What is the size of your EP lab facility? When was the EP program started at your institution?
The Center for Care and Discovery, a 10-story, 1.2 million square foot hospital, opened in 2013. The Heart and Vascular Center (HVC), which just opened last month, is located on the entire fourth floor of this new facility. There are 2 EP labs and a hybrid surgical lab with full EP capabilities on the fifth floor. The Arrhythmia Technology Suite opened last month in a fully renovated space to create the “EP Lab of the Future,” which features remote magnetic navigation, 3 commercially available mapping systems, and a floor-to-ceiling glass observation and conference room.
What is the number of staff members? What is the mix of credentials at your lab?
We have 14 dedicated EP procedural staff comprised of 9 nurses, 3 radiologic technologists, 2 CCI credentialed, 1 EP scheduling coordinator, 1 billing coordinator, and 1 lab manager.
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 approximately 400-500 ablations, 400-500 pacemaker and ICD implantations, and 100 lead extractions procedures per year. Our ablation volume is focused on complex ablation procedures, including ventricular tachycardia and atrial fibrillation.
Who manages your EP lab?
The EP lab is part of the HVC at the University of Chicago, and is led by our Executive Director, Erin Shaffer, Medical Director of the Center for Arrhythmia Care, Dr. Roderick Tung, EP and Cath Lab Manager, Christopher Buzzard, and HVC Nursing Manager, Sandra Coslett.
Are employees cross-trained? Do you have cross training inside the EP lab?
The EP and cath labs do not cross-cover procedures. We feel cross-training within the EP lab is an integral way to increase efficiency, meet operational goals, and increase employee engagement, which are all immensely important to the overall patient care experience.
What type of hospital is your EP program a part of?
The University of Chicago Medicine is an academic teaching program that is committed to advancing patient care, translational scientific research, and clinical innovation.
What types of EP equipment are most commonly used in the lab?
Our imaging systems are all from Philips, including 2 biplane FD20/FD10 and 1 single-plane FD10. Additionally, we have the CARTO (Biosense Webster, Inc., a Johnson & Johnson company), EnSite (St. Jude Medical) and Rhythmia (Boston Scientific) mapping systems. Hemodynamic monitoring is performed on the CardioLab Recording System (GE Healthcare), and intracardiac echo is utilized with the ACUSON SC2000 (Siemens). We use a magnetic navigation system by Stereotaxis. We use 3 different vendors for catheter ablation: Stockert and SMARTABLATE (Biosense Webster, Inc., a Johnson & Johnson company), the Ampere RF Ablation Generator (St. Jude Medical), and Arctic Front cryoablation (Medtronic) for selective atrial fibrillation (AF) procedures. We use the Excimer Laser System (Spectranetics) and intravascular ultrasound (Philips Volcano) for lead extraction.
How is shift coverage managed? What are typical hours (not including call time)?
Staff has a mix of 10- and 12-hour shifts starting at 6:30 am, with rotation for late coverage for nurses and technologists.
Tell us what a typical day might be like in your EP lab.
Staff arrive at 6:30 am and convene in the lab at 6:45 am for our morning huddle, during which we review cases, plan for the day, and go over our key performance metrics. From there, our pre-op nurses and anesthesiologist assess and begin to prep patients, while the remainder of the team works to set up the rooms. We typically perform 3-4 cases in the EP suites, along with 2-4 cardioversions or tilt table tests in the pre-op space. Typical procedures that we perform are for atrial fibrillation, atrial tachycardia/flutter, ventricular tachycardia/PVC, supraventricular tachycardia, Wolff-Parkinson-White (WPW), and AV nodal ablations, as well as implantations of pacemakers (including MRI compatible and leadless), ICDs (MRI compatible and subcutaneous), BiV ICDs, and loop recorders. We also perform TEE/cardioversions and DFT testing.
What new technology has been recently added to the EP lab? How have these technologies changed the way you perform procedures?
We have recently been utilizing electroanatomic mapping systems to perform completely fluoroless procedures, including for AF. This has allowed our lab staff, anesthesia staff, and operators the ability to perform the procedure without wearing lead, which minimizes fatigue, musculoskeletal aches and pains, and cumulative radiation exposure.
What types of cardiac mapping systems do you utilize?
One of the challenging and exciting prospects with EP in an academic setting is having all current mapping technology. Not only is this a large financial investment, but it is also challenging in regards to room space, integration, and staff training. In our 2 main EP suites, we have 2 integrated CARTO systems (Biosense Webster, Inc., a Johnson & Johnson company) along with 1 mobile EnSite system (St. Jude Medical) and 1 mobile Rhythmia system (Boston Scientific). In our new Arrhythmia Technology Suite, we have 1 CARTO and 1 EnSite system that share a monitor, keyboard, and mouse through a KVM switch, as well as a Rhythmia system. In all of our EP suites, the PCs for the mapping systems are located remotely in a closet to decrease the clutter from computer cables and PC boxes that normally lie on or under the countertop.
What imaging technology do you utilize?
Our EP suites all have Philips imaging systems (2 biplane and 1 single plane). The hybrid OR utilizes the Artis Zeego (Siemens).
Tell us more about your use of MR conditional devices.
We implant both MR conditional and traditional devices. Our MRI team has innovated protocols that are MR safe under supervision for any type of device.
Who handles your procedure scheduling? Do they use particular software?
Scheduling is routed through our dedicated patient scheduler, who coordinates our daily schedule along with arranging for anesthesia and echocardiology support. She works closely with the physicians and is integral to the success of our team, as the nature of EP cases is quite dynamic. The University of Chicago uses EPIC as our EMR, and we use a function called OpTime for all EP and OR scheduling.
What type of quality control/assurance measures are practiced in your EP lab?
We routinely perform timeout procedures with the entire team, and review case durations using OpTime. Procedural complications are reviewed in structured morbidity and mortality conferences.
How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies?
We have a dedicated supply chain person who manages the inventory in the labs through a mix of RFID and Kanban. The RFID system is a product called Helios (ARC Healthcare Technologies). Some of our supply carts have RFID readers built into them that read when packages are removed. For other products, we use the Kanban system, which works for hanging catheters as well as products stored in bins. For hanging catheters, we have RFID cards on the designated hooks for each product, which are clearly labeled with descriptions and par located at the threshold point. For example, if we have a par or 5 decapolar catheters, we would set a reorder threshold of 3 and place the card in front of the third catheter. Once we remove the 2 catheters in front of them on the hook, the card would be pulled by the staff member or supply chain coordinator and placed in the RFID reader, which then generates an order.
Similarly, each bin is stocked with enough product to last 1-2 days, and has an RFID card on the front. When one bin is empty, the card is pulled and placed in the RFID reader for reorder. As new product is delivered, the remaining product in the second bin is moved to the first bin and new stock is placed in the empty bin, which helps rotation and reduces expired waste.
How has managed care affected your EP lab and the care it provides patients?
Our duty and mission is to provide the highest-level clinical care and at the present time, managed care has not significantly affected our ability to do so. Cost-containment measures such as resterilization are appropriate as long as quality is not compromised.
Have you developed a referral base?
The niche of our program is to innovate with new technologies and approaches in order to tackle cases are that are not fully treated in the community. We have developed a wide referral base throughout the city to complement community practice with specialized “last resort” procedures to ensure that patients return to their referring physicians for local follow-up.
In what ways have you helped to cut/contain costs and improve efficiencies in the lab?
We have a very strong relationship with our materials management partners. EP, along with all other departments, has a monthly Value Analysis Team meeting to discuss new and old products, current usage, new technology pipelines, reprocessing opportunities, and service contracts. Physician involvement is very important to the overall success of a program, and we have had great engagement from our physicians in past years.
How do you ensure timely case starts and patient turnover?
Lean Management principles are ingrained at University of Chicago Medicine and are becoming more prevalent throughout the healthcare industry. All of our KPI metrics are visible on a board in the control room for all to see. On-time starts and delay reasons are some of the metrics that we discuss during our morning department huddle and are reported weekly during our VP huddle in front of the executive team, which helps to quickly identify, address, escalate, and resolve issues.
Does your EP lab compete for patients? Has your institution formed an alliance with others in the area?
We have recently acquired and merged with the Ingalls Health System and look forward to establishing physician collaboration. Additionally, physicians in our group have outreach clinics in Glen Oaks, Streeterville, and Little Company of Mary.
How are new employees oriented and trained at your facility?
New members are paired with a preceptor to work with throughout their 8-week orientation. We work to provide biweekly feedback to the orientees from their preceptor and physicians, as well as give them the opportunity to give feedback. This is an opportunity to build communications skills and teamwork, and provide valuable input on how our preceptors can refine the process.
What types of continuing education opportunities are provided to staff members?
We recently were able to block off biweekly meeting time in the mornings to offer educational opportunities from our faculty and vendors.
How is staff competency evaluated?
Staff receive and give quarterly peer evaluations, which include physician comments. This feedback is centered on teamwork, clinical knowledge, professionalism, communication, and excellence/quality from the whole team. We feel that honest and open conversations are key to setting expectations, improving teamwork, and building a culture of safety.
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?
Some of our staff have advanced credentials, but at this time, there is no incentive bonus or raise after passing the exam. We have started discussions with our director and HR compensation, but still need to do more work in order to enact this. We feel staff should be rewarded for advanced credentialing because it acknowledges and incentivizes professional and personal growth, which only betters patient care.
How do you prevent staff burnout? Do you also practice any team-building exercises?
Burnout can be a serious problem when it comes to morale and retention. Through discussions with the team, we are in the process of adding more 12-hour positions in order to accommodate our caseload increase, reduce overtime, and provide a better work-life balance for the staff. Competition and support for the local sports teams is a great unifying subject for our EP team. Over the summer, the staff and faculty joined together for the Crosstown Classic game (Cubs vs White Sox) along with another Chicago favorite, Whirly Ball, which were both great successes. We plan to do more outside events in the future to carry on the success of this first outing.
What committees, if any, are staff members asked to serve on in your lab?
We have staff involvement in our Unit-Based Council and Local Practice Council, as well as some who work with the Patient Advisory Board.
How do you handle vendor visits to your department? Do you contract with vendors?
All vendors go through Vendormate Credentialing (GHX). Mapping system and device reps that are on campus daily are eligible for hospital ID, while other vendors have calendar appointments scheduled in Vendormate for when they need to be on campus for meeting or case support.
Describe a particularly memorable case from your EP lab and how it was addressed.
Two cases embody the goals of our program. In the first highlighted case, we performed a case on a patient with complex congenital heart disease, in which ventricular tachycardia originated from the hypoplastic left ventricle, and used magnetic navigation technology to cross the membranous ventricular septal defect (VSD) from the aorta due to tricuspid atresia. The case could only be completed with this technology due to the twists and acute turns required.
The second case was one that was refractory to standard ablation in the region of the left ventricular summit. The patient was then taken to the hybrid lab, where a totally endoscopic robotic surgery was performed using only EP catheters for mapping and ablation. The arrhythmia was eliminated on the first ablation lesion, and this first-in-man case was accepted by the HeartRhythm journal for publication.
How does your lab handle call time for staff members?
There is currently no on-call time for staff.
Does your lab use a third party for reprocessing or catheter recycling? How has it impacted your lab?
We have a longstanding program in place with both Stryker and Sterilmed for reprocessing of EP catheters. Although we have a limited scope of products that we reprocess, the impact is quite substantial in the cost savings for the organization.
Approximately what percentage of ablation procedures is done with cryo vs radiofrequency?
We currently perform >80% of cases with radiofrequency, but are evaluating the role of cryoablation through future clinical trials.
Does your lab use contact force sensing technology during radiofrequency ablation of atrial fibrillation?
Yes, we utilize products from Biosense Webster (SMARTTOUCH) and St. Jude Medical (TactiCath).
What are your techniques for LAA occlusion? Do you have a primary approach?
We are looking to launch the WATCHMAN (Boston Scientific) program, but primary treatment is still surgical via robotic ligation.
What are your thoughts on the use of the new oral anticoagulants (NOACs) in patients with non-valvular atrial fibrillation?
We routinely use NOACs before and after AF ablation.
Is hybrid epicardial and endocardial ablation of atrial fibrillation performed at your institution?
Both procedures are performed frequently in isolation, but we recently developed a hybrid program and successfully performed our first “same-shot” procedure in the hybrid lab, where endocardial mapping was performed before and after epicardial surgical ablation of the posterior wall and pulmonary veins.
What other innovative EP techniques are being utilized in your lab?
We are actively pursuing high-density mapping of epicardial and endocardial VT, with the aid of hemodynamic support devices to fully characterize reentrant circuits. We have interest in developing non-arrhythmic ablation, which includes pulmonary and renal denervation as well as septal reduction for hypertrophic cardiomyopathy.
Do you perform only adult EP procedures or do you also do pediatric cases?
We are developing a strong collaboration with our pediatric EP to manage patients who benefit from expertise in both adult and pediatric approaches.
What measures has your lab taken to reduce fluoroscopy time? In addition, what types of radiation protective shielding and technology does your lab use?
As with any lab, radiation safety is very important. The imaging protocols are default to the lowest settings. Additionally, we try to utilize intracardiac echo and 3D mapping technology as often as possible to reduce exposure.
What are your methods for device infection prophylaxis?
We use dual IV antibiotics during implant and 24 hours post implant. Gloves are frequently changed one time during the implant procedure prior to closing. Dermabond (Ethicon) has been used to diminish stitch abscesses.
What are your thoughts on EHR systems? Does it improve your quality of care?
We believe that it helps to standardize order templates.
What are some of the dominant trends you see emerging in the practice of electrophysiology?
There is certainly a trend toward high-density and automated mapping systems. Epicardial access for mapping and ablation is increasingly being used for complex cases. Newer technologies that can speed up procedures and deliver similar efficacy are being adopted, such as cryoballoon for AF.
How does your lab handle device recalls?
Recalls are managed through our supply chain coordinators.
How is outpatient cardiac monitoring managed?
Our Heart Station, which is directed by Gaurav Upadhyay, MD, manages Holters, ECGs, and event recorders.
Is your EP lab currently involved in clinical research studies? Which ones?
We are currently the U.S. principal investigator site for MAGNETIC-VT, which is a multicenter trial comparing magnetic vs manual ablation of post-infarct VT. We are also the principal site for His-SYNC, which is a multicenter study evaluating the role of His bundle pacing versus a standard LV lead for resynchronization. We have been very active in trials for the subcutaneous ICD (PRAETORIAN and UNTOUCHED), and have also enrolled in the TRUE HD Study of high-density mapping using the Rhythmia mapping system.
Are you ACGME-approved for EP training? What are your thoughts on two-year EP programs?
We are ACGME-approved program, and on average, have 2-3 fellows. We look forward to expanding to 4 fellows once the EP program moves to two years. An extension of the fellowship will allow our trainees more time to complete research projects and develop skills in more complex procedures, including extraction and epicardial VT ablation. There is a tradeoff whereby many candidates may be dissuaded from pursuing additional years of training, and this may hinder the recruitment process.
Does your hospital offer a cardiac device support group for patients?
We have a specialized device clinic with two experienced nurses that spend time with our device patients.
Describe your city or general regional area. How is it unique from the rest of the U.S.?
Chicago, the third largest city in the U.S., is a metropolitan city located on the south side of Chicago. We are a medium-size program due to the presence of other academic institutions in the city.
Please tell our readers what you consider special about your EP lab and staff.
The electrophysiology labs at University of Chicago Medicine are part of the nationally recognized Heart and Vascular Center. The program has recently grown from 2 EP suites to 3 with the September opening of our state-of-the-art Arrhythmia Technology Suite, located in the Mitchell Hospital and adjacent to the Center for Care and Discovery on the main campus. In addition, we also perform minimally invasive robotic-assisted epicardial and endocardial procedures in the hybrid OR.
Dr. Tung envisioned the Arrhythmia Technology Suite to look like an “EP Lab of the Future,” housing not only the latest electrophysiological technology, but also providing an inspiring atmosphere to treat patients and conduct clinical research. Many architectural elements in the Arrhythmia Technology Suite, such as glass and light, were intended to simulate daylight, elicit hope, and illuminate and inspire dreams of the future. Visual enhancements, such as glowing lightboxes, horizontal inset LED light fixtures creating dynamic wall accents, custom floor-to-ceiling leaded glass observation windows allowing transparency and visual connection throughout the suite, and high-end finishes, capture the spirit of Dr. Tung’s vision and elicit a warm and comfortable space unlike any other for our patients. This new suite is equipped with 3 mapping systems, robotic magnetic navigation technology, and a glass-enclosed viewing room for observation, demonstration, and learning. Full integration of physiologic, imaging, and mapping systems is achieved through a flat-panel VantageView monitor (St. Jude Medical). We anticipate a steady growth of patients as our healthcare network expands.
We are very excited about the growth of our facilities, faculty, and lab staff. The future is very bright at the Center for Arrhythmia Care at University of Chicago Medicine.