“How do you fight the boredom?!”
I commonly heard that question a decade ago from an interventional cardiologist as he would pass through the EP lab, where I toiled as an EP fellow. His quip stemmed from the inherent differences between the electrophysiology and cath labs, differences illustrated best by the personnel that they attract.
As 120 new EP fellows graduate and enter the workforce each year, and as smaller regional hospitals try to capture new revenue, EP programs are developing in hospitals and communities that would previously act as “feeders” to tertiary care centers. In these labs, where the cath and EP service lines are often forced to share space, staff, equipment, and lab time, melding the innate differences between subspecialties creates unique challenges that must be managed successfully if an EP program is to flourish.
The needs for EP procedures vary greatly from the needs for cath procedures. Complex ablations often require general anesthesia, and the logistics involved — anesthesia equipment, scheduling an anesthesiologist — are far removed from the usual workflow of the cath lab. Additionally, staff must be vigilant for a different set of potential catastrophes (tamponade, heart block) than they routinely encounter in cath cases.
In novice EP labs, it becomes incumbent upon the operator to manage much more than would be required of him in an experienced lab. For example, in dedicated EP labs, the staff is knowledgeable enough to man the external defibrillator during DFT testing following defibrillator implantation. However, in a shared lab situation, the staff may not know that defibrillation patches should be placed ahead of time in case external rescue is necessary. In the early cases, the operator may find it best to place the patches himself to ensure correct positioning.
Expectations vary greatly between the two labs as well. Fast cath cases are considered good cath cases, and if cath lab staff are asked who the best operators in a lab are, the fastest operators are often mentioned first. Taking typical cath lab staff and dropping them into an EP lab environment invariably leads to frustration. A two-hour atrial fibrillation ablation can feel like forever to workers who are used to performing interventions in 30 minutes. Time spent interpreting electrograms or mapping arrhythmias can seem wasteful and the operator may appear indecisive.
The key to creating a harmonious and productive EP lab in a shared environment is creating a positive culture. As anyone who has spent any time in the workplace can attest, culture cannot be mandated, hired, or purchased. Once a culture of excellence is in place, however, its benefits spill over to all facets of the workplace. Workers become energized to come to work, a shared sense of achievement and pride permeates, and staff motivate themselves to levels of greater competence.
The Value of Dedicated Staff and an EP Champion
How does an EP lab create a culture of excellence? Several factors set the stage. First, dedicated EP lab staff is mandatory. Bringing the right personnel together can pose a challenge, as many different staff members may express an interest in participating. However, very few usually are willing to commit the extra time required to learn an entirely new discipline. While some facets of EP may seem exciting — the opportunity to participate in new procedures such as LV lead implantation or transseptal puncture — poring over electrograms and trying to understand the difference between a block cycle length and an ERP may be akin to watching paint dry to those same individuals. A staff member chosen as an “EP champion” in the lab may serve as a nucleus around whom other staff members coalesce.
This EP champion may declare himself to you, or may require investigation to discover. Regardless, key qualities and personality traits are mandatory. Foremost, the EP champion must have a genuine interest in EP. While this is true of all of the core EP team members, having an enthusiastic champion leading the staff will pay dividends in motivation, organization, and loyalty to the program. Often the EP champion will have previously performed EP cases, possibly at another institution or in their training, and that experience can serve as the seed for developing your program. The EP team leader also should have meticulous attention to detail. At the onset of the program, the EP champion likely will be the sole team member with expertise in “connectology” (the art of connecting all of the cables so that they result in electrogram signals rather than uninterpretable noise), troubleshooting, ordering equipment, and handing off the appropriate products. Because of the potentially onerous volume of responsibilities, the EP champion should be capable of multitasking, stratifying tasks by importance, and delegating tasks to other team members.
While it may be tempting to incentivize the EP staff with pay increments, linking those incentives to actual achievement will draw out the individuals who have an inherent interest in electrophysiology rather than those simply seeking extra benefits. Encouraging passage of IBHRE, RCES, or other certification exams provides a more objective measure to justify pay increases or bonuses.
Because the cath lab may only function as an EP lab a few days a week, having the same core group performing all of the cases fosters the continuity upon which a program can be built.
Education, Education, and More Education
One way to identify the most committed staff members is via education. Educating the staff is critically beneficial on many fronts. A more knowledgeable staff is an obvious asset to the operator, the patient, and the program. Cases will be performed more expeditiously if the entire room is working in concert and staff members do not require constant instruction.
Didactic lectures serve as the cornerstone for initially educating any novice EP team. My efforts at educating the staff at my current lab led me to develop a series of a dozen lectures, with topics including device therapy indications, basic arrhythmia concepts, LV lead implantation techniques, SVT discrimination in the EP lab, and ablation techniques. Initially, lectures may occur on a weekly schedule, but as the staff becomes more experienced, the lectures may decrease in frequency. Because of the inherent complexity of electrophysiology, didactic lectures are invariably dense in information. Hence, repetition is necessary, and patience is crucial.
An additional benefit of intense EP education is that it can serve to stratify the team members into those who gravitate to the nuances of EP and those whose interests lie elsewhere. If the electrophysiologist leading the program commits to providing regular educational lectures to the staff, it will become apparent who the interested parties are. They, in turn, will likely form the core EP team.
Leadership plays a crucial role in developing a cohesive culture in the lab. A dynamic and passionate physician will impart an energy in the lab that can draw the staff into the cases. Exceptional EP staff members invariably seek education, and many of the best opportunities to instruct occur during cases. Constant commentary by the operator serves to engage the entire staff in the case, and even simple aspects of the case, such as venous access techniques, lead selection, or electrogram fidelity are riveting to the novice team. The operator that teaches the staff builds enthusiasm, commitment, and loyalty to the program. Electrophysiology becomes more fascinating the more one understands its finer details. An effective mentor facilitates all of this simply by adopting an engaging demeanor.
Offsite, after-hours “team meetings” provide intangible bonding opportunities as well. Often these sessions may revolve around educational discussions, case reviews, or journal clubs. Because of the limited number of staff members in the core EP team, interpersonal relationships can be a major determinant of success or failure of the venture, and care should be taken in choosing personnel.
It should be recognized that in shared situations, the EP lab is a subset of the overall cath lab and that other team members may be asked to participate in EP cases as staffing issues dictate. If the goal of an EP program is to perform all manner of device implants, basic ablations, and some complex ablations, such as atrial fibrillation, it is unrealistic and unfair to expect a cath lab staff to become collectively proficient in all of the procedures. However, a basic level of competence in EP should be the goal throughout the lab so that cases can be performed even if the entire core EP team is not available. In these instances, the EP champion and the operator must assume more vigilant roles.
Describing the goals of the program in abstract terms to the staff will necessarily lack the import of witnessing an experienced lab in action. To that end, site visits are commonly utilized as demonstrations of excellence. It is important to establish the goals of the site visit prior to embarking on the trip. It is unrealistic to expect to learn the science of electrophysiology in a day or two. The value lies in absorbing the nuances of workflow and logistics in running an efficient EP lab. Personnel should be matched to watch and learn from their counterparts in the lab, and the physician can identify along the way the facets of the lab that help create excellence.
The visiting personnel should not be afraid to “steal” from the show site lab; for example, things like pre-printed orders, flow sheets, and checklists need not be recreated from scratch. They can be adapted from existing documents that can be modified to individual institutions.
An additional and important benefit of the site visit lies in the inspiration that it imparts to the visiting staff. Watching an experienced team execute their roles in an efficient and collaborative manner motivates and energizes a unit to work harder for greater goals.
Often, the site visit may inadvertently create unrealistic hopes and expectations. My team went to a robust, busy lab in Texas to absorb some of their “best practices” and came home energized. However, I had to recalibrate their expectations to our market, our hospital, and our resources. Instead of four dedicated EP labs and ten EPs, we work in a shared EP/cath lab with predominantly one EP. The message I tried to convey to them hinged on achieving excellence in every case. We perform the same case variety as the show site lab, including complex ablations and lead extractions, but lack the volume and population draw area. Despite this, we can and should strive to offer all of the latest procedures and the best results.
Community Memorial Hospital in Ventura is a 242-bed hospital serving a community of over 125,000. In our lab, we perform EP cases three to five days a week, performing around 400 electrophysiology procedures annually. We attempt to keep the core EP team together for all of the electrophysiology cases, and they often will work late hours to finish the cases so that the cath call team is not compromised. Though our EP team staffs almost all of the electrophysiology cases, they continue to fulfill call responsibilities as part of the cath lab crew.
Our program began five years ago with only a single regular staff member, an EP champion, and all other members rotating based on the daily cath lab schedule. As expected, the overall level of competence was reasonable, but the situation posed challenges for any substantial growth, and the onus of responsibility fell heavily on the shoulders of the single regular EP staff member.
Over time, a few staff members began to gravitate to the EP lab more regularly and expressed a strong interest in participating on a full-time basis. An attempt at staff-wide educational sessions on EP topics helped to identify these interested individuals; while most of the staff were respectfully attendant, a few were visibly excited. These enthusiastic individuals formed the core EP team, and the cath lab director instituted a schedule to reflect this. An EP team of five members was created.
The EP staff has collectively and individually plunged headlong into intensive EP education, aided by the electrophysiologists as well as industry-sponsored courses. Their intellectual growth has been tremendous, and a cross-training regimen is in place such that all of the core team members will be able to operate the recording system, scrub cases, and troubleshoot problems.
Keys to Success
When an EP program must coexist with an interventional program and share resources, key factors can drive success: a core EP team, strong interpersonal bonds, constant education, and engaging leadership. A shared motivation for excellence drives the EP staff members at our center to function with the precision expected of an experienced team. The physicians strive to create an intellectually rewarding experience for the staff, and constant education propels the team members to push themselves to grow in their roles.
My own experiences in private practice have included development of a tertiary care Heart Hospital with state-of-the-art everything, and building a substantial EP program in the shared confines of a combined EP/cath lab at a mid-sized community hospital. By far, the latter situation has been more challenging, but in many ways, more rewarding.
I have found that the single most important factor in my own professional happiness in the lab and in our program’s success has been the culture of excellence fostered by the EP team. The team continues to grow intellectually and in experience, but their unwavering commitment to the program drives each of us to strive for perfection on every case. Despite resource limitations that tertiary care centers do not face, we challenge ourselves to provide our community with care that equals or exceeds our more well-heeled competitors. This shared mission drives our efforts more powerfully than retribution or reward.
Dr. Rao is the Director of Electrophysiology Services at Community Memorial Hospital, where he is leading the development of an expanded EP program as part of the hospital’s $350 million building project.
Dr. Rao also writes the new blog series “EP Rising” on www.eplabdigest.com. This blog focuses on how EPs can take advantage of increasing opportunities to play more prominent roles in
cardiovascular service lines and provide insights into how to build EP programs.
For more information about Dr. Rao, please visit http://answersinaheartbeat.com/