Spotlight Interview: Holy Cross Hospital

Armando Dorta, BSN, RN, Assistant Nurse Manager,
Electrophysiology Laboratory, and Rishi Anand, MD,
Medical Director, EP Laboratory
Fort Lauderdale, Florida

Armando Dorta, BSN, RN, Assistant Nurse Manager,
Electrophysiology Laboratory, and Rishi Anand, MD,
Medical Director, EP Laboratory
Fort Lauderdale, Florida

Describe your city or general regional area. How does it differ from the rest of the U.S.?

Situated in sunny South Florida, Holy Cross Hospital serves a broad range of patients. Our patient volume has a distinct seasonal ebb and flow, with patients from the northeast corridor of the United States and Canada affectionately referred to as “snowbirds.”  We care for many local area residents and are now starting to see patients from Puerto Rico, Latin America and the Caribbean.

Please tell our readers what you consider unique or innovative about your EP lab and staff.

Cross-trained staff with skill sets in both interventional cardiology and electrophysiology provide for stronger, more well-rounded employees.

Oftentimes the electrophysiologists will find themselves relying on innovative and creative solutions in the arena of device implantation techniques with scrub technicians who have knowledge in interventional cardiology. For the well-versed scrub technician, the knowledge and experience they have with various angioplasty wires is useful in the arena of left ventricular lead delivery.

When was the EP lab started at your institution? What types of procedures are performed at your facility? Approximately how many are performed each year?

The EP laboratory was started in the early 1990s under the supervision of Dr. Richard Luceri. Today, we perform approximately 400 device-related implants annually and approximately 200 ablation procedures annually. Lead extractions are performed in our cardiothoracic surgery suites by our cardiothoracic surgeons.  

What is the primary goal of your program?

We are a full-service electrophysiology laboratory, providing comprehensive ablation services for patients suffering from supraventricular tachycardia, atrial fibrillation, typical and atypical atrial flutter, or ventricular tachycardia. We utilize both radiofrequency ablation equipment and cryocatheters. We are investigating utilizing cryoballoon technology in our laboratory. We perform all standard device implantations such as pacemakers, implantable cardiac defibrillators, biventricular defibrillators, loop monitors and device extractions. We are proud of the fact that our device extractions are performed in an operating room environment by well-trained cardiothoracic surgeons who have mastered the art of extraction and are well trained to handle any potential complications. We are currently building infrastructure that will allow us to perform Impella-supported (ABIOMED, Danvers, MA) ventricular tachycardia ablations, as well as hybrid atrial fibrillation ablations. We have also continued the tradition of being involved in community-based research protocols in partnership with Massachusetts General Hospital and St. Elizabeth’s Medical Center in Boston.

What new equipment, devices and/or products have been introduced in your lab lately?

The lab features the Philips Allura Xper FD10 fluoroscopy system and EP cockpit (Philips Medical, Bothell, WA). One of my main interests was to reduce radiation exposure to not only the patient but to the staff and physician, so it was important to have the right fluoroscopy equipment in the lab. The Philips product allows us to utilize low frames per second while maintaining image quality. We have also been thrilled with being able to organize all of our third-party vendor equipment on an equipment rack, which organizes the clutter that is typical of many EP labs.

We are excited about the rotational angiography that is part of the Philips fluoroscopy equipment. In our lab, we’re starting to get involved with research protocols utilizing some of this technology, evaluating how we can use it to advance our ablation work, particularly in the arena of atrial fibrillation ablation. We’re trying to find new ways to use the technology that is available in EP to speed up our work, reduce radiation exposure, and improve patient outcomes. Practically, I don’t think it would be a stretch of the imagination to see rotational angiography replace pre-procedural CT scans prior to an atrial fibrillation ablation. The benefit to the patient would be less radiation exposure. The trick is to work a new technology into one’s workflow process in an efficient manner that is not disruptive.

What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab?

We operate two full-time dedicated electrophysiology suites with an anteroom for visiting guests/physicians. We have one other catheterization room, which can act as a swing room for device implants in the event that both electrophysiology suites are occupied. There is a total of six core staff members in the EP lab. This does not include various members of the Admitting Recovery Unit (ARU) as well as the Heart Lab, who are cross trained to assist in various procedures as needed. The core staff includes nurses and technicians. Staff members are Mary Cortes, RCVT, Jorge Molina, RCIS, RCES, FACC (Lead Technician), Ann Nobles, BSN, RN, Yvonne Haggerty, ADN, RN, CCVN, Tracey Travis, ADN, RN, Armando Dorta, BSN, RN (assistant nurse manager), Regina Banks-Harrington, RN, MBA (nurse manager, Heart & Vascular services), and Thomas Nicosia, FACHE (Executive Director, Jim Moran Heart and Vascular Center).

Who manages your EP lab?

Our dedicated lead technician, Jorge Molina, assistant nurse manager, Armando Dorta, RN, and nurse manager, Regina Banks-Harrington, RN, are responsible for the cardiac vascular service line of the hospital. Together they have over 24 years of experience in both interventional cardiology and electrophysiology. Like many EP labs, we are constantly looking to add to our core members. However, the skill sets required to work in an EP lab are unique and require many years of on-the-job training. Because of this, we are developing an education program to develop knowledgeable and proficient staff members and new employees. The program will also address other areas of the hospital that care for patients who go through procedures in the EP lab.

Are employees cross trained? Do you have cross training inside the EP lab?

The EP lab, ARU and cath lab all have their own individual employees. So while the EP lab has been separate since inception, the management uses a team approach to appropriately staff the EP labs as well as the cath lab and ARU. Maintaining an appropriate skill mix to ensure patient safety and staff competency is a daily balancing act performed by management. Many members are cross trained to alleviate any staffing issues. The staffing assignments are addressed in a management huddle performed daily and as needed.

Administration is committed to providing our patients with the highest level of care through the utilization of new technology. Training is necessary to ensure that all members, including new ones, are familiar with all procedures and how they are performed. Cross training in various positions and utilization of new equipment is a constant.

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

After careful analysis of the inventory management process, several changes were made to improve utilization efficiency. The EP labs were reorganized to improve efficiency and awareness of supplies needed. A revision to the daily room assignment was made to include emergency equipment and to ensure that the labs are fully stocked. A standardized order form was established to track inventory and improve the purchasing process. The management team is responsible for the purchase of capital equipment and supervision of daily inventory purchases. We strive to ensure that items on consignment to our lab do not sit on shelves unutilized, leading to wasteful inventory handling.

Who handles your procedure scheduling? Do they use particular software?

Scheduling of cases is currently performed by the charge nurse in the ARU, utilizing MEDITECH software.

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

As with any facility, we participate in POC (Point of Care) Quality Controls for Accu-Cheks and ACTs.

What measures has your EP lab implemented in order to cut or contain costs?

Various measures have been used to reduce expenditure, such as reviewing the inventory process, streamlining the products utilized during procedures, and utilizing reprocessed catheters whenever possible. Because we are part of a larger network of hospitals, our parent organization negotiates on our behalf for better equipment pricing.

How are new employees oriented and trained at your facility?

All employees attend a one-day hospital orientation and nurses attend a two-day nursing orientation. Once they have completed the hospital requirements, they are released to their respective departments. The assistant nurse manager then meets with them and provides them with an orientation packet. The packet contains an initial self-assessment skills checklist. They are then assigned to a preceptor to allow for individually tailored training. At the completion of the preceptorship, their skill sets are reevaluated and areas of strength are noted, and weaknesses are improved upon through education.

What types of continuing education opportunities are provided to staff members?

All members attend in-house in-services provided during work hours when available. Members are strongly encouraged to attend the educational events and conferences in the community provided by vendors for all local area hospital employees. Holy Cross also has an annual cardiovascular symposium that is open for all hospital employees. The annual Heart Rhythm Society conference is made available for employees to attend on a rotating basis.

How has new ep technology changed the way you perform procedures?

We utilize the Philips Allura Xper FD10 system that allows for rotational angiography (3DATG) to be acquired at the time of an atrial fibrillation procedure. Those who utilize this new technology are able to register a real-time left atrial volume onto traditional fluoroscopy images. This allows one to “see” on fluoroscopy as well as traditional 3D mapping techniques where the catheter is in relation to anatomic landmarks. The net result is avoiding a pre-procedural CT scan, which has a higher radiation dose exposure to the patient (on average, 13 mSv vs. 2 mSv for 3DATG). 

How do you prevent staff burnout?

The use of flexible per diem staff allows for the decrease or prevention of staff burnout. Proper scheduling of cases can reduce the length of hours that a staff member is expected to spend in the lab.

What committees, if any, are staff members asked to serve on in your lab?

At Holy Cross Hospital, the nursing staff participates in a clinical ladder for their level of professionalism and participation. Some examples of the committees are a healthy work environment/synergy council and the unit-based patient care councils, which aim to improve intradepartmental teamwork and foster cross training.

How do you handle vendor visits to your department? Do you contract with vendors?

The hospital is installing a new security system for vendor tracking. All vendors are asked to arrange for an appointment prior to arriving for a meeting with staff or management. As a member of a purchasing group, we contract with vendors for device implants and for purchasing of products.

Give an example of a difficult problem or challenge your lab has faced. How it was addressed?

The EP labs underwent complete renovations, which included the addition of new equipment. Six months later, flooding damage was sustained due to construction occurring directly above the EP lab. The primary EP lab, which was stocked with the new equipment, was damaged and not available until repairs were completed and appropriate safety inspections passed. The management team was quick to respond. One of the Heart Labs was made into a swing room for implants and cardiac cath procedures. Scheduling became a challenge due to the obvious loss of equipment. Frequent meetings occurred with administration, risk management, and various vendors, with whom equipment and product loss assessment had to be performed. The staff, physicians and management were challenged to provide the services in the interim. The lab was down for approximately 4.5 months.

Tell us about your experience using a third party for reprocessing.

We do utilize a third party company for the reprocessing of certain catheters in the EP lab. The cost savings are significant with regards to certain devices. We are well aware of the importance of providing physicians the tools needed to perform their procedures, so we have to work together in matters of cost containment.

How does your lab handle call time for staff members? How often is each staff member on call?

Our EP lab is open Monday through Friday, so staff is not required to be on call. However, many of the staff take call for the Heart Lab after their daily assignments are complete.

What measures has your lab taken to minimize radiation exposure to physicians and staff?

All staff members are provided and use lead-lined protective wear, shields and glasses. All members wear dosimeter badges for monitoring of radiation exposure on a monthly basis. Utilization of 3D mapping systems assists with the reduction of radiation.

Do you perform only adult EP procedures or do you also do pediatric cases? Is there cross training for pediatric cases?

We do not routinely provide services for pediatric patients. We have a relationship with a local children’s hospital, with a dedicated pediatric electrophysiologist there. The only exception includes teenagers who have reached adult size/weight, who can safely undergo an EP procedure. An example involves an 18-year-old male who was discovered to have Wolff-Parkinson-White syndrome and underwent successful ablation as a prerequisite to enter firefighter academy training. 

Is your lab doing web-based/transtelephonic device follow-up?

Our EP staff does not perform follow-up care on patients receiving device implantation. This function is handled through a cardiologist’s or electrophysiologist’s office practice.

Are you ACGME-approved for EP training? What do you think about two-year EP programs?

We are not an ACGME-approved EP training facility. We fully agree that electrophysiology requires at least two years of training, whether accomplished in a traditional 3 + 2 method (i.e., 3 years of general cardiology plus 2 years of electrophysiology) or an accelerated 2 + 2 program (i.e., 2 years of general cardiology plus 2 years of electrophysiology, in which the final year of a general cardiology program is dedicated to electrophysiology training).

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 for pacemaker or ICD patients?

Our staff are very knowledgeable regarding the procedures our patients undergo. Frequently, our staff is there to provide comfort and reassurance prior to wheeling the patient into the EP lab. Knowledgeable staff can instill a sense of confidence and ease tense patients, enabling the patient to feel more confident about the organization they have chosen for their electrophysiology care. All patients undergoing a procedure are given detailed written discharge instructions upon procedure completion.

Have you developed a referral base?

Our EP lab serves all community electrophysiologists, and occasionally, cardiothoracic surgeons. We have built our referral base through educational activities, television/print advertising, online marketing, and of course, word of mouth. At the end of the day, there is no substitute for referrals generated by satisfied patients.

Does your EP lab compete for patients? Has your institution formed an alliance with others in the area?

There are at least four other area hospitals in our immediate geographic area of Fort Lauderdale against whom we compete. Through networks of cardiologists and primary care physicians, we are able to maintain an active electrophysiology lab.

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 have seen a decided increase in our atrial fibrillation ablation volume and a relative decline in ICD device-based therapy. We are positioning ourselves to continue improving our skill sets and treatment of atrial fibrillation and complex arrhythmia management.

What about device recalls? How has your lab handled these?

All device recalls initially start with notification of the electrophysiologist and hospital administration. Our standard protocol is to identify which patients are affected by device recalls and to provide notification. Additionally, we remain vigilant regarding the products that are stocked in the EP laboratory to ensure that there have been no FDA advisories adversely impacting inventory.

Is your EP lab currently involved in any clinical research studies or special projects? Which ones?

Holy Cross Hospital recently restructured the Jim Moran Heart and Vascular Research Institute, which receives support from JM Family Enterprises, Inc. It is through this institute that I am able to participate in the research process. We were the first in South Florida to participate in the ALERTS trial, a clinical device investigational trial of the AngelMed Guardian System. The trial is designed to test the device’s ability to detect the early onset of an acute MI in at-risk patients, which can alert the patient through an audible and vibratory signal to either see the doctor or go to the emergency room. We were able to bring this technology to Fort Lauderdale because we had a research infrastructure as part of our institution. Once we demonstrated we could adequately enroll patients and collect data in an appropriate and diligent manner, this led to other opportunities.

Another trial we concluded is the ASSESS-AF trial, which is a national trial run by Dr. Andrea Natale and Dr. James Edgerton, looking at implantable loop recorders for the monitoring of atrial fibrillation burden pre- and post-AF ablation.

We are currently engaged in a randomized comparison of rotational angiography/electroanatomical mapping fusion versus CT/electroanatomical mapping fusion to guide atrial fibrillation ablation.

Finally, we recently enrolled as a study site for two different NHLBI-sponsored trials, the BRIDGE and PROMISE trials.