When was the EP program started at your institution? By whom?
The EP program at MetroWest Medical Center in Framingham was started in 1993 by Dr. Mark Josephson and Dr. Donald Love. Dr. Josephson is considered to be one of the American pioneers of cardiac electrophysiology.
What is the size of your EP program?
We have 2 procedure rooms. One room is primarily designed for electrophysiology. It has a mapping system, and all of our ablations and most of our implants are performed in this room. The EP room can also be used for cardiac catheterizations if necessary.
The second room is primarily used for cardiac catheterizations and coronary interventions. In addition, we have a holding area that can be used to perform minor procedures, including transesophageal echocardiograms (TEEs) and cardioversions.
What is the number of staff members? What is the mix of credentials at your lab?
Our EP lab staff includes 11 full-time staff members. This includes 4 registered nurses (RNs), 2 registered cath lab technologists, a critical vascular technician, clinical coordinator, data analyst, administrator assistant, nurse director, and nurse practitioner.
What types of procedures are performed at your facility? What types of complex ablations are performed?
Our EP program offers a wide range of procedures, including temporary and permanent pacemaker (PPM) insertion, implantable cardioverter-defibrillator (ICD) implantation, biventricular PPM/ICD implantation, PPM/ICD generator changes, loop recorder implant/explant, cardioversions, TEEs, EP studies, and ablations. Ablation procedures include AV node, atrial flutter, supraventricular tachycardia, atrial tachycardia, and pulmonary vein isolation for atrial fibrillation (AF).
In what ways has the COVID-19 pandemic impacted your hospital, EP lab, or practice?
When the COVID-19 pandemic hit so quickly and fiercely, it was extremely difficult on our small staff. Elective cases were cancelled and our department closed, except for emergency cases only. We had a small team available 24/7 for emergency cases. We realized that our neighboring critical care area was extremely busy with high volume and extreme high acuity. We were made aware that an additional 25 ICU beds needed to be opened up. As a team, we knew we needed to help our fellow ICU staff. Our critical care-trained nurses, clinical coordinator, and nurse practitioner worked alongside our ICU nurses. Our administrator assistant worked to help staff one of the ICUs. Our technologists worked in a variety of roles, PPE fit testing, staff temperature checks, and assisting the nursing staff. Even our nursing director of the inpatient care area helped out at the bedside. While we are praying that another surge does not hit, we knew that we wanted to be proactive. We are training all of our nurses to be able to care for the critically ill patient and are looking for other potential areas where staff can assist. While the effects of COVID-19 have been devastating, it did leave us with one positive note: we definitely are a stronger team because of it.
What would you consider to be the most frequent procedures performed or the most common arrhythmias seen?
The most frequent procedures performed include cardioversions, device implants, and ablations.
Approximately how many catheter ablations (for all arrhythmias), device implants (ICD, pacemaker, ICM, ILR, etc.), lead extractions, and LAA closures are performed each week?
Our case mix varies from week to week. In 2019, we performed the following procedures:
- 145 EP studies (including 60 radiofrequency ablations and 18 cryoablations)
- 122 PPM/ICD implants and 6 loop recorder implants
- 253 cardioversions
- 230 TEEs
- 5 tilt tests
- 8 temporary pacers
Our monthly averages are 10 PPM implants, 4 ICD implants, 6 EP studies, 6 ablations, 21 cardioversions, and 19 TEEs. We do not perform lead extractions or LAA closures at MetroWest Medical Center.
What percentage of your lab’s device implants use MR-conditional pacemakers or ICDs? What percentage of implants use subcutaneous or leadless devices?
Our EP lab uses greater than 90% MRI-compatible devices. Over the past year, our subcutaneous device numbers have significantly increased. We are not currently implanting leadless devices, but we are considering doing so in the near future.
Who manages your EP lab?
Kimberly Kelley, DNP, RN is the Nursing Director of Acute Care and Critical Services, and Jean Decourcey, RN, who has over 30 years of experience, is the Cath Lab Clinical Coordinator.
Is the EP lab separate from the cath lab? For how long? Are employees cross-trained?
The EP and cath labs are separate, but are located adjacent to each other. We encourage our employees to be cross-trained to work in both rooms. We are a small unit, which requires everyone to maintain current proficiency and competency.
Tell us about your device clinic.
We do not have a device clinic at MetroWest Medical Center. The physicians working in our lab have a private practice device clinic located next to the hospital.
What type of hospital is your EP program a part of?
MetroWest Medical Center is an acute care community-based hospital located in the MetroWest region, a cluster of cities just west of Boston.
Has your EP lab recently expanded in size or patient volume?
Although the physical size of the EP lab has not changed in many years, we have seen significant growth in EP volume since our AF clinic opened in March 2019. The AF clinic is located in the Heart Center of MetroWest adjacent to the hospital.
In addition to seeing more ablations, we have seen an increase in TEE, cardioversions, and device implants.
What types of EP equipment are most commonly used in the lab? What imaging technology do you utilize?
For mapping, we use the EnSite NavX Cardiac Mapping System (Abbott). Our stimulator is made by Micropace. For transseptal punctures, we use an ultrasound machine and ICE catheter from Abbott. Our catheters include the TactiCath Quartz Contact Force Ablation Catheter (Abbott), Safire Bidirectional Ablation Catheter (Abbott), and Advisor HD Grid Mapping Catheter, Sensor Enabled (Abbott). We also use quadripolar and decapolar catheters from Boston Scientific. We use the Medtronic cryoablation system for all AF ablations. We primarily use devices from Medtronic, Boston Scientific, and Abbott. We use Philips imaging in both the EP and cath labs.
How do you manage vessel closure?
We recently started using the VASCADE MVP Venous Vascular Closure System (Cardiva Medical), which has been very effective. By introducing this technology, we have significantly reduced our manual hold time, allowing for much quicker room turnover. We are now able to ambulate most of our patients just two hours after the procedure.
How is shift coverage managed (typical hours)? How does your lab handle call?
At MetroWest Medical Center, our team consists of 9 clinical staff members who cover our lab 24/7. Our shifts are 7:00-3:30 pm and 7:30-4:00 pm. The call team is responsible for covering late cases. We schedule a minimum of three staff members to be on call each night, and we are often able to schedule 4. Each staff member is required to be on call at least 2 weeknights and every third weekend. Staff members generally select the shifts that they want to be on call. If there are gaps remaining in the schedule, then the clinical coordinator will assign shifts. During downtime, the staff members spend time on continuing education, organizing and cleaning the unit (ie, the dreaded staff refrigerator), stocking and checking inventory, or assisting other inpatient units.
Tell us what a typical day might be like in your EP lab.
Every day is different in the EP lab, and this makes it both an interesting and challenging place to work. We have a small team that is very professional and supportive of one another. We like to think of ourselves as a family. This has allowed us to rise to all the unique challenges in the EP lab over the years.
Who handles procedural scheduling?
Our administrative assistant is responsible for scheduling all procedures. She also works closely with the charge nurse for unscheduled add-on cases.
How is inventory managed at your EP lab? Who handles the purchasing of equipment/supplies?
The inventory and purchasing of equipment and supplies in our lab is managed by our lead inventory RN. However, we recognize that it is critically important that everyone in our department take responsibility for assisting in product counts and inventory.
What type of quality control and assurance measures are practiced in your EP lab?
The EP staff at MetroWest Medical Center ensure quality control and assurance measures by organizing and holding EP lab quarterly peer review meetings. We are also currently implementing a practice to record daily first procedure start times in order to monitor and improve lab efficiency.
What are the best features of your EP lab’s layout or design?
We are fortunate that both of our labs are spacious, and can comfortably hold all our equipment and our staff.
How has managed care affected your EP lab and the care it provides patients?
Managed care has impacted the management of our EP patients only as it has presented additional challenges to obtain prior authorization for noninvasive testing. Fortunately, our lab has not had the challenges of obtaining procedure approval because our documentation has been excellent.
Have you developed a referral base?
Yes, we have developed a large referral base by working closely with our primary care physicians over the years.
In what ways have you cut or contained costs in the lab and device clinic?
We have recently implemented a new inventory flow sheet, which has helped us reduce product waste.
What changes have you made to improve lab efficiency and workflow?
We are a very efficient lab. Our case turnover is very fast. All staff members help to expedite getting the patient off the table, cleaning the equipment, escorting the patient to their hospital room, and setting up the room for the next procedure. When we call for our next case, we often personally retrieve the patient rather than waiting for the patient to arrive, since we understand how busy the inpatient unit nurses can be. We are a team, and if we can improve our lab efficiency and keep our patients happy and satisfied, we do it 100% of the time!
How do you ensure timely case starts and patient turnover?
We notify the procedural physician as soon as the patient is placed into the EP room and then again when we are ready for them to begin the scrubbing process. Our team is responsible for wiping down all the equipment post procedure while waiting for environmental services to assist us with the remainder of cleaning to get the lab ready for the next patient. We also like to escort the patient back to their room, assist the accepting nurse, and answer any further questions that need clarification before immediately heading back to the lab to prepare for the next case.
Does your EP lab compete for patients? Has your institution formed an alliance with others in the area?
MetroWest Medical Center is an acute care community hospital in Eastern Massachusetts, located halfway between Boston and Worcester. This is a very competitive market. In order to compete in this market, we have had to offer services that are generally only available in larger academic medical centers. These services would include AF ablations and primary angioplasty. We do not have formal alliances with others in the area. We have earned the referrals from our surrounding primary care physicians by offering exceptional care.
How are new employees oriented and trained at your facility?
Our new employees complete a 1-week hospital orientation. Each new employee then must complete a minimum of 8 weeks of direct orientation in the cath and EP labs. We have unique competencies that need to be achieved and signed off by a preceptor. We check in weekly to monitor progress and identify any learning needs or opportunities.
What types of continuing education opportunities are provided to staff?
Each year, staff members are offered a specific number of educational hours and are able to choose how to use those hours to attend conferences and other learning opportunities.
What options for continuing education are available to your mid-career staff?
Staff members receive education through the hospital’s LearnShare online training modules and through attending conferences. We participate in the Medtronic Academy. Abbott also provides bimonthly EP conferences on topics of our choice for staff continuing education.
How is staff competency evaluated? Does staff receive a bonus based on performance?
Competency of staff is evaluated on an ongoing basis and during annual performance evaluation. Mandatory EP lab yearly competencies are to be completed on topics such as the EP mapping system, IABP, radiation safety, moderate sedation, and fire safety.
Performance evaluations are merit based depending on performance rating.
How do you prevent staff burnout and turnover? What approaches do you use for team building?
We are truly family and a team in the EP lab. We have known each other for a long time. We spend time with each other, and attend each other’s cookouts, weddings, retirement parties, and baby showers. We have also held team events, such as a kickball tournament and volleyball tournament, in the past. If the lab volume is low, we flex out early and take a walk or a run together around the local town park.
What committees, if any, are staff members asked to serve on in your lab?
We have a quarterly EP meeting to discuss statistics, review data, monitor trends for any opportunities for improvement, research new practices or technology, submit capital requests, and to address any open agenda items.
How do you handle vendor visits to your department?
Clinical EP vendors are always allowed in cases to assist. Cath vendors are permitted in the lab to provide in-services/education/support after registering in Vendormate.
Does your lab utilize any alternative therapies to help patients in the EP lab?
We use music in the lab to help our patients. There has been plenty of research over the years demonstrating how music improves respiration, lowers blood pressure, and is beneficial for mental health. Music plays an important role not only for our patients, but for the staff as well. Working in the EP lab can be very stressful, but listening to “Sweet Caroline” (the song by Neil Diamond, which is also the Boston Red Sox theme song for the 7th inning) lessens the overall anxiety and provides everyone in the room with a sense of comfort and harmony.
How is patient education managed?
Patient education begins when our physicians see their patients in their private practice. When the patient arrives at the hospital, they are given additional educational information and pamphlets on the procedure being performed. Post procedure, we give both verbal instructions and written individualized discharge instructions to patients upon leaving the hospital. Our device vendors are involved in the educational process as well, and explain home monitoring to patients and their families.
Describe a particularly memorable case from your EP lab and how it was addressed.
The most memorable time in the EP lab was not actually a case, but the milestone of when MetroWest Medical Center approved our AF clinic. From the very beginning, it was a team-based project that included conducting research, ordering equipment, going onsite to various hospitals to observe procedures, and of course, learning how to use the new equipment we would be working with. It was all very exciting! Then, after many practice runs, we had our first patient and things went very well. With each subsequent case, we became more proficient in our technique. Knowing that all of our hard work had paid off, being able to provide a specialized AF approach to help our patients, and having our physicians’ support and confidence in our skills meant the world to us!
Discuss your methods for lifestyle modification as therapy for your patients with atrial fibrillation.
We perform a detailed history and physical on each of our patients with atrial fibrillation. We try to identify any potential triggers such as obesity, sleep apnea, and alcohol consumption. We then review the importance of lifestyle modification in addressing the triggers and reducing the burden of atrial fibrillation.
We work very closely with our local primary care physicians, sleep disorder specialists, endocrinologists, and weight loss specialists. It is definitely a multidisciplinary team approach.
Does your lab use a third party for reprocessing or catheter recycling? How has it impacted your lab?
We use SterilMed to reprocess our EP catheters. However, some catheters cannot be reprocessed. We send the platinum tips from these catheters, and the hospital receives a small reimbursement.
Approximately what percentage of ablation procedures are done with cryo vs radiofrequency? Why?
Our percentage of radiofrequency ablations is approximately 77%, and cryoablation is approximately 23%. We recently started performing AF ablations on Wednesdays. Our plan is to increase the number of procedures; however, the demand for other types of ablations is much higher.
Does your lab perform His bundle pacing? In what percentage of cases? Describe your approach.
We do perform His bundle pacing for a small percentage of our cases, although this percentage has been increasing. We are using the Medtronic deflectable catheter and His lead (SelectSite C304-HIS deflectable catheter system) for our cases while mapping and pacing the His channel.
What are your thoughts on the use of NOACs in patients with non-valvular AF?
We believe NOACs are an excellent choice for patients with nonvalvular atrial fibrillation. We almost always initiate a NOAC, and only initiate warfarin when patients do not choose to have a NOAC due to financial constraints or when medically contraindicated.
Is hybrid epicardial and endocardial ablation of atrial fibrillation performed at your institution?
We do not perform those procedures, as we do not have open-heart surgery onsite. Very high-risk patients requiring CT surgery backup are referred to academic medical centers.
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 have been using a 3D mapping system that has dramatically reduced fluoroscopy times for our ablation procedures. We still use fluoroscopy in a very limited fashion for most of our ablations, but we use the lowest setting. We use standard lead shields for all cases. When standing close to the patient, the staff have a portable lead shield that can be used for giving medications or panning the table.
What are your methods for device infection prophylaxis?
For every implant and generator change, the physician uses a pocket flush consisting of 1 gram vancomycin and 80 mg gentamicin in 250 mL normal saline (NS). If the physician feels that the implant or generator change has a high potential for infection, they will use the TYRX Absorbable Antibacterial Envelope (Medtronic).
What are your thoughts on EHR systems? Does it improve your quality of care?
Our hospital currently uses MEDITECH to access medical records. We have found that EHR systems have been moderately helpful with our patients from different health care systems. Unfortunately, these systems each have their own EHR and do not communicate with each other. We look forward to when all of these systems are connected, as we believe this will significantly improve the care of our patients. In Spring 2021, we will be upgrading to Cerner, which we anticipate will further improve the quality and safety of patient care.
What are some of the dominant trends you see emerging in the practice of electrophysiology?
We anticipate major advancements in ablation therapy over the next several years. We are particularly excited about the potential role of electroporation and other novel forms of ablation therapy, which will make ablations safer and more effective.
Do you utilize digital tools or wearable technologies in your treatment strategies for patients?
We are increasing our use of wearable technologies for the diagnosis and management of arrhythmias in patients. We have discovered that patients are much more complaint with these devices, so they have become very effective tools. The ability of smartphones and Apple Watches, etc., has made a difference in our patients’ ability to be proactive in the management of their health.
Are you ACGME-approved for EP training?
Yes, MetroWest Medical Center has a residency training program that is ACGME accredited.
Has your lab achieved EP accreditation, or does it plan to in the future?
We are currently in the process of applying for accreditation from the Intersocietal Accreditation Commission.
How do you see social media changing the field of healthcare?
Social media has become a powerful tool that can be used in multiple ways in healthcare. Many healthcare systems are using social media for marketing and patient education. However, the role of social media in healthcare will continue to grow. We expect that it will become a driver in the areas of public health and research recruitment.
What trends have you seen in your procedures and/or patient population?
Despite national trends in decline of cardiac procedural volume over the past decade, we have experienced a slow but steady growth in diagnostic cardiac catheterization, PCI, and EP procedures.
Describe your city or general regional area. How is it unique from the rest of the U.S.?
Our EP lab is located in Framingham, which is the birthplace of the Framingham Heart Study. This is an ongoing cardiovascular cohort study of residents of the city of Framingham. The study began in 1948 with 5209 adult subjects, and is now on its third generation of participants. Many of our patients have a sense of pride knowing that they and their ancestors have participated in this seminal study.
What specific challenges does your hospital face given its unique geographic service area?
Being in the Boston suburbs places us in competition with some of the most esteemed medical institutions in the country. We pride ourselves on being able to compete with these institutions, and perpetually strive to deliver exceptional quality care with expert staff using state-of-the-art equipment and facilities. We aim to do all of this with the convenience of patients receiving their care in their neighborhood with a friendly and personal community hospital ambience. Patients appreciate being able to receive the same treatment and care that they would at the larger hospitals, but with the convenience of being close to home (and a lot less traffic)!
What is considered historic about your EP program or hospital? Has your program or hospital recently experienced any “firsts”?
We perform cryoablations, left-sided ablations, and primary PCI without onsite surgical backup. A major Boston hospital serves as our offsite backup. We were a leading enroller in the MASS COMM trial, which concluded that elective PCI without surgical backup was as safe as with the presence of surgical backup.
Please tell our readers what you consider special about your EP lab and staff.
Everyone on our small staff is highly motivated, eager to learn, and always striving to provide the best patient care possible. One thing that we pride ourselves on at this organization is that we are able to take the time to get to know our patients and create a rapport with them, which really eases their anxiety. We work hard and are very professional, but we also try to have fun!