In this article, we learn more about how the pediatric EP program at St. Louis Children’s Hospital (SLCH) became one of the first two pediatric EP labs to receive IAC Cardiac Electrophysiology accreditation. George F. Van Hare, MD is the Chief of Pediatric Cardiology, and Louis Larrick Ward Professor of Pediatrics at Washington University School of Medicine in St. Louis, Missouri. He also serves as Co-Director of St. Louis Children’s and Washington University Heart Center.
What can you tell me about the pediatric EP program at St. Louis Children’s Hospital?
We have a very comprehensive program. We do everything that a pediatric cardiology and cardiac electrophysiology program does, including catheter ablations, device implantations, etc.
We have three full-time pediatric electrophysiologists. The leader of our program is Jennifer Silva, MD and the other faculty are myself and our newest faculty member, Aarti Dalal, DO. We also have a full staff in the cath lab and in our outpatient area.
I am the Chief of Pediatric Cardiology at St. Louis Children’s Hospital and Washington University School of Medicine Department of Pediatrics, so I oversee all aspects of cardiology. I’m also the Co-Director of the Heart Center at Washington University and St. Louis Children’s Hospital, so my days of leading EP programs are behind me. I’m considered the senior member of the group, and Dr. Silva is the Director of the EP program.
Why did your facility choose to pursue this accreditation?
First of all, as a leader in the Heart Rhythm Society, I was very involved in and supportive of the initiative to offer EP laboratory accreditation to the entire electrophysiology community. We at the Heart Rhythm Society think it is incredibly important that there be a way of recognizing laboratories that have chosen to adhere to a certain high standard for their programs. Several years ago, we published a consensus document on EP lab standards, describing the minimum standards or requirements to operate an electrophysiology laboratory. Part of that process was to call out the important differences between pediatric and adult electrophysiology laboratories. There is a lot of overlap, but there are also a lot of distinctions between the two, and we wanted to call that to people’s attention. Obviously, one of the more important differences is the ability to care for children of all ages. We treat kids from the newborn period well into adulthood, particularly if they have congenital heart disease. However, we also deal with children who have coexisting significant structural heart disease. The most common of those would be congenital heart disease, either unrepaired or palliated/repaired. We also have a very large pediatric heart transplant program here, and that leads to a lot of patients with ventricular dysfunction who develop arrhythmia problems. Therefore, our expertise in the pediatric laboratory needs to include the ability to not only understand and manage all forms of congenital heart disease, but also the ability to do a combined procedure in a laboratory. This means that we are able to do hemodynamic and interventional catheterization work and electrophysiology procedures in the same laboratory, on the same table, in the same patient, with the same anesthesia run. That is a capability that I think is generally considered to be an important feature of a pediatric electrophysiology laboratory. In other words, in a biplane laboratory, we’re able to perform all the needed procedures in an EP laboratory, and our interventional colleagues are able to come in and work as well.
So this accreditation is coequal with the adult accreditation?
Exactly. It’s at the same level, but it’s distinct. So while there is a lot of overlap in terms of the criteria, there are a lot of specific things that pediatric laboratories need to have in place in order to qualify for accreditation that wouldn’t necessarily be in place in every single adult electrophysiology laboratory.
What can you tell us about the process for achieving accreditation?
It’s pretty straightforward. We paid a lot of attention to the EP lab standards document. In fact, I was on the board of the Heart Rhythm Society when that document came through for discussion and endorsement. At SLCH, we had already adhered to most of the criteria and requirements for accreditation, especially those involving facilities and certifications, etc. Some of the things we had to develop were written protocols that we hadn’t previously written down but had already been following. So for us, it was a matter of formalizing a lot of the things that we were already doing. In particular, this meant formalizing our quality improvement (QI) process and putting that on a much more concrete platform. The field of QI in pediatric electrophysiology is also rapidly developing. There is a new module under the NCDR’s IMPACT Registry, called MAP-IT, that includes pediatric electrophysiology procedures — this includes a registry of interventional procedures in patients with congenital heart disease. The vast majority of those participating are pediatric programs, but there are also adult congenital heart disease programs participating in IMPACT. MAP-IT exists largely through the efforts of Stephen Seslar, MD, PhD in Seattle and other colleagues in PACES (the Pediatric and Congenital Electrophysiology Society). The module is essentially a successor to the prior pediatric catheter ablation registries that we’ve been involved with for over 25 years. MAP-IT puts the pediatric EP practice on a firm QI basis. This initiative is just getting started, and my expectation is that all pediatric electrophysiology centers — certainly all those that are accredited — will participate in and use MAP-IT as a way of collecting their own quality data and comparing it with benchmark data collected nationally.
What members of the staff were involved in this IAC accreditation process? How long did the process take from start to finish?
Carrie Dehart, RN and nurse manager of the cath lab, led this along with Dr. Silva. The process took about 6 months. As mentioned before, our pediatric electrophysiology laboratory is not freestanding — it is part of a suite of two biplane laboratories, both of which can do all forms of interventional catheterization. Lab B is outfitted for electrophysiology, and Lab A is outfitted for hybrid procedures.
Can you give an example of some of the ways your facility’s approach to pediatric care has changed since earning this accreditation?
I don’t think we’ve changed things dramatically in terms of our clinical practice. I would say the major thing was that by preparing the accreditation application and reviewing the criteria, we recognized that we needed to develop standard work in a lot of our processes to put us on a firm quality and safety footing.
What does achieving this accreditation mean for the staff at St. Louis Children’s Hospital?
We are incredibly proud of this achievement, particularly given that we were one of the first two pediatric programs to achieve accreditation. From our point of view, going through the process as an interdisciplinary team was very important for us and calls out the efforts of all the members of our team. Also, as President of the Heart Rhythm Society, I have a strong interest in seeing the accreditation process succeed nationally both for adult and pediatric laboratories. Anything that we do in this space to include pediatric programs is really important to me. I am personally very proud that our accreditation efforts have put pediatric programs on equal footing with adult programs.
Is there anything else you’d like to add?
Labs looking into accreditation might wonder why it’s important. First and foremost, it’s so that they can ensure their laboratory meets the minimum national standards and that their heart rhythm care will improve. I think it also gives labs a platform and a structure around quality and safety, which is obviously important in terms of outcomes. Finally, it’s a way for labs to differentiate themselves from their competitors in any particular region — being able to cite the fact that they are a fully accredited program may actually give them an opportunity to gain market share.