Spotlight Interview: The University of Utah, Cardiac Electrophysiology Division

Nassir F. Marrouche, MD, Director of the Atrial Fibrillation and Cardiac Electrophysiology Laboratories, University of Utah Health Science Center, Salt Lake City, Utah

Nassir F. Marrouche, MD, Director of the Atrial Fibrillation and Cardiac Electrophysiology Laboratories, University of Utah Health Science Center, Salt Lake City, Utah

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 EP labs, with approximately seven dedicated full-time staff, five RNs and two CVTs. A third EP lab is currently in design and should be available in mid 2008.

When was the EP lab started at your institution?

The concept of a dedicated EP laboratory at the University of Utah dates over 20 years.

What types of procedures are performed at your facility?

Our volume comprises of pacemaker, ICD and CRT-D implants to complex lead extractions and ablations. With the advent of our new atrial fibrillation program, currently the only one in the region, a large percentage of our ablation cases at the University of Utah involve pulmonary vein antrum isolation for atrial fibrillation.

What is the primary goal of your program (AF ablations, lead extractions, BiVs, etc.)?

The goal of our program is to provide comprehensive electrophysiological support to our referral basis, which extends to the whole intermountain region. We perform a large variety of implants, extractions and complex ablations, including atrial fibrillation ablation.

Approximately how many are performed each week? What complications do you find during these procedures?

Our procedure volume is approximately 10-15 cases a week, with up to six atrial fibrillation ablations per week. Our complication rates are very small and similar to the academic institution’s national average.

Who manages your EP lab?

Dawn Young, RN is the Manager of Cardiology Services, which includes Invasive Cardiology (EP and Cath), Non-Invasive (Echo, EKG, Holter, Event), Preventive Cardiology (In- and Outpatient Cardiac Rehab), and Mobile Echo.

Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained?

The independence of the EP lab from the Cath lab has been one of the main stems of our success. Organizationally, all of the nurses work for the same department, but for staffing, we are separate operations.

What new equipment, devices and/or products have been introduced at your lab lately? How has this changed the way you perform those procedures?

The latest technologies are available in our institution. We utilize commercial electroanatomical imaging systems available, along with intracardiac echocardiography, and biplane fluoroscopy when necessary. We also provide our patients with the latest ablation techniques, including cryo and open irrigation catheters.

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

We have a dedicated assistant/NP who provides scheduling for both inpatient and outpatient procedures, including pre-operative labs, medication changes and CTs or MRIs required pre-procedure.

What type of quality control/quality assurance measures are practiced in your EP lab?

We follow JCAHO standards in our lab. The EP team (both manager and staff) meets weekly to discuss problems and solutions to optimize the appropriate efficient function of the electrophysiology labs.

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

We have had a Cardiac Technician responsible for managing inventory, using a bar coding system that is linked to the Purchasing Department for ordering. In the near future, we will employ a Materials Management Facilitator who will be responsible for managing inventory.

Has your EP lab recently expanded in size and patient volume, or will it be in the near future?

Our expanding volume and characteristics of the procedures required us to upgrade to a third EP lab, which will be available very soon. This new lab will provide new, real-time imaging methods including MRI, which will markedly improve the quality of care to our patients, providing the latest technologies available.

Have you developed a referral base?

The University of Utah is the only institution providing third level academic cardiac electrophysiology services in the intermountain region. Our referral basis extends to different states in the region, including Idaho, Nevada, Wyoming, Colorado, and northern and southern Utah. The atrial fibrillation program has greatly expanded our referral base by attracting patients from California as well as other states in the northwest, along with international referrals from countries as far as eastern Europe and the Middle East.

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 implemented a bar coding system for supplies, have frequently negotiated prices with vendors based upon benchmarks, started a value analysis process to review the introduction of new supplies or technologies, and have made consistent efforts to decrease overall inventory. As far as improving efficiencies, we now block days for MDs, and also pull sheaths in the Holding Room so procedure rooms can be turned over more quickly.

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

Competition in the metropolitan Salt Lake region has always been present. Our main interest to referring physicians is our high level of care and academic excellence provided at the University Hospital. As mention earlier, we are the only academic referral center in the region and the first atrial fibrillation program in the intermountain region and northwest.

What procedures do you perform on an outpatient basis?

Only patients who need routine electrophysiological tests or an implantable loop recorder are discharged home the same day. The remaining procedures, even though outpatient, will remain in 23-hour observation until the next morning.

How are new employees oriented and trained at your facility?

We provide one day of hospital orientation. Employee and nursing orientations are performed for three days. The overall orientation for devices is approximately one month; orientation for ablations is two months. All staff is encouraged to be proficient in complex ablation procedures and electroanatomical mapping systems.

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

Most Tuesday mornings we have a dedicated meeting for staff education. Annually, required education meetings (on radiation safety, sterile techniques, ACT, etc.) are scheduled and are monitored by the University's education departments. Staff is encouraged to perform research and submit original research projects to national meetings. This year, three members of our staff went to the Heart Rhythm Society scientific meeting.

How is staff competency evaluated?

Staff competency is evaluated via direct observation, return demonstration, CDs, and written tests.

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

Vendors are notified when they are needed for cases. Others contact our Nurse Manager and arrange a date and time to come in.

How does your lab handle call time for staff members? How often is each staff member on call? How frequently do they have to come in, on average? Is there a particular mix of credentials needed for each call team?

We have a call team for urgent device cases on Saturdays, Sundays and holidays. Each staff member is on call about once per month, coming in approximately every four to six months. An RN must be one member of the call team.

Does your lab use a third party for reprocessing?

We do reprocess some of our catheters and supplies.

Do you perform only adult EP procedures or do you also do pediatric cases? Is there cross training for pediatric cases?

Our division provides only adult cardiac electrophysiology care. Pediatric arrhythmia care is provided by the Primary Children's Hospital located on campus.

What are your thoughts about non-EPs implanting ICDs? Do you train such individuals?

In our institution, only physicians with formal training in electrophysiology are credentialed to implant ICDs and perform DFT testing. We do not provide any training for non-EP implanters in any of our satellite centers.

Is your EP lab currently involved in any clinical research studies or special projects? Which ones?

Our institution is involved in several multi-center trials, some of which are structured and designed by our division. A great proportion of our research interest is dedicated to advanced imaging and procedural characteristics of pulmonary vein antrum isolation for atrial fibrillation.

Are you ACGME-approved for EP training? What do you think about two-year EP programs?

We currently have two EP fellows per year (for a total of four fellows), although we plan to expand to a three fellow per year program in July of next year. Given our volume and characteristics, our fellowship program is quite competitive, and we tend to only accept candidates who have completed at least three years of general cardiology. Due to the complexity of electrophysiology, we believe two-year programs are the minimum training requirement needed to establish proficiency in the field.

Please tell our readers what you consider unique or innovative about your EP lab and staff.

Our EP lab includes highly-skilled physicians and staff who are dedicated to the best available care. Our atrial fibrillation program is cutting edge in clinical care and research. Furthermore, we believe a vital part of our success has been the overall academic and research-oriented treatment we provide to our referral base. Every single individual who participates in the care of the patient plays an essential role in the outcomes. No matter what your role is on our team, you are valued and treated as such.