Spotlight Interview

Spotlight Interview: St. Bernards Medical Center

Devi G. Nair, MD, FHRS, Director of Cardiac Electrophysiology,

St. Bernards Heart & Vascular Center

Jonesboro, Arkansas

Devi G. Nair, MD, FHRS, Director of Cardiac Electrophysiology,

St. Bernards Heart & Vascular Center

Jonesboro, Arkansas

What is the size of your EP lab facility? When was the EP program started at your institution? 

The electrophysiology program at St. Bernards Medical Center began in 2000. We have two fully functional EP labs and one hybrid cath/EP lab. 

Has your EP lab recently expanded in size and patient volume? 

Yes, earlier this year we added a brand-new EP/hybrid lab, which helps us take care of our expanding patient volume in a timely manner. This has also helped facilitate our extraction program and WATCHMAN device (Boston Scientific) procedures. As part of this expansion, our pre- and post-op recovery areas were also renovated and expanded. 

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

The EP team at St. Bernards has eight staff members. There is a mix of credentials in our program, including physicians, registered cardiac electrophysiology specialists, registered nurses, radiologic technologists, and scrub techs. 

What types of procedures are performed at your facility? Approximately how many catheter ablations (for all arrhythmias), ICD implants, and pacemaker implants are performed each week? 

Our EP team performs different types of EP procedures, such as: cardiac rhythm management, including implantation of pacemakers (including Micra transcatheter pacing system [Medtronic] and His bundle pacing), defibrillators (including subcutaneous defibrillators), and cardiac resynchronization devices; ablations, including for atrial fibrillation and ventricular tachycardia (ischemic and non-ischemic); laser lead extractions; left atrial appendage (LAA) closure implants; and Impella implants (Abiomed, Inc.). In addition, we are part of multiple IDE clinical trials, which help advance the field and technology. 

Who manages your EP lab?

The EP team is led by Connie Hill, DNP, MBA, FACHE, vice president of heartcare and cancer care services at St. Bernards. The EP lab is managed by Jason Martin, BSRS, RT(R)(CI), and supported with an experienced specialized crew. Alyssa Edens is the director of the heart care center that houses the cardiac suites.

Are employees cross trained?

There is cross training among employees, but St. Bernards has employed staff completely dedicated to EP since 2011. 

Do you have cross training inside the EP lab? 

Dr. Devi Nair, the director of cardiac EP at St. Bernards, offers cross training, but her medical practice is dedicated to EP. 

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

The EP program is part of St. Bernards, a non-profit healthcare system based in Northeast Arkansas that serves as the corporate parent of a number of healthcare entities. This includes the largest hospital in the region, St. Bernards Medical Center, a 438-bed acute care hospital that serves as a regional referral center for 23 counties in Northeast Arkansas and Southeast Missouri. It is the only level III trauma center in the region, houses the only neonatal intensive care unit in the eastern part of Arkansas, and has served as the trusted provider of comprehensive, compassionate healthcare services for 117 years. St. Bernards is also a teaching facility with an internal medicine residency program and partners with the University of Arkansas for Medical Services (UAMS) for a primary care residency.

What types of EP equipment are most commonly used in the lab? 

We are excited that St. Bernards administrators have made cutting-edge technology a priority for the EP program. We have 3 three-dimensional mapping systems, including CARTO 3 (Biosense Webster, Inc., a Johnson & Johnson company), the EnSite Precision Cardiac Mapping System (Abbott), and Rhythmia HDx Mapping System (Boston Scientific). We have the EP-WorkMate Recording System (Abbott) and stimulator in one lab, and the LABSYSTEM PRO EP Recording System (Boston Scientific) and a Micropace stimulator (GE Healthcare) in the second lab. We have the MAESTRO 4000 Cardiac Ablation System (Boston Scientific), Cool Point Irrigation Pump (Abbott), and SmartAblate system (Stockert), as well as the NRG Transseptal Needle (Baylis Medical) for transseptal puncture. We have cryoablation as well as radiofrequency ablation capabilities; about 20 percent of ablations are done with cryo, and the other 80 percent are done with radiofrequency. We also have the capability of providing Impella (Abiomed, Inc.) support for complex VT ablations. Our hybrid lab helps us offer LAA closure and laser extraction in a safe manner. 

We use technology from Philips and Toshiba for fluoroscopy. We also use both Siemens and Zonare intracardiac echo systems for imaging during complex ablation procedures. 

What measures has your lab taken to reduce fluoroscopy time? 

We use ICE guidance and high-density 3D mapping for 90 percent of our ablations, which lets us not only reduce fluoro, but also allows us to do lead-free ablations.

Do you implant MR conditional pacemakers or ICDs?

Yes, 75 percent of our devices are MR conditional pacemakers.

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

In the EP lab, we usually have 4-5 ablations and 4-5 device implants a day. Our day starts at 7:30 AM. Personally, I spend four days a week in the EP lab and one day in clinic, where I see patients for pre- and post-procedural visits. The two other electrophysiologists on our team keep a similar schedule. Patients are checked in at 6:30 AM, procedures begin at 7:30 AM, and continue until 6:30 to 7:30 PM each evening. Our lab team does shift coverage.

How does your lab handle call time for staff members? 

The EP staff are dedicated to EP only, and do not cover cardiac call. This change came about due to the volume and hours being required in EP.

What new technology has recently been added to the EP lab? How have these technologies changed the way you perform procedures?

We have upgraded all of our mapping systems to the most current versions, which has helped us perform ablations with extremely low fluoro dosing or radiation exposure. I am particularly proud that 90 percent of all our ablations are completely lead and fluoro free, which is very exciting. This is better for both patients and staff members, which is very important to me. 

Who handles your procedure scheduling? Do they use particular software?

We have a staff member employed on the physician practice side who is dedicated to scheduling all EP procedures. This staff member uses MEDITECH for scheduling. 

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

Inventory is managed electronically through our CVIS system, which generates an order list to be placed into the hospital’s electronic data interchange (EDI) system. The inventory is managed by the two department managers for cath and EP. 

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

We have a very strict way of monitoring patients’ radiation exposure as well as fluoroscopy times. We are very good at monitoring our infection rates and keeping them as low as possible. We keep a database of all AFib ablation patients so that we can monitor the complication and redo rates. St. Bernards Heartcare Center hosts a monthly conference where physicians gather on a peer-to-peer level to discuss complications, mortality, and difficult cases. We have internal audit checklists for each device implant to make sure each case meets criteria and there are no contraindications. We are using a shared decision tool for consents. We participate in the LAAO and NCDR registries as well. 

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

We utilize several of the NCDR databases, all of which supply us with information that improves the quality of care we provide to our patients and allows us to spot any early safety concerns or patterns where we may need to alter our processes. 

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

We are fortunate to work for an organization that puts the patient and their healthcare needs first. We have seen some increases in reimbursement for ablation, and improvement in the ability to utilize the Impella device for high-risk cases. 

As expected, the payers take a little longer to catch up with reimbursement for new technology, such as for devices that can detect heart failure in advance of the patient having symptoms. This is when our purchasing relationships through our buying groups such as Captis and Vizient become very important.

In what ways have you helped to cut or contain costs, and improve efficiencies in the lab?

At St. Bernards, our mission is to provide Christ-like healing to the community, and we take that very seriously. When it comes to each patient, we evaluate what would be best for their particular condition and/or symptoms. We do a very strict per-case cost analysis and look at the patient’s best options. We also look at how we can keep costs managed while not sacrificing quality in the least. As a team, we visit on market shares and cost per cases. In addition, we look at new technologies that can help cut costs. 

Our cases have a very good flow. We do them in a set way to limit variation, so the staff is very knowledgeable about the procedure and more efficient. Staff members know what to pull for the cases and what not to pull. They are all highly educated and experienced about each of the procedures we do. I am incredibly proud of how efficient we all work as a team. 

In addition, we offer same-day discharge for our patients whenever possible, which benefits the patients who get the care they need while also having the opportunity to sleep in their own beds that night. 

How do you ensure timely case starts and patient turnover?

The EP lab staff works very efficiently to ensure cases start on time. We have 100 percent anesthesia coverage and a dedicated anesthesia team for every EP case. Our entire team is always working forward; for example, the staff member in charge of scheduling reviews the next week’s schedule, and while EP is finishing the procedure on one patient, the team is getting the next patient ready. We are always striving for and maintaining maximum efficiency. 

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

We have competition in the market. There is a second hospital in town, but EP services for this hospital are in another city. We have outreach clinics and a partnership with outreach hospitals where we offer EP clinics. 

How are new employees oriented and trained at your facility?

New employees go through 6-10 weeks of initial training with a mentor, and additional skills are updated as needed. This is in addition to the two weeks of hospital orientation, which includes a course on ECG rhythms.

What types of continuing education opportunities are provided to staff members?

In-service opportunities by our vendors are offered to all staff members, so our team is up to date on all equipment and procedures. Our team also visits national conferences to learn the latest, most groundbreaking techniques. 

I have been asked to provide continuing education classes at the local, state, and national level to a host of audiences, including fellow cardiac specialists, internal medicine and family practice physicians, and advanced practice providers. We also regularly host in-service events for our cardiology team — in addition to other providers in the regional referral area — to keep them updated on all the new procedures we are doing. 

How is staff competency evaluated?

We work hard to ensure a daily learning environment in the EP lab. We offer employees constant feedback, and participate in the St. Bernards annual employee evaluation program. We also use multiple industry-provided education learning tools, such as Medtronic Academy and VuMedi.

Have members of your staff taken the registry exam for the Registered Cardiac Electrophysiology Specialist (RCES)? Does staff receive an incentive bonus or raise upon passing the exam?

Yes, we have one staff member who has completed the RCES registry. Incentives are paid for post-credentialing in this area. 

How do you prevent staff burnout? Do you also practice any team-building exercises?

We have found that the staff who burn out are typically looking for additional growth in their career. We try to remedy this with additional tasks and roles within the department. 

How do you handle vendor visits to your department? Do you contract with vendors?

Vendors are scheduled by appointment only. All are required to be compliant through our Reptrax system. 

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

Yes, we use Innovative Health for reprocessing catheters; this has helped us cut down our cost per case in a very safe and efficient manner.

What are your techniques for LAA occlusion? Do you have a primary approach?

We primarily use the WATCHMAN device (Boston Scientific). We also use the AtriClip (AtriCure, Inc.) in patients undergoing open-heart procedures. We are also part of the AMPLATZER Amulet LAA Occluder trial (Abbott).

What are your thoughts on the use of NOACs in patients with non-valvular AFib? 

I think the use of NOACs in patients with non-valvular AFib has improved compliance and ease of use for patients. 

Do you perform only adult EP procedures or do you also do pediatric cases? 

We perform pediatric procedures in children over age 10. Younger children are referred to pediatric hospitals in the region. 

What are your methods for device infection prophylaxis?

Ninety percent of our devices are done on an outpatient basis — it is very rarely an inpatient setting. Patients get a Hibiclens bath/shower before procedures. Patients also get pre-procedural antibiotic prophylaxis, and we use the TYRX Absorbable Antibacterial Envelope (Medtronic) in high-risk patients. We try to reduce hospitalization time and encourage same-day discharge. 

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

I absolutely believe EHR systems improve quality of care. The coordination of a patient's health records improves continuity and allows for a better patient experience. 

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

Some of the main trends we see include a reduction in fluoroscopy and radiation exposure; ablation of more and more complex arrhythmias; biotelemetry; population health; and devices with more sophisticated and improved algorithms to track arrhythmias and improve quality of life.

How is outpatient cardiac monitoring managed?

We have Mobile Cardiac Outpatient Telemetry (MCOT, BioTel Heart) and Preventice Solutions as our 30-day monitoring services. We use seven-day Holter monitoring out of the ER, as well as the CardioKey (BioTelemetry) and BodyGuardian Mini (Preventice Solutions). We use implantable cardiac monitors for long-term monitoring. 

Is your EP lab currently involved in clinical research studies? Which ones?

In addition to the AMPLATZER Amulet LAA Occluder trial (Abbott), we are involved in the Boston Scientific-sponsored trials ASAP-TOO, APPRAISE ATP, PINNACLE FLX, and SMART CRT, and the SMART Registry (Boston Scientific).

Are you ACGME-approved for EP training? What are your thoughts on two-year EP programs?

We are not ACGME-approved for EP training. I think two-year programs are absolutely necessary, because it is very hard to get well trained in complex ablations and all of the new EP technologies in one year. 

Does your hospital offer a cardiac device support group for patients? 

Our hospital does not, but our practice has a device clinic and device specialist that is in constant contact with patients to help orient them to any new changes. About once every 2 years, we have a combination heart failure and device patient focus group. Every February, all device patients are also invited to a heart luncheon hosted by our medical center, and patients have an opportunity to interact with their providers at this setting.

Has your EP program achieved IAC accreditation?

Yes, we have received IAC accreditation. 

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

Social media allows for better communication between the hospital and patients. When we share information about new procedures or stories of patients who have had wonderful experiences at our facility, that is a direct line of communication with people we can be helping. If they hear that story or learn about that procedure and we can help that person (or one of their friends or family members), that is an amazing opportunity. 

Describe your city or general regional area. How is it unique from the rest of the U.S.?

Jonesboro is the regional hub for Northeast Arkansas, and approximately 128,000 people live in this region. Our area is mostly rural, which can make living a healthy lifestyle more difficult for people. Our draw area for EP is approximately 650,000. 

Where you live makes a difference. For example, there are many rural areas that do not have a grocery store. It’s not uncommon for little towns to have only a gas station with a fast food restaurant. For the people who live at the poverty level, it’s probably cheaper for them to visit a fast food restaurant and buy off of the dollar menu than it is to eat fresh fruits and vegetables. I hope that our healthcare access in these communities reaches the point where we can partner with people on community gardens, so that people can eat and have access to fresh fruits and vegetables. So much is tied to our diet. Additionally, if you live in a rural area where there is a food desert and no sidewalks, this can impact your health. People don’t realize how much where you live affects your healthcare. This problem certainly isn’t unique to our area, but it’s one we frequently encounter here. 

St. Bernards administrators have made it a priority to offer the highest quality healthcare to residents of this region, so as a physician, I am able to provide the best, most innovative procedures to my patients. I am proud to work here and serve patients in this area. 

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

We have a very comprehensive EP program here in Northeast Arkansas — this has helped our patients stay in this community and not have to travel to receive the lifesaving care they need. We have always been at the cutting edge of technology, and our crew is dedicated and excited to be here every day. Our team is always striving to learn so that we can offer the most innovative procedures and technologies. We truly work as a team — we believe that a team approach is absolutely what’s best for the patient — and that is what makes this team special. Administration works hand-in-hand with the physicians to make sure we are able to provide quality care in a safe and efficient manner.

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