Spotlight Interview

Spotlight Interview: Banner - University Medical Center Phoenix

Claudia Tarin, RN and Debbie Klose, RT(R)
Electrophysiology Department-Cath Lab 
Phoenix, Arizona

Claudia Tarin, RN and Debbie Klose, RT(R)
Electrophysiology Department-Cath Lab 
Phoenix, Arizona

Banner University Medical Center-Phoenix campus, formerly Banner Good Samaritan Medical Center, is a 733-bed, non-profit academic medical center in Phoenix, with approximately 1600 physicians on medical staff, 8 residency programs, and 9 fellowships. The Cavanagh Heart Center cares for a high volume of heart disease patients throughout the state of Arizona and the southwest. Our physicians stand out as being active participants in national research and as providers of cardiac training to physicians from all over the United States and the world. Our goal is to offer patients excellent cardiac services by providing safe, compassionate care and the best advanced treatment options.

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

Our EP department consists of 2 dedicated procedure rooms and 1 shared EP/cath procedure room. The EP program at Banner University Medical Center was started in 1987 by Dr. Sivaramakrishnan Sridhar, the first cardiac electrophysiologist in Arizona.  

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

We have 10 full-time staff members including our supervisor, and 4 per diem staff members. Our lab consists of EP specialists, radiologic technologists, and registered nurses. Many of our staff members have advanced certifications, including RCES, IBHRE, CCRN, CV, RCIS, CMC, and CPAN.

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? 

In 2015 we performed a total of 1157 procedures, including radiofrequency ablations, cryoablations, epicardial ablations, and implantation of permanent pacemakers (as well as MR-conditional pacemakers), implantable cardioverter-defibrillators (ICDs), and subcutaneous ICDs. A total of 184 Reveal LINQ (Medtronic) insertion procedures were performed along with 11 left atrial appendage (LAA) closures. Our EP lab averages 11 PPM devices per week, 6 ICDs per week, and 14 ablations per week.

Who manages your EP lab?

The EP lab at Banner UMC-Phoenix is managed by our Medical Imaging Supervisor Vicki Maestas, ARRT RT (R)(T)(CV). She has over 18 years of experience in electrophysiology. The RN Senior Clinical Manager for Cardiac Services is Lisa Roberts, MSN, RN, NE-BC, and the Cardiac Services Director is Tami Biggs, BSN, RN. 

Are employees cross trained?

Five of our EP lab staff members, both radiology techs and nurses, are cross trained to the cath lab and assist when necessary or float on occasion to keep skills up. 

Do you have cross training inside the EP lab? 

Yes, cross training is provided for staff members inside the EP lab. All staff are trained to perform the roles of scrub, monitor, circulator, and recorder of the EP recording system and stimulator. Cross training is made available to staff by means of classroom training, educational EP conferences, and hands-on training. 

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

Banner UMC-Phoenix is an academic, medical research, and teaching facility affiliated with the University of Arizona. It offers fellowship and residency training programs to medical professionals of various specialties.

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

We use the Claris Recording System (St. Jude Medical). The CARTO 3 (Biosense Webster, Inc., a Johnson & Johnson company) and EnSite Velocity (St. Jude Medical) are our mapping systems; we are currently trialing the Topera system. 

We use fluoroscopy systems from GE and Toshiba; 2 of our labs use GE technology, and 1 lab uses Toshiba. We utilize intracardiac echocardiography (ICE) by Siemens Healthcare, and trialing of upgraded GE, St. Jude Medical, Philips, and Siemens Healthcare imaging technology is in progress. 

All 3 of our primary electrophysiologists use cryoablation (Medtronic), the SMARTABLATE generator (Biosense Webster, Inc., a Johnson & Johnson company), Ampere RF Ablation Generator (St. Jude Medical), and AcuNav (Siemens Healthcare). Our multiscreen display is from Stryker and GE. We primarily use catheters by Biosense Webster and St. Jude Medical, and devices from Medtronic and St. Jude Medical, depending on patient need and doctor preferences.

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

Each staff member works four 10-hour shifts per week, and 2 staff members work three 12-hour shifts. Typical hours are 6:30 am to 5 pm, with the first case start time at 7 am. We do not take call per se, but we rotate late coverage to accommodate cases that may run over our regular shifts.

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

A day in the EP lab starts with patients being prepared for their procedure in the designated cardiac pre-op department. We may start with 4 scheduled cases and end up with 8. Post-procedure patients are recovered in the Cardiac Treatment Center (CTC department), a recovery/observation unit for post-cardiac procedure patients only. 

What new technology has been recently added to the EP lab? How have these technologies changed the way you perform procedures?

Atrial fibrillation (AF) ablation using the cryoballoon has been the primary highlight of our lab, and it was here where our very own Dr. Wilber Su performed the very first procedure in the world using the second generation Arctic Front Advance cryoballoon (Medtronic). Hundreds of physicians from around the world have traveled to our lab to learn the best techniques for cryoballoon ablation to minimize complications and fluoroscopy exposure. The full spectrum of patients, from those with paroxysmal to longstanding persistent AF or severe congestive heart failure, have benefited from our ablation program. Patients from around the world have also traveled here for the cryoballoon procedure; due to our tremendous volume of experience, we can help provide the best outcomes and minimize risk.

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

Procedure scheduling is handled by our cardiac department schedulers using Cerner Millennium PowerChart. 

What types of quality control and assurance measures are practiced in your EP lab?

Charge audits are done on a daily basis by our business analyst. Safe Procedure Audits are done on a monthly basis. ICD Pre-Implant Medical Necessity checklists are completed for all implant patients as well as for NCDR Registry Forms.

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

We have an inventory manager/coordinator who is responsible for all supply orders and management of inventory. She works closely with department managers to maintain appropriate par levels of supplies. Large equipment purchases go through management and corporate leaders. We utilize SpaceTRAX (Stanley Healthcare) to aid in inventory management.

Has your EP lab recently expanded in size or patient volume? 

Banner UMC-Phoenix has one of the largest EP lab patient volumes in Phoenix, and it continues to grow annually. We recently remodeled and upgraded one of the two dedicated EP lab rooms, and upgraded a cath lab room to an EP/cath shared or hybrid room to meet the demands of patient volume increase. 

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

For many years now, healthcare in the United States has been provided by “managed care plans”. While the overall goal of managed care is to have control over cost, quality, and access to healthcare services, every healthcare organization faces the daily struggle to keep a financial and ethical balance between them all. At the Banner University Medical Center-Phoenix EP lab, both staff and physicians do their part to be cost-conscious and cost-efficient while maintaining quality provision of care, ethical practice, and good patient-physician/staff relationships. 

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

We do this by expediting patient care and procedure times, managing the organization and accountability of supplies, minimizing the vendors used, and reprocessing of supplies.

How do you ensure timely case starts and patient turnover?

Case start times and patient turnovers can vary from case to case. We continue to make interdepartmental (pre-op, EP lab, CTC) improvements through Performance Improvement projects to improve our case start and turnaround times, and continue to maintain safe and timely patient flow. 

How are new employees oriented and trained at your facility?

Typically the new hires are already experienced in either the cath or EP lab. New employees attend Banner employee orientation, and specific cardiac/EP lab training is provided within the department by means of assigned preceptor/shadow training, physician education, EP conferences, and vendor education.

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

The department supports continuing education opportunities for all staff members, and funding can be provided to attend both local and out of town EP education conferences. Some of our vendors also put together multiple educational sessions throughout the year, in addition to all new equipment and procedure inservices. 

How is staff competency evaluated?

We have a system of staff competency evaluation monitored by our own cardiac services educator. All staff members are responsible for completing by the assigned deadline multiple computerized courses within the Banner Learning Center, as well as attending both a yearly skills day and a yearly Advanced Clinical Education (ACED) day session. 

Have members of your staff taken the registry exam for the Registered Cardiac Electrophysiology Specialist (RCES)? Does staff receive an incentive bonus or raise upon passing the exam?

Some of our radiology techs have taken the exam. If passed, the staff member obtains the title of EP specialist and is placed in a higher pay scale. 

How do you prevent staff burnout?

Cross training of staff to all areas of the EP lab is a powerful tool, not only for getting work done more efficiently, but also for preventing staff burnout. The work is spread out over all staff members without overloading just one person. Cross training allows for an even distribution of work, so we are each other’s backup and support.

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

Staff members participate in departmental shared leadership committees. 

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

In the EP lab, the majority of our patients are placed under general anesthesia for their procedure; since few are given moderate sedation, we don’t specifically offer alternative therapies to our patients inside the lab. However, we do have the capability to play music off the Image Stream system and off the internet. From time to time, patients will request specific music to be played to help them relax until anesthesia is induced. The hospital does also offer pet therapy to patients. 

How does your lab handle call time for staff members? 

EP lab staff do not take call. We have late case coverage every day, in which 3 staff members stay until all cases are completed.

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

Yes, we definitely participate in reprocessing and catheter recycling with an outside vendor. Our EP lab saved approximately $1 million just on reprocessing in 2015. 

Approximately what percentage of ablation procedures are done with cryo vs radiofrequency?

Our overall percentage of cryoablation is about 32%. Our 3 primary electrophysiologists perform both radiofrequency and cryoablation procedures. 

Does your lab use contact force sensing technology during radiofrequency ablation of atrial fibrillation?

Currently we do not use contact force sensing technology. However, it was trialed here and our EP lab was very impressed with this technology. There are plans to definitely submit for purchase request this quarter.

What are your techniques for LAA occlusion? Do you have a primary approach?

We have operators experienced in use of both the LARIAT Suture Delivery Device (SentreHEART, Inc.) and WATCHMAN device (Boston Scientific), as well as with surgical excision with the AtriClip (AtriCure), depending on the needs of the patient.

What are your thoughts on the use of the new oral anticoagulants (NOACs) in patients with non-valvular atrial fibrillation? 

Avoidance of complications is critical when it comes to anticoagulation. Warfarin complications such as cerebral hemorrhage have been diminished with the use of NOACs. The predictability, convenience, and ease of use has provided our patients with improved quality of life and reduced complications. NOACs are also increasingly covered by insurance, which improves overall compliance.

Is hybrid epicardial and endocardial ablation of atrial fibrillation performed at your institution?

Yes, hybrid MAZE has been performed here since 2004 with simultaneous mapping and ablation in our hybrid operating room. Our hybrid MAZE protocol has been highlighted and has served as a teaching tool for colleagues from around the United States.

What other innovative EP techniques are being utilized in your lab? 

Substrate mapping and ablation using the cryoballoon for extra-pulmonary vein lesions was recently published by Dr. Su, along with the “Best Practice Guideline” for performing cryoballoon ablation. Studies for novel products as well as new mapping algorithms have been central to the advancement of our program. 

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

The Banner University Medical Center-Phoenix EP lab is for adult procedures only. 

What measures has your lab taken to reduce fluoroscopy time? In addition, what types of radiation protective shielding and technology does your lab use?

In an effort to reduce fluoroscopy time, new x-ray equipment has been purchased. Also, low fluoroscopy doses set in the 2 dedicated EP labs, as well as the utilization of 3D mapping systems and ICE catheters to follow/view placement of catheters instead of using fluoro, has significantly reduced fluoro time. Dr. Su and Dr. Ashish Sadhu have been very proactive in minimizing fluoroscopy time techniques. Dr. Su was able to perform nearly “zero fluoro” ablation in the left atria on a 7-month pregnant patient with severe tachycardia and congestive heart failure.

What are your methods for device infection prophylaxis?

Our everyday practice in the EP lab is the use of personal protective equipment (PPE), including a mask inside the lab and strict sterile techniques for all procedures (not just for device procedures). Infection prophylaxis for devices includes administration of IV antibiotics, device pocket irrigation with triple antibiotics, and the use of antibiotic pouches. 

Does your hospital offer a cardiac device support group for patients? 

Yes, regular “heart-to-heart” programs have been a popular support forum for device patients as well as ablation patients.

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

Phoenix is located in the Salt River Valley in south-central Arizona, nicknamed “Valley of the Sun” for its year-round warm and sunny climate. Phoenix’s population has well over a million residents (helping make Arizona the second fastest-growing state in the country), and attracts people of all ages and backgrounds. We have “winter visitors” who come from all over the U.S. and Canada to enjoy our wonderful weather. We have a strong cultural melting pot: Hispanic, Pacific Islander, and Asian cultures are just some of the many who have made Phoenix their home. In parts of Phoenix, you can get the best, most authentic Mexican food and then, walk next door to get the best, most authentic Chinese food.

With over 30,000 acres of Phoenix Mountains Preserve, Phoenix is perfect for events such as scenic hiking, biking, trail running, horseback riding, water rafting, and camping. All around, it’s an active city. People are always jogging on the streets or riding their bicycles down greenways. We have over 140 year-round golf courses as well as the famous Phoenix Open, which caters to around a half million attendees each year. In addition, Phoenix is a proud host to several national sports teams. You can watch the 2001 World Series Champions, the Arizona Diamondbacks, play baseball at Chase Field. You can watch Larry Fitzgerald, one of the undeniable stars of the NFL, make the Arizona Cardinals proud as he runs for a touchdown out of the University of Phoenix Stadium.

By having such a diverse and active foundation, it makes sense that health care plays an important part in Phoenix’s economy, employing over 33,000 people in the greater metropolitan region. Banner University Medical Center-Phoenix is one of the largest tertiary care hospitals in the Southwest, and is a Magnet hospital that has been cited for over 12 years as one of America’s “Best Hospitals” by U.S. News & World Report

The Banner’s mission statement is “to make a difference in people’s lives through excellent patient care,” and the world-renowned Banner MD Anderson Cancer Center and the Banner-University of Arizona are just two of the many health care institutions that exemplify that mission statement. 

Living in the desert is a funny thing. At first, it can almost feel unnatural with the heat and the arid desert. It’s a destination city with most of its residents originating from other parts of the world, to hike its mountains and run its trails, to swing at a golf ball on the 9th hole when it’s 100 degrees out. To me, this means just one thing: You have to want to come to Phoenix. I look at my coworkers and think: If you are here, it’s because you want to be. 

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

The makings of a special EP lab consist of many factors. First, you need a manager. Not just any manager, but a manager who is truly educated in the ways of electrophysiology — fully knowing and understanding all the procedures. This is an essential skill that allows the manager to jump in and assist without delay when the need arises, as well as to provide all essentials of policy and procedures with staff and doctors’ needs and desires to fully complete all procedures as successfully and timely as possible. This manager also needs stellar people skills to manage all varying personalities of staff and doctors, while setting an example for all to follow suit. The manager needs to be a great mediator when the inevitable challenges are presented, providing a positive outcome for the team as a whole. Our manager definitely represents all these qualities and much more.

You also need electrophysiologists that are able to exercise their years of experience and knowledge while practicing patience and understanding, in order to help educate and train the variety of levels of staff experience and knowledge they will encounter. The electrophysiologist should be sensitive to the needs of staff while not compromising his/her own expertise, confidence, education. or experience, and is a great asset to a happy and less stressful environment in EP.  Our EP doctors are truly an honor to work with, and they go above and beyond what is required of them as they challenge, stretch, and welcome us to grow and learn together. Working alongside our EP doctors has been and continues to be a rewarding experience for all of our team members.

We definitely also need our anesthesiologists. We at Banner University Medical Center in Phoenix have the “best of the best” anesthesiologists who are a great asset in the lab, providing superior care to the patient. Our anesthesiologists are also terrific with the staff, providing us with insight and knowledge while engaging in a friendly, fun, and polite manner.

RNs and techs are truly a godsend to EP. The team needs to be able to come together and be willing to put judgment, criticism, and gossip aside in order to rise above petty nonsense and focus on the procedure at hand. A good team will do this in a professional manner with a positive attitude, while growing in knowledge and confidence. Our RNs are amazing, as they are always available to assist whomever and whenever the need or desire presents itself, while at the same time allowing techs to exercise their skills and knowledge, supporting growth and experience. Our techs work together exceptionally well, helping each other to succeed in our growing field of electrophysiology, while also engaging with laughter and providing excellent teaching as we all learn the ins and outs of this complex and challenging yet very rewarding field. 

Finally, our representatives help to make our lab complete with their support in our procedures, providing excellent teaching in a fun, laidback, and friendly manner as they assist the doctors with complex mapping, ablations, and implants, giving our patients the best outcome possible.

In general, our lab is special because each one of us — the manager, doctor, RN, tech, or rep — bring much support, kindness, and genuine care in a variety of ways to each other as we engage fully in our roles. We each offer experience, insight, knowledge, and laughter (which is truly a great medicine) to one another during our very full days in our world of electrophysiology.