Spotlight Interview

Spotlight: George Washington University Hospital

Dr. Cynthia Tracy and Dr. Ali Boushahri, Department of Cardiology, Medical Faculty Associates (MFA), Washington, DC 

Dr. Cynthia Tracy and Dr. Ali Boushahri, Department of Cardiology, Medical Faculty Associates (MFA), Washington, DC 

The cardiac arrhythmia service at George Washington (GW) University Hospital is a comprehensive electrophysiology service offering advanced therapies for atrial and ventricular arrhythmias, syncope, and conduction disorders. We work in close collaboration with our cardiovascular surgery, interventional cardiology, interventional radiology, and heart failure teams. The close proximity of our state-of-the-art EP lab to all other services facilitates collaborative efforts at managing even the highest risk patients. GW is a busy, active, urban hospital that provides care for a diverse population across the metropolitan Washington, DC area. George Washington University Hospital is the teaching hospital for the George Washington University. We offer training in clinical cardiac electrophysiology in our ABIM-approved training program.

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

We have one dedicated, fully equipped electrophysiology laboratory suite. The new GW Hospital opened in 2002. The lab has undergone one major structural update since that time to accommodate expanding procedures. An electrophysiology lab was present in the old hospital, and EP procedures have been performed at GW Hospital since the 1980s. A hybrid OR/cath suite is situated adjacent to the EP laboratory, and procedures such as laser lead extractions are performed there with OR backup. Pacemakers and defibrillators can also be performed in one of our other cardiac catheterization suites as needed depending on case scheduling and volume. 

We perform tilt table tests in the EP laboratory area. We also have an outpatient device follow-up clinic for on-site and remote device management. One technician with backup from our four full-time electrophysiologists staffs the device clinic. The outpatient arrhythmia clinic is housed adjacent to the device clinic, in one of the freestanding Medical Faculty Associates offices in downtown Washington, DC.

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

We have two dedicated EP lab techs, and four cath lab techs that are cross trained. We have 10 registered nurses (RN) whom we share with the cath lab. The device clinic is staffed by one trained technician. We have one outpatient nurse and share access to two NPs. 

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? 

We perform device implants (pacemakers, ICDs, biventricular devices, subcutaneous defibrillators), right-sided ablations (AVNRT, flutter, accessory pathways), left-sided ablations including atrial fibrillation ablations (both RF and cryo), cardioversions, and laser lead extractions. We perform approximately a total of 1,990 procedures annually. 

Who manages your EP lab?

The director of the EP lab is Cynthia Tracy, MD, FACC. The cath lab director is Joel Sandler. The chief EP technician is Fernando Najera-Molina.

Tell us about where the EP lab is located in relation to the other labs. In addition, are employees cross-trained?

All the interventional procedure suites are located in a single area of George Washington University Hospital, adjacent to the OR suites. There are two interventional cardiac catheterization laboratories, three interventional radiology suites, one electrophysiology suite, and one hybrid room. All employees are cross trained, but we have two dedicated EP lab technicians. There is cross training inside the EP lab as well. 

What type of hospital is your EP program a part of? (e.g., community, academic, for-profit, government, etc.)?

George Washington University Hospital is the main teaching hospital for George Washington University School of Medicine. The hospital has 385 beds, as well as 18,721 patient admissions and 180,121 outpatient visits a year. The emergency department is a Level I Trauma Center seeing 75,482 patients a year. There are over 875 physicians on the hospital medical staff. Training programs are offered through the respective departments in medicine, and surgical specialties and subspecialties including cardiovascular disease, interventional cardiology, and clinical cardiac electrophysiology. There are four full-time electrophysiologists and two active community-based electrophysiologists who utilize our EP lab. 

What types of EP equipment is most commonly used in the lab? (list names of products and companies)

The core of our EP lab consists of a Mac-Lab recording system (GE Healthcare), a fluoroscopy system (Philips), and a multi-screen display. We use the EnSite 3D Mapping System (St. Jude Medical). The catheters used vary by case, and include the Blazer (Boston Scientific) and Safire (including the irrigated Safire BLU, St. Jude Medical) ablation catheters. The majority of pulmonary vein isolations are performed with cryoablation using the CryoConsole Cardiac CryoAblation System (Medtronic). During pulmonary vein isolation and other left-sided procedures, we use AcuNav intracardiac echo (Siemens). For laser lead extractions, we use a laser system by Spectranetics. Laser lead extractions are performed in our hybrid room. Device implants are performed utilizing devices from Medtronic, St. Jude Medical, Boston Scientific, and BIOTRONIK. Subcutaneous implants are only available using the S-ICD System (Boston Scientific), and are implanted in our EP lab.

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

Each staff member has four 10-hour shifts per week. Typical hours are from 7am to 5pm.

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

Typically, we have two to four scheduled cases, with the first starting between 8-9am. The patient is evaluated and worked up in a holding area connected to the lab about 30 minutes prior to the scheduled time. Due to the high activity of the emergency room and the rising acuity of patients in our hospital, it is common for cases to be added on (usually cardioversions and device implants), and these are usually worked into the schedule. Cases that require less specialized equipment may be done in a separate room (our cath labs are well equipped for device implants), permitting us to perform simultaneous cases. Post-procedure care is administered in the Post-Anesthesia Care Unit (PACU). Patients that are same-day procedures are discharged directly from the PACU, and those that require an overnight stay are taken to the telemetry ward. Cases are typically competed by 5pm. 

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

The cryoablation system has been a relatively recent addition, and has quickly become the predominant modality we use for isolating pulmonary veins. Since its initiation, there has been a noticeable shortening in procedure times. We also recently started implanting subcutaneous defibrillators.

What is your experience with MR-conditional cardiac devices? 

We routinely implant MRI-compatible pacemakers. In the DC metropolitan area, many sites are performing MRIs on patients with these devices, but this is not universal. 

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

Our hospital does use PACS for inpatient imaging, but our fluoroscopy images (from the lab) are archived in Heartlab.

Do you employ travel RNs, RT(R)s, or RCISs?

Currently we do not, although we have employed them in the past.

Who handles your procedure scheduling? Do they use particular software? 

We have a dedicated administrative assistant that handles scheduling, and we use the Cerner Scheduling Management solution. Our outpatient staff coordinates admissions and scheduling with the hospital.

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

Each vendor performs annual preventative maintenance checks. We perform a timeout before every case. Fluoroscopy times are recorded, and staff are required to wear dosimeters. We also have a case-by-case QI. We participate in the NCDR and have ongoing peer review.

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

The lab director reviews each case and any items that require attention are addressed. We use the NCDR reports to review our practices and adjust protocol as indicated. The NCDR reports are reported to the Hospital Quality Committee.

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

We have an inventory manager who handles this using SpaceTRAX. 

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

Our lab has not changed in size, but there has been a steady increase in patient volume. Our increase in volume is reflected across the hospital through an increase in patients and in patient acuity.

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

We are currently analyzing the impact of managed care on our revenue.

Have you developed a referral base?

Our EP physicians each have very well-established referral bases. The EP physicians are also part of the Medical Faculty Associates, which is the largest independent physician group in the DC area with over 750 physicians.

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

GW Hospital is part of the Premier Buying Group. We closely monitor par levels, and adjust and manage to maintain a fully supplied laboratory with minimal waste.

How do you ensure timely case starts and patient turnover?

Managing case start times is always challenging in a field such as EP, where procedure times can vary tremendously. Elective cases that require anesthesia are scheduled at least 24 hours ahead of time, and cases that require cardiovascular surgery backup are scheduled even earlier than that. Turnover times are generally quick, as staff works as a team to ensure as rapid turnover as possible. 

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

Multiple alliances have been established both through the hospital and through Medical Faculty Associates to position us well in a competitive environment.

How are new employees oriented and trained at your facility?

The typical hire in the GW EP lab is already well experienced and certified. New employees undergo a six-week orientation. Newly hired RNs will shadow more experienced RNs for several weeks before being assigned to cases in the EP lab.

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

Our staff members are encouraged to seek opportunities that are funded by the department. All new equipment and procedures are extensively inserviced, and staff must be certified as trained before engaging in the new activity.

How is staff competency evaluated?

All staff have annual competency-based evaluations (CBE).

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

The excellent work of our staff is recognized and deeply appreciated. Our staff members are the backbone of our success. After work events are common. 

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

Visits are coordinated through our inventory manager. Industry representatives participate in Reptrax.

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

Alternative therapies, including pet therapy, quiet time, and music, are available in the hospital. Patients in the EP lab may also listen through headphones to the music of their choice. 

How does your lab handle call time for staff members? For example, how often is each staff member on call, and how frequently do they have to come in, on average? Is there a particular mix of credentials needed for each call team?

Each night there are three staff members on call, including at least one RN and one tech. Each RN is on call for two weekends and five weekdays per month. Each tech is on call for one weekend and 10 weekdays per month. They usually come in three or four times per week, but mostly for the cath lab.

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

We do utilize an outside vendor for closely monitored and approved catheter resterilization. This does provide cost savings.

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

Approximately 90% of our atrial fibrillation ablations are performed with cryo, with the other 10% performed using RF. Almost all of our other ablations (flutter, AVNRT, accessory pathways) are performed with RF, although we will occasionally use cryo for ablations close to the AV node.

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

All the staff and fellows are trained in radiation and required to wear dosimeters. Fluoroscopy times for all cases are recorded.

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

We are very strict about sterile technique. All patients use chlorhexidine skin preps prior to any device implant. These preps are used for other procedures in immunocompromised patients. Antibiotics are given pre-, intra-, and post-procedure for device implants, and adherence is monitored closely as part of a hospital-wide QI. We use antimicrobial sutures to close the pocket, and typically will use adhesive glue (DERMABOND) as a barrier once the pocket is closed.

What innovative EP techniques are being utilized in your lab? 

We have a close working relationship with the cardiovascular surgeons who assist us in optimal epicardial lead placement if the patient does not have suitable veins. We collaborate with interventional radiology for difficult access cases. 

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

EHR systems are very important and helpful, not only for accessing information and placing orders, but also as a valuable signout tool (in addition to verbal signout). We participate in the regional CRISP EHR, which facilitates inter-facility exchange of health information. 

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

There is an increased frequency of atrial fibrillation ablations, and a lower threshold to pursue these (both initially and for repeat ablations). Loop recorders are more frequently used, which is most likely related to the ease of insertion of the newer devices.

How does your lab handle device recalls?

We typically rely on the vendors and HRS for updates and recommendations. Each case is managed individually with the participation of the patient’s primary cardiologist (who is notified). 

How is outpatient cardiac monitoring managed?

We have contracts with different companies that perform monitoring, with all information overread by an electrophysiologist. We also participate in remote device monitoring, with all scheduled and automatic transmissions reviewed by staff and immediately conveyed to the managing physician.

How is coding and coding education handled in your lab?

All of our physicians receive mandatory training in coding, and we have dedicated billers and coders to review cases. 

Is your EP lab currently involved in clinical research studies?

We are currently enrolling patients in the CABANA study.

Are you ACGME-approved for EP training? What are your thoughts on two-year EP programs?

We are proud of our tradition of training excellent young electrophysiologists in our ACGME-approved program. The CCEP Board pass rate for the past several years has been 100%. We are positioning ourselves for the shift to the mandatory two years of training. I am more in favor of fast tracking (training a general cardiology fellow starting in their third year). The transition from the funding standpoint may be challenging, and I am looking forward to a time when general cardiology training will be shortened to two years to permit CCEP trainees and others to achieve their completed training in a reasonable amount of time.

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

Washington, DC is a very metropolitan area with a diverse patient population. We have patients coming in from all over the world. People from every demographic imaginable are in DC. This makes our area not only an exciting place to practice, but also an exciting place to live. 

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

Our staff, physicians, and trainees are dedicated, hardworking, and devoted to providing the best possible care to our patients. We recognize that we deal with people as they are facing some of the greatest challenges of their lives, and work hard not only to provide outstanding care, but to do it with compassion. We treat patients as we would like to see our families treated.