Spotlight Interview

Spotlight Interview: Northwestern Medicine Central DuPage Hospital

Abby Doerr, APN, Manager, Neurointerventional Surgery and Electrophysiology, and Omeed Zardkoohi, MD, FHRS, Medical Director, Cardiac Electrophysiology, Bluhm Cardiovascular Institute West, Northwestern Medicine, Faculty, Northwestern Feinberg School of Medicine

Northwestern Medicine Central DuPage Hospital, Winfield, Illinois

Abby Doerr, APN, Manager, Neurointerventional Surgery and Electrophysiology, and Omeed Zardkoohi, MD, FHRS, Medical Director, Cardiac Electrophysiology, Bluhm Cardiovascular Institute West, Northwestern Medicine, Faculty, Northwestern Feinberg School of Medicine

Northwestern Medicine Central DuPage Hospital, Winfield, Illinois

Northwestern Medicine Central DuPage Hospital is a 392-bed acute care facility that has provided quality healthcare to the residents of DuPage County and beyond for more than 50 years. The hospital has been recognized as a 100 Top Hospital by Truven Health Analytics and as one of the best hospitals in Chicago by U.S. News & World Report. With more than 1,150 physicians on the medical staff in 89 specialties, the hospital is a regional destination for such clinical services as cardiology, cardiac surgery, oncology, neurology, orthopedics, and pediatrics. In February 2017, Northwestern Medicine Bluhm Cardiovascular Institute, ranked as one of the top ten Cardiology and Heart Surgery programs in the nation, expanded to Central DuPage Hospital to offer cutting-edge cardiovascular and EP services in Chicago’s western suburbs.

What is the size of your EP lab facility? 

There is 1 primary EP lab and 1 multi-modality room capable of performing EP, cath, and IR cases.

When was the EP program started at your institution?

The program began in June 1998.

What is the number of staff members? 

We have 2 RT(R)s, 1 CVT, 1 primary EP registered nurse (1.0 FTE RN open position), 2 nurses, and 2 RT(R)s cross trained in EP that float as needed.

What types of procedures are performed at your facility? 

Procedures include implants of pacemakers (including the leadless pacemaker) and ICDs (including the subcutaneous ICD), left atrial appendage (LAA) closure, and EP studies/ablations for SVT, ventricular tachycardia, and atrial tachyarrhythmias (such as atrial fibrillation, atrial flutter, and atrial tachycardia).

Approximately how many catheter ablations (for all arrhythmias), ICD implants, and pacemaker implants are performed each week?

We perform approximately 6-8 ablations, 3-5 ICD implants, and 3-6 pacemaker implants per week.

Who manages your EP lab? 

Abby Doerr, APN is the nurse manager.

Is the EP lab separate from the cath lab? 

EP has been a separate cost center since 1998, but over the years, there have been transitions from dedicated staff to cross trained staff. 

We are in the process of integrating the EP lab into the main interventional labs (Neuro IR/IR/Cath). We built a new EP lab in 2016 in the main interventional lab space, and will be sharing supplies and other expenses. We are also promoting cross training across all modalities to promote versatility of the staff and increase our depth of staffing coverage. 

Are employees cross trained? 

Yes, we have clinical staff trained to come into the EP lab, and our primary EP team members are being cross trained to other modalities within the interventional labs department (Neuro IR/IR/Cath). 

Do you have cross training inside the EP lab as well? 

Yes, our radiology technologists and CVT scrub, circulate, and run the stimulator/ablation equipment. RNs manage the patient (sedation) as well as circulate and run the stimulator/ablation equipment. 

What type of hospital is your EP program a part of? 

We are a community hospital affiliated with Northwestern Memorial Hospital, an academic medical center.

What types of EP equipment are most commonly used in the lab?

The types of catheters vary based on case necessity and physician preference. Mapping systems used include CARTO (Biosense Webster, a Johnson & Johnson company) and EnSite (Abbott). We use the Micropace EP cardiac stimulator.

How is shift coverage managed? What are typical hours (not including call time)?

Our team works a mix of 10-hour and 8-hour days. Our day typically starts around 7am and finishes around 5pm. We have assigned individuals to stay “late” to complete cases that are ongoing after 5pm. 

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

Our typical day begins with prepping and stocking the rooms for the day’s procedures. The flow of each day varies based on the cases scheduled and the physicians performing the procedures. The patients are prepped in the dedicated interventional lab pre-op area by our pre-procedure nurses and techs. Our team huddles with the physician and patient in the patient’s room prior to bringing the patient into the lab. This provides an opportunity for the patients and their families to meet all the staff who will be involved in the procedure. We update families every hour on the status of the procedure.

Our first patient is usually in the procedure room by 7:30am. The patient is prepped and the procedure is started. Our patients are taken for recovery to the dedicated interventional lab post-anesthesia care unit upon completion of the procedure. Once the procedure is done, the team and our dedicated environmental services tech turn over the procedure room and prepare for the next patient’s arrival. We often complete 2 or 3 procedures per day (per room) with the procedures being a mix of ablations, EP studies, and device implants. 

What new technology has been recently added to the EP lab? 

New technology includes cryoablation for atrial fibrillation (2016); left atrial appendage closure using the LARIAT procedure (SentreHEART, Inc.) as part of the aMAZE clinical trial (2017); leadless pacemakers (2017); UNIVIEW Module from Biosense Webster, enabling low fluoroscopy procedures; Zero-Gravity Radiation Protection System (BIOTRONIK); and CardioLab (GE Healthcare) hardware and software upgrades.

How have these technologies changed the way you perform procedures? 

We have experienced shorter procedure times, increased volume, broader treatment scope, and lower radiation exposure to patients and staff. 

What imaging technology do you utilize? 

We use the Siemens Artis Q.zen biplane.

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

Office/IL front desk staff manage procedural scheduling using EPIC.

What type of quality control and assurance measures are practiced in your EP lab?

We have implemented peri-procedural checklists to standardize care. In addition, we perform periodic sterile technique competencies for the staff, and all equipment is serviced periodically by Clinical Engineering using their standardized processes. Our procedural staff is required to perform annual competencies on ACT machines and glucose meters. The EP manager, medical director, director, and quality coordinator are members of a Continuous Process Improvement Team (CPIT) that meets monthly to collaborate on quality and operational initiatives. 

How is inventory managed at your EP lab? 

We utilize a frontline staff point person with dedicated resources from inventory management (shared with interventional labs). Inventory management handles the purchasing of equipment and supplies.

Is further expansion of your EP program planned? 

In August 2016, we opened a new lab with state-of-the-art technology and imaging. We hope to expand to a second dedicated EP lab in the next three years. Our patient volume continues to expand as our health system grows.

Have you developed a referral base? 

To help develop necessary relationships, our EP physicians have performed outreach to various clinics and hospitals in the region. These outreach endeavors have included Grand Rounds and other educational talks regarding complex ablation. We also have a large internal cardiology group at both Northwestern Medicine Delnor and Central DuPage Hospitals that refer patients to our EP program.

In what ways have you helped to reduce costs and improve efficiencies in the lab? 

We are transitioning from separate supply rooms for EP and Neuro IR/IR/Cath to gain economies of scale. We are in the process of implementing an RFID solution to manage supplies and expect a reduction in supply cost, lack of missing charges, and visibility of cost/case data. We are cross training across the lab to provide additional coverage without having to hire additional dedicated staff for EP. We have consolidated contracts from hospital level to system level to obtain more cost savings across the system. 

How do you ensure timely case starts and patient turnover?

Our team is empowered to ensure patients are in room and turned over in a timely manner. They are in direct communication with the physicians and pre-procedure nursing staff to ensure everyone is “ready” for the patients to load into the procedure lab. Additionally, we keep and track data from our electronic medical record system (Epic) regarding first case start times and other procedure tracking information. 

How are new employees oriented and trained at your facility?  

We have an extensive orientation to the procedure lab, as well as an EP-specific orientation led by our primary EP RN. This orientation includes moderate sedation, patient setup, pacing, ablation parameters, electrogram interpretation, product orientation, and basics of 3D mapping. Also, the EP medical director has monthly meetings with the staff as part of their continuing education.

What types of continuing education opportunities are provided to staff members?

The EP medical director, Omeed Zardkoohi, MD, gives monthly lectures to the EP staff. These lectures feature a combination of formal didactic information and practical case review from the prior months’ EP studies. The hospital also offers continuing education funding to attend EP conferences such as the annual Heart Rhythm Scientific Sessions and other local offerings. In addition, some of the staff have visited some other EP labs around the country.

How is staff competency evaluated? 

We utilize a variety of methods to verify competency, including testing, return demonstration, direct observation, audits, and verbal review.

Have members of your staff taken the registry exam for the Registered Cardiac Electrophysiology Specialist (RCES)? Does staff receive an incentive bonus or raise upon passing the exam? 

Not at this time. However, a review course and the exam cost are covered by the organization (up to $1000 annually).

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

We have an active staff engagement council that facilitates potlucks, birthday celebrations, and out-of-work activities. This council is also tasked to bring any concerns or suggestions regarding employee engagement to the executive council.

What committees, if any, are staff members asked to serve on in your lab? 

Committees include the Practice & Quality Council, Professional Development & Staff Engagement Council, Staffing Committee, housewide shared governance councils, and a Patient Safety Liaison group.

Do you contract with vendors? How do you handle vendor visits to your department? 

Yes, the Northwestern Medicine system engages in contracts with many EP vendors. We have a closed lab — vendors are invited for case coverage only. 

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

Music is utilized to ease any potential anxiety experienced by patients in our lab. 

Describe a particularly memorable case from your EP lab and how it was addressed.

We recently became a primary site for the aMAZE Trial, evaluating LAA ligation with the LARIAT Suture Delivery System (SentreHEART, Inc.) as an adjunctive therapy to pulmonary vein isolation. We performed our first two successful LARIAT left atrial appendage closure procedures on April 27, 2017. This highlighted the multi-specialty and multimodality collaboration among our outpatient and EP lab staff, research coordinators, inpatient care teams, and cardiologists.  

In addition, a recent atrial tachycardia ablation involved complex right and left atrial mapping, as well as non-coronary cusp mapping. Eventually, the successful termination site was ablation in the non-coronary cusp. We relied on our multimodality imaging technology, including 3D electroanatomic mapping and intracardiac echocardiography, to achieve a successful outcome.

How does your lab handle call time for staff members? 

Members of our team are required to take a select number of call days in various modalities based on their background. One team member takes interventional lab call (cath/IR); another with a neuro IR background takes neuro IR call. The nurses typically take neuro call. Additionally, the team takes “late” days, during which they are designated to stay after scheduled hours to complete cases that are still in progress. Once these cases are done, they are able to sign out for the day and are not “on-call”. 

Approximately what percentage of ablation procedures are done with cryo vs radiofrequency?

Thirty percent of cases are done with cryo, and the rest (70%) are performed with RF.

Does your lab use contact force sensing technology during radiofrequency ablation of atrial fibrillation? 

Yes, we use THERMOCOOL SMARTTOUCH catheters (Biosense Webster, Inc., a Johnson & Johnson company).

What are your thoughts on the use of the new oral anticoagulants (NOACs) in patients with non-valvular atrial fibrillation? 

The majority of our patients in the EP clinic and during EP procedures are on novel agents. We have specific protocols for perioperative NOAC management.  

What other innovative EP techniques are being utilized in your lab? 

Low fluoroscopy and zero fluoroscopy techniques have been implemented this year. This includes not only additional shielding, but techniques using mapping systems to reduce the need for fluoroscopy while performing safe and effective ablation procedures. In addition, this reduces the operator’s need to wear heavy lead, which has been shown to increase EP physicians’ risk of orthopedic injury.

Do you perform only adult EP procedures, or do you also do pediatric cases? 

Adult only. We are affiliated with a children’s hospital, where we refer the pediatric cases. However, we have several patients with adult congenital heart disease that have undergone successful ablations at our center, including ablations of atrial arrhythmias and WPW in patients with Ebstein’s anomaly as well as ablation of arrhythmias in Tetralogy of Fallot.

What measures has your lab taken to reduce fluoroscopy time? 

Over the past year, we have worked diligently to use technology and novel techniques to reduce the need for fluoroscopy during the EP procedures. Some of our atrial fibrillation and supraventricular tachycardia ablations involve either zero or extremely low fluoroscopy, which reduces patient and operator risk of exposure. Using 3D mapping systems and intracardiac echocardiography, we have seen a dramatic decrease in fluoroscopy time and dose.  

In addition, we have the Zero-Gravity suspended radiation protection system (BIOTRONIK) and the CATHPAX radiation protection cabin (Anthem Medical) for procedures that involve fluoroscopy. Our technicians are educated on standard radiation reduction approaches and ALARA principles.

What are your methods for device infection prophylaxis? 

We have patients use a pre-procedure HIBICLENS scrub (Mölnlycke Health Care) and Sage 2% CHG prep cloths (Stryker) at home, then we use Sage wipes and Triseptin scrub (CareFusion) in the pre-op area as well as pre-op antibiotics. TYRX Antibacterial Envelopes (Medtronic) are used in patients with identified risk factors for CIED infection.

How do you use the NCDR Outcome Reports to drive QI initiatives at your facility? 

We review the NCDR ICD registry at our quarterly quality improvement meeting, and this has led to improved data reporting and outcomes.

What are your thoughts on EHR systems? Does it improve your quality of care? 

It streamlines documentation and has future opportunities for capturing quality as well as process improvement data.

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

Decreasing fluoroscopy exposure to patients and staff is a trend that is gaining traction across the country. With new technologies, many EP labs have been able to reduce operator and patient exposure. We are fortunate to have such technologies, and we continue to strive for excellence in this arena. In addition, LAA closure is another dominant trend. 

How does your lab handle device recalls?  

There is a resource dedicated to recalls across the system. When notified of a recall, information is uploaded into an electronic system to inform the impacted departments. For EP-related recalls, inventory management pulls and works to replace any recalled product on the shelf. For implants that are recalled, the manager/director runs a report in Epic and then notifies the clinics. 

How is outpatient cardiac monitoring managed?

We have device clinics at Northwestern Medicine Central DuPage Hospital in Winfield, IL, Delnor Hospital in Geneva, IL, and recently, at Kishwaukee Hospital in DeKalb, IL. These device clinics are staffed by three device nurses. We have specific follow-up protocols for patients after device implantation, as well as protocols for managing silent atrial fibrillation detection in patients with a cardiac implantable electronic device (CIED).  

Is your EP lab currently involved in clinical research studies? Which ones?

We have been involved in three clinical trials since 2013: CROSS X4 trial (Boston Scientific), Cangaroo ECM Envelope (CorMatrix) Phase 4 registry, and the aMAZE trial (SentreHEART, Inc.).

We are actively pursuing additional research opportunities, and the expansion of the nationally-ranked Northwestern Medicine Bluhm Cardiovascular Institute to Central DuPage Hospital has been instrumental in our growth in clinical capabilities and research opportunities.

Are you ACGME-approved for EP training? 

We are currently not training EP fellows, but in the future, we would like to participate in the Northwestern Medicine EP fellowship program. Our EP physicians do participate in the EP fellows conference at Northwestern Memorial Hospital. 

Does your heart rhythm service offer patients with a suspected inherited arrhythmia a referral to cardiovascular genetics clinic?

Yes, we have a genetics department available for inpatient and outpatient consultation, and they often assist us in the management of patients with inherited cardiovascular disease.

Describe your city or general regional area. How is it unique from the rest of the U.S.?

DuPage County is one of the collar counties of the Chicago metropolitan area. With a population of approximately one million residents, DuPage County is Illinois’ second-most populous county. The socioeconomic status of residents varies from below the poverty line to some of the wealthiest in the Midwest. There are several colleges and universities within DuPage County, including the College of DuPage, Wheaton College, Benedictine University, Elmhurst College, and North Central College. 

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

The EP physicians are excited to come to work in the EP lab every single day, and the staff we work with make that possible. A recent patient sent Dr. Zardkoohi a letter after his experience after an ablation procedure in the EP lab, stating “the level of professionalism by your staff was truly incredible to watch.” 

In addition, we have had the benefit of institutional support for staffing and technology to expand the EP lab breadth and depth of EP procedures. This is made possible, to a large degree, by the strong relationships developed over time between our EP physicians and hospital administration.  

Finally, we have the opportunity to work closely with Albert C. Lin, MD, who splits his time between Northwestern Memorial Hospital and Central DuPage Hospital. The collaboration among the EP physicians within the Bluhm Cardiovascular Institute Central and West Regions, led by Patrick M. McCarthy, MD, Bradley P. Knight, MD, and Dr. Lin, have truly provided a catalyst for growth of our EP services and capabilities, and we hope to continue to expand.