Spotlight Interview: Akron General Medical Center

Marguerite Shanahan, RN, BSN
Coordinator Electrophysiology
Akron, Ohio

Marguerite Shanahan, RN, BSN
Coordinator Electrophysiology
Akron, Ohio

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

Akron General Medical Center has three dedicated EP labs. The staff consists of six registered nurses (RNs), one radiologic technologist (RT) and one cardiovascular technologist. The RNs have 75 years of combined experience, with 23 of those years dedicated in EP.

When was the EP lab started at your institution?

Akron General’s EP program was started in 1997. At that time, the EP program was incorporated into the cath lab.

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

Akron General’s EP lab performs the full spectrum of EP procedures. These include complex ablations such as: atrial fibrillation (AF), ventricular tachycardia (VT), atrial tachycardia (AT), atrial flutter, SVT, inappropriate sinus tachycardia, and AV node ablations. The EP lab implants pacemakers, ICDs, biventricular devices and implantable loop recorders. Other procedures being done in the lab are: lead extractions, direct current cardioversions, tilt table studies and drug challenges. The average number of procedures performed in the EP lab ranges from 25 to 30 per week.

What is the primary goal of your program?

Prior to 2007, the primary goal of the lab was implanting devices, with a lesser emphasis on ablation. However, with the arrival of Dr. Robert Schweikert, the primary goal of the lab has shifted to the capability of providing a very broad range of EP procedures and in doing so, utilizing advanced technologies and techniques.

In May 2009, Akron General opened the first dedicated EP lab with robotic capabilities in the Akron area. Ablations are performed on a daily basis for the treatment of various complex arrhythmias including AF, AT, and VT. Under the direction of Dr. Schweikert, the EP lab has also become known for its ability to perform lead extractions using a variety of specialized tools, including laser. Akron General’s EP program continues to maintain a strong emphasis in the area of cardiac implantable electrical devices (CIED). In 2010, implantable device procedures increased by 10%; this area is expected to continue to grow. 

Is the EP lab separate from the cath lab? How long has this been? Are the employees cross trained?

The EP lab separated from the cath lab in January 2006 with the opening of the Akron General Heart and Vascular Center. With this separation, both labs expanded and upgraded. At that time, the employees of the EP and cath labs were not cross trained, but several cath lab team members chose to transfer into the EP lab. Although the staff has not been officially cross trained, members of the EP lab have the necessary skills and knowledge base to assist the cath lab in times of need.

Do you have cross training inside the EP lab? What are the regulations in your state?

All of the RNs in the EP lab are trained to circulate, provide moderate sedation and monitor and maintain the patient’s airway. Additionally, all staff are trained to scrub, monitor/document and pace from the external stimulator. The RT and CV techs are trained in all procedural areas, with the exception of providing medication. Ohio does not permit techs to administer any type of medication. Several staff members are cross training in the device clinic. We encourage our entire lab staff to gain a complete understanding in all areas of electrophysiology.

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

The lab has recently been equipped with the Carto 3 mapping system (Biosense Webster, Inc., a Johnson & Johnson company, Diamond Bar, CA) and EnSite Velocity mapping system (St. Jude Medical, St. Paul, MN), and the Stereotaxis Niobe lab (Stereotaxis, St. Louis, MO) and Siemens Artis unit (Siemens, Malvern, PA) were added in May 2009. Cases are now scheduled based on the equipment requested for each individual procedure. Additional set-up times vary depending on the equipment used. The staff must anticipate the requirements of each case and adjust accordingly to keep case start times on schedule.

What type of quality control assurance measures do you practice in the EP lab?

Akron General Medical Center has an active QA/QI process. All procedures in the EP lab are reviewed for complications. Dr. Robert Schweikert, Director of Electrophysiology and Chief of Cardiology, heads the EP QA/QI committee. The committee consists of three electrophysiologists, the department coordinator, an EP staff RN, and a member of the Heart and Vascular Center’s quality department. Cases are reviewed, and recommendations (if any) are made to the physician responsible for the procedure. Akron General participates in the NCDR® ICD Registry™. All ICD implants are reviewed for CMS compliance guidelines. The selection and timing of pre-procedure antibiotics are reviewed quarterly by the HOPS committee.

Has your EP lab recently expanded in size and patient volume, or will it be in the near future? In addition, is your EP lab part of a separate “heart hospital”?

In 2011, Dr. Jeff Courson and Dr. Sergey Vitebskiy joined Dr. Robert Schweikert at the Heart Rhythm Associates group. The Akron General EP lab has seen an increase in procedure volumes in recent months. The overall vision for the lab is to provide high-level EP services to the Akron area and outlying communities, eliminating issues of traveling long distances to obtain this care. The goal of the Akron General EP lab, and partnered Heart Rhythm Associates group, is to offer other area electrophysiologists the means to provide their patients with higher level EP procedures in the local setting. Emphasis is placed on the patient maintaining their relationship with their referring physician.

How are new employees oriented and trained at your facility?

All new employees at Akron General attend a three-day, hospital-wide orientation. Once the employee enters the lab, he/she is assigned a preceptor to guide their orientation in the lab setting. The basic orientation begins with an eight-week focus on safety. The following four-month period focuses on specific procedures and equipment setup and use. Evaluations are completed in two- to four-month intervals until the new employee is deemed competent by both the preceptor and lab coordinator. Physicians are asked for input regarding the performance of the new employee.

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

Typically, two or three staff members attend the annual Heart Rhythm Society meeting. Additionally, the staff is encouraged to attend many American Heart Association continuing education programs, such as the “Go Red” campaign. Akron General also promotes the Cardiovascular Invitational, one of the longest-running continuing education programs in cardiology in northeast Ohio. The program provides CEUs for physicians, RNs and RTRs. Akron General also provides weekly staff development courses with a wide variety of topics, from cardiac MRIs to stress relief in the work environment.

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

John Flavelle, RN serves as the president of the Heart and Vascular Relationship Based Care committee; Lori Long, CVT serves on the Patient Satisfaction committee; Kara Miller, RT (R) serves on the Radiation Safety committee; and Kristin Galehouse, RN serves on the EP lab QA committee.

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

Vendors are not permitted to enter the EP lab unless they have been contacted by an EP staff member or have made an appointment to meet with the lab coordinator. Vendors are typically requested to be present for a particular case at the time of scheduling. All vendors must sign into the hospital through the materials management department, and must obtain an approved hospital vendor ID badge before proceeding to the lab. Akron General’s EP lab does not participate in any “market share” contracts with vendors.

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

Recently an elderly patient was referred to Heart Rhythm Associates by a local electrophysiologist for a device/lead extraction. The patient’s device had begun to erode through the skin. She was seen by Dr. Courson, and was scheduled for her extraction within a few days. Unfortunately, the patient fell and fractured her hip the next evening. She was admitted to Akron General and seen by a team of physicians, including Dr. Robert Schweikert, on a Saturday morning. The orthopedic surgeon felt it was in the patient’s best interest to have the fracture surgically corrected as soon as possible. The patient’s risk of mortality increased with each day the hip repair was postponed. The Infectious Disease physician felt that the eroded pacemaker and leads needed to be extracted before the hip repair could be done. Calls were placed to assemble an EP team. Anesthesia agreed to support the case. Dr. Schweikert contacted a cardiovascular surgeon to be on standby during the extraction. On Sunday morning, the patient was brought to the EP lab. Prior to moving the patient out of traction and onto the EP table, the anesthesia team opted to place her under general anesthesia to minimize the patient’s anxiety and pain. Dr. Schweikert and Dr. Courson successfully performed the extraction. After the incision was closed, the patient was immediately transferred to the OR for her hip repair. Three days later, the patient was re-implanted with a new pacing system. The patient made a full recovery and is now back at home with her family.

Patient safety was our first priority. Multiple specialties collaborated in this case to ensure the best care for the patient was provided in a safe and timely manner. We at Akron General Medical Center are proud to work in an environment that facilitates teamwork, allowing us to provide exceptional patient care. 

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

The staff strives to create a calm and relaxing environment for the patients inside the electrophysiology labs at Akron General. There is often soothing music playing throughout the EP lab. Warm blankets are given to every patient when they arrive into the room to keep them comfortable in the cold electrophysiology environment. The patient’s modesty and privacy is protected at all times. The most effective way the lab has found to decrease patient anxiety is by providing exceptional anesthesiology consultations. The anesthesia team is asked to consult with those patients undergoing potentially long and complex procedures. The partnered anesthesia group at Akron General and the EP lab have formed a very cohesive patient care relationship, and share in the goal of minimizing anxiety while providing safe and effective care.

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

Approximately 15% of the ablations performed in the Akron General EP lab are done with cryo, and 85% are done using radiofrequency.

Do you perform only adult EP procedures, or do you also do pediatric cases?

Most patients who present to the EP lab are 18 years of age or older. The Akron community is extremely lucky to have a dedicated pediatric electrophysiologist, Dr. John Clark, on staff at the area’s children’s hospital. Dr. Clark does refer complex procedures such as lead extractions to Dr. Robert Schweikert, EP Medical Director. Special care is taken when dealing with these pediatric cases. The type of anesthesia, past medical history, specialized equipment and needs of the family are taken into consideration when planning in advance for the case.

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

Lead aprons are provided to everyone entering the room, and all staff and physicians wear radiation monitoring badges. Vendors are required to wear their radiation badges while working in our lab. We utilize sterile lead-free shields during lengthy procedures, as well as collimation and decreased exposure times. Staff try to maximize their distance whenever possible. The use of robotic mapping/ablation technologies have substantially reduced radiation exposure to the physicians, EP staff and patients. 

Do your nurses/techs participate in the follow up of pacemakers and ICDs? If so, how many device visits per week do they handle? Do you use any particular software for follow up? How many of your ICD/pacemaker patients require a doctor for their visit?

Included within the Department of Electrophysiology is the EP lab and Cardiac Device Clinic. The clinic is run by very experienced device RNs. They handle approximately 200 device checks per week. These staff members have been cross trained into the EP lab. They perform both inpatient device interrogations and outpatient checks as needed, as well as assist with EP lab procedures. All team members use the Medtronic Paceart® (Medtronic, Minneapolis, MN) software to document device interrogation findings and schedule visits. The Paceart software has proved a valuable tool for communicating between staff and coordinating patient appointments, incorporating the inpatient and outpatient settings. On average, one to two patients per week require a subsequent physician visit as a result of the device interrogation.

Is your EP lab doing web-based/transtelephonic device follow up?

Web-based and transtelephonic transmissions are done both in the outpatient Device Clinic setting and in the EP lab. These types of visits can range from scheduled/routine transmissions to an urgent/same-day request from a provider looking for new onset of arrhythmia.

What innovative EP techniques are being utilized in your lab?

We are one of five centers in Ohio that offer remote magnetic navigation (Stereotaxis) and state-of-the-art advanced non-fluoroscopic mapping systems (Carto 3 and Velocity). For the Akron area adult population, Akron General is the only center to offer cryoablation as an alternative to radiofrequency. As one of only a few centers in Ohio and the country, we offer percutaneous pericardial instrumentation for epicardial mapping/ablation. 

What are some of the dominant trends you see emerging in your practice of electrophysiology? How is your lab preparing for these future changes?

We are committed to reducing radiation exposure, reducing procedure duration, and increasing patient comfort and safety, especially during complex procedures. We strive to provide comprehensive care to area patients with an emphasis on patient education. 

What about device recalls? How have they been handled?

We consider any device recall a priority. The use of Paceart to query our patient population with affected devices has been vital. Based on device company recommendations and physician input, patients are notified of the recall. The device clinic staff promptly perform any programming or increase in device monitoring. The patient’s electronic chart is flagged as having a recall, so that during subsequent visits, the issue of concern can be evaluated on an ongoing basis.

Is your EP lab currently involved in any clinic research studies or special projects?

Akron General has been very involved with a number of clinical research projects, including various device studies in the area of electrophysiology. Dr. Schweikert and his team are actively pursing research opportunities at this time.

Does your staff provide any educational materials for patients? In addition, does your hospital or lab offer a device support group?

Each new device patient is provided with specific information regarding their implantable device, post-operative care and follow-up appointments. Patients who have undergone an AF ablation are also provided with educational materials upon discharge. Detailed discharge teaching is provided to each patient and their family within 24 hours post procedure. It is the staff’s responsibility to ensure all patients who may be discharged shortly after their EP lab procedure are provided with discharge information prior to sedation. Our Arrhythmia Support Group meets quarterly and is open to all patients who have an implantable cardiac device, arrhythmia, or for those who simply wish to be kept informed.

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

The Akron General EP lab operates under an open model plan. In addition to our partnered electrophysiology group, other non-partnered electrophysiologists have the opportunity to apply for EP privileges, utilizing the lab and staff to perform cases. The staff is exceptionally well trained and provides each electrophysiologist with the highest level of support. Our robotics technology is state of the art, and the only one in the Akron area. We pride ourselves with the ability to offer our lab and exceptional technologies to the Akron EP community. We strive to accommodate the needs of the patient, as well as those of our physicians. The diverse exposure to advanced technologies and approaches in electrophysiology serves to set Akron General’s EP lab staff apart from others.

For more information, please visit: www.agmc.org