Spotlight Interview: THE HEART HOSPITAL Baylor Plano

Willis Hassell, RN, RCIS, BS, Director of Invasive Cardiology, and Paul Johnston, RN, Manager, Electrophysiology Labs THE HEART HOSPITAL Baylor Plano Plano, Texas

Willis Hassell, RN, RCIS, BS, Director of Invasive Cardiology, and Paul Johnston, RN, Manager, Electrophysiology Labs THE HEART HOSPITAL Baylor Plano Plano, Texas

What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab? At THE HEART HOSPITAL Baylor Plano, we work in four EP suites and one OR/ENDO suite for lead extractions. Our staff includes an Invasive Cardiology Director overseeing multiple departments, an EP department manager, 13 full-time RNs, two full-time technologists (RCIS/CEPS), and two PRN RNs. Additionally, there is one IS Analyst that maintains our documentation/charging/coding functions and one materials coordinator. There are two dedicated non-invasive cardiology nurses who are part of the EP staff. These nurses are responsible for tilt table tests (HUTT), cardioversion/TEEs and supporting nursing service and radiology procedures throughout the hospital. We currently have five electrophysiologists who primarily practice at THE HEART HOSPITAL Baylor Plano, and three electrophysiologists that perform cases on an occasional basis. Several interventional cardiologists perform pacemaker and AICD implants in the EP lab. When was the EP lab started at your institution? THE HEART HOSPITAL Baylor Plano open in January of 2007. The EP program began in November 2004 within Baylor Regional Medical Center at Plano, a full-service hospital on the same campus as, and physically connected to, THE HEART HOSPITAL Baylor Plano. What types of procedures are performed at your facility? We perform EP studies, ablations (supraventricular tachycardia [SVT], ventricular tachycardia, atrial fibrillation [AF], AV node), and implants for pacemakers, loop recorders, AICDs, and biventricular devices. We also perform laser lead extractions. We use both Carto (Biosense Webster, Inc., a Johnson & Johnson company, Diamond Bar, CA) and EnSite (St. Jude Medical, St. Paul, MN) for 3-D mapping and, beginning March 4, 2009, we started performing procedures with the Stereotaxis NIOBE® Magnetic Navigation System (Stereotaxis, Inc., St. Louis, MO). Approximately how many are performed each week? What complications do you find during these procedures? We perform 30-35 procedures weekly and approximately 1,500 procedures annually. This included more than 100 laser lead extractions performed last year. Complications are rare and well below the national benchmarks. Who manages your EP lab? The EP lab is managed by Paul Johnston, RN, EP Lab Manager, and Willis Hassell, RN, RCIS, BS, Director of Invasive Cardiology. Brian DeVille, MD is the Medical Director. Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained? Yes, the EP lab has a dedicated staff separate from the cath lab staff. This was established at the opening of the program in 2004. Staff members are not routinely cross-trained from EP to the cath lab, however, there are staff members experienced in both the cath and EP settings who will occasionally work in the cath labs. Do you have cross training inside the EP lab? What are the regulations in your state? All staff members are trained to perform every function within the lab with two exceptions. While everyone is trained to scrub implants, monitor and record hemodynamics, and perform all functions during an EP study and ablation, sedation is performed only by the nursing staff while x-ray generation is performed only by the physician or RT/Texas LMRT. What new equipment, devices and/or products have been introduced at your lab lately? How has this changed the way you perform those procedures? In 2008 we upgraded our Biosense Webster Carto mapping systems to include two CartoMerge/CartoSound systems and one Carto RMT system. In one existing suite, we upgraded a GE CardioLab to a GE CardioLab/Mac-Lab/ComboLab system (GE Healthcare, Chalfont St. Giles, UK). Our newest EP suite, brought online March 4, 2009, features Stereotaxis’ NIOBE® magnetic navigation and Odyssey Navigant 3.0 OEM system management, Siemens Axiom Artis imaging and DynaCT technology (Siemens AG, Erlangen, Germany), Biosense Webster Carto RMT 3-D mapping system, and Skytron LED lighting (Grand Rapids, MI) designed to reduce heat and improve patient and physician comfort. The custom control room includes three control rooms in one, with dedicated control stations for GE CardioLab/Mac-Lab/ComboLab, GE DMS physician reporting/DynaCT work station, and Odyssey with remote head controlled ablation generators (EPT and Stockert). There is also custom room cabinetry, an in-room warmer, ceiling mounted gases and electrical power, and Skytron lighting to support the anesthesiologist. The suite is punctuated with a dedicated nine-seat observation theater, electronic fogging privacy glass, and sophisticated AV capability for live case presentation and broadcast. We view the Stereotaxis technology as an opportunity to reduce case time, patient anesthesia time, and staff and physician fatigue. We anticipate the technology will also allow us to be more efficient with scheduling cases and perform more cases with the same resources. Two labs have GE ComboLab monitoring systems, which will allow us to be more efficient with cases that occasionally require left- or right-heart catheterization at the same time as their EP procedure. In January 2009, we also improved our storeroom space with the addition of high-density shelving units and RFID storage cabinets (Mobile Aspects, Pittsburgh, PA). The RFID cabinets allow us to secure and monitor usage of high value products within the department, particularly implants. Who handles your procedure scheduling? Do you use particular software? THE HEART HOSPITAL Baylor Plano employs a centralized scheduling department that is staffed by three full-time schedulers. They handle all scheduling needs for the hospital and use GE Centricity Enterprise Perioperative Manager (CPM) software for scheduling EP procedures as well as for OR services, radiology, the cardiovascular cath labs and non-invasive cardiology. What type of quality control/quality assurance measures are practiced in your EP lab? We monitor the 2009 Joint Commission patient safety standards and use a pre-op checklist that follows those guidelines. The department monitors safety issues, including Omnicell (Mountain View, CA) computerized medication administration system usage, expiration dates, and radiation safety. We have an extensive patient follow-up program. This involves post-procedure telephone calls to all patients to assess the hospital education process and complications. Every patient is contacted at 24 hours, 1 week and 6 months post procedure. We believe this will allow us to record post-procedure complications that may not have been reported to us or that were treated at another facility. We also gain valuable patient satisfaction data during those calls. The hospital’s quality department maintains statistical and outcomes data that is reported at our bi-monthly EP section meeting. The biomedical department maintains QC on all patient care and monitoring equipment in the lab, while Physical Plant Operations monitor fire and life safety equipment. A new initiative within Baylor is the “Stop the Line” program. This allows nursing and ancillary staff to stop and receive clarification of any procedure as needed to provide the highest level of safety for our patients and caregivers. How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? We work very closely with our Material Management department and have a full-time Material Management employee dedicated to the EP lab. This person maintains inventory levels and orders all disposable supplies and catheters. All purchasing of capital equipment and bulk purchases are a collaborative effort involving the EP manager, the director of invasive cardiology, the EP medical director and the director of Material Management. Additionally, we bring all new products through the physician procurement committee for review and approval. Has your EP lab recently expanded in size and patient volume, or will it be in the near future? Yes, we have completed construction and opened our fourth EP suite and have plans to build a fifth lab. We do not yet know if the fifth EP lab will function as a dedicated EP lab, overflow cath/specials lab, or a combination lab. Our volumes continue to steadily grow as we add to the number of physicians on staff and as the physicians expand their referral base. Our physicians have received patients from 36 states as well as internationally. 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 continually evaluate our supply costs in partnership with the director of Material Management and our physician-led Supply Chain Forum committee. We implemented reprocessing of diagnostic catheters, which has resulted in significant savings. We work to manage other costs as it relates to devices and leads, through bulk buys and negotiated catheter costs. In some cases we use a single or dual vendor when quality is met while bringing us cost advantages. In 2008 we reduced supply cost by more than $1,000,000 with these initiatives. We continually evaluate productivity and work flow to utilize staff and manage the lab in the most efficient manner possible. In 2008, turnover time was a primary focus. We evaluated our processes and worked to identify the very complicated components of our turnaround time. We were able to identify our weakness and confirm our strengths. Using this data, we have eliminated or modified contributing factors that staff controlled. At the same time, we are working to set appropriate expectations — it is a work in progress. How are new employees oriented and trained at your facility? New employees spend the first week in hospital orientation, with EP orientation lasting three months. During this orientation process, the new employee is paired with a preceptor/mentor. Each employee is provided an exceptional reference manual developed within the department for didactic learning. After three months, the schedule is planned on a day-to-day basis for the new employee to be in a room with two experienced staff members for up to one year if necessary. If a nurse or tech has previous experience, we evaluate their knowledge and modify the program as needed. What types of continuing education opportunities are provided to staff members? Baylor offers a wide variety of educational opportunities for employees, including substantial online CE opportunities. Every staff member is encouraged to attend continuing education, and each staff member is funded yearly to attend education opportunities related to their job description. Baylor Health Care System and THE HEART HOSPITAL Baylor Plano host several EP symposiums each year that staff either participate in or attend. Education is also provided to staff who perform in special functions, such as our laser safety officer attending laser training courses and conferences. THE HEART HOSPITAL Baylor Plano encourages staff to attend the Heart Rhythm Society’s (HRS) scientific sessions. HRS may be sponsored as a reward for highly valued work or achievement. The department has 2 one-hour in-services each month from our industry partners that are tailored to a variety of topics as determined by the staff and their needs. How is staff competency evaluated? Competency of high-frequency, low-risk tasks are evaluated during orientation and then monitored periodically during the course of employment. Competencies of low frequency or moderate- to high-risk tasks are evaluated on an annual basis. We use performance checklists for individual tasks. If a staff member is not at a level required for independent performance, then we will assign a “super user” to work with that individual until their skill set is at par. We have just launched an effort to revise competency testing from an old school simple check-off philosophy to a new approach focusing on critical elements and outcomes. The EP labs will be heavily involved in the development of that program at THE HEART HOSPITAL Baylor Plano. How do you prevent staff burnout? In addition, do you practice any team-building exercises? Staff members attend outside events together, individually and/or with their families, to interact in a more relaxed environment. We recently participated in a hospital-sponsored bowling tournament with 25 teams consisting of four or more team members. The “electricians” had a strong showing and made it through several brackets before falling to the Surgical Services team. The department makes every attempt to recognize strong work performance with our “5 Star Service” program and Baylor Health Care System Service Award programs. The department has a “shared leadership” committee in which the staff collaborates on solutions to departmental issues. The intent is for staff to have a significant ownership into the daily operations and direction of the lab. Staff members also have significant input into the procedure and patient’s care. The EP physicians are part of the team and are mindful of the staff’s experience and expertise. Leadership has an open-door policy for staff to discuss work-related or personal issues at any time. Hospital leadership is very “flat” so that if there is a concern, the staff can bring the issue to the manager, director, or CEO. Each staff member has their “project” to champion on the occasional “slow day.” What committees, if any, are staff members asked to serve on in your lab? Employees are encouraged to be active on committees in the hospital and/or throughout the health care system. As previously mentioned, we have a “shared leadership” committee where staff members work together to solve department issues. Some are on health care system-wide staff nurse councils that work on improvements for nursing throughout Baylor Health Care System. Some staff members are on a peer review care committee, which helps employees and their families who have financial or other support needs. There are other committees as well, including a staff interview committee that has a significant voice in bringing new staff into the department. How do you handle vendor visits to your department? Our vendor policy is open, yet with boundaries. All vendor credentials are verified in Material Management when they initially come to the hospital. Each subsequent visit requires a check-in and “visitor” badge. Device vendors are the only vendors allowed in the suite during procedures, unless prior approval is obtained by the physician through the EP manager. Vendors are restricted from areas where inventory is kept. Non-device vendors are allowed one visit per month. Does your lab utilize any alternative therapies? We use positive attitude and humor to relax our patients and families. Our facility is aesthetically pleasing and accented with interesting artwork. There is XM Satellite Radio in all of the labs, and we tune in commercial-free music of the patient’s choosing. The new room also has a built-in iPod station/dock if the patient prefers to listen to their personal selection of music. How does your lab handle call time for staff members? There is no call during the weekdays, but staff members do take call on Friday, Saturday and Sunday. There are three on-call staff members during the weekends for implants that are emergent or if the patient is unable to leave the hospital and return as an outpatient. This approach reduces length of stay, costs, and risk of hospital-acquired infection by requiring a patient to stay in the hospital over a weekend before their implant. Our staff works 7am-5:30 pm. If cases run late, there is a pre-scheduled, three-person “late team” that handles the late cases. Does your lab use a third party for reprocessing? How has it impacted your lab? Yes, we use Ascent Healthcare Solutions. Reprocessing in 2008 has saved more than $100,000 in supply costs. It has been a significant point in our strategy for cost-cutting measures here at the hospital. Approximately what percentage of your ablation procedures are done with cryo? What percentage is done with radiofrequency? Approximately 80-85 percent of our ablations are performed with radiofrequency, and approximately 15 percent are completed using cryo energy. Most of the cryo ablations are utilized for difficult AVNRT and perihisian pathway ablations and some supplemental use during AF ablations. Do you perform only adult EP procedures or do you also do pediatric cases? Is there cross training for pediatric cases? Our patient population is mostly adults. We occasionally will have a tilt table test or SVT ablation on older adolescents, though. What measures has your lab taken to minimize radiation exposure to physicians and staff? We strictly adhere to ALARA recommendations with regards to shielding, time and distance. We supplement the lead shielding on the table with a lead apron during long procedures such as AF ablations. This additional layer of shielding has had a major impact on the amount of x-ray the physicians receive. We anticipate the Stereotaxis Niobe/Odyssey and remote operation for fluoro, Carto and generators in the control room also will reduce radiation exposure. The physician is now behind lead glass in the control room driving the catheter with Stereotaxis and operating fluoro, Carto and ablation generators. Do your nurses/techs participate in the follow up of pacemakers and ICDs? The device vendors generally perform checks the next day on all new implants, and most of the physicians have device clinics in their offices. We have an extensive patient follow-up program; this involves post-procedure phone calls to all patients to assess the hospital education process and complications. Every patient is contacted at 24 hours, 1 week and 6 months post procedure. We believe this will allow us to record post-procedure complications that may not have been reported to us or that were treated at another facility. We also gain valuable patient satisfaction data during those calls. What trends do you see emerging in the practice of electrophysiology? How is your lab preparing for these future changes? We see an increase in the number of AF ablations, and continually look for ways to decrease their case length and x-ray exposure. We also see an increase in biventricular device implants with the continual rise of heart disease and CHF. We see a huge need for education and training of EP staff and physicians. We hope to partner with industry to train both groups to support our program, and others, around the country. We also anticipate more research with devices, disposable products and techniques. Our goal is to participate in the latest treatments and technology. We anticipate the need for a fifth EP room by the end of 2009. As a result, we are in the process of developing the plans to build the room now. Is your EP lab currently involved in any clinical research studies or special projects? Which ones? We have a hospital-based research department supported by the Baylor Research Institute. THE HEART HOSPITAL Baylor Plano has 25 research trials either active or in the IRB queue. Trials that specifically relate to the EP patient populations are ABLATE, EXCLUDE, GAME, SLS, CABANA, VEST, Medtronic’s StarFix trial, and a collaboration trial that has been submitted, but not yet named, to investigate head-to-head surgical vs. catheter-based ablation. When was your last inspection by the Joint Commission? Our last review was in 2007 when the hospital opened. We expect, and are prepared for, an unannounced follow-up visit anytime. Give an example of a difficult problem or challenge your lab has faced. How it was addressed? Staffing shortages are the most difficult to manage. Finding and training new staff is a long and difficult process with high associated costs. As is typical of a high-volume program, staff members have industry opportunities once they become proficient. Sometimes it can be a challenge to retain staff members that may be persuaded by those opportunities. We recently completed a large construction project that included a new cath lab and a new EP/Stereotaxis lab, as well as replacing imaging equipment in a cath lab and upgrading hemodynamic equipment in an EP lab. Basically, we built three rooms simultaneously within an active department. The time line was significantly compressed, but we received our Certificate of Occupancy in 60 days for all rooms. During this 60-day period, almost 900 cases were performed in the EP and cath labs combined. Thoughtful planning was critical, as was efficient management of the EP and cath labs throughout the construction. The staff’s “can do” spirit, flexibility, and unselfish dedication helped with the delivery of safe, quality, compassionate care, and made this process appear seamless to the physicians and the rest of the hospital. Cath lab cases with staff had to be floated to an EP lab while they had two rooms out of service. Implants and EP staff floated to the cath lab while their rooms were down. Naturally, there was a great deal of strain on the schedule as the EP lab worked with one less room than normal without a reduction in volume. We also shifted hours of operation, starting first cases at 0700 and last cases at 1700, which allowed additional cases in each room each day. The new rooms and equipment were well worth the effort. Describe your city or general regional area. How does it differ from the rest of the U.S.? Plano, Texas is located mainly within Collin County and is a northern suburb of Dallas. According to the 2007 census estimate, the population was 260,796 people, but it is experiencing very active growth and was voted the 11th best place to live by CNN in 2006. Plano has many indoor and outdoor activities, large businesses, shopping opportunities, and restaurants. Plano has been voted one of the healthiest cities in Texas. The Texas and Dallas/Ft. Worth economy is faring mostly better than other pockets around the country. The housing market has done well, with reasonable “Cost of Living to Salary” ratios. Please tell our readers what you consider unique or innovative about your EP lab and staff. There are many interesting attributes to THE HEART HOSPITAL Baylor Plano and its EP program. The staff is a rigorously trained blend of professionals who demonstrate the service, quality and financial servanthood that Baylor Health Care System strives to achieve each day. The physicians that perform cases here respect the experience of the staff, their individual and collective talents, and their dedication to electrophysiology. They strive for excellence each day and support each other both in and out of the EP lab environment. A unique thing about our lab is that seven of our staff members have taken and passed the IBHRE exam — the highest ratio of certified staff in the Dallas Metroplex. Our certified staff includes nurses as well as our RCIS and CVT team members. Complementing this is the level of years of EP lab experience the staff bring to the department. Only two (while excellent in their own right) have less than 3 years of EP lab experience, and half of the team members have greater than 10 years of EP experience in addition to years of nursing/healthcare experience. Today, THE HEART HOSPITAL Baylor Plano remains the first and only freestanding, full-service hospital in this region dedicated solely to heart and vascular health care. It is a partnership between Baylor Regional Medical Center at Plano and 113 cardiovascular physicians and surgeons practicing in North Texas. We are very much a boutique hospital, with an approach to medicine that has ambitious ideals and goals. Administrators, physicians and staff alike are forward-thinkers and willing to be innovative. Because of the way that the hospital is set up to deliver care, and because of the strong, productive working relationship shared by hospital administration, physicians, and staff, the hospital continues to achieve excellent patient outcomes that are better than national benchmarks. In fact, the hospital typically ranks in the top five percent nationwide on inpatient, outpatient and Emergency Department patient satisfaction surveys through the Press-Ganey member network. For more information, please visit: https://www.thehearthospitalbaylor.com/Pages/default.aspx