We have one dedicated EP lab as well as one combined hybrid OR room for lead extractions and device implants. Our first case took place in August 2014.
What is the number of staff members? What is the mix of credentials at your lab?
Our program is comprised of 1 director, 3 RNs, 2 BSNs, 1 BSN CNOR, 1 BSN CCRN CEN, 1 BSN CCRN, 5 AARTs, 1 RCIS, 4 CVTs, and 2 scheduling coordinators.
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?
We perform a wide range of ablations, including complex ventricular tachycardia (VT) and atrial fibrillation (AF) ablation. We also perform supraventricular tachycardia (SVT) ablations for a wide array of arrhythmias in pediatric and adult patients. We handle complex device management cases, including pacemaker/ICD lead extraction, pacemaker implantation, CRT-D implantation, and CRT-P implantation.
All ablations are currently performed with radiofrequency (RF), with the intention of starting cryoablation in 2017.
We perform 10-15 cases per week. Per year, we average 250-300 AF ablations, 100-150 SVT ablations, and 50-80 VT ablations.
Who manages your EP lab?
The director is Charlie Tagawa, CVT, and the RN supervisor is Devin Maher, RN, BSN.
Is the EP lab separate from the cath lab?
The EP and cath labs are staffed by the same team that rotate out every week. We have staffed the EP department this way since its inception.
Do you have cross training inside the EP lab?
Yes, the staff is cross trained to do EP, cath, and interventional radiology (IR).
What type of hospital is your EP program a part of?
We are a full-service community hospital that is licensed for 126 beds. We are the STEMI Receiving Center for the San Luis Obispo County with Gold status from the ACTION Registry®-GWTG™ and Silver Plus recognition from Mission: Lifeline national registry program. We are currently in the process of applying for the Pulmonary Hypertension Regional Care Center accreditation. Our cardiac program also includes TAVR and surgical valve replacement.
What types of EP equipment are most commonly used in the lab?
We have a fully integrated EnSite Velocity system (Abbott). For the most part, we use ablation catheters from Abbott. We also use the WorkMate Claris Recording System (Abbott) for mapping. We use Spectranetics technology for our laser lead extraction cases.
How is shift coverage managed? What are typical hours (not including call time)?
We staff the EP lab with two overlapping shifts: 6:30 to 15:00, and 11:00 to 19:30. There are three teams available for the AM shift and one team for mid shift to cover cardiac, IR, and EP.
Tell us what a typical day might be like in your EP lab.
Typically, the team comes in at 6:30 for a 7:30 start time. The technologists set up the RF ablation and mapping equipment, while the RN performs quality control on the point-of-care (POC) testing and emergency equipment. All of our ablation cases have an anesthesiologist on staff. After the sterile tray is set up, the anesthesia equipment is checked and restocked, and the patient is brought to the room.
What new technology has been recently added to the EP lab? How have these technologies changed the way you perform procedures?
The updated 3D mapping system allows us to perform better mapping with reduced fluoroscopy. We are using the Radiofrequency NRG Transseptal Needle (Baylis Medical), which assists in fluoroless AF access. We plan to start using cryoablation during 2017. We are also planning to start transcatheter pacing implementation and left atrial appendage (LAA) closure cases this year (we hope to start implanting Boston Scientific’s WATCHMAN LAAC Device in the early part of 2017).
What imaging technology do you utilize?
We use the AlluraClarity system (Philips). For intracardiac echocardiography (ICE), we use Philips ultrasound with 3D TEE and ICE and the Allura Xper FD20 system (Philips).
Do you implant MR conditional pacemakers or ICDs?
Yes, we implant MR conditional pacemakers and ICDs from Boston Scientific and Medtronic.
Who handles your procedure scheduling? Do they use particular software?
We have two scheduling coordinators for our department that use Microsoft Outlook to schedule cases. The coordinators contact the referring office and patients, and coordinate with lab staff.
What types of quality control/assurance measures are practiced in your EP lab?
Fluoroscopy and ablation equipment are checked daily by the technologists working in the room. The RNs QC the anesthesia machine, POC testing devices, balloon pump, temporary pacemakers, and crash cart. Our RN coordinator, Dana Churchill, submits data to the American College of Cardiology’s AFib Ablation Registry™. We also conduct a weekly cardiology conference, and discuss electrophysiology topics and case reviews. Cases are reviewed weekly by our quality department. Every quarter we also hold a peer review meeting.
How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies?
A technologist, Terry Schneider, is assigned to reorder EP supplies and keep track of inventory.
Has your EP lab recently expanded in size and patient volume?
We hope to add a new EP lab in the next year or two, to allow for a new mapping system and fluoroscopy suite for both ablation and research.
Have you developed a referral base?
We are the only electrophysiology program in our city and county, and have developed a good referral base from the surrounding area here on the Central Coast.
In what ways have you helped to cut or contain costs and improve efficiencies in the lab?
All of our high-cost products are purchased through the SharedClarity purchasing agreement and/or Dignity Health corporate.
How do you ensure timely case starts and patient turnover?
It helps to have a mid shift to be able to relieve staff for lunch, so that we can turn over the EP lab without having to break for a half hour. Both anesthesia and the lab staff work hard to stay on time.
How are new employees oriented and trained at your facility?
New employees are given lectures by educators from our EP physician director, Dr. Chris Porterfield. He also holds quarterly EP talks in which cases are reviewed and various topics are discussed. The majority of the EP orientation is on-the-job training for 12 weeks.
What types of continuing education opportunities are provided to staff members?
Staff is encouraged to travel to the Heart Rhythm Society’s annual conference. In-services by vendors, physicians, and staff educators are performed on a regular basis.
How is staff competency evaluated?
We perform yearly competency reviews.
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?
We do have one staff member, Terry Schneider, who is RCES certified. There is currently no bonus or raise offered. However, we are in the process of encouraging staff to take the exam and for an incentive to be added.
How do you prevent staff burnout? Do you also practice any team-building exercises?
Dr. Porterfield holds quarterly dinners during which EP topics are discussed. Staff is encouraged to take vacations, and is offered opportunities for flex time to help prevent staff burnout.
What committees, if any, are staff members asked to serve on in your lab?
Delegates from each discipline of the department are asked to participate in the Cardiovascular Department’s bi-weekly Unit-Based Council Committee. At this meeting, each delegate can bring forward one or two issues to discuss, and the committee decides upon an action plan to resolve whatever issue is brought forward. Staff members are also asked to participate in weekly cardiovascular conferences during which cases are reviewed and quality improvement strategies are discussed.
How do you handle vendor visits to your department? Do you contract with vendors?
All of our vendors must sign into Vendormate upon entering the facility. Vendormate prints off a badge that has the vendor’s picture, name, and company printed on it. If there are non-contracted vendors that are requesting to have an in-service with the department, they must schedule a day through our office administrators, who then send an invitation through Outlook to that vendor and the department staff, informing the department when the vendor will be at the hospital. The vendor is also sent a list of things they need to do in order to have access to the department on their scheduled day. A few items on this list include donning proper surgical attire, wearing a name badge, and asking staff permission before being involved in cases.
Describe a particularly memorable case from your EP lab and how it was addressed.
We had a young teenage patient with recurrent syncope and Wolff-Parkinson-White (WPW) syndrome, who had a failed ablation several years prior and presented to the ER in AF with very rapid rates. We were able to bring the patient to the EP lab on a Saturday and perform ablation of an anteroseptal accessory pathway. The patient was discharged home later that day.
How does your lab handle call time for staff members?
The lab staff is assigned call to cover cases that take place after hours and on weekends. Weekend coverage is mainly for urgent device implants.
Does your lab use a third party for reprocessing or catheter recycling?
Yes, we currently utilize Stryker Sustainability Solutions for sterile reprocessing of our catheters.
What are your thoughts on the use of the new oral anticoagulants (NOACs) in patients with non-valvular atrial fibrillation?
We perform catheter ablation on uninterrupted NOACs with the exception of dabigatran, in patients with normal renal function and no history of bleeding. We will also continue warfarin with a goal INR of 2-2.5 throughout the procedure. NOACs are more commonly used in our practice for patients with non-valvular atrial fibrillation.
What measures has your lab taken to reduce fluoroscopy time? In addition, what types of radiation protective shielding and technology does your lab use?
We have quarterly reviews of fluoroscopy times, which are presented to the department by the head of radiology at our weekly meetings. During these quarterly reviews, the head of radiology also gives a radiation safety talk. The data given at these meetings consistently show that our EP lab patients have the least exposure to fluoroscopy in the department.
All staff involved in fluoroscopy cases are custom fitted for lead-protective equipment and eyewear. Multiple movable lead shields are present in each room. We also offer disposable lead skull caps, which offer protection to the staff member’s head. We have very low fluoroscopy times, and always use the lowest exposure during all of the EP cases.
What are your methods for device infection prophylaxis?
All patients are given IV antibiotics during device procedures. The device pocket is irrigated with antibiotic solution. Sponge counts are conducted during every case to ensure foreign bodies are not retained. We have a strict surveillance program, and if an infection is determined to be related, a thorough analysis is performed. We have not had a device-related infection in many years.
How do you use the NCDR Outcome Reports to drive QI initiatives at your facility?
We have just begun submitting our data to the AFib Ablation Registry™, and those results will come back during the first quarter of 2017. ICD Registry™ results are shared at our quarterly quality meetings and are used to steer program changes.
What are your thoughts on EHR systems? Does it improve your quality of care?
Our hospital uses Cerner EHR for documentation. The best feature of this system is to allow prompt documentation of H&P, procedure notes, and any recent changes. We utilize Dragon dictation at all computer stations for rapid integration of documentation.
What are some of the dominant trends you see emerging in the practice of electrophysiology?
Fluoroless ablation is a now welcome and dominant trend. New mapping systems with a higher degree of mapping density as well as better detail of our understanding of arrhythmia physiology and treatment options will be dominating the future of EP.
How does your lab handle device recalls?
When a recall occurs, we respond accordingly with the advisement of the FDA or mandated and necessary changes. Patients are notified typically through the implanting physician’s office.
How is outpatient cardiac monitoring managed?
Patients who undergo catheter ablation for atrial fibrillation undergo long-term monitoring using an outpatient system performed through the EP outpatient office. This is usually performed 3-6 months after ablation and again at 12 months post ablation for AF ablation patients.
Device remote monitoring is provided through the outpatient device clinic.
Is your EP lab currently involved in clinical research studies?
Yes, we are currently involved in several trials evaluating MR conditional pacing/ICD therapy and device closure techniques.
Are you ACGME-approved for EP training?
No, we do not have an EP training program. There are biomedical engineering students that shadow Dr. Porterfield and are part of courses that he assists with, as well as pre-medical education students.
Does your hospital offer a cardiac device support group for patients?
There is an outpatient support group that meets with the local AHA/ACC program.
Does your heart rhythm service offer patients with a suspected inherited arrhythmia a referral to cardiovascular genetics clinic?
Yes, we work closely with both Stanford and UCLA with referrals for genetic testing, and also perform genetic testing for patients with suspected inherited arrhythmia disorders.
Describe your city or general regional area. How is it unique from the rest of the U.S.?
San Luis Obispo County is seated in between Los Angeles and San Francisco. San Luis Obispo County offers a beautiful coastline, with rolling hills and diverse weather systems. The average temperature is 73 degrees, with sunlight most of the time. We are also the proud home of California Polytechnic State University. All of these aspects create a diverse and active city with a great amount of outdoor activities. We are known as the “Happiest City in America.”
Please tell our readers what you consider special about your EP lab and staff.
We work together as a strong team that is committed to safety and learning about arrhythmias, new technology, and how to improve on the current state of treatment. We work hard and enjoy life, and aim to keep standards at the highest level. For a new EP program, we have had a very rapid, safe, and successful two years. We hope for many more to come!