Spotlight Interview: Sequoia Hospital

Vem Acosta, RN, CCRN, Clinical Nurse II, Charge Nurse, Sequoia Hospital Electrophysiology Lab, and Rob Patrawala, MD, Cardiac Electrophysiologist, Silicon Valley Cardiology

Vem Acosta, RN, CCRN, Clinical Nurse II, Charge Nurse, Sequoia Hospital Electrophysiology Lab, and Rob Patrawala, MD, Cardiac Electrophysiologist, Silicon Valley Cardiology

What is the size of your EP lab facility and number of staff members?

Sequoia Hospital’s cath lab has five rooms (two dedicated EP labs, one cardiac cath lab, one device room, and one IR room). We have 13 RNs, a special projects manager, and six radiology techs. Both EP labs perform two to three ablations on most days, and the device lab performs anywhere from zero to six cases on any given day.

The team is comprised of pre-staging staff members Dana Engelhardt, RN, Jan Beach, RN, Clinical Nurse II, Nenita Nguyen, RN, as well as cath lab/EP staff members Amy Meteney, RN, Angie Boncutter, RN, Gail Gagas, RN, Geneva Reyes, RN, LaVern Colgate, RN, Clinical Nurse II, Michele Kermani-Sutton, RN, Clinical Nurse II, Nancy Olsen, RN, Valerie Pagendarm, RN, Vemelyn Acosta, RN, Clinical Nurse II, Yasmine Zapata, RN, and Lourdes Gueco, RN. Support staff includes Karen Pring, Lab Coordinator, and Chip Voelker, RT, Special Projects Manager.

When was the EP lab started at your institution?

The EP lab was started in 1984 under the direction of Dr. Roger Winkle and Dr. Hardwin Mead. Dr. Michael Ruder and Dr. Nellis Smith joined in the 1980s. The 1990s did not see the addition of any new EP doctors. The advent of AICDs for primary prevention and ablation of atrial fibrillation (AF) has resulted in the addition of three new EPs in the new millennium: Dr. Rob Patrawala, Dr. Greg Engel, and recently, Dr. Melissa Kong.

What types of procedures are performed at your facility? Approximately how many are performed each week?

We provide comprehensive electrophysiology services. Our EP lab performs electrophysiology studies and ablation cases, device implants including pacers, biventricular devices, loop recorders and laser lead extractions. The laser lead extractions are performed in the operating room with CV surgical backup. We perform ablation procedures for all types of supraventricular arrhythmias and ventricular arrhythmias including both ischemic and idiopathic. Roughly 70 percent of our ablation cases are AF ablations, including both primary cases and redo procedures.

We have performed over 2,000 AF ablation cases since 2004. We can generally do an AF ablation in less than two hours and can get through three AF ablations in one lab. We perform approximately 1,000 total procedures annually.

What is the primary goal of your program?

The primary goal of our program is to provide excellent care with good outcomes and to continue to grow volume.

Our EP program has a large referral network. Our patients travel long distances from all over California, and many come from Alaska and Hawaii. The physicians and nurses are passionate about improving the lives of these patients.

Who manages your EP lab?

Michelle Isonio, RN, MPA is the director of the cardiovascular labs at Sequoia Hospital. Gayle Johnson, RN is the manager of the cath lab. Nancy Olsen, RN, LaVern Colgate, RN, Clinical Nurse II and Vemelyn Acosta, RN, Clinical Nurse II are the charge nurses, who ensure efficiency of the day-to-day operations of the lab. Together, they have about 100 years of EP and cath lab experience.

Is the EP lab separate from the cath lab? How long has this been? Are employees cross trained?

The EP and device rooms are separate from the cath lab. However, the staff has been cross trained in the labs and all the roles since the 1990s. This unique feature of our lab allows flexibility in staffing and allows the staff to have variety in their day-to-day responsibilities. The charge nurses also rotate taking charge and work in the lab with the rest of the staff.

Do you have cross training inside the EP lab? What are the regulations in your state?

All RNs work in the EP and device rooms. Each RN is trained and fulfills annual competencies in both these areas.

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 use the ZeroGravity Radiation Protection System (CFI Medical Solutions, Fenton, MI) to decrease fluoroscopy exposure to physicians. The ZeroGravity has resulted in a dramatic reduction in fluoro exposure to the physicians as well as improved comfort (less backache, etc.) due to the weight being suspended. The physicians also recently started using the EnSite Velocity system (St. Jude Medical, St. Paul, MN), which has greatly improved the 3D geometry resolution and the time to create these images during our AF ablation cases. We started using the NRG™ RF Transseptal Needle (Baylis Medical Company Inc., Montreal, Quebec, Canada) three years ago, which improves the speed and safety of our transseptals. In fact, at one point we had done 800 consecutive AF ablations without a tamponade utilizing the RF needle.

Have you recently upgraded your imaging technology?

We have a biplane Philips system in one room and a single plane GE system in the second room. These rooms were upgraded about five years ago.

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

Our lab coordinator handles our scheduling. Currently, it is done by hand. We do have plans to upgrade to a computerized system in Spring 2012.

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

Our lab coordinator also manages the inventory. The staff helps out in notifying her when we are low on equipment and supplies.

Has your EP lab recently expanded in size and patient volume, or will it be in the near future? In addition, is your EP lab part of a separate “heart hospital”?

Our EP cases have expanded in volume. There was an increase of 4% in the past year. Similar to other centers, our EP growth is mainly due to AF ablations, which continues to grow each year. Our device volume has been flat after an initial surge between 2002-2005 due to data supporting AICD use in primary prevention and the benefits of biventricular pacing. We recently started a lead extraction program that has added to EP volume, although these cases are done in the OR.

Have you developed a referral base?

Sequoia Hospital is located in the San Francisco Bay area, which has multiple excellent electrophysiology programs. There are at least 40 EPs in this region, and therefore, our referral base needs to draw from a larger geographical area.

Our EP physicians are well known in the field and frequently give lectures/talks to cardiologists and other EPs. We aim to deliver the highest level of care and often do the most complex cases that may have failed elsewhere. We have found that patients are willing to travel long distances in search of the best care possible.

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?

We reprocess all cables and most diagnostic catheters with Stryker. Our physicians continually evaluate new technologies with regard to their cost-to-value ratio. If a new technology will bring a significant benefit to a patient, then we absolutely make the investment. On the other hand, many new technologies do not add significant value and are not worth the cost. This continual evaluation of new technologies is particularly important in our current era of diminishing reimbursements.

How are new employees oriented and trained at your facility?

New staff members attend a one-day hospital orientation and a two-day hospital training for nurses. Once they are released to the cath lab from the hospital orientation, they are assigned a preceptor to allow for individualized training. Qualified staff also takes turns in orienting new employees.

New employees are encouraged to attend classes offered locally as they go through each area of the lab.

The orientation takes approximately two months in each aspect of the lab. They are then assigned a mentor after their orientation.

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

In-services and workshops are given to staff by the local industry reps. Staff is encouraged to take classes online or attend conferences. CE reimbursement and CE days are given for each staff.

How is staff competency evaluated?

The manager and charge nurses determine the competencies needed for the year. The cath lab dedicates two days every year for the staff to go through each competency, which fulfills the requirement for the year.

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

The staff dedicates one hour each month to discuss new things in the lab, including staffing concerns. We brainstorm on ways we can get better as a team.

We also allow time for staff to discuss emergency or code situations. We review each case and discuss how we can improve each emergency situation.

The staff rotates roles and cath lab rooms since we are all cross trained in all aspects of the cath lab. This allows flexibility and variety in our daily work, which helps us to minimize burnout.

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

Staff members are asked to participate in QI committees, become leaders for our annual competency, and to be super users of new equipments.

How do you handle vendor visits to your department?

Each vendor schedules through our lab coordinator. Each vendor typically is allowed one day a month, and they need to follow our Vendor Policy.

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

We often play some light music in the lab. This helps to lighten the mood, and several of the electrophysiologists enjoy it. We often let the patient pick their favorite artist so they enjoy their experience as they drift off to sleep.

Describe a particularly memorable or bizarre case that has come through your EP lab. Can you think of any cases that had a significant effect on the nurses?

During a routine AF case the staff in the room noticed that the patient was having intermittent ST elevation. The MD viewed the whole heart under fluoro and saw an air bubble above the aortic valve. The staff quickly paged an interventional cardiologist, who came and aspirated the air bubble. The ST elevation resolved and we proceeded with the case without any resultant complications.

This case made an impression on all of us. Even though the nurses are very meticulous in setting up all the equipment in the room (inspecting each catheter, flushing every catheter that needs flushing, purging every minute bubble they could see), we have now reached an even higher level of obsession with keeping the whole procedure air free. It is also clear that any change from baseline needs to be taken seriously and investigated.

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?

We have a dedicated scheduler for call time. Our call team is on call for all the labs, and is comprised of two RNs and one tech. Each RN is scheduled to take call one night a week and every fourth or fifth weekend. The call team is called in approximately 0-3 times a week. More often, the staff works late.

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

Yes, we work hand in hand with Stryker Sustainability Solutions. In 2011, Sequoia Hospital saved $375,000, of which $350,000 was savings from the EP lab. Stryker Sustainability Solutions reimburses us for the platinum tips, and we reprocess all our catheters and cables. The savings go directly into our department’s account to offset supply costs.

Do you perform only adult EP procedures or do you also do pediatric cases? Is there cross training for pediatric cases?

Sequoia’s cath lab does not have a pediatric EP program, but will often do procedures on teenage patients who have reached adult size.

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

All staff members are provided lead aprons, glasses and lead shields. Each staff also wears a dosimeter badge for monthly monitoring of radiation exposure. 

The physicians use the ZeroGravity during procedures, which eliminates their need to wear lead aprons.

The utilization of 3D mapping also helps reduce fluoro use. For EP procedures, we keep the frame rate as low as 3.75 frames/sec.

Is your EP lab currently involved in any clinical research studies or special projects? Which ones?

The electrophysiologists are continuously involved in various research and clinical studies. Multiple device studies are going on at any one time. We are participating in the CABANA study, although enrollment has been difficult as many patients who are referred prefer the ablation route. In addition, the physicians maintain a large database of their atrial fibrillation ablation patients and results, and are continually publishing research papers.

Does your staff provide any educational materials for patients who may have additional questions about their condition/procedure? In addition, does your hospital or lab staff have a device support group?

A packet is given to each patient at the physician’s office for his or her specific procedure. The packet includes details regarding their procedure, outcome, and frequently asked questions. The same packet is available for patients when they are admitted to the hospital.

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