Central Minnesota Heart Center at St. Cloud Hospital

Jackie Bruhn, CEPS and Nate Manning, RN St. Cloud, MN
Jackie Bruhn, CEPS and Nate Manning, RN St. Cloud, MN
What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab? Currently we have two dedicated procedure rooms designed with state of the art imaging and mapping systems. Another lab is shared with the cath lab when we have three or more EP physicians doing procedures on any given day. We have a total of 14 staff in the EP lab. Our procedure rooms are staffed with nine EP techs with backgrounds ranging in cardiovascular technology, surgical technology and exercise physiology. The remaining five staff members, including our lab manager, are registered nurses. Each of our four staff electrophysiologists is supported by one of six practice nurses. We still have one physician occasionally practicing here from the University of Minnesota group. Our technical staff is dedicated to EP and does not cross train in the cath lab. When was the EP lab started at your institution? The EP service began in the late 1980s to early 1990s with a group of cardiologists implanting devices. It progressed with the addition of a select group of physicians from the University of Minnesota, practicing here occasionally, similar to an outreach. Of those physicians, Dr. David Benditt still practices here part time and Dr. Keith Lurie has become a partner. In May 2003, Central Minnesota Heart Center (CMHC) recruited Dr. Simon Milstein to expand the program to include complex ablations, CRM, and lead extractions. These procedures were done in a single-plane imaging room until a bi-plane room was available. In December of the same year, Dr. Ann Dunnigan joined the group and brought the pediatric population to CMHC, including ablation and CRM. Dr. Dunnigan practices both adult and pediatric cardiac electrophysiology. A brand new bi-plane room was built and opened in March 2004. In January 2006, we opened a second bi-plane room, and shortly after, welcomed Dr. Mevan Wijetunga to the team. What types of procedures are performed at your facility? Approximately how many are performed each week? We perform up to 13 cases per day, depending on the number of electrophysiologists working in the lab. We average about 35 to 40 cases per week. We provide EP studies, ablation for all complex arrhythmias (including endocardial and epicardial ablation procedures), head-up tilt studies, tachycardia and bradycardia device therapy (including biventricular devices), as well as laser lead extraction. What is the primary goal of your program? Our goal is to provide any cardiac arrhythmia service needed for all age groups. Who manages your EP lab? Nate Manning, RN, Electrophysiology Specialist, manages and works in the lab. He started out as a flight paramedic in Sioux Falls, South Dakota, and eventually became a registered nurse. He began working at St. Cloud Hospital in 2001, and in 2004, he left the telemetry unit to join the EP group. Nate has been our EP Specialist since 2006. Is the EP lab separate from the cath lab? How long has this been? Are employees cross trained? We are physically set up in close proximity to the cath lab, but are not directly involved in the cath lab operations. Our staff is dedicated to EP and has been since around 2005. The majority of our technologists have come from the CV program after they complete their rotation with the cath lab. For a time, a few techs worked in both areas and took call for the cath lab. At present, we do not have any techs that do both. However, the nurses occasionally will do a case in the cath lab or take a call shift. Do you have cross training inside the EP lab? We cross train each EP technologist for all aspects of the EP suite. We do not require each tech to perform all tasks, as time required to become proficient and maintain skills is sometimes unattainable with the number of staff we have. We have a select group that is proficient in each area, including monitoring complex ablations, mapping with 3D mapping equipment, scrubbing EP studies, device implantations and laser lead extractions, and intracardiac echo operation. Each technologist finds his or her strengths and completes the team. We have tripled our technologist staff since 2004 and have been in constant learning mode ever since. Our nursing staff is dedicated to sedation, direct patient care and drug infusion. We use Versed and Fentanyl for sedation. Typically, anesthesia support is only used for lead extractions. What new equipment, devices and/or products have been introduced at your lab lately? How has this changed the way you perform those procedures? With existing equipment, we have always made sure to have a contract with the vendor that allows us to have access to any new upgrades as they are released. We are always prepared to give the patient the best possible care with the best technology available. What type of quality control/quality assurance measures are practiced in your EP lab? Chart tracking is done via EPIC (Epic Systems Corporation, Verona, WA) for start times, antibiotic times, pre-procedure verification, timeouts, etc. Daily QA checks include room temp, refrigerator temp, iStat, Glucometer, Broselow™ cart (Armstrong Medical Industries, Inc., Lincolnshire, IL), and Omnicel. Daily QA is done by the RNs. How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? We manage inventory and billing through GE Healthcare Centricity. Most major supplies are scanned during the case and then easily ordered and billed electronically through this system. Stock and non-stock items that may be included in the procedure cost and/or rarely used items are systematically counted each AM by staff and are ordered through the Lawson Inventory System. Electronic orders and manual orders are managed by the Materials Management Coordinator in our lab. She also directs major equipment purchases through capital approval processes, CRM inventory and vendor relations. Has your EP lab recently expanded in size and patient volume, or will it be in the near future? In addition, is your EP lab part of a separate “heart hospital”? We are part of CMHC, located at St. Cloud Hospital. We are proud to have been designated one of the nation’s “100 Top Cardiovascular Hospitals” eight times by Thompson Reuters. Have you developed a referral base? We receive referrals from numerous areas of central Minnesota. Two of our electrophysiologists do outreach a few times a month at other facilities. Dr. Dunnigan sees most of her pediatric population in Sioux Falls, South Dakota, Rapid City, South Dakota, Mankato, Minnesota, and various St. Paul/Minneapolis sites. Dr. Wijetunga sees patients in Grand Forks, Minnesota and Willmar, Minnesota. All of our electrophysiologists get referrals from the Cardiology Outreach here at CMHC. How are new employees oriented and trained at your facility? New employees complete a two- to three-day hospital orientation the first week of employment. Once in the lab, they work closely with a preceptor for about three months completing and documenting tasks learned. There is a follow-up review at around three months with the new hire, preceptor and educator to see how things are progressing. Depending on the individual’s background, technologists typically begin in the circulating and scrubbing roles. Monitoring EP/ablation cases can be quite a long learning process, as our physicians rely on us for an in-depth, post-procedure report. We take extra time, generally 8-12 months, to learn all of the different types of arrhythmias and how to monitor them. Vendors provide us with bi-weekly education in a classroom setting, which really enhances the learning curve within the group. We have new hires complete the RCES examine after two years of EP lab work. What types of continuing education opportunities are provided to staff members? Each May about four individuals are sent to the HRS Annual Scientific Sessions to learn about all the new technology. We also have vendors present onsite training in which employees can obtain CEUs. Any educational EP programs within the state are offered to those who wish to go. We are able to apply for reimbursement of the cost through an educational fund here at the heart center. How is staff competency evaluated? Nurses are required to complete sedation competency every year including a written exam. How do you prevent staff burnout? In addition, do you practice any team-building exercises? We do this funky birthday skip for everybody’s birthday. This always gets the laughter going in the workroom, sometimes to the point of other staff wondering, “what’s going on?” We have potluck to celebrate each birthday and occasionally get together outside of work to enhance friendships. Our physicians frequently arrange a dinner or party at a restaurant or at one of their homes. This is really a great way of relieving day-to-day stresses we feel in the lab. Our team is very accommodating to each other, whether it is for switching a day, picking up another’s late stay or picking up the slack when one of us is just not on their game for the day. With the group mix we have at present, it is easy to allow staff a break from the more difficult cases after they’ve already been involved in two or three that week. This definitely impacts the morale of the group. What committees, if any, are staff members asked to serve on in your lab? The Specialist (EP Lab Manager) serves on the Education Council, House Practice Committee, Central Minnesota Heart Center Practice Committee, and House Sedation Committee. How do you handle vendor visits to your department? Do you contract with vendors? The Materials Management Coordinator handles all appointments with vendors. To minimize supply costs, we do have contracts with several companies. We bring products in on consignment and pay for them as they are used. This decreases the amount of inventory that could potentially expire and also keeps the shelves adequately stocked. Does your lab utilize any alternative therapies? For patient comfort and satisfaction, we remove all of sheaths in the procedure room while the patient is under sedation. This technique is especially important with the pediatric population, as the stress level is greatly reduced for the child and his or her parents. Families are with patients in the procedure room until patients are sedated and comfortable, with separation in the pediatric population. Customized scrub hats are made by one of our staff for the kids. Additionally, parents of our young patients tour the labs when they come for their pre-procedure clinic visit so that it is a bit more familiar to them the day of the procedure. How does your lab handle call time for staff members? How often is each staff member on call? How frequently do they have to come in, on average? Is there a particular mix of credentials needed for each call team? We do not have any EP physicians on call after hours or on weekends. However, we do have a rotating late team Monday through Friday for the cases that progress beyond 5:00 PM. Each person has one or two scheduled late nights per week. The late team consists of two EP technologists and one RN. If the late case is more complicated and requires three techs, an extra staff member routinely volunteers to stay until the case is complete. Occasionally, we require two teams to stay late when two rooms are still operating at 5:00 PM. Does your lab use a third party for reprocessing? Yes, we do. We have just recently implemented this on diagnostic catheters, and our projected cost savings was substantial. Approximately what percentage of your ablation procedures are done with cryo? What percentage is done with radiofrequency? About five percent of our ablation procedures are initially scheduled with cryo technology. These cases are generally patients presenting with a septal pathway or an unusual, or difficult, AV nodal pathway. Periodically, we use cryo technology when we need more stable catheter positioning or happen upon a risky arrhythmogenic area near the AV node. The other 95 percent of our ablations are done with radiofrequency, including closed-loop irrigated, open irrigated and non-irrigated. Tell us about pediatric procedures at CMHC. Is there cross training for pediatric cases? Dr. Dunnigan treats the majority of our pediatric population. Most of the pediatric procedures in the lab are ablations of accessory connections with a few being devices and other. Each of our critical care nurses are trained in pediatric sedation and care. Nurses are all PALS certified. Two of our nurses were on pediatric and flight teams, and one was on a neonatal flight team. All of our technologists are trained in pediatrics as well. What measures has your lab taken to minimize radiation exposure to physicians and staff? We use sterile radiation barriers, which are placed on the sterile drapes during pulmonary vein isolations, atrial and ventricular tachycardia ablations, biventricular implantation and any other procedure requiring lengthy fluoroscopy doses. A couple of our physicians wear radiation barrier surgical gloves to protect their hands. One has also incorporated a radiation barrier surgical cap into his attire. In addition, we supply leaded glasses for our scrubbed staff. Do your nurses/techs participate in the follow up of pacemakers and ICDs? We have a separate department that does all of the pacemaker checks, so we are not directly involved. What innovative EP techniques are being utilized in your lab? We recently incorporated help from our cardiac surgeons for placement of sheaths into the pericardial space for patients requiring epicardial ablation. The surgeon makes a pericardial window to allow precise placement of one or two sheaths. This has virtually eliminated the problems we’ve encountered when access into the pericardial space is difficult from the subxiphoid approach. Does your lab provide any educational or support programs for patients who may have additional questions or those who may be interested in support groups? In addition to literature provided by our clinic, our patients find numerous sites on the CentraCare website that describe, in detail, the problems they might be experiencing and how the treatments work. These web pages educate patients and their families through animations, interactive tutorial and easy site maps. Describe your city or general regional area. How does it differ from the rest of the U.S.? We are a centrally located, rural community just one hour northwest of the Twin Cities and two and a half hours southeast of the Fargo/Moorehead area. Our EP program offers all services to patients, which therefore eliminates the need for west-central and northwest patients to travel further to the Twin Cities or other areas for care.
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