Spotlight Interview: Prairie Heart Institute

Kriegh P. Moulton, MD
Springfield, Illinois

Kriegh P. Moulton, MD
Springfield, Illinois

The Prairie Heart Institute (PHI) combines the 55-member Prairie Cardiovascular Consultants with St. John’s Hospital and is based in Springfield, Illinois’ capital city. St. John’s is a 500-bed tertiary care referral facility, one of 13 member-hospitals of the Hospital Sisters Health System, and offers a wide spectrum of medical and surgical specialties including a Level IV Trauma Center, Maternal and Child Care, Orthopedics, Interventional Neurology, and Cardiology. It is the city’s fourth largest employer. 

PHI serves as a focal point for cardiovascular care in the central two-thirds of the state, providing consultative services for 33 communities with six satellite centers encompassing 30, mostly rural, counties.

The referral base is a population of 1.5 million.

Research within our system is led by the Prairie Educational Research Cooperative, offering a wide range of services including clinical trial management and a complete staff of project coordinators for in-house research, and acting as a CME provider.

What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab?

We have two dedicated EP labs. There are five cardiac electrophysiologists: Kriegh Moulton, MD, Director of Cardiac Electrophysiology, Brian Miller, MD, James Mullin, MD, Ziad Issa, MD, and Bernard Lim, MD. The EP staff is a dedicated group within the cardiac catheterization lab. Within cardiac catheterization, we have ten RNs, sixteen RT(R)s, and eight CVTs. Of those, two RNs, four RT(R)s, and two CVTs are dedicated to EP.

When was the EP lab started at your institution?

Cardiac electrophysiology services began in 1989 and incorporated catheter ablation in 1991. Device implantation by electrophysiologists began in 1993.

What types of procedures are performed at your facility?

Cardiac rhythm management services include all forms of diagnostic electrophysiologic testing and therapeutic options such as catheter ablation, lead extraction, and device implantation.

Our first atrial fibrillation ablation was done in 2001 and was limited to biplane fluoroscopy with contrast injections using the Bordeaux technique. With the advent of electroanatomic mapping in 2006, the incorporation of pre-procedure CT imaging and refinement of technique, the process has been greatly simplified. Currently, we perform about two to three per week on average. Anesthesia loads the case at 7 a.m. (or noon), and the case gets underway at 8 a.m. (or 1 p.m. for afternoon cases). Cases usually take about two hours (not including an hour of anesthesia prep time), and patients are recovered in the surgical cardiac recovery unit before discharge from the telemetry unit on the following day. Unless warfarin is indicated for other reasons (mechanical valve), direct thrombin or Factor Xa inhibitor usage has helped simplify the transition from the procedure to re-anticoagulation prior to discharge.

With regard to devices, PHI electrophysiologists perform more new implants in Illinois than any other group. All device implants are performed in any of the eight labs. This includes those associated with AV junctional ablations. We routinely implant products from all three of the largest U.S. manufacturers.

Virtually all lead extractions are accomplished using the laser technique. Mechanical methods are rare and usually reserved for heavily calcified subclavian regions. The five years that we have been performing extractions coincides with a period during which the need to extract either malfunctioning or potentially threatening leads has become increasingly evident. As a result, infection represents a minority indication, roughly 10–15%, which we would also like to attribute to best practice implant behaviors. Pacemaker and ICD leads are equally represented while twice as many ventricular pacing leads are removed when compared to atrial leads. The average duration of the extracted ICD lead is 5.5 years, while that of atrial and ventricular pacing leads is 13 and 17 years, respectively. Extraction of coronary sinus leads is done infrequently, but is generally not a problem.

How many EP procedures are performed each week?

The procedure load at PHI has varied little in the past three years. Typical annual figures include 3,100 total EP procedures involving 1,250 patients. We perform about 1,100 device implants each year, which includes generator replacements. Atrial fibrillation cases total about 120.

A little over half of our procedures are processed through outpatient services with the majority of them being discharged the same day.

Who manages your EP lab? Who handles your procedure scheduling?

Jenny Chambers, RT(R) is the catheterization lab manager, and Barbara Smith, RN, BSN is the EP facilitator in charge of EP staffing and schedule management.

Are employees cross-trained?

Currently, the EP staff is not separate from the catheterization lab staff. All EP staff start in the cardiac catheterization lab and rotate through EP as part of the general orientation. The EP staff derives from those members who express a desire to dedicate time and skill sets to electrophysiology. We feel very lucky to have physicians who dedicate their own time to further the EP staff education.

What are the regulations in your state?

In Illinois, a radiologic technologist must be present in the room when ionizing radiation is being administered, and they may scrub, monitor, or circulate cases. Registered nurses are to administer all drugs. RNs may scrub, monitor, circulate, and administer drugs. Cardiovascular technicians may scrub, monitor, and circulate cases.

What new equipment, devices and/or products have been introduced at your lab lately?

Both dedicated EP labs have digital biplane imaging. Within the last five years we have upgraded our biplane fluoroscopy to Philips Allura Xper FD flat panels in both EP labs. Both have “low dose” programming with pulse fluoroscopy. In addition to general cardiac cine capabilities, we have as low as 3 fps rates available. In addition to obtaining traditional multichannel bipolar catheter recordings, we enjoy the latest versions of both EnSite NavX and Array (St. Jude Medical) and Carto (Biosense Webster, Inc.) for electroanatomic mapping when needed.

How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies?

We have two dedicated inventory specialists. We also have a dedicated purchasing agent. The purchase of any new equipment must be approved by a committee that consists of our purchasing agent, the cardiovascular product line manager, and co-directors of the cardiac catheterization lab.

What measures has your EP lab implemented in order to cut or contain costs? In addition, does your lab use a third party for reprocessing?

Our EP lab is constantly vigilant in looking for ways to cut or contain costs. Barb Smith, our EP facilitator, looks at our schedule the day before and adjusts staff according to need. The EP staff and physicians are always looking at and discussing current volumes of products and adjusting for need. For example, a substantial number of ablations are carried out within the right atrium and right ventricle. This requires a large curve ablation catheter with a 5 mm tip electrode — a workhorse catheter. We are in the process of trying such catheters from the major manufacturers to determine if we can negotiate a better price for the best catheter. We are also using Stryker to reprocess the appropriate equipment and save on the cost of new inventory.

In what ways have you improved efficiencies in patient through-put?

The most recent change in practice pattern involves initial device implants, which we are now undertaking same-day discharges. Exceptions include pacemaker-dependent patients, those requiring re-anticoagulation, and anyone in whom there might be a suspected complication.

What types of continuing education opportunities are provided to staff members? Also, how are new employees oriented and trained at your facility?

All of the lab personnel attend both the Basics and Beyond the Basics courses of the Order and Disorder EP Training Program (www.orderanddisorder.com). In addition, all employees go through a four-day comprehensive EKG class as well as a hemodynamics class. We also have an orientation check-off list specific to EP for new employees. Other programs, particularly those which are device oriented, are encouraged as well.

We schedule a one-hour didactic education period, usually at 7 a.m. on Wednesday mornings, twice monthly, taught by the EP physicians. These involve slide presentations of a wide array of topics including reviews of common clinical problems encountered in electrophysiology, tracing review/discussion, and basic and advanced electrophysiologic principles. Often the best time to educate is during a case when an important principle or interesting observation can be witnessed. In such cases, operation of the stimulator by the staff member and directly making measurements on the screen makes the experience more memorable. When possible, members of the staff also attend the Heart Rhythm Society’s annual sessions.

How do you prevent staff burnout?

The EP staff is a tight-knit group of individuals. Most share professional and personal interests. They often set aside time to go to the movies or theatrical performances or to share a meal.

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

The vast majority of patients are age 18 or older. Although we do not have a pediatric electrophysiologist on staff, one of our physicians has had prior pediatric experience and performs diagnostic and therapeutic procedures on patients under age 18.

What innovative EP techniques are being utilized in your lab?

Our most recent procedure additions include SentreHEART’s LARIAT® procedure to percutaneously ligate the left atrial appendage, and participating as a center for CardioFocus’ HeartLight® laser balloon for pulmonary vein isolation. A new Spectranetics’ laser sheath, the GlideLight®, is also now in operation.

Does your lab provide educational materials for patients?

Most of the patient educational materials are issued at the time of the clinic visit that would predate the procedure. Instructional materials outlining signs and symptoms of potential complications as well as wound care recommendations are given to all outpatients upon discharge.

Describe a particularly memorable or bizarre case that has come through your EP lab. What lessons did you learn from it?

We had a percutaneous removal of an intracardiac 0.45 caliber bullet using deflectable-tipped EP catheters. While Dr. Moulton indicates this case wasn’t an EP study, its success was entirely dependent on special EP catheters. One Saturday afternoon in 1993, a patient was transferred from a referral hospital for management of a bullet thought to be lodged in his heart. The gentleman was shot on his porch; the bullet traveled through his arm and entered the right upper quadrant, piercing the liver. Emergency abdominal surgery at the referral hospital was performed to control bleeding, and a post-op chest film disclosed the bullet’s mysterious location — in the center of the chest. Believing the bullet’s location to be within the heart, the patient was brought to our EP lab for verification. Had a bullet of this size traveled through the diaphragm, cavitation would have resulted in death.

Contrast injections through a Swan-Ganz catheter in the right ventricle disclosed a “halo” appearance suggestive of clot around the bullet. I felt that the only device other than a snare that could potentially dislodge the bullet was a deflectable-tip ablation catheter. I had a beefy, 8 French custom-made catheter (Will Webster) that could do the job. After clawing the bullet loose into the right atrium, another custom Webster catheter (270º deflection) was used to grasp the bullet and drag it down to the femoral vein, outside the peritoneal space, allowing it to be surgically removed by venotomy just outside the inguinal ligament without opening the abdomen.

The bullet’s seemingly uneventful destination in the right ventricle occurred as the result of “bullet embolism.” After passing through the liver, it fortuitously came to rest within the inferior vena cava and was carried by blood flow into the right ventricle.