Spotlight Interview

Spotlight Interview: UCHealth University of Colorado Hospital

Wendy S. Tzou, MD, FHRS, FACC, Associate Director of the Cardiac Electrophysiology Laboratory and Associate Professor of Medicine, University of Colorado; and Kari Jackson, RN

Nurse Manager, Cardiac Electrophysiology, University of Colorado Health 

Aurora, Colorado

Wendy S. Tzou, MD, FHRS, FACC, Associate Director of the Cardiac Electrophysiology Laboratory and Associate Professor of Medicine, University of Colorado; and Kari Jackson, RN

Nurse Manager, Cardiac Electrophysiology, University of Colorado Health 

Aurora, Colorado

What is the size of your EP lab facility? When was the EP program started at your institution? 

We have 3 large fluoroscopy suites and 1 minor procedure room dedicated to EP. The EP program at the University of Colorado was started when Dr. Michael Reiter was recruited here in 1982. Dr. William Sauer has been EP section chief since 2008, over which time, our program has experienced dramatic growth and evolution. 

What is the number of staff members? What is the mix of credentials at your lab? 

We have 10 full-time positions: 9 RNs and 1 technologist (position vacant).

What types of procedures are performed at your facility? Approximately how many catheter ablations (for all arrhythmias), ICD implants, and pacemaker implants are performed each week? 

Any and all contemporary EP procedures are performed at our facility. This includes device implants (e.g., transvenous pacemakers, ICDs, implantable loop recorders, leadless pacemakers, and subcutaneous ICDs) as well as left atrial appendage closures. We also perform lead extractions in the hybrid OR, in a multidisciplinary program involving Cardiothoracic Surgery and Cardiac Anesthesiology. We routinely perform contemporary catheter ablation procedures for all treatable arrhythmias, including atrial fibrillation, ventricular tachycardia (both endocardial and epicardial approaches), and supraventricular tachycardia. We utilize both cryotherapy and radiofrequency ablation. Approximate volumes per week are as follows: 

  • Device implants, including generator changes, PPMs, and ICDs (all types + ILRs) = 8/week;
  • Ablations (all types, including add-on SVT or PVI) = 13/week; 
  • Tilts = 3-4/week;
  • CV = 5-6/week; 
  • Lead extractions = 1/week;
  • LAA closure procedures = 2/week. 

Who manages your EP lab? 

Kari Jackson is our nurse manager, with 11 years of EP experience.

Are employees cross trained? 

We have 1 cross-trained individual, with occasional assistance provided as needed between departments. Otherwise, EP lab staff are not scheduled regularly for duties in the cath lab, or vice versa.

Do you have cross training inside the EP lab? 

All staff are trained to perform necessary duties within any EP procedure, with the exception of technologists, who are not licensed to administer medications. 

What type of hospital is your EP program a part of? 

University of Colorado Hospital is an academic hospital. Our EP attendings are all University of Colorado School of Medicine faculty, and we have an ACGME-accredited EP fellowship program through which we have 3-4 fellows per year.

What are your thoughts on 2-year EP fellowship programs? 

Two-year programs have become critical in the comprehensive training of cardiac electrophysiologists, especially as proficiency in catheter ablation of complex arrhythmias has become an expectation of new graduates. Our program at UCH has had a 2-year requirement for full certification of EP fellows ever since its development.

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

Our fluoroscopy systems include Philips (biplane and single-plane) and Siemens (single-plane). One of the single-plane rooms contains a Stereotaxis magnetic navigation system. We use the Bloom stimulator and the Prucka recording system. 

We routinely use the ACUSON SC2000 and X700 ultrasound systems (Siemens) for intracardiac echocardiography. We use a portable handheld ultrasound (SonoSite) to assist with vascular access.

CARTO 3 (Biosense Webster, Inc., a Johnson & Johnson company) and the EnSite Precision Cardiac Mapping System (Abbott) are the predominant mapping systems. Topera (Abbott) is also used in conjunction with either. We are in the process of acquiring the Rhythmia Mapping System (Boston Scientific). 

In addition to the SmartAblate (Stockert) and Ampere (Abbott) RF ablation generators, we use the Arctic Front Advance Cryoballoon and CryoConsole (Medtronic). We implant devices from Boston Scientific, Medtronic, Abbott, and BIOTRONIK. 

Commonly used catheters for EP studies or ablations include the following: quadripolar JSN and CRD-2 (Abbott) catheters; decapolar catheters by Boston Scientific, Abbott, and Biosense Webster (F-type); PENTARAY and LASSO mapping catheters, THERMOCOOL SMARTTOUCH or SMARTTOUCH Surround Flow (FJ or DF curves), and 8 French intracardiac echocardiography catheters (SOUNDSTAR or ACUNAV) (Biosense Webster, Inc., a Johnson & Johnson company); circular mapping catheters (Reflexion Spiral or Advisor, Abbott); and TactiCath F-J Contact Force and FlexAbility D-F or F-J ablation catheters (Abbott). Commonly used long sheaths include Agilis (medium or large curl), SL1, SR0, and long SL0 (all Abbott). We use the Radiofrequency NRG Transseptal Needle (Baylis Medical) for transseptal access. We also use MR conditional pacemakers and ICDs, as well as subcutaneous and leadless devices.

Has your EP lab recently expanded in size or patient volume? 

Yes, we opened the third fluoro suite/Stereotaxis lab in Fall 2014, and renovated one of our outdated procedure rooms/control rooms in 2017.

What new technologies were recently added to the EP lab? How have these technologies changed the way procedures are performed? 

Adding Stereotaxis technology has assisted us in performing complex ablations in which manual catheter manipulation or stability is challenging (i.e., papillary muscle VT or arrhythmias in patients with congenital heart disease). Updates to existing mapping systems (Biosense Webster’s CARTO and Abbott’s EnSite Precision) and increased utilization of intracardiac echo have dramatically improved our ability to safely and effectively treat complex arrhythmias with marked reductions in fluoroscopy use. 

How is shift coverage managed? How does your lab handle call time for staff members? 

All staff work four 10-hour shifts per week. Operating hours are 0700-1730.

We have 2 staff on call Monday through Thursday, and 4 staff on call on Fridays, to manage cases that extend past business hours. They are paid callback (time and a half) for time worked. We also have limited weekend call shifts, from 0800-1600 Saturdays, Sundays, and major holidays, to cover emergent VT storm and heart block requiring pacing. 

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

We typically have 2 fluoroscopy rooms scheduled with elective outpatient procedures (each with at least 1 complex ablation, including AF and VT), and 1 open lab for inpatient add-ons. Our multi-procedure room is utilized for a variety of non-fluoroscopy procedures, including ILRs, cardioversions, non-invasive programmed stimulation tests, or tilt-table tests.

Tell us about your procedure scheduling and software. 

Our procedural scheduler, managed by the EP lab manager, uses Epic Radiant as well as Epic OpTime (for anesthesia cases).

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

We track complications and discuss cases in a monthly morbidity and mortality conference, via ACGME-accredited EP and general cardiology fellowships. We also participate in the ACC-NCDR ICD Registry as well as the American Heart Association’s Get With The Guidelines initiative, through which adherence to national standards is checked. EP fellows are required to generate QI/QA projects annually to optimize EP lab safety and efficiency; nurses also execute this responsibility as a requirement for additional credentialing, and several of our nurses are on safety committees for the hospital.

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

This is managed mostly by the nurse manager, with assistance from the supply coordinator. Our manager submits all requests and rationale to Supply Chain for approval and setup. The manager submits capital requests for equipment via cash or bulk purchase. An RN staff member places automatic orders in our third-party system to replace items used (this task is transitioning to the materials technician).

Have you developed a referral base? Has your institution formed an alliance with others in the area?

Yes, we are a tertiary referral center offering comprehensive care for management of all arrhythmia-related issues. We are known throughout the region for taking on complex ablation and device-related cases, and have established a referral network within the city as well as within the Rocky Mountain area for this purpose. 

UC Health has been in the process of expanding its clinical reach, recently acquiring the Medical Center of the Rockies in Fort Collins (north of Denver) and Memorial Hospital in Colorado Springs (south of Denver), as well as planning construction on a new facility in southwest Denver. Most complex cases are still referred to our specific facility (UCH Central).

In what ways have you helped to cut/contain costs and improve efficiencies in the lab? For example, does your lab use a third party for reprocessing or catheter recycling? 

Yes, we currently use Stryker for reprocessing of cables and quadripolar diagnostic catheters. We are in negotiations with Sterilmed regarding incorporating their services relevant to this process.

How do you ensure timely case starts and patient turnover? 

We monitor monthly metrics for on-time starts and room turnover, and discuss weekly with staff. 

How are new employees oriented and trained at your facility? 

We provide on-the-job training for 12 weeks for staff without EP lab experience, and adjust for experienced staff. We recently purchased the EP Academy training program through SpringBoard Healthcare to assist with onboarding of staff. Our service specialist arranges training each week during a dedicated 1-hour timeframe for inservices/education needs. 

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

Since we are a teaching facility, there are multiple CE opportunities throughout the hospital as well as at the Colorado Arrhythmia Symposium (hosted by our own cardiac electrophysiologists and the Heart Rhythm Society). Staff are also invited to the Annual Rocky Mountain Interprofessional Research & Evidence-Based Practice Symposium, which offers CE credits for EP-based learning.

How is staff competency evaluated? 

The CVC educator, EP service specialist, and nurse manager create and send a yearly questionnaire to staff regarding competency needs, and then create competencies based on the response from staff. It is mandatory that the questionnaires are completed prior to annual performance evaluation time.

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? 

We have had 3 staff certify in RCES and 1 in IBHRE in the last few years. This is included in their yearly performance evaluation and can lead to a higher merit increase to base wage. 

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

We try to “downstaff” if there is the option and the staff have been working a lot. The physicians are also great about buying lunch for the staff on really busy days. The teamwork is amazing right now, everyone supports each other and tries to keep each other happy. We try to meet up for dinners during conferences, and occasional happy hours are scheduled when the lab isn’t busy. 

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

Staff members participate in our Quality-Safety Advocates Committee, Safety Committee, and Department-Based Council.

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

Vendors must register with Reptrax to be in our facility. If they are not here for a scheduled case, then we require an appointment. 

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

We often utilize music therapy according to patient preference.

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

Less than 5% of cases are done with cryotherapy.

What are your techniques for LAA occlusion? Do you have a primary approach? 

We primarily implant the WATCHMAN
device (Boston Scientific). We also have utilized the LARIAT (SentreHEART, Inc.) for LAA occlusion. We are currently an enrolling site for the Amulet IDE clinical trial.

What are your thoughts on the use of NOACs in patients with non-valvular AF? 

NOACs provide a much more palatable alternative to warfarin, for ease of use and maintenance in most patients, assuming that compliance or cost is not prohibitive. They have also been demonstrated to be safe to continue without interruption for AF ablation procedures. The expectation is that their use will continue to become more widespread, especially as the antidote for the Factor Xa inhibitors becomes FDA approved. 

Do you utilize lifestyle modification as therapy for your patients with atrial fibrillation? 

Yes. Although we do not yet have a dedicated ancillary clinic for this specific purpose, weight loss and diagnosis/treatment of sleep apnea are routinely encouraged.

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

Initiated by our EP chief, Dr. William Sauer, we now routinely perform bipolar ablation to treat complex arrhythmias that are particularly resistant to standard unipolar RF ablation; this can be accomplished using existing CARTO (Biosense Webster, Inc., a Johnson & Johnson company) or EnSite Precision (Abbott) Cardiac Mapping Systems. Also led by Dr. Sauer, initially at our center and now at many others that have learned of this concept because of our associated success with it, we often use half-normal saline for open-irrigated catheter ablation in order to enhance the size of RF ablation lesions (versus normal saline). This technique has been instrumental in helping us to successfully control complex arrhythmias that are particularly resistant to standard RF ablation.

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

We primarily perform only adult cases. In rare exceptions, pediatric cases have been performed for teenagers weighing >40 kg. Almost all pediatric EP cases are performed at our affiliated Children’s Hospital, where a few of our electrophysiologists have occasionally assisted the pediatric EPs in cases.

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

Routine use and proficiency with electroanatomic mapping systems for ablations, including the frequent incorporation of intracardiac echocardiography, has dramatically reduced fluoroscopy time over the last decade. With rare exceptions, fluoroscopy is used with the lowest frame rate and exposure. All fluoroscopy suites are equipped with standard mobile leaded shields as well as skirts affixed to the fluoroscopy tables, and EP providers wear standard lead and leaded eyewear. We have recently purchased the UNIVUE software from Biosense Webster.

What are your methods for device infection prophylaxis? 

We utilize the usual methods for sterile preparation and draping of patients, as well as intravenous antibiotics given within 60 minutes of incision. For first-time implants, IV antibiotics are continued to maintain 24 hours of coverage post procedure. For generator changes, oral antibiotics are administered for 5-7 days after the procedure.

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

We regularly use these reports for quality assurance. Any outliers are individually reviewed to verify accuracy in data abstraction as well as appropriateness of management.

How does your lab handle device recalls? 

Letters are generated to inform patients. Clinic visits are specifically arranged for those recalls that are felt to be of higher risk (e.g., premature battery depletion among pacing-dependent patients) and individualized discussions are conducted to determine the best subsequent steps in care (ranging from continued, perhaps closer observation, to device revision or system extraction).

How is outpatient cardiac monitoring managed? 

We have a device clinic in the outpatient CVC that monitors remote transmissions as well as patient visits.

Do you utilize digital tools and wearable technologies in your treatment strategies for patients? 

Yes. In cases in which the indication for ICD implantation is ambiguous, the LifeVest (ZOLL Medical Corporation) is utilized for temporary management. Many patients have the AliveCor mobile EKG monitor and smartphone application to assess heart rhythms in association with symptoms in the absence of an implanted device. Ambulatory event monitoring is also often used to guide treatment among patients with arrhythmias or suspected arrhythmias based on symptoms. 

Is your EP lab currently involved in clinical research studies? 

We are an enrolling center for the RADAR study, a multicenter trial evaluating the efficacy of newly designed software to identify potential AF drivers in persistent AF, as well as evaluating the efficacy of targeting identified drivers. We are also an enrolling site for the VENUS-AF study and GENETIC-AF study. We participate in a number of NCDR-sponsored registries, including the ICD, AF ablation, and LAA occlusion registries. Finally, we also routinely conduct our own clinical research based on clinical questions that often arise in the management of complex arrhythmias. 

Does your heart rhythm service offer patients with a suspected inherited arrhythmia a referral to cardiovascular genetics clinic? 

Yes, we have a dedicated Cardiovascular Genetics clinic for this purpose.

Has your EP program achieved IAC accreditation, or does it plan to in the future? 

Not at this time. We will pursue it once insurance companies acknowledge its importance and benefit.

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

Our medical center serves the Denver metropolitan area as well as a wide-reaching network of patients within the Rocky Mountain region. Although Denver is becoming more representative in terms of size of other urban areas, this region of the country is overall less populated than urban centers on the East and West Coasts. We routinely care for patients throughout the state of Colorado as well as out-of-state patients, including those in Kansas, Nebraska, Wyoming, Montana, Nevada. 

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

With innovation and interdisciplinary/inter-institutional collaboration, our hardworking team has evolved, amidst humble beginnings, into a thriving group that has become well respected in the area as well as the nation. We pride ourselves on quality work and camaraderie, the latter of which has been critical in allowing us to thrive.

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