Grandview Medical Center opened its doors in October 2015. As a new hospital, this gave us a chance to build our electrophysiology program from the ground up. Physicians worked closely with administration to design the EP labs, choose equipment, and most importantly, hire an outstanding staff.
Our vision was to build an EP program centered around patients with atrial fibrillation (AFib), with strong quality initiatives. From its inception, we tried to create protocols and set our own standards in every aspect of our day-to-day operation. In May 2016, we learned about the newly created Cardiac Electrophysiology Accreditation program launched by the Intersocietal Accreditation Commission (IAC). In 2017, our EP lab at Grandview became the fourth in the country, and the first in the southeast to achieve such distinction.
It was a great opportunity to enhance our EP service by creating and updating protocols, as well as to develop quality improvement (QI) programs to ensure our continued growth with an emphasis on quality and patient safety. We also continued to build databases and appropriate follow-up protocols for our AFib ablation patients.
A very important focus of our ablation program has been to reduce or eliminate the use of fluoroscopy in our procedures. We have performed almost 4000 ablations (mostly for AFib) without fluoroscopy. Hundreds of electrophysiologists and staff members from all over the country have visited our institution to learn these techniques.
When was the EP program started at your institution?
The EP program started when the hospital opened in 2015. Jose Osorio, MD was named the director of the EP laboratory, and worked closely with Chris Cooper, RN (EP Lab Manager) and Rick Kolaczek (Assistant Chief Executive Officer, Grandview Medical Center) to design the labs and EP program.
Describe the EP lab facility and equipment used.
We currently have 4 similarly equipped EP laboratories and a hybrid OR where lead extractions are performed. The EP labs are located next to the cath labs.
All of our labs are equipped with 3D mapping systems. We have the CARTO 3 System (Biosense Webster, Inc., a Johnson & Johnson company), EnSite Precision Cardiac Mapping System (Abbott), and Rhythmia HDx Mapping System (Boston Scientific) in our labs. We also have Medtronic’s cryoballoon system. All of our rooms are equipped also with a Siemens ultrasound machine.
What is the number of staff members?
We have 8 EP techs, and 3 of them are radiology techs. We have 6 RNs, not including our manager. Each room is staffed with 2 techs and an RN, as well as a CRNA. We work four 10-hour shifts, with rotating coverage on Fridays. We have a late team scheduled daily for cases that run later than normal hours. We do not shut down rooms for lunch. Team members will relieve each other when appropriate to provide lunch breaks.
Who manages your EP lab?
Our EP lab is managed by Chris Cooper, RN, who is responsible for planning our lab flow every day. As we typically perform up to 15 procedures a day, in multiple rooms, it is important to have the day planned early in the morning, and then adapt as patients arise and procedures are completed. We try to assign an EP team to each lab prior to procedure starts; this helps ensure turnover time is short for every case. Chris is responsible for identifying all issues and barriers, and we try to address them on an ongoing basis, with root cause analysis.
How many and what types of procedures are performed at your facility? What types of complex ablations are performed?
In 2018, we will have performed almost 2500 procedures. Our lab is performing 1500 ablations a year; 900 are for atrial fibrillation ablations, and over 200 ablations are for ventricular arrhythmias. We perform 700 device implants (230 defibrillator implants, 250 pacemaker implants, and 230 loop recorder implants). We also performed over 150 left atrial appendage (LAA) closures and 130 lead extractions. Our lab volume increased over 19% compared to 2017.
What percentage of your lab’s device implants use MRI conditional pacemakers or ICDs? What percentage of implants use subcutaneous or leadless devices?
The majority of the devices we implant now are MRI conditional, including both pacemakers and defibrillators. We also implant leadless pacemakers and subcutaneous ICDs, although we did less than 30 in 2018.
Are employees cross-trained?
Our staff members work exclusively in the EP lab and do not participate in cath lab call. We believe it is extremely important to have dedicated staff to improve the staff’s expertise as well as satisfaction.
What new initiatives or technologies have recently been added to the EP lab, and how have they changed the way you perform procedures?
In terms of new technology, we started using the CARTO VIZIGO Sheath (Biosense Webster, Inc., a Johnson & Johnson company), the ablation index, and EnSite Precision system (Abbott) in 2018. The CARTO VIZIGO Sheath is a steerable sheath that can be visualized on the CARTO 3 System, greatly facilitating AFib ablations without fluoroscopy; we have also seen decreases in procedural times with it.
Our most important initiative was to expand our research program; as a result, we have significantly increased the number of clinical trials we are part of. We are now enrolling patients in trials for cardiac devices, atrial fibrillation, VT ablation, and LAA closure. This has led to a significant increase in the number of clinical trial-related procedures performed in our lab, requiring our staff to learn about new therapies and technologies.
Tell us what a typical day might be like in your EP lab.
We commonly perform 12 ablations and many device implants on a daily basis. We try to efficiently manage our lab so that we only rarely work past 5 PM. For that to happen, we have set a goal to start our procedures by 7 AM every day.
Chris Cooper, RN arrives at the hospital at 5 AM to map the day out, while the rest of the staff arrives at 6:30 AM. Our anesthesiology department works very efficiently with us on every case, and they have been a huge part of our success and efficiency. We have established expectations for each step of the patient journey, and try our best to stay within it on a daily basis.
Our physicians work with “block time” in the lab, which leads us to have predictable case volumes every day and makes planning much easier.
What type of quality control and assurance measures are practiced in your EP lab?
We have an EP Quality Committee that meets frequently. The committee reviews and updates our protocols, and we have at least one quality improvement project we are working on at a given time. We review all minor complications and address any trends needed. Major complications are carefully presented and reviewed by the group members.
How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies?
We have a dedicated person from Materials Management who is assigned to the cath and EP labs, and orders inventory according to clinical needs. She does an excellent job of ordering and tracking supplies, as well as helping us set appropriate par levels. She also manages the inventory to make sure products are used prior to expiration dates.
Have you developed a referral base?
We have a large referral base, and our patients come from Alabama and neighboring states. As Grandview Medical Center continues to grow its base of primary care physicians in the network, we have also seen an increase in local referrals. We have established partnerships with cardiology practices around the state.
There are many hospitals with complete EP programs in Birmingham, Alabama, that compete with us. This has clearly driven a higher quality of all programs.
In what ways have you cut or contained costs as well as improved efficiencies in the lab and device clinic?
We have been very cost efficient in our lab, with efforts both in the supply cost and staff utilization. Our lab has minimal use of staff overtime, which significantly decreases cost. We have also worked very closely with all vendors and have taken advantage of several corporate initiatives to reduce cost.
How do you ensure timely case starts and patient turnover?
We believe that maintaining an efficient lab improves patient care and minimizes overall costs. We put a lot of effort into making sure our procedures start on time and that patient turnover is optimal. The two most important ways to maintain this level of efficiency are to define our goals and expectations for the whole team, and then closely monitor that time. We immediately address any deviations from our expectations. The efficiency of our lab stems from strong teamwork.
How are new employees oriented and trained at your facility?
We have competencies developed for the EP laboratory. Each new employee goes through all basic competencies with an experienced staff as preceptor. At the end of the probationary period, a formal review takes place with the EP manager.
What types of continuing education opportunities are provided to staff?
When a new product or procedure is introduced, the staff is trained in the lab with the subject expert. Some of our members have also attended local and national conferences. Online education resources are used as well. Typically, 2 to 3 staff members will attend the Heart Rhythm Society’s annual scientific sessions.
Does staff receive a bonus based on performance?
Our staff does not receive a bonus based on performance. However, there is an annual performance review along with merit increases.
How do you prevent staff burnout and turnover?
We believe that the most effective way to prevent staff burnout and turnover is by providing a consistent and predictable work day. Our staff members only rarely work late, and they do not participate in the cath lab call schedule.
We also perform the majority of our ablations without fluoroscopy, meaning that physicians and staff members do not have to wear lead apron. This decreases fatigue and has certainly increased job satisfaction.
What approaches has your lab taken to reduce fluoroscopy time? What percentage of cases are done without fluoro?
Some of our electrophysiologists began performing ablations without fluoro back in 2010. Today, all of our radiofrequency ablations for AFib and 97% of our ablations are performed without fluoroscopy.
What types of radiation protective shielding and technology are used?
During ablation procedures, we rarely use fluoroscopy. During device implants and LAA closure procedures, we use ceiling-mounted shields, and the Zero-Gravity Suspended Radiation Protection System (BIOTRONIK) is also available if needed.
What committees, if any, are staff members asked to serve on in your lab?
Staff members attend daily safety huddles, and several serve on the EP Quality Committee, Infection Prevention Committee, and Cardiovascular Operations Committee. Our staff was also heavily involved in the accreditation process.
How do you handle vendor visits to your department?
Vendors must register prior to visiting the cath and EP lab areas.
Describe a particularly memorable case from your EP lab and how it was addressed.
We recently performed an ablation of ischemic VT in a patient that had over 100 appropriate shocks over a few hours, prompting emergency ablation. His procedure went very well, with complete suppression of the VT. He was discharged home just 2 days later.
Does your lab use a third party for reprocessing or catheter recycling?
We do not use reprocessed catheters, but we do use reprocessed cables purchased from a third party.
Approximately what percentage of ablation procedures are done with cryo vs radiofrequency?
About 2% of our AFib ablations were performed with cryo in 2018.
Does your lab use contact force sensing technology during radiofrequency ablation of AFib?
All RF ablations of AFib were performed using contact force sensing catheters. We have been using these since market approval, and have observed significant improvements in our success rates at one year. All of our patients are followed systematically after AFib ablation, and we have been able to document incremental improvements in success rates as new technologies were adopted.
Does your lab perform His bundle pacing?
Yes, we perform selective His bundle pacing device implantation.
What are your techniques for LAA occlusion?
We currently implant the WATCHMAN device (Boston Scientific). We have performed LARIAT (SentreHEART, Inc.) procedures in the past, and also participate in clinical trials for the LAA closure device. We recently completed enrollment of the trial evaluating the WATCHMAN FLX (Boston Scientific).
What are your thoughts on the use of NOACs in patients with non-valvular AFib?
The vast majority (over 95%) of our patients undergoing AFib ablation are on NOACs. We have performed ablation with uninterrupted anticoagulation. While NOACs are much easier to manage before and after an ablation, we do have concerns about patient compliance; therefore, we have been performing pre-ablation transesophageal echocardiograms for most patients to rule out LAA clots.
Do you utilize lifestyle modification as therapy for your patients with atrial fibrillation?
Absolutely. We focus particularly on blood pressure and weight management. We also screen all of our patients for sleep apnea, and refer most to sleep studies.
What are your methods for device infection prophylaxis?
We follow typical guidelines. We preferentially use cefazolin for patients with a penicillin allergy, and a vancomycin infusion 60 minutes before the procedure. We are in the process of re-examining our current practice by working with the infectious disease team to come up with a comprehensive protocol for all device patients.
How do you use the NCDR Outcome Reports to drive QI initiatives at your facility?
We closely monitor reports and have recently found some areas that need improvements. We have implemented many changes in data entry, completeness of documentation, and standardization of reports to ensure the data is robust.
What are your thoughts on EHR systems? Does it improve your quality of care?
The implementation of the EHR system has greatly increased documentation as well as safety. Medication scanning has reduced the amount of drug interactions as well as allergic reactions. The previous use of paper charts was oftentimes challenging when trying to read an individual’s penmanship. The electronic health record has eliminated that issue. We have also been able to create standardized templates for ablation procedures.
What are some of the dominant trends you see emerging in the practice of electrophysiology?
As the number of patients with AFib continues to grow, we see an ever-growing need for EP labs to standardize their practices and become more efficient while maintaining or improving quality. We strongly believe that quality and efficiency can occur together.
Do you utilize remote monitoring of CIEDs? What clinical and economic benefits have you seen?
We encourage all of our patients that undergo device implantation to be monitored remotely. Patients with CHF are also monitored remotely using device technology. The device clinic and CHF clinic work together with a goal to reduce hospitalizations, and we have had great success.
Tell us about the clinical research studies that your lab participates in.
We are part of many clinical trials, and have a team of five research coordinators and one administrator. Some of the trials that we are currently enrolling patients and will soon start include: ASAP-TOO, PINNACLE FLX, SMART CRT, STOP AF FIRST, WAVECREST, DIAMOND-AF II, SURPOINT, and LESS-VT.
We also have a registry of our AFib ablations, allowing us to closely monitor our success rates. We are working with a dozen other U.S. hospitals that perform AFib ablations with a similar workflow to create the REAL-AF registry, which will allow us to follow real-world outcomes of patients undergoing radiofrequency ablation of AFib.
Does your hospital offer a cardiac device or AFib support group for patients?
We do not offer a support group, but we offer quarterly community education programs for the public.
Describe your city or general regional area. How is it unique from the rest of the U.S.?
Grandview Medical Center is located in Birmingham, which is the largest city in Alabama and has a metro population of 1,136,650. Birmingham and the surrounding suburbs enjoy warm summers and mild winters. The majority of commuting is performed by driving. Birmingham offers excellent healthcare, college sports, and restaurants. The cost of living in Birmingham is roughly equivalent to the national average, with housing prices varying greatly by neighborhood.
Please tell our readers what you consider special about your EP lab and staff.
Our staff understands the importance of what they do each and every day. Their responsiveness is second to none. Our turnaround time is very impressive, and programs from both around the county and abroad come to Grandview to learn how we have implemented and maintained our efficient operation.