Spotlight Interview

Spotlight Interview: AdventHealth Orlando

Amber Arnold, RN, BS, RCIS, EPS Invasive Lab Supervisor; Orlando, Florida

Amber Arnold, RN, BS, RCIS, EPS Invasive Lab Supervisor; Orlando, Florida

AdventHealth Orlando is a designated statutory teaching hospital and trains physicians from around the world on the newest technology and procedures. AdventHealth Orlando was recognized as the No. 1 hospital in Florida as well as the top in Orlando by U.S. News & World Report in their 2019-2020 Best Hospitals ratings. 

What is the size of your EP lab? Has the EP lab recently expanded in size? 

All of our invasive EP labs are dedicated to electrophysiology procedures. We currently have five full-time EP labs; each has approximately 750 square feet of procedural space. We have two biplane GE labs, two single-plane GE labs, and one single-plane Philips lab with Stereotaxis remote magnetic navigation. 

We will soon be expanding to a sixth room, which will be a biplane Siemens lab; this is under construction, with completion expected in April 2020. Additionally, we use one invasive lab that is shared with the cath lab for implant procedures, and two non-radiographic special procedure rooms for cardioversions, tilts, transesophageal echocardiograms (TEEs), and loop implants. We also have a pediatric hybrid room (Philips biplane) located within our CVOR that can accommodate electrophysiology, cardiac catheterization, and structural heart procedures.

What is the number of staff members?

With an increasing number of electrophysiology cases, we have had the opportunity to grow our staff. This has also required us to expand our hours through the use of multiple shift options. Our team is scheduled on 8-hour, 10-hour, and 12-hour shifts. We also have a later staggered 12-hour shift to assist with afternoon cases, turnover, and lunch relief. Within the EP department, we have 45 dedicated team members consisting of registered nurses, cardiovascular technologists, respiratory therapists, and radiology technicians that are all cross trained. We also have a paramedic to assist with transport, prep, and support of turnover. Our pediatric team is made up of six team members that work four 10-hour shifts.

What are the most frequent procedures performed?

Our most frequent procedures are ablations, which make up the bulk of our procedures. Secondary to ablations would be our implant procedures, including subcutaneous ICDs. 

Approximately how many catheter ablations (for all arrhythmias), device implants (ICD, pacemaker, ICM, ILR, etc.), lead extractions, and LAA closures are performed each week? 

In 2019, the single event breakdown was approximately 749 atrial fibrillation ablations, 150 ventricular tachycardia (VT) ablations, and 416 other ablations. We also perform the majority of implant procedures within the hospital, with approximately 1,480 completed in 2019 and a total volume of 225 subcutaneous ICDs. Our 2019 pediatric volumes included approximately 125 ablations (without fluoro) and 22 implants.

What types of EP equipment are most commonly used in the lab? 

We are a very diverse lab in regards to EP equipment. We utilize three different mapping systems, including six CARTO 3 systems (Biosense Webster), three EnSite systems (Abbott), and one Rhythmia system (Boston Scientific). Additional ablations are performed with our cryoablation system (Medtronic). Our EP study procedures are still performed using the Bloom stimulator (Fischer Medical) because of physician preference and its robust dependability. We utilize Baylis Medical for almost all of our transseptal punctures, with a few physicians still preferring non-radiofrequency transseptal needles. For vascular and intracardiac ultrasound, we have four Zonare (Mindray) and five ACUSON SC2000 (Siemens Healthineers) ultrasound systems that are cross utilized for both. Our pediatric electrophysiologist, Bhavya Trivedi, MD, utilizes the EnSite mapping system (Abbott) including the EP-4 cardiac stimulator as well as cryo energy for his ablation patients. Dr. Trivedi uses Zonare for vascular access and intracardiac ultrasound imaging. 

Who manages your EP lab?

Barry Egolf, BSN, RN is our cardiovascular invasive lab manager; he manages the EP and cath labs. Ashley Hall, MBA, BSN, RN manages our pediatric program as well as our procedural support and recovery team. 

The EP lab supervisor is Amber Arnold, BS, RN, RCIS; she is responsible for planning and operationalizing the daily, weekly, and monthly logistics of the EP labs. Amber’s insight is also critical to the evaluation and acquisition of new technology that helps shape our future. We also have a dedicated educator in the EP lab, Oria Jordan, BS, RCIS, who oversees the orientation and continued education of EP. 

Tell us about your device clinic, including its staffing model.

We have five pacer clinic-certified staff that oversee the regular checkups and post-implant follow-ups. They also handle all alerts that may come in as well. The staff also travels to meet the need of our patients who are not as mobile.

What new initiatives have recently been added to the EP lab, and how have they changed the way you perform procedures?

We are adding an additional biplane lab this year to help accommodate physician requests. Additionally, we have placed four of our mapping systems on mobile carts to assist physician preferences. Lastly, we have been able to support all vascular access needs with the use of nine vascular ultrasound machines.

Tell us what a typical day might be like in your EP lab.

Every day, our lab starts with a morning huddle to go over the day and any important information that may need to be communicated to the team. We highlight team success, challenges, and quick education takeaways. After our morning huddle, the team disperses into their assigned room for the day to begin setting up for their first procedure. Our first cases will have arrived to the room no later than 7:30 AM. To keep the day on schedule, we have six people that come in at 9:00 AM and work until 9 PM. This helps with lunches and turnaround times. Another big help is that all of our team members are cross trained, so they can work with each physician, modality, and in each position. The rooms are also multipurpose, so we’re able to perform both implants and ablation procedures. 

How do you ensure timely case starts and patient turnover?

We have worked on improving our start times through a systematic process of identifying specific areas of improvement. These areas were identified by creating a process flow that started from registration to case start. We created a team comprised of an electrophysiologist, anesthesiologist, director, manager, supervisor, and nurse. The following improvements were instituted as a result: to confirm transport the day prior for transfers, review critical lab values 24 hours prior to schedule start, confirm cases with anesthesia the day prior, and confirm all orders are complete with consents. We have also begun work on patient turnover with focused intent on minimizing variables. Anesthesia has given us a dedicated team that is familiar with EP procedures. This requires collateral support from the team to help meet the educational needs of our CRNA teams. Furthermore, we have hired a paramedic to assist with transport of patients to and from the lab, set up equipment between procedures, pull supplies for procedures, assist with IV access, and perform CPR when needed. We also attempt to have one or two team members that are assigned as a turnover person to assist between cases for room breakdown, cleaning, and setup for the next patient. We have found that this has had a significant impact on decreasing turnaround times and providing support to the team.

What are the best features of your EP lab’s layout or design?

In terms of layout, the labs surround our central stockroom, allowing for easy access to equipment. Additionally, the rooms empty out into our designated PACU area for decreased travel time. Each lab is connected in the control room, making it easy to share resources, equipment, and intellect at different times, or get help in emergent situations. Lastly, although our EP lab operates as a dedicated team, we are located within the same department as the cath lab for additional assistance if needed.

In what ways have you cut or contained costs in the lab and device clinic? 

We have a very dedicated team of physicians that help us navigate new technologies for best practices and cost efficiencies. Our physicians are also very supportive of using resterilized products. Bulk purchases also help in negotiating lower prices as well. The culture of our team is to be good stewards of the hospital and to be mindful of opening equipment at the time of physician request. Adequate staffing and support allow for increased efficiency and patient time within the labs.

What types of continuing education opportunities are provided to staff? What options for continuing education are available to your mid-career staff? 

The staff are provided with continuing education throughout the year. We are implementing an individualized continuing education program in which staff can focus on areas they would like to excel in and help maintain progress of their learning levels. Our mentorship program also allows staff to focus on areas within a procedure that they would like to improve upon. Our prior educator, Paula Carrera, RN, was invited to speak at a special session at Heart Rhythm 2019 covering the topic of “How to Create a Culture of Success in the EP Lab.” We have implemented simulation with our orientation program, and use simulation to continue education throughout the lab. We offer opportunities to attend conferences such as the Heart Rhythm Society’s annual scientific sessions, the VT Symposium, and the AF Symposium. Many vendor in-services are scheduled throughout the year to maintain competency with procedures and equipment. Staff must complete annual competencies and computer-based learning throughout the year as well. We also encourage staff to utilize resources provided by continuing education websites to maintain up-to-date knowledge. AdventHealth encourages staff to continue their education and offers reimbursement for certifications and degree advancements. We are encouraging staff to complete their RCES certification, which is being reimbursed by AdventHealth. 

Describe a particularly memorable case from your EP lab and how it was addressed.

A patient who was referred to one of our electrophysiologists (Usman Siddiqui, MD) was experiencing long runs of supraventricular tachycardia, causing a compromise in her cardiac output. Dr. Siddiqui took great care in organizing a team involving anesthesia, obstetricians, and pediatrics to cover all potential eventualities. A strategy was outlined as a team with the patient involved, laying the groundwork for a successful ablation procedure without fluoro. Her remaining pregnancy was uneventful, and culminated in the birth of a healthy baby.

Does your lab perform His bundle pacing? 

Yes, we perform His bundle pacing and find it to be very beneficial. Our physicians have surpassed the learning curve and utilize this technique when the patient has been identified as a good candidate.

Do you have a primary approach for LAA occlusion?

Our dedicated LAA coordinator (Nora Byrd, RN) facilitates LAA reviews of all cases with at least three of our electrophysiologists. The LAA team also has three invasive cardiologists that are credentialed for LAA occlusion. Additionally, the meetings are also attended by one of our specialized echo techs as well as our EP supervisor (Amber Arnold, RN). 

Does your program have a dedicated atrial fibrillation clinic? 

Yes, our integrated atrial fibrillation clinic involves a multitude of specialists tailored to meet the unique needs of our patients.

What approaches has your lab taken to reduce fluoroscopy time? What percentage of cases are done without fluoro? 

Our physicians have adopted a standard low dose of 7.5 frames per second, and have maximized the mapping system for guidance. Our lab has also worked on approaches to reduce fluoroscopy time. Several of our physicians perform a majority of their ablation procedures without fluoroscopy by utilizing a quadripolar catheter attached to an esophageal temperature probe, intracardiac ultrasound, and mapping technology from Biosense Webster and Abbott. Our pediatric electrophysiologist performs cases without fluoroscopy, and relies on a mapping system and ultrasound to identify location. 

What are some of the dominant trends you see emerging in the practice of electrophysiology? 

The priorities are initiatives that reduce fluoro, increase the efficiency of turnaround time, assist with decreasing overall procedure time, and develop a more comprehensive outreach program to the underserved.

How do you utilize digital tools or wearable technologies in your treatment strategies for patients?

Patients that do not meet the need for an implantable loop recorder are encouraged to purchase an Apple Watch or the KardiaMobile (AliveCor).

What trends have you seen in your procedures and/or patient population? 

Our patient population has become more educated on the types of procedures performed and the types of outcomes to expect. Patients are using the internet to educate themselves before seeing their doctors. This helps us with treatment plan options that meet the expectoration(s) of the patient. Patients are also using Healthgrades as a way to review their physician’s performance. 

Please tell our readers what you consider special about your EP lab and staff.

The EP department at AdventHealth Orlando is a team that is dedicated to learning and applying EP. We have built a strong team that our physicians trust and depend on. All of our team members are cross trained and can perform any procedure that they are presented with on any given day. We have a vast continuing education program, and are always looking to grow our team’s understanding of EP. The culture that is integrated within our team is to truly take care of our patients and to provide them with safe, professional, and compassionate care.