Spotlight Interview: Methodist University Hospital

Yehoshua Levine, MD 
Memphis, Tennessee

Yehoshua Levine, MD 
Memphis, Tennessee

What is the size of your EP program? When was it started?

We have 2 fully equipped, dedicated EP labs. Our program was formed in July 1989.

What is the number of staff members and mix of credentials? 

We have 10 full-time staff members, including 4 physicians, 3 RNs, 1 RT, 1 RCIS, and 1 RCES.

What types of procedures are performed at your facility?

We perform ablations for atrial fibrillation (both cryo and RF), atrial tachycardia/flutter, ventricular tachycardia/premature ventricular contractions, His bundle, supraventricular tachycardia, and Wolff-Parkinson-White. We perform diagnostic EP studies, defibrillator threshold testing, and lead extractions. 

We also implant cardiac devices such as pacemakers (including leadless pacemakers and MRI-compatible pacemakers), ICDs (including subcutaneous and MRI-compatible ICDs), biventricular devices, and implantable loop recorders. 

Who manages your lab?

Our Manager and Education Coordinator are in charge of the EP lab. The lab manager is Angela Knox, BSN, and the education coordinator is Matt Deshotels, BSN.

Are employees cross-trained to the cath lab?

Although many of the EP staff initially came from the cath lab, they are dedicated EP staff, and the cath lab has its own dedicated staff. The EP rooms are not used for cath procedures, and the cath rooms are not used for EP.

What type of equipment is most commonly used in the lab?

For three-dimensional mapping, we utilize Biosense Webster’s CARTO and St. Jude Medical’s EnSite mapping systems. We are also considering Boston Scientific’s Rhythmia Mapping System. We use the CardioLab Recording System (GE Healthcare), Micropace Cardiac Stimulator (Micropace EP), and the WorkMate Claris Recording System (St. Jude Medical). We implant devices from Medtronic, St. Jude Medical, and Boston Scientific.

How are shifts covered? What are the hours?

We have 10-hour shifts, from 7 am to 5:30 pm.

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

The day starts with patients being prepared for procedures in the holding area. Anesthesiologists and holding area nurses assess the patient and begin prep. We can do about 7-9 cases per day.

What imaging technology do you utilize?

We use imaging equipment from GE Healthcare and Siemens.

Who handles your procedure scheduling? Do they use particular software?

Our hospital’s scheduling department does the pre-procedural scheduling in consultation with the office staff of our electrophysiologists.

How is inventory managed? 

Whitnie Anderson, RCIS, CVT is the cardiovascular technologist responsible for ordering and maintaining inventory.

Has your EP lab recently expanded in size or patient volume?

Yes, our patient load has been increasing exponentially, especially patients with atrial fibrillation/flutter. We will soon be getting a hybrid room.

How has managed care affected the EP lab?

We are a not-for-profit hospital. Managed care has not affected our patient volume, because we treat patients of all socioeconomic levels.

Have you developed a referral base?

Our patients come from the Memphis metropolitan area and the surrounding regions, in a geographic area spanning about 500 square miles, including parts of eastern and northeastern Arkansas, northern and central Mississippi, western Tennessee, and southern Missouri. As the EP lab in a large, tertiary care academic medical center, we receive many referrals from smaller or less experienced EP programs.

In what ways have you helped to cut/contain costs and improve efficiencies in the lab?

We are punctual — we show up on time and our patients usually show up on time. We know our patients well and keep close track of their comorbidities, medications, and allergies. Case start times and room turnover times are efficient. 

In terms of inventory, we open supplies on the scrub table only after being specifically requested to do so by the electrophysiologists. We keep our inventory on a par level system. We also use reprocessed ultrasound catheters.

Does your EP lab compete for patients? Has your institution formed an alliance with others in the area?

Our experienced lab and staff draw patients from a large geographic region, so we do not need to compete for patients. We strive to be the best EP lab in the city. Some patients have to go where their insurance tells them to go, but once they check in at our hospital, we ensure that they get the best care possible. Word of mouth goes a long way; we have a 27-year history, and many patients refer their family and friends.  As a tertiary care academic medical center, we also receive many patients from other hospitals.

How are new employees oriented and trained at your facility?

Most of our new employees come with some form of EP knowledge, but for those who do not, there is a 6- to 8-week orientation.

What types of continuing education opportunities are provided?

Once a month, our electrophysiologists give a talk on EP topics for the staff. The vendors also schedule bimonthly talks. In addition, we have a skills fair once a year.

How is staff competency evaluated?

Staff competency is evaluated by the manager and education coordinator.

Do staff members receive an incentive bonus or raise upon passing the registry exam for the Registered Cardiac Electrophysiology Specialist?

Our staff is reimbursed for taking the RCES registry exam, but no incentive or bonus is provided.

How do you prevent staff burnout? Do you also practice any team-building exercise?

We try to prevent burnout by sticking to a 10-hour shift schedule. EP staff also do not take call; off-hours emergencies are temporized by the cath lab staff.

Our staff work well together as a team. If possible, they rotate their schedule if another coworker needs their assistance.

How do you handle vendor visits? Do you contract with vendors?

Vendors must check in with the hospital before coming to the lab. There are some contracts that the hospital administration deals with.

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

Right over the procedure table is a beautiful picture of a blue sky and puffy clouds — patients often remark how much they love the photo. We take music requests. We have a warm, friendly, caring, and genuine staff that is universally beloved by our patients.

What percentage of ablation procedures are done with cryo vs radiofrequency?

Historically, over the last 5 years, 90% were RF and 10% were cryo. Since our new EP physician joined the staff 7 months ago, cryoablations are now performed approximately 30-40% of the time.

Does your lab use contact force sensing during RF ablation of atrial fibrillation (AF)? 

Yes, we use Biosense Webster’s SMARTTOUCH ablation catheter for both AF and ventricular tachycardia (VT) ablations.

What are your techniques for LAA occlusion? Do you have a primary approach?

No. Our EP physicians are waiting for more convincing data to emerge. Some of our cardiac surgeons use the AtriClip (AtriCure) in patients referred for cardiac surgery for another reason.

What are your thoughts on the use of the new oral anticoagulants (NOACs) in patients with nonvalvular AF?

This is one of the areas in which we are efficient. We plan for our patients with AF or atrial flutter to take the NOACs for >3 weeks prior to their ablations so that they do not need a TEE. We have embraced the data showing that it is safe to not do a pre-procedure TEE for patients consistently taking NOACs.

Is hybrid epicardial/endocardial ablation of AF performed?

Not yet, but we have begun discussions about building this program.

What other innovative techniques are being utilized in your lab?

Some of the innovative technologies we use are the leadless pacemaker, advanced electronanatomical mapping, subcutaneous ICD, and the Reveal LINQ insertable cardiac monitor (Medtronic).

What measures has your lab taken to reduce fluoro time? What types of radiation shielding does your lab use?

We lower the frame/pulse rate to 7.5. We use a lead shield and lead eye shields. Our EP physicians are depending more and more on ICE.

What are your methods for device infection prophylaxis?

All patients are medicated with an antibiotic both before and after the case. We scrub for 3 full minutes. We ensure that all staff wear appropriate protective clothing and masks when the prep has begun.

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

In addition to leadless pacemakers and advanced multielectrode electroanatomical mapping, we believe remote monitoring is another dominant trend in EP.

Is your lab currently involved in clinical research studies?

Yes, we have been actively involved with leadless pacemaker, ICD-compatible device, and CRT and sudden cardiac death trials. Some of the clinical trials we are currently involved with include the LEADLESS Pacemaker Study, St. Jude Medical’s Cardiac Lead Assessment Study, Evera MRI study, QuickFlex study, and MultiPoint Pacing study.

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

Our lab is unique on many levels. We can adjust to any situation that arises. We are a very flexible crew that adheres to whatever comes our way. Our EP physicians are among the most experienced and best-trained electrophysiologists in the country (if not the world), and have been actively involved in trials that have revolutionized the field of cardiac electrophysiology. We consider ourselves “top notch” because we are always seeking out new ways to improve the most up-to-date techniques, technologies, and skills to deliver outstanding and unparalleled patient care.