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Kaiser Permanente Santa Clara Medical Center

Sung Murata, BSN, RN, WCC, Cardiac Procedures Unit/EP, Assistant Nurse Manager, Santa Clara, California

Sung Murata, BSN, RN, WCC, Cardiac Procedures Unit/EP, Assistant Nurse Manager, Santa Clara, California

What is the size of your EP lab facility? When was the EP lab started at your institution? 

The electrophysiology (EP) program at Kaiser Permanente Santa Clara Medical Center provides EP services for all of Northern California Kaiser Permanente members. There are 2 dedicated EP suites designed for advanced diagnosis and treatment of arrhythmias. The EP labs were opened in 2007 in the Santa Clara medical facility. Prior to 2007, the EP program was located at the Kaiser Permanente facility in San Jose.

What is the number of staff members? What is the mix of credentials at your lab?

There are 5 electrophysiologists who lead a team of 8 registered nurses (RNs), 1 radiology technologist, 2 cardiovascular technologists, and 2 physician assistants. Each procedure is staffed with a minimum of 2 RNs, a radiology technologist, and a cardiovascular tech. The electrophysiologists are all board certified. Several of the staff members have IBHRE or RCES certification.

What types of procedures are performed at your facility? Approximately how many catheter ablations (for all arrhythmias), ICD implants, and pacemaker implants are performed each week? 

The team performs invasive procedures including diagnostic EP testing, radiofrequency and cryo ablation, lead extractions, and implantation of ICDs and cardiac resynchronization devices. Ablations are performed to treat a wide range of arrhythmias, including supraventricular tachycardias (AVNRT, AVRT, atrial fibrillation, atrial flutter) and ventricular tachycardias (including epicardial ablation). Left atrial appendage ligation procedures using the LARIAT Suture Delivery Device, (SentreHEART, Inc.) are also performed throughout the year.

Who manages your EP lab? 

The Cardiovascular Procedure Unit, which includes EP services, is managed by the nursing director, assistant nurse manager, and charge nurse, as well as by Charlie Young, MD, chief of cardiac electrophysiology for Kaiser Permanente Northern California.

Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained?

Kaiser Permanente Santa Clara has 5 labs. Two are dedicated EP labs, and three are cardiac cath labs. The department relocated from San Jose to Santa Clara in 2007. 

What is the number of staff members? What is the mix of credentials at your lab?

There are 5 electrophysiologists who lead a team of 8 registered nurses (RNs), 1 radiology technologist, 2 cardiovascular technologists, and 2 physician assistants. Each procedure is staffed with a minimum of 2 RNs, a radiology technologist, and a cardiovascular tech. The electrophysiologists are all board certified. Several of the staff members have IBHRE or RCES certification.

What types of procedures are performed at your facility? Approximately how many catheter ablations (for all arrhythmias), ICD implants, and pacemaker implants are performed each week? 

The team performs invasive procedures including diagnostic EP testing, radiofrequency and cryo ablation, lead extractions, and implantation of ICDs and cardiac resynchronization devices. Ablations are performed to treat a wide range of arrhythmias, including supraventricular tachycardias (AVNRT, AVRT, atrial fibrillation, atrial flutter) and ventricular tachycardias (including epicardial ablation). Left atrial appendage ligation procedures using the LARIAT Suture Delivery Device (SentreHEART, Inc.) are also performed throughout the year.

Who manages your EP lab? 

The Cardiovascular Procedure Unit, which includes EP services, is managed by the nursing director, assistant nurse manager, and charge nurse, as well as by Charlie Young, MD, chief of cardiac electrophysiology for Kaiser Permanente Northern California.

Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained?

Kaiser Permanente Santa Clara has 5 labs. Two are dedicated EP labs, and three are cardiac cath labs. The department relocated from San Jose to Santa Clara in 2007. 

Do you have cross training inside the EP lab? 

EP has dedicated core staff. There are opportunities for cardiac cath lab nurses to cross over to EP to help with procedural sedation. California’s Title 22 outlines the scope of practice for RNs and RTs. To the fullest extent allowed by the law, the staff is cross trained, allowing for more flexibility with staffing and greater staff satisfaction. The RNs, CVTs, and RTs can scrub, circulate, and operate the cardiac stimulator and the CardioLab System (GE Healthcare). Only the RNs can administer medications, and monitor and assess patients; RTs are the only staff that can operate the fluoroscopy equipment. In addition, several of the staff is trained to operate the 3D mapping systems.

What type of hospital is your EP program a part of? 

Kaiser Permanente was founded in 1945 and is one of the largest not-for-profit healthcare systems, with over 9.6 million members across California, Georgia, Colorado, Hawaii, and the Mid-Atlantic and Northwest regions. Santa Clara Kaiser is part of the Northern California Kaiser Region, with over 3.6 million members. 

What types of EP equipment is most commonly used in the lab? 

We utilize the Carto 3 mapping system (Biosense Webster, Inc., a Johnson & Johnson company), Niobe Magnetic Navigation System (Stereotaxis), CardioLab Recording System (GE Healthcare), Micropace Cardiac Stimulators, radiofrequency generators by Boston Scientific and Biosense Webster, a CryoConsole Cardiac CryoAblation System (Medtronic), Vivid q intracardiac echo (GE Healthcare), and x-ray systems by Philips.

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

We have one team that arrives at 7:00 am and another team at 8:00 am. We work 10-hour shifts. If cases run later than 6:30, the team will stay to complete the procedures.

Tell us what a typical day might be like in your EP lab.

A typical day in the EP lab starts with a 5-minute group huddle to go over and plan the day. This also gives us an opportunity to make any staff adjustments. The primary nurse from each lab will follow the physician to the pre-op area to do a “meet and greet” prior to bringing the patient into the EP lab. Tuesdays and Wednesdays are when we have general anesthesia coverage. Approximately 6-8 cases are performed across the two rooms, and the cases are typically completed by 6:30 pm.

Does your program utilize a cardiovascular information system (CVIS), picture archiving system (PACS), or cardiology picture archiving system (CPACS)?

The EP program utilizes the LUMEDX Apollo and McKesson Cardiology systems.

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

QA is combined across the cardiac services and includes cardiology, EP, interventional cardiology, and the heart failure services. QA cases are reviewed by the cardiology QA committee. In addition, checks on the equipment in the procedure rooms are performed on a daily basis by the staff, while the biomed department tracks and performs preventative maintenance. Daily checks include the defibrillators, emergency equipment, and the ACT machines.

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

Our inventory is managed by a materials specialist who coordinates the ordering of supplies needed by the EP team. There is a regional capital submission process for all specialty services including EP.

Has your EP lab recently expanded in size and patient volume, or will it be in the near future? 

Yes, annual growth of the EP service has been 6-10% over the last 7 years. More recently, we have seen a significant increase in EP procedural volume, especially with atrial fibrillation and ventricular tachycardia ablations. The complexity has also increased with the EP population.

In what ways have you helped to cut or contain costs and improve efficiencies in the lab?

We recycle catheters and connectors for cost savings. In addition, cardiac device contracts are negotiated at the Kaiser national level, which results in cost savings. Performance improvement efforts are focused on standardization and reducing variation in procedure room setup. Reducing variation in setup and periprocedural steps has reduced the turnaround time and improved the percent of first cases that start on time. 

How does your lab communicate necessary information to staff? 

In addition to our daily huddles, we have weekly staff meetings that help to engage MDs and RNs in relation to patient care. We also have a communication binder and coordinate extracurricular activities to help with team building. In addition, we utilize a Lean visual board to keep everyone informed of monthly goals, achievements, and celebrations.

How do you ensure timely case starts and patient turnover?

We ensure timely case starts and patient turnover through constant communications within the healthcare team. We discuss and consistently update plan of care for our patients throughout the day. Anticipation and communication are our biggest assets.

How are new employees oriented and trained at your facility?

New employees are paired with two primary preceptors with complementary teaching styles. The leadership provides weekly meetings to ensure successful training for our EP team.

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

For annual heart and vascular symposiums, time off is requested by staff. We also utilize in-service education as well as education provided by company representatives. There is a monthly EP case conference that staff is invited to attend. Kaiser provides tuition reimbursement for continued education and encourages professional development. Staff is able to attend the Heart Rhythm Society’s annual scientific sessions as well.

How is staff competency evaluated?

Staff competencies are evaluated on an annual basis; however, as leaders, we provide support and assessment on a daily basis. This helps to ensure best practice for our patients.

Do you encourage your clinical staff members to take the registry exam for Registered Cardiac Electrophysiology Specialists (RCES)? How many members of your lab have taken the exam? Does staff receive an incentive bonus or raise upon passing the exam?

Yes, we encourage RCES and IBHRE certification. We have several staff who hold the RCES and/or IBHRE certification. There is not an incentive bonus, but there is professional satisfaction for those who have successfully passed the exam.

How do you prevent staff burnout? 

We prevent staff burnout by promoting brisk walks during breaks. We also utilize opportunities to have staff address concerns and issues during daily/weekly huddles. We try to create a culture of teamwork based on shared responsibilities and mutual respect. We celebrate our successes together. 

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

We recently completed a workflow meeting with a physician and a team of 5 EP RNs and techs; from this workflow meeting, we identified 5 key areas to work on. 

How does your lab handle call time for staff members? 

Kaiser EP does not have call. We work Monday through Friday, with complex cases and anesthesia support scheduled on Tuesdays and Wednesdays.

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

Yes, we use Stryker Sustainability Solutions for catheter recycling. We were the largest cost-saving facility in Kaiser Permanente California with $1.8 million in savings for the 2014 calendar year.

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

For the treatment of AF, we currently do approximately 60% cryoballoon ablations and 40% RF ablations.

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

We provide EP procedures to the adult and pediatric population (if the patient is >90 lbs).

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

We are mindful of fluoro exposure and use radiation shields, 3D mapping systems, and Niobe MNS. The MDs also use the lowest fluoro exposure rate as possible. We employ RADPAD drapes (Worldwide Innovations & Technologies, Inc.) with protection on both the operator’s and scrub nurse’s sides. 

What are your methods for infection prevention (e.g., during device implants, etc.)?

We follow evidenced-based practice to reduce infections, including using prophylactic antibiotics, clipping hair at surgical site, doing skin prep, maintaining normal temperature and glucose levels, and following strict monitoring to maintain an aseptic environment. Even though we implant in the EP lab setting, we follow strict OR standards and culture of sterility. 

Do your nurses/techs participate in the follow-up of pacemakers and ICDs? 

The patients are followed up in the cardiac device clinic, which has a separate staff.

What innovative EP techniques are being utilized in your lab? 

The newest procedures we are utilizing include left atrial ligation procedures and epicardial ventricular tachycardia ablations. 

How do you use the NCDR Outcome Reports to drive QI initiatives at your facility?

The quarterly report is reviewed and evaluated for opportunities for improvement in quality care. We are typically within the desired targets, and the reports keep us aware if we should slip below those standards. 

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

Kaiser has a robust EHR. The EP lab cares for patients throughout the Northern California region. The EHR provides a complete source of the patient’s health information that can be accessed when the patient is in Santa Clara for their EP care. In addition, the referring cardiologists have access to the procedural record via the EHR.

What are some of the dominant trends you see emerging in the practice of electrophysiology? 

We expect to see an increase in atrial fibrillation ablations and left atrial appendage occlusion procedures.

How does your lab handle device recalls?

Patients with a device under recall are treated under guidelines proposed by vendors. In some cases, reimbursement costs have been negotiated by the National Product Council. 

Describe your city or general regional area. How is it unique from the rest of the U.S.?

Kaiser Permanente Santa Clara is an A-rated hospital in the heart of Silicon Valley. We are in between the beautiful city of San Francisco and San Jose. We are unique from the rest of the U.S. in that we are fortunate to be immersed with diversity. The beautiful weather year round is another added bonus to promote healthy living. 

Please tell our readers what you consider special about your EP lab and staff.

Our EP lab staff is a cohesive team that supports the greater Kaiser Permanente Northern California facility. Due to an increase in the complexity of cases and number of patients we are seeing in the EP lab, our staff is one of the most knowledgeable in this specialized cardiac area. The physicians and staff all work together on behalf of our patients — we are all one department with no independent practitioners. Despite the growing demands, a culture of mutual respect and pride is maintained in our work.