Novant Health is an integrated network of physician clinics, outpatient facilities, and hospitals that delivers a seamless and convenient healthcare experience to communities in Virginia, North and South Carolina, and Georgia. Named in 2017 by Becker’s Hospital Review as one of the nation’s 150 best places to work in healthcare, Novant Health network consists of more than 1,500 physicians and over 28,000 employees that provide care at over 580 locations, including 14 medical centers and hundreds of outpatient facilities and physician clinics. In 2017, the health system provided more than $789 million in community benefit, including financial assistance and services.
When was the EP program started at your institution?
Novant Health Forsyth Medical Center’s EP program began in 1998 under the leadership of Mark Mitchell, MD.
What is the size of your EP lab facility? Where is the EP lab in relation to the catheterization department?
Our lab utilizes three procedure rooms, two of which are fully dedicated to electrophysiology. One lab room is shared with the catherization department. The EP and cath labs are located on the same floor within the same procedural area. The EP and catherization labs are two separate departments that collaborate for patient care and support each other on high-acuity patients.
What is the number of staff members? What is the mix of credentials at your lab?
After its founding, the electrophysiology program at Novant Health grew quickly and is currently supported by four physicians: Mark Mitchell, MD, Michael Drucker, MD, and Lai Chow Kok, MD (our current EP lab physician director), all three of whom completed their EP fellowship at the University of Virginia. In 2014, Bryon Rubery, MD joined the team. Dr. Rubery was the EP lab program director and assistant professor at Wake Forest Medical School before he joined the team at Novant Health Forsyth Medical Center. In addition to the providers that see patients in the hospital and clinics, the EP team is comprised of 10 full-time team members, including six registered nurses, two RNs, two RTs, and two RCISs.
What types of procedures are performed at your facility? What types of complex ablations are performed?
Novant Health Forsyth Medical Center’s EP team performs a wide array of procedures daily. This includes implantations of loop recorders, permanent pacemakers, leadless single-chamber pacemakers (e.g., Micra transcatheter pacing system, Medtronic), ICDs and biventricular ICDs, and subcutaneous ICDs. In addition, Dr. Drucker implants the remedē® System (Respicardia), a transvenous neurostimulation device that is used to treat patients with central sleep apnea.
Other procedures include WATCHMAN Device (Boston Scientific) implantations as well as patent foramen ovale, atrial septal defect, and ventricular septal defect closures. Laser lead extractions are performed in the OR using an excimer laser system with a CVOR surgeon in the room on standby. We also perform complex ablations for atypical atrial flutter, atrial tachycardia, atrial fibrillation (AFib), PVCs, and ventricular tachycardia.
Approximately how many catheter ablations (for all arrhythmias), device implants, lead extractions, and left atrial appendage (LAA) closures are performed each week?
What percentage of your lab’s device implants use MRI-conditional pacemakers or ICDs? What percentage of implants use subcutaneous or leadless devices?
All new transvenous pacemakers and defibrillators being implanted are MRI-conditional devices. About 5 percent are subcutaneous ICD implants, and 5 percent are leadless pacemaker implants.
Who manages your EP lab?
Linda Harris, RN, MSN is our director of cardiac procedures. Sue Lippow, RT(R), RDCS has been the EP lab manager for the past 12 years. Rebekah Phillips, RN, BSN is the lab supervisor and has worked in the EP lab for nine years.
Are employees cross-trained?
Currently, two team members in each department are cross-trained and able to “float” between departments as needed.
What type of hospital is your EP program a part of?
Novant Health Forsyth Medical Center is part of a multi-state, not-for-profit, community-centered healthcare network.
What types of EP equipment are most commonly used in the lab? What imaging technology do you utilize?
The lab utilizes devices from Abbott, Boston Scientific, BIOTRONIK, and Medtronic. The two 3D mapping systems used in the lab are CARTO (Biosense Webster, Inc., a Johnson & Johnson company) and EnSite Velocity (Abbott). We use Medtronic technology for cryoablation, and the Maestro 4000 Cardiac Ablation System (Boston Scientific) for radiofrequency (RF) cases. We also use the EP-4 Cardiac Stimulator (Abbott). In addition, we utilize force-sensing catheters for complex ablations.
We use diagnostic catheters from Biosense Webster, RF ablation catheters from Boston Scientific, and computer-based charting from GE Healthcare. This links into Dimensions (Epic), our hospital’s EMR system. We have three different intracardiac echo machines: ACUSON (Siemens Healthineers), Ultra ICE (Boston Scientific), and Zonare (Abbott). We have fluoro systems from Siemens Healthineers in all three labs. The Site~Rite Ultrasound System (Bard) is used to aid vascular access.
What new technologies have recently been added to the EP lab, and how have they changed the way you perform procedures?
Cryoablation for AFib ablation has significantly improved efficiency and patient access. Because of the shorter AFib procedure duration with cryoablation, there is no need to place Foley catheters in patients, and they also recover more quickly with a shorter duration of general anesthesia.
The introduction of the Micra TPS system (Medtronic) has also been welcomed by patients. As a result, our patients now need only four hours of bedrest instead of 12 hours. No arm sling is needed due to arm restrictions, and they no longer need a next-day post-op chest x-ray.
How is shift coverage managed? How does your lab handle call?
Our lab is supported by full-time positions. Eight team members work four 10-hour shifts a week, while two staff members work five 8-hour shifts.
Tell us what a typical day is like in your EP lab.
Our lab typically sees 8-10 cases per day. During each shift, we have two physicians in the lab, rotating through three procedure rooms. One physician will perform complex ablations, while the other physician performs straightforward ablations and implants. Team members working on the unit are assigned to the physician and not the procedure room, so that the staff can assist in staying a case ahead for the proficiency of the lab.
Who handles procedural scheduling?
Scheduling for EP procedures is handled in the physician offices in collaboration with the EP supervisor.
How is inventory managed?
Inventory for the cath and EP labs is managed through the Department of Cardiac Procedures.
Have you developed a referral base?
With more than 1,500 physicians, Novant Health has a vast internal referral network. In addition to Novant Health referrals, our physicians are actively engaged with the cardiology section and the primary care network. Our team provides teaching to non-EP physicians, hosting a twice-yearly learning symposium for nurses, cardiologists, CT and vascular surgeons, and primary care providers. Our physicians speak at this dinner program, and attendees receive credit for continuing education. It has proven to be a nice format to discuss relevant practices pertaining to the care of the EP patient. Our physician team is also very active in the community, providing lectures and educational opportunities that have generated patient referrals.
In what ways have you cut or contained costs and improved efficiencies in the lab?
Novant Health has implemented a variety of strategic sourcing practices to reduce cost. From a supply perspective, we reprocess our diagnostic EP catheters and intracardiac echo (ICE) catheters as part of cost containment. Efficiency reports and targets are reviewed on a monthly basis to ensure compliance and to identify any trends that may impact our efficiencies.
How do you ensure timely case starts and patient turnover?
Our lab implemented a patient case time sheet that lists all patient interactions in detail. Tracking procedure, physician, blood draw, and other interactions helped our team determine where inefficiencies took place and how we might improve performance in that area. Last month, we achieved 98 percent compliance with our first case start times.
How are new employees oriented and trained at your facility?
All team members at Novant Health receive a multi-day intensive initial orientation. Once employees arrive on floor, they are assigned a preceptor for the duration of their three-month department orientation.
What types of continuing education opportunities are provided to staff? How many of your staff members attend medical conferences each year?
Our physicians and vendors are outstanding in providing educational opportunities. In addition to vendor education and industry conferences (e.g., SASEAP), our physician team provides monthly teach-ins for the department.
How do you prevent staff burnout and turnover? What approaches do you use for team building?
Team member resiliency is a priority for Novant Health. Our team members benefit from resiliency retreats for physicians and nurses across the organization. Team building is important to our department. We understand that sometimes life happens outside the workplace, and we work to create scheduling flexibility so that our team members can enjoy special events with their family and friends. Our team gathers socially a couple of times a year. Past outings have included bowling, a day at the lake, GoPro go kart racing, chicken stews, and holiday festivities. We are blessed to have such a great group of team members and physicians.
What committees are staff members asked to serve on in your lab?
Our committees include Magnet, joint practice, career ladder, quality and safety, procedural unit continuous improvement committee (UCIC) and EP lab UCIC, and nursing research.
How do you handle vendor visits to your department?
All vendors are approved via Vendormate. We schedule vendor appointments to the hospital. Vendors must always have a visible badge printed from Vendormate, and wear a red hat.
Describe a particularly memorable case from your EP lab and how it was addressed.
We had the wonderful privilege to care for a married couple that ended up getting scheduled for their procedure on the same date. All the team members throughout the facility worked together to make sure that this couple could be as close as possible. We made sure that the husband got to see the wife post-procedure while he was getting prepped for his procedure. We kept the family updated via phone and through face-to-face updates as well. We made sure that both patients were located on the same pre- and post-procedure units. As they both had to spend the night, we worked to get them on the same floor and not too far away from each other. The family was very appreciative, telling us they could see the true heart in what we do here at Novant Health Forsyth Medical Center and that we were “all a blessing from God.”
Does your lab use a third party for reprocessing or catheter recycling? How has it impacted your lab?
We use a third party for reprocessing our diagnostic EP catheters and ICE catheters. We performed an internal survey on the quality of reprocessed ICE catheters compared with new ones, and found no significant difference in the image quality. We use Stryker Sustainability Solutions for our diagnostic catheters, and Sterilmed for AcuNav catheters. We also send our catheter tips for platinum recovery.
Approximately what percentage of ablation procedures are done with cryo vs radiofrequency?
Approximately 80 percent of cases are done with cryo, and the other 20 percent are done with RF.
What are your techniques for LAA occlusion? Do you have a primary approach?
We occlude the left atrial appendage with the WATCHMAN Device (Boston Scientific) using TEE guidance. Although we only started doing this procedure in September 2016, our program has seen rapid growth, becoming one of the most active WATCHMAN programs in the Southeast (61 procedures completed to date).
What are your thoughts on the use of NOACs in patients with non-valvular AFib?
NOAC/DOACs have revolutionized anticoagulation for atrial fibrillation. Several advantages have been noted. Each NOAC/DOAC has a different strength/weakness profile. In general, these medications are associated with lower rates of stroke and cerebral hemorrhage compared to warfarin. In addition, patients can eat vitamin K-rich foods without restriction. There is no need for routine lab draws and there are fewer medication interactions. The transition on and off anticoagulation for surgical/medical procedures is also much easier, and the timing of anticoagulant interruption for these procedures is shorter. Lack of reversibility was a concern early on, but reversal agents are now available for dabigatran, rivaroxaban, and apixaban.
Do you utilize lifestyle modification as therapy for your patients with atrial fibrillation?
Lifestyle modifications are important in the management of patients with atrial fibrillation. Assessment of alcohol and stimulant use (nicotine, caffeine, and recreational stimulants) is important. Limiting the use of these substances may reduce the frequency of atrial fibrillation. We’ve seen many patients who are heavy drinkers have resolution of their atrial fibrillation with alcohol cessation. Many have been referred for ablation and have not been assessed for alcohol use prior to referral.
Weight management is another important area; in 2015, it was demonstrated that overweight AFib patients who lost 10 percent of their body weight had a very significant reduction in symptomatic atrial fibrillation, with reduced need for procedural intervention. Also, assessment and treatment of sleep apnea is helpful in managing patients with AFib, and should be done early in the course of treatment.
What measures has your lab taken to reduce fluoroscopy time? In addition, what types of radiation protective shielding and technology does your lab use? What percentage of your cases are done with a fluoroless approach?
We keep our frame and pulse rates low (at 7.5) to minimize the amount of radiation that is delivered to our patients and team members. All procedure rooms are equipped with standard lead-lined drapes and gowns for our team members. Our physicians have a Zero-Gravity suspended radiation protection system (BIOTRONIK) to help with fatigue, allowing for thicker lead usage. All of our procedures use fluoroscopy with 3D mapping systems, decreasing the amount per procedure.
What are your methods for device infection prophylaxis?
Patients are educated on infection prevention as part of the procedure clearance process. Our team employs Dyna-Hex and Sage cloths to sterilize the field. In advance of an implant procedure, patients are given pre-operative antibiotics. At the time of the procedure, the device pocket is flushed with antibiotic and saline solution.
What are your thoughts on EHR systems? Does it improve your quality of care?
We have seen an improvement in patient care since implementation of our EHR. This improvement is largely due to better communication between healthcare providers as well as between providers and their patients. In addition, we are more readily able to track data regarding patients’ medications, anticoagulation status, and emergency room visits.
What are some of the dominant trends you see emerging in the practice of electrophysiology?
Some of the most influential trends include alternative forms of energy for ablation procedures and having the ability to more consistently and reliably map complex arrhythmias with the advancement of computer technologies/engineering.
Do you utilize remote monitoring of CIEDs? What clinical and economic benefits have you seen? What tips do you have for adopting a remote monitoring program?
Our lab was an early adopter of remote monitoring for CIEDs, so most of our patients (over 95 percent) are using remote monitoring. Remote monitoring has several advantages. First of all, it is easier to track device function and to assess compliance with monitoring. If a patient has a clinical episode (e.g., a shock from an ICD, or a syncopal episode), we can get prompt analysis of the device function and assess the stored data to determine if the event was arrhythmic or due to device malfunction. This early acquisition of data enables us to more quickly and appropriately triage patients. Also, remote monitoring allows us to determine if a patient has increasing AFib burden. New-onset AFib is frequently identified on remote monitoring in asymptomatic patients. This allows earlier identification of the arrhythmia as well as earlier assessment for stroke risk and implementation of stroke prevention strategies.
Is your EP lab involved in clinical research studies?
Yes, we participate in the SMART CRT study by Boston Scientific, and the Plexa and QP ExCELs studies by BIOTRONIK. Studies that are completed but remain in follow-up include the Protego study by BIOTRONIK, S-ICD studies by Boston Scientific, and WRAP-IT study by Medtronic. We are also participating in an after-market registry for Respicardia.
What is considered historic about your EP program or hospital? Has your program or hospital recently experienced any “firsts”?
Novant Health Forsyth Medical Center was the first lab in North Carolina to implant the subcutaneous ICD, and was one of the 35 centers in the U.S. implanting S-ICDs for the trial. Our facility was also one of 25 in the U.S. utilizing the remedē® System (Respicardia) prior to its FDA approval.
Please tell our readers what you consider special about your EP lab and staff.
Novant Health Forsyth Medical Center uses a partnership model. That means each administrator has a physician partner that co-leads the department. The partnership model creates a workplace that places patient care at the center of every decision. Our department in particular has a demonstrated spirit of research, innovation, and growth.