Clinical cardiac electrophysiology services are the fastest growing branch of cardiology. A lot of hospitals and private groups are looking to establish this service or expand it. Invariably, they look to hire fresh new graduates who are well trained in device implantation as well as in simple and complex ablations. Often the newly hired electrophysiologist is asked to establish this service in a place that never provided it, or to expand the ablation services to include complex ablations (such as atrial fibrillation ablation as well as ventricular tachycardia ablation) that were not provided before. This task is not easy, but it is doable. In this article I will share some of the advice I was given by my mentors and colleagues, as well as share some of my personal experience in establishing a new electrophysiology laboratory in a hospital that previously did not offer electrophysiology services.
In establishing any new electrophysiology lab, there are four variables that need to be considered. The first is having and ensuring the support of the hospital or group administration. The second is the physical aspect; for example, you need to assess what type of equipment is available and what type of new equipment is needed. The third variable is training the staff, who are usually nurses or technicians from the intensive care unit, the cath lab or at times from the emergency department or telemetry units, and have never had exposure to electrophysiology procedures. Finally, the fourth aspect is the flow of the cases in the lab, and how things progress in day-to-day operations. More details about these four variables are described below.
Consideration #1: Support
The first aspect is to have support of the hospital administration and/or physician group. This is of great importance, not only because the electrophysiologist will have to ask the hospital administration to buy the equipment for the lab, but also because you want to ensure that the administration and physician groups understand that training the staff takes time, so things will be slow in the beginning, and procedures might be longer initially than they usually are. In addition, you might want to consider sending some members of the new EP lab staff for training courses. The device or mapping companies provide some of these courses, and allied professional courses are also available through societies such as the Heart Rhythm Society. This all will take time and add to the cost of starting a new program.
Consideration #2: Equipment
The second aspect is choosing and buying the equipment for the lab. I personally think that while it is important to get the latest technology, it is equally important to choose the equipment that the electrophysiologist is most familiar with. So if the electrophysiologist is a fresh graduate, it would be wise to ensure that he or she choose a mapping system, recording system and stimulator that they are comfortable with. This way they can help teach the staff and minimize the unknown variables during the case. The last thing you want to happen is to start learning the strengths and weaknesses of a mapping or recording system in the middle of a case, with new staff and support personnel who you’ve never dealt with.
Consideration #3: Training
The third aspect is staff training. This is a long process that takes time and needs plenty of patience. To ensure that this aspect is smooth and successful, it is vital to hire a nurse or technician who has excellent EP lab experience to help train the lab staff. This is of paramount importance. The electrophysiologist will not always be available to train the staff, often because he or she will have clinic and call responsibilities. Furthermore, during the procedures, a lot of things might come up and the new staff might get easily overwhelmed. The presence of an experienced EP nurse or technician will help make the procedures safer, smoother and teach the fresh staff how to troubleshoot and solve different problems, from simple things like placing the magnetic patches or the grounding pads, to more sophisticated problems dealing with connections between the stimulator, the recording system and the mapping system.
In training the staff, the electrophysiologist will need to make sure that the staff has heavy exposure to him or her in the beginning. Weekly or bimonthly lectures that are simple and clarify the fundamentals of lab setup for certain cases, the fundamentals of pacing, the setup for defibrillation and the golden rules when it comes to ablation, are important. Furthermore, it is important to start with simple ablations, like right-sided atrial flutter ablations and supraventricular tachycardia ablations (especially atrioventricular nodal reentry). Even though these cases might not take a long time, it is important to have the case load light but constant in the beginning to ensure patient safety and to spend time teaching the staff. A steady case load will make certain that they will see the procedures time and time again. With each case, it is important to take time (even as little as 5 to 10 minutes) before the case to explain the procedure to the staff in a nutshell, and spend some time after the case (again, even as little as 5 to 10 minutes) to explain what happened during the case, point out the good things the staff did, the things they need to work on and teach staff a simple concept with each case. This way the staff will feel they are part of the team and will receive good feedback. Finally, it is important to emphasize to the staff that it will take them time before they feel fully comfortable, and the more cases they see and do, the more they will learn and grow.
Consideration #4: Flow
There are other reasons to start with simple cases, and this brings us to our final point about the flow of cases in the lab. These reasons include knowing the support staff from the mapping system and device companies. It is important to get to know the strengths and weaknesses of the support staff before starting to do complex cases. Furthermore, the new electrophysiologist will want to establish a good reputation and get good outcomes before starting on complex cases. There is nothing more damaging than having a bad outcome while starting a new service line. Therefore, it is important to start slow, with simple cases, get good outcomes, and build up a good reputation, so the physicians in the community, the staff in the lab as well as the hospital administration will all gain confidence with the electrophysiologist.
These are just some of the things I have learned from my mentors and colleagues as well as from my own personal experience. When we established the new electrophysiology service at Cheyenne Regional Medical Center, there were no EP services provided in Cheyenne prior to July 2009. I hired an experienced lab technician to help train the staff, set up the equipment and help establish the protocols for the cases. I chose the equipment that I was most familiar with, and since I trained on the Carto system, I chose the latest version (Carto 3, Biosense Webster, Inc.). We initially didn’t have a biplane fluoroscopy, so I learned to do all my cases with a uniplane system. We started with simple ablations such as cavotricuspid isthmus-dependent atrial flutter ablations as well as supraventricular tachycardia ablations. Within six months, we performed the first atrial fibrillation ablation in the state of Wyoming. We then started doing more complex cases, and did our first ischemic VT ablation in 10 months. We had a new physical EP lab built, which was operational on January 18th, 2011. We celebrated our 100th ablation case last month. This was done with the support of the administration and physicians, and with the help of an experienced EP technician and experienced EP nurse.
Of course there are no rigid rules as to when to do a complex ablation, but in my opinion it is important to take your time, build up a good reputation, and establish safety. Once you feel comfortable with your lab staff and supporting staff personnel, then you can perform complex ablations without exposing the patient to unnecessary risks.