Cross Training in Today's EP Lab

Condensed and Edited by Jodie Miller
Condensed and Edited by Jodie Miller
Readers, is your lab a dedicated EP lab or is it shared with the Cath Lab? We are finding that many EP labs these days are now separate from the Cath Lab. The following accounts of cross training in the electrophysiology lab were taken from Spotlight Interviews published in EP Lab Digest dating back to September 2001. Please note that some of the managers comments were edited slightly so as to focus solely on the management and organizational aspects of their cath labs. Readers, is your EP lab separate from the Cath lab? How long has this been? Do you have cross-training inside the EP lab? What are the regulations in your state? From 2004, Vol. 1, No. 4: At Medical City Heart in Dallas, Texas, the EP program was started in 1990. The EP lab is a dedicated crew which includes Kelly Taylor, RCIS (who has been there since 1997); Gail Metcalf, CIS (who has been there since 1980); and Sue Hamner, RN (who has been there since 2001). It is in the same area as the cath lab, and they share a pre/post area. The cath lab staff fill in when someone is on vacation. From 2004, Vol. 1, No. 3: At Tufts-New England Medical Center and Cardiac Arrhythmia Center in Boston, Massachusetts, the EP lab is separate from the cath lab; it has been this way since 1984. Employees are not cross-trained due to this separation. From 2004, Vol. 1, No. 2: At St. Luke s-Roosevelt Hospital Center in New York,  the EP lab and Cardiac Catheterization lab function completely independent of each other there is a separate staff and leadership. Nursing staff in the cath and EP labs are cross-trained, but are rarely called on to cover for one another. All nursing staff is credentialed in the full range of EP laboratory procedures. Nurses share responsibilities in preparing the room and procedure tray, setting up the patient, circulating, and administering conscious sedation, patient care and defibrillation. Electrophysiology equipment, such as recording, monitoring, and mapping systems, are typically manned by the EP attendings, fellows, and support staff. From 2004, Vol. 1, No. 1: At Parkridge Medical Center in Chattanooga, Tennessee, the EP lab employees are cross-trained to operate the Prucka monitoring system (GE Medical, Waukesha, Wisconsin), the Bloom stimulator (Fischer Imaging Corporation, Denver, Colorado) and the Carto mapping system (Biosense Webster Inc., Diamond Bar, California), as well as scrub for all cases. RNs are also cross-trained to sedate. As far as sedation goes, their physician has attended classes offered through the anesthesia department and gives Brevital during the case. The RNs monitor the patient and provide supplemental sedation as needed per physician orders. There are respiratory therapists available, per protocol, throughout the procedure that perform multiple functions in the lab. From 2003, Vol. 3, No. 9: At Emory Crawford Long Hospital in Atlanta, Georgia, the Cath/EP area consists of five cath labs and two EP labs (the fifth cath lab is shared between cath and EP as needed). Adjacent are 20 cardiac observation beds with a central monitoring area. They have always had the EP and cath labs in the same area. They find that this facilitates patient management pre- and post-procedure, speeds turnover time, and permits ready access to cross-trained cath lab staff as needed during breaks or in overtime situations. The staff is fully cross-trained so that all employees can perform all tasks. Their staff tends to rotate responsibilities during the day to lessen the possibility of fatigue. The state of Georgia requires all personnel to be credentialed, but the type of credentials needed may vary. From 2003, Vol. 3, No. 8: At St. John Hospital and Medical Center in Detroit, Michigan, the EP laboratory has been independent of the catheterization laboratory since 1994. Some of the cath lab nurses are cross-trained to assist in the EP laboratory, and play a vital role given the expanding patient volume. On the other hand, the lab staff works exclusively in the EP lab. They provide cross-training for cath lab nurses who have demonstrated certain aptitude for EP lab procedures. They were not aware of any specific state regulations pertaining to this issue. From 2003, Vol. 3, No. 7: At the UCLA Cardiac Arrhythmia Center in Los Angeles, the EP lab is separate from the cath lab. However, employees are cross-trained. From 2003, Vol. 3, No. 6: At the University of Massachusetts Medical Center in Worcester, six new cath labs and an EP lab (maybe two) were under construction and were to be completed by the Fall of 2003. Thus, they were a separate entity from the cath labs, but were going to merge resources when construction was completed. Their EP trained nurses and staff will remain dedicated to the EP service. From 2003, Vol. 3, No. 5: At the University of Iowa Hospitals in Iowa City, Iowa the EP laboratory is separate from but adjacent to the cardiac catheterization laboratory. It is conveniently located to all nursing staff and EP faculty members. This has been the case for over 20 years. Employees are cross trained. Due to the unpredictability of scheduling needs, they have gone to a fully cross-trained system. The crossed-trained staff enjoys the variety in their work and each staff has chosen a type of EP role with which they are particularly pleased. The concept that all the employees are cross-trained is relatively new. It has worked out well in fact, better than having a dedicated EP staff. Cross-training offers a distinct advantage for a device implantation as the staff technically trained in cardiac catheterization procedures is highly competent in venous access and placement of leads in unusual positions (based on their experience with angioplasty procedures). In addition, the nursing and radiographer staff performs the following: 1) starts IV lines; 2) places catheters; 3) closes device (pacemakers, ICDs) pockets; 3) removes lines; 4) runs the stimulator; 5) runs ablation equipment; and 6) operates complex mapping equipment including CARTO and ESI. There are weekly conferences with the nursing staff and Dr. Olshansky to discuss issues in the lab and to become educated in EP issues. Dr. Olshansky and Mr. Eischens collaborate to ensure that the nurses and radiographers have the expertise to perform all procedures. There are no regulations from the state, but they have identified areas of expert knowledge and skill that are expected to perform EP procedures. Critical practice competancies are evaluated annually to assure that the staff participating in the various procedures have an optimal level of skill. From 2003, Vol. 3, No. 4: At the University of California - San Diego in California, 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. There is no cross-training of staff. From 2003, Vol. 3, No. 3: At the University of Rochester Medical Center at Strong Memorial Hospital in New York, the cath and EP rooms are operationally separate, but share the same geographic location. The technical (mapping, etc.) work is performed exclusively by two RCVTs. The role of the nurses is to circulate, administer medication and perform patient care. Regulations are that RNs are responsible for conscious sedation, medication administration, assessment intervention and defibrillation. Cath and EP lab nurses do not cross train in the labs, but do work together in the pre-/post area. From 2003, Vol. 3, No. 2: At Advocate Illinois Masonic Medical Center in Chicago, Illinois, the EP labs are distinctly separate from the cardiac cath labs. They are located geographically next door to one another, but managers and staff members are entirely separate. This has been the case since the inception of the EP labs in 1989. Staff members are not cross trained with the cath lab, since they function as two entirely separate entities. All their nurses are cross-trained in the outpatient device clinic as well as all the procedures performed in the electrophysiology laboratories. Their nurses are trained to use all computer equipment, specialty technologies, as well as all the device programmers. The nurses also rotate the position of in-hospital clinical service nurse with the physician who is scheduled to see in-house patients. The nurse then provides all pre-op and post-op teaching, makes patient rounds with the physicians and fellows each day, provides liaison between the patients and physicians if they are in procedures, and sets up outpatient follow-up as well as discharge planning. The nurse keeps a daily log of patient events, recording them in their database, reviews labs and diagnostic tests with the physicians, and plans follow-up with their outpatient nurse. From 2003, Vol. 3, No. 1 At the Carle Heart Center in Urbana, Illinois, the EP lab is a dedicated lab within the cath lab suite. The EP lab staff started in the cath lab and fills in there when needed. Within the EP lab, employees are cross-trained, with the exception of giving meds, which must be done by an RN. From 2002, Vol. 2, No. 6: At Mercy General Hospital in Sacramento, California, the EP program has always been a separate entity there is no cross training with the cath lab staff. Within the EP and Pacer labs, the staff are cross-trained within their job classification. In addition, the RNs are being cross-trained to scrub for the surgical procedures. From 2002, Vol. 2, No. 5: At the Einstein Heart Institute in Philadelphia, Pennsylvania, the electrophysiology services are separate from the cardiac cath lab; however, they work together to provide optimal care to all of their patients. Einstein s electrophysiology nurses are dedicated EP staff. Currently, cross training has not been a necessity, though it would be explored if necessary. From 2002, Vol. 2, No. 4: At the Georgia Heart Center in Macon, Georgia, the EP lab is separate from the cath lab; therefore, the employees are not cross-trained. Staff is cross-trained in all areas except conscious sedation. Only their RNs perform this responsibility due to hospital regulations. All staff members are ACLS-certified. From 2002, Vol. 2, No. 3: At Riverside Methodist Hospital in Columbus, Ohio, the lab is completely separate from the cath lab. They are not cross-trained, although located in close proximity to one another. All of the EP staff nurses are trained to assist in all procedures performed in the lab, both invasive and non-invasive. All staff nurses are expected to know how to operate all equipment and computer systems used during procedures. Certain nurses have undergone extra training for specialty technologies such as Biosense and Cardiac Pathways. Patient care technicians have the responsibility to help set up patients and labs for procedures and to help nurses during non-invasive procedures. From 2002, Vol. 2, No. 2: At Saint Vincent Heart Center in Erie, Pennsylvania, the EP and cath labs are in the same area of the hospital, but EP procedures are separate from all cath procedures. The strength of their service is that the responsibilities of the nurses and techs are only to the EP lab and Pacer Clinic.The majority have cath lab/critical care experience and help out in those areas when needed. The nurses in the lab are also cross-trained to work in the Pacemaker Clinic. In the lab, nurses and techs perform all the same duties, with the exception of conscious sedation and medication administration handled by the RNs. From 2002, Vol. 2, No. 1 At the EMH Regional Healthcare System, which has campuses in Elyria and Amherst, Ohio, the EP RNs are dedicated to EP and Pacing, but their dual lab has staff that is cross-trained for both EP and cath lab procedures. This increase in staff has helped to provide enough staff to perform procedures during vacations and personal days off. All of their staff are trained to operate all equipment, which includes the stimulator and monitoring system, mapping system, ablative therapy generator, analyzer, and device manufacturer programmers. They have been using the Carto mapping system (Biosense Webster, Inc.) for ablative procedures. Their implants now include device therapies for atrial fibrillation and heart failure. A manufacturer representative is involved in all of their internal defibrillator implants, but staff analyzes and programs pacemakers for implants. From 2001, Vol. 1, No. 2: At Walter Reed Army Medical Center in Washington D.C., the EP and cardiac catheterization labs coexist in one location. However, their EP monitoring system is hardwired into one lab. All EP studies are done in this lab. Device implants are done in any available room. All employees are cross-trained to be proficient in any procedure performed in their lab. New employees are exposed to every procedure that they perform. Every employee in the cath lab is able to prepare a patient for an EP study. Only those who show a strong interest in electrophysiology are trained to operate the stimulator and monitoring system. All employees in the EP lab are cross-trained for maximum efficiency. There is no differentiation between the nurse and tech role. From 2001, Vol. 1, No. 1: At Morristown Memorial Hospital in Morristown, New Jersey, the laboratory has a full-time physician director as well as a nurse coordinator. The EP lab is a separate entity from the cath lab, although the staff and physicians work closely with members of the catheterization laboratory. Many of the electrophysiology laboratory employees have catheterization laboratory experience. The nurses have also had prior cardiac care or subacute cardiac care unit experience. However, cross-training per se, between the cardiac electrophysiology laboratory and the interventional cardiac catheterization laboratory has not been applied directly, to enable a higher degree of concentration on the overall management of patients with cardiac rhythm problems. The rhythm management team is dedicated to the clinical care, education, and support of the patients treated, as well as participation in continuing education and clinical research.