Spotlight Interview North Mississippi Medical Center Heart Institute and Atrial Fibrillation Center

Ophebia Pegues, RN, BSN, Electrophysiology Lab Manager Tupelo, Mississippi
Ophebia Pegues, RN, BSN, Electrophysiology Lab Manager Tupelo, Mississippi
What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab?    At North Mississippi Medical Center (NMMC) we have two large EP rooms that are staffed with six RNs, three techs and three electrophysiologists. The EP lab is located in our hospital’s Heart Institute. When was the EP lab started at your institution? The lab opened in 1998. What types of procedures are performed at your facility? Approximately how many are performed each week?    Last year we performed: 49 pulmonary vein isolation and atrial fibrillation (AF) ablations; 57 SVT ablations; 93 atrial flutter ablations; 90 AVN ablations; 2 ventricular tachycardia ablations; 56 EP studies; 382 pacemaker implantations; 173 ICD implantations; 63 biventricular pacemaker implantations; 145 biventricular ICD implantations; and 15 implantable loop recorder implantations.    The number of procedures per week varies. What is the primary goal of your program?    Our goal is to offer patients the latest, most up-to-date treatment options for atrial fibrillation. NMMC’s Atrial Fibrillation Center was established in 2008. However, for several years NMMC has led the region in treatment of atrial fibrillation with advanced mapping systems (EnSite system, St. Jude Medical, St. Paul, MN) to detect complex abnormal heart rhythms and state- of-the-art ablation techniques to correct them. NMMC’s electrophysiologists were the first to use a computer-generated, three-dimensional (3D) “virtual heart” to find the spot where abnormal heartbeats originate. The cardiac catheter system allows physicians to more quickly and accurately map electrical current inside the hearts of patients who have irregular heart rhythms. Treatment options include the Maze procedure, in which a device placed on the outside of the heart delivers ultrasound energy across the wall of the heart in an attempt to stop atrial fibrillation permanently. Energy sources for ablations include radiofrequency and cool-tip therapy. After treatment for atrial fibrillation, the patient returns to his or her primary care physician for follow-up care that can be coordinated, if necessary, with the electrophysiologist or cardiac surgeon. Through a unique collaboration between electrophysiologists and cardiac surgeons, patients are evaluated for the most appropriate treatment. NMMC’s electrophysiologists were also among the first in the nation to use cardiac resynchronization therapy. Who manages your EP lab?    Our EP lab is managed by Ophebia Pegues, RN, BSN. She has been a cardi- ology nurse for 19 years, and has served as charge nurse on cardiology units. She also facilitated and managed the cardiol- ogy device clinic, which involved inter- rogating pacemakers, ICDs and biven- tricular devices.That program increased in patient volume from approximately 350 patients to greater than 1,300 in a six-year span. Is the electrophysiology lab separate from the cath lab? How long has this been? Are employees cross-trained?    Yes, our EP lab is separate from our cath lab. It has been separate since 1998. Five of the nine EP staff members are cross-trained in the cath 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?    Our EP lab was the first in Mississippi and Tennessee to implement the PlasmaBlade (PEAK Surgical Inc., Palo Alto, CA). This product provides the precision of a scalpel and the bleeding control of traditional electrosurgery without the extensive collateral tissue damage. We are currently negotiating the acquisition of a laser lead extraction system.    The PlasmaBlade is useful for patients with chronic conditions that inhibit proper wound healing. It also minimizes compromising the integrity of leads during device exchanges. The laser lead extraction system would promote patient safety during lead extraction procedures. St. Jude Medical’s Velocity mapping system provides enhanced 3-D imaging during our pulmonary vein isolation procedures. Their Cool Path irrigation ablation technique is utilized for SVT, atrial flutter, and AF ablations. Cook Medical’s EVOLUTION® is our current product for lead extraction. Who handles your procedure scheduling? Do you use particular software? All EP patients are scheduled with our appointment clerk. A scheduling template was created using Microsoft Excel, and an additional schedule template is used in our electronic medical record. What type of quality control/quality assurance measures are practiced in your EP lab?    Surgical Care Improvement Project (SCIP) measures are monitored monthly. Currently we have a 100% compliance rate, which ensures that antibiotic timing is correlated with our incision time. We have a performance improvement project that monitors our effectiveness in ensuring that all first-case start times are before 8 a.m. How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies?    We have a Materials Management Team, which consists of two EP lab staff members who perform a weekly supply inventory. They submit their order request to our EP charge nurse, who then reviews and forwards the requisition to our invasive cardiology purchaser.    Routine purchases are the responsibility of the EP charge nurse. New acquisitions or proposals are the responsibility of the EP manager. Has your EP lab recently expanded in size or patient volume?    Yes, our atrial fibrillation ablation cases are increasing. How has managed care affected your EP lab and the care it provides patients?    Through managed care contracts, our organization has been able to increase the amount of coverage for patients in our region. Have you developed a referral base?    We are the only EP lab in our region. We receive patients from surrounding counties and cities. What measures has your EP lab implemented in order to cut or contain costs?    We have implemented a device formulary to standardize device cost among all vendors. We participate in platinum tip collection and reprocessing of our EP catheters, which allows an estimated monthly savings of $10,000. In addition, in what ways have you improved efficiencies in patient through-put?    With increased volume, we added a second room as well as more staff. We found that four 10-hour shifts provided better coverage for higher volume days and better staffing efficiencies. We also try to match the patient schedule based on the length of procedures. If we know we have a long case scheduled, we adjust the next patient appointment time accordingly. When we have one physician in the lab, we take advantage of using the second room as a flip room. Does your EP lab compete for patients? Has your institution formed an alliance with others in the area?    While our EP lab is the only one located in north Mississippi, patients do have the option of using an EP lab in Jackson, Mississippi, Memphis, Tennessee, or Birmingham, Alabama. We have not formed an alliance with others in the area. How are new employees oriented and trained at your facility?    New employees participate in behavioral interviewing by the EP team. They are assigned a preceptor for at least six weeks and must complete a skills competency checklist. The checklist allows for remediation if applicable. The remediation must be completed within 30 days. The employee has a formal 90-day evaluation. What types of continuing education opportunities are provided to staff members?    Our EP team is encouraged to participate in our annual cardiovascular and medical/surgical conferences, as well as to complete various computer-based testing provided by our facility. Every year one or two EP team members are given the opportunity to attend out-of- state EP-based programs or seminars. How is staff competency evaluated?    Everyone must complete an annual competency assessment, which is validated by another EP staff member. How do you prevent staff burnout?    We meet monthly to address issues, concerns and/or difficult cases. Many members informally meet weekly before work for devotion and prayer. What committees, if any, are staff members asked to serve on in your lab?    Two of our techs serve as radiation safety officers for the entire invasive cardiology department. They monitor radiation levels, inform staff and physicians of their levels, and manage radiation badges. Two serve as our EP Materials Management coordinators. Their responsibilities include maintaining a par level for EP catheters and assisting the charge nurse with ordering EP supplies. Everyone assists with logging in when new and reprocessing supplies are received. Two members monitor our EP schedule daily to ensure that anesthesia coverage is scheduled and that appointments are evenly distributed. Our EP team also participates in a Shared Governance Council, which comprises of members of the entire invasive cardiology department (i.e., cath lab, cath lab holding and cardiac observation unit). Inter-departmental issues are addressed in order to improve processes. Do you contract with vendors? How do you handle vendor visits to your department?    Yes, we contract with vendors. Vendors contact the EP manager to schedule visits. They must enter our facility through our facility’s purchasing office. They cannot enter without being issued an identification badge. Does your lab utilize any alter- native therapies?    We do allow soft music during cases. Please describe one of the more memorable cases that have come through your EP lab. What lessons did you learn from it?    There was a patient that presented to our EP lab for a device system extraction due to infection. During the extraction, a complication prompted resuscitation efforts. The patient received several units of blood before being escorted to emergency surgery. CPR continued en route to surgery. Our EP team and physician responded quickly, causing a miraculous outcome. The patient became alert within 24 hours after surgery and was discharged home within a week. His discharge disposition was comparable to his pre-admission status. How does your lab handle call time for staff members?    There is no call. Approximately what percentage of your ablation procedures are done with cryo? What percentage is done with radiofrequency? Atrial fibrillations ablations are done with cooled-tip irrigation. Approximately 90% of supraventricular ablations and atrial flutter ablations are performed with radiofrequency energy. Do you perform only adult EP procedures or do you also do pediatric cases?    We perform adult cases only. What measures has your lab taken to minimize radiation expo- sure to physicians and staff?    We use a radiation pad that reduces radiation exposure for the physicians and EP scrubber. We have large mobile lead shields/screens for the EP circulators. What trends do you see emerging in the practice of electrophysiology? How is your lab preparing for these future changes?    We foresee the need for a laser extraction system in order to provide a safer extraction of leads. We are discussing options with a company representative. What are your thoughts about non-EPs implanting ICDs?    At our facility, only our electrophysiologists implant devices. What about device recalls? How has your lab handled these?    Device recalls are scheduled by the cardiology clinic rather than the EP lab. Is your EP lab currently involved in any clinical research studies or special projects?    No. Does your staff provide any educational materials for patients who may have additional questions about their condition or procedure?    We have several pamphlets that are distributed related to pacemakers, ICDs and atrial fibrillation. We have also provided educational programs for the public about atrial fibrillation and have educational information available on our website. Give an example of a difficult problem or challenge your lab has faced. How it was addressed?    Because of moderate sedation concerns related to our patient population (i.e., co-morbidities, reduced ejection fractions), we have increased our anesthesia coverage to four days a week. Previously, anesthesia coverage was only available for our atrial fibrillation ablations. Currently, we can use them for any case. Describe your city or general regional area. How does it differ from the rest of the U.S.?    Tupelo is a rural area; however, we pull patients from a large geographic area. We depend on our referral network to support our program. We typically attract patients from a 30-county area of more than 750,000 people. Although Tupelo is a “small town,” North Mississippi Medical Center is “big city” when it comes to the medical care provided. Please tell our readers what you consider unique or innovative about your EP lab and staff.    Our EP team members are Ophebia Pegues, RN, BSN, Electrophysiology Lab Manager; Emily Hicks, RN, BSN, Charge Nurse; Stacie Young, RT(R); William Derek Starnes, RT(R)(N), CNMT; Lee Anderson, RT(R); Betty Ericson, RN; Curtis Rainey, RN; James David Minnis, RN; Jennifer McCraw, RN; and Melinda Osborn, RN. Our electrophysiologists are Dr. Karl Crossen, Dr. James Stone, and Dr. Keith Kyker. Our EP staff is relatively new to the EP lab. The most tenured has approximately five to six years of experience. We have worked diligently to create the right team with the right chemistry. We enjoy our work because we enjoy each other. Four members carpool to work. We fellowship after work hours. We visited our staff member Emily after the birth of her first son. We mourned with another staff member, Curtis, during the loss of his father; we attended the funeral, which was out of town, and supplied meals for one week. Our team has participated in several community service projects by supplying clothes to nursing home residents and giving clothes to a teenage boy whose family was experiencing financial hardship. We enjoy football games together, as well as an annual Christmas party. We always celebrate birthdays with some form of humor. The team gave me (the manager) a broom, because my birthday is on Halloween. Two years ago we began an annual “We’ve-Been- Together-For-A-Year” anniversary party, which is also attended by our EP physicians. We support each other’s lives. Our EP team has received several accolades since we make a concentrated effort to introduce ourselves and the rest of our staff to our patients, explain the procedure to the patient and/or family, and express our gratitude to them for choosing our facility. One of our patients was so touched by our service that he volunteered to be featured in a “CARES: The Calling” patient satisfaction training video filmed at our facility. In the video, he discussed how our service promoted a friendly and caring atmosphere. He stressed that our service is “a calling” or “ministry.” I feel our compassion to our community and each other makes us unique. I am proud to be a part of this GREAT team. For more information, please visit: http://nmhs.net/