Spotlight Interview: Lancaster General Hospital

Lisha Esbenshade-Smith, AS, RCIS, NASPExAM AP/EP/Pacing, EP Staff Educator; John Minnich, RCIS, NASPExAM AP/EP/Pacing, EP Educational Coordinator; and Tara E. Ziegler, BS, RCIS, NASPExAM AP/EP/Pacing, Supervisor, EP and Pacing Services
Lisha Esbenshade-Smith, AS, RCIS, NASPExAM AP/EP/Pacing, EP Staff Educator; John Minnich, RCIS, NASPExAM AP/EP/Pacing, EP Educational Coordinator; and Tara E. Ziegler, BS, RCIS, NASPExAM AP/EP/Pacing, Supervisor, EP and Pacing Services
What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab? Currently our facility consists of one biplane room, two single-plane rooms, an ICD check room, and a Tilt Table Testing (TTT) room. We also share a pre- and post-procedure care unit staffed by RNs educated in both cath lab and EP procedures. Our staff includes a wide variety of personnel. We have seven sedation RNs, one inpatient facilitator, one outpatient facilitator, 11 EP techs, three patient care assistants, a secretary, and a billing coordinator. When was the EP lab started at your institution? Our EP lab began in 1987. What types of procedures are performed at your facility? We are performing a wide variety of cases. As far as EP studies, we perform all diagnostic wire studies, TTTs, Brugada challenges, supraventricular (SVT) ablations including those requiring transseptal access, VT ablations, and circumferential atrial fibrillation (AF) ablations. With regard to devices, we offer standard PPG and ICD implants, Reveal Implants, biventricular (BiV) implants, subclavian and CS venoplasties, and laser lead extractions. How many are performed each week? What complications do you find during these procedures? We perform approximately 70 procedures per week, or just over 3,600 annually. About 60% of this volume comes from device implants, and the other 40% from EP studies and ablations. Our complications are reviewed by a cardiology performance improvement committee, which monitors for quality control. There is a list, reviewed quarterly by this committee, of several potential complications that may occur during or after a procedure. Our most recent data reflects the most common complication rate, as it relates to device implants and laser lead extractions, as 1%. Other complications worth mentioning are cardiac tamponade and pneumothorax; however, these are rare occurrences and make up less than 0.5% of our complications. Who manages your EP lab? The medical director of the EP Lab is Dr. Douglas C. Gohn. Timothy Zellers, MSN is the Assistant Vice President of Cardiology, Andrea Hostetter, RN, BS is the Director Electrophysiology and Pacemaker Services, and Tara Ziegler, BS, RCIS is the supervisor. There are also four staff members two RNs and two EP techs who rotate the Charge position and manage the day-to-day operations. Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained? Our EP lab has been separate from the cath lab since 1991. The cath lab has three dedicated rooms; the EP lab has five dedicated rooms. Although the two services are separate, during emergent situations both labs come together to help each other out. One area we do share is the pre-/post-procedure area. This 14-bed unit, staffed by RNs, is currently undergoing construction; when it is complete, it will accommodate 28 beds. Some of our EP technologists are cross-trained, as they came to EP after working in the cath lab. Do you have cross training inside the EP lab? What are the regulations in your state? Our technologists are trained in the areas of scrub, circulate and record. This allows more options and flexibility, and ultimately, a more manageable staffing schedule. Another area of cross training is among our RNs, who perform conscious sedation. In the past, our RNs were only allowed to sedate. Now, we are beginning to teach them to scrub for basic PPG and ICD implants. What are some of the new equipment, devices and products introduced at your lab lately? How has this changed the way you perform those procedures? Most recent products we are using have helped improve our biventricular implants. For extremely difficult implants, where there is an occlusion in the subclavian vein that has not responded to venoplasty, we have used the Frontrunner ® catheter (LuMend Inc., Redwood City, California). This product has made crossing total occlusions easier and allows us to obtain the access we need to implant the necessary leads. We have used the Frontrunner for standard device implants and BiVs. Another product we use daily is the CSG Worley Sheath (Pressure Products, Inc., San Pedro, California), which we are proud to say was developed in our lab. This product has greatly improved our CS access times and has allowed shorter procedure times. We also use contrast to help localize the CS, and for those patients with severe renal dysfunction we have implemented the use of Magnevist ®. This form of contrast is eliminated from the kidneys more rapidly than Visipaque, thus reducing the chance of acute CHF. With regard to ablations, our newest product is the CryoCath. Is your EP lab filmless? Yes. We have had digital imaging since 1996. Who handles your procedure scheduling? Do you use a particular software? How do you handle physician timeliness? Our secretary schedules the majority of procedures. She has been with our department for seven years and has a great understanding of the procedures we perform and how long they can take. The program we currently use is MS Outlook; however, we are planning to transition to USA scheduling due to its greater efficiency and user-friendly process. Our physicians usually arrive to the hospital the same time each day. If there is an issue with recurrent tardiness, we will notify the medical director of the specific cardiology group. What type of quality control/quality assurance measures are practiced in your EP lab? Our QA/QC measures include conscious sedation, equipment, complications and documentation review. The conscious sedation QA examines the documentation of our sedation personnel. This looks at everything from vital signs to appropriate medication administration. Also, anytime a reversal medication is given, the sedation flow sheet is reviewed to figure out the cause of over-sedation and how to prevent it in the future. The equipment QC involves making sure our day-to-day equipment, such as X-ray, ACT machines, refrigerators, and contrast warmers, is functioning appropriately. Our complications, as previously mentioned, are tracked and any common denominators are noted and a root-cause-analysis is determined. Our documentation QA examines the procedural recordings to be sure that all mandatory fields are completed and accurate. This QA also includes looking at all equipment used throughout the case and making sure the usage of the equipment is contained in the procedural notes. How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? We have several individuals handling our inventory. One person is our materials manager, who is involved in the purchase of large equipment such as Cryocath, ESI, etc. The second individual orders our sterile supplies such as suture, staples, marking pens, etc. Another person inventories all device-related equipment and communicates our needs to the appropriate vendor. Lastly, we have a person who orders all EP equipment. This includes catheters, sheaths, cables, wires, balloons, etc. Has your EP lab recently expanded in size and patient volume, or will it be in the near future? Lately our patient volume has been trending upward. Due to this, plans are in place to build an additional biplane room and single-plane room. How has managed care affected your EP lab and the care it provides patients? Managed care has had no real impact. Patients receive the procedures and devices they need. 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? Our department shares a very unique database with our cath lab. Among its numerous capabilities, one thing we use it for is inventory monitoring. Each day our ordering personnel can access inventory information. The computer can tell us the count of inventory available on the shelves, whether or not we have reached our par level, and what items need to be reordered. Along with the database, we also have very aggressive vendor pricing for devices and other EP supplies. One other measure that has helped tremendously was the review of our salary structure. This has greatly improved our turnover rates from 28% in 2002 to 0% 2004. Does your EP lab compete for patients? Has your institution formed an alliance with others in the area? Lancaster General is the primary provider for cardiac care. Our market share is at least 65% for cardiology services and generally higher for EP services. Currently, there is only one other hospital in the county implanting devices and performing studies. What procedures do you perform on an outpatient basis? Outpatient procedures include TTTs, three- and four-wire studies and ablations, and device implants. However, if an ablation requires transseptal puncture, patients will remain overnight for observation. Device implants are also routinely admitted. How are new employees oriented and trained at your facility? All new employees are brought into the lab through the Electrophysiology Internship Program. The program is 22 weeks of didactic and clinical education in both electrophysiology and devices. The interns are assigned to a mentor, which is a senior staff member, who is responsible for assisting the interns in all aspects of the clinical processes. Our Internship Educator works with the Clinical Educational Coordinator to coordinate the weekly didactic lectures with the EP cases performed in the lab for the week. Our staff and interns are equally important, so all staff members are encouraged to attend outside educational programs, whether they be during the week or weekend, with the expectation that all staff will obtain HRS certification in either Electrophysiology or Pacing, two years from their hire date. What types of continuing education opportunities are provided to staff members? The Division of Cardiology and Division of Cardiothoracic Surgeons have organized a monthly Cardiology Journal Club. All Physicians, NPs, and PAs are able to submit an article for discussion. Generally facilitated by a Cardiac Physician, nine to eleven articles are presented and discussed at the open forum, and CMEs are awarded. Additionally, there are several websites that offer CEUs for online education, and all staff are encouraged to attend nearby conferences. Our Clinical Educational Coordinator works with vendors which provide educational inservices on a monthly basis. Our hospital also incorporated NetLearning, which is a hospital-based education program. Specific educational courses are easily accessed and PSNA credits are provided. How is staff competency evaluated? We perform annual departmental competencies as well as the JCAHO mandatory competencies. We have a Clinical Educational Coordinator and a Staff Educator in Electrophysiology, who are responsible for the administration and grading of our departmental competencies. The required competencies for JCAHO are completed on NetLearning. How do you handle vendor visits to your department? The vendors are asked to coordinate their visits to the EP Lab by contacting our Materials Manager of The Heart Center. The Materials Manager schedules time for the vendor to be in laboratory that is generally half days in duration. Vendors are allowed in our break room, but are only allowed in the procedure room if there is a case going on where their assistance is needed and determined necessary by the performing physician. Please describe one of the more interesting or bizarre cases that have come through your EP lab. We have had a couple of cases that were pretty interesting. During one of our atrial fibrillation ablations, it was mentioned that a patient undergoing an AF ablation somewhere else actually had his esophagus ablated during the procedure. This had one of our electrophysiologists thinking what he could do to prevent an esophageal ablation. We ended up inserting a Biosense Navistar down the esophagus and actually created a map. This ended up showing us our proximity to the esophagus during ablation. Another case was a BiV. Our target coronary was blocked, and the vessel prior to the blockage had poor pacing thresholds. Ultimately, a stent was placed to open up the vessel. Upon advancing the lead, we still were unable to pass beyond the stent. Interestingly enough, when we placed the lead at the stent, we found pacing was conducting through the stent to the area where we would have liked the lead placed. Thresholds were great. The other bizarre case was a BiV with a totally occluded subclavian vein. We accessed the left subclavian with a 7 French (Fr) peel-away sheath, and followed that with the Frontrunner device. After trying a few Frontrunners, we proceeded to the groin to obtain retrograde access. Once again we used the Frontrunner, going retrograde, and advanced into the left subclavian vein. We followed by advancing a Glidewire ® in retrograde fashion to the subclavian vein. Next we took a snare, advanced it through the 7 Fr sheath, and snared the Glidewire. We pulled the Glidewire out of the sheath. We were then able to advance a balloon over the wire and perform venoplasty. Ultimately, CS access was achieved, and the CS lead placed within minutes. 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? Currently there are three call teams consisting of five members. For one week, the same five individuals will stay as long as necessary to complete the day s work. We do not return for emergencies, work weekends, or holidays. At least one RN is assigned to each call team in order to provide moderate sedation. Does your lab use a third party for reprocessing? Yes. We currently use Alliance for the reprocessing of some diagnostic catheters. Our instruments and cables are sent to our in-house sterile processing department. Approximately what percentage of your ablation procedures are done with cryo? What percentage is done with radiofrequency? A very small amount of cases have utilized cryoablation. Currently, we use radiofrequency (RF) ablation about 99% of the time, and cryoablation about 1%. Do you perform only adult EP procedures or do you also do pediatric cases? No, we do not perform pediatric electrophysiology. Does your lab provide surgical backup for procedures? Yes. Surgical backup is always available to us for any procedure. It is only our laser lead extractions that require pre-procedure planning with the OR to be sure a room and heart team on standby should an emergency occur. What trends do you see emerging in the practice of electrophysiology? As electrophysiology continues to grow, so does the advancement of technology and techniques to optimize our outcomes. Dr. Seth J. Worley has foreseen several trends on the horizon based on current technology and available tools: 1) patients who need atrial pacing will only get bi-atrial (Bi-A) or Bachman pacing to reduce AF; 2) we will begin to avoid RV pacing as much as possible; 3) all patients requiring ventricular pacing support (about half the total PPG/AICD patients) will receive BiV pacing; 4) patients requiring both A and V pacing will have Bi-A/BiV systems; 5) ablation for AF will become the preferred treatment instead of drugs; 6) new device-based treatment for CHF will develop to add, but not replace, a BiV for CHF (Impulse dynamics and related devices). Is your EP lab currently involved in any clinical trials or special projects? Currently we are involved in 11 trials. Eight of these trials are device-related, while the other three involve EP studies, evaluation for sudden cardiac death (SCD), and medical treatment. Does your lab undergo a JCAHO inspection? Yes. Our institution had a JCAHO inspection in September 2003, when we received our highest mark ever of 98% with no Type 1 recommendations. 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. Our most common support group is the Zapper Club. This is a once per month meeting for our ICD patients and their spouses. Vendors from various companies are present to answer questions and educate those attending. At these meetings, everyone gets a chance to share stories, talk about problems, and make new friends. It is really just a great way to let people know they are not the only ones facing this new challenge. Fun events are also incorporated into these meetings such as comedians, movies, etc. Give an example of a difficult problem or challenge your lab has faced. How it was addressed? For the longest time, we were very short staffed. The same crew would put in 10-12 hour days night after night. As the Lancaster General name grew more popular in the EP arena, our patient population skyrocketed and has continued to grow. In the last two years, we have done an extensive retention and recruiting campaign. We have a closely-knit team, and there is a real camaraderie among the group. Another issue we faced was schedule management. There would be days where we would have about 30 cases scheduled for one day. This would include inpatients and outpatients. We have since made adjustments to our outpatient schedule to allow more room on the schedule for inpatients. Due to these efforts, more procedures are getting accomplished and less patients are getting cancelled. Describe your city or general regional area. How does it differ from the rest of the U.S.? Lancaster General is a 521-bed community hospital located in Southeastern Pennsylvania, not far from New York, Baltimore and Philadelphia. Our area attracts tourists who are interested in seeing the Amish way of life, as well as antique collecting. Although we are located in a small city, we are a big hospital offering every procedure related to EP. We are a Trauma center, and are also honored to be a center for excellence in nursing, having received Magnet Recognition. We have the distinction of being listed as a top 100 hospital in cardiology we were ranked as one of the top 50 hospitals in cardiology in US News & World Report in June of 2004 and our employees ranked us as one of the best places to work in Pennsylvania. Please tell our readers what you consider unique or innovate about your EP lab and its staff. Our EP lab has no fellows. All of our technologists are trained to be the physician s second pair of hands and eyes. We allow the technologists to have a great deal of autonomy. Some things they are responsible for are device pocket closure, stimulation protocols, and screen watching during all ablations. Our lab also has a clinical ladder consisting of Intern, EP Tech, and Senior EP Tech. Each level must be achieved by a certain period of time, or the employee is placed on probation. The technologist must pass a written examination developed by our Clinical Educational Coordinator, and complete the clinical skills appropriate in order to advance to the next level. Advancement ultimately depends on our physicians, as they have the final say as to whether or not the technologist is competent for that level of the clinical ladder. Our expectation is that all EP technologists will be HRS-certified, in either Pacing or EP, within two years of their hire date. For more information, visit: www.lancastergeneral.org