Spotlight Interview: Cheyenne Regional Medical Center

Bonnie Christensen, RN, BSN and M. Obadah Al Chekakie, MD, MSc
Clinical Cardiac Electrophysiology Lab
Cheyenne, Wyoming

Bonnie Christensen, RN, BSN and M. Obadah Al Chekakie, MD, MSc
Clinical Cardiac Electrophysiology Lab
Cheyenne, Wyoming

What is the size of your EP lab and number of staff members?

The electrophysiology lab at Cheyenne Regional Medical Center (CRMC) is 600 square feet in size and has a separate control room. There are six staff members that primarily work in the EP lab.

What is the mix of credentials at your lab?

Both nurses and technicians work in the EP lab. We have four Registered Nurses (two are Associate Degree Nurses and two are Bachelor Degree Nurses). Our nursing staff members include Bonnie Christensen, RN, BSN, Abby Kennison, RN, BSN, Amy Tinney, RN, ADN and Nikki Sipes, RN, ADN. We also have two bright lab technicians, Paul Shedd, RCIS and Tim Kirk, RDCS, RVT. 

When was the EP lab started at your institution?

The electrophysiology lab was established in July 2009. This is the first functioning electrophysiology lab in the state of Wyoming.

What types of procedures are performed at your facility?

We provide comprehensive electrophysiology services and perform simple and complex ablations, including supraventricular tachycardia ablation, premature ventricular complex ablation, ventricular tachycardia ablation (both in normal hearts and in patients with structural heart disease), as well as atrial fibrillation (AF) ablation. We also implant pacemakers, implantable defibrillators (ICDs), and biventricular pacemaker and biventricular defibrillators. 

Approximately how many are performed each week?

We perform four to six device implants a week, and two to three ablations a week (one of which is an AF ablation procedure).

What is the primary goal of your program?

The primary goal of the lab is to provide comprehensive electrophysiology service to all the patients in the state of Wyoming. Cheyenne Regional Medical Center is the largest of Wyoming hospitals and functions as a tertiary care center that provides a comprehensive cardiology service, with electrophysiology as part of a larger team, the Wyoming Heart and Vascular Institute, which includes cardiothoracic surgery, vascular surgery, interventional cardiology as well as general cardiology services.

Who manages your EP lab?

We have a dedicated EP lab manager, Bonnie Christensen, RN, BSN. Bonnie has experience as a critical care nurse for over 20 years; she previously worked in the cardiac cath lab and also managed a trauma unit before transitioning to the EP lab.  

Is the EP lab separate from the cath lab?

Yes. We have a dedicated EP suite and two dedicated cath lab suites. Members of the EP lab are cross trained and can help in the cath lab and or noninvasive suite.

Do you have cross training inside the EP lab?

All the members of EP lab are trained in the sterile scrubbing technique for device implantation, monitoring patients during EP cases, and using the intracardiac electrogram recording system (Prucka, GE Healthcare, Waukesha, WI). The staff is also being trained on the Carto 3D mapping system (Biosense Webster Inc., a Johnson & Johnson company, Diamond Bar, CA).

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

Our EP lab is a brand new, state-of-the-art lab. We have biplane fluoroscopy, the latest version of Biosense Webster’s Carto mapping system (Carto 3), as well as a dedicated echocardiography machine (Siemens S300) for intracardiac echocardiography (ICE) imaging.

Who handles your scheduling? Do they use particular software?

Patients are scheduled through a dedicated scheduling secretary, who works diligently with the EP lab manager to make sure that patients have everything that is needed for their procedure. Our EP lab manager communicates with  Carto representatives, device representatives, as well as anesthesia, so our patients have a pleasant experience.

We use a program called Tracker as well as the Pathways Healthcare Scheduling system (McKesson, San Francisco, CA) to schedule our patients. We are currently looking at other software options to better suit our needs.

How is inventory managed at your EP lab?

We have a dedicated product manager, William Ramage, RRT, who is in charge of ordering all of our supplies for the EP and cath labs. Bill works closely with our EP lab manager to ensure all necessary supplies are available for each case.

Has your EP lab recently expanded?

Electrophysiology is a new service in Cheyenne as well as in the state of Wyoming. Our patient volume has increased, and we are seeing patients from all across the state of Wyoming as well as from western Nebraska.

Have you developed a referral base?

We have a large referral base that includes primary care and family practice physicians as well as cardiologists in the community. We also provide outreach services in the surrounding areas of Wyoming and western Nebraska. We are in close contact with our referring physicians to ensure the best medical care is provided to our patients as well as provide lectures in quarterly bases to help update the medical community on the latest studies and services provided in our EP lab.

What measures has your EP lab implemented in order to cut costs or contain costs?

We ensure the best medical services are provided first, with cost being important but secondary to patient care. We have contracts with vendors to ensure we receive competitive pricing. We also utilize EPreward (Boynton Beach, FL) to recycle our used catheters and use the funds for staff education.

How are new employees oriented and trained in your facility?

New employees go through a specialized general orientation at the hospital for their first three days to ensure they know the electronic system and general safety protocols. Once the new staff member joins the EP lab, they are oriented by a senior EP nurse, who teaches them the scrubbing technique and who is usually scrubbing with them for the first few cases. For ablation procedures, we ensure that a short summary is given before and after the procedure. Brief lectures on ablation physics and basic electrophysiology principles are given by Dr. Al Chekakie.

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

We have monthly EP lab lectures covering the fundamentals of pacing and ablation. Our staff members are encouraged to attend conferences, especially the Heart Rhythm Society’s annual sessions. At least two staff members go each year.

How is staff competency evaluated?

Yearly competency is evaluated by the EP lab manager through skills check-off and testing. EP competency tests are conducted every six months.

How do you prevent staff burnout?

Staff members are able to function in all positions in the EP lab including scrubbing, patient monitoring, and handling of the recording system. The rotation as well as continual medical education helps keep the staff engaged and helps grow their knowledge and interest.

Do you practice team building?

The EP lab manager meets with each staff member monthly on a one-on-one meeting to see how they are doing and what is going well and what needs improvement. Our staff is encouraged to provide feedback, and we encourage open communication. We like our working environment to be pleasant, and we want the staff to feel that they are part of a team. 

How do you handle vendor visits to your department?

All vendors are asked to make an appointment with our scheduler when coming to our lab. This helps limit how many vendors are here and allows us to monitor who is visiting.

Vendors are also required to check in with our purchasing/materials management department, and receive a photo ID to wear while in our facility.

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

We had a patient who presented with cardiac arrest and had wide complex tachycardia of right bundle morphology. He had right bundle branch block on his electrocardiogram during sinus rhythm. His heart cath was normal, so we performed an EP study and this showed bundle branch reentry ventricular tachycardia. We ablated the right bundle, and the patient was cured of his arrhythmia. This is one of the rarest arrhythmias we have seen; the physiology was amazing. 

How does your lab handle call time for staff members?

EP staff does not take call in the EP lab. Some staff members who are cross trained in the cath lab take eight days of call per month if they choose to. They are compensated separately for each call.

Does your lab use a third party for reprocessing?

Our facility has its own sterile processing service that is right here in our hospital. The turnaround time is very quick, usually within 24 hours.

What percentage of your ablations is done with radiofrequency?

We use radiofrequency energy for all of our ablations, including anteroseptal pathways.

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

We only perform adult EP procedures at our facility.

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

Our lab features all updated equipment that is as radiation safe as possible. New lead suits have been ordered for all EP staff, and we utilize lead shielding/aprons on both sides of the biplane table. Having the mapping system during complex ablation procedures helps minimize our fluoroscopy time. We also use low-energy fluoroscopy to minimize the radiation exposure to physician and staff. We monitor the radiation exposure every three months.

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

We have a dedicated device clinic. Patients are followed closely by our device clinic at Cheyenne Cardiology Associates. We encourage our staff to interrogate the devices and check the leads during the procedure. We also check the devices before and after ablation procedures in the lab.

What are your thoughts about non-EP implanting ICDs? Do you train such individuals?

Currently, the guidelines stress the need for dedicated electrophysiology training to implant defibrillators and biventricular defibrillators. We agree with the new recommendations for training. The implantation techniques as well as device follow-up are complex, and studies have shown that complications from device implantation are lowest when done by the electrophysiologists. We do not provide training for non-electrophysiologists.

What about device recalls? How has your lab handled these?

Patients are contacted if there is a device recall, and have a separate visit with our electrophysiologist in case a device recall happens. To minimize the number of recalls, we are utilizing multiple vendors when it comes to device implantation. This ensures that recalls from a certain company will only affect a fraction of our patient population.

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

After the three-month visit, patients are encouraged to utilize transtelephonic monitoring. Patients are contacted after they transmit the information, whether or not the transmissions are normal.

Does your staff provide any educational material for patients who may have additional questions about their condition/procedure?

Information packets are mailed to our EP and device implant patients when they are scheduled for a procedure. These packets consist of a teaching booklet and letter that explains their procedure and better prepares them for the procedure. A nurse calls each patient the day before their procedure to answer any questions they may have.

An EP staff member visits with the patient and their families the morning of their procedure and teaches them more about the procedure they are about to have. We have visual aides to show patients what an ablation catheter looks like, what a pacemaker looks like, and so on.

Does your hospital or lab staff have a device support group?

We developed a device support group; patients are provided dinner during the session and we provide education on relaxation techniques, including guided imagery. We also invite speakers to talk to the patients about the psychological impact of ICD shocks. Dr. Al Chekakie is present at these meetings, and answers all the questions and concerns the patients have. These meetings are provided four times a year.

Describe your city or general regional area, and it differs from the rest of the United States.

The city of Cheyenne has a population of 65,000 people, and is the capital of the state of Wyoming. Cheyenne Regional Medical Center is the only Heart/Trauma center within a 100-mile radius, is the largest hospital in the state of Wyoming, and acts as a tertiary care center. It is the only hospital in Wyoming that offers comprehensive electrophysiology services.

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

Our state-of-the-art lab performs both simple and complex ablations as well as device implantation. We are the only lab that provides these services in Wyoming. We enjoy what we do, and have a very warm working environment. We love taking care of our patients.