Time to Transition
Electrophysiology has made significant advances over the past 20 years. Today, we are capable of performing therapy over a broader range of diagnoses with a higher degree of safety and efficacy, which has made electrophysiology one of the most essential disciplines in cardiology. The transcendence of electrophysiology as a conventional form of therapy has not only led to further advances in technologies and therapeutic options, but has also facilitated advances in innovative clinical practice. As technology continues to rapidly advance, there is an unspoken, and oftentimes underappreciated value of core staff competency that continues to evolve clinical practice at the rate of technological advancement. While facilities may struggle for time and resources, the expertise involved in these procedures can easily be outsourced to vendors, as this minimally impacts processes in an EP setting. Consequently, there is a justifiable concern regarding the sustainability of the skill and competency of core staff who are essentially the ones tasked to uphold the quality and integrity of the services provided. Ultimately, these factors may lead to an imminent loss of electrophysiology as a true art form, to be championed by core staff and institution in the future as EP technology continues to progress at a rapid pace.
John C. Lincoln Medical Center, formerly known as John C. Lincoln North Mountain Hospital, has endeavored to address this challenge head on. Over the years, we have attempted to achieve a balance by instituting groundbreaking technology while also establishing an inclusive environment between professional disciplines, such as registered nurses (RNs) and radiologic technologists (RTs), within the cath/EP lab. We face the same challenges as other hospital systems to keep up with the demands of emerging technologies and market competition, gain and sustain professional partnerships with key stakeholders, manage financial impacts, and most importantly, ensure outcome and satisfaction. We have implemented breakthrough technologies such as MediGuide Technology and the CardioMEMS HF System (St. Jude Medical) that have led to significant changes in how we practice electrophysiology. For instance, the premise of MediGuide revolves around a minimal fluoroscopy application for routine and complex ablations as well as device implants. Incorporating a system that promotes minimal fluoroscopy in a discipline that champions some of the highest skilled RTs was a difficult concept to promote, and could have easily raised fears regarding the future of this profession in an EP environment that continues to evolve into a minimal fluoroscopy concept. The implementation of these new technologies gave opportunity for core cath/EP staff to reassess their current roles of clinical practice and embrace new roles by adopting new competencies.
To date, we are performing atrial fibrillation ablations with zero fluoroscopy and implanting new biventricular devices in as low as 1.6 minutes of fluoroscopy, collectively reducing our radiation dependency in EP by a combined 90% (100% for ablation procedures). Our RNs and RTs have embraced this idea, and have made significant strides to update their skills in EP studies and device implants. We cross-train interested clinical staff to be experts in EP setup, maintenance, and the operation of the 3D mapping systems (e.g., Biosense Webster’s Carto system, and St. Jude Medical’s MediGuide and EnSite Velocity Systems), the EP recording system and stimulator (e.g., St. Jude Medical’s EP-WorkMate and EP-4), and intracardiac echo systems (Zonare [St. Jude Medical] and the ACUSON Cypress cardiovascular system [Siemens]). In this model, physicians work synergistically with the team during routine and complex EP studies in a manner that illustrates a peer-to-peer interaction, rather than a subordinated one. This requires a great deal of mutual trust; therefore, a collaborative team-based approach is established to ensure the best therapy is being delivered and in a timely manner.
During times of great transition, there is significant value in maintaining the philosophy of fostering growth for all disciplines with new, innovative opportunities. The goal in EP services is to become an autonomous program, in which quality ownership belongs to the core team. This philosophy incorporates a top-down and bottom-up approach in which program leaders institute a vision of excellence that is progressive, transparent, and clearly defined in its purpose. The cath/EP staff is considered an intricate piece of this model, and their professional growth and expertise are vigorously supported in educational opportunities, mentorship, and feedback. This model was developed to give ownership of quality to those whom are direct representatives of institutional core measures in quality, outcome, efficacy, and patient satisfaction. This ensures that quality of care is owned and directed by the institutional stakeholders, and does not promote a clinical disconnect that may be seen from outsourced specializations.
Core Specialization Vs. Outsourcing
Technological trends in EP are shifting rapidly. Today, trends are moving at a much faster pace, and EP programs struggle to develop competent, specialized core staff to autonomously perform these procedures without clinical representative (rep) support. Therefore, this requires much of the specialization to be outsourced to clinical reps while core staff members perform basic procedural duties such as interprocedural documentation, circulating, and radiographic duties. Specialized duties such as 3D mapping and use of the MediGuide, CardioMEMS, and Stereotaxis technologies, etc., are just some of the areas in which specialization is outsourced. Outsourcing can ensure that trained experts in the field perform the skill required to effectively deliver a desired therapy to achieve the best outcome possible. In this model, there is minimal opportunity in which the staff fully engages the EP portion of the study, and their roles are typically absent of participation in recording and/or mapping routine and complex cases. Unfortunately, this model is relatively typical in the EP environment and presents concerns over the future state of electrophysiology as it relates to core staff expertise and the long-term integrity of that state.
The philosophy from companies has historically been to offer training and support to site staff, with the intent to develop competency in each respective site. However, site autonomy in regards to specialized technologies and techniques has been much more difficult to achieve, and has required these procedures to be supported by the vendors rather than by core staff. This is due to factors such as (but not limited to): limited department budgets for staffing and training, lack of interest and buy-in, and lack of monetary compensation for demonstrating competency and acquiring more clinical accountabilities. Without an incentive-based program, core staff that excels in the technology and science of EP is often lost to or acquired by these companies that can offer more competitive salaries and personal benefits. To mitigate this, hospitals and hospital systems must regard electrophysiology as a specialized discipline that requires specialized resources while also advocating for core staff to represent the overall product within a service line.
Today, it seems the philosophy of the companies that support electrophysiology and other specialized procedures has shifted to a more progressive model in which there is greater reliance on their expertise. Since it is becoming more difficult to achieve autonomy in these specializations and there is competition for product utilization, there is also opportunity for companies to establish more “face time” and develop stronger partnerships with both sites and physicians. Providing their own clinical reps to perform specialized procedures can prove to be a valid and sustainable option for an EP program, since it gives electrophysiologists easy access to trained professionals and offers supporting vendors continuous access to both physicians and the clinical site. This strategy unlikely affects patient care from an outcome perspective, and it would be overly critical to assume that any program would willingly conduct services that put patients at risk. However, let us explore the implication(s) that this concept could impose on an electrophysiology program and staff expertise, and why the patient experience should be closely evaluated when EP specialization is primarily outsourced.
The Strength Is In Your Core
It takes a certain group dynamic to achieve this high level of excellence from your core staff to work synergistically with program leaders and physicians. It starts from the leadership down and from the staff up, in which continuous feedback and program development opportunities are openly discussed and executed. This fluid model of teamwork from RNs, RTs, leadership, and physicians encourages autonomy, professional growth, and teamwork within each scope of practice. Leadership provides multiple educational opportunities and training (such as HRS conferences and vendor site visit training), and actively participates in training and competencies as well. We strive for physician buy-in to partner with us on this same venture, which has thus far resulted in positive feedback and generated a closer staff/physician association in providing optimal care.
Deborah Williams, RN, BSN, CEPS, Supervisor of the Cath/EP department at John C. Lincoln Medical Center, supports this concept by stating: “By empowering the core staff to excel in what they do, it provides them with a sense of ownership into the cardiac program and the services we provide. By coming alongside them, it is important to inspire a vision that will encourage them, challenge them, and create opportunities to succeed, as well as learn from the shortcomings. This provides core staff with a personal satisfaction, professional gain, and a desire to be a part of something bigger and marketable. In turn, the core staff, which represent the face of the cath/EP lab, have a huge impact on improving patient outcomes and experiences! It becomes a win-win situation.”
Staff empowerment is the essence of producing high engagement and participation in personal, professional, and program growth. Providing incentives for the staff to pursue innovative practice will not only strengthen the team, but also elicit active participation in the direction of the program as well as the inherent support of the facility’s mission, vision, and values. The patient experience requires more than professional conduct and innovative tools. It requires absolute ownership from clinicians to stand by the quality of their own performance(s) and brand themselves as a team that encompasses all attributes to the patient’s overall outcome. This ownership to the patient’s experience is not primarily achieved by external vendor support, and therefore, is conceptually paradoxical for an EP team to stand by the quality of a skillset they did not provide. The quality of the core staff is a reflection of their work, and the consistency of their work in regards to outcomes and expertise is a reflection of their brand, or rather how they are regarded within the EP community as well as the community of patients served. Deborah adds: “In my opinion, a new technology in and of itself cannot produce the same results in many respects as compared to a clinically competent core team that can stand behind it and accentuate the outcomes.”
Hospital systems across the country have a particular focus on branding. A brand is an embodiment of all things essential to one’s existence summarized in one statement (or symbol). The brand of a hospital network may be in the name, which is intended to be a primary identifier of quality, excellence, integrity, etc., to be recognized by both internal and external forces. Under the umbrella of the network brand, each hospital or affiliated facility is tasked with upholding this brand and emulating the mission, vision, and values of the brand into all forms of operation, all the way to the department level. Although this structure seems rather straightforward, not all hospitals, facilities, or departments within a network operate the same, have similar reputations of excellence, or produce equivalent qualities of care.
Electrophysiology labs act in very similar fashions. In a hospital system, it is not uncommon to have EP labs that are operationally, structurally, and conceptually different. While each department still operates under similar network brands and mission, vision, and values, there still exists a difference in quality, competency, and innovative practice. One of the more overlooked and undervalued properties of these differences is found in the brand of the EP lab in each respective facility. Much like a network brand, the brand of an EP department is also a culmination of critical identifying features of quality, efficiency, competency, and outcome as it relates to patient care and experience. An EP department that encompasses attributes of excellence in the form of autonomy, competency, and commitment will reflect those qualities in their work and then create a brand of excellence that can be acknowledged by the community served. The reward of this brand is a direct reflection of the commitment to empower the program to not limit itself to recruiting strong electrophysiologists and implementing new technologies, but to strive for developing a strong core staff that works synergistically and interactively with physicians, expresses competency with the technologies, and most importantly, creates a culture of excellence as the expectation.
Mark Seifert, MD, FACC, FHRS, Medical Director of Electrophysiology at John C. Lincoln Medical Center, expresses the importance of this brand and what it means for the future state of EP: “At John C. Lincoln Medical Center, the cath/EP lab director, physicians, and staff jointly created a cooperative environment that not only fosters teamwork, but also nurtures team growth. Inherent in the model is having the team not only autonomously operate innovation, but also participate in innovation. More so than in any other specialization, the team is a major component of both program and procedural success. It is essential for the future of EP programs to strive to lessen their dependency from vendor specialization as this will hamper growth and development, making autonomy more difficult to achieve. The future state of EP labs lie in the strength and development of the team and the ability to effectively demonstrate excellence in a cooperative environment.”
Final Thoughts and Acknowledgments
Electrophysiology is a rapidly growing discipline in which new and innovative technologies and techniques continue to transition the world of cardiology. Along with this rapid shift, there is also a corresponding demand to acquire core competencies with this change in order to best equip core EP staff for becoming proficient and autonomous. There are many challenges that prevent EP programs from reasonably accomplishing this as the current state of EP has trended to and developed a comfort for vendor support, lessening opportunity for core staff growth, development, and engagement into a program.
The cath/EP lab at John C. Lincoln Medical Center has faced, and is continuously striving to overcome, many of these challenges to become clinically efficient and autonomous in the EP lab. The focus on strengthening the core staff allows for a more dynamic team-based approach to innovation and patient care, while also incorporating excellence in EP fundamentals. These features of a team-based approach and competency yield a solid foundation for future growth and sustain a department brand of excellence within our network and community. The reputability of our services is key to our growth, and is essential in a competitive marketplace that demands quality and the delivery of care at the highest standard. We feel that the key to success and the future state of EP relies heavily on the growth and development of the core staff and synergistic partnerships with all stakeholders within the EP program. The essence of electrophysiology does not call for more electrophysiologists in the field, but rather the attainment of more clinical expertise within core staff to have active contribution in shaping the future of electrophysiology.
Acknowledgements. A special regards to Deborah Williams, RN, BSN, CEPS for her excellence in leadership and continued expertise in our electrophysiology program. We’d also like to acknowledge Mark Seifert, MD, FACC, FHRS and Mayur Bhakta, MD for all of their support, partnership, and commitment to excellence at John C. Lincoln Medical Center. Lastly, to our staff: all of our successes are because of you. Your hard work and dedication to the program are truly inspirational to anyone who has had the privilege to watch you in action. Your valued commitment to our patients, physicians, and each other is reflected in your work, and recognized in your brand. All things became possible because you dared to believe, you strived to achieve, and you endured countless challenges that got you where you are today. Congratulations on all of your successes and future ventures, as you are not only experts in your craft, but also pioneers in your field.
Disclosures: The authors have no conflicts of interest to report regarding the content herein.