Spotlight Interview

Spotlight Interview—Arkansas Heart Hospital

Monica Lo, MD, FACC and Ashley Hixon, BSN, RN, RCIS, MHA
Little Rock, Arkansas

Monica Lo, MD, FACC and Ashley Hixon, BSN, RN, RCIS, MHA
Little Rock, Arkansas

Arkansas Heart Hospital and area heart specialists have joined together with the goal of assembling the finest facilities, most advanced equipment, and most highly skilled health care professionals at one site. From the hospital’s inception, physicians have been active in planning our specialized care facility. Arkansas Heart Hospital is a nationally recognized and award-winning hospital dedicated to the prevention, diagnosis, and treatment of cardiovascular disease. We offer advanced technology, teamed with a highly trained support staff as well as Arkansas’ leading cardiologists and cardiovascular surgeons.

The hospital operates six cardiac labs, three operating suites, and a 24-hour Heart Emergency Center. Arkansas Heart Hospital is a training center for physicians from all over the world.

Arkansas Heart Hospital is built for patient-focused care. Our patients have access to advanced technology and surgical techniques in a hospital specially designed for their treatment and recovery. From admission until discharge, patient care focuses on personal needs, comfort, and convenience. All rooms are private, designed and equipped for each stage of patient care. As much as possible, we bring services to the patient to minimize the transporting of patients. We encourage family involvement in the recovery process and provide a comfortable setting for all individuals. Arkansas Heart Hospital consistently ranks #1 in the state and in the top 1% in the nation for patient satisfaction!

What is the size of your EP lab facility?

Arkansas Heart Hospital is a 110-bed for-profit acute care facility. Built in 1996 and opened in 1997, the hospital has four cath labs, two EP labs, three ORs, eight PACU beds, eight ER beds, and 27 outpatient beds. The facility is Joint Commission Accredited.

What is the number of staff members?

The EP and cath lab departments are combined and consist of 32 staff members. Six of these staff members work primarily in the EP lab. On an average day, the two EP labs are staffed with a mixture of five RNs and RTs.

What is the range of credentials at your lab?

The required credentials for the lab are an RN and RT. After one year of employment, obtaining a Registered Cardiovascular Invasive Specialist (RCIS) is required of the RNs.  

What types of procedures are performed at your facility?

Procedures include device implantations, EP studies, and complex ablations. Approximately 50 catheter ablations, 35 ICD implants, and 30 pacemaker implants are performed each month.

Who manages your EP lab?

The EP lab is managed by the Director of Outpatient Services, Ashley Hixon, in collaboration with the Medical Director, Dr. Scott Beau.

How is shift coverage managed? What are typical hours (not including call time)?

Staff members work 12-hour shifts (7am-7pm), three days a week. First cases are scheduled at 7 am, with the last elective cases scheduled at 6 pm. A typical day includes two EP physicians working, with 8-12 cases.

What new equipment, devices and/or products have been introduced at your lab lately?

One of our EP labs underwent renovation approximately eight months ago, with installation of updated Siemens X-ray equipment as well as St. Jude Medical’s EP-WorkMate and MediGuide System. We were one of the first centers in the United States to have MediGuide, which has reduced our fluoroscopy time tremendously. Our newest EP physician, Dr. Monica Lo, was the first to perform complex ablations such as atrial fibrillation (AF) and ventricular tachycardia ablations at Arkansas Heart Hospital. With MediGuide and 3D mapping, our fluoroscopy time for an AF ablation is well under 10 minutes. We will also soon introduce St. Jude Medical’s TactiCath contact force catheter to improve procedural outcomes.

Who handles your procedure scheduling? What software is used?

The hospital has a centralized scheduling department that utilizes Siemens’ Soarian software.

What type of quality control or assurance measures are practiced in your EP lab?

Measures include radiation safety for staff and patients, ACC registries, concurrent monitoring of clinical documentation, timeliness of documentation, clinical indications for procedures, and antibiotic administration timeliness.

How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies?

An RT in the EP lab is in charge of assessing the supply needs for the EP lab. The order is then given to the department’s Inventory Control Specialist.

How has managed care affected your EP lab and the care it provides patients?

Arkansas Heart Hospital continues to be at the forefront of innovation to provide excellent patient care despite increased regulations and the need for cost containment. We take pride in having one of the highest patient satisfaction scores in the United States. We introduced the use of CRNAs in our labs for improved sedation and pain control for our patients. Additionally, we have re-focused our efforts on improved documentation for medical necessity, and have put an emphasis on decreasing costs of devices and other supplies required for these cases.

What measures has your EP lab implemented in order to cut or contain costs as well as improve efficiencies in patient through-put?

Vendor contracts are carefully reviewed to ensure appropriate pricing. The procedural documentation software contains the cost of supplies, so that the information is readily available for the staff to verbalize to physicians during the procedure. We also post the monthly procedural volume and cost per physician in the department to raise awareness.

How does your lab communicate necessary information to staff?

Information is communicated via email, staff meetings, and a communication board in the staff lounge. Information of high importance is best communicated face to face with team members.

How do you ensure timely case starts and patient turnover?

Using a patient-centered approach, the team ensures that the cases start on time. The departments within the hospital work well together to ensure the patient is prepped and ready for their scheduled procedure time. Patients arrive at least two hours prior to the procedure start time. To decrease the time spent on waiting on lab results, patients are pre-tested up to 10 days prior to the procedure. The EP staff has been trained to complete terminal cleaning between each patient for improved turnover times. EP staff and physicians also communicate often to facilitate smooth and timely progress.

How are new employees oriented and trained at your facility?

All new employees are paired with a preceptor for a specific period of time. The orientation phase is individualized depending on the team member’s previous experience.

What types of continuing education opportunities are provided to staff members?

Vendors frequently schedule in-service days on new technology, and the Arkansas Heart Hospital presents an annual Heart Summit that focuses on cardiovascular health and developments within the field.

How is staff competency evaluated?

Evaluation of staff competency is ongoing. New employees receive a 30-, 60-, and/or 90-day review (based on each individual) as well as annual evaluation for all employees, which includes a skills lab checkoff.
Do you encourage your clinical staff members to take the registry exam for the Registered Cardiac Electrophysiology Specialist (RCES)?

Currently the only registry exam required is the RCIS exam for our RNs. Employees are encouraged to continue their education in specialty areas and are reimbursed for exam fees after successful completion of the exam.

How do you prevent staff burnout? Do you also practice any team-building exercises?

Many of our cases are complex, so burnout is a huge concern. We currently staff three 12-hour shifts, but most work more than that every week. We provide paid trips for continuing education conferences such as Heart Rhythm, TCT, and other local training mixed with fun. The staff members have a voice in how things are run, and there is an open-door policy with management.

What committees, if any, are staff members asked to serve on in your lab?

Committees include Radiation Safety and Performance Improvement.

How do you handle vendor visits to your department? Do you contract with vendors?
Our hospital uses RepTrax for all vendors. Specifically in the EP lab, we work closely with device representatives who share our focus on teamwork and patient satisfaction.

How does your lab handle call time for staff members?

Monday through Thursday call begins at 7pm and ends at 6:30am. This call team consists of four team members, two of which must be RNs. Depending on staffing levels, each team member is usually on call once during the week and a full weekend every four to five weeks. The weekend call crew works often, usually 12-20 hours over the call period.

Does your lab use a third party for reprocessing or catheter recycling? How has it impacted your lab?

We use Stryker Sustainability Solutions for reprocessing of our EP catheters. This service saves nearly half the cost of catheters, which can be reprocessed four to six times each.

Approximately what percentage of your ablation procedures is done with radiofrequency vs cryo?

All procedures are currently done with radiofrequency.

Do you perform only adult EP procedures or do you also do pediatric cases?

We mostly do adult procedures, though we do occasionally treat teens and younger adults.

What measures has your lab taken to reduce fluoroscopy time and minimize radiation exposure to physicians and staff?

We provide frequent education to staff and physicians regarding radiation safety. Monthly and annual radiation exposure reports are provided to staff and physicians. The 3D mapping and MediGuide systems also allow for reduced exposure.

What are your methods for infection prevention?

We treat our EP labs as an operating room. Additionally, patients are prepped with chlorhexidine wipes before the surgical scrub. Antibiotics are given during device procedures in a timely fashion.

What are your thoughts on EHR systems? Does it improve your quality of care?

Transitions to EHR systems can be costly and difficult. However, after the initial growing pains associated with so much change, we have seen improvements in patient care. Increased accessibility to patient charts from current and prior encounters helps our staff prepare for each procedure with the individual in mind. This increases patient safety and satisfaction.

How is coding and coding education handled in your lab?

We use an online coding system to code each case after completion. Nurses and techs are trained by company representatives, and staff members with additional training are “super users” available to help.

Is your EP lab currently involved in clinical research studies? Which ones?

We have a very active research division, one of the busiest in the nation. We are actively pursuing investigator-initiated research. Below are some of the ongoing studies:

  • AnalyzeST (ST Monitoring to Detect ACS Events in ICD Patients). The intent of this study is to demonstrate the safety and effectiveness of the ST Monitoring Feature. ST segments are monitored 24/7 and have the availability to vibrate from the ICD if there is a significant change or shift in the ST segment to get the patient’s attention to assess their symptoms and go to the ER if needed.
  • SJ4 (Post Approval Study). The purpose of this study is to characterize the chronic performance of the St. Jude Medical SJ4 connector and RV high voltage SJ4 lead in patients that have an approved indication, as per ACC/AHA/HRS guidelines, for implantation of an ICD or CRT-D system for treatment of heart failure or life-threatening ventricular tachyarrhythmia, and who are not currently participating in a clinical investigation.
  • MultiPoint Pacing IDE Study (MPP IDE). The intent of this study is to evaluate safety and efficacy of the Quadripolar CRT-D device system (with MPP feature) when compared to standard BiV pacing in patients that are indicated for a CRT-D device. The MPP feature has the capability to pace from two vectors on the LV lead.
  • Accent MRI Pacemaker and Tendril MRI Lead IDE Study. The intent of this IDE study is to evaluate the safety and effectiveness of the implanted Accent MRI system, which includes the investigational St. Jude Medical Tendril MRI lead and Accent MRI DR pacemaker in the MRI environment. The MRI Activator is also investigational. The patient population under study includes patients with a standard bradycardia pacing indication in the U.S.
  • QuickFlex 1258T PAS. The purpose of this post approval study is to evaluate the acute and chronic performance of the St. Jude Medical QuickFlex® µ 1258T LV lead in a patient population indicated for implantable cardioverter-defibrillators and cardiac resynchronization therapy.
  • Quadripolar Pacing Post Approval Study. The purpose of this post approval study is to evaluate the acute and chronic performance of the St. Jude Medical Promote® Q and Promote® Quadra CRT-D and Quartet Model 1458Q left ventricular heart lead in a patient population indicated for cardiac resynchronization therapy.
  • St. Jude Medical Cardiac Lead Assessment Study (SJM CLAS). This study is a prospective, non-randomized, multicenter, international post market study that will determine the incidence of externalized cables and the risk of progression to electrical malfunction in a large series of ICD/CRT-D devices containing the St. Jude Medical Riata or Riata ST family of Silicone Endocardial leads. Inclusion criteria are patients that have a market-released St. Jude Medical ICD/CRT-D containing Riata or Riata ST Silicone Endocardial leads (Models 1560, 1561, 1562, 1570, 1571, 1572, 1580, 1581, 1582, 1590, 1591, 1592, 7000, 7001, 7002, 7010, 7011, 7040, 7041, 7042). In order to determine the incidence of externalized cables on Riata Silicone Endocardial leads, the Riata Lead Evaluation study will enroll a minimum of 500 patients at approximately 10-15 sites. In order to determine the risk that externalized cables will result in an electrical malfunction, patients with evidence of externalized cables will be followed every three months for a two-year period in the study. Patients with no evidence of externalized cables will be followed every year for a two-year period in the study.
  • OPTIMUM Lead Registry. OPTIMUM is a prospective, outcome-oriented registry of patients implanted with St. Jude Medical Optim™ leads. This registry will evaluate the chronic clinical performance of the market-released St. Jude Medical Cardiac Rhythm Management (CRM) leads with Optim™ insulation material.

What innovative EP techniques are being utilized in your lab?

We have performed a few LARIAT (SentreHEART, Inc.) and PARACHUTE (CardioKinetix, Inc.) procedures over the past year. Dr. Scott Beau has one of the state’s busiest lead extraction programs and performs the procedure in the operating room. Dr. Wilson Wong has implanted CardioMEMS (St. Jude Medical), a pulmonary artery pressure monitoring system, to improve heart failure patient outcomes and prevent heart failure readmission. We are also investigating other hybrid procedures, such as Convergent pulmonary vein isolation. ■


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