LDS Hospital, Salt Lake City, Utah

Tom Foley, RCIS, NASPE/EP Testamur, Salt Lake City, Utah

Tom Foley, RCIS, NASPE/EP Testamur, Salt Lake City, Utah

What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab? There are two dedicated EP labs and one implant lab. Our EP staff is comprised of six electrophysiologists and a core group of six RNs and four RCISs, of which two are NASPE/EP Testamurs. We rotate four additional members from the cardiac staff as needed. The mix of credentials at our lab includes RNs, RTs, RCISs, NASPE/EP, NPs, and PAs.

When was the EP lab started at your institution? Our first His bundle recording was in 1972.

What types of procedures are performed at your facility? Procedures include EP studies (EPS) and ablation of any dysrrhythmia (including atrial fibrillation [AF], supraventricular tachycardia [SVT], ventricular tachycardia, and atrial flutter). We also perform pacemaker and ICD implants, including biventricular and laser lead extractions.

Approximately how many are performed each week? What complications do you find during these procedures? We perform approximately 15-20 EPS and ablations and 12-15 device cases each week. We have seen the known complications such as pericardial effusion, tamponade, esophageal injury, femoral access complications, and infections, although they are less frequent than the reported complication rates.

Who manages your EP lab? Scott Allison, Cath Lab Director, oversees the integrated Invasive CV Services program at LDS Hospital and Intermountain Healthcare. Dr. Brian Crandall is the Medical Director of our EP program.

Is the EP lab separate from the cath lab? Are employees cross-trained? EP is a dedicated program with its own identity. It is an integral part of our comprehensive Cardiac and Vascular program. For patient monitoring, all employees are cross-trained. However, we employ a dedicated core that operates the recording, stimulator, and three-dimensional (3D) mapping equipment.

What are the regulations in your state? Fluoroscopy is limited to radiologic technologists and physicians. Medications are given by trained staff under direction of the attending physician.

What new equipment, devices and/or products have been introduced at your lab lately? How has this changed the way you perform those procedures? The most important has been the acquisition of 3D mapping equipment both Carto and ESI three years ago. This markedly facilitated the AF ablation program, reducing procedure and fluoroscopy times while improving procedural success. With the use of 3D mapping in AF cases, our total procedural fluoro time average is under 10 minutes.

Who handles your procedure scheduling? Do you use particular software? Patient and staff scheduling are handled by the cath lab coordinator, Mary Shepherd. We use a proprietary computer scheduling program, which is available via network in the electrophysiologists' offices, the adjacent nursing support unit, and the labs. It was designed and developed at our facility, and has been in use for 10 years.

What types of quality control/ quality assurance measures are practiced in your EP lab? We have bi-weekly case and peer review in both cath and EP conferences, as well as weekly Cardiology grand rounds. We monitor short- and long-term patient outcomes using an arrhythmia service database.

How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? Richard Caywood is our full-time inventory specialist. Device and supply selection is done by committee with clinical and financial input. Purchasing is coordinated in the central office through the supply chain organization.

Has your EP lab recently expanded in size and patient volume, or will it be in the near future? Since the introduction of our AF ablation program, our volumes have doubled each year. We anticipate this trend will continue with the opening of our new facility in 2008, which will have four EP labs.

Have you developed a referral base? We routinely receive referrals throughout the states of Utah, Wyoming, Idaho, Nevada, and Colorado.

What measures has your EP lab implemented in order to cut or contain costs? We have worked closely with our electrophysiologists to standardize procedural supplies and techniques that allow for a reduction in variation and inventory needs. Pricing is negotiated centrally using the volume of the entire Intermountain Healthcare network of hospitals.

Does your EP lab compete for patients? We do have competing labs in our region, but we are the busiest facility in the referral area.

How are new employees oriented and trained at your facility? We are in the process of developing a comprehensive EP training program that will include didactic education, proctored, hands-on training, and skills development.

What types of continuing education opportunities are provided to staff members? This is accomplished with our weekly Cardiology grand rounds, quarterly EP grand rounds, attendance at national EP conferences, and vendor training sessions.

How is staff competency evaluated? Staff competency is evaluated through yearly written and practical testing, observation of skills, and competency reviews. ACLS is required.

How do you prevent staff burnout? We haven’t experienced this. We employ a strong team focus, with close collaboration with the electrophysiologists and active participation by the staff. Each procedure is seen as a team effort, and procedural success is shared by all.

What committees, if any, are staff members asked to serve on in your lab? Service on a committee is on a volunteer basis. Our staff members currently serve on six committees encompassing operations and management, service quality, case review, patient satisfaction, equipment selection, and skills development.

How do you handle vendor visits to your department? Do you contract with vendors? The lab is closed to vendors, but we do make allowance for implantable device clinical support reps. In addition, we do contract with vendors; it is done centrally through the corporate offices.

Please describe one of the more interesting or bizarre cases that have come through your EP lab. We had a young patient who was scheduled for an SVT study. After many different drugs and pacing strategies, we were not able to induce SVT. As we were about to pull the catheters, the patient started talking and the SVT began. We went on to do the mapping and ablation while the patient recited their family genealogy. The SVT was successfully ablated, but it was truly one of the most bizarre cases we have had.

Does your lab use a third party for reprocessing? We do reprocess the ICE catheters due to pricing and product availability shortages.

Do you perform only adult EP procedures or do you also do pediatric cases? Our primary focus is on adults.

Do your nurses/techs participate in the follow up of pacemakers and ICDs? No, it is all done through the physician's office.

What trends do you see emerging in the practice of electrophysiology? How is your lab preparing for these future changes? We see continued growth in AF ablations with evolving technologies and products to better perform the procedure and achieve improved success rates. In our new facility, we are adding two additional dedicated EP labs (for a total of four), and are planning to equip two of the labs with magnetic navigation capability.

What are your thoughts about non-EPs implanting ICDs? Do you train such individuals? We strongly support ICD implantation by electrophysiologists only. In addition, we have an integrated Heart Failure program that works in conjunction with our Arrhythmia Service on assessment and long-term management of most of the patients receiving these devices.

Is your EP lab currently involved in any clinical research studies or special projects? Which ones? LDS Hospital and Intermountain Healthcare are involved in many clinical studies, some of which include MADIT, CABANA, PEGASUS, MENDMI, SITELINE, STABLE study, and Rapid AF.

When was your last JCAHO inspection? We are currently expecting a Joint Commission survey.

Are you ACGME-approved for EP training? No.

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? We use a combination of printed and video educational resources, along with personal interaction with program coordinators and physicians.

Give an example of a difficult problem or challenge your lab has faced. How it was addressed? The biggest challenge has been keeping up with the explosive growth in the program over the last three years, both in terms of the facility and staffing limitations as well as the acquisition of necessary new technologies. Our new facility, which will be opening in October 2007, will have four new full-service EP labs. Two EP labs will have magnetic navigation. To staff the expansion of the new EP labs and increased patient volume, we are aggressively recruiting experienced EP personnel.

Describe your city or general regional area. How does it differ from the rest of the U.S.? Salt Lake City hosted the Winter Olympics in 2002. We enjoy great skiing and outdoor activities. Our weather allows us to experience four distinct seasons. Utah has two of the fastest growing cities in the nation, but people will find affordable housing and a lower than average cost of living. We have an international airport with easy access to the world. Our mass transit is convenient and continues to expand to match our fast-paced growth.

Please tell our readers what you consider unique or innovative about your EP lab and staff. The team approach at LDS Hospital allows both physicians and staff to share in performing patient assessment, treatment plans, procedural tasks, and responsibilities. The atmosphere is extremely collegial among the electrophysiologists and the staff. The staff enjoys the flexibility and support offered by management with respect to their work and personal life. The EP program allows for advancement and active participation in the procedures performed at our facility. It is a dynamic environment that allows for continual personal and professional development. Flexibility in the work schedules and the diversity of procedural roles limit staff "burn-out. This is truly a unique working environment that fosters a team commitment and optimizes personal satisfaction.