Spotlight Interview: Athens Regional Medical Center

Kent R. Nilsson, Jr., MD, FACC, Athens Regional Medical Center, Athens, Georgia
Kent R. Nilsson, Jr., MD, FACC, Athens Regional Medical Center, Athens, Georgia

The Cardiac Electrophysiology Program at Athens Regional Medical Center (ARMC) provides the most cutting-edge therapies for the treatment of all aspects of cardiac arrhythmias. Located adjacent to the University of Georgia’s health sciences medical campus in Athens, Georgia, ARMC is proud to serve the Northeast Georgia community with a complete portfolio of cardiac electrophysiology services. In addition, we are proud to be at the forefront of techniques to reduce the risk of stroke through closure of the left atrial appendage. We have a robust clinical and translational research program, and are among the first hospitals in the country to be designated by the American Heart Association as both a STEMI and Cardiac Resuscitation Receiving Center.

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

We have one room devoted to complex ablations and three rooms equipped for device implantation.  In addition, we have recently built a hybrid OR. David Woodard, MD, FACC founded the EP laboratory in 2007.

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

Three ABIM board-certified electrophysiologists routinely perform cases at our facility. We have ten staff devoted to the EP lab, including RNs and CVTs, trained in devices and ablations. In addition, we have CRNAs who provide anesthesia coverage five days/week. All staff members are encouraged to be RCES certified, the cost of the exam being paid for by the cath lab. 

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

Our facility provides comprehensive electrophysiologic care, including pacemaker and ICD (including S-ICDs) implants, cardiac resynchronization therapy, SVT ablation, and complex arrhythmia ablation (e.g., atrial fibrillation, ischemic ventricular tachycardia). In addition, we perform left atrial appendage ligation with SentreHEART’s LARIAT Suture Delivery Device. We currently perform 250 ablations/year and 450 device implants/year. 

Who manages your EP lab? 

Dr. Woodard is the medical director. Analana Valdez, RN manages the EP lab staff. 

Do you have cross training inside the EP lab? 

Staff members routinely rotate responsibilities within the EP lab: scrub, ablator, stimulator, etc. 

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

We are a tertiary community referral hospital affiliated with the University of Georgia/Georgia Regents University Medical Partnership.  

What types of EP equipment is most commonly used in the lab? 

We utilize St. Jude Medical’s ViewMate Z Intracardiac Ultrasound System, EnSite mapping, Quadra Assura CRT-D, and catheters such as their Therapy Cool Path irrigated tip ablation catheter and Inquiry steerable diagnostic catheters. We also use Medtronic’s Revo MRI SureScan Pacing System and Reveal XT Insertable Cardiac Monitor, as well as Boston Scientific’s S-ICD System.

Tell us what a typical day might be like in your EP lab. What are typical hours?

A typical day includes two complex ablations and a device implant, an SVT ablation and two device implants, or four device implants. Typical hours for the staff are 7:30am – 5pm. 

What imaging technology do you utilize? 

We use Philips for fluoroscopy. We also use EnSite (St. Jude Medical) for 3D imaging and the ViewMate Z (St. Jude Medical) for intracardiac echocardiography. 

What is your experience with MR-conditional cardiac devices? 

We were a leading enroller in St. Jude Medical’s MRI-compatible Accent pacemaker trial. In addition, we implant Medtronic’s Revo MRI SureScan Pacing System. 

Who handles your procedure scheduling? 

EP procedures are scheduled by midlevels working with the physicians during clinic. We use Apollo and Sunrise scheduling software to coordinate scheduling for the lab. 

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

In addition to following ACC guidelines with reporting the NCDR ICD registry, each physician has a dashboard of metrics that are being tracked. These include device infections, fluoroscopy time, and intraprocedural complications. 

How is inventory managed at your EP lab? 

Inventory is managed by a CVT who keeps track of monthly volume and scheduled procedures. 

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

Yes, since we started the complex ablation program in January 2013, we’ve had a four-fold increase in ablation volume and a 20% increase in device volume. We anticipate additional growth in 2014. 

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

In the era of declining reimbursement, we are constantly looking at ways to increase efficiency and minimize patient length of stay. These include minimizing inventory and taking a proactive role in negotiating prices with industry.  

Have you developed a referral base? 

Yes. In addition to cardiologists affiliated with the hospital, we have a very large catchment with primary care doctors. We also have a large outreach network. 

What measures has your EP lab implemented in order to cut/contain costs and improve efficiencies in patient throughput? 

All patients are seen the 1-2 days prior to the procedure to address pre-procedure issues (e.g., acute care, medications, etc.). We have a streamlined process involving office midlevels, nurses in the cardiac outpatient holding area, and the EP staff to ensure efficiencies on the day of the procedure. Patients are discharged either directly from holding or the following morning, depending upon the complexity of the case. With regards to inventory, vendors have negotiated tiered pricing.  

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

Like most EP laboratories, there is stiff competition from competing health care systems. We found that the most effective method of competing is to provide the highest quality and most innovative care in the region. 

How are new employees oriented and trained at your facility? 

New staff members to the EP laboratory participate in a ten-week, two-hour/week course taught by industry and physicians. This course serves as a primer to EP lab experience, and covers all aspects of EP including devices, the biophysics of ablation, and pacing maneuvers. New staff are then proctored by an experienced member of the EP staff until proficiency is demonstrated. 

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

We send a certain number of staff to the Heart Rhythm conference each year. In addition, all staff are encouraged to participate in the annual South Atlantic Society of Electrophysiology for Allied Professionals (SASEAP). 

How is staff competency evaluated? 

Staff members complete an annual skills assessment. 

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

All staff members are encouraged to take the RCES exam. A pay raise is awarded upon passing the exam. 

How do you prevent staff burnout? 

This is a difficult issue given the unpredictability of complex ablations. We have moved to a model where staff are assigned certain days off, as well as having staggered relief at the end of the day by the on-call team. 

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

All vendors register with material services, which verify credentials and issue identification. We do not have a particular policy with regards to vendors visiting the actual EP laboratory, although industry-sponsored lunches are strongly discouraged. Prices are directly negotiated with individual vendors based on market share. 

Describe a particularly memorable case that has come through your EP lab. How was it addressed, and what lessons were learned from it? 

A patient became unresponsive during an ablation, and developed pulseless electrical activity (PEA). Ultimately, this was determined to be due to oversedation from propofol. While the patient recovered fully, the event served as an important reminder to put protocols in place and to regularly have mock codes. 

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

For a while we reprocessed our catheters. However, it was the experience of our physicians that the quality of the recycled catheters was sufficiently variable, and it was not worth the cost, hassle, or frustration. 

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

Ninety-nine percent of our cases are done with radiofrequency; the other one percent of cases are performed with cryo. 

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

We encourage all operators to be conscious of fluoro times and to minimize use. To that end, one of the physician quality metrics is fluoro time.

What are your methods for infection prevention?

Standard device implantation precautions; in addition, we use the disposable AIGISRx Antibacterial Envelope (TYRX, Inc.) on high-risk patients. 

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

Prior to discharge, an EP midlevel provides patient education. All patients then follow-up at 10 days for a wound check with an RN or NP. 

What innovative EP techniques are being utilized in your lab? 

We routinely perform the LARIAT procedure for left atrial appendage occlusion. In addition, we recently built a hybrid lab. Currently, this is being used by our structural heart program (e.g., TAVR), but we anticipate developing a hybrid ablation program in the near future.  

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

The NCDR data is routinely reviewed to ensure that implants are performed in keeping with current appropriate use criteria and guidelines. In the unusual circumstance where an implant is flagged by the NCDR, the case is reviewed to ensure that the implantation was appropriate and that adequate documentation was provided. 

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

The greatest benefit of EMR is the ability to rapidly access a patient’s problem list and recent cardiovascular imaging studies. The timely access to this data undoubtedly improves patient care. 

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

Increasingly, there is a broadening of the scope of practices to include techniques that were traditionally not in the purview of most electrophysiology programs: LAA occlusion, interventional techniques to facilitate CRT lead delivery, epicardial procedures, and hybrid ablation procedures. Issues with regard to credentialing and competency need to be defined. 

How is outpatient cardiac monitoring managed? 

We have a dedicated team of nurses and support staff who manage the device clinic. Transmissions are reviewed by ABIM board-certified cardiac electrophysiologists. 

How is coding and coding education handled in your lab? 

We regularly have audits by an external consulting group (MedAxiom) to improve coding and education. Clinical documentation specialists work with the staff and physicians to ensure that each procedure is properly documented and that appropriate charges are filed.

Are you ACGME-approved for EP training? 

No, we do not teach fellows. Given the increasing breadth of procedures that an EP is expected to do, a two-year program will soon be necessary to ensure competency in all procedures. 

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

ARMC is located in Northeast Georgia, and is the tertiary referral center for a 17-county catchment area. Athens itself boasts an exciting mix of cultural and ethnic diversity that complements the college town atmosphere. 

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

The staff here at Athens Regional strive to marry the latest in cardiac rhythm care with a relaxed environment. We are committed to bringing the most innovative technologies and therapies to our patients. To that end, we are beginning a multi-million dollar capital improvement project that will add another EP lab to our facility. In addition to being at the forefront of electrophysiology therapies, we strive to provide our patients with a warm and relaxed environment. The staff treat each patient with true Southern hospitality, while providing excellent cardiovascular care.

For more information, please visit: www.athenshealth.org/