University of Massachusetts Medical Center

Lawrence S. Rosenthal, MD, PhD
Lawrence S. Rosenthal, MD, PhD
The UMass Memorial EP lab is truly the ‘little engine that could. UMass Memorial Medical Center is a tertiary care center and an academic medical center, serving central Massachusetts and the greater Worcester community, as well as northern Connecticut and northern Rhode Island. The institution separated from the state of Massachusetts and merged with Memorial Hospital in 1998. The hospital is affiliated with several smaller hospitals throughout central Massachusetts. Electrophysiology at UMass originated back in the early 1980s under Charles Haffejee, MD, and subsequently by Stephen Huang, MD. In fact, Dr Huang performed one of the earliest radiofrequency (RF) ablations. We currently utilize a single lab constructed back in the early 1990s. It consists of a single-plane fluoroscopy room, with a second smaller recovery area off to the side. The physician staff includes 4 full-time academic faculty, who cover the University campus as well as the Memorial campus. Our nursing professionals include three full-time registered nurses who rotate call schedules. There are always two RNs present for all cases involving conscious sedation. We use headphones and relaxing music for patient comfort, as well as Versed and fentanyl for conscious sedation. The institution has conscious sedation guidelines and all physicians and nurses adhere to these guidelines. We also have anesthesiologist support if needed. EP nurses perform regular quality assurance using an extensive outcomes database. We have a full-time nurse practitioner, who assists with procedures, sees consultations, performs post-op wound checks, assists in patient teaching, and generally ‘sets the table each day. She also oversees our pacemaker and ICD clinics, which performs approximately 6,000 device checks per year. We have 2 dedicated EP fellows and a rotating general cardiology fellow on our service. We have an active clinical research program and have 2 excellent clinical research nurses to assist in patient recruiting and data tracking. Our volumes have continued to grow steadily. We typically perform 1,200 procedures per year in the lab. These procedures include approximately 150 pacemaker implants, 300 ICD implants, 50 biventricular ICD implants, 150 catheter ablation procedures, 200 EP studies, 150 cardioversions, and other miscellaneous procedures. We also perform 30-50 LASER lead extraction procedures per year. Six new Cath labs and an EP lab (maybe two) are currently under construction and are to be completed by the Fall of 2003. Thus, currently we are a separate entity from the Cath labs, but will merge resources when construction is completed. Since EP is a specialized field, EP trained nurses and staff will remain dedicated to the EP service. Our recording equipment is a PRUKA NT system, and we currently use CARTO 3-dimensional electroanatomic mapping for complex ablations. Our EP studies and ablations are digitally stored on disks. Fluoroscopic images can also be digitally stored via the Prucka system. Our days start at 8 am, and our goal is to complete our work in time for dinner. This actually happens 2-3 days per week. Unfortunately, there are days that never seem to end. Procedure scheduling is done through a dedicated Lab Coordinator who also assists with billing and communicating with outside physcian s offices. We maintain an extensive database of patient procedures and implanted device information. Information is manually entered into an EXCEL file and is used for billing, inventory, staffing and Q & A purposes. The various jobs within the lab, such as staff scheduling, troubleshooting equipment problems, scheduling of preventative maintenance, dealing with hospital systems issues, and maintaining current policies and procedures are divided among the staff. The nursing staff, through general stores and negotiations with various vendors, also does inventory and purchasing. Requests for new equipment must be submitted for review through the hospital capital equipment finance board. However, as with most labs, we are able to purchase many items within our operating budget. Massachusetts is tightly governed by manage care contracts. Occasionally, certain procedures such as tilt table testing can present a difficult challenge in getting insurance carriers to reimburse these tests. Our greatest challenge remains the need for more resources, i.e. EP lab space, staff and equipment. With expanding indications for ICDs and catheter ablation, there are instances where patients can wait 4 to 6 weeks for elective procedures. We are constantly faced with the challenge of meeting the clinical needs of our patients while maintaining our own commitments toward academic pursuits. While relatively close to the greater Boston area, we do not compete with these institutions for patients or procedures. Our institution is visited by JCAHO every 4 years and by the Department of Public Health on regular intervals. We always have quality control projects going on. In our lab, we have a large database that contains all of the information and statistics on the patients and cases that we have done in the past. Periodically we doublecheck this information and determine if there is something going on that we haven t looked at yet, or if there is something that we can improve upon. This is generally taken care of by the nursing staff. With new indications for ICDs and the implantation of biventricular pacing ICDs, as well as lengthy pulmonary vein isolation procedures, routine device procedures are often performed in the Cath labs or in the operating rooms. We have also expanded our services at the Memorial campus to decompress the ever-expanding volume of device implants. The recent increase in device volume (driven by MADIT II) has also presented some difficulty with patient education. Currently, prior to leaving the hospital, written and verbal wound care and activity instructions are given to all patients who receive device implants. In my experience, most patients forget that information. Thus, recently we have begun performing patient teaching on a one-on-one basis in the outpatient setting during follow up with our nurse practitioner (approximately one week after implantation). We have abandoned regular support group meetings in favor of a more personal approach. However, in the future, we would like to initiate monthly informational support groups for patients seeking more information. Although quality patient care is our primary objective, we are also committed to research and academic pursuits. UMass Memorial is a Focus Center for the Guidant Corporation and is involved with many of their clinical trials. Most recently we have begun examining different pacing modes for cardiac resynchronization (BiV pacing verses LV pacing verses LV offset pacing in heart failure patients indicated for and ICD (DECREASE-HF). We are also involved with pacing trials comparing AV pacing to intrinsic AV conduction (SAVE-PACE). Teaching and continuing education and growth are priorities for all of us and we generally attend regular meetings (i.e. NASPE). In addition most nurses are NASPE TESTAMURS in EP and in pacing. Our staff participates in both sponsored and original research projects and has presented abstracts at national and at international meetings. Any clinical question worth asking is supported for further study. We are basically a well-rounded EP lab. We do all sorts of procedures, and we do them very well. We are able to accommodate all kinds of pathology. Our location allows us to provide service to much of the surrounding areas, including central Massachusetts, northern Connecticut, northern Rhode Island, southern Vermont, southern New Hampshire, and occasionally southern Maine.