Spotlight Interview

Spotlight Interview: Saint George Hospital University Medical Center

Dr. Salah Chouairi, Dr. Johny Abboud, Dr. Joseph Akar, Beirut, Lebanon

Dr. Salah Chouairi, Dr. Johny Abboud, Dr. Joseph Akar, Beirut, Lebanon

Located in the heart of Beirut, Saint George Hospital was established in 1878 by community leaders who formed a philanthropic society to care for the poor. It has since grown into a 305-bed tertiary hospital dedicated to providing excellence in healthcare. Saint George Hospital University Medical Center is a major non-profit academic hospital in Lebanon. It provides the highest quality healthcare services to the sick and indigent, and is committed to treat all patients with dignity, respect, and compassion regardless of their religion, nationality, socioeconomic status, and race. In 2014, the hospital treated over 21,000 inpatients, 111,000 outpatients, and 25,000 emergency visits, and spent over 15% of its annual budget to help patients in need.

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

Our EP program was established in 1997 by Dr. Salah Chouairi. The EP facilities include a fully equipped dedicated EP lab and an adjacent EP procedure room and holding area, with plans for construction of a second lab. 

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

In addition to the physicians, our full-time staff members include 3 lab technicians, 3 nurses, one lab manager, one procedure scheduler, one lab engineer, and dedicated custodial staff in order to facilitate room turnover.

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? 

Our EP lab has always been on the forefront of clinical electrophysiology in the Middle East. We offer the entire spectrum of ablation and device therapy. We are among the pioneers of catheter ablation in Lebanon since 1997 and continue to be on the cutting edge by offering complex ablation using minimal fluoroscopy. We perform radiofrequency ablation for SVT, right and left atrial tachycardias, paroxysmal, persistent, and longstanding persistent AF, PVCs, percutaneous endocardial and epicardial ablation of idiopathic, ischemic, and non-ischemic VT, as well as ablation in patients with significant structural heart disease and mechanical prosthetic valves. We offer the full spectrum of devices from pacemakers to CRT-Ds, and were the first in Lebanon to perform left atrial appendage occlusion with the WATCHMAN LACC Device (Boston Scientific). We perform more than 120 ablations and 240 devices per year and are the national leaders in lead extraction.

Who manages your EP lab?

Dr. Johny Abboud is the director of the EP lab. He works closely with Ghada Mouhasseb, RN, our lab manager.

Are employees cross-trained?

Our renovated EP lab can accommodate interventional, peripheral, and structural procedures if needed. The EP lab is adjacent to the cath lab, and staff members are cross-trained for both.

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

We are part of an academic tertiary medical center with 305 inpatient beds and a full spectrum of medical and surgical care specialties. The hospital is expanding to accommodate 380 beds in the coming 2 years.

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

We utilize a spectrum of lab equipment, and are the only EP lab in Lebanon equipped with two 3D mapping systems for ablations (Biosense Webster’s Carto and St. Jude Medical’s EnSite). We implant devices from Medtronic, Boston Scientific, St. Jude Medical and BIOTRONIK.

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

A typical day is from 7:30 AM until 4:30 PM. 

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

Elective cardioversions, tilt tests, and device interrogations are scheduled every day in the morning in the EP procedure room and are supervised by an attending physician, while the other attending starts the patient preparation for the EP cases in the lab. All ablations are performed as a team effort with the attending physicians present in the case.

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 significant expertise in intracardiac echocardiography (ICE), so the use of the CartoSOUND Module (Biosense Webster, Inc., a Johnson & Johnson company) has facilitated radiofrequency ablation with limited use of ionizing radiation. Our latest technological upgrade, the CartoUNIVU Module (Biosense Webster, Inc., a Johnson & Johnson company), has further allowed us to decrease fluoroscopy in all ablation procedures so that we can now perform complex ablation using less than 60 seconds of fluoroscopy. Performing highly complex ablations with virtually no ionizing radiation has been one of our greatest recent achievements.

What imaging technology do you utilize?

We have a Philips Allura Xper FD20 C-arm, which is a single-plane fluoroscopy system.

What is your experience with MR conditional cardiac devices? 

We have been implanting these devices since they were introduced to market, and have not had any issues. 

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

The EP lab currently employs local archiving and is in the process of integrating within the hospital PACS.

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

We have one administrative assistant dedicated to scheduling for the EP and cath labs. We use a proprietary software that was developed in-house and custom built for Saint George Hospital.

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

Our lab manager is responsible for all inventory and device purchasing.

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

We have had a major increase in ablation volume as we have expanded into treating complex arrhythmias. We are currently in the midst of planning for a second laboratory.

Have you developed a referral base?

We were among the pioneers of electrophysiology in the Middle East, and we continue to be on the cutting edge. This has allowed us to establish a national referral network that has now expanded regionally. In addition, we perform a substantial amount of pro bono care as part of the humanitarian mission of Saint George Hospital, which was established by the Greek Orthodox Archdiocese of Beirut. We offer medical care, including ablation and devices, to all patients regardless of race, religion, ethnicity, or socioeconomic status, which has been especially important in recent years given the unfortunate political climate in the Middle East.

In what ways have you helped to cut/contain costs and improve efficiencies in the lab?

We work very closely with the hospital administration to control costs in the best methods possible.

How does your lab communicate necessary information to staff? 

Our attendings, administrators and staff work very closely as one cohesive unit and hold weekly meetings to address lab issues.

How do you ensure timely case starts and patient turnover?

Time management and laboratory efficiency are absolutely critical for cost containment. We take a team approach to ensure timely first case starts. We have two physicians available in the early morning: one to start the EP lab case, and the other to simultaneously deal with the elective EP work such as cardioversions, tilt-table testing, and device interrogations. Room turnaround time is minimized by having a dedicated crew for lab cleaning and turnover.

Does your EP lab compete for patients? Has your institution formed an alliance with others in the area?

We strongly believe in our mission to provide excellent clinical care. Our approach has always been less focused on volume and more on quality and outcomes. In addition to the local healthcare market, we are witnessing a significant increase in regional referrals from across the Middle East. We maintain a strong network of alliances with a variety of cardiology groups across the nation, and we welcome local, regional, and international collaborations with physicians and institutions who share our passion for high-end clinical electrophysiology care.

How are new employees oriented and trained at your facility?

Our hospital has a standard orientation process for all new employees.

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

We hold a weekly staff meeting and a quarterly journal club.

How is staff competency evaluated?

We have instituted staff competency evaluations in line with the 2013 HRS Expert Consensus Statement on Electrophysiology Lab Standards. We have also fully adopted the QC/QI recommendations as delineated in this consensus statement.

Do you encourage your clinical staff members to take the registry exam for Registered Cardiac Electrophysiology Specialist (RCES)? 

All staff members are encouraged to seek advanced degrees and certification, although the overseas travel and expense render it somewhat difficult.

How do you prevent staff burnout? In addition, do you practice any team-building exercises?

We attempt to limit late cases and overtime work as much as possible. We routinely hold social outings for the staff and family members. Holiday parties are standard in the lab.

What committees, if any, are staff members asked to serve on in your lab?

One of our medical staff members serves on the Medical Credentials Committee.

How do you handle vendor visits to your department? Do you contract with vendors?

The hospital administration directly contracts with vendors and handles price negotiations after seeking guidance from EP physicians regarding clinical need. 

Does your lab utilize any alternative therapies to help patients in the EP lab? 

We do not standardly utilize these techniques in the lab, but we do inform our patients regarding the potential benefits of yoga for both atrial and ventricular arrhythmias.

Describe a particularly memorable case that has come through your EP lab. How was it addressed, and what lessons were learned from it?

An 11-year-old boy was referred for primary prevention ICD implantation for non-ischemic cardiomyopathy with severe heart failure and compensatory tachycardia (LVEF <20%). He was suspected to have a tachycardia-induced cardiomyopathy, and electrophysiological study demonstrated evidence for permanent junctional reciprocating tachycardia (PJRT). Following radiofrequency ablation and restoration of sinus rhythm, the LVEF improved to 55% within 3 months. The patient is now in medical school. 

How does your lab handle call time for staff members? 

Call schedules are made in advance and all members participate. At any given night, a call team consists of one physician, one nurse, one cardiology fellow, one EP technician and one radiation technologist.

Does your lab use a third party for reprocessing or catheter recycling? How has it impacted your lab?

Our hospital has the capability for reprocessing catheters, which has helped cut down on EP lab expenditure. We do not reprocess irrigated tip catheters or any other catheter or sheath with a lumen. 

Do you utilize cryoablation, or are ablations primarily done with radiofrequency?

We currently only perform low-fluoroscopy radiofrequency ablation.

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

We mainly perform adult EP procedures, but also perform occasional pediatric procedures if the weight is above 30kg.

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

This is an extremely important topic and we are on the forefront of minimizing radiation for EP procedures. We strongly believe that the best method of protecting against radiation exposure to patients, staff and physicians is by eliminating the use of radiation in the first place. We have a tremendous amount of experience in ICE, which we can use with both the Carto and EnSite systems. In addition, we are utilizing Biosense Webster’s CartoSOUND and CartoUNIVU systems to further limit radiation. We standardly perform complex ablation procedures in less than 5 minutes of fluoroscopy, and often in less than 60 seconds.

What are your methods for infection prevention during device implants, etc.?

We administer prophylactic IV antibiotics on call to the procedure, and perform standard perioperative precautionary measures to ensure sterility. We also administer post-operative antibiotics.

What innovative EP techniques are being utilized in your lab? 

Three years ago, we were the first in Lebanon to perform WATCHMAN left atrial appendage occlusion (Boston Scientific). We were also the first to perform epicardial VT ablation as well as left atrial ablation in patients with prosthetic mitral valves more than 2 years ago. Currently, we are the only group in the Arab Middle East that standardly performs complex ablation with minimal or no radiation.

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

We do believe that EHR has great potential to improve quality of care and enhance outcomes. We are implementing an EHR system in the hospital.

What are some of the dominant trends you see emerging in the practice of electrophysiology? 

We believe that one of the most important emerging trends is the mandate of reducing radiation during EP lab procedures.

How does your lab handle device recalls?

We maintain an in-house, custom-built device registry that enables us to track implanted devices.

How is outpatient cardiac monitoring managed?

We offer 24-hour, 48-hour and 7-day cardiac monitoring through the EP lab. Patients present to the EP lab and are fitted with the devices in the EP procedure room. The EP physicians are responsible for interpretation of all the monitors.

Which clinical research is your EP lab currently involved in?

Our clinical research consists of investigator-initiated projects. Over the past 2 years, the abstracts that we presented at the Heart Rhythm Society’s Scientific Sessions mainly revolved around radiation reduction and identification of novel biomarkers for AF.

What are your thoughts on 2-year EP training programs?

Although the ACGME process is not applicable to us, we feel very strongly that in the current era, a minimum of 2 years of training is required for EP certification and ensuring competence in the full spectrum of EP procedures.

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

A good description of Beirut was written in 2005 by the reporter Michael J. Totten. Some excerpts include:

“Beirut is a bullet-riddled Holiday Inn with 15-foot holes blasted into the side of it towering above elegant new construction downtown.

Beirut is a Starbucks that is identical to the one near my house in Portland, Oregon down to the last nail.

Beirut is the most impeccably polite and charming waiter who has ever served me dinner and wine.

Beirut is where everyone calls me 'sir' and says 'welcome.'

Beirut is a taxi driver leaning on his horn and screaming at cars.

Beirut is Eastern.

Beirut is Western.

Beirut is a veiled 50-year-old woman in a black head-to-toe chador shuffling past a young scantily clad jogger plugged into her iPod.

Beirut is a French colonial architectural masterpiece.

Beirut is a row of 1970s eyesore apartment towers.

Beirut is an elegant cobble-stoned street.

Beirut is a leg-breaking hole in the sidewalk.

Beirut is Christian.

Beirut is Muslim.

Beirut is ground zero of a liberal-democratic revolution in the Middle East.

Beirut is the muezzin's haunting call to Muslim prayer.

Beirut is the soft peal of church bells.

Beirut is booze, gambling, flirtatious women, and Playboy Magazine sold on the streets.

Beirut is the capital of a Middle Eastern country that actually holds elections.

Beirut is Christians and Muslims living together in peace.

Beirut is people who say in public whatever they want.

Beirut is the Paris of the Middle East.

Beirut is the Sarajevo of the Middle East.

Beirut is civilized.

Beirut is wild.

One thing Beirut is not, and has never been: Beirut is not boring.”1

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

We are committed to excellent clinical outcomes and compassionate care that is accessible to anyone in need. We have cutting-edge technology and an abundance of clinical experience, and provide care that emphasizes safety, quality and enhanced outcomes. 

Reference

  1. This is Beirut. Michael J. Totten. Published April 27, 2005. Available online at http://www.michaeltotten.com/archives/000805.html. Accessed August 31, 2015.