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Spotlight Interview: Advocate Christ Medical Center

Laura Grafrath, RN, BSN, Manager, Clinical Ops Invasive Cardiology, Oak Lawn, Illinois

Laura Grafrath, RN, BSN, Manager, Clinical Ops Invasive Cardiology, Oak Lawn, Illinois

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

Advocate Christ Medical Center has 2 electrophysiology (EP) labs. The first EP lab opened in 1991, and the second opened in 2003.

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

We have a total of 10 staff members on our team, consisting of registered nurses (RNs), radiology technologists, (RTs) and cardiovascular technicians (CVTs). There are 2 dedicated device specialists that perform device checks and assist with programming devices during procedures. Cardiology fellows practice in our lab and assist with procedures. 

Eight electrophysiologists perform procedures in our labs. All interventionalists are board certified. Staff member tenures in the EP lab range from 8 months to 30 years. 

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 types of procedures performed in our labs include implantations of cardiac defibrillators (ICD), subcutaneous ICDs, leadless pacemakers, pacemakers, biventricular pacemaker/ICDs, and injectable loop recorders. We also perform ablations for complex atrial fibrillation (AF), atrial flutter, ventricular tachycardia, and supraventricular tachycardia. In addition, we perform laser lead extractions, lead revisions, and left atrial appendage closures. We use a navigation system that allows for decreased incidence of perforation and decrease in physician fatigue by allowing remote control for the physician. 

Approximately how many catheter ablations (for all arrhythmias), ICD implants, and pacemaker implants are performed each week? 

Advocate Christ Medical Center’s EP lab is a high volume lab that performs approximately 35-60 cases a week. 

Who manages your EP lab? 

There is a manager that oversees both the cath and EP labs. 

Are employees cross trained?

Although the EP lab has dedicated staff, both cath and EP lab staff are cross trained to perform device implantation. 

Do you have cross training inside the EP lab? 

Yes.

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

We are a 695-bed trauma center with academic affiliations.

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

There are two shifts in the EP lab. The first shift begins at 7am, and the second shift begins at 8am. The late team stays until the cases are complete. 

Typical hours of operation are from 7am to 6:30 pm. The late team stays until the last case is complete. 

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

As a quaternary hospital, our EP lab takes on very complex procedures from many referring hospitals in the area. Case mix varies on a daily basis. Our lab works hard to accommodate the complex schedules of our physicians. Staff are very skilled in caring for patients with complex multiple morbidities and are equipped to handle the simplest to the most complex. 

What new equipment, devices and/or products have been introduced at your lab lately? 

Advocate Health Care does not endorse new devices or products. Advocate Christ Medical Center uses the latest innovative devices and products available during our EP procedures. 

How has this changed the way you perform those procedures? 

The leadless pacemaker provides patients therapy while avoiding potential lead complications. The subcutaneous ICD provides ICD therapy without transvenous leads for patients who would otherwise not receive this therapy. 

Navigation systems allow the physician to remotely move catheters to check for pulmonary vein isolation. The use of a navigation system allows for the case to be performed from the control room once femoral access has been obtained along with transseptal puncture. 

We utilize systems that provide great stability in use with an intracardiac echo catheter, allowing the physician to perform a transseptal puncture without losing site of the septum. This system also allows for the manipulation of the ultrasound catheter from the control room, where the physician is able to validate ablation catheter contact. 

A mapping catheter allows for a quick FAM map, which can determine where the arrhythmia is originating, in a relatively short period with the collection of multiple points, thereby assisting with ablation strategy. Effective contact is crucial for successful radiofrequency (RF) ablation. 

The use of a specialized catheter gives the physician immediate feedback on the amount of force being delivered, thereby validating effective contact is being achieved throughout RF delivery. 

 A suture delivery system allows for left atrial appendage closure for patients that are intolerant to anticoagulants. 

What imaging technology do you utilize? 

Our lab utilizes Biosense Webster’s Carto 3, St. Jude Medical’s EnSite Velocity System, and imaging by Siemens and GE.

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

Our program utilizes CPACS.

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

We have an inventory associate dedicated to the EP and cath labs. He handles the purchasing of equipment and supplies based on caseload and collaboration with the EP coordinator and manager. 

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

We plan on opening an additional EP lab in 2016.

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

Managed care has affected length of stay and appropriate use. Our cases are reviewed for regulatory compliance prior to the case by our device specialist RNs. They work in collaboration with physicians to ensure appropriateness is qualified. 

Have you developed a referral base? 

We have developed our referral base with regular community outreach programs to physicians and patients. 

What measures has your EP lab implemented in order to improve efficiencies? 

In order to improve efficiencies, our labs evaluate first case start times and turnaround times. A team approach is taken with our prep area to improve on-time first case start times. We also collaborate with our post-procedure area and environmental services to improve efficiencies with turnaround times. 

How does your lab communicate necessary information to staff? 

We communicate necessary information during daily huddles, staff meetings, email, information boards, and department newsletters. 

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

The Chicago area is extremely competitive in all arenas involving heart and vascular services. Advocate is a 13-hospital system, and Advocate Christ Medical Center serves as the only robotic program within the system.

How are new employees oriented and trained at your facility? 

A preceptor is assigned to new employees, and they train for approximately 3-6 months depending on experience and how quickly the new employee meets the appropriate competency level to work independently. 

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

An annual heart and vascular symposium is held within the institution. Staff scheduling accommodates those that want to participate. In-services are provided to staff by company representatives. There is tuition assistance and support for any and all opportunities for growth. 

How is staff competency evaluated? 

Staff competencies are evaluated annually through written tests, computer-based training, and coworker feedback. 

Do you encourage your clinical staff members to take the registry exam for Registered Cardiac Electrophysiology Specialist (RCES)? Does staff receive an incentive bonus or raise upon passing the exam? 

All EP staff members are encouraged to take the registry exam for the RCES. They are incentivized through tuition reimbursement for costs. 

How do you prevent staff burnout? In addition, do you practice any team-building exercises? 

We attempt to prevent staff burnout by encouraging feedback during staff meetings and huddles. Every effort is made to ensure staff have the necessary equipment and training to perform their job duties. We have a Unit Council on which staff is encouraged to serve; this allows staff to assist with processes to help improve the work environment as well as to have a voice. 

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

Advocate Christ Medical Center is a Magnet Center with shared governance. Staff are encouraged to identify what they are passionate about, and are provided development opportunities.

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

We contract with vendors on equipment pricing and optimization. Vendors are to make appointments with the EP coordinator. In-services are scheduled on a monthly basis. New product in-services are timed appropriately for first cases. 

How does your lab handle call time for staff members? 

We have a late team scheduled on a daily basis and rotated throughout the staff members. They are on call to complete the scheduled cases and add-on cases for the day. 

Does your lab use a third party for reprocessing or catheter recycling? 

Yes, our lab utilizes a company for reprocessing and recycling.

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

Approximately 88% of our ablations are done with radiofrequency and 12% are performed with cryo.

Is there cross training for pediatric cases? 

A few of our staff members are cross trained to assist the dedicated PEDs team on EP procedures. 

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

The use of navigation systems has reduced fluoroscopy times and minimized radiation exposure by allowing physicians to visualize the catheters in the cardiac system without using fluoroscopy.

What are your methods for infection prevention? 

Staff members are trained on sterile techniques when prepping and performing procedures. Staff members witness one another’s technique and immediately discuss any identified variances. Annual computer-based training is performed by each employee on infection prevention.

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

We have 2 dedicated device specialists that perform device checks and program implanted devices. They educate patients and family members on how to care for the insertion site, signs and symptoms of infection, and when to follow up with their physicians after discharge. 

What innovative EP techniques are being utilized in your lab? 

We are currently performing left atrial appendage closures and laser lead extractions as hybrid procedures in our larger cath labs. We collaborate with surgery and the cardiovascular surgeons to have backup if needed. A hybrid suite is currently under construction and is anticipated to open early this year. 

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

The EHR system has streamlined access to the medical record for healthcare providers. It improves quality of care by allowing access from multiple areas at any given moment as compared to having to view the paper chart in the unit. It also allows for chart review post discharge for quality measures and process improvement. Alerts can be built into the EHR to alert physicians on important information to improve quality care.

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

The dominant trends we see emerging include increased complex ablations, increased options for minimally invasive left atrial appendage closure, and increased scrutinization regarding appropriate use criteria for device implantation.

How does your lab handle device recalls? 

We collaborate with device companies to ensure that appropriate follow-up occurs. 

How is outpatient cardiac monitoring managed? 

Outpatient cardiac monitoring is managed by the cardiologists. 

How is coding and coding education handled in your lab? 

Staff is updated on any coding changes. New staff members are trained on utilizing charge sheets we provide during each case. Batch entry associates work closely with staff to ensure that correct coding of charges occurs on a daily basis. 

Is your EP lab currently involved in clinical research studies? Which ones? 

We are currently involved in St. Jude Medical’s Leadless II study and Biosense Webster’s reMARQable study.

Are you ACGME-approved for EP training? 

Yes, we are ACGME approved for EP training. 

Describe your city or regional area. How is it unique from the rest of the United States? 

We are located in the Chicagoland area where competing hospitals are available within a short distance. Advocate Christ Medical Center is a quaternary institution that receives complex patients from the surrounding areas. Our cardiac patient population has a high case mix index.   

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

Advocate Christ Medical Center’s EP lab is highly skilled in caring for complex disease processes. We provide the latest technologies and medical treatments to care for our patients.

For more information, please visit: http://www.advocatehealth.com/cmc/