Email Discussion Group: August 2007

New Questions: EP Protocols/Procedure Lists We are expanding into EP procedures (i.e., ablations, EPS, mapping) when our EP lab opens soon. We would very much appreciate some help with protocols/procedure checklists for EPS, ablations (right atrial and AV nodal), and CRT-D procedures. We are very experienced with caths, interventions, pacer and ICD insertions, but are starting an EP service from scratch. Thanks for your help! Cindy Muto, RN (To reply to this question, please type EP Protocols in your subject line.) ICD Complication Rates What are the national averages for lead dislodgements for ICDs? Thanks for your help! Anonymous (To reply to this question, please type Complication Rates in your subject line.) Alcohol Septal Ablation Does anyone have, or are they willing to share, established written procedures for this procedure? In addition, if performing this procedure, do you use ECHO contrast? If so, how is it administered? name withheld by request (To reply to this question, please type Alcohol Septal Ablation in your subject line.) Under Discussion: Catheter Placement Competency Check-Offs I would like a job description and/or competency check-off list for placement of EP catheters during diagnostic studies by allied health professionals. Does any facility out there have a policy or procedure regarding this? If so, I would like a copy! Vicki Maestas, ARRT R.T.(R)(T)(CV), CVRT/EP, Banner Baywood Heart Hospital (To reply to this question, please type Catheter Placement Check-Off in your subject line.) We have three or four techs who are permitted to put in arterial and venous lines and catheters. We limit the number of techs who do this to two or three. They must do 50 sheath insertions under direct observation of the medical director and then they get signed off. They then must do at least 25 a year to maintain that competency (we track their numbers quarterly). We also track complications anytime there is a vascular complication, we look at who put the lines in. So far, none of our techs have had any complications. Sue Deck, BS, RN, EP Educational Coordinator, Lancaster General Hospital, Lancaster, PA Back-up Defibrillator for EP Lab (Second Defibrillator) A question that continues to be brought up in our lab is that a second defibrillator is required in case of failure of the primary defibrillator. We have tried to find if this is a standard recommendation, etc. Do you have any insight as to where this information can be located, if it in fact exists? Mary Hosler, RN, BSN, Bay Regional Medical Center, Bay City, MI (To reply to this question, please type Back-up Defibrillator in your subject line.) We do not know of any standing protocol regarding two external defibrillators in the EP lab. However, our lab does possess two defibrillators on a daily basis. Our physicians depend on having the second as a back-up, especially in VT cases. As a matter of fact, we place a defibrillator on either side of the patient in said cases. As an example, we had a VT ablation in which a rapid VT was induced and the first defibrillator failed to cardiovert as a result of an internal error. The back-up was quickly attached, and disaster was averted. If you have the means, having two defibrillators in the EP lab provides a nice level of comfort for all cases. Edmund Donovan, CN II, New York Presbyterian Hospital-Columbia, New York, NY I don t know where it came from, but we follow the same routine, so in any ICD or EP case we have two defibrillators. We have used the second one twice (that I can think of) in nine years. Once was to shock with both defibrillators at the same time. name withheld by request Regarding back-up defibrillators, I do not know if there are any guidelines out there regarding that, but we do sometimes hook patients up to two defibrillators. We do not do that for every patient, though. It depends on the procedure type and the patient's medical history. Sue Deck, BS, RN, EP Educational Coordinator, Lancaster General Hospital, Lancaster, PA In Practical Electrophysiology, written by Dr. Todd J. Cohen, he states, The electrophysiology laboratory requires at least two external defibrillators, one a backup in case the primary one fails" (page 37). I hope this answers your question. Since we are inducing VT/VF, most labs consider this a standard of practice. Christine J. Reoch, RCIS Billing for Transseptal Punctures I have a question regarding billing for transseptal punctures. Our billing department at New York Hospital states that we cannot bill for a transseptal puncture during an atrial fibrillation (AF) ablation because it falls under the category of access. This is confusing to me as the cath side can bill for the same procedure under a valvuloplasty. How do other institutions, or do you, bill for this portion of the AF procedure? Thanks. Edmund Donovan, RN, CN II, New York Presbyterian Hospital, New York, NY (To reply to this question, please type Billing in your subject line.) Here in Nevada, we are in the same arena as you are: we cannot bill for transseptal punctures, either. D.L. Hart, RCIS, Valley Hospital Medical Center, EP Lab, Las Vegas, NV Billing for transseptal access for any procedure requiring entrance into the left atrium can be billed with CPT code 93527 (combined right heart catheterization and transeptal left heart catheterization through intact septum with or without retrograde left heart catheterization). In the Med Learn 2007 Cardiac Rhythm Management Coder manual (pages 70-72), it clearly indicates that reporting of 93527 should include all elements of reporting and performance relating to catheterization including pressure measurements. If you chose to bill for this procedure, the physician must dictate that information and procedure including both left and right heart pressures. Utilizing pressure measurements also helps to confirm appropriate access into the left atrium. We have successfully billed for this procedure when appropriate since the inception of our atrial fibrillation program four years ago. Good luck! I hope this helps to clarify with your future billing. James H. Combs, EMTP, RCIS Working in the United States: State Licensing I am a cardiac physiologist (CVT) from the United Kingdom, and am trying to find out about state licensing. Do I need to be licensed to work in the United States? There seems to be variance from state to state. Stuart Allen, Southampton General Hospital, Southampton, Hants, UK (To reply to this question, please type Working in the US in your subject line.) There are no licenses required here. There are CVT positions: Cardiovascular Techs, which have either been to a school or on-the-job trained. Then there are RCIS positions: CVTs that went to school or were on-the-job trained that have PASSED the Registry Exam, hence RCIS (or Registered Cardiovascular Invasive Specialists). To prove the passing of the Registry exam, you must have your Registry Certificate. Many hospitals pay more hourly wage to those who are Registered. For more information, you can contact Cardiovascular Credentialing International (CCI) at Hope this helps! D.L. Hart, RCIS, Valley Hospital Medical Center, EP Lab, Las Vegas, NV