Spotlight Interview: Presence Covenant Medical Center

Sharon Ingrum, RN, BSN and Abraham G. Kocheril, MD, FACC, FACP, FHRS, Director of Electrophysiology, Urbana, Illinois
Sharon Ingrum, RN, BSN and Abraham G. Kocheril, MD, FACC, FACP, FHRS, Director of Electrophysiology, Urbana, Illinois

Presence Covenant Medical Center is one of east central Illinois’ most advanced medical facilities, offering a full scope of inpatient and outpatient care. As a regional hospital serving 13 counties, we offer the latest technology and treatment options while focusing on providing patient- and family-centered care. The 210-bed hospital is at the forefront of robotic-assisted minimally invasive surgery and cardiac navigation, and is an accredited Chest Pain Center and certified Primary Stroke Center.

Created in November 2011 through the merger of Provena Health and Resurrection Health Care, Presence Health is the largest Catholic health system based in Illinois. We offer more than 150 locations around the state, in communities large and small, so health care access is convenient.

With 12 hospitals, 27 long-term care and senior living facilities, dozens of physician offices and health centers, home care, hospice, behavioral health services and more, we care for people in all stages of life.

What is the size of your EP lab facility? When was the EP lab started at your institution? 

Presence Covenant has one dedicated EP lab and two Cardiac Cath / Invasive Radiology suites. Our EP lab opened in 2000; however, volumes were minimal until the addition of our current director, Dr. Abraham Kocheril, who joined the staff in June 2010.

What is the number of staff members? What is the mix of credentials at our lab? 

There are eight RNs (four of which work in the prep-recovery area and four that work in the procedural area), and five radiologic technologists (RTs). All professional staff must maintain current state licensure and maintain CEU requirements. ACLS is required for all nursing staff and encouraged for the rad techs.

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? 

The lab performs EP diagnostic studies, ablations for SVT, atrial flutter, atrial fibrillation, and ventricular tachycardia. We insert pacemakers, loop recorders, ICDs, and CRT devices in the EP lab. In addition, we perform cardiac caths, coronary interventions, TEEs, cardioversions, tilt table testing, and invasive radiology procedures. On average, the EP lab performs 14 EP studies and catheter ablations per month, and 10 pacemaker/ICD/CRT implants per month.

Who manages your EP lab? 

Dr. Abraham Kocheril is the Director of Electrophysiology at Presence Covenant Medical Center. The Director of the Cardiac Cath Lab is Stephanie Yates, RT(R), and the Manager is Sharon Ingrum, RN, BSN. 

Is the EP lab separate from the cath lab? Are employees cross-trained? 

No, the EP lab is located within the three-lab setting that houses electrophysiology, cardiac catheterizations, and interventional radiology procedures. All employees are cross-trained to work in all procedure types.

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

Yes. RN staff members are trained to monitor, circulate and scrub procedures. Radiologic technologists scrub, monitor, and are responsible for the X-ray equipment.

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

Presence Covenant Medical Center is a not-for-profit hospital. Affiliated with the University of Illinois College of Medicine, medical students and Internal Medicine residents are frequent observers in the EP lab.

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

Our X-ray system is a Philips Allura Xper FD 10/20 biplane. Three-dimensional mapping is done with St. Jude Medical’s EnSite Velocity Cardiac Mapping System; we also use their EP-WorkMate Recording System. In addition, we use the Sensei® X Robotic Catheter System by Hansen Medical. For ablations we use the Stockert Generator (Biosense Webster, Inc., a Johnson & Johnson company) and the EPT-1000XP System (Boston Scientific). Our cardiac stimulators are from ST Cardio Technologies as well as the EP-4 Cardiac Stimulator (St. Jude Medical). Hemodynamic monitoring is achieved using technology by Philips/Witt Biomedical.

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

We currently have one-day shifts from 0700 – 1530. Staff will stay later as needed to complete procedures.

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

On a typical day, staff will arrive at 0700. There may be any combination of cases scheduled, an EP/ablation in the morning, start time of 0800 or 0900, depending on physician schedule. Another case will follow, which could be another EP/ablation, a pacemaker insertion, generator change, pocket revision, or CRT. The schedule may also include, to be done prior to or following, a tilt table exam or cardioversion.

What new technology has been introduced in your lab recently? 

Since 2010, we have been utilizing the Sensei® X Robotic Catheter System (Hansen Medical). We have recently begun using the IntellaTip MiFi XP catheter (Boston Scientific). Its microelectrodes allow for the detection of discrete signals, increasing mapping accuracy. The catheter is used for mapping and ablation, further reducing case times.

What imaging technology do you utilize? 

In addition to the Philips Allura Xper FD system, we use Biosense Webster’s AcuNav for performing intracardiac echocardiography, especially in transseptal procedures.

What is your experience with MR conditional cardiac devices? 

This has not yet been an issue in our lab; however, we have the capability to accommodate that requirement.

Does your program utilize a CV information system (CVIS), picture archiving system (PACS), or cardiology picture archiving system (CPSCS)? 

Yes, for both PACS and CPACS, we currently use McKesson. 

Do you employ traveling RNs, RTs, or RCISs? 

While we have occasionally staffed with travelers in the past, we do not make it a routine practice.

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

Our cases are scheduled in the hospital’s MEDITECH system, by a central scheduling department. The physician’s office coordinates with central scheduling to achieve this.

Has your EP lab recently expanded in size and patient volume, or will it be in the near future? 

After the addition of our EP director in 2010, our lab volume increased dramatically. In 2013, pacemaker insertion/revision/battery changes moved from the OR to our EP lab, also greatly impacting volumes.

How does your lab communicate necessary information to staff? 

Our department holds a brief “huddle” each morning before the start of the day’s schedule (time permitting). Staff is provided with any new information they may require. Staff is encouraged to ask questions and share their own knowledge/experience.

How do you ensure timely case starts and patient turnover? 

Staff arrives well before the scheduled start time for an exam. This assures that there will be plenty of time to have the room set up and the proper equipment available. The patient is taken into the lab approximately 30 minutes prior to start time. This allows the staff time to settle the patient in, hook up necessary equipment, and prep the patient for the arrival of the physician. In the case of room turnover, generally any available staff will pitch in to expedite the start of the next scheduled case.

How are new employees oriented and trained at your facility? 

A new employee is oriented for a 12-week period. This includes general hospital orientation and EKG training through our education department. The orientee is assigned a preceptor within the department. That person will be of the same role/background (i.e., nurse to nurse, rad tech to rad tech). That preceptor will guide the new employee through the remainder of their training in the lab, assuring a seamless transition to a fully capable staff member, assuming all required duties, including call coverage.

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

Dr. Kocheril can be counted on routinely for numerous learning opportunities in the lab. He also conducts a yearly EP symposium. In addition, multiple “lunch and learn” meetings are held each year. The hospital also provides online opportunities for nurses to acquire their needed education points.

How do you handle vendor visits to your department? 

Our hospital uses the Reptrax system. Reps are required to sign in at the front lobby. They are issued a nametag that is dated with an expiration time for that visit. If a rep enters the lab without having done so, they will be directed back to the lobby to sign in. Vendors are encouraged to schedule their visits in advance.

How is staff competency evaluated? 

Staff is required to complete an annual cath lab skills day. This includes being checked off on various equipment skills and EKG testing. Skills day is administered through the education department. In addition, all staff members are required to complete computer-based learning modules (CBLs). These CBLs meet the requirements for many Joint Commission standards. Staff members are also required to hold a current CPR certification. ACLS is required for RNs.

Does your lab utilize alternative therapies for patients in the EP lab? 

Our EP lab has a state-of-the-art music system. Our physicians believe the use of music is very beneficial to both patient and staff. We also have a 52” FlexVision monitor (Philips), which can be configured to include relaxation videos. We currently use beach scenes and tropical fish videos to put patients at ease.

How does your lab handle call time for staff members? How often is a staff member on call, and how frequently are they called in? Is there a particular mix of credentials for the call team? 

Our call team currently consists of three people: at least one RN, one RT, and a third that could be either an RN or RT. Call is one to two weekends a month, with a total of about 10 to 12 days per month, per person. The call team covers all cases performed within the cath lab including STEMIs, pacemakers, cardioversions, and invasive radiology. EP cases are rarely done on call, although they may run late in the day, in which case the on-call team would stay to complete the procedure.

Approximately how many of your ablation procedures are done with cryo versus radiofrequency? 

Currently all of our ablations are done with radiofrequency.

What measures has your lab taken to reduce fluoro time and minimize radiation exposure to staff and physicians? 

Radiation safety is taken very seriously in our lab. In the EP setting, X-ray is always set on the lowest possible frames per second. Everyone present is expected to wear proper radiation protection, and additional shielding is provided where possible in the room. Nurses have lead shields to stand behind when administering medication at the patient’s side, and physicians have extra shields tableside. Utilization of Hansen Medical’s robotics system also significantly reduces fluoro time. 

Fluoro time and dose are recorded for all cases. In some procedures, catheter manipulation is performed using EnSite and ICE rather than with fluoro.

How is coding and education handled in your lab? 

Currently, coding is overseen by our department manager. Education for EP and implant patients is handled on site by our Heart Rhythm Center nurse. The patients’ families receive comprehensive education while procedures are being performed.

Have you developed a referral base? 

Our physician’s patient base is spread across a wide area of east central Illinois. Our facility has direct ties to both Presence United Samaritans Medical Center in Danville, Illinois, and Iroquois Memorial Hospital in Watseka, Illinois. We also serve patients from a significant geographic region, reaching as far as Chicago.

How many staff members currently have the RCES credential? 

We currently have no staff with this designation.

Does your lab use a third party for medical device reprocessing? 

Yes, we currently use Stryker Sustainability Solutions for this function. The process allows us to keep costs down, while still providing expert care.

What methods are used for infection control during device implants? 

When the decision was made to move pacemakers from the OR to the cath lab, great care was taken to ensure a compatible environment. Before the move was made, our EP lab was completely renovated, adding all required equipment and medical gases. For device implants, our EP lab is treated as an OR suite, with all the accompanying sterile practices.

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

Electronic managing of health information helps assure that information is not lost and is always available. Being able to access EHR from other facilities that we work closely with enables our staff to be that much more efficient in caring for our patients.

How does your lab handle device recalls? 

We have a carefully monitored process for dealing with this issue. Our manager works closely with the pacemaker clinic staff and hospital quality management. Notices from manufacturers are compared to stock, and if the device has been used, proper steps are immediately taken to assist the patient.

Is your lab currently involved in clinical research? 

Dr. Kocheril will soon be publishing results from a music study performed in our lab. The study centers around the effects of music on autonomic tone and cardiac rhythms. Dr. Kocheril is also in the process of obtaining approval to conduct pre-discharge cardiopulmonary exercise tests on heart failure patients using the Shape-HF Cardiopulmonary Exercise Testing System (Shape Medical Systems, Inc.) to predict and prevent readmissions. 

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

Staff evaluates stock on hand to determine what should be ordered. A designated staff member ensures that we maintain par levels on all cardiac supplies. Capital equipment purchases are handled through management and the purchasing department.

What measures has your lab implemented to cut/contain costs and improve efficiencies in patient through-put? 

Our hospital is part of a healthcare system that is dedicated to reducing costs. Our combined buying power ensures competitive pricing on most supplies. This has been achieved by streamlining the purchasing process, by having all facilities use the same product lines, and by having staff members who are committed to being good stewards of our resources.

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

First, our staff is privileged to have Dr. Kocheril, whose name is synonymous with the field of EP. We are lucky to have a staff that is highly adaptive and very motivated. Most of the staff had not seen EP until Dr. Kocheril arrived. He was able to take us from that beginning to the lab we have today. With his guidance, our staff has been able to grow and adapt, employing state-of-the-art equipment that is in use in very few places, none of which are in our immediate area. Because of the dedication and hard work of our staff, we take great pride in considering our lab to be the place for EP in our region. 

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

 

Presence Covenant Medical Center is located in Urbana, a central Illinois city with a population of over 82,500. Urbana is, with its twin city of Champaign, home to the University of Illinois’ main campus. Champaign-Urbana has the unique quality of offering small-town ambience with a number of city amenities. Because of the university as well as Parkland College, we have access to theater and symphony. We are situated just two hours south of Chicago, and two hours west of Indianapolis, making it easy to avail yourself of all that those cities have to offer. As a university town, we have a very diverse population.