Spotlight Interview: Robert Wood Johnson University Hospital

Michael Cargill, RN, BSN, CCRN, Bobbie Tindall, RN, Huckman Kwok, RN, CCRN

Michael Cargill, RN, BSN, CCRN, Bobbie Tindall, RN, Huckman Kwok, RN, CCRN

What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab? Robert Wood Johnson University Hospital is the principal teaching hospital of University of Medicine & Dentistry in New Jersey (UMDNJ)-Robert Wood Johnson Medical School. Our hospital is a 572-bed Level I Trauma Center, and is home to the Heart Center of New Jersey, one of New Jersey's busiest cardiac programs. The Children's Heart Program of New Jersey at the Bristol-Myers Squibb Children's Hospital is the only academic pediatric cardiovascular program in the state. Our hospital has two dedicated EP labs within the Cardiac Cath Lab. The Cath Lab has a total of seven suites and a 12-bay holding area. Our staff is comprised of 50 registered nurses, three respiratory therapists, one radiology tech and one cardiovascular tech. The EP lab is staffed primarily by registered nurses and respiratory therapists with advanced training. The RNs on our staff are critical care experienced, and 80 - 90% of them are critical care certified (CCRN). When was the EP lab started at your institution? The first electrophysiologists to perform procedures at Robert Wood Johnson University Hospital were Drs. Dwayne Siu and Luanne Beauregard. Prior to 1996, EP procedures were done in the OR on weekdays and in the Cath Lab on Saturdays. In 1995, the UMDNJ-Robert Wood Johnson Medical School expanded their cardiology service to include electrophysiology. Dr. Mark Preminger was recruited as the EP Lab Director. Our first EP lab was built shortly thereafter. In 2003, the EP program was expanded and a second EP suite was built. Since its inception, our program has grown dramatically. Today, ten electrophysiologists utilize our EP lab. What types of procedures are performed at your facility? The procedures we perform include electrophysiology studies, ablations (atrial fibrillation/flutter, SVT, WPW, VT), cardioversions, tilt table tests, device implants (pacemakers, event monitors, automatic intracardiac defibrillators [AICDs] and biventricular devices), and post-implant defibrillator testing. What is the primary goal of your program (AF ablations, lead extractions, BiVs, etc.)? The goal of our program is to provide full-spectrum, state-of-the-art electrophysiology. Approximately how many are performed each week? What complications do you find during these procedures? We perform approximately six EP studies, five ablations and 20 device implants per week. Complications are rare and are thoroughly reviewed by our EP performance improvement committee and at our monthly morbidity and mortality meeting. Who manages your EP lab? The medical director of our EP Lab is Dr. Mark Preminger. He is an Associate Professor of Medicine and the Director of the Cardiac Electrophysiology and Arrhythmia Program at UMDNJ-Robert Wood Johnson Medical School, and has over 14 years of experience in the field of cardiac electrophysiology. Our Administrative Director, Eileen Algeria, has over 30 years of cardiology and ambulatory care management experience. Anna Kuchinski, RN, BSN, is our head nurse with over 10 years of cath lab experience. Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained? The two EP labs are nestled in between our five cath labs. About three-quarters of our cath lab staff is EP trained. There are, however, a core group of nurses and respiratory therapists staffing the EP lab almost exclusively. Do you have cross training inside the EP lab? What are the regulations in your state? The EP nurses are cross-trained to monitor, scrub and circulate. Respiratory therapists scrub and monitor cases. No specific EP staff regulations exist in New Jersey. What new equipment, devices and/or products have been introduced at your lab lately? How has this changed the way you perform those procedures? We have recently purchased EP-WorkMate® Computerized EP Lab Recording System (EPMedSystems, Inc., West Berlin, New Jersey), including the CARTO Interface and the NurseMate® documentation system. The electrophysiology lab has two mapping systems: CARTO (Biosense Webster, Inc., a Johnson & Johnson company, Diamond Bar, California) and ESI (St. Jude Medical, Minnetonka, Minnesota). These systems have allowed us to import MRI and 64-slice CT images, making for more accurate mapping. We routinely use the Siemens AcuNav Intracardiac Echo System (Malvern, Pennsylvania) for transseptal catheterization and left atrial procedures. Intracardiac echocardiography also aids our electrophysiologists in selecting patients for resynchronization therapy and in optimizing biventricular pacing to maximize patient benefit. There are two techniques that we routinely perform for patients with atrial fibrillation to maximize patient outcomes and prevent complications. A barium swallow is given to patients during atrial fibrillation ablations to allow for visualization of the esophagus so the electrophysiologist can avoid ablating areas of the atrium that might cause injury to the esophagus. We use dual-sided atrial pacing to remodel the atria, which aids in controlling refractory atrial fibrillation. Who handles your procedure scheduling? Do you use particular software? All procedures are scheduled online. We have a dedicated scheduler who is trained to coordinate procedures with the physicians' offices and our admitting department to make scheduling smooth and efficient. We utilize the Tempus One software program (Tempus Software, Division of Quadramed, Jacksonville, Florida). What type of quality control/quality assurance measures are practiced in your EP lab? The EP lab staff documents all peri-procedural complications. These complications are reviewed by the Head Nurse and Medical Director. Cases are brought to the EP Morbidity and Mortality meetings for discussion, resolution, and education. The Cath Lab PI representative is a member of the hospital's PI committee. Our administrative director is a member of the hospital's overall PI committee. How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? We have an inventory technician who orders equipment based on established par levels. EP lab staff, physicians and administrators play an integral role in evaluating all new equipment prior to its purchase. The Materials Management Department and cath lab administration negotiate consignment, pricing, and par levels for the new products. Prior to initial patient use, vendors provide inservices for the Cath/EP lab staff and physicians. Has your EP lab recently expanded in size and patient volume, or will it be in the near future? Volume has increased 40% in 2005 and an additional 20% through March 2006. A third EP suite is in the planning stages. We have received approval from the Department of Health on a temporary basis for two on-site mobile EP labs to accommodate this increased volume. The new laboratory will be equipped for Stereotaxis. 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? Price negotiation is done on a regular basis to ensure the lowest price for our institution's volume. In addition, lab turnaround time for physicians and staff is monitored on a continuous basis in order to improve efficiency in patient throughput. Does your EP lab compete for patients? Has your institution formed an alliance with others in the area? We compete by providing our community high-quality patient care coupled with the latest technology. Our success is demonstrated by our excellent patient satisfaction scores, as measured by Press-Gainey surveys. Our 2005 Press-Gainey scores were in the 90th percentile or better for the entire year, and we have continued this trend into 2006. We have successfully achieved Magnet Hospital recognition for the third consecutive time. Robert Wood Johnson University Hospital is one of only four hospitals in the nation to maintain this status. Our institution has formed with local hospitals to transfer their patients to our center for EP procedures. What procedures do you perform on an outpatient basis? Outpatient procedures include end-of-life pacemaker/defibrillator changes, tilt table testing, cardioversions, and defibrillator testing. How are new employees oriented and trained at your facility? Every staff member who has been in the lab for more than 1 year is eligible to be oriented to EP. Orientation consists of working side by side with an experienced preceptor and lasts approximately 1 month. What types of continuing education opportunities are provided to staff members? We regularly provide staff with continuing education at lunch in-services. These in-services are done either by vendors or our own EP lab staff. Vendors educate staff whenever new equipment is introduced, and on an ongoing basis. EP lab staff writes and presents their own CEU-accredited in-services. The staff also attends local and national meetings. We send 1 - 3 staff members to the Heart Rhythm Society Scientific Sessions each year. How is staff competency evaluated? Our Head Nurse evaluates staff competencies yearly. How do you prevent staff burnout? We prevent burnout by maintaining a personal and professional relationship between the management and staff. Our management strives to always be responsive to the individual needs of each staff member. We provide flexible scheduling, variable shifts (8-, 10-, and 12-hour shifts), ample educational growth opportunities, and exciting new procedures. What committees, if any, are staff members asked to serve on in your lab? Staff members are encouraged to participate in hospital committees. Current EP lab staff participate in the hospital's Research Committee, Performance Improvement Committee, and the Latex Allergy Task Force. How do you handle vendor visits to your department? Two vendors per day are allowed to enter the cath lab. They are not limited to any specific area of the lab. Representatives sign up in advance for either an afternoon or evening time slot. This assures we will not have an overlap of competing vendors. We have complete control of vendor visits. Does your lab utilize any alternative therapies? Our hospital has an Integrative Healing program, in which services such as therapeutic massage, reflexology, Reiki, guided imagery, and music therapy are offered to patients free of charge. 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? Since the majority of cath lab staff is EP trained, we do not have a separate on-call EP staff. For weekday call, the call team consists of three nurses or two nurses and one tech. On weekends, there is a fourth on-call staff member who gets called in the event of concurrent emergency cases. Weekend on-call rotates every eight weeks and weekday on-call rotates every two weeks. For holiday call, each staff member takes one holiday call every other year. A few times per month, the staff is called in for EP procedures. We have extended our days of operation to include Saturdays. Does your lab use a third party for reprocessing? No. We use disposable trays and equipment. Approximately what percentage of your ablation procedures are done with cryo? What percentage is done with radiofrequency? All of our ablations are done with radiofrequency. Do your nurses/techs participate in the follow up of pacemakers and ICDs? We have just completed recruitment of an Advanced Practice Nurse and Registered Nurse to the Arrhythmia Service specifically to perform pacemaker and AICD follow-up. What trends do you see emerging in the practice of electrophysiology? How is your lab preparing for these future changes? The number of device implants is growing and will continue to grow. We are preparing by always embracing new technology. What about device recalls? How has your lab handled these? Each recall is specifically addressed by the Cath Lab Administration, Risk Management, Materials Management, Senior Management and physicians. The decision to replace a device is specifically left up to the patient's electrophysiologist. Is your lab doing web-based/transtelephonic device follow-up? Yes, device follow-up is done via the Medtronic CareLink and Guidant Latitude at the UMDNJ-Robert Wood Johnson Medical School Arrhythmia Service and at the offices of our community cardiologists. When was your last JCAHO inspection? We underwent JCAHO inspection in the spring of 2004 with no citations. Our advice is to develop an ongoing inspection readiness plan. Are you ACGME-approved for EP training? What do you think about two-year EP programs? No. 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? The UMDNJ-Robert Wood Johnson Medical School Arrhythmia Service and community-based electrophysiologists provide 24/7 telephone support for those patients with questions or problems regarding their care. One of the roles of the newly hired Advanced Practice Nurse and Registered Nurse will be to begin a support group for patients with device implants in the near future. Give an example of a difficult problem or challenge your lab has faced. How it was addressed? One problem we faced was how to accommodate the continuing increase in the number of device implants. For the short term, we focused on improving turnaround time and opened the lab to Saturday cases while investigating the possibility of opening up a new EP lab suite. We sought and received Department of Health approval for two on-site mobile EP labs. Plans are in progress for a third EP suite. Describe your city or general regional area. How does it differ from the rest of the U.S.? New Brunswick's nickname is the Healthcare City. Midway between New York City and Philadelphia, it is the home of two academic hospitals, a cancer institute (the Cancer Institute of New Jersey), Robert Wood Johnson Medical School (campus of the country's largest medical school, University of Medicine and Dentistry of NJ) and the site of Johnson & Johnson's world headquarters. Because of our location and high volume, our lab is often first to receive the latest drugs, devices, and equipment. This is especially attractive to our physicians and staff. We are eager to learn about new technology. Please tell our readers what you consider unique or innovative about your EP lab and staff. The EP staff prides itself on being strong patient advocates. Our priority is to educate the patient before, during, and after the procedure to ease their anxiety and help them adjust their lifestyle according to the needs of their disease. Our EP staff is very dedicated as evidenced by their longevity. Our core EP staff has an average of 10 years experience working in our EP lab. For more information about Robert Wood Johnson University Hospital, please visit their website: www.rwjuh.edu