Spotlight Interview: New York Presbyterian Hospital, Columbia University

Edmund Donovan, RN, Clinical Nurse II

Edmund Donovan, RN, Clinical Nurse II

What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab? At Columbia University Medical Center (CUMC), we have two dedicated cardiac EP laboratory rooms. Both rooms are equipped for performance of EP studies, catheter mapping and ablation of arrhythmias and for device implantations. The majority of the catheter ablation procedures are carried out in one of these two rooms, equipped with biplane fluoroscopy and three-dimentional mapping systems. We share a third room, equipped with a remote navigation Stereotaxis system, with the cardiac catheterization laboratory. We also have a small room for tilt table and T-wave alternans tests, as well as cardioversions. Our staff consists of six attending physicians, two EP fellows, and nine nurses. Our attending physicians are fully credentialed cardiologists and clinical cardiac electrophysiologists. Our nurses possess CCRN and HRS memberships. When was the EP lab started at your institution? The cardiac EP lab here at CUMC was started in the early 1970s by Thomas Bigger, MD, who performed original research in sinoatrial node function and in defining arrhythmic death risk in patients with organic heart disease. He was also one of the first cardiologists to implant an automatic defibrillator. Later, Dr. David Rubin played a key role in developing interventional cardiac electrophysiology at CUMC. Throughout the years, Dr. James Reiffel and Dr. James Coromilas have played important roles in educating the fellows and overseeing their development. They, along with Dr. Bigger, have also kept Columbia on the map by maintaining our prominence in several seminal multicenter trials. What types of procedures are performed at your facility? We perform the full spectrum of EP procedures, ranging from tilt table studies to catheter ablations of simple and complex arrhythmias, including atrial fibrillation (AF) and arrhythmias in adult congenital disease, to biventricular ICD insertions. We also utilize advanced EP technologies such as recent softwares in the Carto mapping system (Biosense Webster, Inc.), non-contact mapping system (St. Jude Medical), and Stereotaxis. What is the primary goal of your program (AF ablations, lead extractions, BiVs, etc.)? Our primary goal is to offer cutting-edge arrhythmia treatment combined with superior patient care. To achieve this end, we are striving to enhance the efficacy and safety of our treatment techniques, such as catheter ablations for AF, by utilizing the Carto RMT system coupled with Stereotaxis. Since we take care of a large heart failure patient population, we also strive to become one of the premier centers for cardiac resynchronization therapy in the country. Approximately how many are performed each week? What complications do you find during these procedures? We perform 3 - 4 AF ablations weekly and approximately 5 - 10 catheter ablations for cardiac arrhythmias other than AF per week. We can do up to 20 devices a week with 3 - 5 biventricular pacemakers and ICDs. Our complication rates for implant-related complications and other commonly reported ones such as cardiac tamponade, pulmonary vein stenosis, and femoral vascular complications, are under the national benchmark figures. Who manages your EP lab? The director of our EP lab is Dr. Hasan Garan, affectionately known as The Chief. On the nursing side, Amelita Rivera is the leadership resource for the nurses. LuKann Gorman is the Nurse Coordinator for both the EP and Cath labs. Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained? As of March 2007, EP lab nursing staff will be separate from the Cath lab nursing staff for the first time at this institution. The EP nurses are cross-trained in both EP and Cath lab duties; however, the EP nurses are only responsible for diagnostic cath procedures on slow EP days, and this is rare. What new equipment, devices and/or products have been introduced at your lab lately? We are a major center for industry to unveil new technologies. These novel technologies include new softwares for mapping, new catheters, new energy delivery systems, and new, advanced versatile implantable devices. Who handles your procedure scheduling? Do you use particular software? We have a team of nurse practitioners who work along with our physicians to coordinate scheduling. Our administrative assistant then coordinates rooms, times, anesthesia (where applicable), etc. How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? Our nurses are responsible for keeping track of stock, with Karen Kahrs and myself overseeing overall stock. We have a purchasing agent who is ultimately responsible for submitting equipment orders. Has your EP lab recently expanded in size and patient volume, or will it be in the near future? We recently had two new attendings join our practice, so we do anticipate our volume to expand even more than it already has. Our numbers for early 2007 are already higher than the same interval in 2006. Furthermore, the new Heart Hospital, scheduled to open in 2009, is being already built; it will incorporate a new EP lab along with other state-of-the-art interventional cardiology care. Does your EP lab compete for patients? Has your institution formed an alliance with others in the area? We are a referral center for a large number of the tri-state area's complex arrhythmias, such as atrial fibrillation and ventricular tachycardia cases. Also, Dr. Garan specializes in difficult ablations such as those observed in adult congenital heart disease population. We have formed several alliances with hospitals in Connecticut, upstate New York, and of course our sister hospital, New York Hospital Cornell. What procedures do you perform on an outpatient basis? We perform a wide variety of outpatient procedures ranging from tilt table studies, T-wave alternans tests, to diagnostic EP studies. In performing the simpler ablations, it is purely a matter of physician preference and the time of the day whether or not the patient is admitted. How do you prevent staff burnout? We alter two people from the morning shift as potential late-stayers to cover the cases that continue past 7:30 pm. This designation is usually only once a week, limiting multiple late stays per week. We are blessed to have a very coherent staff that gets along quite well among themselves. What committees, if any, are staff members asked to serve on in your lab? We do not have any intra-facility committees per se. However, all nurses are asked to join PENNY (Pacing and Electrophysiology Nurses of New York), which is a network for EP nurses within the five boroughs and Westchester county. It is a growing network for EP nurses within New York to develop protocols and share ideas to improve our own facilities. It is chaired by Aileen Ferrick, NP, of New York University Hospital. How does your lab handle call time for staff members? There is no call for EP nurses. What trends do you see emerging in the practice of electrophysiology? How is your lab preparing for these future changes? Atrial fibrillation continues to be a challenge as new protocols and technologies emerge to treat the disease. We are in the process of acquiring the Carto RMT system to complement the Stereotaxis system already in place at our institution. We are also exploring the use of bypass machines for unstable VT ablations. What about device recalls? How has your lab handled these? We've instituted more frequent follow-ups in this population and followed the manufacturers' guidelines for recall. Each patient was assessed individually by the attending physician involved, and those patients deemed pacer-dependent or high risk for frequent ICD treatment underwent explantation and replacement of the pulse generators. Is your EP lab currently involved in any clinical research studies or special projects? We are involved in a variety of industry- and NIH-funded studies. The CABANA trial (June 2007) will be a study comparing catheter ablation for AF versus medical treatment. PACE MI (Summer 2007) will address RV pacing in post-MI patients. These are just a few of the many research projects we are involved with. Please tell our readers what you consider unique or innovative about your EP lab and staff. I think what is unique about our lab is the type of patients we treat and care for. Because of Columbia's stature, we are privileged to treat patients with severe heart failure, complex congenital heart disease, and patients referred after previously failed ablation attempts, to name a few. The team we have assembled works efficiently, and the expertise of our electrophysiologists is matched only by the strength of our nursing staff. We strive to address the personal, as well as the medical, needs of the patient to enhance his/her overall hospital experience. On top of all of this, our patients are treated to free lessons on astrophysics and music, with a special emphasis on the life and music of Wolfgang Amadeus Mozart by Dr. Hasan Garan. Now what other institution can offer that?