Scripps Health is the leading provider of cardiac care in San Diego County. The Scripps Prebys Cardiovascular Institute (SPCI), San Diego’s first comprehensive “heart hospital,” opened in 2015 on the campus of Scripps Memorial Hospital, La Jolla. However, the electrophysiology program dates back to 1985, as Scripps was the first location for catheter ablation and arrhythmia surgery in the region. Since then, the Scripps EP program has grown from 1 part-time to 6 full-time EP labs in one location on this campus. Presently, there are 16 electrophysiologists from diverse groups, including 7 independent physicians, 4 Scripps Foundation doctors, and 5 Kaiser Permanente physicians. All of San Diego’s 500,000 Kaiser population receives their procedural cardiac care at Scripps. This has resulted in a unique collaboration of physicians dedicated to patient care.
How many staff are employed in your EP lab?
There are 32 electrophysiology staff at the Scripps EP labs — a combination of nurses, radiologic technologists, and cardiovascular technologists (CVTs) (Figure 1). As a result of a close relationship with Grossmont College, San Diego has an abundance of CVTs compared to other areas in the country. A small number of Scripps staff remain cross-trained in both EP and interventional cardiology, but the focus is on specialized care from dedicated EP staff. New EP staff are assigned a mentor until properly trained. A core competency of skills is necessary for independent staff function at Scripps EP, including device implantation, ablation assistance, and 3D mapping skills. An education program exists with both regular educational lectures as well as Journal Club for staff and physicians, focused on specific topics in EP. Due to the rapid growth in our field, like most EP programs, Scripps Health struggles with the nationwide shortage of trained EP staff.
What is the number of procedures in your lab?
As we have just combined the EP programs from Scripps Memorial Hospital and Scripps Green, our numbers are estimates. In the past year, we have performed over 4000 EP procedures, including approximately 2000 ablations, 1000 pacemakers, and 750 ICDs (approximately 50% of which are CRT devices). We do laser and non-laser lead extractions, epicardial VT ablations, and other complex procedures in our large program. Besides traditional CRM devices, we also implant leadless pacemakers (Medtronic’s Micra Transcatheter Pacing System and St. Jude Medical’s Nanostim), CardioMEMS HF System PA sensors (St. Jude Medical), and WATCHMAN (Boston Scientific) and LARIAT (SentreHeart, Inc.) left atrial appendage occlusion devices. We rarely perform AngioVac (AngioDynamics) percutaneous cardiac mass removal.
How many EP labs do you have? How are they structured?
With a sixth EP lab under construction, Scripps will have more EP labs than any program in the western U.S. For efficiency of scheduling, each room is designed with capabilities for both surgical device implantation as well as complex ablation (Figure 2). Each room has both of the major vendors’ 3D mapping systems, Biosense Webster’s CARTO 3 and St. Jude Medical’s EnSite Velocity, as well as flat-panel Odyssey Vision™ system (Stereotaxis), LED OR lights (Steris), intracardiac echocardiography, and an anesthesia machine and cart. For assistance with complex ablation, the Scripps EP labs have upgraded software modules in each room, such as the Biosense Webster CARTO CONFIDENSE, PASO, VISITAG, UNIVU, CARTOSOUND, and CARTOREPLAY modules, and the St. Jude Medical EnSite loaded with Precision, Fusion, and Verismo modules, as well as both vendors’ contact force catheters. Though used infrequently, 3 robotic EP catheter systems are available — 2 Sensei X Robotic Systems (Hansen Medical) and 1 Amigo Remote Catheter System (Catheter Robotics). We utilize 3 different vendors’ radiofrequency delivery systems, as well as Medtronic’s Arctic Front cryoablation system for selected atrial fibrillation patients. (Figures 3-4)
In addition to the 6 EP labs, 7 cath labs, and 4 cardiac operating rooms, there are 2 hybrid operating rooms in the SPCI, shared between EP and interventional cardiology. For EP, these are utilized for laser lead extractions and LARIAT left atrial appendage occlusion (LAAO) procedures. WATCHMAN LAA closure (Boston Scientific) procedures are done in the regular EP labs as well as the cardiac cath labs; Scripps has one of the highest volume WATCHMAN programs in the country. Epicardial VT ablations are also routinely performed in the regular EP labs, although the hybrid rooms are available for high-risk patients including those with ventricular assist devices.
How do you handle patient flow?
To support the EP program, there is an adjacent 17-bed EP Post-Anesthesia Care Unit (EP PACU) (Figure 5). It is utilized for pre-procedure care as well as post-procedure recovery. After registration, patients start in the EP PACU, and when they are moved to the lab, the family waits in the adjacent waiting room which utilizes the Orchestrate navigation system for updates. The majority of Scripps EP procedures are performed with general anesthesia (either endotracheal or with a laryngeal mask airway), so Level I post-anesthesia care is available in the EP PACU. Patients return to this same area post procedure, often with same-day discharge for non-complex ablations and most device implantations. Overnight observation occurs in the SPCI, which has 3 cardiac telemetry floors consisting entirely of private rooms. The EP PACU is also utilized for cardioversions, transesophageal echocardiograms, device induction studies, and implanted loop recorder insertions. The EP labs are organized in a central unit comprising the 6 labs, EP PACU, waiting room, storage areas, conference room, and other support, separate from the interventional cardiology area in SPCI.
Who are the physicians in your EP program?
There are 16 electrophysiologists at Scripps La Jolla. Steven Higgins, MD has been Director of the Scripps La Jolla program since its inception. His latest book, entitled Live Better Electrically, A Heart Rhythm Doc’s Humorous Guide to Cardiac Arrhythmias, is focused on patient education (Figure 11). Doug Gibson, MD is also a Director of the SPCI EP labs. Dr. Gibson is the largest WATCHMAN implanter in the U.S., and specializes exclusively in that and complex ablation. Other well-published physicians on staff include John Rogers, MD, a leading implanter of Medtronic’s Reveal LINQ ICM, and Andrea Natale, MD, who performs cases one week a month, commuting from Austin, Texas. The Kaiser EP physician group is led by Brant Liu, MD. (Figures 6-7)
Within the past year, the cardiology programs at Scripps Memorial and Scripps Clinic combined on the one La Jolla campus of SPCI (Figure 8). There are over 100 physicians in the Department of Cardiology. This centralization of cardiac patient care has resulted in improved outcomes, safety, and quality of care. Scripps Hospitals and Clinics have been ranked in the top 30 by U.S. News & World Report for the past 4 years, an uncommon recognition for a program without an attached medical school. Also, Scripps has also been ranked as one of the top 15 programs nationally by Truven Health Analytics and has achieved Magnet recognition for nursing care 3 consecutive 4-year terms. Recently, Scripps La Jolla received 5 stars in the new CMS rankings, a distinction for only 2% of hospitals nationally.
How is your EP program administered?
Aside from the physician leadership, Scripps has many administrative leaders who have contributed to the success of the program. Lynn De Guzman, RN is the Senior Director for Clinical Services, overseeing all the cardiac programs at Scripps La Jolla sites. Angelle Romero is the Manager of Cardiology Clinical Services, supervising both the interventional cardiology and EP labs. Allison Krager is the Manager of the EP PACU and other cardiac recovery areas. Weizhou Li, RN is the Supervisor of the EP labs, and Nanette Souza, RN is the EP Lead (Figure 9). The physician and administrative leaders meet weekly to discuss patient care issues. Our success would not be possible without close collaboration between administrators and physician leaders in a co-management model pioneered by Scripps Health CEO, Chris Van Gorder.
Do you use fundraising to help support EP needs?
Proper reimbursement for EP procedures is increasingly challenged, particularly in our competitive geographic location. As a result, we have developed a close relationship with the Scripps Foundation, our fundraising arm. In recent years, the Foundation raised over $150 million for the cardiac campaign. This source has been utilized for buildings, unusual equipment needs, and special projects. Current fundraising is focused on a dedicated EP conference room with real-time video and Odyssey Cinema transmission from each EP lab to be utilized for staff, physician, and industry education and quality assurance purposes. Another fundraising project is to create a dedicated EP staff education program, a unique need in the complex world of EP. The Scripps Center for Learning and Innovation (SCLI) works closely with EP administration on staff education programs.
What measures has your lab taken to reduce fluoroscopy time?
Radiation safety in our EP program is taken seriously. Physician utilization is monitored and reported for feedback in comparison to colleagues. We encourage the use of non-radiation alternatives such as intravascular and intracardiac ultrasound, 3D mapping technologies, and options such as the CARTO UNIVU system. Other than our hybrid rooms (Siemens), we utilize GE fluoroscopy systems tuned for the lowest radiation possible. Scripps has more GE fluoroscopy units than any hospital west of the Mississippi. A poster was created to remind physicians about radiation reduction techniques using the mnemonic TPCC (for the fictional Torrey Pines Country Club), which stands for Table (raise the table height), Protocol (our nominal setup is the lowest frame rate, 7.5 fps), Cone (narrow the field of view) and Cine (actually, avoid cineangiography utilizing digitally stored fluoroscopy available in each room).
What are some of the dominant trends you see emerging in the practice of electrophysiology?
Scripps EP program has been a leading investigator in both of the leadless pacing systems under FDA review. We anticipate advances in this technology to include dual- and triple-chamber leadless pacing, potentially entirely replacing extra-thoracic pacemaker generators and leads. Future advances being investigated at Scripps include stem cells for cardiac regeneration (PI Richard Schatz, MD) and non-invasive cardiac ablation utilizing CyberKnife technology (Steven Higgins, MD). Led by Eric Topol, MD, Scripps recently received a $120 million NIH grant to pursue mobile sensors, smartphone apps, and genomics in disease.
Describe your city or general area. How is it unique from the rest of the U.S.?
Scripps Memorial, Scripps Clinic, and the SPCI are located in La Jolla, a suburb of San Diego, the nation’s seventh largest city. Other Scripps Health campuses are in downtown (Mercy), Chula Vista, and Encinitas, which also have their own single-lab EP programs. While we receive referrals from throughout the nation, many patients come from San Diego County and the adjacent Imperial Valley, Orange County, and Inland Empire regions (Riverside and desert areas). Due to our location in La Jolla, we have many celebrities, executives, and physicians as patients; we try to provide the best care for each and every patient. Uniquely adjacent to our southern border, Scripps has many international referrals from Mexico and Central America.
Please tell our readers what you consider special about your EP lab and staff.
In medicine, volume translates into quality. Due to our large cardiac and EP volume (4000 EP procedures annually), we routinely see unusual presentations of cardiac disease. As a result, our staff and physicians are better able to diagnose and treat not only the common but the unusual presentation as well. Our EP staff are integral to our success, with a focus on shared responsibility, beginning with the Time-Out process. We have regular team-building opportunities for physicians and staff to interact. One interesting program included role model exercises, in which staff acted out problematic physician behaviors in the lab setting and their potential for poor outcomes. Using this team approach, we recognize that close collaboration between the EP staff and physicians results in the best care for our patients. As we stated when the SPCI opened last year, “San Diego’s best heart care just got better.”