Spotlight Interview

Spotlight Interview: Geisinger Heart Institute

Pugazhendhi Vijayaraman, MD and Angela Naperkowski, RN, FHRS, CEPS, CCDS; Wilkes Barre, Pennsylvania

Pugazhendhi Vijayaraman, MD and Angela Naperkowski, RN, FHRS, CEPS, CCDS; Wilkes Barre, Pennsylvania

When was the EP program started? Who manages the EP lab?

Our EP lab was started in 2005 under the direction of Pugazhendhi Vijayaraman, MD and Jim Bonczek, RT(R) (CV) RCIS. We were the first EP lab in the Wyoming Valley. Dr. Vijayaraman is the Medical Director of the EP lab. Jim Bonczek, RT(R) (CV) RCIS is the Operations Manager of the cardiac cath, electrophysiology, and peripheral vascular lab. Angela Naperkowski, RN, FHRS, CEPS, CCDS is the Clinical Coordinator of the EP lab. 

Where is the EP lab located?  

Our EP lab is located on the same floor as the invasive cardiac lab, but in a separate wing.

What is the size of your EP lab facility? 

We presently have a separate EP suite with 2 electrophysiology labs and an 8-bed pre- and post-procedure units for both inpatients and outpatients. Our EP unit was in the top 10% nationally for patient satisfaction based on a Press-Ganey survey in 2019.

What is the number of staff members? What is the mix of credentials at your lab? Describe your lab staffing and structure. 

Our electrophysiology team consists of 2 electrophysiologists (Dr. Vijayaraman and Dr. Faiz A. Subzposh) and 4 physician assistants.

Our EP lab staff consists of 3 RNs and 3 electrophysiology technologists. We are currently in the process of hiring another electrophysiology technologist.

All EP staff are certified by the RCES registry; IBHRE CEPS and/or RCES is mandatory within 2 years of hire. The EP lab manager, Angela Naperkowski, RN is IBHRE certified in both CEPS and CCDS. The device clinic is staffed by 2 very experienced nurses, one of whom (Kelly Austin) is certified in IBHRE-CCDS; Kelly manages the entire cardiology outpatient department.

What type of hospital is your EP program a part of? 

Our hospital is an academic facility with approximately 275 beds.

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

Our facility performs the full spectrum of ablations for supraventricular tachycardia, ventricular tachycardia (VT), PVCs, atrial fibrillation (AF), atrial flutter, and AV node. We perform epicardial VT ablations as needed. We also perform all cardiac implantable electronic device (CIED) implants, including subcutaneous ICDs and leadless pacemakers. Most importantly, our center has the largest experience in His bundle pacing (HBP) and left bundle branch pacing (LBBP), with more than 1,300 implants. Finally, we perform both endocardial and epicardial left atrial appendage (LAA) closure procedures.

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

It varies from week to week. Each year, we perform an average of 300 ablations and 450 CIED implants, 25-30 complex lead extractions, and approximately 50 LAA closures.

Are employees cross-trained?

The EP lab has been separate from the cardiac cath lab since August 2016.

We primarily do not cross train; however, some of the seasoned staff in both EP and cath can cross cover when necessary.

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

Our lab utilizes the Innova biplane imaging system (GE Healthcare), CardioLab monitoring and recording system (GE Healthcare), CARTO 3 (Biosense Webster, Inc., a Johnson & Johnson company), EnSite Precision Cardiac Mapping System (Abbott), Vivid ultrasound system (GE Healthcare), CryoConsole Cardiac CryoablationSystem (Medtronic), and cardiac stimulator (Micropace).

How do you manage vessel closure?

Vessel closure is obtained using figure 8 suture or manual compression for venous access, and Perclose (Abbott) venous closures for WATCHMAN Devices (Boston Scientific), Angio-Seal Vascular Closure Devices (Terumo Medical Corporation), or manual pressure for arterial access.

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

We have been using the CARTO 3 mapping system (Biosense Webster, Inc.) for most of our AF and left atrial flutter ablations, including the use of high-power, short-duration ablation as well as VISITAG SURPOINT (Biosense Webster, Inc.), which has shortened our procedure duration and improved first-pass pulmonary vein (PV) isolation rates. We are also excited about the utility of the EnSite Precision system (Abbott) with isochronal late activation mapping (ILAM) mapping for VT ablation. While our lab is not in an OR suite, we have a semi-hybrid environment. Our surgeons are very supportive (Dr. Deepak Singh, Dr. Michael Harostock, and Dr. Joseph Stella) and actively involved in most of our lead extractions, which are performed in the EP lab. The very high-risk extractions are performed in the OR.

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

Our hours of operation are 7:30 AM-4:00 PM. We alternate covering late team assignments to finish the cases of the day. We do not have a call team, but for rare EP emergencies, our team will come in on a purely voluntary basis.

Who handles procedural scheduling? 

Our scheduling is handled by Joan Marino, Clerical Coordinator of the invasive cardiac labs.

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

We use an inventory management system by QSight. Pars are set and reorder reminders are displayed. It also provides updates on products nearing expiration and expired products.

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

We have a monthly departmental meeting involving the entire EP team to discuss issues and solutions. We also have an educational session, including lectures from basic topics to advanced discussions. The EP physicians (from 4 hospitals in the Geisinger Health System) have a quarterly mortality and morbidity conference to discuss the complications and opportunities to improve outcomes. More importantly, our team members frequently undertake quality improvement projects such as improving workflow, preventing infections, managing emergency response to complications, and reviewing safety drills.

What are the best features of your EP lab’s layout or design? What would you include on a “wish” list? 

Our EP lab was designed with input from physicians, staff, and anesthesia. Its design is conducive for most procedures. As always, more room and storage are on everyone’s wish list. Using our headphone communication system (Quail Digital) helps us interact and react quickly.

Have you developed a referral base?

Yes. We have an extensive Geisinger Referral Network in Pennsylvania and New Jersey with referring cardiologists and primary care physicians. We have several physicians referring from around the country (New York, New Jersey, Maryland, Tennessee, and New Mexico) for conduction system pacing when other approaches have failed. Some physicians also prefer to directly send elective patients for physiologic pacing. Additionally, many patients have self-referred based on published literature from our center. Dr. Vijayaraman is world-renowned for his innovations in the field of His bundle and left bundle branch pacing.

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

Our inventory system has par levels to prevent overordering. Also, pars are reviewed and adjusted on products that have not been used in specific periods of time. 

What changes have you made to improve lab efficiency and workflow as well?

We have implemented LEAN strategies to address time starts and room turnover time. 

How are new employees oriented and trained at your facility?

After hospital-wide orientation, EP staff undergoes a minimum of 3 months of orientation. A preceptor is assigned to the orientee. Assessments are done using EP competencies. Also, all staff has annual competencies and hospital-wide goals training. 

What types of continuing education opportunities are provided to staff? 

Almost all staff has rotated to attend the Heart Rhythm Society’s annual scientific sessions. Attendance is also determined by staff participation (ie, presenting, faculty, chair). We also have EP physicians and staff present educational PowerPoint presentations at our monthly EP meetings. Additionally, our EP staff are actively encouraged to participate in research and data collection, and often get to present our research at both national and international EP conferences. 

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

We have daily morning huddles to discuss the schedule, events, and any problems of the day with staff participation in decision-making. The work atmosphere is collegial, and patient care and safety are our priority. All members of the team are quick to adjust their work schedule to the personal and professional needs of each team member. We encourage additional training such as CEPS and CCDS, which allow our staff to advance their career. We are currently looking to add another EP technologist to bolster our workforce!

How do you handle vendor visits to your department? 

Vendors must be pre-approved and scheduled ahead of time. We use Symplr, a vendor credentialing service, for all of our vendors.

How is patient education managed? 

Patient education is a multidisciplinary approach utilizing EP unit nurses (in our pre and post area), EP physicians, APs, EP staff, and pharmacists.

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

We recently had a highly active endurance athlete referred for conduction system pacing due to RV pacing-induced dysfunction in the setting of complete heart block. Interestingly, the patient did not want any sedation and wanted to know, observe, and understand every detail of the procedure. He had complete infranodal AV block and underwent successful deep septal left bundle branch pacing with significant narrowing of paced QRS duration from 170 ms to 108 ms, with immediate normalization of LV function observed during post-procedural echo. He was one happy customer (patient).

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

We preferentially use cryoablation for all of our paroxysmal AF ablations (34%), and radiofrequency for persistent and longstanding persistent AF ablations (66%). 

Describe your approach to His bundle pacing. 

Dr. Vijayaraman has been performing HBP in our lab since 2005. Dr. Dandamudi (2010-2015) and Dr. Subzposh (2015-current) also perform HBP. Since 2011, every patient that requires permanent pacing has undergone an attempt at conduction system pacing in our lab. We have the largest experience in HBP. Currently, we attempt HBP first in all of our patients with normal His-Purkinje conduction, while we prefer left bundle branch pacing in patients with infranodal AV block (HV block). Our success rates for conduction system pacing is currently greater than 95%. Our EP lab is one of the centers for HBP training. We have demonstrated and provided education on the techniques of HBP to more than 100 electrophysiologists from across the U.S., Japan, Australia, Europe, Canada, and Mexico. In May 2019, we performed 2 live cases of HBP and left bundle branch pacing in our lab during the Heart Rhythm Society’s Annual Scientific Sessions.

Do you have a primary approach for LAA occlusion?

The WATCHMAN Device (Boston Scientific) is our primary approach for LAA closure. We also perform LARIAT LAA closure (AtriCure) when indicated or preferred by the patient.

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? 

Our fluoroscopy time is extremely low. We use 3.5 frames/sec in fluoroscopy. Also, 3D mapping and US are used to decrease fluoroscopy times. Our physicians use a specialty lead (Zero-Gravity, BIOTRONIK) that is suspended from the ceiling in both rooms. We also use RADPADs (Worldwide Innovations & Technologies, Inc.) to reduce scatter. In addition, we perform low-fluoro His bundle pacing and LBBP using 3D mapping.

What are your methods for device infection prophylaxis?

We use antibiotic prophylaxis along with intraprocedural antibiotic flush. Also, TYRX Absorbable Envelopes (Medtronic) are used when indicated. Our CIED infection rate is 0.35%. 

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

EHR has been used in our system for many years. It provides a comprehensive review of our patients. It also provides our patients with access to their medical records and communication with their providers. 

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

We believe that conduction system pacing will emerge as the preferred and recommended mode of pacing in the next several years. This is also likely to change the practice of cardiac resynchronization therapy.

Is your EP lab involved in clinical research studies? 

We are very actively involved in clinical research. We participate in both NIH-sponsored trials (CABANA, VEST) and industry-supported trials such as WATCHMAN, ECG Belt, and IMAGE-HBP. Additionally, investigator-initiated studies are well-supported in the health system. In the last few years, our physicians presented the findings from our research in three late-breaking clinical trial sessions at ACC.18 and Heart Rhythm 2019. We were also part of the recently presented His-SYNC trial, led by the University of Chicago team, at Heart Rhythm 2019. 

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

Twitter has created a global community for the medical field to share ideas, innovations, and relevant teaching cases. Most of our staff are active Twitter followers of EP physicians and technologists, and share cases, new articles, or research with our team.

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

Our procedural volumes have steadily increased in both ablations and pacemaker implants, while ICD volumes have flattened over the last decade. The patient population has also become more complex.

What is considered historic about your EP program or hospital? Has your program or hospital recently experienced any “firsts”? 

Our EP program was the first in our region, and has grown in both volume and stature over the years. Both patient and staff satisfaction are very high. The staff turnover rates are very low. Our physicians are extremely interested in staff education and clinical excellence. Research is strongly encouraged. Several members of our team have presented our research findings in both national and international EP conferences. Numerous publications from our center have been coauthored by EP staff. Recently, Angela Naperkowski, RN won the best abstract award at the Venice Arrhythmias conference held in October 2019 in Venice, Italy. Jessica Pugilese, BS, RT(R), RCES won a travel scholarship to present her research abstract at the 3rd Annual Physiology of Pacing Symposium held in November 2019 in Chicago, Illinois.

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

Our electrophysiology department works together as a cohesive team. Our EP nurses and technologists are very involved in education and advancing their knowledge of EP. As a training site for His bundle pacing, the staff has had the opportunity to share their knowledge of conduction system pacing with medical professionals from all over the U.S. and the world. 

The dedication of our physicians and staff to our patients, the field of electrophysiology, and to each other is what makes our EP lab special.