Spotlight Interview: Rockford Memorial Hospital

James Combs, RCIS, EMTP
James Combs, RCIS, EMTP
What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab? We currently operate from two rooms shared by the entire cath lab. The largest of those rooms will become a dedicated EP lab at the completion of our cath lab expansion in early 2006. We have two full-time Electrophysiologists, Dr. Jeffrey Smith, our EP Director, and Dr. Leela Narra. Four staff members are dedicated to the EP lab, but also participate in other cath lab cases as needed: two RNs, 1 RCIS, and 1 RT(R). All of our staff have some form of critical care experience, and are required to have ACLS certification. When was the EP lab started at your institution? The Cardiac Cath Lab program was organized in 1972 by Dr. Terry Fisher and Dr. Charles Osadjan. The electrophysiology program was established in 1995 by Dr. Jeffrey Smith, who is also our EP Lab Director. What types of procedures are performed at your facility? Being an integrated lab, we perform diagnostic cardiac catheterizations, coronary interventions, and upon completion of our expansion, diagnostic and interventional peripheral procedures. EP procedures performed in our lab include diagnostic EP studies, 3D mapping with Endocardial Solutions Inc. (ESI), intracardiac ultrasound with Boston Scientific, radiofrequency ablation for all arrhythmia types, including supraventricular tachyarrhythmias, ventricular tachyarrhythmias, atrial fibrillation, atrial flutters, and AV node modifications. We implant all permanent pacemaker, ICD and loop recorders, as well as CRT devices in the lab. ICD checks are also completed on an outpatient basis in our lab. Tilt table studies are performed on an outpatient basis in our cardiology services department. Approximately how many procedures are performed each week? What complications do you find during these procedures? Our cardiac cath lab averages approximately 45-60 procedures per week; of those procedures, 10-15 of them are EP-related cases. Complications are similar to those experienced at other institutions, and our rates are very low. Who manages your lab? The lab is managed by William Anderson RT(R), Assistant Director of Cardiovascular Services. He is responsible for day-to-day operations, strategic planning, budgeting and appropriately delegates other specific responsibilities to key staff members in order to complete the organization s mission. Bill is very proactive and utilizes a team approach to his management style. He frequently organizes teams to review our departmental processes, and keeps everyone in the department active in determining their own destiny. Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained? We have an integrated cath lab and all staff participate in EP to some degree. Currently we have two labs, and EP cases are scheduled like any other case and placed into the daily mix. At the completion of our 2006 expansion, our EP staff will have a dedicated room for all EP procedures. Four of our sixteen staff members are considered fully trained in EP. Do you have cross training inside the EP lab? What are the regulations in your state? Cross training in the EP lab does not currently exist, although all team members are acutely aware of each other s responsibilities and are quite capable of assisting as needed. The State of Illinois has specific guidelines for Nurses and Radiological Technologists. I am not aware of any current regulations providing direction, guidance or licensure to allied health care staff in the lab (e.g RCIS, CVT, CIT). Our nurses provide conscious sedation and medication administration for our patients. All staff are ACLS certified and operate based on departmental and hospital policy. 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? The newest equipment or technology in our lab is already three years old, but has certainly changed the way we perform our procedures. Three-dimensional mapping with the Endocardial Solutions ESI 3000 array system and NavX has changed the face of our diagnostic and ablative capabilities. The ability to utilize contact and non-contact mapping with one system has allowed us to effectively perform more complex cases with greater success. Who handles your procedure scheduling? Do you use particular software? How do you handle physician timeliness? Scheduling of our outpatients is done through the cardiology office. Scheduling of inpatients is done by the cardiologist who sees the patient. Patient information is called into our cath lab office and our business unit support coordinator, Jane Coogan, coordinates the information, entering it into a scheduling software program called IPATH. Regarding physician timeliness, cases in the cardiac cath lab will inevitably be altered during the day. Some cases are quicker than others, some are much longer. Having only one group of physicians who are real team players makes getting through even the worst day a lot easier. We have staff-selected coordinators whose daily responsibility is to maintain a direct line of communication with our physicians and make necessary changes to the schedule to improve patient flow. Therefore, if a physician is running late, we understand and make necessary adjustments to keep our patients moving. There are no hard fast rules regarding physician timeliness, only mutual understanding and respect of each other s schedules, and a fantastic line of communication. What type of quality control/quality assurance measures are practiced in your lab? Rockford Memorial Hospital recently received the 2005 Health Grades Distinguished Hospital Clinical Excellence Award in eight areas, including Cardiology. Our hospital is ranked among the top 5% of hospitals in the nation. In order to determine how well we care for our patients, Press Ganey scores are used to identify our strengths and weaknesses, ranking regularly in the 90th percentile. This is a national program that reflects customer satisfaction. Our cardiology program also subscribes to The National Registry of Myocardial Infarction (NRMI), which assesses our ability to effectively care for patients who are having a myocardial infarction. Our response times have been well below the national median, with our last quarter results reflecting an 83-minute door to dilatation time, 90-120 minutes being the recommended range. We also participate in the American College of Cardiology (ACC) database. Our department performs its own hospital point of care quality assurance testing for hemoximetry, glucose, and activated clotting times. How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? Inventory is managed by EP lab staff. A designated area for EP supplies has been established, and at the completion of each day, used EP supplies are reordered. Capital purchasing is a dynamic process that begins with the decision to purchase new and necessary equipment. Each year, capital purchase requests are created based on need and justification. New technology is reviewed by staff and management, and a decision is made to submit a capital purchase request for new equipment. Capital purchase requests are submitted through the budgetary process and are ultimately approved or denied. Therefore, good research, documentation, and appropriate justification is necessary for a successful request. Has your EP lab recently expanded in size and patient volume, or will it be in the near future? The cardiac cath lab at Rockford Memorial Hospital has been approved for renovation and expansion, to be completed during the 2005-2006 fiscal year. Two additional procedure rooms will be added as well as additional ancillary space. A dedicated EP lab is part of the projected expansion. As far as patient volume is concerned, our lab volume has certainly increased with the addition of atrial fibrillation ablations and the increased number of ICD and CRT implants due to the completion of the MADIT I/II, MUSTT, and SCD-HeFT trials. How has managed care affected your EP lab and the care it provides patients? Managed care has changed the way we do business on a day-to-day basis. It has required us to focus more on cost containment and constantly re-evaluate our processes to make sure we are being cost effective without compromising quality of care. Our physicians are extremely helpful and deserve a great deal of credit for their cooperation and efforts. Some patients outside of our managed care contracts require specialized procedures in our EP lab, such as atrial fibrillation ablation. These patients require pre-approval, and this has not been a problem to date. Prior to each EP case, we pre-plan our procedure and determine the best equipment to start with based on the patient s specific findings. This allows us to eliminate use of unnecessary supplies, and more importantly, expensive catheters. Reprocessing of diagnostic catheters was implemented in order to offset the rising cost of technology. 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? We are extremely effective in negotiating our capital purchases with major vendors, and our reprocessing program has saved thousands of dollars. The number of vendors we utilize has been decreased, allowing us to offer exclusivity and the ability to more effectively negotiate product pricing. We have modified many of our procedures and now pre-plan them, decreasing the number of wasted catheters and disposable supplies; this would not be possible without the cooperation of our physicians. Bulk purchases have also offered us the ability to dramatically reduce product cost if it is known that the product will be used in a timely manner. Does your EP lab compete for patients? Has your institution formed an alliance with others in the area? We compete with two other local not-for-profit organizations in the city of Rockford, and we have regional alliances with two smaller hospitals to provide outreach device clinic services. There is a large Medicare/Medicaid base that requires constant re-evaluation of our services and patient satisfaction scores. There is also a large referral base from the greater Rockford region that appears to be shared equally among the three major institutions. What procedures do you perform on an outpatient basis? The majority of our procedures are done on an outpatient basis. Patients who are receiving a newly implanted device or have complex ablative procedures (e.g. atrial fibrillation) require an overnight stay, and are discharged the next morning after follow-up by our staff or field clinical engineers from our vendors. How are new employees oriented and trained at your facility? Up until this last year, individuals who had an interest in EP were trained on the job, utilizing a format similar to that of our general cath lab orientation. Our physicians have been instrumental in educating and making sure those individuals were given opportunities to learn and operate the equipment. We have recently completed a formal EP orientation program that should be in place within the next couple of months. It is currently being reviewed by our electrophysiologists and manager. It is composed of basic, intermediate, and advanced levels that will offer those individuals interested in learning EP a more realistic orientation program and guidelines for successful completion. What types of continuing education opportunities are provided to staff members? We receive the typical continuing education programs from vendors that any other institution has access to, making recommendations for their programs and asking them to design those programs based on our needs. Web-based continuing education programs are sometimes offered as well as small local educational dinners with local, regional, and national speakers. Funding for continuing education programs has been virtually eliminated for many institutions, making it necessary to be more creative and selective of programs. How is staff competency evaluated? Our hospital has an incredible Information Management System that has won many awards for its great achievements. Annual validations are done through our EDUNET learning program at an institutional level, and each department has its own validation program for their specific needs. The cardiac cath lab utilizes the category of low-volume, high-risk need when deciding to develop and implement new validations. Completion of competencies and maintenance of licensure/certifications are reviewed at annual staff evaluations with management. How do you handle vendor visits to your department? Vendors are first of all required to schedule all visits to the lab with the cath lab manager. They are required to report to our purchasing department for a vendor s badge, and then they can report to the lab. Vendors are required to provide some form of continuing education or product review during their visits. Does your lab utilize any alternative therapies? Absolutely; we have an extensive collection of music to satisfy almost anyone s taste and offer our patients the opportunity to listen to music or local radio station during their procedure. We try and encourage our staff to dim lighting after setting up for the case, giving the patient an opportunity to relax and ease into a pre-procedure state of mind. Warming systems are utilized for our patients to keep them comfortable in our cooler envirmonment. Finally, we utilize light humor and a personal approach to each patient s needs as appropriate, to ease any procedural anxiety. Please describe one of the more interesting or bizarre cases that have come through your EP lab. I cannot personally recall any bizarre cases. As far as interesting cases, a few patients who we may have otherwise opted not to perform ablations for AVNRT due to the close proximity of the slow pathway to the AV node have been done with a modified approach. Specialty sheaths for positioning and stabilization of the ablation catheter have allowed us to proceed with great success. We have not yet had an accidental AV node ablation because of our modified efforts. How does your lab handle call time for staff members? How often is each staff member on call? Is there a particular mix of credentials needed for each call team? Being an integrated lab, our staff members regardless of EP responsibilities are required to take call. We take one weekend a month, and average 7-8 days a month on call. Three staff members are on call, and there is a minimum of at least one technologist scheduled with one or two nurses. Typically there are two technologists, and one nurse on call together. Does your lab use a third party for reprocessing? Yes, we use SterilMed Inc., located in Minneapolis, Minnesota. Initially there was great debate about the safety and efficacy of using a third-party reprocessor. After visiting their plant and spending time with their engineers and administrators, it was clear that reprocessing of EP catheters was a viable option. In the first year, our program saved several thousands of dollars, and other areas within the hospital saved even more. Approximately what percentage of your procedures are done with cryo? What percentage are done with radiofrequency? Cryoablative therapy is not currently utilized in our lab. We utilize radiofrequency ablative therapy only. In 2006, we are budgeting for capital purchase of a cryotherapy system. Our decision will be based on preliminary results of the trials conducted by CryoCath Technologies Inc. and their ablative technology utilizing a balloon in the pulmonary veins. Their European trials were very promising, and are now being investigated in the United States. Do you perform only adult EP procedures, or do you also do pediatric cases? Is there cross training for pediatric cases? We provide services for all patients 13 years and older. Should there be a time we begin to perform pediatric cases, our orientation program will reflect that change and staff will be oriented and trained appropriately. What trends do you see emerging in the practice of electrophysiology? I think most labs are trending toward more advanced ablative therapy for arrhythmias, such as atrial fibrillation, and treatment of heart failure patients with CRT implants. I believe ablative therapy that is safe and more effective should be further investigated, such as cryotherapy. Electrophysiology is a dynamic field that has many talented researchers, physicians, nurses, and allied health care providers who possess the desire to advance technologically. I am confident that the future of electrophysiology will be a rewarding one for anyone who accepts its challenges. Is your EP lab currently involved in any clinical trials or special projects? Our program is currently not involved with any clinical trials, although we are open to opportunities. A newly established atrial fibrillation ablation program is in place and we are following patients at appropriate intervals. The Endocardial Solutions Inc. NavX system is our system of choice, and we have completed 10 cases with good results. Does your lab undergo a JCAHO inspection? Yes we do! In fact, having just completed our most current JCAHO inspection in June, I am proud to say that we as a hospital and organization showed why Rockford Memorial Hospital is one of the best hospitals in our region. There were no major infractions. The inspectors were impressed with the overall attitude and friendliness of hospital personnel. They were also impressed with some of the processes we had in place to make sure the national patient safety goals were implemented in our daily practice. 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? Rockford Memorial Hospital has been involved with the Mended Hearts program for approximately two years now. We have a local chapter with several members. The Mended Hearts program is nationally recognized by the American Heart Association, and serves all who have an interest in or who have been afflicted with any form of heart disease. Our institution offers to the general public several educational programs annually that are hosted by local and nationally-recognized speakers. Give an example of a difficult problem or challenge your lab has faced, and how was it addressed. Probably one of the more difficult problems encountered in any organization is finding a way to retain competent staff members who fit in as an integral part of the team. Our lab has a team approach to everything we do, and retention of staff members is no different. There was a period of time in the past where our attrition rates ballooned, and retention was difficult. We began to utilize an interview process that included our own staff members, and their input was instrumental in hiring of new personnel. As a group, we recognized a vision that each of our needs was as important as the others. To succeed, we would need to build a culture in the lab that preserved that vision, and we would need to share in the responsibility of hiring future colleagues. Describe your city or general regional area. How does it differ from the rest of the U.S.? Rockford is the third largest city in Illinois, with a metropolitan population of approximately 300,000. There are a large number of smaller cities and towns in the greater Rockford area, and we are approximately 1.5 hours from both downtown Chicago to the east, Madison and Milwaukee Wisconsin to the north. Each year there are a large number of festivals and events, including Rockford s annual "On the Waterfront," a week-long celebration in September with great music, entertainment, food, and drink. Please tell our readers what you consider unique or innovative about your EP lab and its staff. I think all EP labs are to some degree unique and innovative, some more than others. I oftentimes hear friends and professionals I know from other institutions describe their working environments as less than satisfactory. Our lab has been designed to promote respect for every staff member s professional and sometimes even personal opinion and needs. We offer a customer service oriented approach to health care, meanwhile recognizing the individualized needs of each patient. Our physicians are extremely complimentary, and assist our staff in realizing that approach to patient care as well as our individual professional growth; therefore, our success rates in the lab are very high and our complication rates are very low. Our patient satisfaction scores are outstanding, and we have a group of professionals who embrace the opportunity to work together as a team in every possible way. What more could anyone ask for? For more information, please visit: www.rockfordhealthsystem.org