Spotlight Interview: Staten Island University Hospital

Valay Parikh, MD, Vincent Quinn, RN, Marcin Kowalski, MD, FHRS, and Souad Bekheit, MD, PhD, FHRS, Staten Island, New York
Valay Parikh, MD, Vincent Quinn, RN, Marcin Kowalski, MD, FHRS, and Souad Bekheit, MD, PhD, FHRS, Staten Island, New York

The Heart Institute at Staten Island University Hospital (SIUH) operates at the North Campus of Staten Island University Hospital (part of North Shore-LIJ Health System). SIUH is a 700-bed teaching hospital with two campuses located in Staten Island, New York. Staten Island is believed to be the birthplace of electrophysiology. The first His bundle potential recording was performed here in the 1960s by Dr. Anthony Damato at the U.S. Public Health Service Hospital. Many of the physicians considered to be the fathers of EP, such as Mark E. Josephson, MD and Joseph Gomes, MD, were trained under him. 

What is the size of your EP lab facility?

Currently we have two active EP labs.

When was the EP lab started at your institution? 

The EP program was started in 1994 by Souad Bekheit, MD, PhD, who has been the Director of Electrophysiology since the inception of the program.

What is the number of staff members? How is shift coverage managed? 

Average daily staffing consists of five RNs working 10-hour shifts. Staff also includes the nurse manager, quality RN and a secretary/registrar. The first nurses arrive at 7:30am and, barring emergencies or a case running late, the last shift leaves at 7:30pm. The nurse manager will also assume a staff role when necessary.

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

On average, we perform six catheter ablations, seven ICD implants and six pacemaker implants per week. In addition, we also perform conduction studies and tilt table studies. Atrial fibrillation (AF) ablations using cryoballoon catheters from Medtronic comprise roughly half of our total ablation volume.

Has your EP lab recently expanded? 

The addition of Marcin Kowalski, MD, FHRS in 2009 greatly expanded our scope of services, especially newer techniques for AF ablations, endocardial and epicardial VT ablation, left atrial appendage (LAA) closure devices and subcutaneous ICD implants. Our success in this area has led to patient referrals not only from Staten Island, but also from Brooklyn and New Jersey.

Are the EP and cath lab employees cross trained?

Although the EP lab is separate from the cath lab, we support each other from a staffing perspective when necessary, in a non-procedural role. 

Do you have cross training inside the EP lab?

All of our RNs are cross trained to function in any role in the EP lab.

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

We utilize GE Healthcare’s CardioLab as our recording equipment, and use Biosense Webster’s Carto 3 System and St. Jude Medical’s EnSite Velocity System for mapping. We also have Stockert and St. Jude Medical generators for radiofrequency ablations, and Medtronic catheters for cryoballoon ablation. We also use the Impella (ABIOMED, Inc.) for ventricular tachycardia ablations.

What new technology has been introduced into your lab lately? 

We routinely implant Medtronic’s Reveal loop recorder and have recently started implanting their new Reveal LINQ Insertable Cardiac Monitor for outpatient cardiac monitoring. This is done in the recovery area instead of the OR, and the entire patient stay is approximately one hour.

What imaging technology do you utilize?

Our imaging equipment consists of an Innova 2100 Biplane system (GE Healthcare) in one lab, and an OEC 9900 portable C-arm (GE Healthcare) in the other lab. We also recently installed the ViewMate Intracardiac Ultrasound System (St. Jude Medical), which is used for both transesophageal and intracardiac echo during our AF ablations.

What innovative EP techniques are being utilized in your lab? 

We recently started implanting subcutaneous ICDs, and also have been performing LAA closures using the LARIAT Suture Delivery Device (SentreHEART, Inc.) for about 18 months.

What is your experience with MR conditional cardiac devices? 

We have worked with the radiology department to develop a protocol to accommodate these patients. When a patient is identified as having an MRI-compatible device, the EP lab is notified. The information is verified and we make arrangements with Medtronic to have one of their clinical personnel present at the time of the scan.

Does your program utilize a cardiovascular information system, picture archiving system, or cardiology picture archiving system?

We use GE’s Centricity IMS (image management system) and Centricity DMS (data management system). 

Do you employ travel RNs, RT(R)s, or RCISs?

We do not utilize travel or agency personnel.

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

Our registrar, Ms. Caroline Denuzzie, schedules the patients using McKesson’s Pathways Healthcare Scheduling software.

How is staff competency evaluated? 

Staff competency is evaluated annually basis using a tool developed for that specific procedure/subject. It is evaluated by a certified staff member or physician leadership. 

Do you encourage your clinical staff members to take the registry exam for Registered Cardiac Electrophysiology Specialist (RCES)? How many members of your lab have taken the exam?

The majority of our RNs have some sort of certification (i.e., CCRN, RN-C, etc.). We have discussed the benefits of RCES certification in a great detail with our staff. Although none of our staff members have taken the exam yet, they are willing to take it in the near future. 

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

Our staff members regularly participate in our internal Collaborative Care Council (CCC). Furthermore, they also represent at the Cardiology CCC at monthly meetings.

How does your lab handle call time for staff members? 

There is no call in the EP lab. The nurse manager reports to the Associate Administrative Director for Cardiology. 

Does your lab use a third party for reprocessing or catheter recycling? 

We do not use a third party for reprocessing or recycling catheters.

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

Currently, we serve only the adult community.

Do your nurses/techs participate in the follow-up of pacemakers and ICDs? 

The EP staff is responsible for the majority of ICD and pacemaker interrogations.

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

Dr. Kowalski has significantly reduced radiation exposure for our patients by relying more on non-fluoroscopic imaging modalities such as intracardiac echo and 3D mapping. In fact, we have been able to reduce fluoroscopy time during AF ablations to less than 10 minutes. Our lab has also developed tools such as a “call back” sheet that identifies patients who might have experienced excessive fluoroscopy time due to a complex procedure. We routinely call all patients within 72 hours and again at two weeks to make sure they are following instructions and taking the appropriate medications, and to give them the opportunity to clarify anything they might have questions about. Knowing that the fluoroscopic time in a particular case was excessive allows us to discuss the potential consequences of this, such as skin irritation. We also instruct the patient to inspect the area affected, and if necessary, contact their physician. 

What are your methods for infection prevention?

In addition to strict universal aseptic techniques, our methods for infection prevention include routine audits for handwashing as well as antibiotic administration within one hour of the start of device implants. Our infection rate is less than 0.01%.

Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR)? How do you use this to drive QI initiatives at your facility?

Currently, we report to the ACC-NCDR ICD registry. We compare our results to the national averages and constantly perform reviews to determine if there is a room for improvement.

Does your hospital offer a cardiac device support group for patients? 

There is a support group (Heart to Heart) that meets monthly in the hospital, and is open to anyone who has had any kind of cardiac procedure or event.

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

A recent memorable case was a 27-year-old man with a three-year history of incessant atrial tachycardia (AT) at 130-140 bpm referred to our center for evaluation. The patient was offered a tachycardia ablation. When the right atrium (RA) was mapped, we found the earliest activation of the AT originating from the lateral wall of the RA. However, pacing at the location of the earliest activation revealed phrenic nerve capture; therefore, ablating this location would have resulted in phrenic nerve injury (PNI). The only way to terminate AT and prevent PNI was to separate the phrenic nerve from the origin of the tachycardia. We then obtained pericardial access and inserted a 10 mm x 40 mm Admiral Xtreme balloon (Medtronic, Inc.). A low-pressure inflation was performed which displaced the phrenic nerve, allowing for safe and successful ablation of the AT. During the ablation, the phrenic nerve was paced from the SVC to monitor its function. Our lab was the first to describe monitoring of phrenic nerve function during cryoballoon ablation for AF by utilizing compound motor action potentials (CMAPs). The decrease of CMAP amplitude during ablation is the earliest indication of phrenic nerve injury. (The manuscript was published in the March issue of HeartRhythm). The patient did very well and was discharged home with a heart rate of 75 bpm the following day. 

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