University of California at San Diego

Gregory Feld, MD
Gregory Feld, MD
Just one of the strenghs of this busy EP lab in Southern California is that it stays involved with clinical and basic research programs in EP. We have one dedicated EP lab (1,200 sq. ft) at UCSD Medical Center Hillcrest downtown, where we do EP studies, ablation, and implantation of pacemakers and ICDs. We also share a single plane cath lab at UCSD Medical Center Hillcrest where we do only device implantation. We are also building an additional procedure lab that will be shared with the cath lab at our La Jolla campus at Thornton hospital. I opened the EP lab at UCSD Medical Center Hillcrest in 1987 when I was first recruited. We perform approximately 600 procedures/year at UCSD Medical Center Hillcrest, and anticipate that we will perform an additional 200 procedures/year at Thornton Hospital, after the initial lab opening. Currently, we perform up to four atrial fibrillation ablations/week, four to six atrial tachycardia or atrial flutter ablations/week, one or two ventricular tachycardia ablations/week, and 4-6 device implantations/week. The EP lab is managed by the EP Lab Head Nurse (RN), who is supervised by the EP Program Nurse Coordinator (RN) and the EP Program Director (MD). The EP Lab is separate from the cath lab, since its opening in 1987. There is a dedicated EP staff, which staffs all EP cases, regardless of location. These is no cross-training of staff. We have a full complement of EP lab systems, including the Bard Electrophysiology Lab-Duo recording system, the ESI non-contact mapping system, the CARTO contact mapping system, and EP Technologies and Medtronic ablation systems. We will be adding the ESI NavX localizing system to the ESI mapping system shortly. We have an older, film-based x-ray system, but it has been updated with a digital storage system, so we do not process film anymore. My office administrative staff, in conjunction with the EP program nurse coordinator, schedule all cases under the supervision of the program director. Scheduling is done by block times, with certain types of cases scheduled in certain time slots, based on the availability of specific faculty. This EP lab is scheduled with regard to other program activities as well such as clinical activities and conferences. A daily log is kept by the nursing staff documenting all patient care activity and the time that it occurs so we can audit the efficiency of our operation, including physician timeliness. The EP lab head nurse is responsible, with the help of the nursing and technical staff, to maintain the inventory and purchase required supplies. This is done online, and all inventory is updated by computer after each case is performed. As noted before, we expect significant increase in patient volume over the next several years; and will be opening a new procedure lab, partly dedicated to EP cases. Managed care has not impacted our patient volume, only the reimbursement received from each case. In fact, we have had to make a concerted effort to renegotiate our contracts recently, especially to increase reimbursement for devices, since our case load and charges in this area has grown dramatically. We have an ongoing process that evaluates EP lab utilization efficiency. We continuously monitor staffing requirements to maintain optimal cost-effective utilization of staff. We regularly review our procedures, practices, and contracts with vendors in order to reduce costs and maximize our reimbursements. We are currently reviewing our payer contracts in order to ensure optimal reimbursements. Because of the highly advanced nature of our EP and ablation practice, we receive a large number of referrals locally, regionally, and even nationally, particularly for ablation of complex atrial arrhythmias and atrial flutter. Therefore, we do not have to complete to any great degree for these types of referrals. In addition, we have ongoing contracts and referral arrangements with several regional medical centers and medical groups for referrals for ablation procedures. We have five half-day outpatient arrhythmia clinics staffed by our faculty, where we see new patients, follow-up patients post-procedure, and follow-up patients chronically with pacemakers and ICDs. New employees spend up to six months in a probationary training status. They are trained by existing senior staff members and EP program faculty. We are required by the university to provide a performance evaluation of all staff annually. This is done by the program director with input from co-workers and supervising staff, as well as direct observation by the program director. We do not participate in any herbal, homeopathic or other alternative medical treatments of that nature. We do however, utilize investigational therapies as part of our clinical research program. By our nature as a tertiary referral center, we have numerous rare and challenging cases that continue to make our job interesting. We have all staff member s beeper and home phone numbers available in case of emergencies. However, we only rarely do cases in the EP lab on an emergency basis. Therefore, the lab still maintains a full schedule even if the staff had to come in the night before, or on weekends. Since we have a large enough staff, however, this allows those who might have been on call to start at a later or staggered hour if necessary. We have a standard quality assurance committee, which has regular meetings to review all cases in which complications might have occurred. We have periodic meetings to review lab efficiency and performance characteristics (e.g. case volumes, turn-around times, procedure times, start times, etc.). We conduct periodic patient satisfaction surveys. We periodically assess competencies of staff in various duties by direct observation or written examination. We provide regular training and meeting attendance to staff in order to maintain and update credentials. We see an increasing role of interventional EP for the treatment of atrial fibrillation. We expect a dramatic increase in the use of ICDs for sudden death prevention. We see a dramatic increase in the use of bi-ventricular pacing to treat heart failure. We undergo periodic JCAHO external and internal (institutional) inspections to ensure compliance with JCAHO policies and regulations. We also undergo periodic physical plant, toxic and hazardous materials, and radiation inspections. We have a standard pre-op and post-op educational program implemented by the clinical nursing staff for patients undergoing procedures. Presently we do not have a support group for ICD patients, but have done so in the past and are considering re-implementing such a program for ICD and heart failure patients. Obtaining new equipment (capital budget expenditures) has always been a problem in the university system. We recently developed a cost savings analysis based on the use of non-contact mapping system/with catheterization localization system (ESI with NavX) to demonstrate how the cost savings generated in less than one year would pay for the cost of purchasing all the new equipment required for our new procedure lab. We are involved in numerous clinical trials from new antiarrhythmic drugs, to new pacemaker and ICD devices, to new ablation devices. These trials are both industry and faculty sponsored trials. We consider the clinical and basic research programs in EP at our institution one of our major strengths.