Spotlight Interview: Via Christi Regional Medical Center

Nita Bugner, RN, IBHRE Certification AP/EP Wichita, Kansas
Nita Bugner, RN, IBHRE Certification AP/EP Wichita, Kansas
What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab? We have one EP lab, with a second under construction, and two procedure rooms. We have nine staff members and a working supervisor. There are seven full-time and two part-time staff members, with one PRN staff member who helps out with vacations and time off. Two of our staff are IBHRE-certified in EP. In total, we have seven RNs, two LPNs and one RT. When was the EP lab started at your institution? We started in 1984 in a small room at the end of the ICU. In the beginning, we used reams and reams of paper on the VR 16. Only the older EP people will remember that huge machine! In 1992, we became a dedicated EP lab and continue to be so today. One of our employees who worked in the EP lab in 1984 is still working with us. What types of procedures are performed at your facility? We do adult and pediatric cases. We are trying to treat patients who are eight years of age and older for now, as pediatrics is relatively new to the staff. Our pediatric EP, Dr. Mohamad K. Al-Ahdab, joined the lab 20 months ago, and he and Dr. Sambit Mondal have been teaming up for complicated pediatric and adult EP cases. Both Dr. Dhaval R. Parikh and Dr. Vuy H. Li are new to our lab and are just starting to do cases. Our lab currently performs all ablations — ranging from the simple to the very complex. We also implant devices, including loop recorders, ICDs, BiV ICDs, and PPMs, and perform laser lead extractions. In addition, we perform DCCVs, TEEs, and TTTs. Our Atrial Fibrillation Program does 8–10 procedures a month. Our lab also treats adults with complex congenital heart defects. Approximately how many are performed each week? What complications do you find during these procedures? Our EP lab performs 10–12 ablations and 12–15 device implants per week; added to that are the TTT, TEEs and DCCVs. Our complication rate is less than 1 percent. What is the primary goal of your program? Our primary goal is always to help the patient in the best way possible. We are moving forward in the community by establishing ourselves as the primary state-of-the-art facility to have EP procedures for both adults and pediatrics. We have the largest and most experienced lab within the area for most of the state of Kansas. We are also the first in Kansas to have a cryoablation system. Who manages your EP lab? Our day-to-day manager is Nita Bugner, RN, who has been instrumental in the success of the lab. She is responsible for the daily activities as well as working on cases. Deanna Buford is the manager of CV diagnostics, which includes the EP lab, HCL, and the noninvasive side of cardiology. Are employees from the EP and cath labs cross-trained? The EP lab is a separate department from the cath lab; however, we are under the umbrella of Cardiovascular Diagnostic Services. Therefore, employees are cross-trained enough to help with circulating and sedation of routine cases. The cath lab is also located next door to the EP lab, so frequently, when one department is busy, the other can assist. Do you have cross training inside the EP lab? Our goal is to have everyone able to move around the room, serving in various positions. Specific staff are considered “system experts” and work hard to cross-train the remaining staff to these positions. Management has been very generous about letting everyone fall into their “corner of knowledge” in the EP lab, and everyone is valued for the skills and knowledge they bring to the lab. Currently Todd Klausmeyer and Neal Hanson are able to operate the 3-D mapping system independently for all of our cases. This is something we are all very proud of, as we are the only hospital within the state that can boast this! What are the regulations in your state? The most stringent regulation is that RTs and LPNs cannot administer medications for sedation. What new equipment, devices and/or products have been introduced at your lab lately? We recently added a cryoablation system by CryoCath Technologies Inc. Within the last three years we have exploded with new technology in all areas of EP, including Biosense Webster’s Stockert generator and ThermoCool system, Boston Scientific’s Chilli™ catheter, and Medtronic’s Atakr® II RF ablation system. We have also added AcuNav for ICE procedures, EnSite for 3-D mapping, and laser lead extraction by Spectranetics. How has this new technology changed the way you perform procedures? At first it was a huge learning curve for the staff — it seemed we had to move equipment for each case we did, because of all the options and types of procedures. However, the staff has done a tremendous job with all the new technology. Who handles your procedure scheduling? Do you use particular software? We do not use any particular software. A staff person handles the scheduling each day. Our physicians have different clinic days, so that also helps with outpatient scheduling. What type of quality control/quality assurance measures are practiced in your EP lab? We have a paper checklist of QA issues that are monitored on all patients. We also keep a radiation log for all fluoro times. Once each quarter, we meet with staff and physicians to review. If there is a trend, we address it at these meetings. How is inventory managed for your EP lab? Our current inventory system is mostly by counting, while maintaining a par level of supplies. Our supervisor orders most supplies on a daily basis. Who handles the purchasing of equipment and supplies? Our manager does a lot of the major equipment purchasing with input and research from other areas. Has your EP lab recently expanded in size and patient volume? Describe your plans for expansion in the near future. Our volumes have doubled and almost tripled in the last year, especially with the addition of two new EPs to the area. We are adding another complete EP room now and soon will have another device room. We do almost all of the EP procedures (business) in the Wichita area. How has managed care affected your EP lab and the care it provides patients? Within the EP lab we have not felt a lot of change with managed care. We continue to see a busy patient schedule. (Our patients are required to be admitted the morning of the procedure instead of the night before.) Have you developed a referral base? Most of the patients in the region are referred to various EPs in Wichita who in turn prefer to use our lab. What measures has your EP lab implemented in order to cut or contain costs? We are constantly looking for ways to cut costs, as they always seem to be rising. We reprocess diagnostic catheters, buy in bulk for a lower price, and buy catheters from a Web company that sells items from other institutions that are no longer using a particular piece of equipment. We have also negotiated for a dual-vendor contract on devices to keep costs down. In what ways have you improved efficiencies in patient through-put? We are always working very closely with the Admissions Department and Express Admit Unit, which admits early morning patients and gets them to the surgical areas promptly without burdening staff nurses at the beginning of their shift. Does your EP lab compete for patients? At present, there is very little competition in the area. Our lab is considered the best in town, with a full line of technology required in today’s EP world as well as very knowledgeable staff. What procedures do you perform on an outpatient basis? Roughly 70 percent of our EP patients are considered outpatients, and 30 percent of device patients are outpatients. How are new employees oriented and trained at your facility? After new employees complete the hospital’s general orientation, we have a clinical nurse specialist who assists with a lot of basic cardiology training. When employees start in the EP lab, they are usually given about six months of training. We try to get them to several classes from the various vendors within the first year. Most of the training is done on the job with different staff, depending on the tasks. Our physicians are also really great about providing education to the staff. What types of continuing education opportunities are provided to staff members? We send some staff to the Heart Rhythm meeting every year, and we take advantage of the opportunities provided by our vendors. We also use online resources, and staff within the EP lab give presentations to others on specific topics. How is staff competency evaluated? We have an annual in-service training day to complete, which is tailored to the area that you work in. Our supervisor also monitors procedures, audits charts, does follow-up and provides feedback to the staff on a regular basis. How do you prevent staff burnout? In addition, do you practice any team-building exercises? We are open enough with each other to share when someone needs to change their specialty roles. For example, after a few long days of scrubbing, someone else might take over for a while. The staff has scheduled late days each week so they can be assured that they are able to leave on time the other days. We are also huge believers in family time and try to honor that when someone needs time off for personal reasons. We have monthly luncheons to celebrate birthdays or babies. We get together after work sometimes just to hang out; this helps a lot. Overall, the staff is a terrific bunch and we have a lot of fun in the lab. What committees, if any, are staff members asked to serve on in your lab? Some committees include Safety, Code Team, and Ambassadors. If a staff member has a strong interest in serving on a committee, I encourage it, to assist with their professional growth. Do you contract with vendors? How do you handle vendor visits to your department? Yes. All vendors must check in with Purchasing prior to visiting us. Most of our usual vendors are really great about contacting us to see if they can drop by. The exception is the device representatives, who are required to be present for each implant. Does your lab utilize any alternative therapies to help patients in the EP lab? Pediatric patients are encouraged to bring their iPods to listen to during their procedure. Describe a particularly memorable or bizarre case that has come through your EP lab. What lessons did you learn from it? On a routine office visit for a sore throat, a nine-year-old girl was noted to have “an irregular heartbeat.” Her primary care physician performed a 12-lead EKG, which showed multiple runs of VT. She was referred to our pediatric electrophysiologist, who completed a Holter recording that showed sustained runs of VT up to 50 percent of her rhythm, and more excitable with exercise. She had septal RVOT VT and underwent radiofrequency catheter ablation using NavX with merge with MRI study. It was amazing to see how, post ablation, VT had completely suppressed with no recurrence, and at one-year follow-up showed no recurrence. However, many of our patients are memorable to the staff for a variety of reasons. How does your lab handle call time for staff members? How often is each staff member on call? How frequently do they have to come in, on average? Is there a particular mix of credentials needed for each call team? Three people each day (with a mix of credentials) are scheduled for late nights. Those staff members stay until the cases are completed. Two staff members are on call each weekend day from 7 a.m. to 7 p.m. for devices, averaging about one callback every 5–6 weeks. Does your lab use a third party for reprocessing? Yes, this has just been revisited and, so far, seems to be going well. We currently reprocess only our diagnostic catheters. Approximately what percentage of your ablation procedures are done with cryo? What percentage is done with radiofrequency? About 10 percent of cases are done with cryo. We are just starting cryoablation procedures with Dr. Mohamad Al-Ahdab for children and adolescent patients with AVNRT and septal accessory pathways. Most of the other ablations are done with Boston Scientific’s Chilli system. Our physicians prefer this for atrial fibrillation or atrial flutter cases. The remaining 40 percent or so are radiofrequency. What measures has your lab taken to minimize radiation exposure to physicians and staff? We track all radiation doses and have set limits of exposure. The staff and physicians must complete a form if we go outside these limits. Do your nurses/techs participate in the follow up of pacemakers and ICDs? How many of your ICD/pacemaker patients require a doctor for their visits? Via Christi does not have a device clinic, so all patients must follow up with their doctors. What trends do you see emerging in the practice of electrophysiology? How is your lab preparing for these future changes? Cardiologists are realizing the benefit of ablation as a first line of treatment, so referrals are made sooner. The amount of AF ablations that we are doing is going through the roof. Our hospital is the only one within the area to do this in the EP lab. To date, we have a very successful program. What are your thoughts about non-EPs implanting ICDs? Do you train such individuals? Because of prior need in the community and recent HRS modification to requirements, many of the cardiologists in town implant ICD and CRT devices. The lab was part of the training of some of the cardiologists who are now fully independent in such implants. However, there is more pushback now from HRS and the EP community to limit this to EP-only docs if possible and available, especially in complicated procedures with marginal safety zones. What about device recalls? The device recalls that have happened have all been handled very professionally and quickly by both Via Christi and the vendors. Purchasing is made aware immediately, as well as the patients. Is your lab doing Web-based/transtelephonic device follow-up? No. Is your EP lab currently involved in any clinical research studies or special projects? We are not currently involved in any projects. When was your last inspection by the Joint Commission? Our last inspection was two years ago, with great results. Are you ACGME-approved for EP training? What do you think about two-year EP programs? No, but some physicians are leaning toward becoming a training site for fellows. That would be a first in Wichita. Does your staff provide any educational materials for patients who may have additional questions about their condition/procedure? In addition, does your hospital or lab staff have a device support group? We have printed information available when needed, and the staff constantly ensures the patient understands what is happening as the procedure progresses. We had an ICD support group, but realized there was a much larger population who were in need of a group. In an effort to reach more patients, we have blended that group into a local chapter of Mended Hearts, which is part of a citywide collaborative among all hospitals in Wichita. The EP staff happily volunteers their time and knowledge at the meetings as requested. We also provide discharge teaching in writing to all device patients, and we often field phone calls with questions about devices, limitations and airport security issues. Give an example of a difficult problem or challenge your lab has faced. How it was addressed? Our biggest challenge is growing volumes! It is a nice challenge to have. We have scheduling issues with getting general anesthesia to cover complex cases. Everyone came together to collaborate. In the end, we are doing anesthesia cases on certain days each week, and have strongly encouraged our physicians to arrive for a prompt case start time. Describe your city or general regional area. How does it differ from the rest of the U.S.? Wichita is located in the south central portion of Kansas. Our city is the largest in the state. We have a tremendous amount of patients from western Kansas, which is primarily an agricultural region. Please tell our readers what you consider unique or innovative about your EP lab and staff. We are most proud of our longevity of staff at Via Christi, as seen in the EP lab. We continue to deliver quality, professional and caring service to our patients. In today’s fast-paced, ever-changing business world, this is a rare commodity. I can truly say that after 20 years of service, I continue to be proud to be part of our core mission: (Matthew 25:40) “Whatsoever you do to the least of my brothers and sisters, you do to me.” We would also like to include a notable quote from our pediatric EP, Dr. Al-Ahdab, who said, “I think what strikes me most is the amount of personal growth and professional skills that I have encountered in our EP staff since I have joined the lab. They were able to adapt very well to the needs of the pediatric population and show patience and a willingness to learn more. There is a real team spirit around, and no one is shy about expressing their opinions and feedback between the EP staff and the EP docs.”