Oregon Heart & Vascular Institute at Sacred Heart Medical Center is known as one of the premier providers of cardiovascular care in the Northwest. The institute was established in 2004 to better integrate care of both the heart and circulatory system and enhance the coordination of patient care. The Institute is composed of cardiologists, cardiac surgeons, interventional radiologists and vascular surgeons partnering with research teams at the University of Oregon. The Oregon Heart & Vascular Institute is dedicated to providing exceptional care for patients with cardiovascular disease with an emphasis on prevention and community education.

Figure 1.

Jade McAllister, Mitch Costin, Karen Lefkowith, Jim Lewis, Dr. James McClelland, Bryan Burke, Dr. Ramu Reddy, Jim Saylor.

Sacred Heart Medical Center, located 110 miles south of Portland, in Eugene, Oregon, is the largest hospital between Portland and San Francisco (432 beds), serving as a regional referral center and the only level II trauma center in the region.

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 EP suite equipped with a Siemens biplane system. We also have two cardiac and two peripheral vascular suites in the cath lab. We have a 23-bed prep/recovery unit that supports EP and the other cath labs. All of the rooms are private and optimal for providing pre-procedure education for patients and their families.
       The EP lab is staffed by 4 FTEs. Credentials include RT, RCIS and RN. The RT and RCIS are dedicated to EP; both the RT and RCIS scrub and monitor cases. The RNs circulate and rotate between EP and the cardiac and peripheral labs.

When was the EP lab started at your institution?
       Dr. Michael Antimisiaris founded the EP lab in 1995. In the beginning, EP procedures were performed in one of the coronary rooms. In 1997 we opened a dedicated EP lab. For many years, we were the only biplane EP lab in the state.

Figure 2.

Jim Lewis, Mitch Costin and Bryan Burke.

What types of procedures are performed at your facility?
       We perform a comprehensive array of diagnostic and therapeutic procedures. We ablate for SVT, WPW, VT and atrial flutter. Implants include pacemakers/ICDs, loop recorders and biventricular devices.

What is the primary goal of your program (AF ablations, lead extractions, BiVs, etc.)?
       Our goal is to provide safe and effective rhythm management for our community. An integrated team of physicians, nurses and allied health professionals work to provide a complete range of care from diagnosis to intervention to maintenance. Because we provide service to such a wide area in Oregon, we maintain ongoing training to stay abreast of the latest technology.

Approximately how many are performed each week? What complications do you find during these procedures?
       We perform approximately 14 cases per week. Our complication rate is 0.25%. On occasion we come across pocket infections. The infection control committee, which includes EP staff, reviews each case and performs a root-cause analysis. Two years ago, as a result of a root-cause analysis, we changed our prep; we no longer use betadine or razors, and patients take a pre-op shower.

Figure 3.

Dr. McClelland, Dr. Reddy, Dr. Padgett, Bryan Burke, Jim Lewis and Mitch Costin consult.

Who manages your EP lab?
       Dr. James McClelland, Director of Heart Rhythm Services at the Oregon Heart & Vascular Institute, provides medical leadership for the EP lab. Jade McAllister, Cath Lab Supervisor, manages the daily operations and Chris Berry, Director of Cardiovascular Services, has administrative responsibility.

Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained?
       Our EP lab is integrated with the cath lab as it relates to scheduling, supply management, billing and supervision. Although a core group of staff is dedicated primarily to EP, they are also cross-trained in cardiac and peripheral vascular procedures.

Do you have cross training inside the EP lab? What are the regulations in your state?
       Our technical staff rotates between scrubbing and monitoring. Our institution does not support anyone other than an RN administering medications from a risk management perspective.
In general, all members of the EP team are expected to be competent in the use of all the equipment in the lab.
       The state of Oregon requires that a RT be present when fluoroscopy is used.

Figure 4.

Bryan Burke inserting venous sheaths using ultrasound guidance.

What new equipment, devices and/or products have been introduced at your lab lately?
       Cryoablation was introduced last fall. Our primary use for cryoablation is accessory pathways or atrial arrhythmias originating very close to the AV node.
       We have been using ultrasound visualization of the vessels for the greatest number of our procedures. Ultrasound has been beneficial for venous access in the femoral region and axillary vein for device implantation. Although we have been doing this for more than two years now, this is the biggest recent advance in our laboratory. It is a remarkable revelation to be able to see the vessels clearly as you introduce local anesthesia, or the needle and guidewire. This has reduced vascular complications.

How has this changed the way you perform those procedures?
       With the cryoablation catheter we have found indications for use at sites of catheter instability (e.g., the lateral tricuspid annulus). The catheter functions by affixing to the endocardial surface. Once the temperature reaches -30 degrees, the catheter stability is dependable. Cryo is also useful at sites where the impedance is high, such as the middle cardiac vein and coronary sinus. Just today we successfully ablated a right posteroseptal accessory pathway in the MCV and CS; impedance measured 150 to 160 ohms there (Figure 7).

Figure 5.

James McClelland, MD.

Who handles your procedure scheduling? Do you use particular software?
       We have one scheduler that supports the entire cath lab. She coordinates scheduling between the physicians, their offices and the prep/recovery unit.
       We currently use ESI for scheduling. We are expecting to transition to Picis later this year.

What type of quality control/quality assurance measures are practiced in your EP lab?
       One of our RNs functions in the role of Quality Assurance Coordinator for the EP and cath labs. He reviews case documentation, critiques, and communicates findings with our staff and the hospital quality team. We perform monthly audits of the national patient safety goals.
       The Oregon Heart & Vascular Institute has a quality council comprised of physician representatives from each of the four disciplines, representatives from other departments in the cardiovascular service line, the Center for Healthcare Improvement and administrative staff. The council monitors adherence to standards and practices, reviews outlier cases and makes recommendations for improvement.
Environment of Care Rounds are conducted on a quarterly basis by an interdisciplinary team that simulates a JCAHO survey.

How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies?
       EP staff works with our Materials Specialist to order supplies and manage inventory. We work closely with our physicians and the Materials Director to negotiate optimal contract pricing.

Figure 6.

Linear epicardial bipolar RF lesion on the left pulmonary antrum.  The left superior and left inferior pulmonary veins are seen passing through the pericardium toward the right.

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 new hospital, which is scheduled to open in the summer of 2008. Sacred Medical Center at RiverBend will be among the finest facilities in the country. Our new EP lab will be larger than our current lab, and will be equipped with a state-of-the-art GE biplane system.
Our volume has remained fairly constant during the last year, although our case mix has changed. We are doing longer and more complex cases, with the exception of catheter ablation for atrial fibrillation, which we stopped doing in 2004. The biggest change that we have seen is the increase in the use of BiVs and ICDs and pacemakers in heart failure patients.

Have you developed a referral base?
       We have always had good relations with physicians in our area; we have not done a great deal, over and above what we consider to be good patient care, to develop this referral base. Our referral area ranges from the coast, which is the Florence and Coos Bay regions, south to Roseburg, the Eugene/Springfield area, and somewhat north toward Corvallis, Albany and Lebanon.

What measures has your EP lab implemented in order to cut or contain costs? In addition, in what ways have you improved efficiencies in patient through-put?
       We continue to work closely with our vendors on pricing. Last year we entered into a capitation agreement for rhythm management products, which has resulted in substantial savings. A third-party vendor reprocesses some of our diagnostic catheters, and we re-sterilize all of our catheter cables in house.

Does your EP lab compete for patients? Has your institution formed an alliance with others in the area?
       Competition has not been an issue for us. The closest EP labs are 60 miles north and 170 miles south. Therefore, we have more of a collaborative than competitive working relationship with other EP labs in Oregon.

Figure 7.

A posteroseptal accessory pathway potential recorded in the middle cardiac vein; it is seen on both the ablation electrodes (ABL ds) and the unipolar electrodes (UNI ds). It was successfully ablated using cryoablation.

What procedures do you perform on an outpatient basis?
       We do pacemakers, ablations, ICD replacements, loop recorder implants and tilt table studies on outpatients.

How are new employees oriented and trained at your facility?
       The EP training is intense, as one is required to know how to start rhythms, identify rhythms, entrain rhythms, pace terminate rhythms, and locate areas to ablate. After a tech has completed the check-off sheet and passed the exam, they can start vascular access and catheter manipulation training. This training has emphasis on venous anatomy and cardiac anatomy. We have a training manual and final exam. The first 25 accesses are with doctor’s proctor. After that, the doctor needs to be in the room, but does not have to be scrubbed in. Our techs take great pride in this program, as we are one of the only programs in the Northwest to have techs do vascular access and catheter manipulation. It increases our ownership in the case and awareness of patient needs.

What types of continuing education opportunities are provided to staff members?
       EP staff attends the national HRS meeting and the Northwest EP Society meeting to keep up with the latest trends and techniques in the field. They also attend vendor-sponsored training/lectures. In addition, once a year the EP lab is closed, so that all of the staff can participate in a didactic day with the physicians.

How is staff competency evaluated?
       Staff competency is formally evaluated on an annual basis by the supervisor with input from physicians. Core skills are assessed annually. Because the EP staff work more autonomously in our lab, physicians expect the staff to demonstrate a high degree of competency on a daily basis.

How do you prevent staff burnout?
       We are constantly encouraged by our physicians to take our knowledge base to the next level. They take time to teach and explain aspects of cases. This atmosphere of learning has a positive impact on our daily routine. We have professional growth opportunities (i.e., venous sheath insertion, catheter manipulation, and pacemaker/ICD pocket closures) that keeps our interest at a high level.

What committees, if any, are staff members asked to serve on in your lab?
       Because of the size of our lab, most of our staff are involved in procedures and are not available to participate on committees on a regular basis. They do participate on the infection control committee and quality control committee on an ad-hoc basis.

How do you handle vendor visits to your department? Do you contract with vendors?
       Several years ago the hospital established vendor guidelines, which all vendors must agree to prior to gaining access to the facility. Vendors are required to check in with Materials Management when entering the facility and obtain a vendor identification pass. Vendor appointments are scheduled directly with the supervisor. Each company gets one day a month in the facility. Vendors must consult management about pricing and financial arrangements prior to engaging physicians in new product evaluations.

Does your lab utilize any alternative therapies?
       No, but our patients do.

Please describe one of the more interesting or bizarre cases that have come through your EP lab.
       We had a 39-year-old brittle Type 1 diabetic who was originally referred for a prophylactic ICD due to a non-ischemic cardiomyopathy and an EF of 30%. He described always having a fast resting heart rate that never really bothered him; on Holter, he had asymptomatic sinus tachycardia from about 100–140 bpm throughout the day. He was not considered a candidate for beta blocker due to poor sugar control.
Prior to considering a prophylactic ICD, we decided to attempt a sinus node modification as an alternative to beta blockers. Using the ESI array for mapping and a 6 mm cryoablation catheter, activation during resting sinus tachycardia was mapped and ablated. After eight cryolesions, his rate was 75 bpm with right atrial activation originating from lower in the sinus node region. A Holter monitor used one month later showed sinus/low right atrial rhythm with normal circadian variation and rates from 70–100 bpm. An echo performed two months later showed improvement of his EF to 50%. He did not get a prophylactic defibrillator.

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? Is there a particular mix of credentials needed for each call team?
       EP participates in the normal call rotation for the cath lab. Our call crew consists of three techs and one RN, and they cover all three modalities in the lab (EP, cardiac, and peripheral vascular cases). Each member of the staff takes call one night a week and one weekend a month.
       The call team consist of 1 RN, 2 RTs, and 1 CVT or RCIS.

Does your lab use a third party for reprocessing?
       Yes. Some of our diagnostic catheters are sent out for reprocessing, with mixed results.

Approximately what percentage of your ablation procedures are done with cryo? What percentage is done with radiofrequency?
       Fewer than 5% are done with cryo. Nearly all ablations are done using radiofrequency energy.

Do you perform only adult EP procedures or do you also do pediatric cases? Is there cross training for pediatric cases?
       Most of our patients are adults. We do occasionally perform procedures on adolescence and young adults. Our pediatric population (usually less than 13 years of age) is referred to the Oregon Health and Sciences University in Portland, which specializes in pediatric cardiology.

Do your nurses/techs participate in the follow-up of pacemakers and ICDs? If so, how many device visits per week do they handle? Do you use any particular software for follow-up? How many of your ICD/pacemaker patients require a doctor for their visits?
       No. Our follow-up is done in the Device Clinic, which is office-based rather than hospital-based. We use the Paceart software for all device checks. Our ICD and pacemaker patients are scheduled for an annual visit with their cardiologist or electrophysiologist. Other visits, such as device checks, are addressed in the Device Clinic. The clinic employs several full-time staff to facilitate our patients’ needs.

What trends do you see emerging in the practice of electrophysiology? How is your lab preparing for these future changes?
       A great deal of emphasis surrounds the management of atrial fibrillation, in particular, curative procedures for atrial fibrillation. These are growing rapidly; we are no longer performing catheter ablations of atrial fibrillation, having stopped about two years ago when reports of deaths following left atrial esophageal fistula were published from other institutions. We originally intended to have about a six-month moratorium, to see if this was going to be an important issue, and by the HRS meeting the next spring (just under a year later), there appeared to be about 25 fatalities. During that time, we became very interested in the minimally invasive procedure developed by Dr. Randall K. Wolf at the University of Cincinnati, using the AtriCure bipolar epicardial clamp, and we have switched over to this completely. Our patients have done a little bit better than they did with the catheter ablation, in my opinion. The downsides are more discomfort and a longer hospital stay (averaging about four days), but I think there are several advantages as well. These include that very clean linear lesions can be made with this clamp (Figure 6), that conduction block can be clearly demonstrated by epicardial recordings, that no equipment (which could be a nidus for stroke) is inside the heart, that the left atrial appendage can be removed, that the Ligament of Marshall is routinely ablated, that there is no fluoroscopic exposure, and, perhaps most importantly, that the autonomic ganglia can be carefully mapped and ablated. The latter is much more easily done in the operating room than in the EP lab, where we were doing it before. (Those interested in viewing a video of this procedure can find it on the minimaze website at “www.minimaze.org”.) There it was very time-consuming and not quite as accurate. Perhaps our focus on this procedure skews our perception a little bit, but it does seem as though there are more and more electrophysiologists who have wondered if the success rate of catheter ablation might be somewhat overstated and the complication rate understated; for this reason, there does seem to be an increase in interest in minimally invasive surgical approaches. That seems to be a trend to us.

What are your thoughts about non-EPs implanting ICDs? Do you train such individuals?
       This is of course a very controversial issue. We did train one such individual, a very skilled implanter in a neighboring town, for where there is no electrophysiologist available, and he has done well. One of our general cardiologists here also implants BiVs pacemakers, but not ICDs. Generally speaking, I think it is reasonable for non-EPs to implant ICDs, if certain conditions are met, primarily with respect to training, and perhaps more importantly, follow up. My suspicion is that most of the problems associated with non-EPs implanting ICDs are related to appropriate patient selection and follow up, rather than technical aspects of the implantations themselves.

What about device recalls? How has your lab handled these?
       We have been conservative in our management of these; generally speaking, if the mode of failure of the device is thought to be loss of pacing output, in patients who are pacemaker-dependent, we have replaced these devices. In patients who are not pacemaker-dependent, we generally just follow up with them a little bit more closely. For ICDs, if the mode of failure is lack of shock output, we have replaced these if patients have required frequent shocks; however, if that was not the case, we have sometimes simply monitored these patients more closely. Basically, we have taken an individualized approach and tried to balance the risks of device replacement (in particular, infection), with the risks of leaving the old device implanted.

Is your lab doing web-based/transtelephonic device follow-up?
       None of our follow-up happens through the lab, but yes, we have been doing web-based follow-up with Medtronic's CareLink. We also implant devices from all of the other manufacturers, but have yet to start using their web-based systems.

Is your EP lab currently involved in any clinical research studies or special projects? Which ones?
       At this past Heart Rhythm Society meeting, two abstracts were accepted from our lab. One of our techs, Mitch Costin, submitted an abstract regarding reprocessing of EP lab catheters. He presented it as a poster at the 2006 Heart Rhythm Society meeting. It was an ingenious study; he prospectively evaluated these catheters by marking them with a letter, A through Z, on the connector, using a Dremel Moto-Tool. They were used and then sent back for reprocessing; when they returned, they were marked with a hash mark, and once again, were used in the normal fashion. They were evaluated for usability, how long they took to return, and, of course, if they were returned at all. Deflectable catheters did not fare well in this study, but non-deflectable catheters fared better than we expected, and many of them returned for the full five uses.
       Dr. James McClelland presented an abstract regarding minimally invasive surgery for atrial fibrillation. We are currently involved in two research protocols regarding the minimally invasive surgical procedure for atrial fibrillation, as well as a trial comparing dabigatran versus Coumadin for high-risk atrial fibrillation patients; these are run through our separate research entity, Endovascular Research. The other special projects that we have been involved in include a training program for nurses and techs to close pacemaker and defibrillator pockets, and for femoral venous sheath insertion and catheter manipulation during ablation procedures.

When was your last JCAHO inspection?
       We had our first unannounced JCAHO survey early this year, with no citations. Our hospital has instituted a continuous readiness plan, which includes quarterly Environment of Care Rounds and monthly audits of the national patient safety goals.

Are you ACGME-approved for EP training?
       No.

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, we do. Our nurse coordinators/educators provide pre-procedure teaching upon admission. We are re-instituting the defibrillator support group for patients with implants. The support group meeting consists of a physician lecture, and provides the opportunity for patients to ask questions. Patients appreciate the opportunity to meet and socialize with other patients.

Describe your city or general regional area. How does it differ from the rest of the U.S.?
       Eugene is nestled between the Cascade Mountains and the beautiful Oregon Coast, along the banks of the Willamette River. The natural beauty of the Willamette Valley, with its mountains, lush forests, rivers and lakes, makes Eugene and the surrounding area ideal for outdoor recreational enthusiasts. Eugene boasts a perfect blend of small-town charm and cultural opportunities usually found in larger cities.
       Eugene is the second largest city in Oregon, with a population of 146,000, and is home to the University of Oregon and the Oregon Ducks. It is known as “track town USA.”

Please tell our readers what you consider unique or innovative about your EP lab and staff.
       About three years ago, we instituted a program to train EP lab staff to close pockets; currently about 15 of them are trained, and they now close the vast majority of the pockets during device implantations here. The track record has been very good.
       More than two years ago, we instituted a program to train the EP lab staff to insert venous sheaths during catheter ablation procedures, and to advance catheters to the heart and manipulate them during the procedures. There was some resistance from the hospital initially, but eventually after they were shown the data suggesting that this is done at many of the better institutions around the country, and following unified support from the cardiologists and cardiothoracic surgeons, a protocol was approved. Two of our EP lab staff were fully trained (1 has since gone to industry), and we are beginning to train the third now. This has been very exciting for everyone involved; the EP lab staff love to work as high a level as possible during the cases; indeed, during some of our cases (such as AV junction ablations), the EP lab staff have directed the entire case, including mapping for appropriate electrograms and delivery of RF. Vascular ultrasound is used for all sheath insertions, and, in part for that reason, and because of the concentration of expertise in just a few staff members, the vascular complication rate is exceedingly low. I think it has also added to the “team spirit.” I am routinely told “you have a great team up there,” which I think is due at least in part to the very high level at which they work, which translates to being very highly engaged during the procedures. Of course, having someone else manipulate the catheters allows the electrophysiologists to concentrate exclusively on the electrograms as well, which I think is important for the patient and the success of the procedure itself.

For more information about the Oregon Heart & Vascular Institute, please visit their website:
www.ohvi.org