Spotlight Interview: University of Pennsylvania (Penn Presbyterian Medical Center)

Fiorenzo Bendotti, RN, Philadelphia, Pennsylvania

Fiorenzo Bendotti, RN, Philadelphia, Pennsylvania

What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab? Our campus includes two EP labs and a dedicated procedure room. There are 12 attending electrophysiologists and 11 EP fellows that practice at three different campuses. (There are a combined total of six EP laboratories). Our lab staff includes seven RNs and one CVT. There are four PAs that also work with our group at our current facility. When was the EP lab started at your institution? The EP lab was started in the early 1990s. What types of procedures are performed at your facility? Procedures include device implants (ICDs, pacemakers, Bi-V ICD/PPM), lead extractions, loop recorders, tilt table testing, EP studies, and ablations (which include SVT, atrial tachycardia, atrial flutter, inappropriate sinus tachycardia, pulmonary vein isolation for atrial fibrillation [AF], complex VT, and accessory pathways). We feature a comprehensive state-of-the-art electrophysiology program. Approximately how many are performed each week? What complications do you find during these procedures? We perform approximately four atrial fibrillation ablations per week at our campus. We also perform other ablations, implants, and procedures throughout the week. Most of the complications are self-limiting. The most common complications we encounter are usually groin complications (e.g., hematoma or AV fistula). These complications are probably due to access difficulty and/or relatively high anticoagulation with left heart procedures. I have been involved in more than 500 AF/PVI ablations. Complications that I have encountered include cardiac perforation (tamponade), anaphylaxis (due to medications), pulmonary edema, stroke, and heparin-induced priapism. Who manages your EP lab? Our lab is self-managed. Each individual has unique responsibilities. Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained? Our labs have been separate from the cath labs since 1997. There are several staff members that possess prior cath experience. Do you have cross training inside the EP lab? There is no requirement to be cross-trained. What new equipment, devices and/or products have been introduced at your lab lately? How has this changed the way you perform those procedures? Over the past year, we have switched to digital documentation via our Prucka-CardioLab system. Newer versions of 3-D cardiac mapping/navigation systems have been implemented. Stereotaxis automated 3-D mapping is currently scheduled for installation in 2007. Who handles your procedure scheduling? Do you use particular software? Procedure scheduling is a collaborative effort. Nursing staff, physicians, secretaries, and physician assistants all play a role in scheduling. We utilize customized proprietary scheduling software. What types of quality control/quality assurance measures are practiced in your EP lab? Daily QA data is collected and analyzed. Data is presented at QA meetings monthly. We are also an active participant in the national ACC-NCDR ICD Registry. How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? There is a Cath/EP Lab Inventory manager who assists with ordering of supplies; a few of the nurses also participate. Ordering is placed through our central Lawson order acquisition database. Inventory count is done manually. Bar code scanners are available, but have not been implemented as of yet. Has your EP lab recently expanded in size and patient volume, or will it be in the near future? Our EP program continues to grow in size and patient volume. We are constantly challenged by the most complex ablations. Many of our referrals come from other electrophysiologists. Our EP program is planning to consolidate its practice from three campuses to two. The ultimate goal is to enhance our region by providing a state-of-the-art Electrophysiology Center of Excellence. There will be five electrophysiology laboratories at the main campus (University of Pennsylvania), and one laboratory at the Veterans Administration Hospital of Philadelphia. Have you developed a referral base? The referral base continues to grow. Each doctor has their own referral base that they brought with them when they joined the group. We also receive referrals from the tri-state area, which includes Pennsylvania, New Jersey, and Delaware. In addition, we receive referrals that are nationwide. Does your EP lab compete for patients? Has your institution formed an alliance with others in the area? There is a high concentration of EP labs in the Philadelphia area. The doctors that we work with have strong referral bases. Patients also travel here from various parts of the country; in fact, many times we will get patient cases that are considered to be technically challenging by other electrophysiologists. What procedures do you perform on an outpatient basis? Procedures we perform on an outpatient basis include generator changes, loop recorders, tilt table studies, baseline electrophysiology testing, IV drug infusion studies (e.g., total autonomic blockade), TEE cardioversions, and ICD DFT testing. How are new employees oriented and trained at your facility? What types of continuing education opportunities are provided to staff members? Nurses and techs are given opportunities to attend training classes sponsored by industry partnerships. Our university practice holds an annual state-of-the-art EP symposium that everyone attends. In addition, there is a lot of one-on-one training that is provided by senior staff. Our fellows have formal discussions during monthly case presentations with staff members. New product in-services are provided throughout the year. There are also opportunities for staff members to attend HRS meetings. How is staff competency evaluated? We implement annual competency evaluations of our nurses and techs. How do you prevent staff burnout? To prevent burnout, we encourage learning, allow self-scheduling, and permit lab staff to choose cases that they want to be involved in (if the schedule/staffing allows). We also try to rotate tasks as much as possible. We rotate our late shifts to be fair to each staff member. What committees, if any, are staff members asked to serve on in your lab? Committees include our QA committee and performance improvement committees. How do you handle vendor visits to your department? Do you contract with vendors? Vendor visits are by appointment. Contracts are aggressively negotiated throughout the health system. Does your lab utilize any alternative therapies? No. Please describe one of the more interesting or bizarre cases that have come through your EP lab. During a recent pulmonary vein isolation/AF ablation procedure, we imported CT images of our patient's heart into our CARTO XP mapping system. We were surprised to see an unusual left atrial/pulmonary venous anomaly. The left superior and inferior pulmonary veins were joined together with the right inferior pulmonary vein, creating a common ostium that measured about 30 mm. The right superior pulmonary vein had its own distinct ostium. Based on fluoroscopic images and intracardiac echocardiography, this anomaly would not have been visualized. This helps demonstrate the utility of advanced imaging and its application during catheter ablation procedures. How does your lab handle call time for staff members? There is no call. Does your lab use a third party for reprocessing? Yes. Approximately what percentage of your ablation procedures is done with cryo? What percentage is done with radiofrequency? Almost all of our cases are done with radiofrequency. For anything that is remotely close to the His bundle (e.g., parahisian atrial tachycardia), cryoablation will be used. We will sometimes use cryo for an extremely difficult AVNRT case. We have performed hundreds of AVNRT ablations here, and I have never seen permanent heart block due to RF ablation, though I have encountered this at other facilities I have previously worked at. Do you perform only adult EP procedures or do you also do pediatric cases? We perform adult cases only. Do your nurses/techs participate in the follow up of pacemakers and ICDs? Our physician assistants are responsible for follow up. There are nurses in the lab who also perform follow up (e.g., pre-ablation of patients that have devices, and during ICD checks). In addition, sometimes our nurses will go to the OR and do a device interrogation pre- or post-surgery. What trends do you see emerging in the practice of electrophysiology? How is your lab preparing for these future changes? Atrial fibrillation continues to be a growing problem. We are also seeing more challenging VT cases becoming common at our institution. Baseline EP studies seem to be a thing of the past since defibrillator implant criteria has changed. Our nurses must learn how to use newer equipment such as intracardiac echo, 3-D mapping, etc. What are your thoughts about non-EPs implanting ICDs? Do you train such individuals? We do not train those individuals. I believe that the device companies will do whatever it takes to sell more devices. Having non-EPs implant ICDs would absolutely benefit the device companies. However, I think the device companies will implement preset modes that will allow non-EPs to program the devices safely and effectively. I do believe that EPs are definitely more knowledgeable when it comes down to managing difficult patients. The question is, how will you know what patient will be the difficult one? As with any new changes, I think initially there may be some issues if non-EPs implant ICDs. As long as those issues are minor and are not life-threatening, I think we will see non-EPs implanting ICDs. However, I do not think this will happen soon. One of the things that will keep this from happening in the near future is the recent defibrillator recalls; these recalls have put the companies under the microscope as of late. Until this settles down, I don't expect any major changes from the device companies. What about device recalls? How has your lab handled these? We explanted certain devices. It has been very difficult situation for all of us. Patients today are more informed due to the abundance of media sources available. We carefully discuss the situation and options with patients and referring physicians. We try to answer as many questions as possible. We strictly adhere to the published guidelines. Some physicians avoid putting in devices that are from companies that have had major recalls; their rationale is that they can avoid dealing with the problem completely if they do not implant those devices. Many of the doctors also report spending most of their clinic time discussing the recent recalls. Spending time discussing the recalls can limit the time that physicians and patients can discuss their clinical issues. Is your lab doing web-based/transtelephonic device follow-up? Our lab doesn't; the associated outpatient clinic handles this. Is your EP lab currently involved in any clinical research studies or special projects? Yes. We are involved in multiple clinical trials. We also do extensive in-house research. When was your last JCAHO inspection? Our last inspection was about three years ago. Are you ACGME-approved for EP training? What do you think about two-year EP programs? Yes, we are ACGME-approved for EP training. I believe that EP fellowships should be a minimum of two years. Does your lab provide any educational or support programs for patients who may have additional questions or those who may be interested in support groups? Literature and other sources of information are provided at the outpatient clinics. Our lab does not handle this. However, we do provide pre- and post-procedure teaching to all of our patients. Give an example of a difficult problem or challenge your lab has faced. How it was addressed? Since we have one of the largest fellowship programs in the country, we are challenged yearly by the influx of new fellows that are accepted into the program. This poses a significant challenge to everyone. The cases are distributed relative to their complexity. The procedure times tend to be longer since the newer fellows are less experienced and require more time to become oriented. The attending physicians, senior fellows, and senior staff members respond by taking the initiative to provide assistance in training the first-year fellows.  Describe your city or general regional area. How does it differ from the rest of the U.S.? We are located in southeastern Pennsylvania. According to the U.S. census in 2000, the city of Philadelphia has a population greater than 1.5 million people. Philadelphia is part of the northeastern corridor, which includes large cities such as New York and Boston. The entire region is densely populated with EP programs. Please tell our readers what you consider unique or innovative about your EP lab and staff. Our program is the only electrophysiology program that has 12 EP attending physicians. It has become one of the largest EP fellowships in the world. Our philosophy is based on teamwork. Our current lab staff has worked together for many years. There has been relatively little turnover in our workforce. We stand committed to providing personalized, quality, and superior care to all of our patients. Each individual in our group possesses distinct personal and clinical qualities. When these qualities are combined as a whole, it makes for a perfect team.