Spotlight Interview

Spotlight Interview: Swedish Medical Center

Sara Downing, RN, Brian Marshall, RN, Dawn Kearns, RT, RCIS, and Kevin Spalti, RN
EP Lab, Swedish Medical Center
Seattle, Washington

Sara Downing, RN, Brian Marshall, RN, Dawn Kearns, RT, RCIS, and Kevin Spalti, RN
EP Lab, Swedish Medical Center
Seattle, Washington

Founded in 1910, Swedish Medical Center is the largest non-profit health care provider in the Greater Seattle area. Swedish provides a variety of specialties throughout its seven campuses, and boasts more than 1,500 inpatient beds. 

The Swedish Cherry Hill campus, located in downtown Seattle, provides specialized treatment including cardiovascular and neuroscience care. Swedish has garnered a reputation throughout the state of Washington as a center of excellence, with many of its practitioners receiving high honors as the “area’s best” in their given specialty. 

Our EP program is located at the Cherry Hill Campus and was introduced in 1989 as an independent department with 3 technical/RN staff and 2 MDs sharing one procedural suite. 

Today, we operate 3 EP labs, including a Stereotaxis lab, and employ a dedicated EP staff of more than 20 highly skilled RNs and technologists. We currently have 8 electrophysiologists that practice in our lab.

Has your EP lab recently expanded in size and patient volume (or will it be soon)? 

Our EP lab has grown by 1 room, 2 electrophysiologists, and 11 staff members in the last year! There are plans for future expansion, moving us to a brand-new facility at our First Hill campus. This new tower is slated to open in 2019 and will include a variety of services. There will be 4 new operating suites for EP, 5 catheterization labs, and 2 hybrid procedure rooms. In addition, the facility will have 32 pre- and post-procedure beds, several of which are designated for procedures such as cardioversions and transesophageal echocardiograms. 

Approximately how many catheter ablations (for all arrhythmias), ICD implants, and pacemaker implants are performed? 

To date, our lab has performed approximately 670 ablation procedures and 508 ICD/CRT/PPM implants this year.     

Do you have cross training inside the EP lab? How are new employees oriented and trained at your facility?

Our team members are encouraged to learn at least two roles: circulating, monitoring, and/or scrubbing. After completing hospital orientation and computer training, our new team members are started with orientation in one of the 3 roles, typically wherever their expertise is strongest (e.g., an RCIS might start with scrubbing, while an experienced EP tech might start with monitoring). Once competent, they move on to another role. We are happy to enjoy a diverse work force employing people with varying backgrounds, education, credentials, and experience, so this process is highly individualized. 

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

  • WorkMate Claris and EP-WorkMate Recording Systems, TactiCath Quartz Contact Force Ablation Catheter, and EnSite NavX (Abbott)
  • CARTO 3, SMARTTOUCH, and CARTOSOUND (Biosense Webster, Inc., a Johnson & Johnson company)
  • MAESTRO 4000 Cardiac Ablation System, Blazer catheters, iLAB Ultrasound Imaging System and ULTRA ICE PLUS Ultrasound Imaging Catheter (Boston Scientific). 
  • Cryoablation (Medtronic)
  • Artis Q imaging system and ACUSON ICE (Siemens)
  • Magnetic navigation system (Stereotaxis)
  • Laser lead extraction (Spectranetics)

How is shift coverage managed? What are typical hours (not including call time)?

Our lab runs 5 days a week from 6:30-7 pm, with a three-person team assigned to stay for case overflow. Currently, our staff is exclusively working 12-hour shifts.

Tell us what a typical day might be like in your EP lab.

All rooms are equipped for any type of ablation or implant, with the exception of Stereotaxis cases. Case placement and staff assignments are determined the day before. Start of the day is at 6:30 am, with a safety huddle and brief overview of the day’s cases. Patients are checked in and prepped in our Surgical/Procedural Admission Unit, then transferred to the lab and interviewed by Anesthesia. Induction and placement of mapping electrodes takes place simultaneously. The patient is scrubbed, prepped, and draped. At the conclusion of each case, sheaths are pulled in the lab and the patient is transferred to PACU or Telemetry as determined by Anesthesia. Rooms are turned over and the next patient is sent for. Our typical day winds down by 6 pm, but a late team is available if needed.

Do you implant MR conditional pacemakers or ICDs? What about subcutaneous or leadless devices?

We implant MRI-compatible devices and subcutaneous ICDs. We are not yet implanting leadless devices, but are looking forward to adding this option for our patients.

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

Centralized Heart Center scheduling handles both invasive and non-invasive appointments for cardiac specialties. All scheduling is done through our EMR applications. Add-on cases are put on the schedule by the lead of the day after consulting Anesthesia.

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

Inventory is managed by our materials coordinator using our recently installed Pyxis cabinets (Becton, Dickinson and Company). New equipment for the lab is requested as budget allows, and must pass through several purchasing committees before being approved for acquisition.

In what ways have you helped to cut/contain costs and improve efficiencies in the lab?

Our lab reprocesses all catheters and cables that allow for it, and sends others for recycling. We have a recycling program for all of our paper and approved plastic waste. The pharmacy has been our partner in cutting the cost of some of our medications through contract negotiation or by compounding the medications in house. We are ever mindful of our staffing needs, and utilize our low census resources as needed. Supplies are not opened until confirmed with the physician, which can sometimes hurt our efficiency, but helps to cut down on waste.

How do you ensure timely case starts and patient turnover?

Equipment exchanges (e.g., CARTO for NavX) have always been a source of lengthy turnover times. Our team is focused on this issue, which has recently been facilitated by hardwiring some equipment in our rooms. Another factor affecting turnover is developing a collaboration with our Anesthesia team, who have been exclusively monitoring our cases for the last year. This is an evolving process that takes the participation of every team member. 

Does your EP lab compete for patients? Has your institution formed an alliance with others in the area?

We are fortunate to be part of a large health care system. Swedish Medical Center is comprised of five hospital campuses, two ambulatory care centers, and Swedish Medical Group — a network of more than 170 primary care and specialty clinics located throughout the Puget Sound area. We have recently affiliated with Group Health Cooperative, another large health care system in Seattle; this has brought two additional physicians to work with us. Additionally, we are a part of Providence Health & Services, one of the largest health care systems in the country. 

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

Our vendors are generous with their time and frequently come in to provide continuing education opportunities. We are fortunate to be able to introduce the EP Savant program to our staff this fall. This application will allow for a more formal curriculum for training new staff members as well as allow them to study for the RCES examination. 

Swedish provides an annual allowance for individual continuing education, and our staff takes advantage of these dollars to seek out symposiums. Swedish Continuing Medical Education also offers a large variety of accredited CME full-day conferences, online on-demand courses, regularly scheduled series, and other learning opportunities that are free to our staff. 

Have members of your staff taken the registry exam for the Registered Cardiac Electrophysiology Specialist (RCES)? Does staff receive an incentive bonus or raise upon passing the exam?

A number of our staff has gained their RCES or CEPS, and our vision is to have our lab 100% certified. We are fortunate to have physicians and a management team that are enthusiastic about reaching this goal. The EP Savant education platform will allow us a structured approach to study for the RCES.

How do you prevent staff burnout? Do you also practice any team-building exercises?

We have a group that thrives in our environment of mutual respect, and we are diligent about making sure our staff gets breaks throughout the day. Additionally, our 12-hour workdays allow for a flexible three day a week schedule, which our staff very much enjoy.

How do you handle vendor visits to your department? Do you contract with vendors?

We have several contracted vendors and enjoy a collaborative relationship. They are invited to the lab by our physicians for specific cases. All must register daily with hospital security.

Approximately what percentage of ablation procedures is done with cryo vs radiofrequency?

Currently, our lab is approximately 60% cryo vs 40% RF.

What is your primary approach for left atrial appendage (LAA) occlusion? 

We primarily use the WATCHMAN device (Boston Scientific) for LAA occlusion. 

What are your thoughts on the use of the new oral anticoagulants (NOACs) in patients with non-valvular atrial fibrillation? 

Darryl Wells, MD has the perspective that the data supports their use in our patient population. In general, our patients prefer that there is no frequent monitoring and dosage adjustment. 

Is hybrid epicardial and endocardial ablation of atrial fibrillation performed at your institution?

Not presently; however, we have the technology and expertise to allow for this opportunity.

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

We are currently looking at MRI evaluation of cardiac fibrosis to possibly guide ablation strategies in our atrial fibrillation patient population. WATCHMAN procedures (Boston Scientific) for LAA occlusion are being added with increasing frequency to our caseload. We use QVL measurements in our CRT implants and contact force technology whenever appropriate.

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

Although we are not a pediatric facility, we do perform pediatric procedures at our facility. Pediatric concierge service is provided for all of our young patients. This includes a PICU RN escort for their stay, a designated child-life specialist/case manager, and pediatric-trained anesthesiologists. 

What measures has your lab taken to reduce fluoroscopy time? In addition, what types of radiation protective shielding and technology does your lab use?

We routinely use a very low pulse and frame rate with our cases, and with the increased use of mapping technology and ultrasound, our fluoroscopy times have gradually been decreasing. Nevertheless, younger patients are protected with a radiation shield under their lower abdomen to reduce exposure. 

All staff are fitted with personalized lead aprons upon employment and annual radiation safety training. Our Anesthesia providers are encouraged to utilize freestanding lead shields, in addition to aprons, to increase their protection as they are positioned closest to the C-arm. 

What are your methods for device infection prophylaxis?

We have a standardized antibiotic protocol for all of our implant patients. We also routinely screen (usually completed through the clinic) for the presence of MRSA, so that we may administer the correct antibiotic. All of our device patients are asked to complete a chlorhexidine shower both the night before and the morning of their procedure. Patients get a pre-op CHG wipe-down of the implant site in addition to the standard peri-op scrub and draping.

How do you use the NCDR Outcome Reports to drive QI initiatives at your facility?

We participate in the NCDR ICD Registry, and will soon participate in the AFib Ablation and LAAO Registries. These outcome reports help inform our quality groups and actively push us to better ourselves. These types of registries will see increasing use for data reporting with regard to quality and value for third-party payers.

What are your thoughts on EHR systems? Does it improve your quality of care? 

Our EHR system has been very helpful in maintaining a fully accessible lifetime record for our patients. It has also been invaluable in allowing us to maintain continuity of care for our patients in today’s highly mobile society.

What are some of the dominant trends you see emerging in the practice of electrophysiology? 

Trends include earlier ablation for atrial fibrillation in its disease process (e.g., pre-antiarrhythmic therapy), better pre-procedural imaging to risk-stratify patients (e.g., cardiac MRI for fibrosis), and stroke mitigation provided by LAA occlusion strategies.

Is your EP lab currently involved in clinical research studies? 

Yes, we are involved in the World-wide Randomized Antibiotic Envelope Infection Prevention Trial (WRAP-IT) trial, the Efficacy of Delayed Enhancement MRI-Guided Ablation vs Conventional Catheter Ablation of Atrial Fibrillation (DECAAF II) study, and the QUARTET Study. 

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

Jumpstarters is our longstanding ICD support group.

Describe your city or general regional area. 

Seattle is a vibrant metropolis set within the Salish Sea. Views of Puget Sound and the Olympic Mountains are truly breathtaking, and the proximity to the water and mountains supports a variety of outdoor activities. A short drive from Seattle will find you in a rainforest, a rocky tidal shore, high desert sand dunes, or atop one of the tallest mountains in the United States. The Seattle metropolitan area includes the headquarters of several Fortune 500 companies, including the tech giants Amazon and Microsoft. The strong economy supports a thriving art and music scene. There are incredible restaurants for every budget and palate, from hole-in-the-wall to waterfront fine dining. It truly is a one-of-a-kind place with a temperate climate and diverse cultural communities.

Please tell our readers what you consider special about your EP lab and staff.     

What makes our lab special are the staff members and the amazing group dynamic we have cultivated here. There is also punch and pie!