Mercy Heart and Vascular Hospital is part of the Mercy Hospital and Mercy Clinic of St. Louis, a 979-bed hospital and adjoining clinic located in St. Louis, Missouri. Mercy Hospital is one of the busiest hospitals in the St. Louis metropolitan area with a total of 42,243 admissions last year. Its physicians performed a total of 10,240 inpatient surgeries and 18,050 outpatient surgeries. Mercy Heart and Vascular Hospital is a dedicated cardiovascular hospital offering a wide array of cardiovascular care. Services provided include clinical consultation, cardiac catheterization, cardiac surgery, structural heart procedures, peripheral intervention and cutting-edge electrophysiology evaluation and treatment.
What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab?
Currently we utilize three EP labs. Two are used for either ablation or devices, with dedicated state-of-the-art mapping and recording systems, while the third room is a device-only room. We are planning on upgrading the third room to have the capacity to simultaneously ablate in three rooms to account for our increasing ablation volume.
Our staff includes four board-certified electrophysiologists and two HRS-certified implanters. We are supported by our nurse practitioner and our EP lab staff, including six registered nurses and two cardiology technicians. Mercy is fortunate to have a dedicated cardiovascular research center that provides exceptional support for our research endeavors.
When was the EP lab started at your institution?
Mercy has had an EP program for some time. However, our integrated program began in 2010, allowing a closer working relationship as well as cooperation on infrastructure and planning to allow for increased growth, exceptional care and clinical innovation.
What types of procedures are performed at your facility? Approximately how many are performed each week?
We perform a full spectrum of electrophysiological procedures, from device implantation to laser lead extraction, to complex ablations including both endocardial and epicardial ablation. Our ablation volume for 2012 was over 450 ablation procedures, with half of these for the treatment of atrial fibrillation. We also performed over 650 device-related procedures. This averages out to approximately 8–9 ablations per week and 12–13 devices per week. With regard to innovation, we have implanted left atrial appendage occluder devices since 2011 as part of the PREVAIL trial and CAP 2 registry, with the WATCHMAN device (Boston Scientific) in over 40 implants. We also perform the LARIAT (SentreHEART) non-surgical left atrial appendage ligation procedure.
What is the primary goal of your program?
Our goal is to develop the highest quality program in the region, with the end result being the best outcomes and care for our patients. This includes a comprehensive electrophysiology program that focuses first and foremost on patient care, patient outcomes, and patient experience.
Who manages your EP lab?
Kevin Politte, RN, BSN, is our director, with responsibility for the EP and cath labs.
Do you have cross training inside the EP lab?
What new equipment, devices and/or products have been introduced at your lab lately? How has this changed the way you perform those procedures?
Intracardiac echo has become an increasingly used technology in our EP laboratory. The images provided allow for a degree of precision on transseptal puncture, which is difficult to replicate with fluoroscopy alone. We have increasingly used this technology for ventricular tachycardia (VT) cases, especially when papillary muscle VT is suspected. The ability to monitor contact in these cases as well as AF cases adds to the incremental precision as well as decreased radiation exposure by avoiding excess fluoroscopy.
Have you recently upgraded your imaging technology?
We have recently upgraded to a new Siemens system. We have been happy with the quality of the images obtained and the improved safeguards to lower radiation exposure. We are in the planning process of upgrading another room with the same intent.
Who handles your procedure scheduling? Do they use particular software?
Our charge nurse schedules our patients. We use EPIC as our electronic medical record; scheduling is also performed on this system.
What type of quality control/quality assurance measures are practiced in your EP lab?
Both complication and infection rates are tracked and reviewed by the director of the electrophysiology lab and the lab manager. These results are then discussed with the physician EP section head for review. We are fortunate to have a dedicated and professional group of individuals that truly practice a collaborative team approach. We believe this results in excellent outcomes, which is confirmed by our data.
How is inventory managed at your EP lab?
Our inventory is currently managed by one of our EP lab cardiac technicians, Mike Marshal. We utilize a web-based program supported by Mercy.
Tell us about your recent growth in patient volume.
Our volume has been increasing steadily for the last several years with continued anticipated growth. Our volume has increased 11% from January 2012 to January 2013. We expect another 8–10% growth in the coming year. This presents many challenges as well as opportunities. We are blessed with a flexible, hardworking and professional staff as well as a supportive administration.
Have you developed a referral base?
Our electrophysiology section is part of a larger cardiovascular medicine group that provides a large portion of our referrals. We also receive a significant amount of referrals from independent physicians in the area as well as self-referrals from local patients. Regional referrals come from our neighbors to the east, south and west including Illinois, Arkansas, and Oklahoma. These numbers continue to grow.
What measures has your EP lab implemented in order to cut or contain costs? In addition, in what ways have you improved efficiencies in patient through-put?
One of the by-products of physician integration is our ability to form stronger, more aggressive ties between the clinical care we provide and the purchasing power provided by the volume in our lab. We leverage this volume in order to impact contract pricing across the wide array of EP equipment and supplies.
We have utilized several avenues to increase patient through-put. As a high-volume center, our operators are quite experienced allowing for efficient use of lab time. We utilize cross-trained staff from the cardiac cath lab to assist with device implants. This often allows us to continue with our ablation cases and provide for timely device implants as well.
Does your EP lab compete for patients? Has your institution formed an alliance with others in the area?
There are other EP labs in the St. Louis area. While we have not formed alliances in our local area, we have begun an alliance with another Mercy facility in Arkansas. Recently we have taken a physician and staff to their facility to assist with device implants. We will begin utilizing telemedicine in a relationship with the hospital, their cardiologists, their patients, and our EP physicians. Complicated ablation cases will be brought to our EP lab in St. Louis.
How are new employees oriented and trained at your facility?
New staff members participate in a 12-week orientation program. During this time, they are not considered part of our staff. They are also paired with a preceptor and work alongside them on a daily basis. Orientation includes all aspects of device implants and ablations, including programmed stimulation and EP education. Over time, staff members learn to assist with 3D mapping as well.
What types of continuing education opportunities are provided to staff members?
EP staff education is important to the entire program. Both didactic as well as informal daily teaching is performed. Staff members take advantage of industry-provided seminars and web-based education as well.
How is staff competency evaluated?
Competency is evaluated through orientation checklists, formal annual evaluations, and ongoing physician supervision and mentoring.
How do you prevent staff burnout? In addition, do you practice any team-building exercises?
Staff members rotate through all roles in the EP lab, so that they do not get burned out with one or two particular roles over time. Communication between management, staff, and attending physicians is critical. We have cultivated a culture of communication that allows issues to come to the surface so they can be dealt with in a timely manner.
What committees, if any, are staff members asked to serve on in your lab?
Members of the EP physician staff are asked to serve on the cardiovascular peer review committee as well as new technology committee. Staff members are asked to participate in ad hoc committees as needed. Examples include when we started our Lead Extraction Program and house-wide Nursing Council.
How do you handle vendor visits to your department? Do you contract with vendors?
As a hospital and a healthcare system, we do contract with vendors. We use our local and Mercy-wide volume to leverage better positioning in these contracts. These contracts are largely done through ROi, Mercy’s sister company that serves as our GPO. We do have ablation and CRM representatives in our department as needed for case support. In addition, they provide education on new products.
Describe a particularly memorable case that has come through your EP lab.
I recently did an ablation on a patient with supraventricular tachycardia. The induced arrhythmia was an orthodromic tachycardia mediated by a retrograde conducting parahisian pathway in a 20-year-old man. We utilized cryoablation to freeze at the earliest atrial signal mapped during tachycardia. However, because this was parahisian, I monitored antegrade conduction. He had minimal pre-excitation that I initially thought was antegrade conduction across the same pathway. I froze while pacing faster than the antegrade block of the pathway to monitor normal conduction. When the first freeze was complete, he was noninducible but still had the same mild pre-excitation antegrade. He had no retrograde conduction. Upon further evaluation, I noted that his antegrade conduction was decremental and his pre-excitation never changed, even with a significant increase in PR interval. He was diagnosed with a anteroseptal fasciculoventricular accessory pathway that was unrelated to his parahisian pathway which medicated ORT. The lesson learned was that in spite of all the wonderful technology available in EP, basic principles of electrophysiology still rule the day.
How does your lab handle call time for staff members?
Officially, our EP lab staff do not take EP call. We are able to maintain this policy because of our strong team work. Occasionally, there is a need to pull a team together over a weekend or holiday. Because of our staff and physicians, it is easy to put a team together during off hours. When this is necessary, a team of two RNs and one staff member to scrub will come in.
Does your lab use a third party for reprocessing? How has it impacted your lab?
We have been reprocessing diagnostic catheters and intracardiac echo catheters with great success. It has improved our efficiency and ability to deliver more cost-effective care as well as decrease waste. The use of reprocessing saved our hospital nearly $200,000 in consumables in 2012.
Approximately what percentage of your ablation procedures are done with cryo versus with radiofrequency?
Currently, cryoablation is limited to septal pathways or AVNRT with close proximity to the fast pathway. I exclusively utilize cryo in my younger patients with septal re-entrant mechanisms. We recently evaluated our data over the last year with AVNRT treated with cryo versus RF, and there was no difference in recurrence rate. With regard to AF, our lab utilizes RF for our AF ablations with excellent results.
Do you perform only adult EP procedures or do you also do pediatric cases?
We primarily perform procedures on adults. However, we will consider procedures on older teenagers of adult size when necessary. We are fortunate to have colleagues in the community to whom we can refer our younger patients.
What measures are taken to minimize radiation exposure to physicians and staff?
Our staff is very cognizant of the dangers of radiation exposure. There has been a purposeful attempt to decrease these dangers with particular focus on developing excellent 3D maps from which to rely on. We sparingly utilize fluoroscopy, and only when necessary. Intracardiac echo has also been exceedingly helpful in allowing for the non-radiation evaluation of position and contact of the catheter within the heart in real time. Our AF ablation fluoroscopy times average less than 15 minutes a case and can be as low as three minutes.
What innovative EP techniques are being utilized in your lab?
Innovation supported by excellent data is embraced in our practice. This stems from a collaborative mindset amongst operators and our collegial relationships. Whether it’s venoplasty in CRT, epicardial ablation of VT, or percutaneous closure of the left atrial appendage, we have actively pursued and employed the necessary techniques and innovations that benefit patient outcomes.
What are some of the dominant trends you see emerging in the practice of electrophysiology? How is your lab preparing for these future changes?
Our focus is continually on excellence of care. This requires having the right individual team members and perfecting the process as much as possible. That means volume. Our continued growth and ability to perform these complex procedures at a high volume results in better patient outcomes. With healthcare reform will likely come some form of evaluation of these outcomes and ability to provide the level of care required by payers. This may limit lower volume hospitals.
How does your lab handle device recalls?
Recalls are unfortunate and frequently confusing for patients. Our goal is always to look at the data in deciding what the next course of action should be. It is critical to discuss the available data, risks, and benefits of potential intervention with the patient.
Is your EP lab currently involved in any clinical research studies or special projects?
Our EP lab has been involved in several clinical research studies. The two largest include PREVAIL / CAP 2 and CABANA. PREVAIL compares the left atrial appendage occluder WATCHMAN device to coumadin in patients with atrial fibrillation. CABANA is an NIH-sponsored trial comparing ablation to pharmacologic therapy for atrial fibrillation.
Give an example of a difficult problem or challenge your lab has faced.
As our EP lab has grown significantly in both volume and types of procedures performed, we have impacted other areas of the hospital. We now require anesthesia more than ever. We require more services from our pharmacy department. We are more readily able to meet the needs of our patients, before they are discharged, meaning we have impacted the inpatient nursing floors and now require more from their staff. Our impact across our hospital and ancillary areas is definitely noticed by other areas of the hospital. This is a positive for the institution, but at times has come with difficulty. These challenges have required multi-disciplinary problem solving. Ultimately, by putting the patient first, we are always able to come to solutions that provide a win-win for everyone, most especially, for the patient.
Describe your city or general regional area.
The St. Louis metropolitan area has approximately 2.8 million people, with a great diversity in both urban and rural surroundings. Because of our central location in St. Louis County as well as our large outreach network, patients come from far and near for care to our institution. It is not uncommon to have a patient drive five minutes or even five hours to receive their care at Mercy.
Please tell our readers what you consider unique or innovative about your EP lab and staff.
I am constantly impressed by the enthusiasm and dedication of our staff — they truly place the patient first. The culture of focusing on the patient permeates in every way, resulting in a wonderful workplace centered on collaboration and cooperation. I feel blessed to be a part of this team.