When was the EP program started at your institution? By whom?
Texarkana Cardiology Associates, in conjunction with CHRISTUS St. Michael Health System, recruited Dr. Kevin Hayes, the area’s first and only cardiac electrophysiologist, to launch the CSMHS EP program in August 2015.
What challenges did your program initially experience?
Prior to starting our EP program, CSMHS provided an excellent cath lab staff with many years of experience, but no EP experience.
During Dr. Hayes’s EP fellowship in Wisconsin, members of the staff travelled to Wisconsin to begin the process of learning EP and honing their skills. Through Dr. Hayes’s teaching, and through hands-on sessions with Biosense Webster, the staff quickly became proficient in EP as well.
What is the size of your EP lab facility? Where is the EP lab in relation to the catheterization department?
There is currently one designated EP lab directly attached to two cath lab suites and positioned between the cath lab and OR. In addition, CSMHS offers a hybrid OR suite with EP capabilities.
What is the number of staff members? What is the mix of credentials at your lab?
The EP lab shares staff with the cath lab. Two registered nurses, a radiologic technologist, an anesthesiologist, a Biosense Webster associate (to operate the CARTO equipment), and a certified scrub are dedicated to each EP case. Dr. Hayes is board-certified in internal medicine, cardiology, and electrophysiology. All RNs are Certified Sedation Registered Nurses (CSRNs). Three of our seven radiologic technologists are board certified in cardiovascular intervention through the ARRT, and three more are actively pursuing board certification.
What types of procedures are performed at your facility? What types of complex ablations are performed?
Our EP service performs radiofrequency ablations of all arrhythmias except epicardial ventricular tachycardia (VT). We offer all device therapies except appendage ligation at this time. We do not perform cryoablation at our center.
What do you consider to be the common arrhythmias seen in your EP lab?
Atrial fibrillation in this region of the country is an epidemic. This is the most commonly seen and treated arrhythmia.
Approximately how many catheter ablations (for all arrhythmias), device implants, and lead extractions are performed each week?
We typically perform at least 10-15 cases per week in the EP lab, averaging five ablations, two ICDs, and four pacemakers per week.
What percentage of your lab’s device implants use MR conditional pacemakers or ICDs? What percentage of implants use subcutaneous or leadless devices?
All of our device implants are MR conditional. Subcutaneous and leadless devices are less commonly performed.
Who manages your EP lab?
Dr. Hayes serves as the Medical Director of the EP lab. Cath/EP lab staff are managed by the cath lab’s radiologic technologist supervisor. A clinical nurse specialist is in charge for day-to-day operations.
What type of hospital is your EP program a part of?
CHRISTUS St. Michael Health System is a tertiary referral hospital set in a community that services a four-state area of approximately 350,000 residents.
Has your EP lab recently expanded in volume?
Volumes have grown as expected with the availability of an EP physician. Our cardiac service line strategic plan includes the addition of a second electrophysiologist in the next few years, which should equate to additional volume growth.
What types of EP equipment are most commonly used in the lab? What imaging technology do you utilize?
Our equipment includes the Artis zee single plane system (Siemens Healthineers USA), ComboLab Hemodynamic & Recording System (GE Healthcare), Micropace Stimulator (GE Healthcare), Avance CS2 anesthesia delivery system (GE Healthcare), defibrillator (ZOLL Medical), Hemochron Signature Elite Whole Blood Microcoagulation System (Accriva Diagnostics), Maquet Satelite Anchoring System (Getinge), Healthcare Headset System (Quail Digital), and the CARTO mapping system (Biosense Webster, Inc., a Johnson & Johnson company). Ninety percent of the catheters used in our EP lab are THERMOCOOL SF catheters (Biosense Webster, Inc., a Johnson & Johnson company). We also take advantage of savings by using reprocessed catheters.
What new initiatives or technologies have recently been added to the EP lab, and how have they changed the way you perform procedures?
Our EP lab is constantly working to reduce radiation. We have been doing only fluoro-free ablations since our lab opened. We are now working to reduce fluoroscopy in device implants as well. We have also started ablating atrial fibrillation at 50 W (irrigated, contact force sensing) with overall reduced time to isolation.
How is shift coverage managed? How does your lab handle call?
We function with rotating shifts, beginning with in-times starting at 6 AM, then every 30 minutes until 8 AM. The call team is always the latest shift and remains on duty until all cases are complete. All staff cover both the EP and cath labs, and the call team does the same.
Tell us what a typical day might be like in your EP lab.
Historically, Mondays tend to be our busiest procedure day. We typically start the first case by 7:30 AM. We strive to utilize the other cath labs for device implants to help reduce turnover times in the EP lab. Our turnover time is generally less than 30 minutes for ablations. Most often, we have all procedures completed before 5:00 PM.
Who handles procedural scheduling? Do they use particular software?
Dr. Hayes and his clinic staff manage scheduling. When a patient is scheduled, cases are added to the hospital’s online calendar system, which immediately synchronizes to the pre-operative area, cath lab clerk, anesthesiology, appropriate device vendor, and CARTO representatives. The information is also transmitted to the EP staff’s mobile devices. No patient identifiable information is used in this system.
What type of quality control and assurance measures are practiced in your EP lab?
We work closely with our Quality Department to track repeat ablations, post-implant device infection rates, complications, procedure times, and case turnaround times. Equipment Quality Control (QC) is performed on the equipment as required with daily checks performed and documented by the staff. Preventive maintenance is conducted by our Biomedical Engineering team or equipment vendor. Medical physicist surveys are done annually and as needed.
How is inventory managed at your EP lab? Who handles the purchasing of equipment/supplies?
We currently utilize the Pyxis SupplyStation inventory management solution (BD), which charges supplies and reorders based on par levels. A Central Services associate maintains inventory.
Do you have any issues with your EP lab’s layout or design? What would you include on a “wish” list?
Our EP lab was converted from a Cysto room in the OR. The current size accommodates the considerable amount of equipment, supplies, etc., required for each case. While we receive many compliments on the layout and size, our wish list would include additional space.
How has managed care affected your EP lab and the care it provides patients?
Managed care has not negatively impacted the care we provide. As with any patient we serve, we ensure appropriate criteria is met and documented. CSMHS is a not-for-profit health care system, and our mission of extending the healing ministry of Jesus Christ compels us to provide charity care for the underserved in our community.
Have you developed a referral base?
CSMHS has collaborated closely with Dr. Hayes to educate local and area physicians as well as other referral sources about the EP lab and services we can provide. In addition, extensive marketing efforts have informed consumers in our region about this technology being available. The clinical providers in Texarkana and the outlying communities have been supportive of our EP program, and have valued our EP services as a resource for their patients. As the only EP program within a two-hour radius of Texarkana, we would not be successful without the support of our local physicians and other caregivers who have the option of sending their patients to a larger city.
In what ways have you cut or contained costs and improved efficiencies in the lab and device clinic?
We utilize reprocessed items whenever possible, which results in substantial cost savings. In addition, we work with the CHRISTUS Health system office to capture savings on devices by complying with an 80/20 vendor market share. By focusing on processes, the EP lab has been able to decrease turnover times to less than 30 minutes.
How do you ensure timely case starts and patient turnover?
The cath lab clerk plays a crucial role in ensuring cases start on time through detailed coordination of the processes such as calling for patients, transport, etc., to ensure timely care and turnover of rooms.
Does your EP lab compete for patients? Has your institution formed an alliance with others in the area?
The nearest EP program is located a minimum of two hours from Texarkana. While there is no direct local competition, we have worked diligently with cardiologists and other referral resources to educate them about our program and nurture confidence that our program is robust and offers the services, skills, and quality as EP programs in larger cities.
How are new employees oriented and trained at your facility?
New associates with cath lab experience complete required GE modules (which came with GE system/monitor equipment) and work one-on-one with EP staff for three to six months, depending on the needs of the new associate. Dr. Hayes assesses each associate throughout the process and provides sign-off on initial clinical orientation. Skill competencies are reviewed annually for all staff.
What types of continuing education opportunities are provided to staff? How many of your staff members attend medical conferences each year?
EP lab associates attend education mapping series through Biosense Webster. For 2019, one of our EP lab RNs attended the American College of Cardiology’s 68th Annual Scientific Session and Expo. Our electrophysiologist also provides ongoing topic-specific learning sessions to staff.
How is staff competency evaluated? Does staff receive a bonus based on performance?
Staff competency is evaluated both initially and annually by either direct observation, demonstration of procedure, or procedure review on low-volume studies. Currently, associate incentives are tied to individual, departmental, and overall hospital performance.
How do you prevent staff burnout and turnover? What approaches do you use for team building?
Rotation of staff between the cath and EP labs does help in some regards. Call is rotated, and staff are encouraged to use all of their PTO. Turnover is not a major concern most of the time — the only staff we have lost resulted from vendor recruitment after our EP lab first opened. As expected, properly training EP staff requires time and money, which can be a challenge at times.
What committees, if any, are staff members asked to serve on in your lab?
CSMHS is on our journey for Magnet status; therefore, cath and EP lab RNs are encouraged to participate in nurse governance. Members from the cath and EP labs sit on Peer Review and Nurse Advisory Council as well as other committees if they wish.
How do you handle vendor visits to your department?
Vendor visits are scheduled through the cath lab manager, and each vendor must be an appropriately vetted vendor for CHRISTUS with access to Vendormate.
Describe a particularly memorable case from your EP lab and how it was addressed.
One patient with two previous unsuccessful ablations had to travel over 300 miles to another institution for each of her treatments. When our lab opened, which is located in her hometown, the patient came to us for her needed third ablation, which was successful and resulted in her condition being completely resolved. Patients treated in our lab frequently comment on how nice it is to be able to stay home and have these services available to them.
Does your lab use a third party for reprocessing or catheter recycling? How has it impacted your lab?
Sterilmed (a Johnson & Johnson company) is the CHRISTUS Health contracted vendor for SOUNDSTAR catheters (Biosense Webster, Inc., a Johnson & Johnson company). Biosense Webster will not support cases utilizing any other reprocessing vendor with the SOUNDSTAR catheter.
What are your thoughts on the use of NOACs in patients with non-valvular AFib?
We prefer to perform ablations on patients while taking NOACs compared to warfarin. NOACs are not interrupted for ablation procedures.
Do you utilize lifestyle modification as therapy for your patients with atrial fibrillation?
Absolutely. In the clinic setting, we focus on dietary changes, weight loss, moderate exercise, and especially, CPAP compliance.
What other innovative EP techniques are being utilized in your lab?
We are working to reduce fluoroscopy time during device cases. We have developed and implemented a nearly zero fluoro workflow for AV node ablation with biventricular device insertion. We offer fluoroless transvenous pacing from a basilic approach at the bedside. We have performed atrial flutter ablations from a neck approach after an occluded IVC filter.
What are your methods for device infection prophylaxis?
We use a strict sterile procedure and prep with a Hibiclens scrub. We then use preoperative antibiotics and a tobramycin pocket irrigation.
What are your thoughts on EHR systems? Does it improve your quality of care?
Our reporting system helps to provide consistency. The safety checklists are built in our system, and all needed documentation is captured in one document. This provides structure and accountability to enhance quality of care.
What are some of the dominant trends you see emerging in the practice of electrophysiology?
Atrial fibrillation ablation is becoming safer, quicker, and more effective as time passes. We strive to keep abreast of the latest developments to ensure we incorporate proven methodologies and information into our program.
Do you utilize remote monitoring of CIEDs? What clinical and economic benefits have you seen?
All of our new device patients are enrolled in either the LATITUDE Home Monitoring System (Boston Scientific) or CareLink Network (Medtronic), and we monitor these closely.
Do you utilize digital tools or wearable technologies in your treatment strategies for patients?
We have utilized the Fitbit, Apple Watch, and KardiaMobile (AliveCor).
How do you see social media changing the field of healthcare?
Social media has become everyone’s favorite place to share his or her outcomes, whether positive or negative. Our staff does follow social media communities that pertain to the cath and EP lab. Our facility has a social media policy in place, and we share EP patient success stories, education, etc. via social media.
Describe your city or general regional area. How is it unique from the rest of the U.S.?
Our city is very unique in that it is a border city located in two states — Arkansas and Texas — with two city governments, two fire departments, two police departments, etc. St. Michael Hospital was originally built in Texarkana, Arkansas, and was relocated to Texarkana, Texas about 25 years ago for growth opportunities. The relocation of CSHMS to a 128-acre campus led to substantial development of the northwest area of Texarkana.
What specific challenges does your hospital face given its unique geographic service area?
Texarkana is a twin city, sitting in Texas and Arkansas, but it is also very near Oklahoma and Louisiana. The EP lab at CHRISTUS St. Michael Health System is the only lab within a four-state region. While CSMHS often offers the same level of expertise, technology, equipment, etc. as larger cities for many services such as heart care and oncology, we are challenged with educating area residents that they can receive care close to home without having to travel to a larger city.
What is considered historic about your EP program or hospital? Has your program or hospital recently experienced any “firsts”?
Our EP lab was the first to be established in our region, so every new thing we do is a “first” for our community. We have been proactive in performing EP cases that are completely fluoroless, and are currently striving to perform device cases without the use of fluoro.
Please tell our readers what you consider special about your EP lab and staff.
An outstanding teacher and mentor, Dr. Hayes consistently focuses on each patient’s comfort and improving their quality of life. Throughout staff training, he has emphasized this approach from day one. Because Dr. Hayes is very approachable and makes himself readily available to physicians and providers in the community for consulting, our EP program has experienced successful growth and offers area patients a close-to-home solution to their electrophysiology issues. Under Dr. Hayes’s leadership, we are on the cutting edge by utilizing no fluoro for our ablation patients. Dr. Hayes continuously strives to stay abreast of innovative technology and inspires the staff to follow suit. Dr. Hayes personalizes each dressing on every device case by creating a unique cutout that might follow a current holiday or something unique for that patient (Figure 9). The patients love this special touch! We will continue to offer the best possible care to patients in our community as we extend the healing ministry of Jesus Christ on a daily basis.
About CHRISTUS St. Michael Health System
Following the mission to “extend the healing ministry of Jesus Christ,” CHRISTUS St. Michael Health System (CSMHS) is a not-for-profit, Catholic integrated health care delivery system serving approximately 350,000 residents of and around the greater Texarkana, Texas region in Arkansas, Texas, Louisiana, and Oklahoma. CHRISTUS St. Michael Health System’s dedicated staff provides specialty care tailored to the individual needs of every patient, striving to deliver high-quality services with excellent clinical outcomes. Two acute care hospitals anchor the system — a 311-bed facility in Texarkana and a 43-bed hospital in Atlanta, Texas, 25 miles south of Texarkana, along with a rehabilitation hospital, two outpatient rehabilitation facilities, two health and fitness centers, an imaging center, a cancer center, and two retail pharmacies. Known as the regional leader in the delivery of health care, CHRISTUS St. Michael has achieved numerous awards and recognitions including being named as an IBM Watson Health Top 100 Hospital in the United States.