Spotlight Interview: Carle Heart Center

What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab?

We have one dedicated EP lab at Carle. In the lab, we have two RNs and one X-ray tech. In addition to 2 EP physicians, the EP program also includes one advanced practice nurse (APN), two pacemaker/ICD RNs, and two office triage nurses. Other Heart Center staff members help with noninvasive tests (tilt table tests, Holters, event recorders). The device implants and laser lead extractions had previously been done in the operating room (OR), and are now being transitioned into the EP lab and one of the cath labs.

When was the EP lab started at your institution?

Diagnostic EP procedures were introduced in 1990 by Dr. Bruce Handler. In 1995, Dr. Abraham Kocheril started the radiofrequency ablation program. In 1996, a dedicated EP lab opened.

What types of procedures are performed at your facility? Approximately how many are performed each week? What complications do you find during these procedures?

Procedures performed here include electrophysiology studies, radiofrequency ablation, transseptal access, device implantation (pacemakers, ICDs, ILRs, biventricular pacemakers and ICDs) and follow-up, lead extraction using laser sheaths, and noninvasive tests including tilt table tests. The volumes are increasing with Dr. Soliman A. Soliman joining us in September 2002, but our annual volumes had been 160 RF ablations and 150 device implants. Complications, fortunately, are rare.

How is your EP lab managed, and by whom?

The EP lab, along with the cath labs, are managed by Alan Kettelkamp, RTR. The EP staff makes decisions about the day-to-day operation of the lab.

Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained? Do you have cross-training inside the EP lab?

The EP lab is a dedicated lab within the cath lab suite. The EP lab staff started in the cath lab and fill in there when needed. Within the EP lab, employees are cross-trained, with the exception of giving meds, which must be done by an RN.

What are some of the new equipment, devices and products introduced at your lab lately? How has this changed the way you perform those procedures?

In 2001, the cath and EP labs updated to the GE/Prucka/Mac-Lab/CardioLab system. This enabled us to customize system configurations, nurses notes and MD reports. Most of our documentation is done by selecting entries from macros with the click of a mouse. We can track statistics. Our inventory usage and supply billing is also generated through the system. This has reduced paperwork and record-keeping hassles. We use Carto and LocaLisa for 3D mapping. Our Atakr and Stockert generators have also been updated recently. Clinical trials include the Revelation Tx phase III (Cardima) for atrial fibrillation (AF), and the Thermo-cool phase III (Bosense Webster) for atrial flutter.

Who handles your procedure scheduling? Do you use a particular software? How do you handle physician timeliness?

Scheduling is a joint effort between the EP lab staff and office staff, using Cadence software. Each physician schedules 2 days in the lab, usually EPS/RF ablation in the mornings and device implants in the afternoons. The physicians and staff speak in the morning and discuss the needs for the day.

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

One person handles all of the ordering for the EP and cath labs. EP staff members communicate with her regarding product needs.

Has your EP lab recently expanded in size and patient volume, or will it be in the near future?

Dr. Soliman joined the group in September of 2002, and the volume is doubling. The need was here already, and adding a second physician has enabled growth. With the recent implementation of device implants in the lab (versus the OR), the EP staff is busier than ever.

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

Managed care directs the flow of patients to different centers, but does not affect how we provide care to our patients. What measures has your EP lab implemented in order to cut or contain costs and improve efficiencies in patient through-put? We are negotiating with all vendors to provide catheters and other equipment on consignment. We have a contract with an outside company to provide re-sterilization of catheters.

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

Carle currently has the only EP program in Champaign-Urbana. Dr. Kocheril is a consultant at Provena Covenant Medical Center (Urbana) and BroMenn Healthcare (Bloomington-Normal). BroMenn Healthcare has developed an EP lab, where Dr. Kocheril performs procedures.

Does your lab have an outpatient program?

EP studies, device generator exchanges, and ILR implants are done on an outpatient basis. The pacemaker/ICD clinic, EP clinic, and some heart failure services are part of the EP outpatient program.

How are new employees oriented and trained at your facility?

Training is primarily on the job. Cath lab training can take 2-4 months, depending on previous experience. All staff are required to complete ACLS training. Both nurses in the EP lab are PALS-certified as well. The physicians teach during EP lab cases. The vendors have also been a valuable source of teaching, especially Biosense Webster.

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

Dr. Kocheril created and chairs an annual one-day EP symposium (7th annual in 2002). The faculty consist of an outside keynote speaker and a mix of EP physicians and nurses from around the state of Illinois (Chicago, Springfield, Peoria, Urbana) and attracts a statewide audience. NASPE is the major meeting that is otherwise attended. Industry-sponsored programs have also been valuable (e.g. Medtronic and Biosense Webster).

How is staff competency evaluated?

Annually, all staff in the EP lab are required to complete competency evaluations on selected procedures and equipment.

Does your lab utilize any alternative therapies?

Research protocols include a study on the therapeutic effects of music, utilizing a harpist during EP procedures.

Have you had any interesting or bizarre cases come through your EP lab?

Patients present with multiple arrhythmias, interesting body piercings and tattoos. Using RA mapping for atrial fibrillation, interesting cases with radiofrequency triggers and atypical flutters have been uncovered. The most troublesome are the infected devices referred in for lead extraction, sometimes in septic shock.

How does your lab handle call time for staff members? How often is each staff member on call? How frequently do they have to come in, on average? Is there a particular mix of credentials needed for each call team?

The EP staff are committed to stay until the EP cases are done, and are exempt from call. There is an on-call cath team 24/7. We are hoping to expand staffing as our volume increases.

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

Most equipment is maintained by the BioMed department of the hospital, who respond promptly when needed. We have maintenance contracts with vendors as well (e.g. GE for fluoro equipment). The EP staff check items such as external defibrillators, emergency drugs, stimulator, and radiofrequency generators on a regular basis.

What trends do you see emerging in the practice of electrophysiology?

The ablation case mix in the EP lab has become less WPW/CBT, less atrioventricular node recovery time (AVNRT), more atrial flutter and fibrillation. More devices are being implanted, especially ICDs and biventricular pacing devices.

Does your lab undergo any sort of inspection?

It is subject to JCAHO, as well as hospital programs such as surveillance for infection control.

Does your lab provide any educational or support programs for patients who may have additional questions or those who may be interested in support groups?

The oldest is our ICD support group. With our chronic heart failure (CHF) projects, Marilyn Prasun, RN, PhD, has made herself available to CHF patients involved in our trials. We facilitate our AF ablation patients talking to each other as appropriate.

Is there a problem or challenge your lab has faced? How it was addressed?

Bringing device implants into the EP lab has required EP staff training in the OR, ordering equipment, developing procedures, and understanding the complex billing process. The EP staff will train other cath lab staff to handle these procedures as well.

Please tell our readers what you consider unique or innovate about your EP lab and its staff.

Linear RA ablation of AF is perhaps what we are best known for. Dr. Kocheril developed a mapping technique for this (JICE 2001;5:505-510). In the Revelation Tx phase III clinical (Cardima) trial, we the leading enrolling site. We were the first center to use LocaLisa (Medtronic) mapping with Cardima catheters. We have had good success with laser-assisted lead extraction and receive patients from a wide referral base for this. Since Dr. Kocheril and Dr. Prasun are interested in CHF as well as EP, the clinical and research arms of our EP program delve into CHF matters. Because of our early entry into biventricular pacing (via a clinical trial), Dr. Kocheril has served as a proctor to assist other centers in getting started. Dr. Prasun presented her study with a diuretic titration protocol at the AHA Annual Scientific Sessions in November of 2002 and earned the Martha N. Hill Young Investigator Award. Dr. Prasun runs an outpatient nesiritide program. Both Dr. Kocheril and Dr. Prasun are specialty advisors to the Medicare Coordinated Care Demonstration project, for CHF and AF (Carle is one of 15 sites in the country chosen to be in this trial). The EP lab staff, the pacemaker/ICD clinic, office staff, advanced practice nurse, and 2 MDs work together in an integrated fashion, allowing our EP program to be successful. We share a passion and enjoy what we do.