Spotlight Interview: Morristown Memorial Hospital (Updated!)

Jay H. Curwin, MD, Robert F. Coyne, MD, Jonathan S. Sussman, MD, and Stephen L. Winters, MD

Jay H. Curwin, MD, Robert F. Coyne, MD, Jonathan S. Sussman, MD, and Stephen L. Winters, MD

What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab? The cardiac rhythm management program at Morristown Memorial Hospital has grown from one lab with a single cardiac electrophysiologist and three full-time staff members to a full-service cardiac rhythm management team, comprised of four board-certified electrophysiologists, a physician assistant, three full-time technologists, nine nurses, an office manager and four office staff members. In addition, we work with a full-time cardiac research nurse coordinator and a team of dedicated cardiac research nurses. What types of procedures are performed at your facility? We perform comprehensive electrophysiology studies, radiofrequency ablations for both ventricular and supraventricular tachycardias, including atrial fibrillation, pacemaker and cardioverter-defibrillator implantations (including resynchronization devices), cardioversions and tilt table testing. The complication rate is extremely low and compares to that of other outstanding laboratories on both a local and national level. Our success rate with catheter ablation procedures is very respectable as well. How is your EP lab managed, and by who? Is the EP lab separate from the Cath lab? Are employees cross-trained? Do you have cross-training inside the EP lab? Our laboratory has a full-time physician director as well as a nurse coordinator. The electrophysiology laboratory is a separate entity from the cardiac catheterization laboratory, although our staff and physicians work closely with members of the catheterization laboratory. Some of the electrophysiology laboratory employees have had cardiac catheterization laboratory experience. Our nurses have also had prior cardiac care or subacute cardiac care unit experience. However, cross-training between the cardiac electrophysiology laboratory and the interventional cardiac catheterization laboratory has not been encouraged, to enable a higher degree of concentration and focus on patients with cardiac rhythm problems. The rhythm management team is dedicated to the clinical care, education, and support of the patients treated, as well as participation in continuing education and clinical research. What new equipment, devices and/or products have been introduced at your lab lately? Is your EP lab filmless, or does it plan to become filmless in the foreseeable future? The facility that housed the original electrophysiology laboratory was originally the hospital's radiology special procedures room. The area then served as the first diagnostic and interventional cardiac catheterization laboratory. In 1991, the space was renovated to become the electrophysiology laboratory. For the first five years, the radiology equipment included a non-mobile Siemens image intensifier in conjunction with a "cradle" designed table, which was more than a decade old. In 1997, a modern, single-plane GE pulse-fluoroscopy system replaced the nearly two-decade-old system. In 2005, we moved down the hall to the Huff Family Electrophysiology Laboratory, a beautiful new room with a flat panel GE fluoroscopy system. This summer a second laboratory opened, with a Siemens flat panel biplane system. In the interest of radiation safety, the staff typically operates the radiologic equipment with the lowest output and at a relatively slow pulsing rate. There are strict regulations for monitoring the dose (DAP) during procedures and notification mechanisms for preventing excessive exposure to patients, as well as to the staff. In addition, we continue to receive a mandatory annual review of appropriate use of fluoroscopy from the hospital’s radiation safety officer. Over the years, equipment has been added on an ongoing basis. Biosense Webster’s Carto mapping system has been very useful in the performance of complex ablations for atrial flutter, atrial tachycardia, accessory pathways, atrial fibrillation and ventricular tachycardia. A GE NT CardioLab upgrade replaced the pre-existing computer-based physiologic recording system. We use two Bloom stimulators and Stockert radiofrequency generators. Images can be stored via a high-definition video system or directly on the Prucka system. Our CardioLab recordings are networked and can be retrieved in remote locations in the hospital. Our intracardiac Acuson ultrasound system has enabled safer performance of procedures that entail left atrial and pulmonary vein mapping and ablation. Presently, we have two electroanatomic mapping systems with the latest upgrades inclusive of CT merge, the newest integrated Acuson ultrasound mapping package, and Complex Fractional Atrial Electrogram (CFAE) detection software. Biosense Webster’s CARTOMERGE system has been used extensively in our ablations for atrial fibrillation, and along with the EsophaStar probe is used to delineate esophageal position during these procedures. We also have incorporated Biosense Webster’s ThermoCool irrigation catheter system at times to help ensure high success rates and maximum safety during ablation procedures. Who handles your procedure scheduling? Do you use a particular software? All procedure scheduling is performed via the main clinical office, located adjacent to the physicians' hospital-based offices and exam room in the hospital. A full-time office manager and secretaries are responsible not only for scheduling, but for report editing and dissemination, patient instruction, and coordinating activities among the various staff members as well as between the staff and the hospital. We had relied upon a manual scheduling mechanism together with fax machines, but have now begun to use the Office Hours Professional appointment scheduler software. What processes does your lab use for pulling sheaths post-diagnostic and interventional procedures? How does your lab handle hemostasis? Catheters and sheaths are usually removed in the laboratory immediately after procedures by the physicians, or at times are assisted by staff members. In cases where patients may have received high doses of intravenous heparin, a cardiac technician dedicated to the removal of angioplasty sheaths will often remove in-dwelling sheaths from our patients in the recovery room or on a telemetry patient care unit. How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? Inventory is managed by the full-time nurse coordinator, the senior technologist, and several staff nurses. More costly or niche equipment and supplies are always purchased with appropriate physician and nurse input. Has your EP lab recently expanded in size and patient volume, or will it be in the near future? How has managed care affected your EP lab and the care it provides patients? Despite the decline in numbers for many other types of cardiac procedures, patient and procedural volume for the EP program has risen steadily over the past decade. In 1992, our first full year, we performed 377 cases with only one physician, one full-time and one part-time nurse, and one technologist; in 2006, there were 1,797 cases. Procedure complexity has also increased with the introduction of resynchronization devices and ablation for atrial fibrillation. We have been able to comply with managed care’s requirements to perform more procedures on an outpatient basis or with limitations in length of hospital stays without any compromise in patient outcomes and safety. The laboratory has consistently contained costs by using only the necessary equipment to perform procedures efficiently and safely, while minimizing waste. Furthermore, costly items such as implantable devices are selected based upon patient need (i.e., single- versus dual-chamber versus CRT devices) and not on a routine basis. Device manufacturers must remain competitive with respect to pricing. Standardization of technical aspects of procedures among the four electrophysiologists greatly aids in accomplishing these goals. What measures has your EP lab implemented in order to cut or contain costs and improve efficiencies in patient through-put? The cardiac rhythm management staff provides outpatient evaluation and management services in hospital-based offices, geographically separated from the laboratory. Ancillary noninvasive tests are obtained through the hospital's available services, or via the patient's personal cardiologist's office. Select patients have been enrolled in home monitoring systems for ICD follow-up, while still being seen in the office periodically. Concerted efforts and constant communication among all lab members, including the physicians, nurses, technologists, office manager and staff (and even the housekeepers and transporters) keep our turnover time to a minimum between cases. How are new employees oriented and trained at your facility? New employees in our hospital all participate in a formal orientation program, inclusive of HIPAA training and infection control precautions. Furthermore, newer staff members who may be very experienced in other aspects of cardiac care but who are new to the electrophysiology service, undergo extensive training with peer nurses and technologists for lengthy periods of time before being asked to work independently. What types of continuing education opportunities are provided to staff members? Continuing education is important both to the physicians as well as to nurses and technologist staff members. In addition to attendance at national meetings, staff members have participated in courses throughout the country, both for ongoing education in electrophysiology in general, as well as for education for more specific reasons, such as when new equipment has been installed. Our electrophysiologists are extremely active in local, state, and national professional organizations. Our physicians remain very active in the New Jersey Chapter of the American College of Cardiology and on numerous committees of HRS, as well as the national ACC. We continue to participate in numerous controlled, randomized clinical trials that are oriented toward patient welfare. The physicians remain active in the submission of clinical abstracts and presentations at national professional meetings. In addition, we are very involved in the education of medical housestaff, medical students, and ancillary staff. We serve on numerous hospital committees, including the Medical Executive Committee, the Heart Hospital Executive Committee, the Hospital Foundation, the Cardiac Care Committee, the Radiation Safety Committee, the Cardiopulmonary Resuscitation Committee, the Research Committee, the Performance Improvement Committee, the Mount Sinai School of Medicine Affiliation Oversight Committee and the hospital Information Systems Committee. Grand rounds for the department of cardiovascular medicine occur every Friday morning. The electrophysiologists present cases with a thematic approach and/or a didactic lecture on the second Friday of each month. Another educational program was our participation in OR Live, during which we performed a live webcast of a defibrillator implant procedure. How is staff competency evaluated? Staff competency is evaluated on several levels. The nurse coordinator, who directs these evaluations to her immediate supervisor, performs the primary evaluations. There are periodic competency assessments for use of conscious sedation, radiation safety, and ACLS. In-service sessions regarding new technologies and procedures are held periodically. 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 laboratory does not have a formal call schedule for staff members. The service is fully staffed from 7 am to 7 pm, Monday through Friday. However, the members of the cardiac rhythm management service are frequently called upon to work well into the evening to complete procedures. There is no evening call, and each staff member has at least one or two days off during the week, as well as all weekends and holidays off. When nurses and technologists stay late, we express our deepest appreciation. We occasionally treat the staff to lunch and dinners where we relax as friends and family would. What type of quality control/quality assurance measures are practiced in your EP lab? Quality assurance is measured on several levels. First, there is a monthly cardiology conference at which both cardiac catheterization laboratory and electrophysiology laboratory complications are presented. Fortunately, as mentioned above, complications have been very uncommon. Another conference is devoted to the presentation of interesting lectures or cases relevant to cardiac rhythm management. As noted above, one of the electrophysiologists serves on the department's formal Performance Improvement Committee as well. Any problems that may occur as system errors are carefully explored, leading to the development of mechanisms to prevent recurrences. In addition, formal reporting to the state is required, both with respect to procedure numbers as well as complication rates. The electrophysiology laboratory has been inspected by various parties including JCAHO, and has exceeded expectations both for efficiency and cleanliness. Do you contract with vendors? We contract with the vendors who provide our catheters and implantable devices. This helps to contain costs, and maintains an ongoing relationship with industry representatives, which in turn provides access to new technology and research endeavors. Our local representatives have also been instrumental in providing ongoing technical support. Regarding installed equipment, the hospital maintains service contracts in several areas to keep laboratory downtime to a minimum. We are most impressed and enjoy supporting manufacturers’ representatives who are knowledgeable in the field and can provide strong technical support during procedures when needed. How has your lab handled device recalls? There have been several serious device recalls and advisories over the past 15 years. We typically abide by formal recommendations from manufacturers and advisory groups. On more than one occasion we have dealt with recalls by holding all-day weekend sessions involving our physicians, nurses, technologists, office staff and manufacturer representatives. Patients have been counseled and advised individually of their options. We have advised surgical replacement when necessary, particularly for pacemaker-dependent patients and for those who have required frequent ICD therapy. However, we have favored a more conservative approach in the patients who have lower risk and in whom the risk of a device malfunction is relatively low. Recent reports have confirmed that the replacement surgery risk must be considered as well. What are your thoughts about non-EPs implanting ICDs? Do you train such individuals? We do not support that approach. There may be some geographically underserved areas in the country where a patient cannot have access to ICD therapy, but that is not the case in most urban and suburban regions. ICD implantation is not an emergency procedure. The impetus for non-EP physicians to implant is often financial and not necessarily aimed at optimizing patient safety. Most cardiologists feel that their extra training, expertise and time commitment to their field allow them to provide superior cardiac care than a general practitioner would, and we have the same view with respect to electrophysiology. The physicians in our group are all board certified in cardiovascular disease management (as well as in Clinical Cardiac Electrophysiology), but we do not perform stress tests, echocardiography, nuclear studies, diagnostic catheterization studies, or angioplasty. We are focused on what we do best and admire other cardiologists who focus on what they do best. ICD recipients commonly have significant structural heart disease, and the additional risks of anesthesia in these patients, arrhythmia induction, etc. should not be discounted. We believe that as much as possible, patients at greatest risk should undergo electrophysiology-based procedures by board-certified electrophysiologists in facilities with appropriate on-site cardiac surgical back-up. We do not train others to implant, and believe that industry-supported training programs may be self-serving and not necessarily in the public interest. Please tell our readers what you consider unique or innovative about your EP lab and staff. Electrophysiology staff members have coordinated a quarterly patient support group that has been well attended and which appears to have improved patient morale and acceptance of implantable defibrillators. A formal presentation as well as dinner is provided at each session. All staff members, including secretarial, nursing, technical staff and physicians, are represented at each meeting. Topics related to general cardiac wellness, as well as rhythm management, are presented. The social and psychological well-being of the patients is addressed as well. Patients and their families are also mailed a quarterly newsletter, which has been well-received. Our program functions as a family, sharing mutual respect among all members, be it the office manager and staff, the nurses, the technologists, and/or the physicians. Each member is a vital element to the program’s success. As a stand-alone electrophysiology group, we receive patient referrals from well over 100 cardiologists who work in several counties. Unless otherwise required (e.g., for device monitoring or adjustment of research-related medicines) or when requested by the referring physician, we do not provide routine outpatient follow-up for these patients after a post-operative or post-procedure visit; we want to support the relationship that the patient has with the referring physician. This type of broad referral pattern is often difficult to maintain by an EP physician who is part of a general cardiology group, since the referring physicians are often reluctant to send patients to a group that may be perceived as being in competition with them. This factor is helpful not only to our group but to our hospital as well. Is there a problem or challenge your lab has faced? How was it addressed? The cardiac rhythm management program, like many similar services, is constantly facing new challenges. Scheduling conflicts, rising costs in conjunction with diminishing hospital reimbursement, and increasing patient expectations are constantly providing new challenges to health care providers. Nevertheless, professionalism and dedication have allowed us to continue to provide the excellent care that our patients deserve. The staff members and physicians relate to each other like members of a close-knit family. Everyone's input is vital to the success of the program.