Spotlight Interview: Hillcrest Medical Center

David A. Sandler, MD, FACC, Director of Electrophysiology, Tulsa, Oklahoma

David A. Sandler, MD, FACC, Director of Electrophysiology, Tulsa, Oklahoma

 What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab? The dedicated EP lab at Hillcrest Medical Center is one of three cath lab rooms. We have two electrophysiologists (Dr. David Sandler and Dr. Craig Cameron) and two mid-level providers. We are blessed with three nurses and three radiology technologists trained in EP. When was the EP lab started at your institution? In 1991, Hillcrest Medical Center opened a dedicated EP lab. Prior to that, basic EP studies were performed in the cath lab beginning in 1986. What types of procedures are performed at your facility? We perform full-service EP, from device implants (pacers, ICDs and BiVs) to ablations (including AF and VT) to laser lead extractions. We pride ourselves on performing complex ablations, including ablations failed elsewhere. We consider ourselves tenacious and creative during LV lead delivery, and will often attempt previously unsuccessful biventricular ICD implants. What is the primary goal of your program (AF ablations, lead extractions, BiVs, etc.)? Like many labs, we have been doing more and more AF ablation. Approximately how many are performed each week? What complications do you find during these procedures? We perform at least two complex ablations weekly. We have been fortunate not to have suffered a significant complication from AF ablation to this point. We attribute our low complication rate on vigilance in avoiding inadvertent arterial puncture during access and avoiding air bubbles in our tubing. We reduce power when ablating on the posterior left atrium while watching for temperature rise with an esophageal probe. Who manages your EP lab? David Sandler, MD is the Director of Electrophysiology. Gail Kelly, RDCS, RVT, BBA is the manager for CV Diagnostic Services; she is responsible for staffing and budget. The EP technical staff handles stocking and reordering of disposable equipment. Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained? All EP techs are cross-trained to scrub and X-ray in the cath lab. Most of the EP nurses function in triple roles. Do you have cross training inside the EP lab? What are the regulations in your state? Lawanda Dunn, RN functions as a nurse (with sedation privileging), scrub tech and EP technician during ablations. What new equipment, devices and/or products have been introduced at your lab lately? How has this changed the way you perform those procedures? We obtained CartoMerge (Biosense Webster Inc., a Johnson & Johnson company, Diamond Bar, California) last year, which has greatly improved navigation accuracy during complex ablation. We have also tackled many complex ablations that we would have treated medically (or referred) in the past. We also hope to add magnetic navigation in the near future. Who handles your procedure scheduling? Do you use particular software? The office schedules and books cases using our EMR (GEMMS), and coordinates with the hospital staff. The procedures are also entered into Outlook, allowing for instantaneous updating of the physicians’ smartphones. What type of quality control/quality assurance measures are practiced in your EP lab? We have automatic triggers for chart review (e.g., tamponade, respiratory arrest, device infection or lead revision within 30 days). Ruth Wilson, RN is responsible for quality review and presents all cases for monthly review.   How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? Stephanie Schuessler, RT is our EP tech responsible for all inventory management. Has your EP lab recently expanded in size and patient volume, or will it be in the near future? We recently hired our second EP (Dr. Craig Cameron) and expect the case load to continue to grow. We will be moving to a brand new, state-of-the-art Heart Pavilion with two dedicated EP labs (and a shell for a third). Have you developed a referral base? Our physicians spend a great deal of time meeting with local general cardiologists and primary care physicians to keep them up to date on current indications for device implantation and ablation. We will be hosting a large symposium for all local physicians to receive CME and mingle with their EPs. What measures has your EP lab implemented in order to cut or contain costs? Cost containment is predominantly based on patient need. We tailor top-tier devices to those patients who are likely to benefit from the available features (e.g., remote monitoring, algorithms to avoid RV pacing). We also use a non-binding contract with a device manufacturer for further price reductions based on percentage of business. For ablation procedures, we save costs by re-sterilizing and saving the platinum tips from the ablation catheters. In addition, in what ways have you improved efficiencies in patient through-put? Turnaround time in our lab is fantastic. This is due to motivation as well as a system process. Orders are given for IV placement in the appropriate arm the day prior to implantation, to be used in case of difficult venous access. We have a transporter and nurses to monitor patients before the case. Often, the patient will be shaved and have stickers/patches placed prior to arriving in the room. Does your EP lab compete for patients? Has your institution formed an alliance with others in the area? The Tulsa area is served by five EPs, and there is plenty of work for all of us. Although we do not have a formal alliance, some of the local EPs get together every other month to present interesting cases to the EP staff, medical students, residents and cardiology fellows. What procedures do you perform on an outpatient basis? Tilt table tests, cardioversions and generator replacements are performed on an outpatient bases. All ablations (with rare exception) and implants are admitted overnight. How are new employees oriented and trained at your facility? All employees begin their training in the cath lab. Specialty training is based on the current need and level of enthusiasm. What types of continuing education opportunities are provided to staff members? The staff is encouraged to attend weekly hospital grand rounds and quarterly Oklahoma Heart Institute meetings. Furthermore, they attend annual meetings approximately every other year. How is staff competency evaluated? We perform annual peer evaluations, including hospital and safety competencies. How do you prevent staff burnout? Our staff is a close-knit unit who spend significant time together outside of work. We joke around a lot and have fun. We also have great relationships with all of our vendors, which helps when working long hours together. In addition, having the city-wide EP meetings and being able to attend HRS really helps the staff mix business with fun. What committees, if any, are staff members asked to serve on in your lab? Although we don't have formal committees in the lab, some of the staff help with various tasks such as giving flu shots and TB tests. One of the nurses performs QA and writes policies and procedures. She also helps with JCAHO surveys. One of the RTs helps collect funds monthly from staff for flowers, cards or any other needs in the cath lab. She also helps with arranging holiday parties as well as any other occasion requiring planning. How do you handle vendor visits to your department? Do you contract with vendors? We are a very vendor-friendly lab. As mentioned before, we use all products on a consignment basis. We use all major vendors. The decision on which product is used is decided case-to-case based on patient needs. Our vendors help with our continuing education by providing in-services and by helping to arrange the city-wide EP meetings. Does your lab utilize any alternative therapies? No. Please describe one of the more interesting or bizarre cases that have come through your EP lab. We recently had a patient with dextrocardia and Tetralogy of Fallot repair present to the hospital with atypical atrial flutter. We took her to the EP lab (at 6 pm!) and mapped the circuit to a surgical scar in the lateral right atrium where successful ablation was performed. Needless to say, catheter orientation in a patient with dextrocardia can be challenging. We inverted the monitors so that an RAO view of her heart looked like a normal LAO view (and vice versa). She has done extremely well in follow-up. How does your lab handle call time for staff members? How often is each staff member on call? How frequently do they have to come in, on average? Is there a particular mix of credentials needed for each call team? Doctors are able to schedule as many cases as they need to, but if they don't add-on before 4:30 pm, the staff will go home. Usually cases run until 5 to 7 pm. If there are no cases scheduled in EP, the staff usually will work in the cath lab or sometimes schedules off, but will be on call for add-on EP cases. The mix of call is one RN and two EP technical staff. EP call frequency varies, because the staff also has cath lab call responsibilities. Does your lab use a third party for reprocessing? Yes. We send our catheters to Ascent Healthcare Solutions. Approximately what percentage of your ablation procedures are done with cryo? What percentage is done with radiofrequency? We perform 100% RF ablations. We are looking into obtaining cryo. Do you perform only adult EP procedures or do you also do pediatric cases? Is there cross training for pediatric cases? We predominantly perform adult procedures. We will on occasion ablate a pediatric patient over 12 years old. What measures has your lab taken to minimize radiation exposure to physicians and staff? We use a sterile radiation shield (RadPad) for all procedures and have a large lead shield protecting staff seated at the EP console. 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? Follow-up is provided in the office at the Oklahoma Heart Institute. All routine pacemaker and ICD follow-ups are performed by the office. They see 150 device patients per week and make routine adjustments. Currently, we do not incorporate specialized software — we scan pages into the EMR. ICDs and pacemakers are interrogated remotely or in the device clinic every 3 to 6 months, depending on the model. We have ICD patients see an EP once a year, and anyone with device-related or arrhythmia issues see an EP (or a mid-level provider) more frequently. What trends do you see emerging in the practice of electrophysiology? How is your lab preparing for these future changes? We expect to be performing more complex ablations (AF and VT). Our new heart pavilion will have two dedicated labs (and a shell for a third) to accommodate the increased volume. What are your thoughts about non-EPs implanting ICDs? Do you train such individuals? Implanting physicians should not be judged on whether they are EPs or non-EPs. There are many cardiovascular surgeons and cardiologists who have been implanting devices with great expertise for many years. That being said, there are enough physicians currently qualified to perform device implantation that we don’t need to train more “non-EPs.” An overlooked aspect of device implantation is the decision process regarding the appropriate device. That decision can only be made by a physician immersed in this field. What about device recalls? How has your lab handled these? Each patient with a recalled device is evaluated separately. The risks of explantation or extraction are weighed against the individual’s risk. Our field has learned that carte blanche device replacement does not reduce risk. Is your lab doing web-based/transtelephonic device follow-up? Oklahoma Heart Institute provides follow-up using both in-office and home monitoring. Home monitoring is available to all of our patients through the manufacturers’ websites. Is your EP lab currently involved in any clinical research studies or special projects? Which ones? We have a tremendous research team and have been involved in numerous multi-center trials over the past few years. We were the leading implanters worldwide in the MVP Trial. We are currently enrolling in MADIT-CRT, PEGASUS CRT, BLOCK-HF and DETERMINE. We recently participated in the Sub-Q Defib Trial and the ASSURE Trial, both involving devices not yet available. When was your last inspection by the Joint Commission? We had the pleasure of a surprise visit from JCAHO in the fall of 2007. We are fully accredited. Are you ACGME-approved for EP training? What do you think about two-year EP programs? We do not have a fellowship program currently, but fellows from a local cardiology fellowship rotate with us when possible. One year of EP training is not enough in 2008. A dedicated EP year during general fellowship should be credited towards EP fellowship, though. 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? One of our office nurses, Iris Herald, is currently receiving her CNS degree and has a strong interest in patient education. She is organizing a support group for patients with atrial fibrillation and/or devices. Give an example of a difficult problem or challenge your lab has faced. How it was addressed? Hillcrest Medical Center recently attracted three cardiovascular surgeons with an interest in atrial fibrillation ablative surgery. Initially, we were concerned about the loss of referrals to our program. Fortunately, we quickly realized that a united approach would be mutually beneficial. Therefore, we have pioneered a comprehensive AF program, including speaking dinners for referrals and radio advertisements. This strategy has helped build both of our practices and has opened a dialogue to streamline better patient care. Describe your city or general regional area. How does it differ from the rest of the U.S.? Tulsa, Oklahoma is a city of almost 400,000 people. The referral population is as large as 1 million, with patients coming from Kansas, Missouri, Arkansas and Texas. Although most outsiders expect to see tumbleweed and desert, Tulsa is actually known as “Green Country” for its lush landscape. The population is composed of a mostly retired oil community and a large Native American population, whose healthcare is provided by the Indian Health Agency. Please tell our readers what you consider unique or innovative about your EP lab and staff. Hillcrest Medical Center and Oklahoma Heart Institute are unique in their approach to patient care. While working in a for-profit hospital at a time of dropping reimbursement rates, it is very easy to provide quick, mediocre care. However, we pride ourselves on taking the extra step to providing only top quality care, even if this strategy is not the most financially appealing. This includes implantation of devices with high-tech features (e.g., remote monitoring) and spending “as long as it takes” to tackle tough arrhythmias for ablation. For more information, please visit: www.hillcrest.com