Accompanying EP Lab Digest’s April 2013 Spotlight Interview with Loyola University Medical Center is this featured video with David Wilbur, MD, Chairman, Department of Cardiology.
Loyola University Medical Center is a nationally recognized leader in cardiac care. U.S. News & World Report recently ranked Loyola as 18th in the nation for cardiology and heart surgery in 2012, making this our 10th year in the top 50. We are an academic, tertiary care, 569-licensed bed facility that includes a Level 1 Trauma Center and a Burn Center.
What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab?
Our EP facility consists of five procedure labs, which includes one lab at the Hines VA Hospital. All of our procedure labs are fully equipped with the most advanced technology available to deliver the best outcomes to our patients.
A hybrid operating room is used for complex device-related procedures. We have eight certified electrophysiology physicians, five cardiac electrophysiology fellows, eight highly skilled nurses, one RCES, two RTs, one biomedical clinical engineer, four advanced practice nurses, two research nurses, one Afib Database RN Clinician, three device clinic nurses, and three clerical support staff.
When was the EP lab started at your institution?
Our EP lab was established here at Loyola in 1984. In 2007, Loyola opened its Center for Heart & Vascular Medicine, which includes our EP lab. We doubled the number of procedure rooms to accommodate our fast-growing volume and improve patient flow.
What types of procedures are performed at your facility? Approximately how many are performed each week?
We perform ablations of complex atrial and ventricular arrhythmias, both in the adult and pediatric populations. This includes both endocardial and epicardial approaches. We also provide pacemakers, defibrillators, biventricular device implants, device and lead extractions, left atrial appendage ligation, insertion of percutaneous external heart assist devices during ablation procedures, cardioversions, tilt table testing, pharmacologic challenge, and non-invasive programmed stimulation. Our EP lab performs approximately 600 ablations and 600 device implants a year.
What is the primary goal of your program?
Advanced technology is the primary goal of our program. Our focus is to provide a comprehensive approach in the diagnosis, treatment, and management of cardiac arrhythmias. We offer expertise in the management of complex cardiac arrhythmias, cardiac device management, device implantation, and lead extractions. Loyola accepts patient referrals from hospitals across the region and country for especially complex and challenging cases that failed previous ablations. Our advanced equipment allows our highly trained and experienced physicians to use leading-edge technologies to perform procedures that produce the best patient outcomes.
Who manages your EP lab?
Dr. David Wilber is Medical Director of Clinical Electrophysiology. Gayle Payonk is the Director of Interventional Cardiology and Electrophysiology. Assistant Manager Grace Lach handles the daily operations, process and quality improvement, staff education and development.
Are employees cross trained with the cath lab?
There is some cross training and cross coverage for both areas, and we have assisted with their procedures during emergencies and vice versa.
Do you have cross training inside the EP lab? What are the regulations in your state?
Our EP staff is cross trained to perform both ablation and device procedures. This offers the most flexibility and versatility to accommodate our high volume. There is a structured staff rotation in each role, so each staff member keeps up with their skills in whichever case they are assigned to.
What new equipment, devices and/or products have been introduced at your lab lately? How has this changed the way you perform those procedures?
Having highly experienced physicians who are key opinion leaders in the field of cardiology and electrophysiology enables us to evaluate new products and obtain access to cutting-edge technologies. Loyola was the first in Chicago to perform a percutaneous external heart assist device to provide hemodynamic support during the ablation of a complex and unstable ventricular tachycardia. Loyola was one of the first centers to utilize multi-electrode mapping (MEM) technology with Biosense Webster’s PentaRay NAV, Lasso NAV and DecaNav in the ablation of complex cardiac arrhythmias. We are beginning the external evaluation for Biosense Webster’s Carto 3 (Version 3.2), which features Alara (fluoroscopy integration to Carto map), PaSo VT Pace Mapping Software, and Visitag (objectively automates ablation strategy with user-defined parameters that accurately track, record and review catheter location and ablation data). Loyola also provides cryoablation for the treatment of atrial fibrillation. We are evaluating the contact force ablation catheter. We have also introduced the LARIAT procedure (SentreHEART, Inc.) for left atrial appendage ligation. These new technologies give our physicians additional tools to improve procedure efficiency and achieve superior quality outcomes.
Have you recently upgraded your imaging technology?
Yes. We have Siemens’ imaging in all four labs, installed when we moved to our expanded lab in 2007. Since then, we have kept up with the most current software upgrades available to improve our EP imaging workflow. We also have Siemens’ LEONARDO workstation, which allows us to integrate CT images into our Carto 3D mapping system.
Who handles your procedure scheduling? Do they use particular software?
Scheduling is a team effort of our physicians, advanced practice nurses, and EP lab team lead. For procedure scheduling we use the Epic OpTime module, which was launched in Spring 2012 to improve scheduling workflow. With OpTime, we eliminated redundant steps in the scheduling process related to admission/registration/pre-authorization as well as scheduling anesthesia. This system improved patient tracking both for bed placement and for patient family updates. OpTime integrates billing and nursing intra-procedure documentation, which is great for streamlining clinical workflow.
What type of quality control/quality assurance measures are practiced in your EP lab?
We are active participants of the NCDR® ICD Registry™. We also have our own atrial fibrillation database to track long-term outcomes for our atrial fibrillation patient population. Loyola’s Center for Clinical Effectiveness requires each department to report quality assurance measures. This includes conscious sedation, surgical infection, procedure complications, LV lead implant success rates, and CAUTI.
How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies?
Inventory management is also a team effort between staff and supply chain. We currently have a hybrid manual and automated system, but are exploring other options to improve and fully automate our inventory management.
How has managed care affected your EP lab and the care it provides patients?
We are extremely focused on efficiency and cost effectiveness. Patients in managed care plans require pre-certification prior to procedures to ensure payment, and we have an effective process in place to effectively accomplish this. If needed, our physicians participate in peer-to-peer discussions with insurance company medical directors. Moreover, being part of a national healthcare system, Trinity Health, gives us an advantage in dealing with managed care contracts.
Have you developed a referral base?
Loyola is among Chicago’s premier academic medical centers, with a strong tradition of providing superior quality patient care. Our EP lab has a large geographic referral across the country. Loyola has an exclusive network of specialty and primary care centers in Chicago’s western and southwestern suburbs.
Does your EP lab compete for patients? Has your institution formed an alliance with others in the area?
Our physicians have affiliations with multiple institutions in the greater Chicago metropolitan area. They regularly see and follow up with patients in these locations, and bring in patients for EP procedures as medically necessary. We are surrounded by competing hospitals, but we continue to be the leading provider in electrophysiology and cardiac care.
What measures has your EP lab implemented in order to cut or contain costs? In addition, in what ways have you improved efficiencies in patient through-put?
We have worked closely with our supply chain and Trinity Health to obtain better contract pricing for our implantable devices and supplies. This has resulted in significant cost savings. OpTime implementation allowed us to have a better system for intra-procedure documentation, improved continuity of care from procedure area to post-procedure care, better reconciliation of supply, and facility charges without impeding turnaround time.
How are new employees oriented and trained at your facility?
We have a comprehensive orientation program. Our lab’s high volume makes it easier to train staff in a shorter period of time, but with maximum exposure to complex procedures.
What types of continuing education opportunities are provided to staff members?
We regularly send staff members to the Heart Rhythm Society’s annual conference and advanced ablation course, as well as to company-sponsored educational sessions that include basic and advanced EP training. We have also provided weekend educational sessions to our EP lab staff. Two of our attending physicians give a weekend presentation on basic EP concepts. In the question and answer portion, the physicians explain complex EP concepts in simple terms. We also have an annual cardiovascular symposium, which is free to our EP and nursing staff.
How is staff competency evaluated?
The field of cardiac electrophysiology undergoes continual changes, including new techniques, procedures, and products. Consequently, we continue to evaluate our staff competency year round. Our Education Committee organizes and coordinates staff competency. We have a monthly schedule for skills demonstration and checklists related to the various equipment and procedure setup. We have an annual pig heart dissection, during which we review the advanced anatomy and physiology of the heart as it relates to electrophysiology. Each staff member is required to pass an annual EP lab exam in addition to our hospital-wide e-learning requirements.
How do you prevent staff burnout? In addition, do you practice any team-building exercises?
Our staff members work four days a week, 10 hours a day, with two scheduled late days. We do self scheduling. Our on-call responsibilities are only on weekends and holidays. We use Loyola’s human resources’ materials to assist us with team-building activities. We have a birthday calendar in which we list each team member’s birthday, and we bring cake and other treats. We also acknowledge the anniversary hire date of each staff member. We create a poster with everybody’s message/notes that highlight the staff member’s strengths and contribution. We have done two team-building activities this year to further strengthen our team and allow us to get to know each other better. This provided opportunities for the staff to connect personally with each other. In addition, we all get together annually at a favorite restaurant for the holidays, and we enjoy time with each other outside of the work environment.
What committees, if any, are staff members asked to serve on in your lab?
The Education Committee, Quality Improvement Committee, and Staff Retention Committee are some of the committees our staff members are actively involved in.
How do you handle vendor visits to your department? Do you contract with vendors?
Loyola’s supply chain controls vendor visits. We use RepTrax. Contracts are handled at a corporate level through the Trinity Health Supply Chain Management Team, with input and involvement from clinicians.
Does your lab utilize any alternative therapies to help patients in the EP lab?
We use diversion techniques such as talking to the patients, making them feel comfortable, and providing music therapy. We have encouraged our patients to bring in their favorite CD or MP3 player with their music of choice.
Describe a particularly memorable or bizarre case that has come through your EP lab. What lessons did you learn from it?
We recently performed a complex epicardial VT ablation one Sunday morning. It was memorable because it reminds us that when patients are in need of our services, our team is always there to provide it no matter what time or day, and make everything possible. Our Anesthesia department was there to provide anesthesia support, and three attending electrophysiologists, a fellow, and three staff members came. The case went extremely well, and we successfully performed the procedure as if it were a regular working day.
How does your lab handle call time for staff members?
EP call time is only on weekends, and is strictly voluntary. Staff members coordinate among themselves with scheduling and rotation. On average, the call team comes in one to two times a month, with a minimum of two staff members and at least one nurse required.
Approximately what percentage of your ablation procedures are done with cryo? What percentage is done with radiofrequency?
We perform the majority of our ablation procedures with radiofrequency. Less than 5% of our ablations are done with cryo, but we make it available to patients who request it.
Do you perform only adult EP procedures or do you also do pediatric cases? Is there cross training for pediatric cases?
We perform both adult and pediatric EP procedures. There is cross training for pediatric cases, and we have PALS-certified staff members.
What measures has your lab taken to minimize radiation exposure to physicians and staff?
We know that dose reduction is a key concern for operators and patients. With the latest imaging software upgrade from Siemens, we now have the entire range of CARE benefits (Combined Applications to Reduce Exposure). This includes radiation-free object positioning, radiation-free collimation and semi-transparent filter parameter setting to precisely target the region of interest. It also features low-dose fluoroscopy with three different fluoroscopy modes that enable us to reduce fluoroscopy dose as much as 50%. Our lab uses the RADPAD (Worldwide Innovations & Technologies, Inc.) to diminish scatter radiation exposure to operators during all EP procedures. We are performing a study to assess the effectiveness of radioprotective draping to further reduce primary and secondary operator exposure. Additionally, we use the most current technology, such as robotic navigation and intracardiac ultrasound with 3D mapping integration as a means to further reduce radiation exposure.
Do your nurses/techs participate in the follow up of pacemakers and ICDs?
Our EP lab nurses do not participate in the follow up of pacemakers and ICDs. However, three dedicated nurses are specially trained to do all device follow ups. We use Paceart software, and device checks will be fully integrated into our electronic medical records within the next few months. We perform approximately 150 device visits per week, and about 70% require a doctor for their visits.
What about device recalls? How has your lab handled these?
Dr. Santucci is the Director of our Device Lab. He collaborates with our device clinic nurses, device reps, and risk management team to address device recalls. He keeps current with FDA and device company recommendations to ensure maximum patient safety.
Is your EP lab currently involved in any clinical research studies or special projects? Which ones?
There are currently about 20 active clinical research protocols evaluating new ablation and device technology and comparative clinical outcome studies of different therapies. We are involved in several research studies such as CABANA, SmartTouch, ASPIRE VT Study, Post Approval Registry for ThermoCool Catheters for Atrial Fibrillation, MADIT-RIT, and the Medtronic Shock-Less Study.
Are you ACGME-approved for EP training?
Yes, our EP Fellowship program is ACGME approved. We provide a 24-month training program, which offers our fellows exposure to complex cases and comprehensive training that will prepare them for their own practices.
Give an example of a difficult problem or challenge your lab has faced. How it was addressed?
One of the challenges our lab had was intra-procedure nursing documentation. Our options were manual paper documentation or electronic charting that interfered with our workflow. With the standard of care having a form of electronic medical record that is accessible to the multidisciplinary team, it was a challenge to find a system that would integrate with the hospital’s electronic medical record without disrupting our workflow. With the help of our IT department, we designed a documentation process within our existing electronic medical records that was customized to fit our procedure workflow. This reduced the amount of paperwork during procedures, eliminated redundancy, and improved continuity of care and communication. Best of all, it improved employee satisfaction by making their work more efficient, leaving more time to attend to patients.
Describe your city or general regional area. How does it differ from the rest of the US?
Loyola is located 12 miles from downtown Chicago, the third largest city in the US. Chicago’s scenic lakeside location, world-class cultural contributions, and unique architecture are among the reasons why Chicago is a great place to live and visit. Chicago is also a center of excellence for healthcare; Loyola is among the academic medical centers serving the city and suburbs. While Loyola treats patients throughout the Chicago area, its primary service territory is Chicago’s western suburbs, which represent a wide socioeconomic diversity.
What are some of the dominant trends you see emerging in the practice of electrophysiology? How is your lab preparing for these future changes?
We see dominant trends focused on improving procedure efficiency, further reduction of ionizing radiation exposure, and cost effectiveness. We utilize Lean Six Sigma methodologies in our quality and process improvement projects. Loyola is a leader in a clinical research that focuses on these future changes.
Please tell our readers what you consider unique or innovative about your EP lab and staff.
In addition to offering advanced technology, expertise and skill, our physicians and nurses and other healthcare team members are committed to fulfilling our mission of going beyond the treatment of disease. We foster an environment that encourages innovation, embraces diversity, respects life, and values human dignity. Our electrophysiology staff is a diverse group that brings experience from fields such as critical care, engineering, paramedic training, and the military. Under the direction of a world-respected electrophysiologist, our physicians represent all that is cutting edge. We consistently work together as a team, drawing from each other’s strengths and talents to make our electrophysiology lab one of the best in the nation. We also treat the human spirit®.