in the lab. Previously, orientation and training were driven by the demands of the schedule. Currently, all sedation RNs complete an intensive 90-day orientation that includes time spent with CRNAs in the operating room. The RNs also worked with the anesthesia department to design a sedation screening tool for all EP patients; the tool is used to determine whether a patient is appropriate for moderate sedation or requires anesthesia care.
       Our efforts have paid off, with great improvement in all monitored outcomes (Table 1).
       Another huge barrier for our lab was getting cases started on time (on the table by 07:30). There were so many variables that could affect start time, especially for outpatients. In an attempt to fine tune outpatient through-put, the Pre-EP Clinic, managed and run by our sedation RNs, was implemented in January 2006. A typical clinic visit includes patient/family education, labs, completion of all required paperwork, surgical site markings, patient/family instructions, and evaluation for sedation. Taking care of these issues prior to the day of the procedure has resulted in fewer delays, more consistent 07:30 start times, and happier patients as well. Currently, only patients scheduled for complex cases (biventricular implants, PVIs, etc.) go through the Pre-EP Clinic, but we plan to gradually include all outpatients in the process in the coming months.

What’s Next?
       So, what does the future hold for EP? At LGH, we have several long-term goals/projects in development, including:
1. Establishing a nationally recognized credential for EP techs, similar to the RCIS already in place for CVTs. LGH is working with Cardiac Credentialing International and the Heart Rhythm Society to establish standards for credentialing and implement a testing process.
2. Encouraging all staff members to challenge at least one of the NASPExAMs for associated professionals.
3. Establishing LGH as a Bi-V referral center for both physicians and patients. Although LGH is currently a Center of Education for Medtronic, we are looking towards a more formal relationship, while establishing a seamless process for accessing our system — both for physicians coming here for training, and patients and their families coming for treatment.
4. Developing a collaborative atrial fibrillation program with the cardiothoracic surgeons to develop and refine a medical/surgical/EP treatment algorithm for patients with atrial fibrillation.
5. Developing a community AED program. This is a value-added program presented to us by our primary device vendor, which entails developing a process to distribute and maintain AEDs in the community we serve.
6. Developing standardized device implant criteria.

       EP is an expanding and challenging discipline, and at LGH, we are constantly working to improve both our processes and our outcomes. We have come a long way in the past three years, but there will always be new knowledge, new technology, and better ways to serve our patients and the community at large.