Spotlight Interview

Spotlight Interview: Memorial Hermann Heart & Vascular Institute-Southwest

Terrence Devine, RN, BSN, RCIS, CEPS, Cath/EP Lab Staff Nurse 
Cath/EP Labs, Memorial Hermann Heart & Vascular Institute-Southwest
Houston, Texas

Terrence Devine, RN, BSN, RCIS, CEPS, Cath/EP Lab Staff Nurse 
Cath/EP Labs, Memorial Hermann Heart & Vascular Institute-Southwest
Houston, Texas

Memorial Hermann Southwest Hospital is part of the largest not-for-profit health system in southeast Texas. An integrated health system, Memorial Hermann is known for world-class clinical expertise, patient-centered care, leading-edge technology, and innovation. The system, with its exceptional medical staff and more than 24,000 employees, serves to advance health in Southeast Texas and the Greater Houston community. Memorial Hermann has 14 hospitals throughout the Greater Houston Area.

Memorial Hermann Heart & Vascular Institute-Southwest opened in 2006, as Houston’s first freestanding heart hospital. The Institute is an accredited Chest Pain Center designated by the Society of Cardiovascular Patient Care (SCPC) and received the Percutaneous Coronary Intervention (PCI) Care Award from the SouthEast Texas Regional Advisory Council (SETRAC). The Institute offers five cardiac catheterization labs, two of which are also electrophysiology labs, a 27-bed pre/post area, five cardiovascular operating rooms, a 14-bed cardiovascular intensive care unit, and a 22-bed telemetry unit.

When did the EP program start at your institution? 

The electrophysiology lab was opened in 1996 by Dr. Sohail Jalal, who continues to be the medical director.

What is the mix of credentials at your lab?

The catheterization/EP lab staff includes five registered nurses (RNs), three radiologic registered technologists (RT(R)s), two cardiovascular technologists (CVTs), and one registered cardiovascular invasive specialist (RCIS). Our staff experience ranges from two to 17 years of service in the catheterization/EP lab.

What types of procedures are performed at your facility?

For electrophysiology studies, we are capable of performing a wide range of procedures; these include ablations for atrial flutter, atrial fibrillation, atrial tachycardia, supraventricular tachycardia, and ventricular tachycardia. We offer MediGuide Technology (St. Jude Medical), the EnSite Velocity Cardiac Mapping System (St. Jude Medical) and Carto 3 System (Biosense Webster, Inc., a Johnson & Johnson company) for radiofrequency ablation procedures, as well as cryoablation (Medtronic). Our electrophysiologists perform device implants of pacemakers and implantable cardioverter-defibrillators (ICDs), including both biventricular and subcutaneous ICDs. We also perform lead extractions, cardioversions, loop recorder implants, and tilt table studies. In 2015, we performed 229 electrophysiology procedures and 370 implants. 

Who manages your EP lab?

Mario Herrera, RN, BSN, CVRN-BC, is the director of the catheterization/EP lab. Charles Brooks, RN, is the program manager.

Is the EP lab separate from your catheterization lab? Are all employees cross trained?

We have a combined catheterization and EP lab. Cross training is an integral part of our lab. This helps the schedule flow on a busy day and builds teamwork among the staff. Currently we have three RNs and three techs dedicated to the EP lab; the RNs circulate and monitor, while the technologists scrub and operate the table. Other catheterization lab staff members float in to help, and can be fully cross trained as time and caseload permit.

What types of EP equipment are mostly commonly used in your lab?

We use a Mac-Lab/CardioLab recording system (GE Healthcare). We have a Philips fluoroscopy system in one room, and another system from Siemens, which is integrated with the MediGuide Technology. We were the first in Texas and the second in the nation to employ St. Jude Medical’s MediGuide Technology. This is a three-dimensional visualization system that uses electromagnetic signals to evaluate a patient’s vascular and cardiac anatomy, to track its therapeutic and diagnostic catheters in real time on pre-recorded fluoroscopy images. Automatic adjustments are made to the previously recorded images to compensate for cardiac motion and respiratory changes. The visualization is outstanding, but the real advantage of the MediGuide is that it helps us perform safer procedures by reducing radiation exposure for all involved. We have done a right-sided atrial flutter ablation using only 40 seconds of fluoroscopy. We use the MediGuide-enabled Safire BLU Duo Ablation Catheter and IBI decapolar coronary sinus catheter. Other ablation catheters we use are St. Jude Medical’s TactiCath and FlexAbility catheters, and Biosense Webster’s ThermoCool SmartTouch ablation catheter. The ViewFlex (St. Jude Medical) catheter is used for intracardiac echocardiography (ICE). For device implants, we use products by BIOTRONIK, Boston Scientific, Medtronic, and St. Jude Medical. Additional equipment commonly used includes the NRG RF Baylis Transseptal Needle (Baylis Medical) and the SonoSite Ultrasound (Fujifilm) for obtaining vascular access.

How is shift coverage managed? What are the typical hours?

Currently we are on a four day (9½ hours) a week schedule, with alternating days off. We are on duty from 7:30 a.m. until the last procedure is completed. Staffing is two RNs and two techs. We have at least one fully trained EP nurse and tech for each EP procedure. There is no EP call, but all staff rotates in to take catheterization lab calls.

Tell us what a typical day might be like in your EP lab.

It seems like there are no typical days in the EP lab — each day has its own unique opportunities and challenges. Usually the pre-op staff arrives at 6:00 a.m., and they do an excellent job in preparing and informing patients, which helps put them and their family at ease. The first case usually starts at 8:00 a.m., but since we are a catheterization/EP lab, we are prepared to rearrange the schedule to accommodate emergencies (such as STEMIs). Depending on the flow of the day and the staffing, we may open up a second EP room, or concentrate the procedures back to back in one room. Following the procedure, the patient returns to the holding area to recover and have their sheath pulled before being admitted or discharged.

What new technology has been recently added to your EP lab? How have these technologies changed the way you perform procedures?

Within the last couple of years, Memorial Hermann Heart & Vascular Institute-Southwest has completely renovated one of our EP rooms to include MediGuide Technology, which provides clear and precise images while using greatly reduced fluoroscopy. We’re utilizing new MediGuide-enabled sheaths, wires, and catheters to further enhance the effectiveness of this innovative technology. Also, we use the NRG RF Transseptal Needle (Baylis Medical) to facilitate access to the left atrium.

Who handles your procedure scheduling? Do they use a specific software program?

Procedures are scheduled by the physician’s office staff through the hospital’s central scheduling department, utilizing the Cerner Scheduling Management software. The catheterization/EP lead office assistant, Fabiola Guzman, works closely with the physician’s office staff to obtain essential patient information and documentation. Program manager Charles Brooks, RN, assists with any scheduling difficulties and same-day scheduling.

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

We use a patient survey from Press Ganey and receive monthly performance reports. Physician performance is also measured by using monthly peer reviews of selected procedures. We comply with all ICD registry criteria for device implants.

How is inventory managed in your EP lab?

We have two trained staff members who handle supplies: Lavell Thorne, CVT for the catheterization lab, and Norman Gerino, RT(R) for the EP lab. We track inventory and ordering using Mac-Lab to scan or capture all items with a drop-down supplies list. We use SAP Crystal Reports to make queries into the Mac-Lab database. All orders are signed off by our director.

In what ways have you cut or contained costs to improve efficiency in the lab?

We have reduced our inventory levels and order items as needed. We work closely with physicians to eliminate unnecessary supplies. We also closely monitor expiration dates and use items based on their expiration dates. Our administration continuously works with vendors to review supply contracts. Staffing is another area where we look to cut costs. We go home early or float to other departments when not needed in the lab.

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

Memorial Hermann Heart & Vascular Institute-Southwest offers free, online continuing education classes. Additionally, employees are provided in-depth training on all new procedures, and regularly review all existing procedures and products. Educational opportunities are often presented by various vendors. Advanced Cardiovascular Life Support (ACLS) classes are provided by the hospital. Staff members have attended the Heart Rhythm Society conventions. Employees are encouraged to take accreditation exams and receive reimbursement for the cost upon successful completion of the exam. This achievement can be used to advance on the clinical ladder. 

According to the International Board of Heart Rhythm Examiners (IBHRE), Memorial Hermann Heart & Vascular Institute-Southwest is one of the few hospitals in Houston to elevate its cardiology program with the addition of two certified electrophysiology specialists (CEPS). Catheterization laboratory nurses Mary Abanto, RN, BSN, and Terrence Devine, RN, BSN, received their competency certification in cardiac electrophysiology for allied professionals from the IBHRE. Recipients of this designation are recognized for professional competency, are highly respected by peers and other medical professionals, can demonstrate advanced skills in clinical practice, and represent a standard of excellence in the arrhythmia community.

How is that competency evaluated?

We undergo annual competency testing and a skills check-off list. ACLS is required by all staff. Our evaluations are based 40 percent on skills and 60 percent on customer service.

How are new employees orientated and trained at your facility? 

After a general hospital orientation, a new employee is assigned to an experienced staff member for a specific department orientation. Using a skilled checklist, new employees are required to keep a daily log of their progress. One of the most experienced staff members is Boonsong Suwankosai, RN, BSN, CCRN, known affectionately to everyone as ‘Boonie.’ She has been with Memorial Hermann Southwest Hospital since 1978, and has been an integral part of the electrophysiology program since 2002. ‘Boonie’ has put in many long hours and late evenings learning and gaining valuable experience in EP. She is greatly respected and appreciated by doctors and co-workers alike. Through her guidance, kind support, and patience, she has helped many staff members, including myself, to become more proficient in the EP realm. Finally, our EP medical director, Dr. Jalal, is also a mentor. He encourages questions and promotes learning. Often he will sketch on scrap paper in an effort to clarify complex procedures for the team. 

How do you prevent staff burnout?

We have strong team unity among our staff and this helps us to excel even on our most challenging days. We have strong support from our director, Mario, and manager, Charles. Both assiduously work on the needs and well-being of the staff, and neither will hesitate to jump in to assist with patient care if needed. Recently, the hospital obtained the services of a traveler nurse, Donnie Barnes, RN. His experience and willingness to step in and “pinch hit” makes him a great addition to our team. 

We have a unique relationship with our sister hospital, Memorial Hermann Sugar Land Hospital. Staff will float between hospitals on busy days, and the extra help is greatly appreciated in both locations. 

We work hard but we have fun too. We celebrate most holidays, including Cinco de Mayo, with a potluck lunch in the department. We have occasional after-hour gatherings, and a catheterization/EP lab reunion picnic is coming up in the spring.

What committees do staff members serve on?

There are several staff members who serve on different committees. These include hospital safety, bioethics, and Partners In Caring (PIC), which organizes fundraising events for charities and blood drives. 

How is coding and coding education handled in your lab?

We have a trained, dedicated catheterization/EP lab RN who reviews procedures and charge sheets, and compares them to the procedure reports. Any discrepancies are brought to the team’s attention and immediately addressed.

How do you handle vendor visits in your department?

Vendors are allowed in the catheterization/EP lab procedure room only when assisting with procedures or providing training. They go through the hospital badging process and wear a disposable white jacket and red surgical cap to identify them as non-hospital employees.

Does your lab utilize any alternative therapies to help patients in the EP lab?

We have warm blankets available from our blanket warmer, a television in each room in the pre-op area, and music in the procedure rooms. We often take requests from the patients on their music preference.

How does your lab handle call time for staff members?

We have no EP call team. The catheterization lab team is comprised of two registered nurses and two techs for call. We take about two after-hour calls each week. Weekend call is Friday through Sunday, every two or three weeks.

Approximately what percentage of ablation procedures are done with cryo versus radiofrequency? 

We have used cryoablation in the past, but during the last year, we have used almost exclusively RF ablation catheters, such as the MediGuide-enabled Safire BLU Duo Ablation Catheter, TactiCath and FlexAbility catheters, and ThermoCool SmartTouch ablation catheter.

What measures has your lab taken to reduce fluoroscopy time? In addition, what types of radiation protection shielding and technology does your lab use?

In addition to use of the MediGuide Technology and appropriate radiation protection training, all physicians and staff are fitted with their own lead aprons and eyeglasses. Additional protection includes clear shields and lead skirts that hang from the operating table. Radiation badges are assigned to each physician and employee, and are monitored regularly.

What are your methods for device infection prophylaxis?

Procedure rooms are clean before each implant. The patient pre-op is shaved with electric clippers if needed and the chest area is cleaned with Sage chlorhexidine presoaked warmed skin preps. An IV antibiotic is started within an hour of the procedure start time and is monitored closely as part of the hospital quality assurance initiative.

Do you use the American College of Cardiology National Cardiovascular database registry (ACC-NCDR) or any other outside data collection registry?

We have used the ACC-NCDR ICD registry for more than ten years, for defibrillator implant patients. We have developed a concise checklist that complies with all NCDR guidelines. Ana Gronberg-Corey, ACNP-BC, our cardiology nurse practitioner, collects all supporting documentation and ensures all criteria are met prior to all implants. Valerie Chukelu, RN, BSN, CCRN, MBA, is our Clinical Programs and Registry Management Manger. She is a key person in analyzing the data, leading to evidence-based practice. We are also a Pathway to Excellence hospital; staff nurses are more involved in decision making at point of care and are encouraged to problem solve and innovate, which in turn leads to better patient outcomes. Our hospital is actively seeking Magnet status, an award given by the American Nurses Credentialing Center (ANCC) to hospitals that satisfy a set of high criteria designed to measure the strength and quality of their nurses. These are just some of the goals we, the staff and administration, are striving to achieve. Our mantra is to be the best of the best.

Is your lab currently involved in a clinical research study?

Yes, we are enrolled in St. Jude Medical’s MediGuide and Quartet LV lead studies, as well as BIOTRONIK’s ICD lead study.

What are some of the dominant trends you see emerging in the practice of electrophysiology?

We are using the Reveal LINQ insertable cardiac monitor (Medtronic); its ease of implant and years of monitoring arrhythmias is advantageous for patients.

Describe your city or regional area. How is it unique from the rest of the U.S.?

Houston is the fourth largest city in the United States, with all the amenities and international flavor you would expect in a big city. The Greater Houston area offers a surprisingly affordable cost of living and mild winters, which attract many newcomers to the area. Houston is home to the Texas Medical Center, the world’s largest medical complex. Memorial Hermann-Texas Medical Center is one of the centerpieces of the Texas Medical Center which includes 20 other hospitals.

Please tell our readers what you consider special about your EP lab staff.

Memorial Hermann Heart & Vascular Institute-Southwest offers the latest technology, state-of-the-art equipment, and high-quality medical care. Our people make us special, beginning with the front desk where our lead office assistant, Fabiola Guzman, makes patients and family members feel at ease. Our administrative staff provides the tools, supplies, and manpower we need when we need it. The support from people like Greg Blunt, our technical support analyst and a technical genius, along with an interdisciplinary approach with other departments, is invaluable. Our catheterization/EP lab physicians and staff, with their special mix of backgrounds and personalities, bring a tremendous amount of talent, experience, and skill to care for each patient. The work brings us closer together and it brings out the best in all of us: commitment, positive attitude, and determination. So it is not without some sense of pride that we can say, “I work in the catheterization/EP lab at Memorial Hermann Heart & Vascular Institute-Southwest.”