Park Nicollet Methodist Hospital is a 426-bed facility located in Saint Louis Park, Minnesota — a suburb of Minneapolis. It is nestled along the beautiful Minnehaha Creek. Methodist was recognized as one of the nation’s Top 50 Cardiovascular Hospitals by Truven Health Analytics in 2017.
What is the size of your EP lab facility? When was the EP program started at your institution?
We currently have two electrophysiology rooms. The Specialty Center was built in 2005, but Methodist Hospital had an EP program combined with interventional radiology and cardiac cath lab prior to that. The EP staff has been a dedicated team since 2005.
What is the number of staff members? What is the mix of credentials at your lab?
We have 12 total staff: six RNs, four RT(R)s, and two CVTs. We had three electrophysiologists, and recently added a fourth this September!
What types of procedures are performed at your facility? Approximately how many catheter ablations (for all arrhythmias), ICD implants, and pacemaker implants are performed each week?
We perform all ablations, pacemakers, ICDs, and cardioversions. In 2016, we performed 21 EP studies without ablation, 158 SVT ablations (AVNRT, WPW/concealed BT, EAT, and atrial flutter), 100 atrial fibrillation (AF) ablations, 25 ventricular tachycardia (VT) ablations, and 24 AV node ablations. We performed 400 pacemaker (single, dual, BiV, Micra, and generator replacement) implantations and 145 ICD implantations. We also performed 21 loop recorder implants and 5 PFO/ASD closures. In addition, we performed 750 cardioversions under deep sedation. All of our MDs are certified to administer propofol, so we can perform our cardioversions independent from anesthesia, which improves efficiency and allows for greater flexibility in scheduling our patients’ procedures.
Who manages your EP lab?
Dr. Jay Simonson is the Medical Director of the EP Lab, and Kathy Westensee, RN is the Manager of the Interventional Labs (Cardiac Cath, Interventional Radiology, and Electrophysiology). Sonja Folven, RN is the team lead for EP, and Jessica Arneson is the Director of the Heart and Vascular Service Line.
Are employees cross-trained?
Currently, one RT(R) and one CVT are cross-trained to Interventional Cardiology.
Do you have cross training inside the EP lab?
Our EP nursing staff are trained to work in our Pre- and Post-Holding area as well as in Interventional Radiology, and all staff are trained to help with cardioversions. RNs are trained to circulate, monitor, and scrub. CVTs can monitor ablations and cardiac device implants as well as scrub ablations and devices. Radiologic technologists can run x-ray, scrub ablations and devices, and monitor devices.
What type of hospital is your EP program a part of?
We are a community facility. Two MDs travel to outreach locations once a month; this allows our physicians to easily reach our rural and suburban populations.
What types of EP equipment are most commonly used in the lab?
We use the Micropace Stimulator, catheters by Biosense Webster, Abbott, and Medtronic, the CARTO 3 mapping system (Biosense Webster, Inc., a Johnson & Johnson company), and almost exclusively Medtronic devices.
How is shift coverage managed? What are typical hours (not including call time)?
Staff work eight-hour shifts with rotating start times Monday-Friday. We also have late shifts (assigned staff stay until cases are complete). Staff are on a six-week schedule, and late shifts are assigned when the schedule is distributed. Dedicated EP staff do not take call except on long holiday weekends or to provide pacemaker implantation support.
Tell us what a typical day might be like in your EP lab.
A typical day in the EP lab starts at 7:00 a.m. Staff check the schedule, check the rooms (for supplies and daily defibrillator checks), and pull supplies for the first case. The second team comes in at 9:30 a.m. If they have a case at 10:00 a.m., they will pull supplies and prep their room for the first case. They will give breaks to the early staff. Most outpatients arrive in our Pre- and Post-Holding area, where they are prepped for procedures. Inpatients are prepped in their room or in our 19-bed Pre- and Post-Holding unit. We run most procedures with three staff: one RN, one CVT, and one RT(R), or two RNs and one RT(R). For an AF ablation or BiV implant, we utilize four staff. Patients (including inpatients) are recovered in Pre- and Post-Holding with the exception of ICU patients, who are covered in their ICU room. At the end of the day, staff will stock the rooms and help out other areas. Staff are trained to abstract and enter the NCDR ICD and AF registries.
What new technology has been recently added to the EP lab? How have these technologies changed the way you perform procedures?
With our equipment remodel, we added a new storeroom that can be accessed through each EP procedure room, which has allowed us to reduce par levels as well as have easier access to frequently used products. We also added two AlluraClarity systems (Philips), which have helped with clearer images as well as with reducing fluoroscopy time and exposure. We added a surgical light, and are performing TAVR procedures two days per month in the FD20 room.
What types of cardiac mapping systems do you utilize?
We utilize the CARTO 3 mapping system (Biosense Webster, Inc., a Johnson & Johnson company), CardioLab recording system (GE Healthcare), and the Micropace stimulator.
What imaging technology do you utilize?
We use the Allura Xper FD10 and FD20 systems, and AlluraClarity (Philips). For intracardiac ultrasound, we use the ACUSON SC2000 Ultrasound System (Siemens Healthineers).
Do you implant MR conditional pacemakers or ICDs? What about subcutaneous or leadless devices?
We implant both MR conditional pacemakers and ICDs. We also implant the leadless pacemaker (Micra Transcatheter Pacing System, Medtronic) and have the ability to implant subcutaneous devices.
Who handles your procedure scheduling? Do they use particular software?
We have a dedicated EP scheduler, Holly Vanderberg, who primarily uses EPIC in conjunction with Centricity (GE Healthcare) and Outlook (Microsoft) for the physician schedules as well as for scheduling clinic and lab procedures for inpatients and outpatients.
What type of quality control/assurance measures are practiced in your EP lab?
We perform monthly audits on ACT machines, monthly sedation audits in the CardioLab, monthly QCs on our glucometers, and daily temperature tracking for our medication fridges in all lab procedure rooms. In addition, we perform yearly audits on staff lead aprons. Annual badge reports are shared with staff, and the dosimeters are changed monthly.
How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies?
Supplies are managed by our Inventory Specialists. They are also responsible for purchasing special order items. During each case, radiologic technologists utilize a scanner for products, which is managed by our supply room and the Lawson software. The RT(R)s work closely with our supply room to make sure par levels are on track for inventory and that supplies are ordered in a timely manner. The RT(R)s also bill for each procedure. Every month, the nurses and rad techs complete a full count of inventory in each room. We also utilize a Kanban system with our central supply services for patient care items such as gauze, bandages, dressings, etc.
Has your EP lab recently expanded in size and patient volume, or will it be soon?
In January 2018, we will open an OR Hybrid room where we will perform laser lead extraction procedures. We are also adding the WATCHMAN procedure (Boston Scientific) in December 2017.
In what ways have you helped to cut/contain costs and improve efficiencies in the lab?
We reprocess/recycle diagnostic catheters from each procedure. Our staff also wait to open certain products and supplies for each procedure to make sure it will be used, rather than open all items prior to the procedure. Additionally, a new shared EP supply room allows us to have combined inventory for our rooms, resulting in savings. Also, our Cath/IR staff support us for staffing needs.
How do you ensure timely case starts and patient turnover?
A resource nurse coordinates the flow of the day. We also use block scheduling for each procedure We recently completed timings of turnover and case start times.
How are new employees oriented and trained at your facility?
New employees go through a two-day hospital orientation, and then are scheduled with a clinical resource staff mentor who acts as their preceptor. We utilize a skills checklist to monitor progress. The average orientation is 12 weeks, but is individualized based on their background.
What types of continuing education opportunities are provided to staff members?
We send 2-3 staff each year to the Heart Rhythm Society’s (HRS) Scientific Sessions. Our Clinical Nurse Educator, Kavitha Malango, RN, MSN, coordinates educational in-service opportunities, and the physician group is very supportive of educational opportunities on a case-by-case basis.
How is staff competency evaluated?
Our Cardiovascular Educator holds yearly skills days along with validation competencies. We also have online mandatory learning modules each year. Physicians provide education for new procedures or techniques.
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?
We currently have three RNs who hold IBHRE (International Board of Heart Rhythm Examiners) certification: Lisa Whitcomb, Faith Bayeur, and Sonja Folven. Kim Jensen, RN has her PCCN certification. Landan Grejtak, CVT and Terasa Bonifas, CVT have RCIS certifications. Staff receive an annual bonus for certifications, and receive reimbursement for the exam upon passing.
How do you prevent staff burnout? Do you also practice any team-building exercises?
We have staff rotate roles within their scope of practice. We also rotate late shifts. We celebrate birthdays, years of service, nurse’s week, radiologic technology week, and CVT week, and several of our staff members participate in our Unit-Based Quality Team.
What committees, if any, are staff members asked to serve on in your lab?
Staff are encouraged to serve on committees. We have staff members involved in Code Blue, Infection Control, Nursing Care Delivery, Nursing and Clinical Practice, Nursing Informatics, Quality and Safety, and Be Well committees. We also have a Unit-Based Quality Team for our floor, and we rotate members every 2-3 years.
How do you handle vendor visits to your department? Do you contract with vendors?
Vendors sign in with Reptrax. Our purchasing department sets up the contracts. The manager or physicians approve department visits.
Does your lab utilize any alternative therapies to help patients in the EP lab?
We use music and aromatherapy in our labs. We use warm blankets for patient comfort. Staff are dedicated to patient excellence and comfort during their procedure.
Approximately what percentage of ablation procedures are done with cryo vs radiofrequency?
We use radiofrequency only.
What measures has your lab taken to reduce fluoroscopy time? In addition, what types of radiation protective shielding and technology does your lab use?
All staff wear lead aprons and glasses during procedures. Lead is scanned annually for cracks and holes. The circulating nurse and physician utilize a moveable lead shield for ablation. We log radiation exposure for each procedure. For pacemakers and ICDs, the physicians use the RADPAD (Worldwide Innovations & Technologies) and lead gloves.
What are your methods for device infection prophylaxis?
Every pacemaker pocket is irrigated with an antibiotic solution. Each patient receives an antibiotic dose prior to incision and post procedure. Some high-risk patients are given a TYRX antibacterial envelope (Medtronic).
How does your lab handle device recalls?
The device clinic is aware of recalls. They contact the device companies for replacement and management of the device.
How is outpatient cardiac monitoring managed?
Patients are followed closely in the device clinic, as well as with Medtronic CareLink, the ZIO Patch (iRhythm Technologies), Holter monitors, and implantable loop recorders.
Is your EP lab currently involved in clinical research studies? Which ones?
- CABANA: Catheter Ablation Versus Anti-arrhythmic Drug Therapy for Atrial Fibrillation Trial
- Product Surveillance Registry (PSR) - Medtronic
- Attain Performa LV lead models still enrolling under the PSR
- 106 patients
- ICY-AVNRT (Intracardiac CrYoablation for AtrioVentricular Nodal Reentrant Tachycardia) Study (Medtronic)
- SureScan Post-Approval Study (Medtronic)
- Stroke AF (Medtronic)
- Medtronic Attain Stability: active fixation CS/LV lead study
Previous significant studies we have been involved in:
- AFFIRM (Atrial Fibrillation Follow-up Investigation of Rhythm Management)
- SCD-HeFT (Sudden Cardiac Death in Heart Failure Trial)
- Ensure CRT (Medtronic)
- Left Ventricular Capture Management study (Medtronic)
- PREFER (Pacemaker Remote Follow-Up Evaluation and Review) (Medtronic)
- Dynamic Discrimination Download Study (Medtronic)
- Model 4396 Left Ventricular Lead Study (Medtronic)
- BLOCK HF (Biventricular Versus Right Ventricular Pacing in Heart Failure Patients with Atrioventricular Block) (Medtronic)
- Shock-Less (Medtronic)
- AdaptivCRT (Medtronic)
- Electrocardiographic Feedback for CRT Response (Medtronic)
- Attain Performa (Medtronic)
- Evera MRI ICD – MRI conditional FDA approval study (Medtronic)
- PACE-MI Registry Study (stopped early in April 2009 due to enrollment)
- ICD Sports Registry
- NAVISTAR THERMOCOOL Catheter for the Radiofrequency Ablation of Symptomatic Paroxysmal Atrial Fibrillation (Biosense Webster) (ongoing)
- INOVATE-HF (Biocontrol Medical) (ongoing)
- VENTURE-AF (Janssen, Bayer)
Describe your city or regional area. How is it unique?
Saint Louis Park is a thriving suburb of Minneapolis. It has easy access to the freeways and the popular Lake Calhoun. Many runners and bikers use this lake as it connects to the many bike trails in Minnesota. The lake is exactly 3.1 miles around, and you can find young and old alike spending their time there. Minnesota is known as the “Land of 10,000 Lakes” and “Minnesota nice.” It is said we have two seasons here: winter and construction. Minnesotans are looking forward to having visitors during the 2018 Super Bowl at the new U.S. Bank Stadium.
Please tell our readers what you consider special about your EP lab and staff.
We are a small and dedicated group, and we truly consider ourselves family. We have great relationships with one another, the physicians, clinicians, as well as our patient population. We are very cohesive and value teamwork. Our physicians are deeply invested in staff education and excellence, and they encourage team certification. They provide staff education and quarterly team meetings to discuss all issues facing the department.