Spotlight Interview: Stanford University School of Medicine, Cardiac Arrhythmia Service & Cardiac Electrophysiology Lab

Amin Al-Ahmad, MD, FHRS, FACC, Associate Director of the Stanford Arrhythmia Service and Cardiac Electrophysiology Laboratory Stanford, California
Amin Al-Ahmad, MD, FHRS, FACC, Associate Director of the Stanford Arrhythmia Service and Cardiac Electrophysiology Laboratory Stanford, California
What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab? We currently have two dedicated rooms for EP, and we also have a third room that is shared with another service that can be used if needed. We have a mix of CVTs and RNs in the lab. There are about 15 EP nurses and techs. When was the EP lab started at your institution? The first EP lab at Stanford was started in the early 1970s by Dr. David Cannom. What types of procedures are performed at your facility? Approximately how many are performed each week? We perform a range of procedures, from simple SVT ablation to complex ablations of atrial or ventricular arrhythmias, including epicardial ventricular tachycardia (VT) ablation and atrial fibrillation (AF) ablation. We also perform device implants as well as lead extraction procedures. Overall, we perform about 30 cases a week, of these usually 4 to 6 AF cases per week and frequently 1 VT ablation per week. We are also starting a program to perform hybrid procedures such as thoracoscopic AF ablation and catheter-based AF ablation. What is the primary goal of your program? We strive to give the best care to our patients, providing both ablation and device implants in the EP lab. Who manages your EP lab? There is both physician leadership of the EP lab, as well as leadership from the techs and nurses. The lab director is Shelly Reynolds, RN. Is the EP lab separate from the cath lab? How long has this been? Are employees cross trained? The EP lab is located in a large suite of interventional rooms. While most of the EP lab staff are mainly doing EP procedures, we do have the advantage of utilizing some cross-trained staff during late hours or times when the EP lab staff may be short due to illness or time off. Do you have cross training inside the EP lab? What are the regulations in your state? In general, the RNs are trained to do multiple tasks, including giving medications (the CVTs are not able to give medications). What new equipment, devices and/or products have been introduced at your lab lately? We are fortunate to have a state-of-the-art EP lab with 3D image capability; we use Siemens’ DynaCT system, which utilizes the C-arm to perform a rotational angiographic image of the heart. We also have a Hansen Medical robotic system that is used for many of our AF cases. We have both St. Jude Medical’s NavX and Biosense Webster’s Carto systems. We have recently begun using the Baylis Medical system to facilitate all of our transeptal punctures. In addition, we have been using the Medtronic CryoCath Arctic Front catheter in the setting of a clinical trial. Who handles your procedure scheduling? Do you use particular software? We have a dedicated administrative person who handles all aspects of procedure scheduling, including noting the type of equipment that is required for any given procedure. This information is then communicated to the EP lab and updated daily. What type of quality control/quality assurance measures are practiced in your EP lab? There are many levels of quality control, including monthly physician QA, a physician practice committee, and hospital committees to evaluate any quality issues. How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? We use a computer program called Q-site (qsight.net) and set par levels for the equipment and supplies that we use. Has your EP lab recently expanded in size and patient volume, or will it be in the near future? We have recently completed a renovation project of one of the EP lab rooms; it is now not only larger in size, but also has many of the advanced technologies used in EP. In addition, a new hospital is being planned, so there will be room to grow in the future. Have you developed a referral base? Yes, we receive referrals from both local cardiologists as well as cardiology practices throughout the state of California and the west coast. 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 review vendor contracts annually as one measure to help contain costs. We also typically have patients undergo pre-op testing in advance, since this allows for a faster start time in the morning and a more efficient day. How are new employees oriented and trained at your facility? New employees are given several months of training and support as well as mentorship by other members of the staff before they are able to function independently. What types of continuing education opportunities are provided to staff members? The EP faculty offer a monthly lecture to the EP lab staff. In addition, some funds are available for CE support. How is staff competency evaluated? Recently, the cath lab instituted competency evaluation for sterile procedures preparation. How do you prevent staff burnout? We engage with the staff for occasional activities such as group dinners or outings. How do you handle vendor visits to your department? Do you contract with vendors? Vendors who serve a technical support role can come to the EP lab; otherwise, they are able to visit with the physicians and EP lab staff outside of the lab, typically by invitation per our hospital policy. Does your lab use a third party for reprocessing? We have started to use a third party for reprocessing. We are able to cut costs using this. Approximately what percentage of your ablation procedures are done with cryo? What percentage is done with radiofrequency? Most ablations are done with radiofrequency, although we do use cryoablation for some AVNRT and pediatric patient cases. We were also able to use the cryoballoon catheter for atrial fibrillation as part of the clinical study. Do you perform only adult EP procedures or do you also do pediatric cases? Is there cross training for pediatric cases? There are two pediatric EP faculty who perform pediatric cases. We often perform procedures together in adult patients with congenital heart disease. What measures has your lab taken to minimize radiation exposure to physicians and staff? Some measures we have taken include appropriate shielding and the minimal use of radiation, taking advantage of 3D mapping systems, and the use of robotic catheter ablation with the Hansen Medical system. Do your nurses/techs participate in the follow up of pacemakers and ICDs? Do you use any particular software for follow up? How many of your ICD/pacemaker patients require a doctor for their visits? The device follow-up is performed by nurses that are not cross trained to be in the EP lab. We use Paceart software. Most patients do not require a doctor visit at the time of a device check. What trends do you see emerging in the practice of electrophysiology? How is your lab preparing for these future changes? We see the use of imaging and the ability to utilize multiple modalities to image and map arrhythmias as some of the future trends in EP. We are well set up to incorporate technologies as they emerge into clinical practice. Other areas that we see as potentially important in treating complex arrhythmias are the development of hybrid procedures and the use of robotic ablation technologies. Is your EP lab currently involved in any clinical research studies or special projects? We have several active investigational protocols that span the field, from AF ablation and VT ablation to device implantation and testing. Are you ACGME-approved for EP training? What do you think about two-year EP programs? Yes, we are an ACGME-accredited program. Most of our fellows stay for an additional year of training. 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? We provide educational materials in print as well as on the web, including an interactive video-based educational supplement for some procedures. Describe your city or general regional area. How does it differ from the rest of the U.S.? We are located in the bay area between San Francisco and San Jose, in the heart of Silicon Valley. We are also on the same campus as Stanford University, and as such, have many of the campus amenities available. Please tell our readers what you consider unique or innovative about your EP lab and staff. We are proud to have a state-of-the-art EP lab that often participates in the design and testing of new technologies and then rapidly incorporates them where appropriate into clinical practice. For more information, please visit: http://stanfordhospital.org/