Spotlight Interview: Hershey Medical Center's Penn State Heart & Vascular Institute

Stephen Artman, Ablation Specialist

Stephen Artman, Ablation Specialist

What is the size of your EP lab facility and number of staff members? When was the EP lab started at your institution? What is the mix of credentials at your lab? Presently we have 1.5 EP labs, and in February 2007 we start reconstruction on a new single-plane, flat-panel Siemens lab, which we hope to occupy by June 2007. After that lab is up and running, we will renovate our current EP lab into a larger bi-plane Siemens flat-panel laboratory. We started the EP program here at Hershey in 1985 with one electrophysiologist and two staff members. Currently we have four adult and one pediatric electrophysiologists on staff, with one more adult electrophysiologist joining us in July of this year. Our staff mix is two IBHRE (formerly NASPExAM) EP techs, one cath lab RT tech, and three nurses. We are also aggressively looking for another fully trained EP tech with IBHRE accreditation. We recently merged our cardiovascular center and vascular program into the Penn State Heart and Vascular Institute. Electrophysiology is one of the key programs in this new, unique way of integrating all of the cardiac and vascular care, including cardiologists, cardiac surgeons, vascular surgeons and interventional radiologists, and imagers. What types of procedures are performed at your facility? We have a varied mix of procedures; devices are the usual sort of pacers, ICDs, CRT-Ds, and CRT-Ps. Ablations, both in adults and children, come in all forms including AVRTs, AVNRTs, atrial tachycardia, and ischemic and idiopathic ventricular tachycardia. In the past year, there has also been a growing number of atrial fibrillation ablations. What is the primary goal of your program (AF ablations, lead extractions, BiVs, etc.)? Our goal here at Hershey is to have a very well-rounded program. We have a two-year fellowship program with two new fellows for us each year. Each one of our attendings has their special niche. We were also very lucky to have Dr. Mario Gonzalez join us in June; he has brought his atrial fibrillation expertise to us. Approximately how many are performed each week? What complications do you find during these procedures? Our mix of procedures per week is usually two pediatric ablations, two atrial fibrillation ablations, and one or two adult ablations (AVNRT, AVRT, atrial flutter, ventricular tachycardia), with the remainder of the cases being predominantly implantable devices. Who manages your EP lab? At present, I run the day-to-day activity of the EP lab. Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained? Our EP and cath labs are separate cost centers and staff. It has been this way since 1985. Of course, we are happy to cross-train staff if they are willing to take the time and energy. Do you have cross training inside the EP lab? What are the regulations in your state? We currently have a small amount of cross training in the EP lab. The techs run the stimulator, the EP recording system and the 3-D mapping system. The nurses do the sedation and patient charting. When time permits, we sit down post cases and teach intracardiac electrograms from the Bard system. What new equipment, devices and/or products have been introduced at your lab lately? How has this changed the way you perform those procedures? When Dr. Gonzalez came in June 2006, we purchased a CartoMerge (Biosense Webster, Inc., a Johnson & Johnson company, Diamond Bar, California) 3-D mapping system. We have also had the EnSite® System (St. Jude Medical, St. Paul, Minnesota) for roughly six years. Both systems have helped us immensely with our ablation practice. The CartoMerge (Biosense Webster, Inc.) is fun to segment the CT scan, then merge it to real time to help with the location of pulmonary veins and other structures during AF ablation. Who handles your procedure scheduling? Do you use particular software? We have a superb scheduling coordinator that the patients love. She and I will discuss the schedule for the future and try to make a plan that works. Soon we will also have a software program (GE Centricity) to help with scheduling. What types of quality control/quality assurance measures are practiced in your EP lab? We have a database that is incorporated with our nursing report that reports any complication or quality assurance problems. In addition, we use the ACC-NCDR® registry for following our ICD patients. How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? We share with the cath lab a store room clerk who manages our supplies. Our purchasing department will order equipment after an exhausting paper trail. Has your EP lab recently expanded in size and patient volume, or will it be in the near future? We have moved from having one tech and one nurse in 1985, to having five electrophysiologists, three techs, and three nurses in present day. In addition, in June 2007 our present EP fellow will be joining our faculty. Each year our numbers have increased, but most recently, since the advent of primary prevention ICD implantation and atrial fibrillation ablation, our numbers jumped dramatically. How has managed care affected your EP lab and the care it provides patients? We are very lucky that managed care has had minimal effect on us over the years. Have you developed a referral base? Over the years our referral base has grown, even though we are in a rural area near Harrisburg, Lancaster, and York, where each one of these towns has multiple EPs practicing. Since we are quarternary referral center and over 1.5 million people live within a one-hour drive of our medical center, there is still a large potential to grow even more, although we are surrounded by competent programs in the small cities nearby. 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 throughput? We have tried to contain cost by bulk-buying with the CRM venders. We have good contract pricing with no percentage commitment to any of the major manufacturers. We use a three-party reprocessing company for most diagnostic catheters. Does your EP lab compete for patients? Has your institution formed an alliance with others in the area? I mentioned earlier that we are surrounded by other EP practices. We have alliances with other hospitals and referring physicians. We also have outreach clinics that stretch near and far. A few of our outreach pediatric EP clinics are at least 100 miles from Hershey. What procedures do you perform on an outpatient basis? We perform most of our pediatric and adult AVNRT and AVRT ablations on an outpatient basis. Most of our patients with device replacements are outpatients. Our patients that receive new implants are called a 23-hour stay unless they have anticoagulation or drug therapy to start or restart post procedure. Our AF ablation patients may stay two to three days post ablation. How are new employees oriented and trained at your facility? Our new employees are oriented using a couple of categories. Our nurses have to be certified with SCIU and have worked in the cath lab. They also have to have training in conscious sedation before monitoring our patients in EP. In addition, I am a true stickler for sterile techniques. Many times people come into the lab and think they know sterile techniques they learned in the cath lab or another procedure lab. In my mind, though, true sterile technique has taking a back seat in many labs over the years. We are very proud not to have an infection statistic at Hershey. We start the techs out with learning devices. A new tech will learn all aspects of device implantation. We will have them watch ablations with us. If a person is truly interested and can focus for long periods of time, then they may want to learn EP. However, electrophysiology cases can be tedious, so not everyone is always willing to learn the fine art of EP. In our lab we have an attending and a fellow scrub for ablations; the tech will run the stimulator and the recording system, and oftentimes must run the 3-D mapping system as well. What types of continuing education opportunities are provided to staff members? In the Hershey area we are very fortunate to have large cities closeby, so many of the vendors have seminars in the area that are free or very reasonably priced. We also send staff whenever possible to HRS and other seminars. How is staff competency evaluated? We have yearly evaluations that critique each staff member's progress throughout the year. However, our staff is also small enough that we can see day-to-day progress and problem areas that may need to be addressed. How do you prevent staff burnout? We run a 10-hour work day, with one day off during the week this really helps with burnout. We also try and rotate roles, such as with pediatric ablation, AF ablation, devices scrubbing, and analyzing. How do you handle vendor visits to your department? Do you contract with vendors? We try and encourage anyone, as well as vendors who would like to observe an EP procedure, to come on in. We try and only have one vendor on any one case. Although we currently have contracts with three devices companies, we alternate and do not want to be committed to any one company, since each company has its strong points. Please describe one of the more interesting or bizarre cases that have come through your EP lab. One of the more interesting cases was a pediatric patient with WPW. When we started, it looked like a nice reasonably simple left-sided pathway: do a transeptal, run the catheter to the mitral valve annulus, locate the pathway with antegrade and retrograde pacing, then burn. However, the funny thing was the retrograde pathway was completely different from the antegrade. We said to ourselves No big deal, we had two separate pathways. We burned the manifested pathway first, only to find there was a second completely different antegrade pathway! After it was all said and done, there was a total of five separate pathways, one of which was a right anterior paraseptal in which we needed to use cryo. How does your lab handle call time for staff members? We are very lucky at the moment that we do not take call. Does your lab use a third party for reprocessing? We do use a third party for reprocessing; we find proper handling and packaging of used catheters can increase their life. Approximately what percentage of your ablation procedures is done with cryo? Cryoablation has been very useful as an alternative in certain patient subgroups. Our pediatric electrophysiologist Mark Cohen uses cryoablation almost exclusively for the children he ablates who have AVNRT. We also use cryoablation with paraseptal, parahisian pathways and also posterior septal pathways that may be in the coronary sinus (epicardial). Therefore, it's hard to give percentages between cryo and RF. The adult EPs rarely use cryoablation unless the pathway is close to the AV node or is in the coronary sinus. During atrial fibrillation ablations, the esophagus may be too close to a RF site, so we may also change to cryo at that time. Do your nurses/techs participate in the follow up of pacemakers and ICDs? If so, how many device visits per week do they handle? Do you use any particular software for follow up? How many of your ICD/pacemaker patients require a doctor for their visits? We are slowly moving to cross-train the pacer clinic and procedure lab. We presently use the Paceart® System (Medtronic, Minneapolis, Minnesota), and will be obtaining Guidant's LATITUDE and the Medtronic® CareLink® Network in short order. Our pacer clinic sees 50 - 70 patients a week, and out of that they may call a physician 10 - 15 times for a multitude of reasons. What trends do you see emerging in the practice of electrophysiology? How is your lab preparing for these future changes? I understand that implanting ICDs for primary prevention is going to save many lives; however, we need better discriminators for those who will have SCD. With a few recent papers that show mortality and morbidity rates with ICD implants, is it in every patient's best interest to receive an ICD? What are your thoughts about non-EPs implanting ICDs? Do you train such individuals? To implant an ICD takes skill and dexterity. Many non-EPs can learn the skill of implantation; however, implanting an ICD is only a small facet of patient care. What about programming, setting proper parameters, and administering appropriate anti-arrhythmic therapy? To me, it is continuity of care if my electrophysiologist implants the device and is there more follow-up care if needed. Therefore, we do not train non-EPs for ICD implants. What about device recalls? How has your lab handled these? In the past few years, recalled devices have been troublesome. We usually followed the vendor's recommendation on each separate recall. We notified the patients, gave them our recommendation, and let them decide. Is your EP lab currently involved in any clinical research studies or special projects? Which ones? We are in the MADIT CRT trial, and just finished enrollment in the REVERSE trial. We also participated in a study assessing a new anti-arrhythmic drug that facilitates conduction across the gap junctions. We are always participating in multiple studies involving new anti-arrhythmic drugs, atrial fibrillation, and device studies. We also started a Biosense Webster ThermoCool AF project as well as a CryoCor study. When was your last JCAHO inspection? We had our last JCAHO inspection this past summer; it went well. Are you ACGME-approved for EP training? What do you think about two-year EP programs? We are EP-ACGME approved at Hershey. We try to have at least two fellows; this may change in the near future to three fellows. A two-year program gives each fellow a well-rounded approach to all aspects of EP. Does your lab provide any educational or support programs for patients who may have additional questions or those who may be interested in support groups? We have an ICD support group that meets once a month. This is set up with our Cardiac Rehab department. Give an example of a difficult problem or challenge your lab has faced. How it was addressed? Here at Hershey Medical Center, one of our biggest problems would have to be staffing. Trying to find a fully-trained EP tech is very tough. Working for a hospital is very rewarding; however, most hospitals monetarily underestimate the worth of a fully-trained and independent EP tech. Unfortunately, private enterprise can pay more than most hospitals. We have just changed our pay scale at Hershey to be more competitive. Describe your city or general regional area. How does it differ from the rest of the U.S.? Hershey is a very interesting place to live. We consider Hershey an urban area. We are 90 miles north of Baltimore, 60 miles west of Philadelphia, 10 minutes from Harrisburg, and three hours from New York City. We are protected from large snowfalls from the west by the Appalachian Mountains. Our only large snowfalls come from Nor'easters, which are infrequent. There is fine dining, theater, and the arts surrounding our area. We have the same concerns in our area as anywhere in the U.S., such as urban sprawl, highway conditions, etc. Please tell our readers what you consider unique or innovative about your EP lab and staff. We are lucky to have pediatric EP and be able to do a lot of accessory pathway ablations. We also have wonderful attending faculty in the adult group. We all get along well together and have a fun time working. With the upbeat attitude we have, the patients feel very comfortable and secure with our staff.