Spotlight Interview: The Cleveland Clinic

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Patrick Parete, RN, BSN, CNOR, RNFA; Kelly Melgun, RN, BSN; Cheryl Bell, RN, BSN; Lisa Keene, RN, ADN; Melissa Williams, RN, MSN; Barb Paulic, RN, MSN
Cleveland, Ohio

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

The Cleveland Clinic is composed of 7 EP labs and 1 cardioversion suite. A hybrid operating room is available within the Heart and Vascular Institute for complex procedures. In addition, we have 20 staff physicians, 10 EP fellows, 40 registered nurses (RNs), 1 clinical engineer/RN, 2 office specialists, 1 supply coordinator, and 1 patient care assistant. All technical support is provided by RNs. We do not employ CT or radiology technologists. Radiology technical support is available when needed.

When was the EP lab started at your institution?

The EP laboratory originated in 1980 with 2 electrophysiologists, 2 RNs, and 1 secretary. The procedures were performed in a single, dedicated EP lab or in the cardiothoracic operating room. The EP Section currently has more than 150 personnel comprised of physicians, fellows, clinical nurses, research nurses, secretaries, monitoring technicians, and others who assist in the care we provide.

What types of procedures are performed at your facility? Approximately how many are performed each week?

On average, we perform 100 procedures per week (over 5,700 cases in 2010). Procedures performed include: pacemakers, defibrillators, biventricular devices, device/lead extractions, loop recorders, and cardioversions. We also perform diagnostic EP procedures and ablations of atrial and ventricular arrhythmias using transvenous or percutaneous epicardial techniques. Procedure duration can range from 1 hour up to 12 hours for patients with exceptionally complex arrhythmias.

The Cleveland Clinic Syncope Center is located near the electrophysiology laboratories, but it is a separate facility staffed by other nurses and physicians. In aggregate, approximately 2,000 diagnostic studies are performed in the Syncope Center each year. These include tilt testing, blood volume studies, and other hemodynamic and neuroregulatory evaluations.

What is the primary goal of your program?

Our mission is to alleviate symptoms related to cardiac arrhythmias and heart failure, thereby reducing the risk of sudden cardiac death. Through world-class care and state-of-the-art technology, we help patients from all over the world who travel to Cleveland because of the expertise we offer. We also accept referrals from other hospitals whose patients have medical problems that are particularly complex or in whom a prior procedure was unsuccessful. This may include extraction of infected leads, or ablation of complex atrial or ventricular arrhythmias.

Who manages your EP lab?

Patrick Parete, BSN, RN, CNOR, RNFA, is the Nurse Manager of the EP Lab with assistance from Kelly Melgun, BSN, RN and Cheryl Bell, BSN, RN. Dr. Bruce Lindsay heads the Section of Cardiac Pacing and Electrophysiology. Dr. Bruce Wilkoff, Dr. Pat Tchou, and Dr. Walid Saliba serve as Associate Section Heads. Dr. Saliba is the Medical Director of the EP Lab and Dr. Mohamed Kanj is the Associate Director. Dr. Bruce Wilkoff heads the Device Clinic and the Center for Electrical Therapy. Dr. Oussama Wazni directs the Outpatient Department and Dr. Callahan directs the inpatient service. Dr. Dresing is the Fellowship Director. Dr. Jaeger is the director of the syncope clinic.

Is the EP lab separate from the cath lab? How long has this been? Are employees cross trained?

The Cleveland Clinic’s EP and cath labs have separate managers, nurses, and facilities. We have found that the degree of expertise required to function at a high level is best achieved by nurses who focus on electrophysiology, so we do not cross train nurses to work in both laboratories. Lisa Keene, RN serves as the education coordinator for the EP lab.

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

The RNs provide world-class care to our diverse and complex patient population by managing conscious sedation and monitoring hemodynamic status; they are also qualified to operate all mapping systems, ablation generators, device analyzers, EP recording systems, and programmable EP stimulators. We take pride in having our nurses develop these skills. Ohio does not permit nurses to administer deep sedation; however, the laboratory is staffed by a team of anesthesiologists and nurse anesthetists, directed by Dr. Sam Irefin, who administer deep sedation or general anesthesia if needed. Each patient is evaluated by our anesthesia team prior to the procedure. We will have an anesthesia machine in each room by the end of this year in order to reduce delays when patients are converted from conscious to deep sedation.

What new equipment, devices and/or products have been introduced at your lab lately?

We strive to improve the quality of care through assessment of outcomes and introduction of new technologies related to ablation of cardiac arrhythmias, cardiac resynchronization, and novel devices for stroke prevention, lead extraction, pacing and defibrillation. We were the first in the United States to implant an MRI-safe permanent pacemaker. We have been involved in many trials for innovative technologies such as magnetic and robotic navigation, left atrial pressure monitoring devices, subcutaneous defibrillator trials, and the left atrial appendage closure device trial. We will begin to evaluate new technologies to assess contact force for ablation catheters later this month.

Have you recently upgraded your imaging technology?

Yes. We utilize state-of-the-art systems manufactured by Philips and Siemens. We also help in the co-development of new imaging features and trial some of their future technology before it becomes available for official release. We track the age and repair costs of all equipment and develop a schedule for maintenance and replacement as the equipment ages.

Who handles your procedure scheduling? Do you use particular software?

EP lab procedures are scheduled by either the Center for Atrial Fibrillation for PVI ablations or by one of the EP lab schedulers for all other types of procedures. Currently, the EP lab schedulers utilize Outlook Software; however, we will transition to OP-Time later in the year.

What type of quality control/quality assurance measures are practiced in your EP lab?

Dr. Brian Baranowski and Ruth Madden, RN, lead the section’s program to monitor quality outcomes, which are reported to the HVI oversight committee. We have a comprehensive database, developed at the Cleveland Clinic, which is used for reports and to track outcomes of all procedures. We are in the process of revising the database to improve our ability to search it for quality measures and outcomes research in accordance with IRB-approved studies. A Database Committee chaired by Dr. Mina Chung reviews our data fields and makes changes as needed to improve functionality. We follow the Centers for Medicare & Medicaid Services (CMS) and the Joint Commission for standards and frequently perform quality audits from hand washing to documentation of procedural outcomes. We also abide by the College of American Pathologists (CAP) for standards of practice and are an accredited laboratory. All ICD implant data is entered into the National Cardiovascular Database Registry (NCDR®).

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

Our chief supply coordinator, Darlena Fisher, manages our inventory using QSight. Our Supply Chain Management Department handles all contracts related to purchasing of supplies and equipment.

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

The Sydell and Arnold Miller Family Heart and Vascular Institute is the largest Heart and Vascular Center in the United States. It is located on the main campus of the Cleveland Clinic and has 278 private rooms for patients and 110 ICU beds. After opening of the Heart and Vascular Institute, we expanded to 7 dedicated EP procedural labs in 2009. This allowed us to accommodate a steady increase in procedural volume.

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

Managed care has not had a major impact on the care we provide to patients.

Have you developed a referral base?

Over the past 30 years, the Cleveland Clinic has been recognized as a leading institution for quality outcomes and clinical research, and because of that, we have trained and educated physicians who practice worldwide. Many of these physicians refer patients to the Cleveland Clinic because of the expertise we provide. We have international patients who come through our doors daily and we take care of those who have been turned away from other institutions because of the complexity of their problems. Since the Cleveland Clinic embraces a group practice model, a large number of patients are referred by other Cleveland Clinic physicians. The Cleveland Clinic has been recognized by U.S. News and World Report as the nation’s leading cardiovascular program for 16 consecutive years. Many patients are referred because of our expertise or they chose to come on their own accord.

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?

The Cleveland Clinic Cardiac Rhythm Management team works with our Supply Chain Management to negotiate with industry to reduce the cost of all supplies used in the EP lab. We also track our start times and room turnover in order to improve the efficiency of the laboratories.

Does your EP lab compete for patients? Has your institution formed an alliance with others in the area?

We compete at a regional and national level with many other fine institutions. The Cleveland Clinic System includes the main campus and 6 other affiliated hospitals in the metropolitan area. 

How are new employees oriented and trained at your facility?

New RNs have a 10–12 week orientation to the EP lab. Through a shared governance initiative, a comprehensive skills checklist was developed to promote growth regarding EP concepts. Further education and training is continued beyond the initial orientation period as well.

What types of continuing education opportunities are provided to staff members?

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