The Value of Education in the EP Lab

Rick Hood, RCIS/NASPE Testamur EP & Pacing
Rick Hood, RCIS/NASPE Testamur EP & Pacing
For those of us who have worked in the field of medicine, the advances of science have provided us with new and improved ways to heal and repair the body. The changes that we deal with are sometimes small improvements to an established process, while at other times they are monumental breakthroughs that restructure the way we approach the world of medicine. Dealing with major alterations in the workplace can be one of the most difficult aspects medical professionals must face. Invasive cardiology is one area of medicine that has faced some significant modifications over the past 20 years. The onset of percutaneous coronary intervention was a major transition in therapy. Patients who would have previously been sent to surgery for revascularization, were now being treated in the cath lab. This represented a major shift in how cardiac medicine was administered. Another major change in the field of cardiac medicine was the introduction of electrophysiology. In the past, there were primarily two methods to deal with abnormal cardiac rhythms. If a patient s heart rate went too slow, they would receive a pacemaker. If the problem were a tachyarrhythmia, the patient could be treated using medications. While these therapies were effective in controlling many rhythm problems, they did not resolve the underlying causes. With the onset of cardiac electrophysiology, problems in the conduction system of the heart could be precisely located. Once found, many of these problems could be corrected using a process known as ablation. Arrhythmias that had previously been difficult to control using conventional treatments could now be cured completely. This was a profound change in cardiac medicine that required cath lab staff members to learn a whole new approach to dealing with abnormal rhythms. The actual technique utilized in performing an electrophysiology procedure is very similar to that which is used in a standard cardiac cath lab. Catheters are delivered to the heart through vascular introducers. Access is usually from a femoral approach though there are times when an internal jugular or subclavian approach may also used. These catheters are maneuvered into position to allow the recording of specific information. If a problem is identified, a second type of catheter is placed for interventional purposes. The technique described here could be applied to both cath and EP procedures. This similarity of technique makes it easy to assume that anyone who works in a cardiac cath lab will be able to switch over to work in an EP lab without a lot of effort. This is usually not the case. Most of the time, the transition from a standard cath lab to an EP lab is a long and uncomfortable process. There are a number of factors that explain why the transition to electrophysiology can be a difficult one. The first fact to recognize is that electrophysiology and cardiac cath labs operate at different paces. Many people who work in the lab will enjoy doing heart caths and angioplasties, yet dislike EP studies. This is often due to the differences in workflow for each of these procedures. While the pace in a standard lab is usually very steady and often hectic, the EP lab will have periods of time when things move a bit slower. Many of the people who work in cath labs will be uncomfortable with this slower pace. The second area of difficulty in the transition to an EP lab involves the type of monitoring equipment that is utilized during these studies. The systems that are used for caths and EP procedures appear to be similar at first glance. These apparent similarities make it is easy to assume that a staff member who is proficient in using a cath lab hemodynamic monitoring system will have little difficulty in making the transition to using the electrophysiology equipment. There are, however, some significant differences involved in how each of these pieces of equipment operate. In order to get an idea of how difficult this change may be, we need to look closely at the function of the recording systems. The electrophysiology procedure relies on gathering information about the electrical conduction system of the heart. This data is collected using catheters that operate similar to temporary pacing wires; they sense intrinsic activity and can deliver pacing stimuli to the myocardium. By placing these catheters at strategic locations within the heart, a map of the electrical activity within the patient s conduction system can be created. Once the native signals are documented, stimulation tests are performed to locate abnormalities that may contribute to various arrhythmias. Interpreting the results of the recordings collected during the testing process requires the operator to look at the electrocardiographic signals in an entirely new manner. Given the amount of information that is recorded and how it is displayed, learning to read this new language is, for most people, a difficult task. Standard hemodynamic recording systems will usually display two or three surface electrocardiograms and one or two pressure channels. An electrophysiology study to evaluate supraventricular tachycardia will often display three surface leads and eleven or more intracardiac recordings. These tracings will often be presented on the monitor at four times the standard sweep speed of 25 mm/second. For the untrained eye, deciphering even the most basic information from the recording system will require an extensive amount of practice. Achieving a level of proficiency in reading the intracardiac signals of an EP study requires patience and dedication. Without an active interest in electrophysiology, it will be difficult for the lab staff to acquire the abilities needed to effectively contribute to the procedure being performed. If the physician can not rely upon the staff assisting him, it will be difficult for the EP program to become successful. The staff member who operates the monitoring system is not alone in facing new challenges while learning electrophysiology. All the staff involved will need to adopt a different approach to dealing with some of the cardiac arrhythmias that may occur in the lab. While these events are infrequent during diagnostic caths and angioplasties, they become sought after goals during an EP study. Trying to cause an arrhythmia goes against the basic teachings of cath lab professionals, yet discovering aberrant rhythms is the primary goal of electrophysiology procedures. In order to solve the patient s problem, you must first identify it. In order to do this, you must expose the rhythm that is causing the patient s symptoms. Once the abnormal rhythm is triggered, it is often necessary to maintain it while information is collected to allow an accurate diagnosis of the underlying cause. For staff members who are new to EP, it can be a bit unnerving to stand back and wait while the person under your care is experiencing a significantly abnormal cardiac rhythm. This becomes especially difficult to deal with when the arrhythmia involved is ventricular tachycardia. Before electrophysiology, dealing with ventricular tachycardia was a pretty basic event. If it happened, you treated it by doing what it took to make it go away. With the introduction of EP, ventricular tachycardia has become an entirely different animal. This familiar creature of the wild turned out to be a whole group of creatures, each one a little different from the others and each one requiring a specific therapeutic approach. VT could now be broken down into classifications such as monomorphic, polymorphic, bundle branch reentry, fasicular reentry, torasdes, hemodynamically stable or unstable. Suddenly, dealing with v-tach had become a significantly more complex event. When a ventricular arrhythmia is induced in the lab, it must be handled differently than it would be during a diagnostic cath or coronary intervention. While the first instinct of most lab staff is to defibrillate the patient immediately, there are times in the EP lab when doing so becomes counterproductive. Some forms of ventricular tachycardia can be treated using a therapy known as anti-tachycardia pacing, or ATP. ATP is performed by delivering short bursts of pacing stimuli at intervals faster than the rate of the tachycardia. The goal is to override the arrhythmia and then suddenly stop the pacing signals. It is possible to restore a normal cardiac rhythm using this technique, though several attempts at ATP may be required before success is achieved. During this time, the staff must stand by in a state of readiness in case cardioversion or defibrillation becomes necessary. When coronary intervention was introduced to the lab staff, most had very little difficulty in adjusting to this new procedure. One reason for this was that it was easy to understand the why of what was being done. It was fairly clear that the purpose of advancing a wire and a balloon across a lesion in a coronary artery was to help produce a larger channel for blood flow. People didn t even have to apply conscious thought to this fact it was obvious. Electrophysiology, however, does not present this clear, easily understandable methodology. While it is not difficult to understand what is being done, deciphering why it is being done can be a difficult task. One component of the EP study where the reasons behind the actions are difficult to fathom (are easily lost) is programmed stimulation. Before the introduction of EP, the reasons why a patient may need pacing therapy had always been simple. The pacemaker provided a safety net when the patient s intrinsic rhythm went to slow to meet their basic metabolic needs. With programmed stimulation, however, pacing runs were being delivered in short bursts at varying intervals that were all faster than the patient s heart rate. The purpose of using pacing signals in this way did not seem to make a lot of sense. In order for the staff to understand why programmed stimulation is utilized as a testing protocol for electrophysiology, they would first have to learn about the underlying mechanisms of reentry arrhythmias. This was an area of cardiac science that most lab staff had never been asked to learn. In the past, it had been important to know how to treat arrhythmias. There were also times when knowledge of contributing factors, such as low potassium or proarrhythmic side affects of specific medications, were important to be aware of when caring for a patient. Learning about the specific mechanisms of arrhythmias had always belonged to the realm of the physician. When many EP programs started, it did not seem important to impart this knowledge to the staff. There seemed to be a general belief that as long as the staff understood what specific actions were necessary during an EP study, that would be enough. Yet working without a full understanding of what was being done became a significant burden on many lab staff. One of the most frequently voiced complaints that I have heard from nurses and techs who dislike working in the EP lab is that they don t understand what is going on. Having staff work through a procedure without comprehending the purpose behind the actions creates feelings of uncertainty that can lead to mistakes. It is far more preferable to have the staff completely comfortable with every aspect of what they are doing. This creates an environment that medical professionals will enjoy working in. When the staff are happy with their work, the level of performance increases and the program, as a whole, will benefit. Education is the key to starting a successful EP program. When you are planning to add electrophysiology procedures to your cardiac program, there are several steps that will help prepare your staff for the transition. First, select a core group of staff members to become your EP experts. Ideally, two nurses and two techs should be utilized. The nurses should be able to alternate between scrubbing and circulating. The techs should also be able to scrub as well as operate the monitoring system. Having four people who can switch between roles like this will prevent anyone from being overwhelmed in the early stages of the program. These four staff members should be the only ones to work in the EP lab until they are proficient enough to teach others. When this happens, other staff can be added in as necessary. Also, when you are selecting your core group, give them the opportunity to experience an EP study before you make the decision to move into the EP lab. Schedule time for the group to visit an EP lab for a few days to see some actual procedures. This will give them an idea what working in electrophysiology entails. Once the core group has been selected, providing education becomes the next major task. Second, before you schedule the first case, your staff should attend classes or visit an EP lab that can provide them with training. There are a number of areas that present significant difficulties during the early days of a new program. Providing the staff with information about these events will give them a higher comfort level for the first few cases. It is often helpful to have an experienced person available on site for the first several cases to provide guidance when your staff have questions. If possible, schedule a group of cases together over a short period of time. The intensified exposure makes it easier to retain new knowledge. It is also easier to have an outside person available for more cases if they are scheduled closer together. Once the staff becomes comfortable with the work they are doing, the program should advance without excess difficulty. Next, the core group should attend formal classes in EP within the first year of starting your program. The learning curve for electrophysiology tends to be a pretty steep one, so sending the staff to classes too soon may be ineffective. As the program progresses, continue to make educational materials available. It takes time to become completely comfortable with electrophysiology, so repeated exposure to outside ideas can be very helpful in the long term development of the EP staff. Finally, whenever you set out to add new procedures to your service line, there are always significant costs to deal with. The trick is spending money efficiently so that you receive the greatest return on your investment. When starting an electrophysiology program, there is no more valuable asset then a knowledgeable staff. By providing education in the early stages of development and continuing to make information available as the program grows, you are giving your lab the best chance for success.