UCSF Medical Center is the academic medical center of the University of California, San Francisco, the nation’s leading university exclusively focused on health. Consistently ranked among the top 10 hospitals in the United States by U.S. News & World Report, UCSF Medical Center is recognized for innovative treatments, advanced technology, collaboration among health care professionals and scientists, and a highly compassionate patient care team, while serving as a training ground for health care leaders of the future. UCSF’s nationally preeminent programs include children’s health, the brain and nervous system, organ transplantation, women’s health, cancer, and behavioral health. This care and training extends to the UCSF-affiliated San Francisco VA Medical Center and Zuckerberg San Francisco General Hospital and Trauma Center, enabling UCSF to follow its public mission of improving the health of underserved communities worldwide.
What is the size of your EP lab facility? When was the EP program started at your institution?
We currently have 3 EP labs in the department, located on 2 separate floors. We also share the department with 3 cath labs and an EP procedure room, as well as a 7-bed holding room for pre- and post-procedure patients. The lab has come a long way from its infancy as a department of the Cardiovascular Research Institute. Dr. Melvin Scheinman and medical technician Booker Pullen began the EP program at UCSF Medical Center in 1979. Through the work of early research, Dr. Scheinman performed the first direct current AVJ ablation in the world in the lab at UCSF. His groundbreaking work, along with Booker Pullen’s ability to rebuild catheters, devices, and patches to be used in the EP lab, has brought us to where electrophysiology medicine is today.
What is the number of staff members? What is the mix of credentials at your lab?
We currently have 9 full-time staff members, as well as one RN in full orientation, one RN starting in orientation next month, and 2 travelers. At this time we utilize a full RN staff, as there are techs on the cath lab side of the unit. Three of our EP staff have their CCRN, and 4 are in the process of working on their RCES credential.
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?
We perform EP studies, ablations, mapping, pacemaker and ICD implants, lead extractions, and loop recorder explants in our lab. The EP procedure room performs a myriad of procedures, including tilt table testing, direct current cardioversions, loop recorder implants, and procainamide challenges. For fiscal year 2016, we performed a total of 2890 procedures, which included 505 ablations and 327 pacer/ICD implantations.
Research is at the heart of our program, and we participate in multiple studies and trials for devices and medications. As a leader in the electrophysiology world, UCSF’s EP lab works closely with the UCSF campus to develop new techniques and innovations for improving patient outcomes.
Who manages your EP lab?
Colleen Hurst, RN, MSN is our current unit manager. She has a longstanding background in cardiac catheterization and recently joined the department from Lexington, Kentucky. Our assistant manager, Lisa Konstantinidis, RN, BSN, has had a long career in EP and recently stepped into the assistant manager role from an EP staff position. Both Colleen and Lisa manage the UCSF Adult Interventional Cardiology Department. The labs are part of the UCSF Heart and Vascular Center, which is under the guidance of Jeff Kalin, Operations Director, and Jeffrey Olgin, MD, Medical Director.
Are employees cross-trained?
We are beginning to cross-train staff to help cover the EP and cath labs during breaks and high-volume days.
Do you have cross training inside the EP lab?
Although we currently have an all-RN staff in the EP lab, we are cross training the radiology technologist from the cath lab to assist with scrub and setup. All current EP staff are trained to scrub, circulate, and monitor. This allows for an easier flow when staff members are on vacation, have a leave of absence, etc. Any staff member can perform any task.
What type of hospital is your EP program a part of?
UCSF Medical Center is an academic center that currently ranks in the top 100 cardiology programs in the nation according to Becker’s Hospital Review in 2016.
What types of EP equipment are most commonly used in the lab?
We currently use St. Jude Medical’s Agilis Sheath, SR0 Sheath, SL1 Sheath, TactiCath Quartz Contact Force Ablation Catheter, and Livewire catheter; Baylis Medical’s Radiofrequency NRG Transseptal Needle; Boston Scientific’s DYNAMIC XT steerable diagnostic catheter and BLAZER PRIME HTD temperature ablation catheter; Medtronic’s cryocatheter and Reveal LINQ Insertable Cardiac Monitor (ICM); and Biosense Webster’s SOUNDSTAR, AcuNav (8 French) catheter, THERMOCOOL, SMARTTOUCH, and EZ Steer.
How is shift coverage managed? What are typical hours (not including call time)?
Most staff work four 10-hour shifts in the lab, with a few staff members working three 12-hour shifts each week. The normal lab hours are from 7:00am-5:30pm, Monday through Friday of each week. We currently do not staff for major holidays or weekends.
What new technology has been recently added to the EP lab? How have these technologies changed the way you perform procedures?
We have cutting-edge technologies such as remote magnetic navigation by Stereotaxis, cryoablation, and contact force radiofrequency ablation available in the lab; these technologies have improved our outcomes in patients with atrial fibrillation (AF), atypical atrial flutter, and ventricular tachycardia associated with structural heart disease. The new approach that we have adopted in our lab is hybrid ablation in collaboration with CT surgery; this has enabled us to offer ablative therapy in situations where there are limitations to conventional catheter-based ablation. This includes ablation of epicardial VT arising from the summit of the heart close to the left coronary arteries, a surgical window for ablation of epicardial VT in patients with difficult epicardial access such as those with pericardial adhesions, and previous open-heart surgery. We are also collaborating with our CT surgeons to develop novel approaches for minimally invasive surgical ablation in patients with persistent AF and an enlarged left atrium.
What types of cardiac mapping systems do you utilize?
We use CARTO (Biosense Webster, Inc., a Johnson & Johnson company) and EnSite (St. Jude Medical).
What imaging technology do you utilize?
We currently utilize imaging systems by Siemens and Philips in our labs.
Do you implant MR conditional pacemakers or ICDs? What about subcutaneous or leadless devices?
Yes, we do implant MR-compatible pacemakers and ICDs, as well as subcutaneous devices. The only leadless device we implant is the LINQ ICM (Medtronic) in our procedure room.
Who handles your procedure scheduling? Do they use particular software?
Outpatients are currently scheduled by the EP clinic scheduler. She utilizes our EPIC hospital software called OpTime. We use this for both cath and EP lab cases. Inpatients are handled by the fellows as add-ons, and the charge nurse or nursing manager adds them into the OpTime schedule.
How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies?
Inventory is managed by our Implant Coordinator, Shane Perez. He is in charge of ordering for both the EP and cath labs via the McKesson Inventory Manager. The product is kept in the Pyxis SupplyStation system (Becton, Dickinson and Company) in the department, and the Pyxis auto-orders our highest usage catheters and supplies. New products are introduced to the department via physician request and vetted through the New Products Committee. This committee meets to approve new equipment and implants on a bi-weekly basis, and includes the manager, operations director, implant coordinator, and supply chain value analysis facilitator.
Has your EP lab recently expanded in size and patient volume?
Our EP and cath labs gained one lab each on the twelfth floor when the pediatric cath lab moved to a new hospital in the Mission Bay area of San Francisco. Since then, we have increased volume by adding a new attending and increasing the days of the week in which we utilize 3 attendings. This growth has our holding room busting at the seams, as the cath lab has also added 3 new attendings to the mix. This has also added a complexity to scheduling, as we must work closely with anesthesia and the echo lab to increase their staffing to assist with our increases.
We will also be revamping one of the fifth floor labs with a FY2017 capital budget spend. This will include a new AlluraClarity system (Philips) and a facelift to the EP suite. One lab will close for a few months while this upgrade takes place.
How has managed care affected your EP lab and the care it provides patients?
The overall goal of managed care is to reduce the cost of the provision of health care services while increasing the quality of the services. In the subspecialty of electrophysiology, it has had a trickle-down impact requiring electrophysiology labs to seek standardization of supplies (including pharmaceuticals) and procedures to control costs. It has also required the addition of an administrative component to manage the referral and authorizations process needed to receive appropriate reimbursement for devices and procedures. It is generally accepted that the benefit of the standardization offsets the addition of the administrative burden.
As cardiac pacing and electrophysiology treatment and advancements continue to evolve, new technology is often introduced at a consumer level. This has changed the conversation between providers and patients, especially when it is known that a new treatment or device specific to a patient’s clinical issues is available, although it may not yet be approved for coverage by a managed care payer. Informing patients of this can be complex and impact the patient/provider relationship. Physician-to-physician relationships may also change when coverage issues are factored into decisions about choices of therapy.
Additionally, our largest managed care organization, Medicare, requires participation in national registries to track quality and outcome data for implantable device patients. This is an additional cost (registry participation fees), and in the case of our labs, we added staff and systems to assist in collecting the reportable data elements. Our intent is to use this population outcome data to improve the quality of clinical decision making.
Overall, managed care has required the EP lab to more acutely evaluate its cost structure and to work even more closely with its physicians to partner in decisions that balance the cost/quality equation.
In what ways have you helped to cut/contain costs and improve efficiencies in the lab?
As growth has continued to push the envelope of our Interventional Cardiology Department, we have embarked on a mission to improve workflow, from scheduling of cases to discharge of patients. This is a multidisciplinary taskforce currently focused on value streaming the flow of the department and improving on inefficiencies. We are also utilizing reprocessing and volume buying with other University of California labs to get the best price for high-volume or high-expense products. This has helped to cut our cost per case.
How do you ensure timely case starts and patient turnover?
Our charge nurse facilitates the workflow in the lab, working with the anesthesia and echo staff as needed. The charge nurse also helps to set up and break down rooms when not relieving for breaks or troubleshooting other problems.
How are new employees oriented and trained at your facility?
New employees are given a 6-week orientation program. We assign each orientee 2 preceptors in order to ensure continuity. We have a standardized format put together by our unit-based professional performance council. Orientees are given a binder that includes the competency-based orientation (CBOs) needed for all our procedures, as well as a schedule/checklist. The schedule allows anyone involved with precepting the ability to know at a glance what the orientee has been working on and what should be the next plan of focus. As part of the orientation program and reference for the staff, our Professional Performance Council has put together a comprehensive reference manual for all EP procedures performed in the lab. This includes lists of equipment and supplies typically used in each case, and a guide for setting up and troubleshooting the mapping systems. There is one manual for each lab, and they are referred to as the “EP Bible.” Orientees are tasked to utilize the “Bible” to gain knowledge for a new task or procedure before the next assignment. In addition, our goal is to have management meet weekly or bi-weekly with preceptors and orientees to make sure the orientation process is going smoothly.
What types of continuing education opportunities are provided to staff members?
Staff have worked together to become CCRN or RCES certified. Our doctors have also invited staff to attend the California Heart Rhythm Symposium when held in the Bay area. Every Tuesday morning, we schedule in-services and equipment updates, alternating with EP council meetings and management/staff huddles. In the past, our EP attendings have also offered educational talks on various EP topics.
How is staff competency evaluated?
Staff complete a CBO checklist for each new procedure and device, and upon beginning their employment in the lab. A yearly review is also performed for each device or procedure, with staff members or vendors serving as super users to sign off from the EP department.
Does staff receive an incentive bonus or raise upon passing the exam?
The hospital does offer an increase in pay for advanced certifications. There is an incentive raise at UCSF given to nurses gaining certification in their specialty.
How do you prevent staff burnout? Do you also practice any team-building exercises?
Initially, we had monthly meetings with our Faculty and Staff Assistance Program (FSAP) to identify and address staff concerns. These meetings, which included staff, management, the UCSF Heart and Vascular Center director, and a facilitator from the FSAP team, were highly beneficial. We continue to hold these meetings with only management and staff involvement. The assistant manager also holds monthly huddles with lab staff so that problems can be identified and marked for intervention and follow-up in a timely manner. Management also practices both daily rounding at the board with the charge nurses and periodic walking rounds to check in individually with the staff.
We have also added a “PHUN” committee with staff members, which encourages team-building and social gatherings outside of the workplace. This committee has scheduled several staff gatherings at local pubs, escape mazes, bowling alleys, etc. This was part of a performance improvement initiative to increase staff engagement and team building. Several years ago, the entire department also engaged in the Crucial Conversations training program to assist with staff communication and conflict.
What committees, if any, are staff members asked to serve on in your lab?
Our staff participate in the Magnet process, and one EP RN is designated as the council member and ambassador for the program. Staff is also encouraged to participate on the EP council, which meets once a month. In addition, we have a Professional Performance Council that works to oversee staff performance and orientation, and update clinical processes.
How do you handle vendor visits to your department? Do you contract with vendors?
Vendors will call anywhere from one day to one week ahead of time to schedule a visit. During this call, their information is placed into a vendor credentialing system (VCS) that tracks information (e.g., HIPAA, immunization, sterile technique, etc.) for that specific vendor. Should all requirements be met and up to date, VCS will give the vendor a pass to visit our facility. On the day of visit, our vendors check in with security, which provides them with a sticker “badge” that has the vendor’s picture and relevant information as to where they should be visiting that day. They are also given red scrubs so that they can be easily identified.
Our contracts with vendors are handled through purchasing for the hospital. They handle all the agreements once the decision is made by the New Products Committee to bring a new device or product into the interventional labs.
How does your lab handle call time for staff members?
Although the EP staff currently do not have a call system, we do have “Late Stay” scheduling. This means the staff who are scheduled Late Stay will work in the lab past 5:30 and stay until the cases are completed.
Does your lab use a third party for reprocessing or catheter recycling? How has it impacted your lab?
Using third-party reprocessing with Stryker Sustainability Solutions, we are on track to save between $900,000 and $1,000,000 by year’s end (2016). We hope to increase this savings as more and more catheters are able to be reprocessed.
Approximately what percentage of ablation procedures are done with cryo vs radiofrequency?
Currently, 15-20% of our ablation cases are performed with cryo. The remaining are contact force-sensing radiofrequency cases.
What are your techniques for LAA occlusion? Do you have a primary approach?
We are currently using the LARIAT Suture Delivery Device (SentreHeart, Inc.), but are preparing to begin WATCHMAN LAAC Device (Boston Scientific) procedures. We will decide which approach to take dependent on the patient anatomy and size/shape of the LAA once we are using both approaches.
What are your methods for device infection prophylaxis?
Our methods include sterile prep, antibiotic pocket flush, and oral antibiotics for five days post implant for generator changes or high-risk patients.
How do you use the NCDR Outcome Reports to drive QI initiatives at your facility?
We have our own database and monthly M&M to guide QI changes.
What are your thoughts on EHR systems? Does it improve your quality of care?
It’s more time consuming, but it improves access to records and care, and implements follow-up after AF ablation through combined mobile Healthy Heart smartphone-based database and procedural/clinic data from EMR. It allows follow-up from patients wherever they are in the world.
What are some of the dominant trends you see emerging in the practice of electrophysiology?
With the changes in health care affecting all aspects, EP continues to focus on quality initiatives to improve patient outcomes and experience, and offer the highest quality of care available. Quaternary referral centers such as UCSF Medical Center are also noticing an increase in more complex procedures. These trends will continue as health care is reshaped to meet the needs of patients and decrease costs.
How does your lab handle device recalls?
Device recalls go through our material service administrator, who then forwards on the information to the necessary individual. Once they are received by the department, items listed in the recall are quarantined and sent to the material service administrator, who handles the return process.
Is your EP lab currently involved in clinical research studies?
Part of UCSF’s mission is teaching and discovering. As an educational center following this mission, our department is involved in many clinical research trials, including the Health eHeart Study, aMAZE, WRAP-IT, Soprano, Holiday ETOH study, Genetics of Cardiac Arrhythmias study, and the PVC Ablation Registry.
Describe your city or general regional area. How is it unique from the rest of the U.S.?
The San Francisco Bay Area is a true melting pot of diverse communities and ethnicities. The population and the development of the area’s commerce is built on the idea that “all are welcome.” Many people from all over the world have moved to the area for finance, the arts, medical/genome research, e-commerce, and the chance to fit in somewhere. This city is the second most densely populated major city in the United States, as the 865,000 residents are settled into a 7-mile by 7-mile square surrounded by the San Francisco Bay, the Pacific Ocean, and neighboring San Mateo County. The San Francisco Bay Area, which includes San Jose, Oakland, and surrounding communities, houses 8.7 million people, which makes it the fifth most populous region in the nation.
San Francisco is also home to a weather oddity known as a microclimate. Each area has its own weather, and the day can be uniquely different depending on where one might be. Fog encompasses the peninsula and the city in the summer, while the East Bay and wine region may have very hot and dry days. Residents must dress for any type of weather on any given day.
Please tell our readers what you consider special about your EP lab and staff.
The EP staff members at UCSF Medical Center are special because they are a diverse set of individuals with different skill sets and experiences from all over the world. Most of our staff moved here from other areas of the country or globe, and have brought their own flavor to the team. They are motivated to do what is best for the patient, and perform to their highest ability in the roles of research and new technologies. They work alongside some of the pioneers of the EP field, and are making changes for the better for patients not only in San Francisco, but from all over the country.
For more information, please visit www.ucsf.edu