Spotlight Interview: The Southeast Hospital Arrhythmia and Cardiac Electrophysiology Center

Jessica E. Umfleet, RT(R)(CI)(VI)-Cardiovascular, Electrophysiology Technologist, and Brooke Harrell, BSN, RN-Cardiac Electrophysiology Nurse Cape Girardeau, Missouri
Jessica E. Umfleet, RT(R)(CI)(VI)-Cardiovascular, Electrophysiology Technologist, and Brooke Harrell, BSN, RN-Cardiac Electrophysiology Nurse Cape Girardeau, Missouri

When was the EP lab started at your institution?

Our EP lab, the Southeast Hospital Arrhythmia and Cardiac Electrophysiology Center, was given a new name and direction in August 2008 with the arrival of electrophysiologist Gabe Soto, MD, PhD, FACC. Prior to his arrival, the electrophysiology service at our institution consisted of only device implantations.

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

Our 260-bed facility, Southeast Hospital, is in the SoutheastHEALTH organization. Our lab, the Arrhythmia and Cardiac Electrophysiology Center, has the distinction of being the only EP lab in the organization. We have one dedicated EP suite equipped with a Philips FD10 biplane system with EP Navigator and Cockpit (Philips Healthcare, Andover, MA), St. Jude Medical’s EnSite Velocity 3D Mapping System (St. Jude Medical, St. Paul, MN), GE CardioLab software (GE Prucka; GE Healthcare, Waukesha, WI), and the Micropace EPS320 Cardiac Stimulator (Micropace EP Inc., Santa Ana, CA). Our EP lab is also equipped to be an overflow room for cardiac catheterization procedures.

In addition to our electrophysiologist and director, Gabe Soto, MD, PhD, FACC, there are five dedicated, supplementary members: Brooke Harrell, BSN, RN, Sherri Wood, BSN, RN, Amanda Chapman, RCIS, Jessica Umfleet, RT(R)(CI)(VI) and Lisa Zoellner-Gullette, APRN BC FNP-C.

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

We perform implantations of permanent pacemakers and implantable cardioverter defibrillators (including biventricular devices, cardiac resynchronization therapy/biventricular pacemakers, and implantable loop recorders). Our comprehensive diagnostic and interventional electrophysiology procedures include typical and atypical atrial flutters, atrial fibrillation, AV nodal re-entry, ectopic atrial tachycardias, accessory pathways, ventricular tachycardias, and epicardial ablations. Currently, we perform between 8 and 15 electrophysiology procedures a week.

What is the primary goal of your program?

The primary goal of our electrophysiology services is always to provide exceptional care to our patients and the community. It is our hope that this attention to superior quality ultimately merits our EP lab the recognition of being an EP Center of Excellence.

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

Since opening the EP lab in 2008, the two labs have been geographically separate, although the EP staff often floats from the EP lab to the cath lab when not working on EP cases. Employees committed to EP often have to be flexible as they are also slated to take Chest Pain Call, or “EP Red Dot,” to cover the additional EP cases scheduled into the day. This level of dedication often leads to some late nights for our staff.  

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

Yes, we offer cross training in our lab. Presently, all employees are trained, or are currently in training, on the Micropace, GE CardioLab, St. Jude Medical EnSite Velocity Mapping System, and ablation generators. In accordance with state regulations, RNs are solely permitted to give medication and the technologists exclusively scrub cases in our lab.

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 now implemented the Philips 3D ATG that is used during atrial fibrillation (AF) ablation procedures. This is a process in which the C-arm spins around the patient, acquiring a CT-like image. This image is then reconstructed in the Philips EP Navigator by the radiologic technologist. This 3D image is then superimposed over the fluoro image and rotates with the C-arm to maintain the left atrial anatomy in all planes. This image is also uploaded into the mapping system to use as a guide and reference point for the left atrium and pulmonary vein(s). 

This process has helped us make great strides when performing AF ablations. Our patients no longer have to have a CAT scan performed the morning of the procedure, thus greatly reducing not only procedure time and radiation exposure, but also the overall cost to the patient.

Have you also recently upgraded your imaging technology?

Yes, in 2010 our lab upgraded the mapping equipment from the St. Jude Medical EnSite system to their new Velocity System.

What type of quality control/quality assurance measures are practiced in your EP lab?

With respect to on-the-job quality measures, a variety of ongoing measures are enforced, including frequent handwashing, time monitoring of both pre-op antibiotic administration for implants as well as documenting time-out. In our facility, we utilize the COPS (Champions of Patient Safety) and SCIP (Surgical Care Improvement Project) Committees as a quality control and improvement process. The COPS committee reports on any unexpected patient safety issues, and the SCIP committee reports on the accuracy of preoperative antibiotic administration.

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 hospital gained its recognition as the region’s first heart hospital in 1984. Since the expansion of the SoutheastHEALTH organization in 2010, our referral base has grown tremendously. In offering the services of both our EP and cath labs, our facility provides a valuable service to this expanded patient load by reducing travel by more than 100 miles in some cases.

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

Training and education is often conducted during cases as the opportunity arises. Our physician takes the opportunity to explain and instruct us when time allows. Vendors also contribute to our education by bringing their specialties to our lab to teach outside of and also during cases. Our management is cognizant of the importance of EP education. Each year, since its inauguration, members of the EP staff have attended national educational and scientific sessions Additionally, staff members are encouraged to seek out their own individual learning sessions by attending local, regional and national meetings.

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

Our lab motto is to work hard, learn one new piece of information during each case, and have fun doing it! To lighten the mood and keep our team focused as a unit, we often use music therapy (Lady GaGa for our electrophysiologist), and we engage in staff-developed “movie quote trivia” during procedures as well.

Describe a particularly memorable or bizarre case that has come through your EP lab. What lessons did you learn from it?

Late one evening, we had a very interesting case that presented. A 72-year-old male with a history of a posterior myocardial infarction and severe mitral regurgitation underwent a four-vessel coronary artery bypass grafting with a concurrent mitral valve replacement. His post-operative course was complicated by cardiac arrest and recurrent ventricular tachycardia (VT). The patient continued to have recurrent episodes of VT despite treatment of many medications.

The decision was made by our electrophysiologist and vascular surgeon to coordinate the OR and EP staff to perform the first open-heart epicardial ablation hybrid procedure in our area.

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?

While we have a dedicated EP staff, these members are still required to take Chest Pain Call. This consists of 2 RNs and 2 technologists that take call 2–3 nights a week, plus one weekend a month. In addition to call, the EP staff continues to work “EP Red Dot,” which consists of any EP cases added on during the day for either early AM or late PM.

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

We are an adult EP lab, but have handled adult-size adolescents (the youngest being 11 years old). We have special equipment for pediatric patients, and our nurses are PALS certified.

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

Our Philips Allura FD20 system has an EP setting that reduces the amount of radiation to our patients. We also use ALARA (As Low As Reasonably Achievable) as our golden standard. Our lab also uses table skirts and shields mounted from the ceiling to help decrease radiation scatter. Staff wear two-piece wrap around lead with thyroid collars, and sit behind a radiation screen when fluoroscopy is performed. All physicians and staff members wear dosimeters that are monitored by the physicist at our hospital.

What other new EP techniques are being utilized in your lab?

We currently use St. Jude Medical’s Velocity three-dimensional mapping system on all cases. We also use St. Jude Medical’s Array Catheter for mapping difficult arrhythmias and their ICE imaging for crossing the septum during any left-sided arrhythmias.

Is your EP lab currently involved in any clinical research studies or in the use of any special products?

Our lab is currently using the St. Jude Medical’s Safire Blu Ablation catheter; in fact, our electrophysiologist is currently the only physician in Missouri, Arkansas, Kentucky, Indiana and southern Illinois currently using this catheter. We are also anxiously awaiting the arrival of Medtronic’s Arctic Front Pulmonary Vein Isolation Cryo Catheter.

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?

Education for our patients starts in the electrophysiologist’s office. Not only is that same information reiterated by the EP staff in our admitting area, but discharge instructions are given to the patient at that time as well (these are given again at discharge). Our patients are given an educational pamphlet and DVD, and device support is provided by the appropriate device representatives.

Give an example of a difficult problem or challenge your lab has faced. How it was addressed?

Our EP lab is currently facing difficult challenges with Chest Pain Call and the amount of early and late EP cases. The cath and EP labs are currently under new leadership with the implementation of a cardiovascular and peri-operative service line director, who deems that this issue is a work in progress. We are hopeful that this issue will be resolved soon.  

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

Southeast Hospital is located in Cape Girardeau, Missouri. The population of Cape Girardeau County is 73,000+; the city is located in the Southeastern part of the state on the Mississippi River. We are the only inland Cape in the United States, and we are considered, appropriately enough for our services, the Heartland of America.

Please tell our readers what you consider unique or innovative about your EP lab and staff.

Considering the workload our EP staff carries, operating in both the EP and cath lab worlds, our relatively small, close-knit group has a great sense of both humor and duty. This contributes to our exceptional teamwork. We share the scheduling burdens and take the initiative to keep morale high, so that each patient’s experience during their procedure is as pleasurable as possible.

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