Spotlight Interview: The University of Kansas Hospital

John R. Florio Executive Director, Cardiovascular Services The University of Kansas Hospital Kansas City, Kansas
John R. Florio Executive Director, Cardiovascular Services The University of Kansas Hospital Kansas City, Kansas
When was the EP lab started at your institution? The University of Kansas Hospital first had an EP program briefly in the early 1980s. After a long hiatus, the program was re-established in June 2001. We have grown from one EP lab to three EP labs. In February 2007, we moved into our new space in the Richard and Annette Bloch Heart Rhythm Center, which is part of the Center for Advanced Heart Care. What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab? In the last six years, the Richard and Annette Bloch Heart Rhythm Center at The University of Kansas Hospital has experienced continuous growth and development. We have a Stereotaxis suite, a second suite suitable for complex ablation and all other types of cases, and a third suite for device implantation and more straightforward EP studies and ablations. In August of last year, a fifth electrophysiologist joined our physician staff. Additional staff includes seven registered nurses, eleven technicians, two unit coordinators, a technical education specialist, and one clerical staff person. The EP and cath labs share a nurse educator and a nurse manager. The driving force behind our incredible program growth — fivefold during the past six years — is our dedication to excellence. This commitment extends beyond our EP program to our entire cardiovascular program, catapulting our academic medical center onto the U.S. News and World Report’s list of top cardiac programs in 2007 and 2008 (Editor’s note: The 2009 list is not yet available). What types of procedures are performed at your facility? What complications do you find during these procedures? Our staff perform a wide range of procedures, including device implants and ablations. Under the direction of Dhanunjaya Lakkireddy, MD, our atrial fibrillation (AF) ablation program averages 4-5 cases per week. We do 2-3 ventricular tachycardia (VT) ablations per month, including epicardial cases. Our device service, under the direction of Martin P. Emert, MD, performs pacemaker and defibrillator implantations and serves as a referral center for patients who have previously failed transvenous left ventricular (LV) lead placement. In addition, we serve as a regional referral center for lead extraction. What is the primary goal of your program? Our primary goal is to provide excellent, compassionate, individualized care to our patients as well as to promote education and research. As our clinical program has become established, we have initiated a Certified Compliance and Ethics Professional (CCEP) fellowship program. In addition, we have developed and expanded our clinical research program, increasing the number and quality of manuscripts and presenting abstracts nationally and internationally. Approximately how many procedures are performed monthly? We average approximately 110 cases per month, including 50-60 device implants and 40-50 ablations. Approximately 10 extractions are completed each month. Temporary pacemakers are typically done in the cath lab. Routine cardioversions are done in the cardiovascular operating room recovery area, which is convenient for anesthesia. Tilt table studies are done in our adjacent outpatient office. We do not include these cases in our EP lab volume. Who manages your EP lab? Nikki Harvey, ARNP, nurse manager, Penny Brackson, CMT unit coordinator, and Zann Roach, RN, unit coordinator, manage our EP lab. Education is handled by Mark Reichuber, RN, BSN, nurse educator, and Wallace Ray, EP clinical education specialist. Our medical director is Loren Berenbom, MD. Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained? When planning and designing the Center for Advanced Heart Care, we located our EP lab and cath lab adjacent to each other to facilitate cooperation. While our cath and EP lab staff are separate, they are under the direction of the same manager. Each lab has a dedicated RN unit coordinator who is the front-line leader and handles daily schedule management. Do you have cross training inside the EP lab? What are the regulations in your state? According to Kansas law, only RNs can administer medication. Therefore, the nurses are the ones who administer medications, including conscious sedation. Our nurses are also responsible for patient assessment and education. Our techs are involved in scrubbing cases as well as operating ablation equipment, the EP MedSystems recording system and stimulators, advanced mapping systems, etc. As our staff has grown, we have been able to begin to cross-train our nurses to perform some of the technical roles in the lab. What procedures do you perform on an outpatient basis? Patients who undergo generator changes typically go home the same day, including for ICD generator changes with defibrillation threshold (DFT) testing. When we place a new lead, patients routinely stay overnight. Simple ablation patients may be discharged the same day, depending on their age and travel distance. Older patients, those with long distances to travel, or complex ablation patients, including AF patients, generally spend the night. What new equipment, devices or products have been introduced at your lab lately? How has this changed the way you perform procedures? We continually introduce new technology and devices to meet our patients’ needs. The Stereotaxis Remote Magnetic Navigation System (Stereotaxis, Inc., St. Louis, MO) was our most important recent technology addition. We performed our first case in August 2007, and have been pleased with this technology. We look forward to a Stereotaxis-compatible irrigated ablation catheter. Recently, we were the third lab in the world to use the new Evolution™ device (Cook Medical, Bloomington, IN) for lead extraction. It is very useful for a subset of cases and is a cost-effective alternative to laser. When it comes to extraction, it is helpful to have as many different tools as possible, as every case is different. We use Carto (Biosense Webster Inc., a Johnson & Johnson company, Diamond Bar, CA) and EnSite (St. Jude Medical, St. Paul, MN) advanced mapping systems and EP MedSystems recording systems. We have recently introduced the EPMed NurseMate™ system (EP MedSystems, Inc., West Berlin, NJ), which facilitates computerized documentation of a patient’s clinical status during cases. Who handles your procedure scheduling? Do you use particular software? We complete case scheduling using the ORSOS software. Two clerical personnel manage the schedule (among other tasks): one for the cath lab and one for the EP lab. When needed, they schedule for both labs. Scheduling is completed for the hospital as well as our outpatient offices. Scheduling is also captured in our EMR, which makes it readily available to our outpatient offices and outreach clinics. The scheduling software assists with documentation and reporting of case start times, case durations, turnover times, etc. We use this information to continually refine our scheduling process. What type of quality control/ quality assurance measures are practiced in your EP lab? One of our EP lab nurses contacts each patient several days post-procedure to evaluate clinical status. Three months post-procedure, the lab follows up with each patient to ensure we have captured all adverse events and to assess clinical results. The physicians have a monthly M&M conference. If we have an adverse event in the lab, our staff and physicians meet within two days to discuss the occurrence, determine how it happened and why, review our response and determine how we can improve in the future. We focus on improving future performance, not placing blame. We comply with Joint Commission Patient Safety Goals and Core Measures. We follow the Association of periOperative Registered Nurses (AORN)-recommended practices and guidelines. We provide magnetic screening of all patients prior to procedures in the Stereotaxis lab. How is inventory, purchasing of supply and equipment managed? Two of our techs order supplies and equipment, monitor par levels, and complete procedural charging. Technicians use a handheld scanner to track items used during each case. Physicians assist with setting par levels. Every quarter we review inventory. During this time, we identify little-used items and adjust par levels based on changes in procedure volume and patterns of use. What measures has your EP lab implemented in order to cut or contain costs and improve efficiency? Our goal is to start on time, minimize room turnover time, work efficiently and complete cases on time. We have worked hard to grow our staff and facilities to accommodate our cases within a busy 10- to 12-hour lab day. Our biggest inventory expense is related to CRM devices. Last year we used an outside contracting agency to help negotiate prices, but we have brought that process back in house. We also save money by reprocessing our diagnostic EP catheters. Has your EP lab recently expanded in size and patient volume, or will it be in the near future? We continue to see 20-30% annual increases in case volume. Over the course of seven years, we have expanded from one lab to three. We have one shelled lab for future expansion. How has managed care affected your EP lab and the care it provides patients? Managed care is a fact of life. Our staff work hard to pre-certify cases with each patient’s insurance. Our biggest challenge has been obtaining approval from one insurance company for pre-procedure CTs for our AF ablation cases. Have you developed a referral base? Do you compete for patients? Have you formed an alliance with other institutions in the area? Our five electrophysiologists are part of a larger group, Mid-America Cardiology, which has had a respected presence in Kansas City for more than 30 years. We have a large network of referring physicians and a number of outreach offices. Over the course of the past seven years, our program has demonstrated consistent growth, which continues in the present year. Although there are several other EP programs in Kansas City and in the surrounding region, we are the largest EP program within a radius of several hundred miles, and also offer the widest range of expertise and services. Growth has been made possible by the addition of three excellent physicians, as well as excellent staff in the outpatient clinics, on the hospital nursing units, and in the electrophysiology laboratory. How are new employees oriented and trained? Is continuing education provided? New employees spend a minimum of one week in general hospital orientation. Each staff member then completes specific unit orientation. Nurses generally complete two months of orientation, working with an experienced EP RN on each type of case. In the state of Kansas, only RNs can administer medication. Anesthesia provides deep sedation during DFT testing and for selected cases. Our Anesthesia staff work cooperatively with our nursing staff. Nurses provide moderate sedation during the early phases of ICD procedures, and anesthesia is typically only present during DFT testing. This ensures our patients’ comfort and safety while being efficient for our anesthesiologists. We are in the process of training selected nurses to scrub cases and operate the recording, mapping, and navigation systems. Technician training is a lengthy process as they learn a variety of procedures and technologies. While we love to hire trained EP lab staff, typically we hire bright, talented individuals and train them ourselves. Techs either begin scrubbing cases or with the recording system, depending on their strength and interests. Ultimately, most of our techs learn both tasks as well as the advanced mapping systems and other equipment in the lab. We have Tech I and Tech II job descriptions to differentiate those who have mastered the complex technology in the lab versus those who are still learning. Our hospital is very supportive of education. In addition to in-house training, we send selected staff members to national meetings and industry-sponsored training sessions. We encourage employees to look for programs outside the hospital to enhance their knowledge. We also have weekly in-services. Our nurse educator does an annual survey of staff to refine the curriculum, based on areas where they believe they need more help. In addition, our nurse educator offers online resources and training, and provides refresher training and updates as needed. As the lab staff grows, we are investigating bringing more training to our area. This allows us to train more individuals in a cost-effective manner. How is staff competency evaluated? We host an annual competency fair for our staff, both in the EP lab and in the entire hospital. Each skill and piece of equipment has an associated competency that is reassessed annually. Before a staff member is independent in an area, he or she must demonstrate competency. How do you prevent staff burnout? With heavy schedules and lengthy procedures, this is a challenge for our lab. We work hard at communicating with our staff. We partner with physicians to develop realistic schedules and set expectations for staff. In addition, staff have the opportunity to customize their schedules. They can choose between 10- and 12-hour shifts and choose their days off. What committees, if any, are staff members asked to serve on in your lab? We have staff members on the Nursing Practice Council and Nursing Standards of Practice and Procedure Committee. How do you handle contract vendors? Device vendors are in the department when they have cases. They receive a vendor hospital ID badge since we are in a secured area. Does your lab utilize any alternative therapies? We are evaluating the role of yoga in the prevention of paroxysmal AF. Please describe one of the more interesting or bizarre cases that have come through your EP lab. We have an active adult congenital heart disease program at the hospital, which provides us with a number of challenging cases. Recently we treated a woman with transposition and a remote Mustard procedure who had recurrent atrial flutter. We used standard techniques via the inferior vena cava to ablate from the baffle to the IVC. We used Stereotaxis retrograde across the aortic and mitral valves to reach the left neo-atrium and ablate from the baffle to the tricuspid valve, completing a line of block and terminating her arrhythmia. She had been refractory to medication and was in and out of the hospital frequently, but is now off membrane-active drugs and has been free of arrhythmia for several months. To our knowledge, this is the first time Stereotaxis has been used in this fashion. It allowed us to avoid baffle puncture with its attendant risks. How does your lab handle cases extending longer than a normal work day? How often is the staff required to stay late? Our normal work day begins at 7 a.m. and ends at 5:30 p.m. Recently we have added a 12-hour shift two days a week, extending the work day to 7:30 p.m. Staff are assigned “late call” two nights per week if cases are late. Our goal is to complete cases within the scheduled time, minimize overtime and maximize staff satisfaction by making their schedules as predictable as possible. Does your lab use a third party for reprocessing? We send most diagnostic catheters to an outside company for reprocessing. Do you utilize cryo energy in ablation procedures? We do not use cryo. Do you perform only adult EP procedures or do you also do pediatric cases? Kansas City has an excellent children’s hospital with an active EP program. We do adult and adolescent cases. Do your nurses/techs participate in the follow up of pacemakers and ICDs? No. This is done through the outpatient offices. What trends do you see emerging in the practice of electrophysiology? How is your lab preparing for these future changes? As baby boomers age, the number of patients requiring our services will continue to increase. Patients have become much more sophisticated than in the past. Previously, patients typically had no idea what an electrophysiologist was, but now they do research online and talk with friends and family to identify their electrophysiologist of choice. We believe that management of atrial fibrillation is the area of greatest growth potential. We have developed a comprehensive atrial fibrillation program, which includes medical management, device therapy, catheter ablation, minimally invasive surgical approaches and open surgical approaches. We have an excellent cooperative relationship with our surgeons. Our biggest challenge is to continue to attract outstanding physicians and staff to our program. What are your thoughts about non-EPs implanting ICDs? Do you train such individuals? While we believe that selected non-EPs can implant devices, we do not train such individuals. We believe implanting physicians should also be expert at managing patients with ICDs, and not just at placing devices. Four of our physicians are CCEP board-certified, and the fifth will take boards in November. What about device recalls? How has your lab handled these? If a device or lead is “recalled,” the outpatient offices notify patients and facilitate necessary management adjustments. In the case of the Fidelis leads, we have not routinely prophylactically removed these leads. However, we have removed approximately 60 fractured Fidelis leads to date, both from our practice and from the surrounding regions. Is your lab doing web-based/ transtelephonic device follow-up? Web-based device follow-up is done through the outpatient offices. Is your EP lab currently involved in any clinical research studies or special projects? Which ones? At any point in time, we have more than a dozen active research projects. Some are industry sponsored and others are investigator initiated. Several of our investigator-initiated projects are proceeding as multi-center studies. Areas of interest include atrial fibrillation, cardiac resynchronization therapy, new device technology, and new ablation technologies. We are also participating in a prospective lead registry, as we strongly believe that such data is critical to making good choices for our patients. We provide training in cardiac resynchronization therapy (CRT) implantation to the staff of multiple vendors, allowing them to return to their home institutions with a better knowledge base. When was your last inspection by the Joint Commission? The Joint Commission inspected our hospital and labs in March 2008. Are you ACGME-approved for EP training? What do you think about two-year EP programs? We are ACGME-approved for CCEP training and graduated our first fellow in 2008. Currently we have a one-year program, but are evaluating expanding to two years. 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? Our White Heart Learning and Resource Center is a beautiful, quiet retreat located down the hall from the EP lab. The White Center has a full-time coordinator who is an advanced practice nurse with an extraordinary depth of clinical cardiac experience. She works with a dedicated staff to provide education and support to patients and family. We have educational programs for patients throughout the year and facilitate one-on-one informal support relationships. We do not currently have a formal EP support group. There is a cardiac support group at the medical center. Give an example of a difficult problem or challenge your lab has faced. How it was addressed? When we installed Stereotaxis, there were problems with older echo machines (used for intracardiac echo). We worked with multiple vendors to resolve the issues. Describe your city or general regional area. How does it differ from the rest of the U.S.? Our hospital is located in Kansas City, Kansas, a block from the Missouri state line. Most of our patients are from Kansas and Missouri. We also attract patients from Iowa, Nebraska, Arkansas and Oklahoma. The Kansas City metropolitan area has a population of almost two million people. Our diversified economic base has helped minimize some of the economic turmoil felt more acutely in other parts of the country. A significant percentage of our patients are from surrounding rural communities. We believe the physician-patient relationship is healthier in the Midwest than in some areas of the country, and that it is a great place to practice medicine. Please tell our readers what you consider unique or innovative about your EP lab and staff. We have five electrophysiologists, each with his or her own area of expertise. We have a long history of excellence and innovation. Members of our physician staff performed the first ICD implant in the region and the first radiofrequency ablation. We continue with that same cutting-edge approach to our practice today. In the seven years we have been at KU, we have become the regional referral center for complex CRT cases, lead extraction, AF ablation, VT ablation, and complex adult congenital cases. We have a cohesive staff. Our physicians, nurses, and technicians work collaboratively with our hospital and outpatient staff to provide the best possible outcomes for our patients. As an academic medical center, we continue to promote education and research and serve as a resource for community hospitals. For more information, please visit: www.kumed.com or contact John Florio at jflorio@kumc.edu