Spotlight Interview: St. Mary's Hospital Medical Center

Dr. Waseem Kazi
Dr. Waseem Kazi
What is the size of your EP lab facility and the number of staff members? What is the mix of credentials at your lab? At present, we have one dedicated EP lab which opened in October of 2003. Overflow implant procedures may also be done in one of our cath labs. We currently have five full-time employees and two electrophysiologists. We will be adding another full-time position in March. At that time, we will have four RNs and two RCIS-certified techs. We average over 10 years experience in cardiac care, and require ACLS certification. When was the EP lab started at your institution? The first electrophysiologist began doing procedures here in the cath lab in 1987. Dr. Jeffrey Kushner arrived in 1989 and built the EP program from that point. Dr. Waseem Kazi arrived in 2002. We opened the dedicated EP lab in October 2003. What types of procedures are performed at your facility? In our lab, we perform diagnostic EP studies and ablations. The ablation procedures employ both radiofrequency (RF) and cryo technologies. We will ablate for all types of SVTs, most types of ventricular tachycardia (VT), atrial flutter, and atrial fibrillation. We use both the transseptal and retrograde approaches to left-sided arrhythmias. We implant pacemakers, ICDs, and biventricular devices. Dr. Kazi also performs lead extractions, with our support, in the Operating Suite. We have been involved in several device research studies with several more beginning soon. We also have a Cardiac Procedures Unit adjacent to our EP lab. This unit admits most of our procedural patients. They also do our tilt table tests, cardioversions, and ICD checks, freeing up last time. This unit will also recover our sedated patients as needed, until ready for a telemetry bed. We have a dedicated Pacemaker Clinic for all device follow-ups, which is devoted to patient education. Approximately how many are performed each week? What complications do you find during these procedures? Our weekly average would include: 3-5 diagnostic/interventional EP cases, 3-4 ICD implants, 1-2 biventricular device implants, and 5-6 pacer implants. Our total case load for 2004 was 750 procedures. Additionally, up to 10 ICD checks per week would be done in the Cardiac Procedures Unit. Our intra-procedural complications are rare. Who manages your EP lab? Our immediate supervisor is the cardiac cath lab supervisor, who reports to the Director of Cardiac Services for the hospital. In practice, we as staff employ a shared governance methodology: developing our own protocols and problem solving as a group. This has been very successful. Is the EP lab separate from the Cath lab? How long has this been? Are employees cross-trained? From 1987 to 2003, the EP lab was integrated in the cath lab. Theoretically, all cath lab staff were cross-oriented to EP; in reality, a small group did most of the EP work. In 2003, our dedicated EP lab opened. Cath and EP lab staff are no longer cross-trained for the most part. Cath lab staff is still responsible for device implants when needed. EP lab staff no longer takes cath lab call. Do you have cross-training inside the EP lab? What are the regulations in your state? The registered nurses have the responsibility for medication administration, including procedural sedation, and patient assessment. All other EP lab functions are shared among the staff, including scrubbing, operating the imaging equipment, and the recording, stimulator and mapping systems. 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? When our dedicated lab opened in 2003, it was with all new equipment. We use the new Siemens Axiom Artis imaging system with the GE Med Systems Cardio-lab monitoring system. We use the EP Med Stimulator. We use the CARTO mapping system from Biosense Webster, Inc. Our newest piece of equipment is the CryoCath ablation system. All of these systems help us to diagnose more quickly and accurately and treat arrhythmias more safely than in the past, thus insuring a quality patient experience our primary concern. Who handles your procedure scheduling? Do you use any particular software? How do you handle physician timeliness? Procedures are scheduled by the physicians clinic secretarial staff and hospital s cardiac services secretarial staff. At present, the hospital uses the HBOC scheduling program, with the long-term goal of integrating with the physician clinic s EPIC scheduling system. We use a block scheduling system, allotting specific times per case type in the daily schedule. This is an attempt to maintain a manageable daily case load. We do a quarterly timing study by case type and adjust the blocks to reflect average procedure length. Physician arrival time is reflected in the block, so promptness is rewarded. What type of quality control/quality assurance measures are practiced in your EP lab? We track vascular complications, and are in the process of setting up a system for tracking implant complications. How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? We use the PYXIS supply management system in the EP lab, which charges the patient, tracks inventory, and sends product reorder messages to the hospital s SAP inventory management system for processing. We have a dedicated material services employee to insure that all works as planned. Our hospital belongs to the Premier buying group to help contain costs. In addition, we try to maintain our inventories on a consignment basis whenever possible to minimize expenditures. Capital budgeting is handled by the Director of Cardiac Services. Has your EP lab recently expanded in size and patient volume, or will it be in the near future? Our dedicated lab opened in October of 2003; in 2004, our volume increased by nearly 25% over 2003. We have had a further 10% increase so far in 2005. St. Mary s Hospital is in the midst of a major expansion program which will result in all new cath labs, operating suites, and additional patient care units. As part of this expansion, we will be adding an additional device implant lab and again totally rebuilding the EP lab. We are examining the feasibility of adding Stereotaxis to our facility. How has managed care affected your EP lab and the care it provides patients? We operate in a heavily managed care environment, with several HMOs dominating the local health care environment. Our hospital and primary physician clinic have a joint venture HMO which provides about 40% of our patient volume. This HMO is the largest in south central Wisconsin, so our patient referral base is large. The hospital, clinic, and HMO work well together to minimize costs and length of stay while assuring quality patient care. We have not as yet been restricted from any new technology. What measures has your EP lab implemented in order to cut or contain costs and improve efficiencies and patient throughput? In addition to keeping inventories low, inventory by consignment, and having multiple checks on the system to insure all charges are appropriate, we negotiate directly with our device vendors to better our pricing. We try to admit as many patients as possible to our Cardiac Procedures Unit which is adjacent to the EP lab. Post-procedure, we try to transfer everyone to the same intermediate care unit to standardize care. We offer all patients a Patient Satisfaction Survey to measure our success in giving quality care. Does your EP lab compete for patients? Has your institution formed an alliance with others in the area? We are one of four hospitals in the area with an EP program, so competition does exist within the framework of our managed care environment. Our institution and the largest physician clinic in the area do have formal alliances and joint ventures. What procedures do you perform on an outpatient basis? We perform device generator replacements and diagnostic EP studies on an outpatient basis. Our non-invasive outpatient procedures include tilt tables, cardioversions, and ICD checks. How are new employees oriented and trained at your facility? In addition to a formalized hospital-wide orientation program, all new EP lab employees receive an extensive orientation. The first week in the lab is spent with the Cath Lab Educational Coordinator for an introduction to cardiac services. Then a primary preceptor is assigned in the lab to coordinate orientation to all the roles in the EP lab. We plan a three- to six-month orientation period to be fully functional in all roles. The orientation process involves intensive one-on-one support during procedures and formalized educational offerings. What type of continuing education opportunities are provided to staff members? We are very pro-active in scheduling biweekly in-services from our device and equipment reps and their clinical support staff. We also schedule case review sessions with our physicians on a regular basis. Thus far, we have also been able to send several staff members to the Heart Rhythm Society Scientific Sessions each year. How is your staff competency evaluated? Staff competencies are evaluated yearly. These include hospital-wide, general cardiac services, and EP-specific topics. We also have a yearly peer evaluation process which includes personal and departmental goal setting. How do you handle vendor visits to your department? We limit vendor visits to one company per day. They must register with our material services department, which issues the vendor a visitor identification badge. We try to limit these visits to new product information. The exception to this would be rep technical support during procedures, or scheduled in-services. Please describe one of the more interesting or bizarre cases that have come through your EP lab. An active 21-year-old college student presented to our lab with a diagnosis of arrhythmogenic right ventricular dysplasia with syncope (EF around 35%). An ICD was placed and tested appropriately. Some time later, the patient received an inappropriate shock for sinus tach and the VT detection rate was changed. The patient again presented to the ER with syncope. Examination showed RVOT VT at a rate below the VT zone of the device. Successful radiofrequency ablation of this VT alleviated the syncope. This eliminated the need for additional medication, maximized the effectiveness of the ICD, and improved the quality of life for the patient, who is now back in college with no further presentations to the ER. How often is each staff member on call? We do not take call for either the EP or cath lab. It is our responsibility to staff the EP lab until the day s cases are completed. After that and on weekends, we are free. The cath lab call team handles emergency temporary pacemakers and emergent permanent pacemaker implantation during the off hours and on weekends. Does your lab use a third party for reprocessing? No, we don t; we have a single use policy for all of our catheters. Approximately what percentage of your ablation procedures are done with cryo? What percentage is done with radiofrequency? We began using cryoablation in November 2004, so we have only used this technology for 1-2% of our ablation procedures. As we and the physicians become more comfortable with the technology, and its approved indications expand, we feel its use will grow for any arrhythmia. Do you perform only adult EP procedures or do you also do pediatric cases? Is there cross training for pediatric cases? As a rule, we do not do pediatric cases in the EP lab. We occasionally do procedures on teenagers in the 14- to 18-year-old range with our normal EP lab staff. What trends do you see emerging in the practice of electrophysiology? We have seen a steady rise in the number of complex ablation procedures, including those for atrial fibrillation, and other left-sided arrhythmias. ICD and biventricular device implants are also steadily rising. Is your EP lab currently involved in any clinical trials or special projects? We have recently concluded participation in several device studies, including the Guidant Intrinsic RV study. We are scheduled to begin participation in several more in the near future, including the Guidant Pegasus study. Does your lab undergo a JCAHO inspection? Yes, we are included in the regularly scheduled hospital-wide survey. Does your EP lab provide any educational or support programs for patients who may have additional questions or for those who may be interested in support groups? Our physician group employs a nurse education who does pre-procedure education for our patients. This person also does post-procedure follow-up contact for further education. Our Pacemaker Clinic discontinued their formalized support group about three years ago as devices became more commonplace. With increased staff, they spend more individual time on patient education and are available by phone for support. Give an example of a difficult problem or challenge that your lab faced. How was it addressed? Since the opening of the dedicated EP lab, staff overtime has been a challenge. The case load has grown significantly and what was once filtered through three cath labs is now focused on one lab and four staff members. Though we no longer take evening and weekend call, the stay until the work is done schedule led to a feeling of frustration and dissatisfaction with the amount of overtime worked. We have strived hard to change this. Solutions include increased physician lab availability as their out-of-hospital responsibilities have been reallocated. We worked harder at the block scheduling concept to spread out the cases more evenly over the work week. We have switched from five 8-hour days to four 10-hour days, with one day off per week. By rotating this day off, we have been able to have four-day weekends every fifth week a real morale booster! Finally, we have been allowed to hire two additional staff members and are now in the orientation process. Long term, the opening of the second EP/implant lab in 2008 will also help. Describe your city or general regional area. How does it differ from the rest of the U.S.? St. Mary s Hospital Medical Center is located in central Madison, near the state capitol and the University of Wisconsin. Surrounded by lakes, Madison is a beautiful city with diverse cultural base supported by the university s spirited liberal atmosphere. We are a tertiary health care center for the surrounding farming communities and small towns. We enjoy all four seasons and their associated outdoor activities. As I write this, looking out of the window of our lab s control room, I have a good view of Lake Wingra, where the annual Midwest Rowing Regatta will be held shortly after the ice is off the water. Please tell our readers what you consider unique or innovative about your EP lab and staff. The original four members of the EP staff (Patty, Lee, Barb, and Karin) average over 15 years of cath/EP experience at this institution. We have been through the good and bad times together, and have a great deal of mutual respect. We work hard to control our own destiny and deliver the best patient care possible to each and every patient, each and every day we work. Service with a smile!