Spotlight Interview: Hartford Hospital

Steven Zweibel, MD, FACC, Director of Electrophysiology, and Sharon Thum-Gebrian, RN Hartford Hospital Hartford, Connecticut
Steven Zweibel, MD, FACC, Director of Electrophysiology, and Sharon Thum-Gebrian, RN Hartford Hospital Hartford, Connecticut
What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab? Hartford Hospital has one dedicated state-of-the-art invasive EP laboratory. We also have a dedicated diagnostic EP laboratory in a separate location where we perform diagnostic EP studies, ICD testing, cardioversions, and tilt table studies. Additionally, we share a cardiovascular OR suite for laser lead extractions and device implants when our primary lab is too busy to accommodate these cases. Our staff currently consists of three board-certified invasive electrophysiologists, three full-time registered nurses (RNs), and one part-time registered nurse (RN), as well as one electrophysiology technologist (RCES). We will be obtaining extra space in a lab next to ours that we will be sharing with the interventional neuroradiologists when their new laboratory is completed in March 2010. With the addition of the new laboratory space, we will have three open positions for two RNs and a CV/EP technologist. When was the EP lab started at your institution? Dr. Jeffrey Kluger established the invasive EP program at Hartford Hospital in 1999 with the recruitment of Dr. Christopher Clyne, who in 2000 became (and remains) our invasive EP laboratory director. In July 2008, Dr. Steven Zweibel joined the faculty of Hartford Hospital as the director of cardiac EP. What types of procedures are performed at your facility? Approximately how many are performed each week? We perform all interventional electrophysiology procedures, which includes radiofrequency ablation of complex arrhythmias (including atrial fibrillation [AF] and ventricular tachycardia [VT]), laser lead extractions and all basic as well as complex device implantations. On a monthly basis, we provide services for approximately 50-60 patients. Our yearly volume includes about 200-250 ablation procedures and 400-450 device implantations. What is the primary goal of your program? Our primary goal is to provide comprehensive electrophysiology services utilizing state-of-the-art technology in a patient-focused environment with particular attention to cost containment. We do not nor do we plan to focus solely on only one type of electrophysiology service. We are privileged to have a group of electrophysiologists, Dr. Steven Zweibel, Dr. Christopher Clyne and Dr. Eric Crespo, who direct us to excellence by providing quality patient-focused care. Who manages your EP lab? Sharon Thum-Gebrian, RN holds joint positions as manager of the EP lab, manager of the arrhythmia services and physician office practice manager. Her background as a cardiac intensive care nurse for 20 years as well as an EP nurse and a pacemaker clinician gives us a unique advantage, as she understands the overall inter-departmental complex dimensions of the EP program here at Hartford Hospital. Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained? Our EP lab has a primarily dedicated EP staff. We are separate and distinct from the cath lab. Minimal cross training of the arrhythmia nurse from the diagnostic EP lab and the device clinician nurse have assisted the lab when staffing issues arise. Do you have cross training inside the EP lab? What are the regulations in your state? Our EP lab staff is trained to perform any task necessary within the lab, with administering medications being the responsibility of the nurses. Frank Natale, RN, Angela Leininger, RN, Ralph Meyer, RN, and Joseph Criniti, RN are credentialed in procedural sedation and function as scrub techs under the guidance of the physician. For deep sedation during ablations and ICD implants, we are covered by the anesthesiology department, who also cover most other cases in the EP laboratory as well. What new equipment, devices and/or products have been introduced at your lab lately? How has this changed the way you perform those procedures? Within the past year we have added or upgraded much of our technology in the laboratory. The biggest addition was the Sensei X Robotic Catheter System (Hansen Medical, Mountain View, CA). We were the first EP laboratory in Connecticut to perform a case with the Sensei robot and the first laboratory in the country to receive the upgraded Sensei X system. We have started to perform more of our atrial fibrillation procedures with the robot, and plan to use it more often for these procedures. We have upgraded our ESI system with the newest EnSite Velocity System (St. Jude Medical, St. Paul, MN), and will be soon upgrading our Carto system (Biosense Webster, Inc., a Johnson & Johnson company, Diamond Bar, CA) with Carto 3. Both systems have the capability to merge or fuse CT or MRIs with our real-time maps for more accurate navigation. We also recently replaced our Prucka recording system (GE Healthcare, Waukesha, WI) with the EP-Workmate EP Lab Recording System (St. Jude Medical). The Prucka system will be moved to our new laboratory when this is available. We also added irrigated catheter systems from both Biosense Webster Inc. (ThermoCool) and St. Jude Medical (Cool Path) to assist us with both atrial fibrillation and VT ablations. In addition, we use the Spectranetics CVX-300 excimer laser for lead extractions (Spectranetics Corporation, Colorado Springs, CO), Biosense Webster Inc.’s AcuNav for intracardiac echocardiography, and Medtronic CryoCath GEN IV for cryoablation. Who handles your procedure scheduling? Do you use particular software? All scheduling for the EP lab is coordinated through our physician’s office staff, which consists of three very dedicated administrative associates, Julie Buerk, AAIII, Demetta Smith, AAII, and Erika Leslie, AAII. We use Novell GroupWise with a shared calendar for lab scheduling. What type of quality control/quality assurance measures are practiced in your EP lab? Our nursing notes are generated from the EP-Workmate (St. Jude Medical) and the CardioLab (GE Healthcare) system. We have incorporated all of our quality control and quality assurance measures within the body of our nursing notes, making the documentation a comprehensive quality report. We include fluoroscopy times, incision start time, verbal time out, verification of correct patient, site/side, and procedure, as well as surgical site fire risk assessment. We also have EP, procedural and OR monthly meetings designed for establishing patient safety quality goals based on Joint Commission’s recommendations. Procedural and anesthesia complications are tracked for each case and presented for discussion at our quarterly EP/arrhythmia M&M conferences. All patients are called within 48-72 hours of their procedure by the EP nursing staff for our patient satisfaction survey. We are extremely proactive with our patient suggestions. How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? Our EP technologist is responsible for the ordering of major vendor supplies. He is also responsible for unpacking all the supplies and stocking the storeroom. One of our EP nurses is responsible for basic store room medical supplies. We are in the process of developing an Excel spreadsheet with all inventory and par levels. Has your EP lab recently expanded in size and patient volume, or will it be in the near future? We are in the process of building an additional EP/neuro biplane laboratory, which will be utilized by EP at least 50% of the time. Our new lab is scheduled to open in Spring 2010. We are scheduling our procedures out at least 4-7 weeks due to lab availability, which will improve with the addition of this new laboratory. Volumes have been increasing over the past few years, and we plan on this continuing into the future. How has managed care affected your EP lab and the care it provides patients? Managed care has not affected our patient-centered care model. We continue to provide the necessary procedures regardless of payment ability. We also work with patient registration and patient accounts for assistance with some of our more financially challenging cases. Have you developed a referral base? Hartford Hospital is a large tertiary hospital with a network referral base. In addition, our electrophysiologists provide regular educational meetings for different cardiology and primary care physician groups in the area. These educational sessions provide information about the capabilities of our physicians and labs, as well as inform physicians about the latest indications for procedures such as ICD implantation for primary prevention of sudden death and AF ablation for patients with symptomatic atrial fibrillation despite antiarrhythmic medications. What measures has your EP lab implemented in order to cut or contain costs? In addition, in what ways have you improved efficiencies in patient through-put? In 2008-2009, our hospital contracted consultants (Cath Source) to guide and formulate new strategies for completive contract negotiations and vendor pricing. This process was a success and we have now internalized the course of action with methodologies that have proved successful. We have developed three Clinical Quality Value Analysis (CQVA) committees (Medical/Surgical, Procedural/Interventional and Periop services). The CQVA is a standard approach to reviewing new clinical supplies and equipment to ensure adherence to hospital standards, as well as appropriate financial reviews, training and education, and trials/implementation. With the addition of our new lab, we are also growing the holding area in radiology by four beds, and increasing the nursing competencies to meet the standards of the American Society of PeriAnesthesia Nursing (ASPAN). Does your EP lab compete for patients? Has your institution formed an alliance with others in the area? Our EP lab is in a small way in competition with a Catholic hospital across the city. We are also in competition with a 200-bed hospital in the next town that also has an EP lab. Hartford Healthcare has been aggressive in forming alliances with area hospitals to form a unified healthcare network in our region. How does your lab handle call time for staff members? Our EP lab does not have call. Our team stages their start times and end times from 10-12 hours to cover the scheduled cases. How are new employees oriented and trained at your facility? We strongly prefer nurses with cardiac critical care experience to apply to work in our EP laboratory. We feel it takes six months to one year to train a new employee in just the basics. It takes about two years before the employee is completely competent in all aspects of EP nursing, including having the capability to interpret EP tracings, interrogate devices, and assist with all equipment in the laboratory. Our physicians and nursing staff are very engaged with the new staff members. We have weekly staff meetings to discuss the upcoming cases and discuss case-specific questions. The physicians make it a point to take time on a regular basis to discuss cases and difficult EP concepts. Ideally, all nurses will eventually take and pass the IBHRE exam for allied professionals. What types of continuing education opportunities are provided to staff members? Our physicians are our best resource. They take the time to explain and answer any of the staff’s questions. We are also privileged to have vendors who share their knowledge with us. We take advantage of the specialized EP conferences offered by Order and Disorder in the Cardiac Rhythm EP training programs (www.orderanddisorder.com) as well as courses offered by St. Jude Medical for basic EP, reading electrograms and training with the EnSite Velocity mapping system. We also send at least 2-4 staff members to the annual Heart Rhythm Society scientific sessions as our budget allows. How do you prevent staff burnout? Our lab is not required to take call, and we are not open on weekends. We have self scheduling within the lab, which is a real crowd pleaser. The staff works four days a week, so if someone has a long day, the other days are usually within the scheduled 10-11 hours. Our employee turnover rate is very low. How do you handle vendor visits to your department? Do you contract with vendors? Vendors are required to participate in REPtrax (www.reptrax.com), a vendor credentialing system. Our hospital has several vendor stations for them to sign in and receive their badge for the day. Regular vendors also receive, through security, vendor badges for access to the EP lab and OR. They also must introduce themselves to the patient as an industry representative who will be in the lab during the case. We contract with the three major vendors (Medtronic, St. Jude Medical, and Boston Scientific), but have no set implant quotas per vendor. Describe a particularly memorable or bizarre case that has come through your EP lab. What lessons did you learn from it? We recently had a case of a young woman who suffered a cardiac arrest. Her husband performed CPR, and EMS successfully defibrillated her from ventricular fibrillation. She was brought to Hartford Hospital and was placed into our hypothermia protocol. She recovered full mental function and underwent diagnostic testing — all of which was completely unremarkable. Diagnostic EP study was unremarkable, and she underwent ICD implant. Afterwards she was noted to have multiple runs of polymorphic VT that were initiated with the same narrow ventricular premature complex (VPC), which we felt was emanating from the left-sided fascicular system. She received ICD shocks for this VT, and antiarrhythmic medications were ineffective in preventing these occurrences. An EP study was performed, and the VPCs were mapped to the left posterior fascicular system using Biosense Webster Inc.’s Carto mapping system. Ablation was performed in this region, eliminating all VPCs. She is two months post-procedure and has had no further episodes of VT. Does your lab use a third party for reprocessing? Yes we utilize a third party for reprocessing. This has resulted in significant cost savings. The catheters are sterilized three times, then disposed. Approximately what percentage of your ablation procedures are done with cryo? What percentage is done with radiofrequency? Most of our cases are done with radiofrequency ablation. Cryo is only used in very selected cases (i.e., accessory pathways or atrial tachycardias close to the normal electrical conduction system). Do you perform only adult EP procedures or do you also do pediatric cases? Is there cross training for pediatric cases? At present we only perform cases on adult patients, although we will occasionally perform ablations on teenage patients of adult size. What measures has your lab taken to minimize radiation exposure to physicians and staff? We routinely monitor radiation exposure with badges that are changed monthly. We use pulsed fluoro and low frame rates for most imaging to minimize radiation. For very long cases, we are careful to keep the fluoroscope in the same angulation for the entire case to avoid radiation burns. We hope using Hansen Medical’s Sensei robot during more cases will also help in reducing radiation exposure to both staff and patients. Do your nurses participate in the follow up of pacemakers and ICDs? Our EP nurses do not participate in the follow up of devices. The Arrhythmia Service is responsible for device follow-up. The three Arrhythmia Service nurses oversee all device evaluations and post-op evaluations within the inpatient arena. We are fortunate to have Danette Guertin, APRN, IBHRE, who has 10 years experience with ICDs; she is the ICD coordinator for our ICD clinics. Danette is joined by Thea Ling, RN, David McComas, RN, and Diane Marci, technician, in the ICD clinic. Our ICD clinic population is about 1,300 patients. We also have an arrhythmia technician with 40 years of experience, Deb Lonkoski, as well as technician, Angela Pastorelli and our pacemaker clinician, Mark Salamacha, RN, IBHRE, to follow our pacemaker population. This staff travels to five satellite clinics in the Greater Hartford area along with our cardiology clinics here on campus to provide ICD and pacemaker evaluations. One of our electrophysiologists are present at all patient clinics. We utilize the Paceart® System (Medtronic, Minneapolis, MN) for our pacemaker database. We also have our own ICD database based off of Microsoft Access that was developed by Danette Guertin, APRN and Dr. Jeffrey Kluger. What are some of the dominant trends you see emerging in the practice of electrophysiology? How is your lab preparing for these future changes? We feel that there are two major trends — more atrial fibrillation ablation procedures and more CRT device implants. We are preparing for these with our recent purchase of Hansen Medical’s Sensei robot to hopefully eventually improve our outcomes and reduce our procedure times, and we are expanding with another laboratory to handle the increase in volume. What are your thoughts about non-EPs implanting ICDs? Do you train such individuals? Given the complexity of ICDs, we strictly believe that only electrophysiologists should implant, program, and follow ICDs. We do not train individuals to implant ICDs. What about device recalls? How has your lab handled these? We analyze each recall independently and determine the risks to our patients. We utilize our ICD database as well as lists of patients from the manufacturers to determine which patients are affected. We also will typically inform patients of the recall with a letter and follow up any concerns by phone or with in-office visits. We carefully weigh the risks of explant and re-implant with the known risks of the recall. Is your lab doing transtelephonic device follow-up? The Arrhythmia Service staff is responsible for all device follow-ups. All ICDs presently implanted are wireless, and we encourage all patients to utilize their remote follow-up capabilities. We have also started to implant St. Jude Medical’s wireless Accent RF pacemaker and Anthem RF (CRT pacemaker) in select patients, and are encouraging all pacemaker patients to switch over to the remote services for follow-up as well. Is your EP lab currently involved in any clinical research studies or special projects? Which ones? We are involved in the VEST/PREDICTS trial (Medtronic and NIH) to determine if a wearable external defibrillator vest in patients after a myocardial infarction with EF ≤ 35% reduces mortality and to determine a predictive algorithm for future arrhythmic events. We are also involved in the PROVIDE trial (St. Jude Medical) to evaluate two different ICD programming strategies for the occurrence of inappropriate ICD therapies in patients receiving an ICD for primary prevention indications. We were just accepted to be a site for the CABANA trial to compare antiarrhythmic drug therapy to catheter ablation for the treatment of AF. Are you ACGME-approved for EP training? What do you think about two-year EP programs? We are not ACGME-approved for EP training. Given the wealth of technology and the number of procedures an electrophysiologist is expected to be proficient in, a two-year training program seems to be almost mandatory. Does your staff provide any educational materials for patients who may have additional questions about their condition/procedure? In addition, does your hospital or lab staff have a device support group? All patients are given educational materials regarding their procedures pre-operatively. We have several forms of educational materials, including booklets we have purchased, a website, and pamphlets we have developed in-house. Angel Rentas, APRN has developed a specific information pamphlet for both ablation procedures and device implants. These pamphlets address the basic questions that we have collected from our patients over the years, including sections pertaining to “Day of Your Procedure,” “After Your Procedure,” “Important Points to Remember,” and “Discharge Instructions.” Along with our post-op device evaluations, we give the patient a packet of information including their follow-up MD and clinic appointments. ICD Coordinator Danette Guertin, APRN, IBHRE and Diane Marci, technician, have been conducting an ICD support group for 10 years. Each year we have two educational dinner meetings sponsored by device vendors, and typically invite someone to give a talk. We have also had meetings that were purely for relaxing, including entertainment with a band and comedian. Give an example of a difficult problem or challenge your lab has faced. How it was addressed? A competing EP lab in our city was in need of EP nurses. One of our nurses was going to leave to go there — principally for a higher salary. Given the need to keep a well-trained team together, we looked at all of the nurses’ salaries to be sure they were in line with surrounding rates. We were able to give all of the nurses a raise as well as keep the nurse who had initially planned on leaving. Describe your city or general regional area. How does it differ from the rest of the U.S.? Hartford Hospital, founded in 1854, is one of the largest teaching hospitals and tertiary care centers in New England, and has been training physicians for nearly 130 years. It is a member of Hartford Healthcare Corporation, a large, diversified health care system. The hospital is an 867-bed regional referral center. The hospital’s active medical staff includes more than 900 physicians and dentists within 17 departments. In 2006, the hospital had over 39,200 discharges and 80,000 emergency department visits. It delivered close to 4,000 babies that year. The hospital has been a “Top 100” hospital multiple times, and was the only one in Connecticut to be named one of the country’s “Top 50” hospitals and a “Top 10” hospital for cardiovascular surgery in a survey published by the AARP. Major centers of clinical excellence include cardiology, oncology, emergency services and trauma, mental health, women’s health, orthopedics, bloodless surgery and advanced organ transplantation. Hartford Hospital owns and operates the state’s only air ambulance system, LIFE STAR. Please tell our readers what you consider unique or innovative about your EP lab and staff. Our staff and physicians are a superb team who all work very well together for the goal of providing top quality, cutting-edge electrophysiology care to our patients. They exhibit dedication and a willingness to go the extra mile in order to achieve exemplary outcomes and patient satisfaction. Each member of our team is constantly looking for ways to grow professionally and personally, and bring back the knowledge to share with the group. We are also fortunate to have the latest in technology to provide our patients with the best electrophysiology care possible. For more information, please visit: http://harthosp.org/