Spotlight Interview: UC San Diego Health System

Ramesh Sivagnanam, MBA, Manager, Cardiac Electrophysiology; Peter Hall, RN, Nurse Coordinator, Cardiac Electrophysiology; Gregory Feld, MD, Director, Cardiac Electrophysiology

Ramesh Sivagnanam, MBA, Manager, Cardiac Electrophysiology; Peter Hall, RN, Nurse Coordinator, Cardiac Electrophysiology; Gregory Feld, MD, Director, Cardiac Electrophysiology

UC San Diego Health System is the San Diego region’s only academic health system and is composed of the UC San Diego Medical Center in Hillcrest, the UC San Diego Thornton Hospital, Moores Cancer Center, Shiley Eye Center, Sulpizio Cardiovascular Center and Jacobs Medical Center (opening in 2016) in La Jolla, as well as other primary and specialty practices of the UC San Diego Medical Group located throughout southern California. We were recently ranked as the #1 health system in San Diego in U.S. News & World Report’s first-ever “Best Hospitals” metro rankings. 

What is the size of your EP lab facility and number of staff members? What is the mix of credentials in your lab?

We have two dedicated EP labs that have been independent from the cath labs since our program opened in 1987. There are six electrophysiologists, four fellows, four nurses, and three cardiovascular technologists. In addition, we have two nurse practitioners, a member of staff that works with clinic device patients and remote monitoring, a data manager, two schedulers, and a program manager.

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

We perform all types of ablations (including SVT, AFL, AF, VT endocardial and epicardial, and AF hybrid approach), device implants, cardioversions, tilt table tests, lead extractions, and left atrial appendage closures. We perform approximately 20 procedures each week.

What is the primary goal of your program?

We aspire to be the leading EP program in the region and to provide high-quality, cutting-edge care to our diverse patient population. We anticipate that our case volume will increase by 10–15% this year, from just over 1,000 cases to nearly 1,200 cases. This will include an increase in AF ablations, CRT and ICD implants, and device lead extractions. We also plan to expand our hybrid AF surgical/catheter ablation program, utilizing our new hybrid operating room.

Who manages your EP lab? 

Dr. Gregory Feld is our chief and has been for the past 25 years. We have an administrator (program manager), who is responsible for budgets, staffing, and vendor negotiations/contracts. The administrator is supported by a nurse coordinator, who is responsible for the daily operation of our labs.

Are employees cross-trained? Do you also have cross training inside the EP lab?

We are fortunate to have a number of RVTs and CVTs that can work cases in both the EP and cath labs.

Some of our RNs have also been trained to scrub in on device cases and to operate various pieces of EP equipment, including mapping and recording systems.

What new equipment, devices and/or products have been introduced at your lab lately?

We have increased our use of Hansen Medical’s robotic system for AF ablations, reducing operator fluoroscopy exposure and orthopedic stress. We have also implemented an EP-specific database management system (created by Perminova, Inc.), which performs all case scheduling, documentation, billing, and reporting functions. We are working to integrate this system with other data and physiologic monitoring systems in the laboratory (e.g., Bard’s recording system, the EnSite [St. Jude Medical] and Carto 3 [Biosense Webster, Inc.] mapping systems, vital sign monitors, etc.). Other new products recently introduced include the CIRCA S-Cath and Temperature Monitoring System (Anthem Medical, LLC), the AIGISRx® Antibacterial Envelope (TYRX, Inc.), and the ACUSON X300 ultrasound system (Siemens Healthcare).

Have you recently upgraded your imaging technology?

We will shortly be moving into a completely remodeled lab with a brand new Philips Allura Xper FD20 X-ray system.

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

We have two schedulers who schedule all procedures. Our program uses a web-based system by Perminova, Inc., which interfaces with our hospital EMR. This system allows us to streamline and improve our workflow, scheduling, billing, and reporting.

Who handles the purchasing of equipment and supplies?

This is managed by our materials management team, in conjunction with the EP manager.

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

Last year, our program saw a 14% increase in volume, and we expect this growth to continue as our health system expands. We are part of the UC San Diego Sulpizio Cardiovascular Center, the region’s only dedicated cardiovascular hospital.

How has managed care affected your EP lab and the care it provides patients?

The majority of our patients are covered by managed care policies. The hospital has contracted with many of the providers in California, so referrals to our center are increasing.

Have you developed a referral base?

Yes, our MDs have well-established referral bases within the UC San Diego Health System and on regional and national levels.

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 operate a flexible staffing model that can flex up and down according to procedure volume. We regularly review inventory and ensure that the duplication of supplies from multiple vendors is minimized. A joint project with anesthesia and the pre-treatment unit has been ongoing for the past three years, and focuses on a punctual start to the day. In addition, our team does a great job of adapting to the circumstances of each day to ensure maximum efficiency in terms of room turnover and staff assignments.

Does your EP lab compete for patients?

There are several major health systems in the San Diego region that have EP labs; thus, we do compete for these patients. However, due to the outstanding reputation that our program has had over the past 25 years, and because we perform the largest volume of complex ablation and device procedures annually, we remain one of the top referral centers in the region. Several of our faculty members go out to regional practices to see referred patients. This is not only more convenient for those patients, but it further increases our referral base, since these patients are then brought into our labs for their procedures.

How are new employees oriented and trained at your facility?

All new employees attend a two- to three-day UC San Diego Health system orientation. EP staff members then go through a focused lab orientation and competency program that is specific to their roles.

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

As an academic institution, we are fortunate to have access to a number of conferences and seminars organized by our faculty.

How is staff competency evaluated?

All of our CVTs go through a robust competency program involving all major equipment. Our lead CVT and vendors assist in ensuring elements of the training are up to date and relevant. Our RNs are continually evaluated through a range of classes provided by our health system.

How do you prevent staff burnout? In addition, do you practice any team-building exercises?

Burnout is a constant challenge due to our growing volume and fluctuating schedule. We aim to be as flexible as possible with staff schedules, offering different shifts that help with work-life balance. Our nurse coordinator does a great job of rotating staff to ensure a good mix of cases in terms of complexity and duration. As a teaching program, we perform cutting-edge therapy and research, providing an exciting, stimulating environment for our staff. This continuous learning and educational environment helps team cohesiveness and motivation. The hospital provides several staff appreciation events during the year, including hospital week, nurses week, holiday meals, and recently an all-staff employee engagement event. Our staff is our greatest asset, and we recognize that this is an area that we need to continually focus on.

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

Since UC San Diego is a Magnet-accredited institution, our nurses are involved in house-wide committees such as the Special Procedures Quality Committee and the Clinical Practice Council.

How do you handle vendor visits to your department?

All vendors must be registered with the Reptrax system.

Does your lab utilize any alternative therapies to help patients in the EP lab?

We find that playing our patients’ favorite music helps them to relax when we bring them into the lab.

Describe a particularly memorable case that came through your EP lab. What lessons did you learn from it?

Many of our cases are unusual, and we often use cutting-edge technology (e.g., LVADs for circulatory support during VT ablations, robotic-assisted ablation). Therefore, both before and after such cases, it is typical that the staff and faculty review plans for and observations made during such cases in order to learn from them and optimize procedures for any subsequent similar cases.

Does your lab use a third party for reprocessing? How has it impacted your lab?

Yes, we use Stryker. The process has been very effective in lowering some of our supply costs.

Approximately what percentage of your ablation procedures are done with cryo?

All of our ablation cases are done using radiofrequency.

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

We are licensed to perform procedures on patients aged 14 years and above.

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

We continually educate staff on radiation safety. All staff complete an online competency program on radiation safety, and we have updates at staff meetings. Our hospital physicists review exposure data and perform regular checks on fluoro, lead aprons, and shielding.

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

Our nurse practitioners see all device patients in the wound check clinic, one week post procedure.

What innovative EP techniques are being utilized in your lab?

Robotic-assisted AF ablation (Hansen Medical), epicardial VT mapping and ablation, hybrid surgical/catheter ablation for AF, left atrial appendage occlusion using the LARIAT® suture delivery device (SentreHEART), and Impella (Abiomed) and HeartMate (Thoratec) assisted VT ablation.

What are some of the dominant trends you see emerging in the practice of electrophysiology? How is your lab preparing for these future changes?

A dominant trend right now is the integration of mapping, monitoring, X-ray, and recording system images into one display system to improve efficiency in the lab as well as safety for patients. For this purpose, we have built a new state-of-the-art EP lab that incorporates robotic ablation technology for the increased volume of AF ablation cases, a large display format video monitor capable of displaying multiple input images on the same monitor (e.g., recording system, X-ray, echo, hemodynamics, esophageal temperature, etc.), and a video broadcast system for the remote broadcast of cases for teaching conferences.

Another major trend is to streamline the scheduling of procedures, intraprocedural documentation, billing, and reporting of procedures performed in the EP labs, and make such data conveniently and readily available for research. Therefore, we have deployed a cloud-based, EP lab database management system accessible via the Internet (web based) from any desktop, laptop, or tablet computer by all staff, fellows and faculty (username and password protected), which can access all patient and procedural information, and perform scheduling, intraprocedural documentation, billing, and reporting of all procedures done in the EP labs.

What about device recalls? How has your lab handled these?

We work closely in conjunction with our vendor partners to ensure that patients are contacted and given the opportunity to discuss their options with our clinical team.

Is your lab doing web-based/transtelephonic device follow-up?

Yes, we have a well-established remote monitoring program. We have a dedicated member of the staff that manages this patient pool, supported by our nurse practitioners in clinic.

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

Yes, we have numerous industry-sponsored and faculty-initiated studies taking place in our laboratory and clinics, involving both ablation and device implantation. On average, we participate in or are the coordinating center for 15–20 clinical trials at any one time.

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

Yes, we are ACGME approved for up to three fellows per year. We have a one-year, ACGME-accredited program, but we only accept fellows who plan to do two years of training in our program. The second year of the program is non-accredited and devoted to advanced clinical and/or basic research training.

Does your hospital or lab staff offer a device support group?

In the past six months, we have begun our device support group. Our second meeting is scheduled for this month.

Give an example of a difficult problem or challenge your lab has faced. How was it addressed?

Complex AF ablation procedures are often long and tiring, and may be very uncomfortable for the patient. Consequently, we perform all such procedures under general anesthesia. We therefore have worked closely with our anesthesia department and trained a cadre of nurse anesthetists who provide general anesthesia for all of our AF ablation patients. In the same manner, all post-operative care is provided by a group of nurses in our post-procedure monitoring unit who are familiar with our procedures. By utilizing the same group of anesthetists and nurses for all of our cases, we provide safe and consistent care for our patients from day to day.

Describe your city or general regional area. How does it differ from the rest of the U.S.?

San Diego is one of the largest cities in the country. Given its weather and location, it is also considered to be one of the best cities in the country in which to live and work. The general population in San Diego, being relatively well educated and tech savvy, has come to expect the best health care available. Therefore, we have continually worked hard to live up to these expectations and provide cutting-edge cardiac care for our patients. Failing to do so can be met with harsh consequences.

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

As part of the UC San Diego Health System, our program is supported by a premier academic health system infrastructure in which our patients receive the highest levels of care. Our program performs the largest volume of ablations for atrial fibrillation in the region. We have state-of-the-art equipment in two dedicated EP labs and have use of a brand-new hybrid operating room, where, in collaboration with our CT surgeons, we perform one of the largest volumes of device lead extractions in the region as well as perform minimally invasive hybrid surgical/catheter ablation for atrial fibrillation. We have a very experienced team of physicians, nurses, and technologists who have worked together on a myriad of cases ranging in complexity for a number of years, developing a unique understanding and comprehensive treatment of arrhythmias.

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