Spotlight Interview

Spotlight Interview: Cleveland Clinic Indian River Hospital

Jesse Mace, MSN, APRN, FNP-C

Vero Beach, Florida

Jesse Mace, MSN, APRN, FNP-C

Vero Beach, Florida

In 1932, a 29-year-old registered nurse named Garnett Lunsford Radin purchased a hotel in Vero Beach, Florida and opened Indian River Hospital. It had 21 beds, an artesian well water system, and a wood-burning stove that provided the building’s only heat. After two moves and exponential growth, we have evolved from a small community hospital to a 332-bed, not-for-profit medical center that is now part of the Cleveland Clinic system. At Cleveland Clinic Indian River Hospital, our mission is to provide exceptional, patient-centered, evidence-based healthcare. We combine clinical expertise with extraordinary technology and compassion, because every life deserves world-class care.

When was the EP program started at your institution? By whom?

The EP program was started here in August 2016 by Dr. Brett A. Faulknier with the assistance of Jesse Mace, MSN, APRN, FNP-C and support from the cardiac cath/EP team. Both of our providers see patients in both the inpatient and outpatient setting. We began doing device cases in the OR in August, and our lab was fully operational by September 2016, when we completed our first ablation procedure. Our state-of-the-art lab was constructed by funding received from our foundation to allow us to further provide comprehensive cardiac services.

What is the size of your EP lab facility? Where is the EP lab in relation to the catheterization department? Who manages your EP lab?

We currently have one EP lab, which is located adjacent to our two cardiac cath labs. Jeff Passaretti, RCIS manages the lab.

Are employees cross trained?

Although the EP lab is separate from the cath lab, it is managed under the same department manager, and all employees are cross trained for EP and cath procedures.

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

We currently utilize five staff members for procedures, including a performing physician, anesthesiologist, RN, RCIS, and RT(R). This includes Dr. Faulknier (performing physician), Stephanie O’Connor, RN, BSN, Kelle Almeida, RCIS, and Edward Diamond, RT(R). The anesthesiologist role is comprised of a select team assisting with cardiac care.

We also utilize the assistance of representatives from Abbott, Medtronic, and Boston Scientific, depending on the type of case being performed.

Approximately how many catheter ablations (for all arrhythmias), device implants, lead extractions, and LAA closures are performed each week?

Our volumes vary weekly depending on outpatient needs and hospital consultations. In 2018, we completed a total of 354 EP procedures (194 device-related and 160 ablation-related cases).

What types of procedures are performed at your facility? What types of complex ablations are performed?

We offer a variety of device and ablation procedures at our facility, including loop recorder implantation and extraction, single-chamber PPM implantation (traditional and leadless), dual-chamber PPM implantation, biventricular PPM implantation, single-chamber ICD implantation, dual-chamber ICD implantation, biventricular ICD implantation, subcutaneous ICD implantation, device extraction and laser lead extraction if needed, atrial fibrillation ablation / pulmonary vein isolation (radiofrequency and cryoablation), atrial flutter ablation, SVT (AVNRT, AVRT, AT, WPW) ablation, ventricular tachycardia ablation (ischemic / non-ischemic), comprehensive EP study, PAC / PVC ablation, AV nodal ablation, and transseptal puncture if needed.

What percentage of your lab’s device implants use MR conditional pacemakers or ICDs? What percentage of implants use subcutaneous or leadless devices?

Since 2018, all of the Medtronic, Abbott, and Boston Scientific devices used here have been MRI conditional.

What types of EP equipment are most commonly used in the lab? What imaging technology do you utilize?

In our lab, we utilize MediGuide Technology (Abbott), the EnSite Mapping System (Abbott), WorkMate Claris Recording System (Abbott), Maestro 4000 Cardiac Ablation System (Boston Scientific), Artis zee system (Siemens), and the Cardiology Hemo system (McKesson/Change Healthcare). We utilize the Achieve catheter (Medtronic) for mapping, TactiCath Quartz Contact Force Ablation Catheter (Abbott), Arctic Front Advance Cardiac Cryoablation Catheter (Medtronic), and Agilis NxT Steerable Introducer (Abbott).

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

We are the first facility in Florida to utilize MediGuide Technology, which allows us to complete our cases with little or no fluoroscopy. We also utilize the Artis zee system. Both systems give us better visualization during procedures while allowing us to decrease the impact on patients.

How is shift coverage managed (typical hours)? How does your lab handle call?

Our lab is staffed from 6 AM-2:30 PM, which fluctuates based on volume and patient needs. We have a call team available 24 hours.

Who handles procedural scheduling? Do they use particular software?

Outpatient scheduling is initiated in our office by Joy Coffey (Patient Access and Scheduling), who utilizes eClinicalWorks and Outlook to set up the procedures and admissions with the various departments. Rosa Davila Feraud (Patient Access and Scheduling) assists from the cath lab side, with scheduling of Anesthesia and Support Services.

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

Inventory is managed by the EP lab’s staff monitoring as well as Materials Services. All purchases are made by our Purchasing Department.

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

We utilize the Get With The Guidelines-AFIB registry (American Heart Association), the ICD Registry (ACC-NCDR), case reviews, and evidence-based practice.

How has managed care affected your EP lab and the care it provides patients?

There has not been a significant impact on our lab from a patient standpoint, as we continually strive to be stewards of our resources to keep the costs down for our patients. We also ensure that prior authorization and notification is completed if needed.

Have you developed a referral base?

Yes, we currently service patients being referred from over 20 local cardiologists, which I see expanding in the near future now that we have joined the Cleveland Clinic system.

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

On the hospital side, we utilize inventory control, turnaround time monitoring, and 100% utilization of anesthesia for each case.

On the outpatient side, we utilize inventory control and patient scheduling, as well as offer in-office and remote device monitoring to our patients.

How do you ensure timely case starts and patient turnover?

One physician lab utilizes the cath lab PRN for devices cases that may be pending room turnover.

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

We do not compete for patients, as there is approximately a 100-mile radius for the services provided by our lab and the next nearest facility able to provide the same services. As we have recently joined the Cleveland Clinic system, there are future partnership opportunities developing with Cleveland Clinic Martin Health and Cleveland Clinic Weston.

How are new employees oriented and trained at your facility?

In the hospital, staff receive cross training for EP and cath procedures, and are routinely trained by vendors on new equipment. They also receive annual education as set forth by their certifying bodies.

In the office, staff receive cross training for both clerical and medical assistance to provide optimum support to the physician and midlevel provider. They are also routinely trained by vendors on new equipment and devices. In addition, they receive annual education as set forth by their certifying bodies.

How is staff competency evaluated?

Evaluation is based on observation, hands-on training, and testing.

What types of CE opportunities are provided to staff? How many of your staff members also attend medical conferences?

Ongoing updates with vendors as well as case review are provided. Although we are not able to send staff to off-site events at this time, we do look forward to more training and development for staff going forward.

How do you prevent staff burnout and turnover? What approaches do you use for team building?

In the hospital and office, we utilize huddles, staff engagement, empowerment, and hands-on staff involvement. In addition, we use recommend utilization of continuing education in the office.

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

Staff members can participate on the Chest Pain Committee.

How do you handle vendor visits to your department?

They must be scheduled visits with a specific education component.

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

Yes, we offer light music during cases and warm blankets for comfort.

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

We utilize Stryker for reprocessing. This has helped our lab overhead by cost reduction.

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

It is approximately 60% radiofrequency and 40% cryoablation.

What are your thoughts on the use of NOACs in patients with non-valvular AFib?

In patients with non-valvular atrial fibrillation, NOACs are recommend over warfarin in our practice, unless they are unable to tolerate NOACs or there is an interaction potential with other prescribed drugs.

Is hybrid epicardial and endocardial ablation of atrial fibrillation performed at your institution?

Not at this time; however, this is something up for consideration in the future.

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

Yes. We utilize dietary modifications (such as heart-healthy foods, reduced caffeine, and elimination of alcohol), weight loss, and evaluation and treatment of obstructive sleep apnea if indicated.

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

Innovative techniques offered include the MediGuide Technology and TactiCath Quartz Contact Force Ablation Catheter. We also now offer leadless single-chamber pacemaker implantation to qualified candidates.

What approaches has your lab taken to reduce fluoroscopy time? What percentage of cases are done without fluoro? What types of radiation protective shielding and technology are used?

We use MediGuide Technology and Artis zee for imaging. Approximately 1% of cases are done without fluoroscopy; however, very minimal fluoroscopy is utilized for all other cases secondary to increased technology. Lead shields, aprons, thyroid collars, and radiation badges are also utilized for all staff entering the lab.

What are your methods for device infection prophylaxis?

Our approach involves pre-procedure antibiotics, pre-procedure screening (UA/C&S/MRSA Screen), device pocket antibiotic flush, post-operative antibiotics, and physician technique.

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

EHR systems allow for quick review and sharing of patient information when medically necessary. It could be better if the EHR systems had better interaction and communication with one another. I do believe that it does help with process improvement and time management, but still does not replace the interaction, education, and hands-on approach with our patients.

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

I see an increasing presentation of atrial fibrillation in the outpatient setting. I feel that many of these cases are being referred to EP specialists too late in the game, and would like to encourage providers to monitor for earlier recognition and intervention in this process. Patients with early intervention will typically experience better outcomes in long-term management of AFib.

Do you utilize remote monitoring of CIEDs? What clinical and economic benefits have you seen?

Yes, this has allowed for early arrhythmia identification and treatment in individuals who may not have immediate access or limited transportation. It also allows for the provider to monitor patients at high risk of events without frequent office visits. This is a much better model of monitoring patients, as most of the home monitoring devices now communicate wirelessly and report anything outside of their normal parameters to the provider, which allows for earlier detection of abnormalities such as lead or device malfunction.

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

Yes, we currently utilize MoMe Kardia (InfoBionic), which allows us to choose between Holter, event, and MCT monitoring, and can be monitored and mode changed if needed by a cloud-based server. We also utilize the MCOT Patch System (CardioNet/BioTel Heart).

On occasion, we recommend watch-based devices for monitoring heart rate, especially if we are adjusting medications.

Describe your city or general regional area. How is it unique from the rest of the U.S.? What specific challenges does your hospital face given its unique geographic service area?

We are located along the Treasure Coast, on the east coast of Florida. We are in a beachside community that offers beautiful lagoon and oceanside views. There is a large population of 55+ individuals, as this is a popular retirement destination. We also have a very diverse culture in the area. Our hospital provides excellent service with the programs we offer, but some needs require referral to facilities upwards of 100 miles away (IE subspecialty care/transplant). However, we do have a lot to offer for a growing community hospital.

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

We are proud to have recently joined the Cleveland Clinic system as Cleveland Clinic Indian River Hospital. Our community hospital offers services similar to that of a larger academic facility. Our lab offers advanced state-of-the-art technologies, and our hospital is highly involved in the community.

Our staff has over 20 years of EP experience. They are kind and compassionate towards our patients, and look forward to serving all the members of our community. We strive to provide the highest quality of care each and every day.

We greatly appreciate all that our staff does for our hospital and our community. Thank you for providing excellent service! 

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