New York University Langone Medical Center

Steven J. Fowler, MD and Larry A. Chinitz, MD, New York, New York
Steven J. Fowler, MD and Larry A. Chinitz, MD, New York, New York

New York University Langone Medical Center, a world-class, patient-centered, integrated, academic medical center, is one of the nation’s premier centers for excellence in clinical care, biomedical research and medical education. Located in the heart of Manhattan, NYU Langone is composed of three hospitals – Tisch Hospital (806 beds), its flagship acute care facility; the Rusk Institute of Rehabilitation Medicine (174 beds), the world’s first university-affiliated facility devoted entirely to rehabilitation medicine; and the Hospital for Joint Diseases (190 beds), one of only five hospitals in the nation dedicated to orthopedics and rheumatology – plus the NYU School of Medicine, which since 1841 has trained thousands of physicians and scientists.

This relationship also allows for clinical cardiovascular care and research activities at Bellevue Hospital Center (820 beds), the nations’ oldest continuously operating hospital in America, and the New York Harbor Veterans Affairs Medical Center (171 beds), the primary referral center for specialized care of veterans in the Northeast region. 

As an extension of the Cardiac & Vascular Institute, the NYU Clinical Cardiac Electrophysiology Service is seamlessly integrated with the NYU Heart Rhythm Center, our outpatient facility.

What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab?

There are 4 dedicated EP labs, a 10-bay observation area, and a dedicated patient waiting area at Tisch Hospital; we share a cardiovascular hybrid operative suite as well. Our team currently consists of 8 attending MDs, 7 EP fellows, 5 PAs, 5 NPs, 2 RNs, 7 administrative staff, 2 research coordinators, 1 data manager, and is fully supported by inter-departmental teams, including: non-invasive cardiology, anesthesia, dedicated EP RN staff, and CVTs who are cross-trained in cardiac intervention. 

When was the EP lab started at your institution? 

The EP lab has been a functional part of the catheterization laboratory since the 1980s; it was separated as a distinct entity and functional area in 2009.

What types of procedures are performed at your facility? Approximately how many are performed each week? 

The full range of electrophysiology procedures are performed, from diagnostic studies and drug infusions, to device implants and extractions, to catheter-based ablation of all arrhythmia subtypes, including epicardial ablation and integrative renal artery ablation, as well as percutaneous left atrial occlusion. We performed 2,306 procedures at NYU in 2012, an average of ~50 cases weekly.

What is the primary goal of your program?

Our goal is to put our patients at the center of everything we do, to provide top-notch care that goes beyond treatment; this includes establishing a considerate and trusting relationship in a warm and welcoming environment. Behind our passion for providing excellent clinical care is a strong foundation in basic science and a thriving research program. We feel that care for our patients comes from being at the leading edge of medicine and technology.

Who manages your EP lab?

Our lab is managed by a dedicated EP administrator. 

What new equipment, devices and/or products have been introduced at your lab lately? How has this changed the way you perform those procedures?

In the past 2 years, we have fully upgraded our imaging technology and lab space, including networking our labs using the Odyssey system (Stereotaxis). Each lab suite supports both EnSite (St. Jude Medical) and Carto 3 (Biosense Webster, Inc., a Johnson & Johnson company) mapping, with HD screens, EP-WorkMate software (St. Jude Medical), rotational CT capability, and integrated intracardiac ultrasound, and is outfitted for full sterile device capability. We have one Stereotaxis suite as well.

This equipment has facilitated our procedural and data flow which permits real-time review of cases, as well as archives for off-line teaching, presentation and discussion. 

How is procedure scheduling managed?

Scheduling is done through our administrative staff utilizing system-wide EPIC software; this is initiated at the point of care in the NYU Heart Rhythm Center, our outpatient facility.

What type of quality control/assurance measures are practiced?

There are monthly audits set up to monitor compliance with best practice measures.

How is inventory managed at your EP lab? 

Supply chain administration is responsible for purchasing of equipment and supplies.

Has your EP lab recently expanded in size and patient volume? 

Our procedural volume has grown over 85% since 2009, and 6 new EP suites, all fully hybrid-operative compatible, are planned for a new NYU hospital that is in the process of being built and expected to be completed by 2017. 

How has managed care affected your EP lab and the care it provides patients?

Managed care, especially in light of the latest round of reimbursement cuts, has affected our lab by making us refocus on our workflow and documentation, especially in our academic setting with a complex population and procedure base, to ensure we appropriately reflect the work we perform. 

What measures has your EP lab implemented in order to cut or contain costs? In what ways have you improved efficiencies in patient through-put?

NYU Langone Hospital Senior Administration established lean management as a fundamental approach to workflow improvement across NYU Langone Medical Center, dating back to 2008. The benefits of lean include simplified and efficient processes, improved quality and safety, reduction of worker overburden, improved finances, and patient and staff satisfaction, to name a few. 

The Invasive Cardiology Service has conducted three rapid improvement events with focuses on registration and scheduling, first case start/patient throughput, and procedure room turnover. In fact, we have dedicated a position to data management, which includes report generation and documentation, to improve efficiency in our communication from pre-admission through the billing process. 

Does your EP lab compete for patients? Has your institution formed an alliance with others in the area?

New York City remains an extremely competitive urban environment; NYU has made alliances with practices within Manhattan and the 5 boroughs to continue growth in the area.

How are new employees oriented and trained at your facility?

Employees are oriented and trained over a 12-week period within the EP lab; they are given programmed days off for continued learning and there is a tuition remission program in place. Competency is evaluated on a quarterly basis, with discussion on an annual cycle and more frequent interactions as needed. 

Staff are encouraged, but not mandated, to take the Registered Cardiac Electrophysiology Specialist (RCES) exam. Our staff often serves on committees related to the cardiovascular institute and patient care, such as resuscitation, supply chain/products, CV best practice, etc.

How do you handle vendor visits to your department? Do you contract with vendors?

We contract with all major vendors and like to maintain parity with products, which enables flexibility for clinical care. We openly participate in industry and institutional research projects, including large animal studies, which often allow access to new products and approaches. Vendors need to register with the lab and are outlined in our consent process for procedures. 

Does your lab utilize any alternative therapies to help patients in the EP lab? 

We use dedicated patient advocates to help address the needs of our patients and families undergoing care at NYU. This liaison plays an important role in facilitating the care during procedures — and serves as a personal guide to the day for family members. We allow personal music choices and have relaxation techniques available to all patients through the medical center. 

Describe a particularly memorable case that has come through your EP lab. What lessons did you learn from it?

The Cardiovascular Genetics Program, which is led by Silvia Priori, MD, PhD and cares for patients with inherited arrhythmogenic diseases, is within the NYU Heart Rhythm Center. Often, these are challenging electrophysiology cases which require ‘out of the box’ thinking to ameliorate aggressive, recurrent arrhythmia. We recently ablated a young man with catecholaminergic polymorphic ventricular tachycardia (CPVT) and have been able to integrate new approaches, stemming from our translational research, to make a huge impact in his life — reminding us to continue to pursue the cutting edge of care.

How does your lab handle call time for staff members?

We have one on-call support team for both EP and cardiac catheterization; this rotates one in 4 nights with the team, with seniority given preference of schedule. Everyone is cross-trained and certified for coverage.

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

We do use a third party for some reprocessing; it helps in maintaining the bottom line. Increasingly, academic medical centers need to be aware of costs at all levels.

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

About 95% of cases are with radiofrequency, and the other 5% is with cryo.

Do you perform only adult EP procedures or do you also do pediatric cases? Is there cross training for pediatric cases? 

We also perform pediatric EP procedures in our lab; there is a full-time pediatric electrophysiologist at NYU who is part of the pediatric cardiology program. There is cross training for staff in pediatric cases — this staff is often shared with the structural heart/interventional program.

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

Radiation safety is maintained through the hospital; everyone is trained and is required to wear badges to record exposure, which is reviewed monthly. We have outfitted the labs with imaging technology to permit low, pulsed fluoro in all cases. There is also a biplane suite. Moreover, we use X-Drapes (AADCO Medical, Inc.) for all of our procedures and have acquired ZeroGravity Radiation Protection Systems (CFI Medical Solutions) for 2 of our labs.

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

Yes, our device clinic is run by a dedicated nurse and nurse practitioner who currently follow approximately 4,000 patients, with 100 visits weekly between the two, which is documented in the EPIC system. Medtronic Paceart is also used to log technical device data, starting from the time of implant. We also readily incorporate web-based/transtelephonic follow-up and are trying to augment this part of the clinic. Physicians are available for review of issues as needed; for instance, device recalls are flagged and patients are scheduled for more frequent monitoring, fluoroscopy, and alarm adjustments.

What innovative EP techniques are being utilized in your lab?

We have been using aquapheresis during ablation cases to mitigate volume administration with open irrigation — with good result — and are preparing to publish this experience. We also have embraced closure of the left atrial appendage, via either endocardial or epicardial approach, and are working on trials in combination with catheter ablation of atrial fibrillation. We are also a tertiary referral center for cardiovascular genetics and have successfully lobbied the FDA to have specialized medications available for improved diagnostics in this area and are engaged in active translational research for both inherited channelopathies and cardiomyopathies. 

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

We have used the NCDR Outcomes to refocus our attention on proper coding, documentation, and follow-up in our workflow. We have created a distinct position of data manager to address these issues and to ensure continued success with the process. EHR has really transformed our medical center and does allow for improved quality of care, although like all larger institutions, it was a difficult transition to make for our team. 

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 are cognizant of the trend toward personalized care, in that, individualized approaches to catheter-based ablation and device-based therapy may portend better amortized outcomes — rather than say, a set of ‘standard’ lesions or ‘out of the box’ ICD programming. Novel mapping techniques and systems, better lead and device algorithms, as well as translational genomic research are at the fore and we are actively pursuing these areas in clinical care and research — we are currently integrating this ideology into our lab. 

Tell us about the clinical research studies your lab is involved in.

We currently have multiple open randomized trials, both in collaboration with industry and institution driven, from diagnostic drug infusions for Brugada syndrome to renal denervation trials to contact/force sensing large animal work to basic pacing maneuvers for SVT discrimination.

Are you ACGME-approved for EP training? What do you think about 2-year EP programs?

Yes; we currently have 7 EP fellows, and this number flexes between 4 and 7 depending on the candidates and integration with the general cardiovascular training program. We feel that a 2-year didactic program in EP is essential to enable satisfactory training in advanced clinical cardiac electrophysiology. The field has grown and simply encompasses too much to be done well in one year.

Does your hospital have a device support group? 

Yes, support groups are available and referred to as needed for device patients.

Give an example of a difficult problem or challenge your lab has faced. How it was addressed?

With the increasing size and complexity of our team, inter-departmental interactions and coordinating smooth workflow with early start times was difficult. As part of lean management improvement, a rapid event initiative was completed in March 2013. As a team, EP, nursing, LIPs, anesthesia, non-invasive cardiology and administration worked to refine and document workflows which depict major elements: notably detailed workflows (as to who does what and when), time stamps on key process points and commitment as to role, and responsibilities of each team member individually and in coordination.  

Describe your city or general regional area. 

New York City is one of a kind — Manhattan is the most populous city in the United States (over 8 million residents) and the center of the New York Metropolitan Area, one of the most densely inhabited urban agglomerations in the world. Diversity among New York’s inhabitants is reflected in the complexity of conditions, immensely adding to our experience and expertise. The pace and demand for medical excellence does not remit — keeping us constantly evolving!

Please tell our readers what you consider unique or innovative about your EP lab and staff.

 

We consider our group unique in our diversity of specialized interests and expertise — from cardiovascular genetics to catheter ablation to device-based therapy and neuraxial modulation — our physicians are involved in both basic science and clinical research, providing a foundational understanding of disease and allowing the team to apply this knowledge to the development of novel therapies used in the treatment of all rhythm disorders. We pride ourselves on establishing trusting relationships both with patients and among the team — we feel lucky to be a part of such an innovative, collegial, and progressive environment! It really is a team, in the truest sense of the word.