Spotlight Interview: Florida Hospital

Penny Porteous, RN, Director of Cardiovascular Services, Orlando, Florida
Penny Porteous, RN, Director of Cardiovascular Services, Orlando, Florida

Florida Hospital was named by U.S. News & World Report for 2013 as the #1 hospital in the state of Florida, scoring in the top 50 in eight different categories in the nation. It is currently the largest healthcare provider in the state. As a non-profit community hospital, Florida Hospital serves the Greater Orlando area and the surrounding community. Orlando sees continuous growth in population due to the alluring weather and several tourist attractions. Founded in 1908 by Seventh-day Adventists, Florida Hospital has grown tremendously from a 20-bed sanitarium to a 2,247-bed acute-care medical facility. It is a major tertiary referral hospital for Central Florida, much of the Southeast, the Caribbean, and Latin America. Since the hospital opened over a century ago, the mission to extend the healing ministry of Christ has remained the same. The goal is for the healing touch of Christ to be felt by all who come to Florida Hospital for care.

The heritage of whole person health (achieving wellness of the mind, body and spirit for patients) is of paramount importance to each member of the exceptionally talented Florida hospital team. 

What is the size of your EP lab facility? 

Our electrophysiology department consists of two biplane labs, two single-plane labs and one single-plane Stereotaxis lab, a cath lab/implant room, a pediatric hybrid lab, and two non-invasive procedural rooms. Florida Hospital’s cath lab department has seven coronary and vascular labs. 

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

We have a total of 25 team members in EP that include a mix of registered nurses (ASN, BSN), cardiovascular technicians (RCIS, RCES) and registered respiratory therapists who equally share the job positions within the room. Many of our staff come from either a critical care or cath lab background. We also work with 12 electrophysiologists and an array of implanting invasive cardiologists.

Who manages your EP lab?

Our leadership team includes Penny Porteous, Director of Cardiovascular Services, Barry Egolf, Nurse Manager of the Cardiovascular Invasive Labs at Florida Hospital Orlando, Amber Arnold, Supervisor for EP, and Maribel Pontieri, Pediatric Cath and EP Supervisor. Rich Duen is the Cardiovascular Invasive Educator dedicated to EP. 

When was the EP lab started at your institution?

Our first EP studies were performed by Dr. Kerry Schwartz, who joined Florida Hospital in 1980. Our second electrophysiologist, Dr. Scott Pollak, joined Florida Hospital in 1987.

How is shift coverage managed? 

Our employees work either 10-hour or 12-hour shifts. Our team members do take call during the Monday through Friday workweek, in order to complete the cases for each day. 

Are staff members cross trained? 

Every staff member is cross trained in every role in the EP lab. All specialties are trained to medically manage patients under physician supervision, including being able to scrub, monitor, and pace procedures. We are not an academic institution, so our team members perform all duties in the lab. As our department is set to expand with a third biplane room, we also plan to continue cross training cath lab personnel to perform implant procedures.

We work hard to protect our culture as a team. We understand the importance of the teamwork needed in order to provide our patients with the best possible care. We all work to build on the skills of each other to excel the department as one team. We realize electrophysiology is not for everyone, and want to protect the integrity and team dynamic we have built in our department. 

Tell us about your pediatric EP program.

Established in August 2012, Florida Hospital’s pediatric electrophysiology program has been at the forefront of complex and innovative procedures. The scope of the program ranges from congenital heart defects to adult structural heart disease. Done in one of our hybrid rooms, these procedures include transcatheter aortic valve replacements, diagnostic and interventional catheterizations, as well as diagnostic electrophysiology studies and arrhythmia ablations. Both radiofrequency (RF) and cryo are utilized as part of the procedures.

During EP procedures, special emphasis is placed on reducing radiation exposure. Hence, a wide percentage of ablation procedures is done without the use of fluoroscopy by using the EnSite NavX mapping system (St. Jude Medical) for catheter visualization. 

Bhavya Trivedi, MD, PhD is the Medical Director of Pediatric Electrophysiology at Florida Hospital for Children. The pediatric team consists of five dynamic and dedicated members with credentials including an RN, EDRN, RT(R), RCIS, and RCES. The team is cross trained in electrophysiology procedures as well as adult cardiac catheterizations and structural heart procedures.

How are new employees oriented and trained at your facility? What types of continuing education opportunities are also available?

During the past three years, Florida Hospital’s EP department has completely revamped education of new and seasoned staff members. We have implemented a successful process of hiring the right candidates for the job. We have a full-time dedicated educator for EP, whose focus is ensuring all staff members have the educational materials, classes, training, and in-services needed to allow for continuous growth. New staff members undergo a series of classes to instruct them on the basics of sterile technique, lab roles and responsiblities, hemodymanics, pharmacology, etc. They are then placed with a preceptor in the cath lab for a few months to gain a grasp of the procedural arena. Upon passing their cath lab rotation, they advance to the EP department, where they continue to follow a preceptor and begin implant training followed by ablation training. This process usually takes 6 to 8 months. When a new employee has completed orientation and training, they are able to perform independently in all positions in the EP department. This has been effective in recognizing whether a new staff member will be conducive to the electrophysiology department.

Progressive learning beyond the orientation phase is encouraged by team members, the lab educator, EP supervisor and physicians, with an emphasis on continued growth. We have successfully implemented a clinical ladder for seasoned employees to ensure continued growth and engagement. The clinical ladder also focuses on education through teamwork. When one person learns something new, we all learn it together.

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

Creating a world-class patient experience is the goal at Florida Hospital as an institution. There are many things we do in the EP department to ensure that our patients know that they are truly cared for by our team members. 

We provide music therapy to all of our patients, utilizing Internet radio such as Pandora. We ask our patients their preference in music, and provide it to them throughout the procedure. This seems to aid in relaxing the patient and offer a distraction from the stress of the procedure. The climate in our rooms is chilly. We provide warm blankets prior to and at completion of the procedure to keep the patient warm. We utilize Bair Hugger® Therapy (Arizant Healthcare Inc.) for all of our cases in order to keep the body temperature within a normal limit. 

How does your lab communicate necessary information to patients? 

Our team members understand the importance of explaining the setup of procedures in a caring and understanding manner every step of the way to help place the patient at ease. We personally call to update family members at the start of the procedure, and hourly until completion. At the end of the case, our physicians sit down with the family and communicate what was done during the procedure and what should be expected in the following weeks. 

How does your lab communicate information to staff? 

We have daily energizers that consist of a team huddle every morning to communicate with each other about pertinent information for the day or about new unit/hospital policies. Every team member has a hospital-issued email address in which to communicate information. We have an open-door policy between the educator, staff, physicians, and management. Our administrative team is streamlined to allow for direct information exchange between the frontline team to upper management. When a team member relieves another team member during a procedure, we utilize “hand-off” communication to relay important information regarding the patient.

Who handles your procedure scheduling? How do you handle vendor visits to your department? 

Our EP department has two scheduling coordinators and an imaging coordinator. Catherine Posso coordinates the day of procedures and Melissa Martinez schedules and coordinates future scheduling for the invasive labs. These two individuals ensure that our patients are scheduled in the correct lab according to their procedure type, equipment required, and physician preference. They also coordinate any needed support from specific vendors and/or other departments for each procedure. Our physicians book procedures several months in advance, and coordinating the schedule requires a skilled person to align all the factors associated with a case.

What types of procedures are performed at your facility?

We have consistently grown our volume of cases year after year. The EP department at Florida Hospital is projected to perform 300 atrial fibrillation (AF) ablations this year. We have been focused on growing our robotic ventricular tachycardia (VT) ablation program, and are projected to perform 100 VT ablations this year. We perform all ablation types including atrial tachycardias, atrial flutters, ANRT and AVNRT. This year we expect to exceed a total of 700 cardiac ablations. We perform more than 1,200 implants per year at Florida Hospital. Our department also executes tilt table testing, cardioversion, and NIPS procedures.

What types of EP equipment is most commonly used in the lab? What new equipment, devices and/or products have been introduced at your lab lately?

We are very fortunate here at Florida Hospital to have the array of equipment available to us. We carry products from Biosense Webster, St. Jude Medical, Boston Scientific, Medtronic, Bard, and BIOTRONIK. We have three Carto 3 systems (Biosense Webster, Inc.) and three EnSite Velocity Cardiac Mapping Systems (St. Jude Medical). We utilize ultrasound with three ACUSON Sequoia systems (Siemens Healthcare), St. Jude Medical /ZONARE ultrasound systems for intracardiac imaging, and the ACUSON X300 machine (Siemens Healthcare). We utilize both RF and cryoablation therapies. We utilize robotic therapy with Stereotaxis-guided ablations. Because our department invests in the continuing education of its team members, many have been trained on mapping systems, ultrasound, and other equipment to ensure we are the leading-edge team in the community for EP. Some supportive equipment we have available to us for higher acuity patients are the Impella (ABIOMED, Inc.), the intra-aortic balloon pump, and cerebral oximetry. We have also just implemented the PEAK PlasmaBlade System (Medtronic) for lead revisions and generator change outs. 

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

Our cardiovascular invasive labs have a vast inventory supply room. Rebecca Lopez is the EP department’s inventory control clerk. The Apollo (Lumedx) system is our primary inventory management tool. With the aid of an RFID system (WaveMark, Inc.), Rebecca ensures our supplies are in stock and available with just-in-time pulling in mind. Tarja Williams, our imaging and procedural support technician, assists physicians with imaging needs and provides our labs with sterile surgical supplies from our central processing unit.

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

Our EP department has maintained quality of care through managed care practice. It is the job of the physicians to move their patients through their phases of hospitalization, such as timely scheduling to decrease length of stay. The EP department has to work closely with the physicians to schedule patients for their procedures in a timely manner so as not to increase length of stay or prolong patient treatment. Our inpatient population takes priority. As a department, we offer flexible scheduling to the physicians as well as the staff to accommodate for longer and add-on cases.

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

Stewardship is one of our core values at Florida Hospital. One of the main ways we cut cost in the EP department is through our recycling/reprocessing programs. Our department recycles catheters, sheaths, and ICE catheters through recycling programs from Stryker Sustainability Solutions, Greymart, and Biosense Webster. We then utilize our reprocessed products during our procedures to help cut the cost of the products to the hospital and patients. Our team is prudent when opening equipment and catheters, and always checks with the physician prior to opening. The team is informed where they can make a difference in decreasing costs, and understands the importance and advantages of being good stewards to the hospital and our patients. 

What are your methods for infection prevention?

Infection control is a fundamental part of all procedures performed in our department. All labs have been constructed to OR standards, with solid ceiling positive pressure systems to reduce potential airborne contaminants. All patients are followed by the hospital’s infection control team. Any infections that incur in our procedures are tracked by the team and reported quarterly to the lab director, management staff, and physicians. All surgical procedures are held to hospital-wide Surgical Care Improvement Project (SCIP) protocols and standards. This protocol includes prophylactic weight-based antibiotic administration and a pre-procedural skin preparation with chlorhexidine- or iodine-based surgical solutions, or a combination of the two. It is also standard practice for a sterile antibiotic irrigant solution to be used. All staff are thoroughly trained in sterile technique and scrubbing the hub of any IV or central line prior to medication administration. The team understands the importance and is engaged in decreasing any potential for infection in the EP lab.

How do you ensure timely case starts and patient turnover?

Our EP lab has grown significantly over the last few years. We have had to pay close attention to the areas that we do well in and the areas in which we can improve. Our department has measures for success of goals in which we can visualize on a scorecard. Our scorecard tracks key performance indicators such as “in room” times, “patient ready” times, “case start” times, etc. We evaluate these monthly and compare and track our results from month to month. Our goal is to be in the green in all of our measurements and continue to move forward in increasing success. The EP department has two individuals that play a large role in our patient turnaround times. David Gopaul is the assigned anesthesia technician for the EP department; he maintains the anesthesia equipment, arterial line setups, and restocking and cleaning the anesthesia carts before and between cases. Johan Antonio is our invasive cardiovascular assistant that helps with room turnovers by breaking down, cleaning, and setting up our rooms between cases. With the help of these two team members, we are able to quickly move in between cases and prepare for the next patients to arrive.

Please tell our readers what you consider innovative about your EP program. 

Florida Hospital’s vision is to be a global pacesetter delivering preeminent, faith-based health care. It is understood by all employees of Florida Hospital that innovation is needed to sustain and see this vision for the future. Our EP department utilizes innovative technology in many ways. We bring together electrophysiologists, cardiovascular surgeons, vascular surgeons, and cardiac interventionalists to work as a team when assistance is needed in access difficulties, cardiac catheterizations, venous angioplasties, as well as pericardial windows for epicardial ablations, etc. Dr. Usman Siddiqui has become our physician champion in robotic VT and epicardial ablations. We have used 3D Spin technology (GE Healthcare) for real-time three-dimensional modeling of the left atrium for AF ablations. Our physicians understand the need to decrease radiation exposure, and perform fluoroless ablations when able. We have a vigorous cardiovascular research program that works with our team. As investigators, our physicians are engaged in bringing the newest technologies to our department and our patients. We are looking in the near future to bring a third biplane room into operation as well as developing a teaching center utilizing wet labs and video conferencing for education of outside facilities. We are also looking into the new Boston Scientific mapping system to assist in decreasing our procedure times.

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