Spotlight Interview: Sinai-Grace Hospital

Mukarram Siddiqui, MD, Director of the EP Lab
Mukarram Siddiqui, MD, Director of the EP Lab
When was the EP lab started at your institution? The electrophysiology program at Sinai Grace Hospital was started in 2002. Dr. Mukarram Siddiqui joined Sinai-Grace Hospital and was named Director of the Electrophysiology Lab in January 2003. Under Dr. Siddiqui s direction, the volume has increased significantly each year. What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab? Who manages the lab? The electrophysiology lab equipment consists of one Siemens Angiostar Plus suite. We have the Prucka System, the CARTO mapping system, and we plan to add an ESI system. For ablations, we utilize the EPT-1000 XP and Stockert Ablation System in addition to the Atakr system. The diagnostic and therapeutic electrophysiology service is one of three major services provided by the division of cardiology. The other services are diagnostic and therapeutic cardiac catheterizations, and diagnostic and therapeutic peripheral vascular procedures. There is a clinical nurse manager who directs all services. There are currently 10 RN positions, two of which are dedicated to the EP lab. In addition, there is a lead angiographer and three angiographers, with 1.5 dedicated to the EP lab. There are two physician assistants, one of whom is dedicated to the EP lab, and the other to the cardiac cath lab. Currently, we have five cardiac invasive specialists, with one dedicated to the EP lab. The remainder of the staff includes four cardiac catheterization technicians and one office coordinator. The hours of operation are 6:30am to 7:00pm, Monday through Friday. Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained? The EP lab is in close proximity to the cardiac catheterization lab and special procedure lab. We have a dedicated PA working in the EP lab along with the nursing staff. The CIS techs are cross trained and rotate through the EP lab and cardiac cath lab. Do you have cross training inside the EP lab? Currently, all the involved staff members are trained in patient setup and handling the Prucka/Bloom system, and they are closely involved in CARTO setup. We strongly encourage all the EP staff to be fully involved and trained in all aspects of EP procedures. 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? In 2003, we acquired the CARTO mapping system, which has significantly decreased the fluoroscopic exposure time in addition to decreasing the overall time for the ablation procedures. We utilize this system for ablations such as post infarct ventricular tachycardia, incisional atrial flutter and atrial tachycardia, and in some cases of idiopathic ventricular tachycardia. Only rarely do we use the system in some typical atrial flutter and AV nodal tachycardia cases. We have closely looked at the technique of LV lead delivery during CRT. We have found the Rapido advance system to be very helpful, along with Rapido inner catheters. We have looked at the fluoroscopy exposure for coronary sinus cannulation and deployment of LV lead. It was noted that with utilization of Rapido advance sheath along with Rapido IC 90, the coronary sinus cannulation can be very short, with a fluoro exposure of 1 to 3 minutes. The total time spent in LV lead deployment has frequently been 15-20 minutes. What types of procedures are performed at your facility? The types of procedures that are performed include diagnostic EP studies and RF ablation for a myriad of cardiac dysrhythmias including: AVNRT, AVRT, WPW, typical and atypical atrial flutters (incisional atrial flutter), post infarct VT, idiopathic VT and AVJ modification. We soon plan to offer ablation of atrial fibrillation cases as well. In addition, we offer a full complement of device therapy, including permanent pacemakers, ICD implants and biventricular ICD implants. Approximately how many are performed each week? What complications do you find during these procedures? During a typical week, we perform 7-10 diagnostic EP studies and 2-5 ablations. Device implants average about 7-10 per week. Currently, we are aggressively looking at purchasing the CVX-300 Excimer Laser System from Spectranectics for lead extraction and other peripheral interventions. The patient population is extremely varied in our hospital, which is reflective of the neighborhood. Patients with awareness of disease process and close follow up tend to be relatively healthy. Unfortunately, there is high incidence of hypertension, ESRD, diabetes mellitus and complications related to poor control of above mentioned diseases. End-stage heart disease with ejection fractions of 5-10%, and class IV congestive heart failure is a norm rather than exception. Considering the patient population, the complication rates have been extremely low. Noted adverse events include occasional pocket hematomas, one episode of groin hematoma and one case of cardiac tamponade. No patients had any lasting sequelae related to these complications, and none required blood transfusion. The lead dislodgement rate is extremely low; in fact, we had only one dislodged atrial lead in over 350 devices performed thus far. In patients who undergo CRT, the reported incidence of LV lead revision is 10-15%, most of which are usually related to dislodgement. Our lab is unique in the fact that we did not have to revise any LV leads thus far, and we are not aware of any dislodged LV leads in patients who have undergone procedure at our hospital. Approximately what percentage of your ablation procedures are done with cryo? What percentage is done with radiofrequency? Currently, all our ablations are performed with radiofrequency. We are interested in acquiring a cryo system in the near future, though. Who handles your procedure scheduling? Do you use a particular software? Appointments are handled by the office coordinator working with the specific physician offices. Usually, we utilize what we call a one-call system. The office manager calls the point person and faxes the insurance information. Subsequently, appointment dates are allocated depending on the urgency of the procedure and the availability of the spots. Our scheduling system currently is not computerized, but automation is under consideration. What types of quality control/quality assurance measures are practiced in your EP lab? The patient undergoes a physical exam immediately post procedure in the holding area, and the CXR is performed if the subclavian vein access was performed. The patient is then transferred to the hospital room. The following day, the pertinent physical exam is performed during which vascular access sites are carefully addressed and any hematoma/ bleeding is documented. The patient receives a phone call by an EP lab nurse after one week to re-address if any procedural complications were noted. The EP team also gets together monthly to discuss any procedural complications. Our complication rates are lower than the national average. How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? The entire dedicated team is responsible for all inventory and for requesting needed supplies. The lead angiographer places orders through the computerized purchasing system. This new system has improved the timeframe of order placement and product delivery; products now arrive next day instead of the previous five-day turnaround rate. Has your EP lab recently expanded in size and patient volume, or will it be in the near future? Under the leadership of Dr. Siddiqui, the procedure volume has increased significantly since the lab was established. Prior to Dr. Siddiqui joining Sinai-Grace Hospital, the EP volume was less than 50 procedures. After his arrival in 2003, the total EP procedures volume rose to 273. In 2004, the total procedures grew again to 346, and the projected 2005 procedure volume is more than 500 cases. How has managed care affected your EP lab and the care it provides patients? Like other places, managed health care has affected Sinai-Grace Hospital as well. There are a multitude of problems faced because of this, including: (1) Securing referral for patients to have the procedure performed; (2) Obtaining separate approvals for the different procedures. There are certain insurance carriers that will cover only the EP study and require a second approval for ICD or ablation. We depend heavily on the support of clerical staff to obtain referrals and streamline the process. 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? As we continue to provide high-quality care to our patients and physician referrals, we have investigated ways of containing and reducing our costs. We are currently in a RFP process, which was initialized by DMC Purchasing, to address cost reduction across a wide range of services and supplies. We continue to look at ways to reduce the turnaround time of the procedure room to improve efficiencies. Does your EP lab compete for patients? Has your institution formed an alliance with others in the area? Sinai-Grace primarily competes with five hospitals for patients. Since Dr. Siddiqui was trained at nearby Henry Ford Hospital, we maintain a close professional relationship with the EP staff at Henry Ford Hospital, one of our competitors. What procedures do you perform on an outpatient basis? Most of the EP procedures are performed on an outpatient basis. These include ICD placement for primary prophylaxis against sudden cardiac death, SVT ablations, and at least 75% of CRT cases. We utilize what we call a 23-hour admission, in which the patient reports on the day of admission, undergoes the procedure and spends the night in the hospital, and is discharged the following day. How are new employees oriented and trained at your facility? Sinai-Grace Hospital follows the DMC policy on new employee orientation. This orientation covers a wide range of hospital policies and specific Environment of Care and Code of Conduct training. There are additional educational requirements for nurses, with special attention and education in critical care competencies. In addition, there are various computer-based education tools and tests that are mandatory. Once an employee starts work, specific department orientation performance measures are addressed. Very specific job-related duties are outlined and job expectations are addressed. What types of continuing education opportunities are provided to staff members? In addition to the computer-based learning, we look to different vendors to provide educational lectures and in-services about their specific products and industry trends. There are numerous opportunities to attend CME programs throughout the various hospitals, as well as at outside educational programs. All employees also attend HRS every year, by turn. How is staff competency evaluated? Staff competencies are reviewed on an ongoing basis and documented annually. We continue to look for opportunities to improve upon the understanding of the industry trends and tools that are available. How do you handle vendor visits to your department? The Detroit Medical Center and Sinai-Grace have strict policies on vendor involvement. Currently, all vendors must contact the specific department requesting visiting time or, if the physician staff requires vendor support, the department manager must enter in the vendor log the name of the rep, the company and the time to be present. All vendors must check in at the reception desk and receive a vendor pass. All vendors are required to have this pass visible at all times. Please describe one of the more interesting or bizarre cases that have come through your EP lab. We have performed a number of interesting cases, including one performed recently on a 53-year-old male with recurrent episodes of ICD discharge secondary to ventricular tachycardia. The patient had been on a combination of anti-arrhythmic drug therapy and continued to have appropriate ICD discharge. The ventricular tachycardia was associated with hemodynamic compromise precluding mapping during the ventricular tachycardia. Based on the morphology of the EKG, VT arising from RV was suspected. We performed a voltage map of RV utilizing the CARTO mapping system. There were several areas of low voltage/fractionated electrograms at the RV base. There were areas of dense scarring noted in the RV free wall. At the borderline zone (between scar and normal myocardium), pace mapping was performed, and good pace map match was noted. RF applications were delivered at this site, extending to the normal myocardium. Post-ablation clinical VT was not inducible; in follow-up, patient has remained free of VT/ICD discharge. How does your lab handle call time for staff members? How often is each staff member on call? With our current staffing, we do not have on-call responsibilities. With the dedicated team that we have, all coverage is handled internally without incident. Does your lab use a third party for reprocessing? At the current time, we do not use a third party. However, with such rapid increase in volume, this is a definite consideration for the future. Do you perform only adult EP procedures, or do you also do pediatric cases? Is there cross training for pediatric cases? At Sinai-Grace Hospital, we perform EP procedures in adult patients only, although we have performed EP procedures in adult patients with corrected congenital heart defects. At our sister hospital, Children s Hospital of Michigan, there is a very active EP program catering to the pediatric population. What trends do you see emerging in the practice of electrophysiology? The growth that electrophysiology has seen over the last few years has been phenomenal. There has been a huge increase in ICD implants, which is related to the robust benefit seen with ICD implantation in patients who underwent enrollment in primary prophylaxis against sudden cardiac death studies. These studies include MADIT I and II, MUSTT, and SCD-HeFT. As more and more patients undergo ICD placement, there will be diversity in implanters as well. More and more patients are considering ablation as primary therapy for SVT. The trends in ablation for atrial fibrillation are encouraging. As the population is aging, the atrial fibrillation burden is increasing and, as a consequence, the procedural volume, i.e. ablation, will increase. The available research results regarding biologic pacemakers are very heartening. Is your EP lab currently involved in any clinical trials or special projects? We are enrolling patients for at least two clinical studies currently. We are part of a multicenter study called the Pegasus study. At Sinai-Grace Hospital, we are conducting a study evaluating heart failure biomarkers in patients requiring RV pacing. Does your lab undergo a JCAHO? We are reviewing all of our policies and updating them as needed as we maintain and prepare for our JCAHO visit in July. We have incorporated the 2005 Patient Safety Goals as well as the Universal Protocol of operative/invasive procedures of calling a "Time Out" to verify the correct patient and procedure to be performed. Does your lab provide any educational or support programs for patients who may have additional questions or for those who may be interested in support groups? The major cardiology groups at Sinai-Grace Hospital have support groups for their ICD patients, and all patients are encouraged to participate in the meetings. Give an example of a difficult problem or challenge your lab has faced, and how was it addressed. In addition to electrophysiology, other disciplines of cardiology have grown at Sinai-Grace Hospital. We are in the process of adding a fourth lab to perform peripheral procedures. At times, the EP lab is utilized to perform peripheral vascular cases. To improve our efficiency, we have acquired a C-arm and perform some of the ICD and pacemakers in the OR. This has significantly improved the overall efficiency and decreased the waiting time for the procedure, as well as the length of stay. Describe your city or general regional area. How does it differ from the rest of the U.S.? Sinai-Grace is located in Detroit, the largest city in Michigan, with nearly one million people. Sinai-Grace is the only hospital in northwest Detroit; most are located in downtown Detroit. The hospital is surrounded by a mixture of neighborhoods, both economically affluent and challenged. Please tell our readers what you consider unique or innovative about your EP lab and its staff. This EP lab is unique in that we offer state-of-the-art electrophysiology care in a non-academic setting and have great outcomes. The EP staff work closely together, and we discuss cases both before and after the procedure. We review the latest literature pertinent to the cases in depth, which has resulted in excellent outcomes. For more information, please visit: www.sinaigrace.org/sinaigrace/