Spotlight Interview: London Health Sciences Centre

What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab? The Ivey Heart Centre is an advanced cardiac care centre managed by London Health Sciences Centre, an academic health sciences centre affiliated with the University of Western Ontario and the Lawson Health Research Institute. It operates six cardiac labs, including a dedicated Electrophysiology Lab and a dedicated Device Implant Lab. Supporting patient care is ongoing research activity into the treatment of arrhythmias. Research physicians and staff are located within the space of the Arrhythmia Service and in an adjacent building known as The Centre for Canadian Surgical Technologies and Advanced Robotics (CSTAR), a collaborative research program of the hospital, university and research institute. The Arrhythmia Services team consists of 45 people, including research staff. Specific to the Electrophysiology Lab, the team is comprised of: Five Electrophysiologists Five Fellows in Electrophysiology Three Registered Nurses One Registered Cardiovascular Technologist All RN staff bring work experiences in critical care nursing, including an inpatient unit specializing in arrhythmia management. They have received additional training to administer conscious sedation in the absence of anesthesia. Their nursing expertise in arrhythmia is in excess of 30 years when combined. When was the EP lab started at your institution? The Electrophysiology Lab was established in 1980 through the efforts of Dr. George Klein and Dr. Gerard Guiraudon. The lab's purpose from its inception was diagnosing and mapping of arrhythmias. Patients were then taken to the operating room for surgical repair of conditions such as WPW. Implantation of pacemakers occurred in the lab until 1999 when a separate Device Implant Lab was established. Please tell our readers what you consider unique or innovative about your EP lab and staff. The unique feature of our Electrophysiology Lab at London Health Sciences Centre is the ability to truly function as a team. We have the availability of five physicians, four to five fellows, three registered nurses and one registered cardiovascular technologist during any case. Opinions are actively solicited and valued, since the sole purpose of the lab is the well-being of the patient. Our philosophy is Egos are checked at the door. What types of procedures are performed at your facility? As of the current fiscal year, we anticipate performing 500 electrophysiology diagnostic studies and 420 ablations using the newest technology, such as CARTO and cryotherapy. The cases range from AV node ablations to multiple pulmonary vein ablations for symptomatic atrial fibrillation. Approximately how many are performed each week? What complications do you find during these procedures? The Electrophysiology Lab performs 10 - 14 procedures each week. The rate of complications in our lab is less than 1% of all cases. They range from simple pneumothorax to cardiac tamponade. In the previous year, there were no significant complications despite a more complex patient population receiving treatment. Who manages your EP lab? Dr. Allan Skanes, MD, FRCP is the Medical Director of the Electrophysiology Lab. His encouragement, support and humor are the reasons why we have a successful and positive working environment. Elizabeth Martin has recently joined the lab as the Manager of Arrhythmia & Specialty Services. Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained? The Arrhythmia Service has been separate from the Cardiac Catheterization Labs since its inception in 1980. Until 1999, the Electrophysiology Lab and the Device Implant Lab were combined. They are now two distinct labs; however, as need requires, they assist each other with cases. An outcome of operating separate labs is the high degree of specialization and expertise among the staff. Since 2004, the Arrhythmia Service has been located in a dedicated wing of the hospital where all arrhythmia procedures (i.e., device follow-up, device implant, and electrophysiology) are performed. What new equipment, devices and/or products have been introduced at your lab lately? How has this changed the way you perform those procedures? With the development of the new Electrophysiology Lab, the first GE Innova Flat Panel Fluoro system in Canada was installed in 2004. Our lab was the first in Canada and one of the first sites worldwide to use CARTOMERGE technology. Similarly, we were among the first to use Quickstar mapping techniques and were a beta site for CARTOSYNC. The complex software has been a great benefit to the physicians and patients in that x-ray exposure time has been reduced. It also allows us to perform more complex cases efficiently and safely. We continue to be a beta testing site for new technologies, including Prucka and Biosense Webster catheters. To advance our electrophysiology practice, we are constantly attempting to perfect techniques and technology. For example, our institution assisted in the development of and implanted the first Medtronic 7215 Programmable Cardioverter Defibrillator and Implantable Loop Recorder. Who handles your procedure scheduling? Do you use particular software? How do you handle physician timeliness? A centralized booking system exists for patient referrals to the Arrhythmia Service. A designated physician determines the complexity of the case, as well as the resource and time requirements. The information is used to code the cases green, orange, red, and double red, with green being a basic electrophysiology study and double red being a pulmonary vein or WPW re-do. Cases are then slotted into a computer-based scheduling system as dates are available in the lab. Patients are not allocated to specific physicians, as a team approach is taken by the physician group. Recognizing that processes and structures can be improved, we are currently in the process of reviewing our patient referral and scheduling practice and are anticipating changes. With five electrophysiologists and five experienced fellows, the physicians are able to fulfill their academic and administrative duties while maintaining a full-service arrhythmia service. What type of quality control/ quality assurance measures are practiced in your EP lab? As mentioned above, processes and structures supporting patient care are reviewed on a regular basis. Quality control is maintained through routine maintenance and daily checks of X-ray and anesthesia equipment and computer systems. In addition, nurses and registered technologists in the lab are required to maintain current registration with the appropriate regulatory college. How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? All registered nurses in the Electrophysiology Lab are authorized to purchase supplies; however, the primary responsibility for maintaining stock and ordering rests with one nurse. Capital equipment, bulk purchase items, and equipment repairs are the responsibility of the manager. Inventory is currently held on-site; however, we are investigating a just-in-time delivery service due to space constraints. Has your EP lab recently expanded in size and patient volume, or will it be in the near future? In December 2004, the Electrophysiology Lab was relocated into a state-of-the-art facility within a new wing of the hospital dedicated to Arrhythmia Services. The move was required due to increased volumes and change of patient practice. Prior to the move, patients were prepared for procedures by the Operating Room staff and recovered on the floor. Today patients are prepared for procedures by arrhythmia nursing staff and are often discharged later the same day. Only complex cases, such as pulmonary veins, are monitored overnight in a Short Stay Unit shared with other cardiology services. How has managed care affected your EP lab and the care it provides patients? This does not apply to the Canadian medical model of patient care. Patients requiring treatment are guaranteed access to care if they meet the residency requirements of Canada. Patients from other countries are treated on a cost-recovery basis. What measures has your EP lab implemented in order to cut or contain costs? The hospital is a member of a national bulk-purchasing consortium that secures best price for commonly used materials. The management team takes advantage of offers provided by vendors of new technology, as appropriate. Recently, a new tendering process for implantable devices has been implemented resulting in savings for the hospital. Does your EP lab compete for patients? Has your institution formed an alliance with others in the area? The Electrophysiology Lab provides a comprehensive service for arrhythmia patients in Canada. Our primary catchment area is southwestern Ontario; however, through alliances with hospitals in underserviced areas in northern Ontario, we do provide direct patient care in their clinics on a regular basis. This expedites the referral-to-treatment time, as patients have been identified as suitable for treatment at our centre. A significant portion of our patient referrals originate in other advanced cardiac centers in Ontario and western Canada. What procedures do you perform on an outpatient basis? All procedures performed in the Electrophysiology Lab are either outpatient or require admission to the hospital for less than 24 hours. Prior to treatment, patients are reviewed in an EP Pre-Admit Clinic by the Nurse Practitioner, who takes the opportunity to provide patient teaching and identify potential outcomes. How are new employees oriented and trained at your facility? Staff turnover in the Electrophysiology Lab is historically low. For example, one of the nurses has worked in the lab since 1982. She joined the lab two years after its inception and remains a key member of the team. When new staff members join the team, they participate in on-the-job-training and educational seminars with daily supervision by the attending electrophysiologist and existing staff. Recently we were asked to provide training for another advanced cardiac center's registered cardiovascular technologist using this model of training. What types of continuing education opportunities are provided to staff members? Staff are encouraged to attend conferences, workshops, symposia, and vendor in-services pertaining to arrhythmia within and external to the hospital setting. Members of the Electrophysiology Lab belong to the Heart Rhythm Society, which provides professional development opportunities and research information. How is staff competency evaluated? Staff competencies are evaluated on a daily basis by the electrophysiologists and other staff members. This is supplemented by regular peer reviews of the registered nurses and technologist. All staff belong to regulatory colleges that establish minimum competency requirements and regulate the performance of delegated acts. How do you handle vendor visits to your department? Vendors will schedule visits to the Electrophysiology Lab in advance, in order to demonstrate new products and techniques. If staff recognize that a particular case may be of interest to a vendor, they will issue an invitation to observe. In the latter instance, the Medical Director of the Electrophysiology Lab would be in agreement with the invitation. 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? The Electrophysiology Lab operates five days a week beginning at 7 am, often finishing at 6 pm. As the lab does not close until the day's allotted cases are completed, there is no formal on-call schedule provided for the service. In the event of an emergent case, the existing staff would be notified and requested to return to the hospital to provide care for the patient. Over the past eight months, there have only been two occasions when staff have been requested to return. Approximately what percentage of your ablation procedures are done with cryo? What percentage is done with radiofrequency? The Electrophysiology Lab does a mix of both radiofrequency ablation (90 - 95%) as well as cryoablation (5 - 10%). Do you perform only adult EP procedures or do you also do pediatric cases? Is there cross training for pediatric cases? The vast majority of procedures performed in the Electrophysiology Lab are on adult patients. Due to the shortage of pediatric anesthesiologists at our institution, children under the age of 12 years of age are sent to The Hospital for Sick Children (Toronto), a tertiary centre. Older pediatric patients are treated in our program if they meet specific height and weight requirements. All pediatric cases are completed in collaboration with the hospital's pediatric program. What trends do you see emerging in the practice of electrophysiology? We are committed to being at the cutting edge of image integration in the Electrophysiology Lab. In the future, most ablation will be performed in a virtual environment using remote access. Is your EP lab currently involved in any clinical research studies or special projects? The electrophysiologists are involved with several clinical trials as both primary investigators or in conjunction with multi-centered trials. The Arrhythmia Service employs six full-time research coordinators who are responsible for continuing trials in new device technology, new ablation technology, and innovative techniques. One project currently underway is the development of a hybrid approach to the treatment of atrial fibrillation using interventional cardiology non-operative therapies and robotic minimally invasive surgery techniques. Does your lab undergo a JCAHO inspection? In Canada, we are accredited by the Canadian Council on Health Services Accreditation. The mandate of CCHSA is to examine all aspects of the hospital's clinical programs and services in order to identify areas for improvement, particularly as they relate to patient outcomes. A review completed in November 2005 indicated that the institution is performing above national average for the various indicators. 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? Education and support is provided to patients in multiple formats. Patients presenting in the EP Pre-Admit Clinic are shown a video on their specific procedure prior to assessment by the Nurse Practitioner. The NP often uses this opportunity to answer questions or concerns a patient or their family may have about the procedure. Written material is given to the patient at this time. Information on specific arrhythmia conditions is available on a website maintained by the electrophysiologists. It can be accessed through the website for the London Cardiac Institute (www.londoncardiac.ca). On the day the patient presents to hospital, any final questions or concerns can be addressed by the nurse or electrophysiologist while the patient is being prepared for the procedure. Under development by the Arrhythmia Service is patient education material in DVD format. It will be given to patients and their families at the time of consultation. The first module will focus on electrophysiology studies. Future modules will include device implantation, tilt testing, and drug infusion studies.