Spotlight Interview

Spotlight Interview: Pulse Heart Institute at MultiCare Tacoma General Hospital

Lane Wilson, RCIS, CEPS, CCDS (Lead EP Technologist); Tariq Salam, MD, MBA, FACC, FHRS (Medical Director, Heart Rhythm Service); Michael McDonald, RCIS, MBA (Cath Lab Manager)

Tacoma, Washington

Lane Wilson, RCIS, CEPS, CCDS (Lead EP Technologist); Tariq Salam, MD, MBA, FACC, FHRS (Medical Director, Heart Rhythm Service); Michael McDonald, RCIS, MBA (Cath Lab Manager)

Tacoma, Washington

Tacoma General’s beginnings trace back to the earliest days of the city of Tacoma. Founded in 1882, just 7 years before Washington achieved statehood, the Fannie C. Paddock Memorial Hospital opened its doors in a former dance hall on North Starr Street in what is now Old Town Tacoma.

Today, what was once the Fannie C. Paddock Memorial Hospital is now MultiCare Tacoma General Hospital, and the health care mission begun in that converted dance hall has evolved over the last 130 years into MultiCare Health System — the premier health care system in the South Puget Sound region.

We remain dedicated to enhancing the health of the people we serve, providing and setting the standard for quality patient care in the region, and supporting the communities that we call home.

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

Dr. Robert Hoyt brought EP services to Tacoma General in the mid 1990s.

We are an established program but share space with general cardiology, vascular surgery, cardiothoracic surgery, and pediatric cardiology services. We are frequently applying creative solutions to scheduling and creating space for expansion. 

What is the size of your EP lab facility? 

Our EP lab is situated on the seventh floor of the Pulse Heart Institute at Tacoma General Hospital. This floor contains our admit/recovery unit, an 8-bed cardiac short stay unit, and our cath/EP/vascular/CT surgery suites. We have 9 total procedure rooms – 4 CVORs, 2 cath labs, 1 EP lab, 1 EP/peds lab, and 1 hybrid vascular OR/cath lab. We have 1 dedicated EP lab, 1 lab we use for EP and share with our pediatric providers, and 1 “mobile” EP lab that we hope to open in Q4 2020 at another regional hospital in our network. 

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

Our lab has 8 procedural RNs and 15 technologists, as well as 2 support personnel who handle supplies and ordering. There are 3 additional RNs who act as nurse navigators for the EP program as well as a dedicated EP ARNP. The majority of our allied health staff are RCIS credentialed (our facility is the host for Spokane Community College’s Invasive Cardiovascular Technologist program in Western Washington), but we have a mix of radiology technologists as well. Our dedicated EP staff are mostly RCES credentialed, and a few of the staff members have secured CEPS/CCDS credentialing as well. 

What types of procedures are performed at your facility? 

We have a well-established program for device implants, including PPMs, ICDs, CRTs, S-ICDs, lead extraction, and physiologic pacing procedures. As for ablations, we offer both radiofrequency (RF) and cryoablation therapies for all types of SVT and VT/PVCs. The lab has spent a lot of time and energy focusing on how we can treat our ablation patients without the need for x-ray. We are happy to say that because of our efforts, we have developed workflows with 3D mapping and ultrasound that have allowed a couple of our providers to go years without the need for fluoroscopy during ablation cases. 

What would you consider to be the most common arrhythmia or type of procedure seen in your practice?

By and large, our EP resources are applied to treating patients with atrial fibrillation (AF). AF also seems to be the predominant type of ablation. We have been tackling more VT, PVCs, and complicated atrial arrhythmias over the last several years as well.

In what ways has the COVID-19 pandemic impacted your hospital, EP lab, or practice?

In the hospital setting, the largest limiting factor has been PPE. Early in 2020, we had to get very creative with securing PPE and making sure we had adequate resources for our cases. There has been a huge effort to make common areas in the hospital safer for staff and families. Cafeteria seating has been limited to 1 person per table, staff break rooms have posted capacities, and patient visitors have been restricted unless necessary. We’ve also had the standard supply chain issues, but we think everyone has been feeling that pain. The practice in general shifted heavily to virtual visits for those patients that could accommodate telemedicine, as well as trying to push for same-day discharges whenever possible or safe to do so. In the lab, we have made quite a few changes specifically targeting our ability to send people home the same day. For example, if patients want to go home and they’ve had no complications, we will use closure devices to shorten their time to ambulation and give us peace of mind about bleeding complications when they go home. In general, our device and AF ablation patients go home the same day. 

Approximately how many catheter ablations, device implants, lead extractions, and LAA closures are performed each week? 

We have 2 EP provider blocks in the lab 5 days a week. We perform 12 to 18 ablations per week. Our device implants vary, but we estimate those at 10 to 15 per week. Our LAA closures are less frequent, maybe 6 to 8 per month. Our lead extractions are even less frequent at 3 or 4 each month.

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

Our new implants use MRI conditional devices unless there is a specific need that an MR device cannot meet. We do implant subcutaneous devices, but we would estimate they are less than 10 percent of our ICD volumes. On the other hand, leadless pacers have been gaining a lot of traction during 2020, specifically because of COVID-19. The ability to send patients home after a leadless pacer placement is a win/win for us: patients don’t usually want to stay, and we get to discharge them sooner and open up a bed.

Who manages your EP lab?

Our combined lab is managed by Michael McDonald, a former staff RCIS who went on to complete his MBA. 

Are employees cross-trained?

EP and cath are, for now, combined. The benefits of sharing staff, a physical space, and support resources are huge for us. Employees are incentivized to cross train and take their EP registry exams. Our management has been extremely supportive and has placed a crucial role in making the EP lab attractive to staff looking for a new home. 

Tell us about your device clinic, including its staffing model.

We currently manage an active device clinic with 1 dedicated device nurse and 4 EP nurse navigators who work alongside 5 device techs.

Our clinic manages patients throughout the state. By increasing remote monitoring compliance, we have noted margin improvement while providing better service.

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

Tacoma General is a not-for-profit tertiary care community hospital. It is one of two Level 1 trauma centers in the county.

It is also the flagship hospital for the MultiCare Health System, which spans across the Pacific Northwest.

Has your EP lab recently expanded in size, or have you seen a change in patient volume?

We expanded the number of EP staff and providers in 2020, but are still using our same procedural space. We are expanding to add other labs at other campuses.

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

Biosense Webster is currently the largest supplier and reprocessor of our disposables; we utilize CARTO 3 for our 3D mapping cases and the SMARTABLATE generator for ablations. Most of our providers prefer the CARTO THERMOCOOL SMARTTOUCH SF line (Biosense Webster, Inc., a Johnson & Johnson company) of force feedback irrigated ablation catheters for everything except AVNRT cases.

We carry the Arctic Front cryoballoons and Freezor products (Medtronic) for our cryoablation cases.

Our 3 labs all have the LABSYSTEM PRO EP Recording Systems (Boston Scientific) paired with the Bloom DTU-215B Stimulators (Fischer Medical). 

We use SOUNDSTAR ICE catheters (Biosense Webster) paired with either X700 or P500 ultrasound machines (Siemens). 

For transseptal punctures, the EP team has been using the NRG Transseptal Needle (Baylis Medical), which has grown to include everyone on the structural heart team as well. 

How do you manage vessel closure?

The Perclose ProGlide (Abbott) has been our primary device since 2019. One of our providers likes to do a figure of 8 suture for hemostasis, and there is always manual pressure.

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

Fluoro-free ablations are a big one for us. We have been developing that for many years, but having a less dose of fluoro is so much better for our patients. Additionally, no lead is a crowd pleaser and has been helpful in recruiting regional EP talent. From a procedural point of view, we have been using the CARTO SURPOINT Module (Biosense Webster) since it was released, and this has changed our workflow a bit. Same-day discharge has probably been the biggest initiative of 2020. While it hasn’t changed how we perform the procedure, it is a big departure from the norm on the recovery side of our world. 

How is shift coverage managed? How does your lab handle call? 

Our EP techs work three 12-hour shifts, from 0600 to 1830. The EP staff doesn’t take STEMI call, but we do have late call 2 days a week, during which 2 techs stay to finish cases. Working 3 days a week and not being required to take STEMI call were huge for the tech staff, not only for reducing burnout, but also for making our program more attractive to new staff. 

Tell us what a typical day is like in your EP lab.

Busy! There is a 0600 staff meeting, daily equipment checks, central supply runs, and restocking. Then there is a 0700 generator changeout (usually in the cath lab), 0800 AF ablation (anesthesia), 1100 AF ablation (anesthesia), 1400 SVT or PVC/VT case, and 1600 is open for add-on device or ablation cases. 

This is the workflow in 2 labs per day, unless one of the doctors has an LAA closure or it’s a device-heavy week, during which they will go lighter on AF cases. 

Who handles procedural scheduling? 

Pulse has a scheduling office, but usually the providers will work out case triage with their nurse navigators before it goes to scheduling. 

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

We use Pyxis SupplyStation cabinets (BD), and have 2 great people from materials management that handle our supply requests and purchasing. 

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

At the end of every year, we typically set quality goals for the following year and hold monthly meetings with the providers during which representation from admin, the lab, and office attend. 

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

We have heard that our lab is unique in that all our staff sits in the procedure room for the case. I guess this is a consequence of small control rooms, but it is nice that we can all talk to each other without having to use headsets. My wishlist would include more space for storage, and cable conduits that we could access when something breaks — because it always does!

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

As we shift towards value-based care, we have started disease-specific clinics including an atrial fibrillation clinic, with clinical protocols to improve compliance of care pathways. Our AF clinic is managed by our ARNP using guideline-based protocols.

Have you developed a referral base?

Our referral base includes patients within the system and many groups outside of the system. 

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

In years past, we only had 1 EP lab to work out of. Once we were able to staff a second lab, it gave us the ability to move a doctor from one room to another and cut our turnaround times. This also has the added benefit of letting a team have breaks between cases. We have incorporated quality improvement processes to decrease wheels in-wheels out time, and have found that involvement of the entire care team is key to success!

How do you ensure timely case starts and patient turnover?

We believe that the key to timely starts and turnovers is staffing. The more staff you have to do the work, the faster it can get done. We found that the key to getting a room turned around quickly is having support staff ready as soon as one patient leaves the room. Having staff to clean, turnover anesthesia equipment, and restock disposables means that patient care staff can not only step away and recharge for a few minutes, but that progress can keep marching on even if the EP staff isn’t physically in the room. 

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

We have a collaborative environment within the Puget Sound region with all of our EP colleagues.

How are new employees oriented and trained at your facility?

Most of our EP staff is pulled from cath lab staff who have worked at the facility for many years. New staff have 3 weeks of general orientation to the facility, then 3 months of supervised EP orientation where they are familiarized with workflows and room setups. 

What types of continuing education opportunities are provided to staff? How many of your staff members attend medical conferences each year? 

All of the lab staff have $500/year to spend on continuing education. Medical conferences are usually attended on a rotation. The lab will sponsor 1 or 2 people from the entire care line each year to go, and then sponsor other people the following year. 

What options for continuing education are available to your mid-career staff?

There are specific resources available for staff who are trying to get a new credential, but otherwise we rely heavily on our vendors for continuing education units. MultiCare also has tuition reimbursement for staff looking for more formal education options. 

How is staff competency evaluated? Does staff receive a bonus based on performance?

Annual performance reviews are performed with staff and management, as well as quarterly “check ins” to see how things are going in general. There is no bonus structure for individual performance, but MultiCare does have a gainsharing program where care units who meet patient satisfaction goals are rewarded each quarter. 

Have members of your staff taken the registry exam for the Registered Cardiac Electrophysiology Specialist (RCES)? 

Yes, we have 4 technologists with the RCES credential. We also have 4 staff members with CEPS credentials. 

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

Work/life balance is an important part of avoiding burnout. This was a big reason we pushed for the 3/12 schedule. Team building usually took the form of activities outside of work — vendor educational dinners or just getting together after a shift. Unfortunately, 2020 has left us with few opportunities for that.

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

Staff are frequently asked to participate in planning committees for projects, specialty procedure meetings, and care line meetings. We’re also trying to reinstate our unit-based council to identify opportunities for improvement. 

How do you handle vendor visits to your department? 

Vendor visits are by appointment only, and in-services are education focused. CEUs generally help with attendance. 

How is patient education managed? 

We have 4 EP nurse navigators who educate our patients pre- and postop. They also focus much of their time on logistics, in coordination with cath lab leadership.

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

Yes, we utilize reprocessed catheters and platinum collection. The biggest impact reprocessing has is its value proposition. 

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

Our lab is approximately 95% RF and 5% cryo. It’s simply what our providers are comfortable with. 

Does your lab perform His bundle pacing? 

We do offer His bundle pacing devices; however, the percentage is very low — comfortably less than 10% of pacers. Typically, we will map with the lead attached to our EP recording system, then fixate it when we find a spot we all like. We are always on the lookout for tools to make this procedure faster and easier. 

Do you have a primary approach for left atrial appendage (LAA) occlusion?

We utilize the WATCHMAN (Boston Scientific) for percutaneous LAA closures. We perform the procedure much the same as we would for any other LA access — with a single fixed curve sheath and the NRG Transseptal Needle. 

Discuss your methods for lifestyle modification as therapy for your patients with atrial fibrillation.

All of our patients are counseled on lifestyle modification including sleep apnea, diet, exercise, and weight loss. We also counsel our patients on stress management.

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

Fluoroless ablation as well as same-day discharge of AF and device patients have made our lab much more efficient. A team-based approach to care and workflow has made iterative changes that have added up significantly over the years.

Are pediatric cases performed in your lab? Does your institution also have an associated cardiovascular genetics research clinic?

We have 1 pediatric provider who visits us 5 or 6 times a month. He is a partner of another cardiology group who practices in our lab as a partnership between his group and MultiCare’s Mary Bridge Children’s Hospital. He brings us mostly pacer implants, ILR implants, and SVT ablations. We also partner with our genetic clinic.

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 rely heavily on our CARTO system and ultrasound for fluoro reduction. Approximately 85% of our ablations are done with zero x-ray. All of our labs have ceiling- and table-mounted shields, as well as disposable shielding that we put on top of the patient for long device cases (eg, CRT).

What are your methods for device infection prophylaxis?

We use the TYRX Absorbable Antibacterial Envelope (Medtronic) for high-risk patients.

How do you use the NCDR Outcome Reports to drive QI initiatives at your facility?

We have been using the ICD registry since inception.

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

Our health network was one of the first in the region to adopt EMRs. While the transition was painful, I think overall it has been a good thing for our community. Not only are the patient records available from any of their visits in the region, but it allows the patient to receive and send electronic communication with care providers. 

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

We would estimate the most dominant trend is the transition of EP services into more remote and less traditional settings.

Is your EP lab involved in clinical research studies? 

Our lab has been involved with both device and NIH trials over the years, including the CABANA, SURPOINT, and Micra AV trials.

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

Twitter has been a good source for education and collaboration. It has been especially helpful managing the lab during the pandemic.

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

We have a true team-based approach to care. Our team includes everyone from leadership to the cleaning crew. We are fortunate to have team members collaborate and make changes with ease. 

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