What is the size of your EP lab facility? When was the EP lab started at your institution?
The electrophysiology program started when I moved to Montana from Houston in 2011. We have one EP lab. We staff cases with two x-ray technologists, who scrub and run fluoroscopy and the stimulator, and 2 registered nurses, who provide sedation and record the case.
What is the number of staff members?
Our core staff consists of three x-ray technologists and four nurses who rotate through the lab.
Approximately how many catheter ablations (for all arrhythmias) and device implants are performed each week?
We perform about three to four ablations, and five device implants per week.
Are employees cross trained?
The EP lab has been utilized for only EP procedures since its inception. Employees do rotate through the cath lab and interventional radiology for call and on non-EP days, but we try to keep staff in one main service area. The lab operates two days per week most weeks, but sometimes we add cases on additional days.
What type of hospital is your EP program a part of?
We are a non-profit community hospital serving as the main regional referral center for Northwest Montana.
What types of EP equipment is most commonly used in the lab?
We use the Philips Integra imaging system, Biosense Webster’s CartoSound mapping, a Bard amplifier and recording system, and a good, old-fashioned Bloom EP stimulator (Fischer Medical Technologies). I wanted to stick with the tactile feedback of that type of stimulator, and I prefer it over an automated computerized or touchscreen interface. We use a cryo system for most of our AF ablation cases.
How is shift coverage managed? What are typical hours (not including call time)?
Our EP techs work four 10-hour shifts, usually from 7am to 5:30pm.
Tell us what a typical day might be like in your EP lab.
Imagine the New York City Ballet going to Grand Central Terminal. It’s usually very busy, but we just go with the flow and everything is done with absolute attention to detail. Our saying is, “It’s not done until it’s just right.” It serves our patients well, and we are very proud of the work we do.
What new equipment, devices and/or products have been introduced at your lab lately?
Our lab performed the first cryoablation procedure in Montana. We were the first lab in the Northwest United States to implant the Medtronic Reveal LINQ insertable monitor, which has revolutionized our ability to longitudinally monitor arrhythmias. We partnered with our neurology colleagues to ensure that we are monitoring appropriate cryptogenic stroke patients for occult atrial fibrillation. Our lab was the first in the Northwest U.S. to implant Medtronic and St. Jude Medical quadripolar LV leads once commercially available. We’ve recently started using Biosense Webster ThermoCool SmartTouch ablation catheters for many of our RF cases.
How has this changed the way you perform those procedures?
This requires a little more setup, but the combination of knowing contact force and having an irrigated ablation system has shortened case time and provides a measure of safety.
What is your experience with MR conditional cardiac devices?
The vast majority of our new pacemaker implants are MR conditional. We weren’t sure at first how many MRIs would be necessary on these patients, but now our radiology department scans about one patient per week with an MR conditional device.
Does your program utilize a cardiovascular information system (CVIS), picture archiving system (PACS), or cardiology picture archiving system (CPACS)?
What type of quality control/assurance measures are practiced in your EP lab?
Every patient requires a checklist to be completed by a holding room nurse prior to coming to the lab. This includes a check of consents, allergies, documentation, and labs along with confirmation that appropriate pre-procedure medications and preparations have been completed.
How is inventory managed at your EP lab? What about the purchasing of equipment and supplies?
The inventory is managed automatically through the Merge system. Each item is scanned before use and reordered as needed. Our lead technologist works with our materials management coordinator to confirm accuracy.
Does your EP lab compete for patients? Has your institution formed an alliance with others in the area?
We are the only EP lab in Northwest Montana, one of four in the state. Most of our patients come to us because we are the regional medical center, but many come to us from other parts of the state or neighboring states because of our strong reputation and word-of-mouth referrals from friends and family.
How are new employees oriented and trained at your facility?
What types of continuing education opportunities are provided to staff members?
Several staff members travel to conferences such as Heart Rhythm, and all staff are encouraged to self study.
What committees, if any, are staff members asked to serve on in your lab?
All nurses serve on at least one hospital committee. The information gathered at committee meetings are shared at monthly staff meetings.
How do you handle vendor visits to your department?
Visits are scheduled with our materials management coordinator.
Does your lab utilize any alternative therapies (e.g., music, guided imagery techniques, etc.) to help patients in the EP lab?
How does your lab handle call time for staff members? For example, how often is each staff member on call, and how frequently do they have to come in, on average?
Call is one day per week and every fourth weekend. Generally they come in once or twice per weekend.
Does your lab use a third party for reprocessing or catheter recycling?
Approximately how many of your ablation procedures are done with cryo? What percentage is done with radiofrequency?
Almost all of our AF ablations are done with cryo. Occasionally we’ll use cryo for SVT, and other ablation procedures are done with RF.
We are mostly an adult lab, but occasionally we will perform ablation procedures on adolescents since the closest pediatric EP program is over 500 miles away. We have implanted a 4-year-old patient with a Reveal LINQ device.
What measures has your lab taken to reduce fluoroscopy time and minimize radiation exposure to physicians and staff?
What are your methods for infection prevention (e.g., during device implants, etc.)?
Our device infection rates are kept very low primarily thanks to meticulous preparation of the patients by the lab staff. On occasion we will use antibiotic-eluting envelopes for high-risk patients (i.e., post transplant, dialysis, etc.).
Nurses are trained to interrogate and reprogram devices. Industry representatives share in this responsibility.
What innovative EP techniques are being utilized in your lab?
We longitudinally monitor the majority of our post-AF ablation patients using insertable monitors to document outcomes. As above, we limit exposure to patients and staff by relying heavily on mapping and ultrasound.
Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) or any other outside data collection registry?
How do you use the NCDR Outcome Reports to drive QI initiatives at your facility?
We review the results quarterly and look for potential problem areas so that we can improve the quality of care we provide.
What are your thoughts on EHR systems? Does it improve your quality of care?
The strength of these systems is that the patient’s entire record is available at any time, but care must be taken to ensure that the record is accurate and that the information is clearly presented. Most EHR systems lack the ability to present information in a useful format.
I think that the use of fluoro imaging will be reduced dramatically as more labs engage in radiation reduction initiatives. EP procedures are uniquely suited to fluoro reduction because of our use of mapping systems and ability to determine location based on intracardiac signals.
How is outpatient cardiac monitoring managed?
Our pacemaker clinic has most of our device patients enrolled in remote monitoring. They have become very efficient in managing the large volumes of information that come in every day. Mostly, this has been addressed by fine tuning alert settings so that patient-specific data is sent.
Is your EP lab currently involved in clinical research studies? Which ones?
We are presently enrolling patients in the REVEAL AF study and the AdaptResponse study. We were previously involved in the MIRACLE EF study prior to its closure.
Are you ACGME-approved for EP training?
Describe your city or general regional area. How is it unique from the rest of the U.S.?
We are located in the Flathead Valley, which consists of six towns in close proximity. Our population is about 90,000, but we receive about two million visitors per year. We are fortunate to be located less than 30 minutes from the West Entrance to Glacier National Park. Flathead Lake is a glacial lake that sits at the south end of the Valley. It is the largest natural freshwater lake in the U.S. west of the Mississippi River, and it is one of the cleanest lakes in the world. The town of Whitefish, which is located at the north end of the Valley, is home to one of the country’s top-ranked ski resorts. Our hospital serves as the regional referral center for Northwest Montana; some patients travel over three hours by car for care here. Our A.L.E.R.T. air transport, started in 1975, was the nation’s first rural helicopter ambulance service.
Please tell our readers what you consider special about your EP lab and staff.
The EP program started in 2011 when I came to Kalispell from Texas Heart Institute in Houston, Texas. The staff embraced the new endeavor with complete dedication, and they quickly developed into the most efficient and capable lab I have worked in. The staff desire excellence, and they continuously seek opportunities to learn and improve. The best ideas we have implemented over the past few years have been born of staff suggestions. The lab staff members are committed to the patients and community we serve, and I am privileged to have the opportunity to work with them.