Spotlight Interview: Morristown Memorial's EP Lab

Jay H. Curwin, MD, Robert F. Coyne, MD, Stephen Winters, MD
Jay H. Curwin, MD, Robert F. Coyne, MD, Stephen Winters, MD
In the last nine years, the cardiac rhythm management program at Morristown Memorial Hospital has grown from one lab with a single cardiac electrophysiologist and three full-time staff members to a full service arrhythmia management team, comprised of three board certified electrophysiologists, two full-time technologists, seven nurses and two office staff members. In addition, we work with a full-time cardiac research nurse coordinator and three additional research nurses. At our facility, we perform comprehensive electrophysiology studies, radiofrequency ablations for both ventricular and supraventricular tachycardias, pacemaker and defibrillator implantations, and tilt table testing. The complication rate is extremely low and compares to that of other outstanding laboratories on both a local and national level. Our laboratory has a full-time physician director as well as a nurse coordinator. In our institution, the electrophysiology laboratory is a separate entity from the cardiac catheterization laboratory, although our 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. The facility that houses the electrophysiology laboratory was previously the hospital s radiology special procedures room. Subsequently, the area served as the first diagnostic and interventional cardiac catheterization laboratory. However, towards the end of 1991, the space occupying roughly 1,100 square feet was renovated to become the electrophysiology laboratory. For the first five years, the radiology equipment present was still an old, non-mobile, Siemens image intensifier in conjunction with a cradle designed table. Fortunately, the laboratory s orphan status changed and a modern, General Electric pulse-fluoroscopy system replaced the nearly two-decade-old system, in 1997. Extremely conscious of the need for radiation safety, the staff typically operates the radiologic equipment with the lowest output and at a relatively slow pulsing rate. There are strict regulations for monitoring the dose (DAP) during procedures and notification mechanisms for preventing excessive exposure to patients, as well as to the staff. In recent years, new equipment has been added to the electrophysiology service to allow for ongoing state of the art patient care. The Biosense Carto mapping system has been very useful in the performance of complex ablations for atrial flutter, atrial tachycardia, accessory pathways, and ventricular tachycardia. A Prucka NT CardioLab upgrade has replaced the pre-existing computer-based physiologic recording system. However, we still maintain a classic Bloom rack system in the coronary care unit procedure room as a back-up. Similarly, we have two Bloom stimulators available for use, should one malfunction at any time. New radiofrequency generators have also recently been introduced into our laboratories. Images can be stored via a high definition video system or directly on the Prucka system. We are also investigating incorporation of our image storage into the Heartlab networked digital storage system that the interventional catheterization laboratory (which now contains 5 rooms) uses. We are finalizing the purchase of an intracardiac ultrasound system to enable safer performance of transseptal procedures. Presently, we rely on transesophageal echocardiographic guidance of trans-septal punctures to enhance patient safety. In addition, all tilt table tests are performed in a small space adjacent to the patient entry area to the laboratory. All procedure scheduling is performed via the main clinical office, located adjacent to the physicians hospital-based offices and exam room. A full-time office manager and secretary are responsible not only for scheduling, but for report editing and dissemination, instructing patients, and coordinating activities among the various staff members as well as between the staff and the hospital. Catheters and sheaths are removed in the laboratory immediately after procedures by the physicians, or at times assisted by staff members. In cases where patients may have received high doses of intravenous heparin, a cardiac technician dedicated to the removal of angioplasty sheaths will often remove in-dwelling sheaths from our patients on a telemetry patient care unit. In all cases, hemostasis is obtained by manual compression, without the use of closure devices. Inventory is managed by the full-time nurse coordinator, as well as by the two lab technologists. More costly or niche equipment and supplies are always purchased with appropriate physician and nurse input. Although our Electrophysiology Laboratory contains state-of-the art equipment, the square footage has not changed at all since the lab opened nearly a decade ago. Nevertheless, patient volume has risen steadily over this time. Managed care has required that procedures be performed more promptly than ever, with extreme attention to maintain costs, but with no compromise in patient outcomes and safety. The laboratory has consistently contained costs by using only the necessary equipment, well thought-out in advance, to perform procedures safely, minimizing waste. Further, high-ticket items such as implantable devices are selected based upon patient need (i.e., single versus dual chamber devices) and not on a routine basis. Device manufacturers must remain competitive with respect to pricing. The cardiac rhythm management staff provides outpatient evaluation and management services in hospital-based offices, geographically separated from the laboratory. Ancillary noninvasive tests are obtained through the hospital s available services, or via the patient s personal cardiologist s office. Patients with implantable defibrillators are followed at regular intervals. For patient satisfaction, as well as for insurance of optimal management, one of the electrophysiologists is present at each interrogation session. When the laboratory was inaugurated, information on patients who underwent clinical procedures was tracked on a database constructed with dBase software. Relevant data on all patients undergoing procedures in the cardiac electrophysiology laboratory, as well as on all ICD implants is presently maintained on a customized Filemaker database. Data are routinely uploaded onto each physician s personal digital assistants to enable instantaneous access when we are contacted about patients at any time of day or night. The arrhythmia service is presently finalizing a purchase of an up-to-date commercial Paceart data management system that will be linked with the hospital s comprehensive computer network. New employees in our hospital all participate in a formal orientation program. Furthermore, newer staff members who may be very experienced in other aspects of cardiac care, but who are new to the electrophysiology service, undergo extensive training before being asked to work independently. Continuing education is important both to the physicians as well as to nurse and technologist staff members. In addition to attendance at national meetings, staff members have participated in courses throughout the country, both for ongoing education in electrophysiology, as well as for education for more specific reasons, such as when new equipment has been installed. Our electrophysiologists are extremely active in local, state, and national professional organizations. At present, the Arrhythmia Service medical director is also the Governor of the New Jersey state chapter of the American College of Cardiology. Our physicians have served on numerous committees of NASPE, as well as the ACC, and we have also been pivotal in the founding of the New Jersey Society of Pacing and Electrophysiology, which holds periodic statewide meetings. We continue to participate in numerous controlled, randomized clinical trials, which are oriented toward patient welfare. The physicians remain active in the submission of clinical abstracts and presentations at national professional meetings. In addition, we are very active in the education of medical housestaff, students from the University of Medicine and Dentistry of New Jersey, and ancillary staffs. We serve on numerous hospital committees, including the Medical Executive Committee, the Cardiac Care Committee, the Pharmacy and Therapeutics Committee, the Cardiopulmonary Resuscitation Committee, the Research Committee, the Performance Improvement Committee, and the Information Systems Committee. Staff competency is evaluated on several levels. The nurse coordinator, who directs these evaluations to her immediate supervisor, performs the primary evaluations. There are periodic competency assessments for use of conscious sedation, radiation safety, and defibrillation. In-service sessions are periodically held regarding new technologies and procedures. Staff meetings with the physicians present are regularly conducted. The electrophysiology laboratory does not have a formal call schedule for staff members. The service is fully staffed from 7 am to 7 pm, Monday through Friday. However, the dedicated members of the arrhythmia service are frequently called upon to work well into the evening to complete procedures, and at times, to assist with procedures on weekends as well. There is no evening call, and each staff member has at least one or two days off during the week. Quality assurance is measured on several levels. First, there is a monthly cardiology conference at which both cardiac catheterization laboratory as well as electrophysiology laboratory complications are presented. Fortunately, as mentioned above, complications have been extremely uncommon. Another conference held with the greater cardiology staff is devoted to the presentation of interesting lectures or cases pertinent to cardiac rhythm management. As noted above, one of the electrophysiologists serves on the department s formal Performance Improvement Committee as well. Any problems which may occur as system errors are carefully explored, leading to the development of mechanisms to prevent recurrences. In addition, formal reporting to the state is required, both with respect to procedure numbers as well as complication rates. The electrophysiology laboratory has been inspected by various parties including JCAHO, and has exceeded expectations both for efficiency and cleanliness. Electrophysiology staff members have coordinated a quarterly patient support group which has been well attended and which appears to have improved patient morale and acceptance of implantable defibrillators. A formal presentation as well as dinner is provided at each session. All staff members, including secretarial, nursing, technical staff and physicians, are represented at each meeting. Topics related to general cardiac wellness, as well as rhythm management are presented. The social and psychological well-being of the patients is addressed as well. Patients and their families have also well received a quarterly newsletter, which is mailed to them. The cardiac rhythm management program, like many similar services, is constantly facing new challenges. Significant space constraints, scheduling conflicts, rising costs in conjunction with diminishing hospital reimbursement, and increasing patient expectations are constantly providing new challenges to health-care providers. Nevertheless, professionalism and dedication have allowed us to continue to provide the excellent care that our patients deserve. The staff members (including the physicians) relate to each other as members of a close-knit family. Everyone s input is vital to the success of the program. Via informal daily meetings, periodic staff meetings, birthday and other family celebrations, and occasional group outings, each member of the team strives to respect and appreciate each other as much as we do our own true families. If you d like more information about Morristown Memorial Hospital, please visit http://www.atlantichealth.org/hospitals/morristown/main.asp