Providence Portland Medical Center

Donna-Lee Moore-Stout, RN, CCRN, Coordinator Cardiac Electrophysiology Providence Portland Medical Center, Portland, Oregon
Donna-Lee Moore-Stout, RN, CCRN, Coordinator Cardiac Electrophysiology Providence Portland Medical Center, Portland, Oregon
Providence Portland Medical Center (PPMC), one of three Oregon Magnet Hospitals for Nursing Excellence (American Nurses Credentialing Center {ANCC}), is located in the heart of the older residential area of Portland, Oregon. PPMC is part of Providence Health & Services in Oregon, a not-for-profit network of hospitals, health plans, physicians, clinics and affiliated health services. We are recognized for excellence in patient care and research in areas such as cancer, heart, brain and spine, orthopedics, women's health, rehabilitation services and behavioral health. Providence Portland Medical Center is one of three facilities in Oregon that was awarded the AHA's “Get With The Guidelines” prestigious "Sustained Performance Achievement Award" in the category of Coronary Artery Disease and acute myocardial infarction treatment for 2009. Providence Heart and Vascular Institute's Heart Clinic/Transplant Program is a community-based program that includes outpatient consultations; individualized plans of medical therapy; advanced techniques in cardiovascular surgery and cardiac arrhythmias; heart failure clinic, assist devices and heart transplantation; nutritional evaluation and counseling, as well as national clinical trials of cutting-edge medicines and procedures. It offers a comprehensive, multi-disciplinary treatment of end-stage heart disease. When was the EP lab started at your institution? The Providence Portland Medical Center (PPMC) EP program was given new energy and direction with a new EP physician, Dr. Ashkan Babaie, and a brand new biplane EP lab in June 2008. Prior to that, the electrophysiology program consisted only of device implantations and an occasional baseline EP study. What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab? We have one dedicated EP suite equipped with a Philips (Philips Healthcare, Andover, MA) biplane system, Carto 3 3D mapping system (Biosense Webster, Inc., a Johnson & Johnson company, Diamond Bar, CA), Bloom stimulator (Fischer Imaging Corporation, Broomfield, CO), GE CardioLab software (GE Prucka; GE Healthcare, Waukesha, WI) and Sequoia ICE imaging (Siemens, Washington, DC). Our device implantations and tilt table studies flow over almost daily to one of the two cardiac rooms in the cath lab. There are five dedicated EP staff members: three RNs, including the EP Coordinator, Donna-Lee Moore-Stout, RN, CCRN, Karen Reiff, BSN, RN, LNC, and Margaret Rotert, BSN, RN, and two EP techs, Brock Jonasson, CEPS, RCIS, and Billy Coliron, RCES. Also integral to our team is John Hatfield, RCIS, and Janet Melton, RT (R), who are training in EP but have not yet been dedicated to the service. Additionally, we are currently training a per diem nurse, Lori Zoborowski, RN, to perform sedation in EP cases. Our full-time staff works 10-hour shifts, four days per week. Karen works 0.87 and Janet is a 0.75 employee. Our electrophysiologists include our Director of Arrhythmia Services, Dr. Ashkan Babaie, and his partners, Dr. Ronald Petersen and Dr. Alexi Zemsky. What is the primary goal of your program? The Providence Health System vision is to provide connected care based on clinical excellence. In EP, we strive to keep the patient at the center of our mission, creating an environment of personal care, in addition to all of the technology. Drs. Babaie and Zemsky perform EP studies and ablations as well as device implantations. Dr. Petersen’s expertise is with device implantations. The goal of our program is to offer our patients safe, appropriate, state-of-the-art and progressive treatment for their cardiac dysrhythmias. We continue to explore new technologies with the intent of providing the best clinical outcomes for our patients. What types of procedures are performed at your facility? Approximately how many are performed each week? We perform a comprehensive array of diagnostic and therapeutic procedures for adult patients. Our EP lab is prepared to perform tilt table studies and implant loop recorders, pacemakers and ICDs, including bi-ventricular devices. Baseline EP studies and radiofrequency ablations for SVT, WPW, ventricular tachycardia, atrial flutter and atrial fibrillation are also part of our normal repertoire. Presently, one of our three EP physicians is scheduled in the hospital every weekday, allowing us to do an average of two to three EP procedures every day. What new equipment, devices and/or products have been introduced at your lab lately? How has this changed the way you perform those procedures? Collaboration with our surgical services colleagues culminated in our first convergent procedure in September 2010. We have subsequently performed five more of these hybrid, combination surgical and catheter ablations on patients with chronic atrial fibrillation. This minimally invasive surgical procedure, performed by cardiovascular surgeon Dr. Charles Douville, affords the opportunity to ablate the epicardium. Dr. Ashkan Babaie completes the line with endocardial catheter ablation and 3D mapping with Carto 3. This technique presents options for chronic atrial fibrillation patients that may not have been considered for ablation, plus the current international data reports up to 80% efficacy. We anticipate that the convergent procedure will reduce the length of our atrial fibrillation ablation procedures on a specific subset of these patients. PPMC is the first institution west of Texas to perform these procedures. There are only 25 institutions globally and only 16 in the United States including this technique in their treatment options. Additionally, in May 2010, we upgraded from the Biosense Webster Carto XP to their Carto 3 mapping system. While the convergent procedures highlight our growth in 2010, we also appreciate the abilities of our new 3D mapping system. In addition to being easier to use for the EP staff, Carto 3 provides the physician with catheter location on the 3D map. Does your EP lab compete for patients? Has your institution formed an alliance with others in the area? Have you developed a referral base? There are multiple facilities in the Portland area that provide EP services, including our sister facility 10 miles away, across town. Our EP referral base is predominantly from the electrophysiologists’ own group: 18 cardiologists and 4 cardiothoracic surgeons. The Oregon Clinic is the largest private, specialty physician practice in Oregon, with more than 120 physicians practicing over 30 different medical and surgical specialties and sub-specialties. All of the device follow-ups are done at The Oregon Clinic rather than in the hospital. Who handles your procedure scheduling? Do you use particular software? The scheduling of our patients is done by the cardiovascular lab (CVL) secretaries utilizing “Pathways Scheduling,” which is the scheduling software used for all PPMC procedural areas. The system is not perfect, but with adequate communication between the secretaries and the EP Lab Coordinator, it works. Is the EP lab separate from the cath lab? How long has this been? Are employees cross trained? The EP lab remains under the umbrella of the cardiovascular lab. All of our staff is experienced CVL staff and capable of assisting with any procedures in the cardiac and interventional radiology rooms. The CVL staff does not routinely cross train into EP, but there are two CVL nurses, Jake McLain, RN, and David Kern, RN, who have been trained to sedate patients during EP procedures, as well as one CVT, Susan McKiernan, RCIS, who is able to scrub EP cases. Who manages your EP lab? Jeff Robins, RT R(CV), MBA, is the manager of the CVL, and Donna-Lee Moore-Stout, RN, CCRN, is the Coordinator of the EP lab. Dr. Ashkan Babaie is the Director of Arrhythmia Services at Providence Portland Medical Center. Do you have cross training inside the EP lab? What are the regulations in your state? Nursing staff is solely responsible for sedation if an anesthesiologist is not being utilized. All staff is being trained on the ablation generators, CardioLab and Bloom stimulator. The EP techs and our X-ray tech scrub cases. The nurses do not, at this point. There are 3 members of our staff that are working with 3D mapping using Carto 3, and we are working to have more of our team comfortable with the system. How does your lab handle call time for staff members? How often is each staff member on call? How frequently do they have to come in, on average? Is there a particular mix of credentials needed for each call team? The EP dedicated team does not take call; however, they are required to stay late to complete procedures when the need arises. While this sounds appealing to those who do take call, there is a tradeoff. The EP staff’s lives are subjugated with little notice, any night of the 5-day work week, as opposed to knowing that they could stay late on the designated night that they are on call. We are fortunate to have a team of committed EP staff members who willingly stay to help our physicians. Providentially, there are relatively few nights when staying late extends beyond 7:00 p.m., but there have been some late nights that were unavoidable. The staffing requirement is dependent upon the type of procedure. Our Standard of Care for ablations presently calls for two RNs and two techs, while a device can be done with three staff members, one of whom must be an RN. How are new employees oriented and trained at your facility? All new RNs and techs undergo an on-the-job training and orientation program. During the orientation process, the new employee is given adequate time to assimilate the required knowledge into practice. They are rotated through the different stations in the EP lab where they learn the fundamentals of each position in which they will participate. Competencies are assessed at the completion of each training session with goals made for continued advancement in the training process. What type of quality control/quality assurance measures are practiced in your EP lab? In the last two years our quality assurance monitoring included device infections, appropriate documentation and billing, as well as x-ray exposure. Quality Assurance and Improvement is an area that we will be focusing on developing further in 2011. We are in the process of developing additional criteria for the Physician Quality Reporting System (PQRS). What types of continuing education opportunities are provided to staff members? Training and education is often done during cases when the situation arises. Our physicians take the time to instruct us whenever their time allows. Case reviews are instrumental as teaching tools whenever there is unscheduled time left in the day. Individual staff members actively search out books from which to learn new material and then share their learning with the rest of the team. Our management is cognizant of the importance of EP education. Vendors have brought their specialists to our EP lab to educate us, and the EP team attends any EP educational offering in the local community. How do you prevent staff burnout? In addition, do you practice any team-building exercises? The prevailing culture of our team is one that embraces each team member’s differences. We acknowledge that each of us has strengths as well as weaknesses. We draw on those strengths and share knowledge to make the team stronger as a whole. Our entire team is comprised of ‘over-achievers’; we revel in the challenges, commitment, and work ethics that we share. During exceptionally long cases, it is not unusual for a ‘rally cap’ to appear or some other humor to crop up that livens up the spirits and serves as a stimulant to keep each other alert and engaged in the procedure. We work hard together, learn together and play together. Food is a great commonality for us. We talk about different restaurants that we’ve tried and occasionally go out to dinner together. We have gone whitewater rafting together twice over the last two years. It is our symbiotic relationships both in and outside the hospital that foster our friendships and enhance the teamwork within the EP lab. The entire team has attended HRS together the last two years and we are hoping to create the same opportunity again in 2011. Does your staff provide any educational materials for patients who may have additional questions about their condition/ procedure? In addition, does your hospital or lab staff have a device support group (e.g., for pacemaker or ICD patients)? Preliminary education is done in the electrophysiologists’ office and reiterated by the staff in our admitting area, the interventional cardiovascular recovery (ICVR) area. Following the procedure, each patient receives a folder with educational information pertinent to the procedure they had done, along with discharge instructions. This facilitates appropriate patient teaching by the unit RN that discharges the patient. Patient teaching is an area that we are monitoring to ensure that the patients are receiving everything that they need to know to care for themselves after discharge. Our sister hospital across town hosts an ICD educational meeting quarterly that our patients are invited to attend. What innovative EP techniques are being utilized in your lab? The 2010 additions of Carto 3 technology and the convergent procedure for atrial fibrillation have been the latest, state-of-the-art techniques that we’ve made available to our patients. Please describe one of the more interesting or bizarre cases that have come through your EP lab. What lessons did you learn from it? One of the most interesting cases that we performed was an epicardial ablation of a focal left ventricular outflow tract tachycardia after extensive 3D mapping. The focus of the tachycardia was located with a 16-electrode 2.5 French Cardima catheter placed into the great cardiac vein via a femoral vein approach. A 4-mm-tip electrode ablation catheter was also advanced to the great cardiac vein. Using coronary angiography, the location of the ablation electrode was confirmed to be clear of the left anterior descending artery and left circumflex artery. The focus was successfully ablated and during the 3-month follow-up, the patient reported no recurrence of PVCs. This case showed us that with multiple technologies available and incredibly skilled hands, even the most difficult cases are routinely successful. Specifically, the benefit of 3D mapping to pinpoint a focal tachycardia and coronary angiography to assure appropriate positioning of the ablation catheter can be key to a successful procedure. How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? The PPMC CVL and EP lab utilize the WaveMark RFID (Wavemark, Littleton, MA) inventory management system that provides real-time inventory and usage information. Sandy Breazille manages all inventory purchases and restocking of supplies. Providence Health & Services, as a system, utilizes a Resource Council for negotiating prices on devices. How do you handle vendor visits to your department? Do you contract with vendors? Providence Health and Services utilizes RepTrax for all vendors. RepTrax is a hospital platform that helps track and manage hospital vendor credentials, vendor activity and vendor behavior. They must have an appointment with Sandy Breazille or the EP Lab Coordinator and sign in before their arrival to the cath and EP labs. Does your lab use a third party for reprocessing? How has it impacted your lab? Reprocessing catheters and cables allows us to put less waste into our landfills as well as decreases the cost of equipment. We reprocess through Ascent (Ascent: A Stryker Sustainability Solution, Phoenix, AZ) as well as some in-house reprocessing of cables. During the first two years of using reprocessed equipment from Ascent, we had difficulty keeping a consistent par level of inventory in the EP lab. Reprocessed equipment came in sporadically and we experienced ‘feast or famine’ on our shelves. We have recently changed to simply attempting to buy reprocessed equipment before going to the original equipment manufacturer (OEM) for purchasing new items. This has stabilized our inventory numbers while giving us the economic advantage of reprocessing as well as keeping the lab as ‘green’ as possible. Describe your city or general regional area. How does it differ from the rest of the U.S.? Portland is a unique health care environment in that there are no ‘for profit’ hospitals. There are approximately 590,000 people within the city and 2.2 million people in the Portland metropolitan area. There are 10 major hospitals, 8 of which offer EP services. Portland lies at the northern end of Oregon's most populated region, the Willamette Valley. However, as the metropolitan area is culturally and politically distinct from the rest of the valley, local usage often excludes Portland from the valley proper. The Willamette River runs north through the city center, separating the east and west sections of the city before veering northwest to join with the Columbia River (which separates the state of Washington from the state of Oregon), a short distance north of the city. The City of Portland has been referred to as one of the most environmentally friendly or “green” cities in the world. The city and region are noted for strong land-use planning and investment in light rail, supported by Metro, a distinctive regional government. Portland is known for its large number of microbreweries and microdistilleries, as well as its coffee enthusiasm. Portland is home to a diverse array of artists and arts organizations, and was named in 2006 by American Style magazine as the tenth best Big City Arts Destination in the US. Portland may be best known for its close proximity to the Pacific Ocean and the Cascade Mountain Range, specifically Mt. Hood, both of which are a 90-minute drive in opposite directions. The Columbia Gorge, just a 25-minute drive from Portland, is famous for Multnomah Falls and multiple other scenic waterfalls along the way. Portland lies in the Marine west coast climate region, marked by warm, dry summers and rainy but temperate winters. Please tell our readers what you consider unique or innovative about your EP lab and staff. The PPMC EP lab did our first ablation in June 2008. The EP team consisted of four inexperienced, but eager to learn, staff members at that time. Our team remains driven to learn and is constantly creating educational opportunities for ourselves. Brock Jonasson passed the IBHRE exam in our second year. Billy Coliron joined the original team and has achieved RCES certification this year and is scheduled for the IBHRE exam in the April 2011. Three more of our staff are preparing for the RCES exam as well. Our EP physicians are patient teachers and encourage us to learn and grow. They have helped create the collaborative environment that continues to feed the exuberance of the entire team. We meld well with each other and hold fast to the goal of seeing our EP lab develop into a center that can improve medical techniques and interventions that greatly improve the lives of patients while creating a work environment that we all enjoy. For more information, please visit: http://www.providence.org/oregon/facilities/hospitals/providence_portland