Spotlight Interview: Methodist DeBakey Heart and Vascular Center

Katrina Dunn, RN, Director of The Methodist DeBakey Heart and Vascular Cath Lab; Nadim Nasir Jr., MD, FACC, Medical Director, Electrophysiology Lab; Charmaine D. Shields, RN, CVRN; Ronnie Sparrow, RN, CVRN; Miguel Valderr√°bano, MD; Glenda Zwambag, RN Houston, Texas
Katrina Dunn, RN, Director of The Methodist DeBakey Heart and Vascular Cath Lab; Nadim Nasir Jr., MD, FACC, Medical Director, Electrophysiology Lab; Charmaine D. Shields, RN, CVRN; Ronnie Sparrow, RN, CVRN; Miguel Valderr√°bano, MD; Glenda Zwambag, RN Houston, Texas
What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab? The Methodist DeBakey Heart and Vascular Center (MDHVC) labs combine the EP and Heart and Vascular suites. Of the 10 procedure rooms, 5 suites may be utilized for EP procedures. Four of these procedure rooms are equipped with biplane fluoroscopy, and 1 cath lab is dedicated to Stereotaxis navigation. All of the procedure rooms flex for pacemaker and AICD implants. We have 50 staff members, including 10 RNs, 5 CVTs, and 7 x-ray techs who primarily conduct the EP cases. The MDHVC has 10 board-certified EP physicians who are privileged to perform procedures at the Heart Center, but the majority of cases are performed by 5 of these electrophysiologists. We are capable of performing 4 complex ablation procedures simultaneously and have performed, simultaneously, 3 left atrial ablations for atrial fibrillation (AF) and 1 ventricular tachycardia (VT) ablation. We staff the rooms with 4 employees consisting of RNs, CVTs and x-ray techs. We have also instituted an EP certification program at the Methodist DeBakey Heart and Vascular Center. The program was developed and implemented by Dr. Nadim Nasir Jr. and Ronnie Sparrow, RN, CVRN. Any staff member earning this certification is awarded a one-time $2,000 bonus. Most importantly, the certification confirms that minimum standards have been met by the staff member and that he or she is able to function in a charge capacity as the EP resource person for all EP procedures. This position is able to troubleshoot all of the EP equipment. We currently have 4 staff members certified in our department, and we believe that they are well prepared for the RCES exam. When was the EP lab started at your institution? Diagnostic EP procedures started in 1983. Ablations and ICD implants started in the early 1990s. What types of procedures are performed at your facility? Approximately how many are performed each week? Every type of EP procedure imaginable, including research protocols, are done at the MDHVC. We perform supraventricular (SVT) and VT ablations, both ischemic and non-ischemic. One of our EPs, Dr. Valderrábano, is a leading authority on VT ablation when required via an epicardial approach. We also perform pulmonary vein isolation/left atrial ablations for AF, routine diagnostic studies, as well as the full range of device implants and laser extractions. The volumes of each procedure naturally vary, but in total, approximately 50-75 EP procedures are done weekly, with an annual volume in excess of 3,000 cases. What is the primary goal of your program? Our ultimate goal is to provide state-of-the-art care in a manner consistent with the principles of The Methodist Hospital system. The provision of this care in a nurturing, helpful environment is respecting each patient’s desire for the best in healthcare. In striving to make the best healthcare decisions, patients and their family may choose to evaluate hospitals based on the quality of care and treatment. For our hospital, quality means ensuring a safe patient care environment, in which we provide clinical excellence with integrity and compassion. As for our staff members, we strive to make each individual as efficient as possible in EP. Who manages your EP lab? Katrina Dunn, RN is cath lab director; she also manages the EP lab. Dr. Nasir is the medical director of the EP lab. Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained? Do you have cross training inside the EP lab? Our department is combined with the EP and cath lab, so most of the staff members who work in EP are cross-trained to work in the cath lab as well. As mentioned before, to be EP certified with us, it means that the RNs scrub, pace and document during the cases. The x-ray techs run the x-ray system, scrub and pace (using the Bard® LabSystem™ PRO [Bard Electrophysiology Division, Lowell, MA] and the MicroPace EP Cardiac Stimulator [Micropace EP Inc., Tustin CA]). The CVTs scrub, pace and run the x-ray system. Everyone gets to learn all aspects of EP. We also utilize reps, who are available most of the time, if they are needed. This type of training provides a lot of flexibility when staffing the rooms. It also helps reduce overtime. In addition, this type of cross-training promotes the ICARE values, to which all employees in our institution adhere. What new equipment, devices and/or products have been introduced at your lab lately? How has this changed the way you perform those procedures? We have two Sensei Robotic Catheter Systems (Hansen Medical, Mountain View, CA) and Carto and CartoSound (Biosense Webster, Inc., a Johnson & Johnson company, Diamond Bar, CA); we also have an EnSite system (St. Jude Medical, St. Paul, MN) and a Stereotaxis Magnetic Navigation System (Stereotaxis, Inc., St. Louis, MO). We recently purchased an additional Carto (Biosense Webster, Inc.) and Bard LabSystem (Bard Electrophysiology Division) to support research studies for the operating room. Over the last five years, we have seen remarkable growth in the performance of more complex ablations due to the improvement in diagnostic and mapping tools in conjunction with the addition of new electrophysiologists. Who handles your procedure scheduling? We have a staff member who coordinates with the doctors for scheduled procedures. Our director, Katrina, assigns a staff member to run the schedule, and we all work as a team to do the procedures in an efficient and timely manner. What type of quality control/quality assurance measures are practiced in your EP lab? We have an active Quality Improvement (QI) program, with any cath lab staff member authorized to request a review of any case. Beyond this, the medical leadership of the EP lab actively reviews cases for indications, procedural complications, success rates, and other related issues such as adherence to published guidelines, etc. These can be handled further on an individual basis or via the hospital’s QI process if needed. With respect to on-the-job quality measures, a variety of ongoing measures are enforced, such as frequent hand-washing and monitoring of the timing of pre-op antibiotic administration for device implants. In our facility, we utilize the Patient Safety Net (PSN), a program used for reporting unexpected patient safety issues/events as a reduction resolution supporting patient safety. For example, long cases such as pulmonary vein ablations (PVAs) or radiation exposure longer than 120 minutes of fluoroscopy are reported to the PSN. We also have annual competency check-offs and weekly in-services given by our EP doctors and/or different representatives. How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? We have a staff member who manages our inventory for our EP/cath lab. She checks what we have used for each procedure. We also do inventory twice a year by doing a manual count on all of our supplies. Has your EP lab recently expanded in size and patient volume, or will it be in the near future? Dr. Valderrábano: Our PVA cases have dramatically increased. We are using more of the Hansen Medical system and Biosense Webster’s CartoSound for PVA cases. Dr. Nasir: The volume of EP cases (in particular, complex VT and left atrial ablations) has increased markedly since 2005, when a concerted effort was made to train EP lab personnel and acquire the technology necessary for state-of-the-art electrophysiologic evaluation and therapy. We were the first hospital in Houston to offer Stereotaxis EP therapy as well as robotic therapy with the Hansen Medical system. Furthermore, the number of EP doctors doing complex ablations has also increased with a commensurate increase in case volumes. Overall, the MDHVC is focused on providing state-of-the-art cardiovascular care. How has managed care affected your EP lab and the care it provides patients? In the Houston metropolitan area, the quality of care provided at The Methodist Hospital is widely recognized as one of the premier locations for medical, and in particular, cardiovascular care. Consequently, most insurance companies are contracted with the hospital through the vast majority of their health insurance products. Have you developed a referral base? The MDHVC is world renowned for its cardiovascular care. We have a referral base that extends from all over the U.S. to Latin America and into the Middle East. This reflects the quality and value provided by our doctors and the hospital. 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? We only recently received approval to participate in catheter reprocessing. There were economic and medico-legal concerns that were addressed, and we now save substantially. Furthermore, as a system where 3 out of the 4 system hospitals have EP labs, we take advantage of the purchasing process to ensure optimal cost containment during product acquisition. On a daily basis, we are mindful of the particular needs of our busiest doctors, and doublecheck with them about their equipment needs prior to pitching supplies. The cases that are scheduled with anesthesia go to the anesthesia pre-op clinic the day prior to the procedure, which saves time on the day of the procedure. In addition, we work closely with our pre-op and recovery units to ensure that the consent forms are completed appropriately, necessary lab works are drawn, and other test results, such as TEE, are readily available. We also utilize our department’s patient liaison to help keep the families informed and updated. Does your EP lab compete for patients? Has your institution formed an alliance with others in the area? We have a unique environment, and competition is fierce in the Houston area. Three large hospital systems including our own, not to mention independent hospitals, generate substantial competition, which we welcome. We are fortunate that our doctors have the expertise to complement the very high brand recognition attached to the MDHVC, and therefore, we are always at the head of the pack in delivering quality EP healthcare to our patients. As previously noted, we were the first to bring several technologies into the marketplace, and our academic industry alliances allow us to constantly expand the envelope on state-of-the-art care. What procedures do you perform on an outpatient basis? What EP procedures are generally only considered inpatient? Approximately 80% of our procedures are performed on an outpatient status. Pulmonary vein ablations are performed on an outpatient basis, as well as procedures that have scheduled patients currently in-house for other medical conditions. How are new employees oriented and trained at your facility? New employees go through a three-month orientation in the EP lab. Nurses learn to scrub and circulate. Our x-ray techs and CVTs learn how to scrub and x-ray. Everyone learns all of the equipment and Bard system set ups. If someone is hired into the EP lab, they must train and orient in the cath lab first, because they are required to take call. Only after they have mastered all the skills for the cath lab, do they come to the EP lab. Once in the EP lab, they must become competent in all the skills required to function in the lab. It is hands-on training and is based on performance. There really is no time limit. We make it a point that in every case, someone is learning and improving to some degree. What types of continuing education opportunities are provided to staff members? Our department and medical directors have given us the opportunity to have our EP in-services every Friday morning from 7am to 8am. This time is dedicated for EP education and additional training opportunities (i.e., Bard, MicroPace EP, reviewing case scenarios, etc). We also utilize each other, representatives and doctors while giving presentations. We found that one hour a week of dedicated EP education has made a huge difference in building confidence in the staff. The staff members are able to ask questions in a non-threatening environment. Lastly, staff members attend classes and conferences for continuing education opportunities. How is staff competency evaluated? We have annual evaluations for the staff. We have approximately 12 different competencies. When each competency has been fulfilled, we are re-evaluated. The orientee works with others who are EP certified and learns all aspects of EP. Our EP physicians also provide input and are generous in sharing their knowledge. How do you prevent staff burnout? In addition, do you practice any team-building exercises? Each staff member adheres to the ICARE values and fully respects each staff member, which contributes to our “happy” staff. Everyone has a voice in the lab. Cross-training really promotes teamwork and respect for everyone’s role. For example, if someone wants to learn the Biosense Webster Carto or St. Jude Medical EnSite system, then he or she is provided the opportunity. We do not deny anyone from learning. What committees, if any, are staff members asked to serve on in your lab? According to the Shared Governance Model for Leadership and Professional Practice, nurses at The Methodist Hospital know how to share — governance that is. We are proud to operate in a shared governance environment where for the past decade, nurses have played an active role in driving their practice. The Shared Governance Practice is a unique and innovative organizational method that allows healthcare professionals to have control over their practice and extend their influence into administrative areas that were previously controlled by management. Every staff member in the EP/cath lab has the opportunity to exercise his or her leadership in helping to improve the lab environment, professional practice, and —most importantly — to improve patient outcomes by being involved in the committees. Do you contract with vendors? How do you handle vendor visits to your department? Yes, we contract with vendors. Vendors must go to the Purchasing Department. The reps that service our department must get yearly contract badges as required by the facility. Does your lab utilize any alternative therapies? Each room in our department has a stereo system installed. Upon patient’s request, their favorite genre of music will be played during the procedure to help alleviate their anxiety and fear, and just for pure relaxation. Describe a particularly memorable or bizarre case that has come through your EP lab. What lessons did you learn from it? Dr. Valderrábano: Our goal is to be able to handle each case in the most effective, safe and quick manner. To do that, the teams have to be ready to handle cases that do not follow the norm. There have been many such instances where ingenuity and a spirit of excellence have been put together to achieve satisfactory outcomes. For example, there was one case of focal outflow tract ventricular tachycardia, where the arrhythmogenic focus was mapped to the epicardium and persisted despite endocardial and epicardial ablation. Successful ablation was achieved by delivering radiofrequency energy from inside the anterior interventricular vein, which required nearly continuous coronary angiography to monitor possible damage to the left anterior descending artery. Such a case would not have been possible without collaboration from our interventional colleagues and an enterprising spirit of excellence. 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? Everyone in the cath/EP lab is expected to take call. There are 42 staff members who share call. There is one RN, one x-ray tech, and a third person who could be either a CVT or an RN. With the evolution of the 90-minute door-to-balloon time and staff living more than an hour away from the hospital, we have created 3-zone mapping. There must be at least one staff member in zone 1, which is the closest to the hospital. There can only be one person from zone 3. When a STEMI call is activated, the CCU charge personnel come to the cath lab to receive the patient coming from the ER. Upon the arrival of two cath lab staff members, they take over the care. Our staff has to perform different functions until all the members are in the procedure room. Each staff is required to take call every month. Does your lab use a third party for reprocessing? How has it impacted your lab? Yes. We cut off the tips of our catheters and they are sent off. The money received in place of the tips is used for education funding (continuing education for staff). We also reprocess the AcuNav catheters (Biosense Webster, Inc.) and quad catheters. Approximately what percentage of your ablation procedures are done with cryo? What percentage is done with radiofrequency? Only about 2% of all ablation procedures are done with cryo energy. The rest (98%) are performed with radiofrequency. Do you perform only adult EP procedures or do you also do pediatric cases? We are an adult lab but have handled adult-sized adolescents as needed. Texas Children Hospital is also adjacent to our facility. What measures has your lab taken to minimize radiation exposure to physicians and staff? We use low fluoroscopy, which Siemens provides. We always use the lead shield. All personnel are encouraged to wear their radiation badges. Some of the staff members also wear protective radiation-blocking glasses. The lead aprons are x-rayed every six months to look for cracks. Our policy is to inform the physician when fluoroscopy reaches 60 minutes and every ten minutes after that; this is documented in the notes. One of the physicians has asked for a RADPAD® (Worldwide Innovations & Technologies, Inc., Overland Park, KS), which we are going to look into. We have a mandatory in-service for the staff on radiation. Do your nurses/techs participate in the follow up of pacemakers and ICDs? We have a separate pacemaker clinic that does all of the follow-up on devices implanted. Most of the follow-ups are done in the physician’s office. What are some of the dominant trends you see emerging in the practice of electrophysiology? How has your lab prepared for these changes? Dr. Valderrábano: There has definitely been a rise in pulmonary vein ablations — these cases have dramatically increased in the last year or so. The new technologies have really contributed to the rise in cases performed. The Sensei Robotic Catheter System (Hansen Medical, Inc.) has brought physicians from other institutions. We anticipate that with the release of the NaviStar® ThermoCool® (Biosense Webster, Inc.), we will see another dramatic increase in our volume. Dr. Nasir: Clearly the emergence of technology that allows imaging of complex left atrial anatomy has promoted interventional therapies of more complex arrhythmias. We see this trend continuing. As industry, with whom we partner at the MDHVC, provides new devices, we are eager to apply them for improved safety, efficiency and efficacy in the care of patients with complex arrhythmic problems. What are your thoughts about non-EPs implanting ICDs? Do you train such individuals? Dr. Nasir: All practicing electrophysiologists at the MDHVC are board-certified in EP, and all feel the same about this topic. We are strongly against untrained individuals performing complex procedures without the proper educational and technical background. Pacemaker implantation is a far cry from dealing with high DFTs in a patient who needs a biventricular device and a subcutaneous lead to achieve a satisfactory margin of defibrillation safety. As a whole, we disagree with the concept that while some cardiologists are technically adequate at pacemaker implantation, that this will translate to adequate skill in ICD implant techniques. To ensure that the patients at the MDHVC receive optimum care, only board-certified EPs or board-eligible EPs can be credentialed to implant, test and monitor ICDs in the hospital. Therefore, it is an unequivocal no: we do not train such individuals at the Heart Center, and to our knowledge, none of our EP doctors are involved in such training outside the Heart Center. What about device recalls? Dr. Nasir: We handle device and lead recalls on an individual basis. Each practicing electrophysiologist must weigh the pros and cons of device or lead removal in the relevant clinical setting as it relates to each patient. We do not practice a “one size fits all” philosophy; rather, we leave each practicing EP to judge the merits and risks of the recall as it is applicable to the patient. How has your lab handled device recalls? Dr. Valderrábano: When there is evidence of device or lead failure, we revise the system. Since we have a very low incidence of device infection and a very high level of expertise in lead extraction, we have been inclusive at offering system revision to all affected patients, but decisions are made individually. Is your lab doing web-based/transtelephonic device follow-up? The hospital routinely follows patients with devices using the various remote systems. Dr. Nasir: The Heart Center has a fully-staffed Device Clinic to manage post implants. Most of our EPs are engaged in this type of follow up for their patients, minimizing the burden on the Heart Center clinic. Is your EP lab currently involved in any clinical research studies or special projects? Yes, we participate in several multi-center trials, several industry-sponsored trials, and also our own investigator-initiated trials. When was your last inspection by the Joint Commission? Our last inspection was in July 2008. Are you ACGME-approved for EP training? What do you think about two-year EP programs? Dr. Valderrábano: We are in the process of applying for ACGME accreditation. With the increasing complexity of EP procedures, full competency in all aspects of EP undoubtedly takes two years of specialized training. In some programs, this can be achieved by starting the EP training during the general cardiology fellowship, so that there is only one additional year of dedicated EP training, but for the most part, two-year programs are likely to become the norm. Does your hospital offer a device support group (e.g., for pacemaker or ICD patients)? Over 10 years ago, we started a support group and found that it was not a self-sustaining program. Without significant and serious support, it was not viable. Now with a number of Internet-based support groups, a local structure is unnecessary. Give an example of a difficult problem or challenge your lab has faced. How it was addressed? Cross training of staff is challenging. New technologies have increased volumes and also stimulated the interest of staff. The energy of the staff to meet the volume demands is remarkable, and is due to our strong physician involvement. As described previously, the key is to be ready to handle every case, even if it takes deviation from the norm. Our priority is to deliver excellent EP care. It is also challenging to learn the 3D mapping system. It is our goal to become fully independent in the use of Biosense Webster’s Carto and CartoSound and St. Jude Medical’s EnSite system. Describe your city or general regional area. How does it differ from the rest of the U.S.? The Methodist Hospital is one of the leading academic and research health institutions in the Texas Medical Center (TMC). Houston is the seat of the internationally-renowned Texas Medical Center, which contains the world's largest concentration of research and healthcare institutions.1 All 47 of the institutions of the Texas Medical Center are not-for-profit. Patient and preventive care, research, education, and local, national, and international community well-being are all provided. There are 13 hospitals and two specialty institutions, two medical schools, four nursing schools, and schools of dentistry, public health, pharmacy, and virtually all health-related careers. It is where one of the first, and still the largest, air ambulance services (called LifeFlight) was created. A very successful inter-institutional transplant program was also developed here. More heart surgeries are performed at the TMC than anywhere else in the world.2 Please tell our readers what you consider unique or innovative about your EP lab and staff. Dr. Valderrábano: The common denominator of all personnel working in our EP lab is the pursuit of excellence, as this was Dr. Michael E. DeBakey’s legacy. Our lab is unique in that the conventional tensions from competing practices are put aside in order to achieve excellence. Thus, we have an unusually collaborative environment among EP physicians. We also continuously strive for innovation, and have been very aggressive at adopting new technologies to improve quality of care. The fact that we were the first in Houston to use the Stereotaxis and Hansen Medical systems is a testament to this. Additionally, we actively participate in research and innovation, and have been pioneers in the use and development of new technologies. For more information, please visit: www.methodisthealth.com