Spotlight Interview: Regions Hospital

Liz Wagner, RN, BSN, CCRN, Clinical Educator Interventional, Cardiology/Electrophysiology/OPCU and Paul Hansen, RN, MBA St. Paul, Minnesota
Liz Wagner, RN, BSN, CCRN, Clinical Educator Interventional, Cardiology/Electrophysiology/OPCU and Paul Hansen, RN, MBA St. Paul, Minnesota
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 one dedicated EP room with the option of using a CV room on our busy days. Our EP lab is staffed by Physicians Assistants (PAs), Nurse Practitioners (NPs), RNs, CVTs and RT’s. The PAs and NPs work to ensure all of our patients are ready for their respective procedures in the lab. In addition, they play a significant role with EP consults, discharge planning and follow-up care. Because we share RN staff between the cath and EP labs, all of our nurses are trained in the specialty. We have two CVTs, one RT and one RN that are dedicated to EP, who are also cross trained to interventional cardiology; the rest of our CVT/RT staff rotate into EP as support to the dedicated staff. All staff must successfully pass ACLS. Of the 10 RNs we employ, two have a current CCRN credential. There are currently two CVTs and one RT that carry the RCIS credential with other staff actively engaged in study. RCIS is not currently required by the department; this practice is under review and will most likely become the standard in the near future. When was the EP lab started at your institution? During the mid to late 1990s we utilized a cardiology group that practiced in another hospital for our EP cases. In 2003, Regions Hospital hired Dr. Dennis Zhu as the Medical Director to start our own EP program. Dr. Marco Guerrero later joined the program as well. Both Health Partners Medical Group physicians are involved with presenting topics at national meetings, local conferences and discussion groups. Dr. Zhu has been a contributing author for many EP papers and texts. What types of procedures are performed at your facility? Approximately how many are performed each week? We perform approximately 20 EP studies, ablations, permanent and temporary pacemakers, ICD implantations, generator replacements, lead placements and lead replacements per week. What is the primary goal of your program? The program at Regions Hospital is designed to encompass a variety of procedures within the EP specialty. Our daily routine consists of device implants and a variety of ablation therapies that include atrial fibrillation (AF). Our primary goal is to be the patient-centered lab of choice in the community and to provide whatever service the patients need, whether it be ICDs, pacemakers, CRTs or ablations. Who manages your EP lab? Paul Hansen, RN, MBA manages the EP lab. Paul started working at Regions Hospital in the CCU unit and then transferred to the interventional cardiology/electrophysiology lab. He had several years of cath lab experience before becoming our manager. Are employees cross trained? Do you have cross training inside the EP lab? There is a shared model for RN staff between the cath and EP labs, and all of our nurses are trained in each specialty. Four staff members are dedicated to EP but are also cross trained to interventional cardiology; the rest rotate into EP as support to the dedicated staff. Within EP, several staff are cross trained and are able to perform multiple functions. Two other nurses are cross trained as scrub techs in electrophysiology. In addition to the EP scrub training, one of our nurses also functions as an EP monitor tech and is involved with training other staff. What new equipment, devices and/or products have been introduced at your lab lately? How has this changed the way you perform those procedures? St. Jude Medical’s EnSite and Biosense Webster’s Carto have increased the speed, accuracy and safety of our ablations. Another particularly interesting improvement that we made recently was the purchase of the CATHPAX® (Anthem Medical). The CATHPAX® has played a significant role in reducing the amount of radiation exposure to our physicians. In addition, the physicians are now able to perform ablation procedures without the use of lead, which has been a major satisfier for the group. Who handles your procedure scheduling? Do you use particular software? Regions Heart Center manages all of our scheduling. The templates used are in our EMR; we utilize the Epic system (Epic, Verona, Wisconsin). What type of quality control or quality assurance measures are practiced in your electrophysiology lab? We currently track the success rate of our ablation procedures as well as all complications that may occur due to a procedure in the EP lab. How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? Inventory, supplies and equipment are managed as a partnership between EP lab staff and the supply chain services team. Equipment acquisition is managed through a capital approval process. Physicians, EP staff and supply chain staff work together to create the balance between patient outcomes and cost. All of the work done to manage supplies is done through our Value Analysis Team (VAT). This team consists of our physicians, staff, department manager and supply chain services personnel. All new products are brought to the monthly VAT to be discussed and evaluated for cost and added value. Has your EP lab recently expanded in size and patient volume, or will it be in the near future? Regions Hospital is in the midst of a large-scale facilities expansion and upgrade. We recently opened our new South Section, which will eventually include 216 private patient rooms and 20 new OR suites. Included in the expansion plans is a redesign of the cath and EP labs. The proposed plan for 2010 will increase the number of EP rooms by one. This will allow for two dedicated EP suites with a third shared space between cath and EP. Have you developed a referral base? Referrals have been developed through our relationships with HealthPartners Clinics and a network of Western Wisconsin hospitals and clinics. What measures has your EP lab implemented in order to cut or contain costs? In addition, in what ways have you improved efficiencies in patient through-put? There have been significant savings found through the VAT, which has helped to manage our expense budget. The EP team (MDs, NPs and PAs) creates the most efficiency by working in tandem to prepare patients for procedures. Maximizing procedure time for our physicians has been a key success of our program. In addition, there are no longer any specific contracts with vendors; any device may be used at any time. Does your EP lab compete for patients? Has your institution formed an alliance with others in the area? We do not currently work in partnership with another EP group. What procedures do you perform on an outpatient basis? What EP procedures are generally only considered inpatient? Approximately 67% are outpatient procedures. Other procedures that lead to inpatient status include initial device implants, AF ablations and transseptal cases. How are new employees oriented and trained at your facility? New employees receive formal training and testing for up to six months. What types of continuing education opportunities are provided to staff members? We have monthly EP journal club meetings to review topics of interest. This meeting is led by either Dr. Zhu or Dr. Guerrero. We have classes that are presented to staff by reps from various companies in addition to the informal teaching during and after cases. Staff rotate attendance at national conferences and give highlights to coworkers. How is staff competency evaluated? All staff are reviewed by their cohort. Specific competencies are developed for the unique preps and procedures in EP. Recently we expanded the role of EP techs to include inserting venous sheaths. This entailed in-depth education on anatomy and education in our Simulation Center working with one of our Emergency Department doctors. The competency was based on points that are taught to residents. What committees, if any, are staff members asked to serve on in your lab? All staff members are encouraged to be active in the hospital and serve on committees such as Shared Governance. One of our cross-trained RNs also serves on the Procedural Sedation committee, specifically for Deep Sedation. Deep sedation is given to those patients receiving a DFT. How do you handle vendor visits to your department? Do you contract with vendors? Vendors must register through the Heart Center. There are no vendor contracts. Does your lab utilize any alternative therapies? Music therapy is available upon request, and inpatients have access to complementary care staff. Describe a particularly memorable or bizarre case that has come through your EP lab. What lessons did you learn from it? We had a patient with sustained ventricular tachycardia (VT) on the table for an ablation, and during the case the computer’s motherboard burned out due to a non-functional fan. The case was finished using EnSite (St. Jude Medical), during which we were only able to obtain vital signs manually. Another unusual case occurred on a late Friday afternoon. The patient was brought in for an AVNRT ablation (dual node physiology), was found to have an atrial tachycardia, after which a left-sided atrial flutter circuit was discovered, which then developed into a stable slower rate VT. Using EnSite, each rhythm was successfully mapped, tracked and burned in the order described! How does your lab handle call time for staff members? How often is each staff member on call? How frequently do they have to come in, on average? Is there a particular mix of credentials needed for each call team? Call is weekday evenings for three hours. There is one RN and one tech (either RT or CVT). Do you perform only adult EP procedures or do you also do pediatric cases? We currently perform procedures on adults only. What measures has your lab taken to minimize radiation exposure to physicians and staff? Staff receives regular radiation safety training. Physical measures include lead aprons on the tables, lead shields and monthly safety checks of the lead worn by staff. Dr. Zhu has a rolling, independent lead shield that he utilizes for EP studies and ablations only. This device has significantly reduced his radiation exposure. Do your nurses/techs participate in the follow up of pacemakers and ICDs? All follow up is done in our Cardiology Device Clinic. What trends do you see emerging in the practice of cardiac electrophysiology? Biventricular devices are being placed more often due to the increase in pacer-dependant cardiomyopathy. What are your thoughts about non-EPs implanting ICDs? We believe it can be done if there is properly structured teaching and competency is evaluated. Is your EP lab currently involved in any clinical research studies or special projects? Which ones? We are currently involved with the BLOCK HF trial, the APPROPRIATE study, and the OPTIMIZE study. In the Biventricular Versus Right Ventricular Pacing in Heart Failure Patients With Atrioventricular Block (BLOCK HF) trial, patients with Class 1-3 NYHA failure and an ejection fraction of 35-50% who require a pacemaker will receive CRT. This study will follow the progression or non-progression of heart failure. In the APPROPRIATE study, dual chamber pacemaker patients will be randomized to minute volume or accelerometer sensor after they have had an exercise stress test to prove chronotropic incompetence. The OPTIMIZE study will evaluate AV-VV conduction delay post pacemaker implant. An echocardiogram will be done post implant to look at improvement or remodeling in relation to the arm of the study the individual was randomized to. When was your last inspection by the Joint Commission? The last inspection was in June 2009. Does your lab provide any educational or support programs for patients who may have additional questions or those who may be interested in support groups? Yes, materials are provided by our Cardiology Device Clinic. Describe your city or general regional area. How does it differ from the rest of the U.S.? St. Paul has a population of roughly 300,000 people. Due to the close proximity to Minneapolis, the two cities are known as the “Twin Cites” with a combined population of 3.5 million people. We have a large population of cross country skiers that have been a support for multiple Olympic participants. For more information, please visit: www.regionshospital.com/