When was the EP program started at your institution? By whom?
When the EP program started here in the mid 1990s, procedures such as device implantations and ablations were performed. Then for a while, only device implants and simple ablations such as AV node ablations and right-sided supraventricular tachycardia ablations were performed. The program was rebuilt in July 2017 when Dr. Kanjwal joined McLaren Greater Lansing.
We now have a brand-new EP lab with a new EP mapping and recording system and new C-arm fluoroscopy. We are now able to perform all types of procedures, including device implants and complex ablations for the treatment of atrial fibrillation and ventricular tachycardia.
As a newer lab, what growing pains or learning curves have you experienced?
Despite being a newer program, we have progressed well over the last year and a half. One of the challenges we initially experienced was the training of staff, including for EP studies and ablation procedures. However, our staff has shown good progress in acquiring both knowledge and skill.
What is the size of your EP lab facility? Where is the EP lab in relation to the catheterization department?
We have one EP laboratory and four cardiac catheterization labs. We have the ability to implant devices in our cardiac catheterization labs as well. The EP lab is located in our cardiac catheterization lab area. Our two cardiothoracic ORs are located on the same floor as well.
Currently, we have two cardiac electrophysiologists, Drs. Omar Bakr and Khalil Kanjwal, at our center. In addition, Dr. Ibrahim Shah is the director of the cardiac catheterization laboratory, and Dr. Ronald Pacis also performs pacemaker and loop recorder implantations.
Dr. Divyakant Gandhi is our cardiothoracic surgeon who performs surgical atrial fibrillation ablations. We plan to establish a center for hybrid AF ablation in the near future.
We hope that the EP lab will soon be fully separate from the cardiac catheterization lab, and that we will have a fully dedicated EP team.
What is the number of staff members? What is the mix of credentials at your lab?
We have 6 EP staff members, including: Brad Kalember, RRT, RCIS, Rick Umlauf, RRT, RCIS, Tara Cornwell, RCIS, Lisa Porubsky, Exercise Physiologist (EP), CVT, Sue Bort, RN, and Megan Hundt, RT(R), RCIS.
In addition, anesthesia support is available for all of our ablations and complex device procedures. We also utilize clinical personnel from Biosense Webster (Jackie Buckley, RN, BSN, CEPS) for all of our mapping cases.
What types of procedures are performed at your facility? What types of complex ablations are performed?
The most common procedure performed in our lab is atrial fibrillation ablation. We also perform ablation for atrial flutter, SVT, PVC, and VT. In addition, we perform all kinds of cardiac device implantations, including leadless devices and loop recorders.
Approximately how many catheter ablations, device implants, lead extractions, and/or LAA closures are performed each week?
We have performed almost 150 ablations and more than 250 device implantations in the last year.
Who manages your EP lab?
Kim Hiltunen, MRE, MBA, RN is the manager of our cardiac catheterization and EP labs; Dr. Kanjwal is the medical director of our EP laboratory.
What type of hospital is your EP program a part of?
Our hospital is an academic community hospital. We are a teaching hospital for Michigan State University. We have residency and cardiology fellowship programs as well.
What types of EP equipment are most commonly used in the lab? What imaging technology do you utilize?
We use the CARTO system (Biosense Webster, Inc., a Johnson & Johnson company), a C-arm (Philips), and the Claris Recording System (Abbott). We use the CARTOSOUND Module (Biosense Webster, Inc., a Johnson & Johnson company) as well. We use GE Healthcare technology for intracardiac echo.
What new initiatives or technologies have recently been added to the EP lab, and how have they changed the way you perform procedures?
With our new mapping system, we have been able to cut down on fluoroscopy to a great extent. We have started a zero fluoroscopy approach during ablation of atrial fibrillation, and are the first in the city of Lansing to offer this service. Our goal is to perform all AF ablations with minimal to no fluoroscopy.
How is shift coverage managed (typical hours)? How does your lab handle call?
Our work shift hours are from 8 am to 4 pm. We expect this to increase to 10-hour work shifts as our patient volumes increase.
Tell us what a typical day might be like in your EP lab.
We typically start our day with an atrial fibrillation ablation. On some days, we do two atrial fibrillation ablations and a few device implants in the afternoon. We have anesthesia support in all of our ablations and defibrillator implants. We perform ablations on Tuesday, Thursdays, and Fridays.
Who handles procedural scheduling? Do they use particular software?
We have two dedicated schedulers, Karen Hess and Michelle Brown, who help schedule our cath and EP cases. They use Outlook and Cerner for scheduling.
What type of quality control and assurance measures are practiced in your EP lab?
We have a monthly meeting to go over all of the issues in the EP lab. We try to pay close attention to the appropriateness of the procedures, especially for pacemakers and defibrillators, and make sure that prior to the procedure, the appropriate indication forms for the device are completed. We also utilize the ACC-NCDR registry.
How is inventory managed at your EP lab? Who handles the purchasing of equipment/supplies?
Kim Hiltunen, MRE, MBA, RN and Lisa Porubsky, EP, CVT, in consultation with Dr. Kanjwal, help manage the inventory and purchasing depending on our procedural needs.
Do you have any issues with your EP lab’s layout or design? What would you include on a “wish” list?
Yes, we would like to have cryo technology and another mapping system available.
Have you developed a referral base?
We have developed a good referral base over the last two years. We have done this by reaching out to primary care physicians and cardiologists, as well as by conducting atrial fibrillation awareness and education programs, which has all helped increase referrals.
In what ways have you cut or contained costs and improved efficiencies in the lab and device clinic?
We have started doing cases on continued anticoagulation, which has cut down on our needs for preprocedural TEEs in select patients.
How do you ensure timely case starts and patient turnover?
Being a new program, getting cases started on time was initially a challenge, especially when anesthesia was required. One of our staff members now comes in early to make sure patients are ready to be rolled into the room. In addition, we have started using a figure of 8 suture at the end of each ablation, and this has cut down on patient turnover time as well as helped with early ambulation.
How are new employees oriented and trained at your facility?
Our lab staff is cross trained for EP and cath procedures. Staff members are also routinely trained by vendors on any new equipment. In addition, the physicians provide teaching and didactics to our staff.
What types of continuing education opportunities are provided to staff? How many of your staff members attend medical conferences each year?
At this time, we are not able to send our staff to national conferences such as the Heart Rhythm Society’s annual scientific sessions. However, we are hoping in the future to send at least one staff member to such a meeting on an annual basis. We do use vendor-sponsored teaching opportunities on a regular basis. Vendors have also helped with tech site visits of our staff.
How do you handle vendor visits to your department?
Vendor visits are scheduled and approved by our manager. These visits usually have a specific educational component.
How is staff competency evaluated?
It is mostly based on hands-on training and observation.
How do you prevent staff burnout and turnover? What approaches do you use for team building?
We utilize staff rotation between the cath and EP lab. Staff engagements and meetings are some other ways we reduce stress in the lab.
Does your lab utilize any alternative therapies to help patients in the EP lab?
We offer warm blankets and sometimes use light music.
Does your lab use a third party for reprocessing or catheter recycling? How has it impacted your lab?
We use Sterilmed (now part of Johnson & Johnson) for reprocessing, and it has helped us with cost reduction.
What are your thoughts on the use of novel oral anticoagulants (NOACs) in patients with non-valvular atrial fibrillation?
In our practice, we prefer NOACs over warfarin in non-valvular atrial fibrillation. We have also started utilized uninterrupted NOAC therapy during atrial fibrillation ablation.
Do you utilize lifestyle modification as therapy for your patients with atrial fibrillation?
Yes. We utilize weight reduction, screening for sleep apnea, and control of risk factors such as hypertension and diabetes in all our atrial fibrillation patients.
What types of radiation protective shielding and technology are used?
We utilize radiation barriers, lead glasses, thyroid shields, and aprons.
What are your methods for device infection prophylaxis?
We perform electrical shaving in the area of implantation. We also utilize preprocedural antibiotics, antibiotics during the procedure, and post-procedure antibiotics. In addition, we are aggressive in achieving hemostasis to prevent hematoma and subsequent infection.
What are your thoughts on EHR systems? Does it improve your quality of care?
EHR in general has revolutionized the way we practice medicine. It allows for quick access, availability, and review of patient information. It has also improved our communication with other providers and personnel taking care of patients. There are areas for improvement, but nonetheless, it allows for easy access to patient-related health information.
What are some of the dominant trends you see emerging in the practice of electrophysiology?
We have observed a lot of patients being referred for atrial fibrillation, especially long-standing persistent or permanent atrial fibrillation. We would like to see these patients referred much earlier, so they can be offered better treatment options. We also see younger patients in their early 40s having atrial fibrillation, mainly because of obesity, sleep apnea, and uncontrolled hypertension.
Do you utilize remote monitoring? What clinical and economic benefits have you seen?
Yes, we use BioTelemetry, Inc. for monitoring at our center.
We also offer remote monitoring for all of our CIED implants; this has helped with early detection of rhythm disorders as well as helped reduce device-related office visits for our patients.
Describe your city or general regional area. How is it unique from the rest of the U.S.?
We are located in Lansing, which is the capital city of Michigan. Lansing is a culturally diverse community with a population of almost 500,000. Our hospital provides most of the services to patients in the community. However, we still have to refer patients for advanced heart failure and transplant needs to a center that is close to 75 miles away. We hope that in the future, we will have our own advanced heart failure program and cardiac transplant center.
Please tell our readers what you consider special about your EP lab and staff.
Our hospital is a part of the McLaren Health System. We have a team of dedicated staff who are experienced and knowledgeable. They are compassionate towards the patients and their needs. Our team is patient centric, and our patients are always our priority.
Our staff members are extremely hardworking and have played a pivotal role in building our EP program. We are highly appreciative of all the effort they put in to make our program even better.