Spotlight Interview

Spotlight Interview: Baylor Scott & White Medical Center – Temple

Javier E. Banchs, MD, FACC, FHRS, Director of Electrophysiology and Pacing; Beth L. Glass, Office Coordinator II, Section of Electrophysiology and Pacing; and Lois E. Lembke  BSN, RN, EP Lab Manager
Division of Cardiology
Scott & White Medical Center
Temple, Texas

Javier E. Banchs, MD, FACC, FHRS, Director of Electrophysiology and Pacing; Beth L. Glass, Office Coordinator II, Section of Electrophysiology and Pacing; and Lois E. Lembke  BSN, RN, EP Lab Manager
Division of Cardiology
Scott & White Medical Center
Temple, Texas

Scott & White Medical Center is a part of Baylor Scott & White Health, the largest non-for-profit integrated health care system in Texas. In 2013, Scott & White Healthcare merged with the Baylor Health Care System in Dallas to form Baylor Scott & White Health. The hospital is located in Temple, Texas, about halfway between Dallas and Austin. 

The hospital in Temple was initially founded in 1897 by Drs. Arthur C. Scott, Sr. and Raleigh R. White, Jr., who primarily served the Santa Fe railroad employees as they were passing through Temple. 

It has since grown to be a 636-bed hospital that serves as the primary clinical teaching campus for the Texas A&M College of Medicine, and has gained recognition in the community as a tertiary care center across Texas and neighboring states. The institution offers a multitude of graduate medical education programs in cardiology, interventional cardiology, and clinical cardiac electrophysiology, as well as advanced services in heart failure, mechanical circulatory support, cardiac transplantation, structural heart disease, and advanced electrophysiology. 

We currently have 5 electrophysiologists: Drs. Javier E. Banchs, James N. Black, Peter Y. Cheung, Gregory D. Olsovsky, and Larry D. Price. We also have one EP fellow in a 2-year accredited EP fellowship program. We perform the vast majority of our lab work here in Temple, but also serve surrounding central Texas hospitals within the Baylor Scott & White Health system. 

All in all, this winning combination allows us to follow our mission as a leader and educator in the field of EP.

What is the size of your EP lab facility? When was the EP program started at your institution?

Electrophysiology was first performed at this hospital in the mid-1980s, and by 1990, a dedicated electrophysiology lab was created. We have 3 dedicated EP laboratories: 1 single plane, 1 biplane, and 1 single plane with Stereotaxis. The single-plane room is used primarily for device implantations, the biplane room is where we perform the vast majority of our atrial fibrillation (AFib) and SVT ablations, and the Stereotaxis room is used for ventricular tachycardia (VT) cases (e.g., ischemic and idiopathic VTs, in addition to some atrial arrhythmia cases).

What is the number of staff members? What is the mix of credentials at your lab?

The staff consists of 7 RNs, 2 CVTs (RCIS), and 1 operations manager for the EP, cath, and CV labs. Our RNs are a mix of ADNs and BSNs. Both our CVTs are RCIS credentialed and have limited fluoro licenses.

What types of procedures are performed at your facility? Approximately how many catheter ablations (for all arrhythmias), ICD implants, and pacemaker implants are performed each week?

We perform all device implants, including pacemakers, defibrillators, CRTs, leadless pacemakers (Micra TPS, Medtronic), implantable loop recorders, subcutaneous ICDs, and the WATCHMAN Left Atrial Appendage Occlusion device (Boston Scientific). We also perform all ablations, including for SVT, AFib, VT, and PVCs. We average 9 complex ablations and 14 device implantations (7 pacemaker and 7 ICD implants) each week. We perform about 10 WATCHMAN device implantations per month. Laser lead extractions are performed in the operating room in partnership with Dr. Daniel Lee and Damian Cabrera, who are part of a very successful cardiothoracic surgical team.

Who manages your EP lab? 

Gwen Vigil is our operations manager for all supplies, equipment, and budget for the EP, cath, and CV labs. Lois Lembke is our RN clinical manager for all clinical operations in the EP lab. Dr. Banchs is our medical director.

Are employees cross-trained to the cath lab? 

Staff are not cross-trained between the cath and EP labs, but both staff provide both pre/post care of both cath and EP patients.

Do you have cross training inside the EP lab?  

Yes, our CVTs primarily scrub, with RNs circulating and documenting. Both CVTs and RNs can use the EP recording system and stimulator. Nurses are also encouraged to learn to scrub. We have outpatient pre/post areas staffed by both cath and EP lab staff. They cover from 7:00 AM until all patients are admitted or discharged.

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

We use the EnSite Precision (Abbott) and CARTO 3 (Biosense Webster, Inc., a Johnson & Johnson company) mapping systems for three-dimensional non-fluoroscopic mapping and navigation. We also have the WorkMate Claris Recording System (Abbott) and the Arctic Front Advance Cardiac Cryoablation Catheter (Medtronic). We utilize the ACUSON SC2000 Ultrasound System (Siemens Healthcare) for intracardiac echocardiography and vascular ultrasound. Stereotaxis is used for magnetic catheter manipulation; they have been instrumental in increasing our VT ablation volumes. We use technology from Medtronic, Abbott, and Boston Scientific for our device implants. Ablation catheters used include the CARTO SMARTTOUCH SF Catheter and occasionally the CELSIUS RMT Catheter (Biosense Webster, Inc., a Johnson & Johnson company), as well as the TactiCath Quartz Contact Force Ablation Catheter and FlexAbility Ablation Catheter (Abbott). Other catheters used in the lab are the PentaRay NAV Catheter (Biosense Webster, Inc., a Johnson & Johnson company) and the Livewire EP Catheter (Abbott).

Approximately what percentage of ablation procedures are done with cryo vs radiofrequency?

About 80% of ablations are done with radiofrequency energy, and the other 20% are performed with cryotherapy.

What new technology was recently added to your EP program? How have these technologies changed the way you perform procedures? 

We started implanting the WATCHMAN device about 1 and a half years ago, and started using the cryoballoon almost 2 years ago. This year, we started implanting leadless pacemakers (Micra TPS, Medtronic). The increasing number of VT ablations has extended the length of our days in the EP lab.

How is shift coverage managed? What are typical hours (not including call time)? 

We currently have 3 RNs on 8-hour shifts (7-3:30), 2 RNs on 10-hour shifts (7-5:30), 2 RNs on 12-hour shifts (7-7:30), 1 CVT on 8-hour shifts (7-3:30), and 1 CVT on 10-hour shifts (7-5:30). Staggering times helps with late cases.

Who handles your procedure scheduling? Do they use particular software? 

We have 3 schedulers utilizing the EHR system (Epic). We also use Omnicell for storage and supply tracking. Mstaff is used to scan items for patient charges; the system reorders when supply is below par. 

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

When patients check in at 6:45-7:00 AM, they are prepared, evaluated by the physician and anesthesia, and sign consents between 7:15-8:45 AM. Between 7:00-7:30 AM (depending on the day), the EP lab staff may huddle or receive education or an update on different systems, devices, or tools. At 8:00 AM, the first patients are taken to the lab; this includes usually 2 simultaneous operators in two of the three labs. We complete 4-10 procedures per day. The staff provides coverage for lunch during cases, and the day ends anywhere from 3:00 PM (on light days) to 8:00-9:00 PM (on busy days).

How do you ensure timely case starts and patient turnover? 

We aim to move patients into the room at 8:00 AM to get cases started. We do this by tracking when consents are signed and when pre-sedation assessments are completed, and by continuing to track any delays.

What type of quality control measures are practiced in your EP lab? 

We monitor radiation exposure as well as track ablation complications both during and prior to discharge. We track all patients with LAAO devices for readmissions or complications, as well as track patients for response to sedation and pain control.

How is inventory managed at your EP lab? Who handles the purchasing of equipment/supplies?

There are 2 supply chain members who order and stock: our operations manager, Gwen Vigil, and clinical manager, Lois Lembke, with the supply team. Supplies and equipment decisions are made by the managers consulting with the medical director to determine cost effectiveness and impact in patient safety and care, all with oversight and final approval at a centralized healthcare system level.

In what ways have you helped to cut/contain costs and improve efficiencies in the lab? 

We routinely meet with physicians to evaluate what supplies they are currently using or no longer using; this helps keep our par levels as low possible without running out of supplies. We utilize the lean A3 to evaluate with input from the whole staff.

Will your EP program be expanding in size? 

From an infrastructure standpoint, we currently utilize 2 rooms daily and rotate on a case-by-case need. With the addition of a new provider and the consistent growth we are experiencing, we anticipate that we will be using our third EP lab more often.

Have you developed a referral base?

We belong to a large healthcare organization with a network of primary care clinics and several hospitals across the region. Demand for EP services is growing — our physicians, nurse practitioners, and physician assistants make a concerted effort to attend to the needs of the referring clinicians and take advantage of the interactions to educate them on the services we provide and how we can help them improve the quality of life and survival of their patients. 

Does your EP lab compete for patients? Has your institution formed an alliance with others in the area?

Our group works as a team and with a principle of collaboration, keeping the patients’ needs at the center of their efforts. There is no competition among EPs; their relationship is courteous and nurturing, and they help each other and share responsibilities for the benefit of the patient and efficiency of the laboratory. 

How are new employees oriented and trained at your facility? 

We typically have our new RNs orient in our outpatient pre/post care area, which allows flexibility if we need to pull them back to the lab. They are paired with a preceptor/clinical coach, who works with them in the lab for various procedures. They progress through various procedures until we are comfortable with them being a team member in the room.

How is staff competency evaluated? 

We have competencies that are required to be completed during orientation and annually with each staff member.

What types of continuing education opportunities are provided to staff members? 

We have in-services provided by vendors about new products. We also work one-on-one on the recording system, and do tachycardia recognition and case reviews. 

How does your lab handle call time for staff members? 

The staff take call on holidays and weekends, but do not cover weekday evenings. The team is made of 1 CVT and 2 RNs.

How do you prevent staff burnout? Do you also practice any team-building exercises?

We have a great team. However, staff burnout is difficult to control, with turnover leaving the team short staffed. We have recently changed the hours for various staff by staggering start times and extending late coverage at the end of the day. We are starting team-building exercises between the cath and EP lab staff to strengthen interactions, particularly since they work together in our pre/post care area.

What committees are staff members asked to serve on in your lab? 

We have a shared governance committee with staff from the CV, cath, and EP labs. Another member serves on our Magnet committee. Each member belongs to 1-2 of our quality committees.

How do you handle vendor visits to your department? Do you contract with vendors? 

We have vendors that work in our labs on a daily basis, assisting with mapping and device implants. Vendors looking to have new products evaluated need to make appointments with our clinical and operations manager.

Does your lab utilize any alternative therapies to help patients in the EP lab? 

Not at this time. However, we are interested in a program in which patients could identify their favorite music, so it can be played during their procedure.

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

We recently had a case in which the patient had an unexpected reaction to protamine. The patient, who had a history of heart failure and suspected tachycardia-induced cardiomyopathy from PVCs, underwent successful ablation of aortic cusp PVCs, but became unresponsive and desaturated after protamine. All our staff immediately assembled as a team: anesthesia intubated the patient, pressers were started, an echo was done at bedside, and the patient was transferred to CT to rule out stroke. Later that night, the patient was extubated and the outcome was favorable. The staff and physicians involved worked efficiently as a team to resolve the emergency, and everybody felt comfortable in their role. The patient is now doing great.

Does your lab use a third party for reprocessing or catheter recycling? How has it impacted your lab?  

We use two vendors for reprocessing and decreased supply costs, with the aim to use close to 100% reprocessed.

What are your techniques for LAA occlusion? Do you have a primary approach?

We implant the WATCHMAN device (Boston Scientific) by strictly following indications and protocols from the FDA and Medicare. We participate in the LAAO registry, and have two days of the month that are designated in one of our laboratories as “WATCHMAN day”. We have implanted 5 WATCHMAN devices in a day in one laboratory. The turnaround of the room remains a challenge, but we have significantly improved the time.

Do you utilize lifestyle modification as therapy for your patients with atrial fibrillation?

Yes, all patients with atrial fibrillation are instructed on lifestyle modification as a tool to prevent recurrences or progression of their disease. We are in the process of seeking funds to start a pilot risk factor modification program with our cardiac rehab team and dietitian.

What other innovative EP techniques are being utilized in your lab?

We are increasingly performing procedures with no fluoroscopy. We have adopted high-density mapping, starting with the PentaRay NAV Catheter (Biosense Webster, Inc., a Johnson & Johnson company), and look forward to soon incorporating the Advisor HD Grid Mapping Catheter (Abbott).

Do you perform only adult EP procedures, or also pediatric cases? 

We have 1 physician who performs ablations on pediatric patients, using a pediatric anesthesiologist for sedation; these patients are normally >9 years of age.

What measures has your lab taken to reduce fluoroscopy time? 

We utilize pulsed fluoro at 3 frames/sec, limit fluoro time, rely on 3D mapping imaging, and maximize shielding.

What are your methods for device infection prophylaxis? 

We use SCIP initiatives for surgical site infection prevention, along with conforming to AORN protocols for dress attire and processes. We use the TYRX Absorbable Antibacterial Envelope (Medtronic), particularly in high-risk patients. We do not implant devices in febrile patients or patients with concomitant infections.

What are your thoughts on EHR systems? Does it improve your quality of care?

Although it is still too early to judge, EHR systems seem to add to the burden of daily work, has become more of an obstacle than a tool, and may even add risk in some circumstances. However, we hope that when optimized, it should improve quality of care. Meanwhile, we take whatever positives it provides, and do what is needed to overcome obstacles to provide good quality care.

How is outpatient cardiac monitoring managed? 

We staff our outpatient (OP) area with both cath and EP lab nurses who are trained to care for all patients pre/post care, including TEE/CV combo procedures and tilt table testing. We have Draeger monitors in each private room, along with an Epic computer for documenting. We also have 4 portable computers for use by anesthesia in the OP area.

Does your heart rhythm service offer patients with a suspected inherited arrhythmia a referral to cardiovascular genetics clinic?

Yes, routinely. We have an excellent genetic counseling clinic.

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

Dominant trends we see emerging in EP include more powerful tools for safer and faster procedures, leadless devices, more incorporation of communication technology, and use of apps and digital tools for education and monitoring. Ablation volumes will also continue to grow as we recognize its benefits more and more.

Do you utilize digital tools and wearable technologies in your treatment strategies for patients?

Yes, we encourage all patients to sign up for the patient portal of the
EHR and keep communication with them. We also routinely recommend personal heart rhythm recorders for appropriate patients. We believe in wearable devices, but also in the need for control of the quality of the data they generate as well as outcomes data, before they are widely adopted and used; this is due to the potential for increasing costs, unnecessary testing, and clinic and emergency room visits.

How do you see social media changing the field of healthcare?

Social media is here to stay. It has the power of mass instantaneous communication, but can be a double-edged sword, spreading education and knowledge but also misunderstanding and fear. Healthcare practitioners and institutions have the responsibility of taking the lead in order to prevent misinformation.

Describe your city or general regional area. How is it unique from the rest of the U.S.?

Temple is a small but vibrant city in central Texas. Strategically placed between Austin and Dallas, there is access to both big cities, but also the benefits of a quiet, loving, and welcoming community. We like to say that Temple provides state-of-the-art medicine but with no traffic and free valet parking!

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

We are a very dedicated, hardworking group of professionals that care and love what we do. Our staff feels pride about the quality of our work and our excellent outcomes and service.

For more information, please see this bonus video content about their program!