Management and Organization in Today's EP Lab

The following accounts of staff management and organizational practices in the electrophysiology lab were taken from Spotlight Interviews published in EP Lab Digest in a 2-year period. The labs were all located in the United States, and were interviewed between September 2001 to September 2003. In this article, comments were edited slightly so as to focus solely on the management and organizational aspects of their labs, including data on the number of procedures performed by electrophysiologists, types of procedures, and mix of credentials at each EP lab. In reviewing over this information, perhaps you will find how your EP lab compares amongst these labs.

From 2001, Vol. 1, No. 1: At Morristown Memorial Hospital in Morristown, New Jersey, the cardiac rhythm management program has grown from one lab with a single cardiac electrophysiologist and three full-time staff members to a full-service arrhythmia management team in the last nine years. The management team is comprised of three board-certified electrophysiologists, two full-time technologists, seven nurses and two office staff members. In addition, there is a full-time cardiac research nurse coordinator and three additional research nurses. Procedures performed include comprehensive electrophysiology (EP) studies, radiofrequency (RF) ablations for both ventricular (VT) and supraventricular tachycardias (SVT), pacemaker and defibrillator implantations, and tilt table testing. The complication rate is extremely low and compares to that of other outstanding laboratories on both a local and national level.

From 2001, Vol. 1, No. 2: The laboratory team at Walter Reed Army Medical Center in Washington D.C. consists of 10 personnel, five military and five civilians. There are four military RCIS-certified cardiac cath techs, two civilian X-ray techs, two RNs (one assigned to the cath lab and the other is the dedicated EP nurse who also has clinic and device follow-up duties on non-cath lab days) and one military EMT. Of this group, one RN and two RCIS personnel perform most of the EP cases. In addition, they have two electrophysiologists, one board-certified in adult cardiology and clinical electrophysiology, and the other certified in pediatric cardiology. The electrophysiology lab performs EP studies and radiofrequency ablations on AVNRT, atrial flutter, ectopic atrial tachycardia, and ventricular tachycardia. They also implant cardiac pacemakers and implantable cardioverter defibrillators. The only pediatric cardiac electrophysiologist in the armed services is assigned to WRAMC, so they also perform many pediatric EP studies and RF ablations as well. In a typical week, they will perform three to four EP/RF ablations, and two to three device implants.

From 2002, Vol. 2, No. 1 At the EMH Regional Healthcare System, which is part of a two-hospital system with campuses in Elyria and Amherst, Ohio, an EP service was implemented in 1992 with one electrophysiologist and two nurses. They now have three electrophysiologists, nine RNs and a cardiovascular technician. Two of their EP labs are dedicated only for electrophysiology procedures and a dual EP/HCL performs both EP and HCL procedures. The new dual EP/HCL lab was completed in 2000 to accommodate an increasing volume of cases. The Device Clinic, which was introduced in 1986, staffs two full-time RNs and one part-time RN. Electrophysiology lab procedures include ablative therapies, device implants, cardioversions, diagnostic studies, and tilt table tests. They perform three to four ablative therapies and 12-15 implants per week.

From 2002, Vol. 2, No. 2: The Saint Vincent Heart Center in Erie, Pennsylvania has three board-certified electrophysiologists, two dedicated EP labs, and an outpatient Pacemaker/Defibrillator Clinic. They have four full-time RNs, one part-time RN, a full-time RT and a full-time pacemaker specialist. The EP lab performs comprehensive EP studies, radiofrequency ablations, pacemaker/defibrillator implants, non-invasive programmed stimulation, and tilt studies; they also organize all cardioversions in the hospital. They average eight implants and four ablations a week. The pacemaker clinic checks 15-20 outpatient and in-house devices a day. Their complication rates are lower than the national and local average.

From 2002, Vol. 2, No. 3: At Riverside Methodist Hospital in Columbus, Ohio, they have four dedicated invasive EP labs, and a fifth that opened in the summer of 2002. They have two additional rooms for non-invasive procedures such as tilt table testing, external cardioversions and implantable cardioverter-defibrillator (ICD) testing. There are 32 staff members, including 28 registered nurses and four patient care technicians. Most of the nurses have critical care experience. They have an inventory manager, two inventory technicians and an administrative assistant. The electrophysiologists who utilize the lab are in private practice. The electrophysiology lab has a block scheduling system for the two physician groups who practice at Riverside. There are a total of seven full-time electrophysiologists. Riverside does basic EP studies and RF ablations for many types of arrhythmias, including AVNRT, atrial flutter, atrial tachycardias, VTs, Wolff-Parkinson-White (WPW) and atrial fibrillation (AF). They implant cardiac pacemakers, ICDs and biventricular pacemakers and defibrillators. They also utilize the laser for lead extractions and perform internal cardioversions. Along with the invasive procedures, they do non-invasive cases, including tilt table testing, external cardioversions, and ICD testing. In addition, they put a special focus on AF ablations. Dr. Emile Daoud performed the first LASSO mapping catheter-guided pulmonary vein isolation procedure in the United States at Riverside in November of 2000. Their physicians often use the transseptal approach to map and ablate left-sided tachycardias. There are many resources used to assist with advanced mapping of arrhythmias, including the Cordis Webster Biosense system, the QMS Basket and the Cardiac Pathways RPM system. In 2001, a total of 8,262 procedures were performed in their lab, of which 5,160 were invasive. The remaining were non-invasive procedures, including Holter monitoring and SAECG testing.

From 2002, Vol. 2, No. 4: The EP lab at the Georgia Heart Center in Macon, Georgia has a mix of six RNs and two cardiovascular specialists. One RN acts as a team leader in each of the labs. They report to the Assistant Vice President/Director of the Georgia Heart Center. They have one electrophysiologist; there are also three cardiologists who implant pacemakers. Electrophysiology lab procedures at the Georgia Heart Center include diagnostic EP studies, radiofrequency ablation, implantable cardioverter-defibrillators, PPM, biventricular pacemaker implantations, tilt table studies, cardioversions, and TEEs.

From 2002, Vol. 2, No. 5: The Einstein Heart Institute in Philadelphia, Pennsylvania has one dedicated electrophysiology lab and an AICD and pacemaker clinic. Their team consists of two electrophysiologists, four registered nurses, and two secretaries. Electrophysiology services provided by Einstein include tilt table testing, cardioversions, diagnostic EP studies, ablations (including for AF), AICD and pacemaker implants including biventricular device implants for heart failure. They perform approximately 13-15 cases per week, as well as a 15-20 person-per-week device clinic.

From 2002, Vol. 2, No. 6: Mercy General Hospital in Sacramento, California has two labs one for EP and one for implanting devices. Two new EP labs were scheduled to open in the spring of 2003, in addition to the present Pacer lab. Their staff consists of four electrophysiologists, eight RNs, one EP tech, two CV techs and one Rad tech. RNs must have ICU experience with a focus of cardiovascular care; technicians must have cardiovascular knowledge as well as computer skills. Mercy has a full-service EP lab performing diagnostic procedures, interventional procedures, and implantable devices (EP studies, ablations, tilt table testing, pacemaker, biventricular pacemakers, and ICD implants). In 2001, there were over 900 procedures performed. From January through September of 2002, there were 564 EP lab procedures, including 11 tilt studies, 146 EP studies, and 407 ablations (atrial tachycardia, SVT, HIS, ventricular tachycardia, atrial flutter, atrial fibrillation). In addition, there were 402 pacer lab procedures (pacers, ICDs, biventricular pacers/defibrillators).

From 2003, Vol. 3, No. 1 At the Carle Heart Center in Urbana, Illinois, they have one dedicated EP lab. In the lab, they have two RNs and one X-ray tech. In addition to two 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 non-invasive 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. 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 non-invasive tests including tilt table tests. Annual volumes had been 160 RF ablations and 150 device implants. Complications are rare.

From 2003, Vol. 3, No. 2: At Advocate Illinois Masonic Medical Center in Chicago, Illinois, there are two dedicated electrophysiology labs. They have one primary group of electrophysiologists consisting of seven physicians who perform procedures in either of the labs. They also are the primary operators of EP procedures at three other hospitals in the Chicago Metropolitan area. There are several other groups of cardiologists/electrophysiologists who periodically perform procedures in their labs as well. They also have active outpatient and a device follow-up clinics. The staff consists of five full-time registered nurses, one of which functions as a laboratory manager/clinical coordinator. There are also two part-time registered nurses and a cardiology technician who does pacemaker transtelephonic monitoring. Additional resources include a dedicated research nurse, an office nurse, three secretarial staff, and an EP program coordinator. There are two dedicated EP fellows and at least one cardiology fellow rotating on the EP service at all times. The seven main physicians are board-certified in clinical cardiac electrophysiology. The registered nurses all have critical care and cardiology backgrounds. They are all ACLS-certified and credentialed in conscious sedation. This institution is involved in several research protocols and serves the Midwest area as a referral site. Consequently, they perform RF ablations for many types of complex arrhythmias including VT, pulmonary vein isolation for AF, scar-mediated atrial and ventricular tachycardia, modified right atrial Maze procedures, WPW, AVNRT, atrial flutter, etc. They perform these both as the primary referral center and when other local EP labs refer them after failures or recurrences. They also implant pacemakers, ICDs and biventricular devices. They do lead extractions and non-invasive procedures such as tilt table testing, NIPS studies on ICD patients, internal and external cardioversions, and emergency temporary pacemaker insertions. In the past three years, Dr. Nazari has guided a special focus on the treatment of AF by atrial linear ablation and pulmonary vein isolation. In October 2002, Drs. Nazari and Maheshwari performed a pulmonary vein isolation procedure via a worldwide live webcast; it was narrated by Dr. Kehoe. They utilize the Endocardial Solutions advanced mapping system and the CARTO advanced mapping system. Dr. Nazari is also the center s principal investigator in the CryoCath FROSTY trial of cryoablation for treatment of SVT. They were the highest enrolling center for that trial and had excellent success rates with cryoablation of AVNRT and AVRT. In 2002, they performed 709 procedures in the EP lab at Illinois Masonic. Their complication rate is well within or below accepted national standards.

From 2003, Vol. 3, No. 3: At the University of Rochester Medical Center at Strong Memorial Hospital in New York, there are two EP labs (both with fixed X-ray systems, one biplane, and one single plane), divided by a control room. They share an 18-bed pre/post area with the cath lab. Tilt tests, cardioversions and non-invasive EP studies are performed in a dedicated holding room. There are 10 RNs eight are full-time and two are part-time. They all have nursing backgrounds in cardiology or critical care. There are four EP attending physicians and one dedicated EP fellow, and more fellows were scheduled to be hired. There is a heart pavilion within the hospital, and a dedicated floor specializing in the treatment of cardiovascular patients and cardiac transplantation. Patients are also placed in other telemetry units as needed. The University of Rochester is a major center for cardiology clinical research studies. In the past, they have been involved in the Companion and Miracle studies, as well as the MADIT I and II trials. Dr. Arthur Moss, who is a UR faculty member and primary investigator in MADIT II, has provided the criteria to implant ICDs in patients that previously would not have been candidates. The laboratory and the EP service have been actively involved in invasive and non-invasive trials investigating issues on long QT syndrome, arrhythmogenic right ventricular dysplasia, inheritable arrhythmias, prevention of sudden cardiac death, as well as evaluation of new implantable devices, antiarrhythmic medications and interventional EP catheters. Annually their procedures include 200 non-biventricular ICDs (154 dual and 55 single); cardiac resynchronization therapy/biventricular: 100 biventricular (65 ICDs, 40 pacers); 300 pacemakers; 25 implantable loop recorders; 300 EP studies; 260 RFAs of ventricular and atrial arrhythmias; 50-100 lead extractions; 50 NIPS; 150 cardioversions; and 100 tilt table procedures.

From 2003, Vol. 3, No. 4: At the University of California - San Diego in California, there is one dedicated EP lab (1,200 square feet) at UCSD Medical Center - Hillcrest downtown, where they do EP studies, ablation, and implantation of pacemakers and ICDs. They also share a single-plane cath lab at UCSD Medical Center - Hillcrest, where they only do device implantation. They were also building an additional procedure lab that will be shared with the cath lab at the La Jolla campus at Thornton Hospital. They perform approximately 600 procedures a year at UCSD Medical Center - Hillcrest. They anticipated an additional 200 procedures a year at Thornton Hospital, after the initial lab opening. At the time of publication, they performed up to four atrial fibrillation ablations/week, four to six atrial tachycardia or atrial flutter ablations/week, one or two ventricular tachycardia ablations/week, and four to six device implantations/week.

From 2003, Vol. 3, No. 5: At the University of Iowa Hospitals in Iowa City, Iowa there are two dedicated clinical EP laboratories. One is generally regarded as the device laboratory, which they use to implant pacemakers and defibrillators including biventricular devices. In this lab, they occasionally perform NIPS and other rather straightforward procedures. In the other larger (1,200 square feet) laboratory, they perform more complex EP studies, device implants, and all ablations. This laboratory has biplane capabilities, and is where all complex (CARTO and ESI) mapping procedures are completed. There is a separate pediatric EP/cardiac catheterization laboratory. A separate area (an adjacent recovery room) is used for tilt table testing. The tilts are generally performed by our team of advanced registered nurse practitioners, who also take care of the majority of our patients after procedures. Lead extractions are generally performed in the operating room.There are three adult EP faculty at the University of Iowa: Dr. Brian Olshansky, Director; Dr. Pamela Nerheim; and Dr. James Martins, who is also Chief of Cardiology at the Iowa City Veterans Administration Hospital. Drs. Martins and Olshansky are board-certified cardiac electrophysiologists; Dr. Nerheim is board-eligible for EP. There is one invasive pediatric EP faculty: Dr. Ian Law. Frank Eischens has a technical and nursing background, is a Testamur of NASPE AP/EP, is RCIS-certified, and has been involved with cardiac electrophysiology for over six years. Three of our radiographers are RCIS-certified. All of our nurses who administer conscious sedation have been trained and are certified by the hospital. Tom Drews is a fully trained, NASPE-certified pacer/defibrillator technician with a BSEE. Dr. Olshansky and Dr. Martins have been certified in deep sedation. This EP lab performs everything from simple EP studies, device implantations including biventricular implants, to simple and complex ablation procedures. They are seeing a great increase in the number of procedures in our AF ablation program. Their technique is to attempt to isolate all the pulmonary veins. They have tried several approaches, including ESI and CARTO. Generally, they have found using Lasso catheters and a double transseptal technique to be the best. At the time of publication, intracardiac echo was scheduled to arrive in the next several months and the plan was to work closely with our echo colleagues, including Dr. Richard Kerber, in this regard. An animal laboratory allows for investigation of innovative therapies and techniques.

From 2003, Vol. 3, No. 6: The EP staff at the University of Massachusetts Medical Center in Worcester includes four full-time academic faculty, who cover the University campus as well as the Memorial campus. This also includes three full-time registered nurses who rotate call schedules. There are always two RNs present for all cases involving conscious sedation. The institution has conscious sedation guidelines and all physicians and nurses adhere to these guidelines. They also have anesthesiologist support if needed. EP nurses perform regular quality assurance using an extensive outcomes database. They have a full-time nurse practitioner who assists with procedures, sees consultations, performs post-op wound checks, assists in patient teaching, and generally ‘sets the table each day. She also oversees the pacemaker and ICD clinics, which perform approximately 6,000 device checks per year. They have two dedicated EP fellows and a rotating general cardiology fellow on our service. They have an active clinical research program and have two excellent clinical research nurses to assist in patient recruiting and data tracking. Volumes have continued to grow steadily. They typically perform 1,200 procedures per year in the lab. These procedures include approximately 150 pacemaker implants, 300 ICD implants, 50 biventricular ICD implants, 150 catheter ablation procedures, 200 EP studies, 150 cardioversions, and other miscellaneous procedures. They also perform 30-50 laser lead extraction procedures per year.

From 2003, Vol. 3, No. 7: At the UCLA Cardiac Arrhythmia Center in Los Angeles, there are two state-of-the art EP labs which aim to serve as a resource for patients in the Los Angeles area. These labs allow for complex ablation work and include an implant lab for devices.  In addition, they offer intra-cardiac echocardiography for guiding procedures, invasive hemodynamic monitoring and support for complex ablation procedures, and intra-operative ablations in the cardiac ORs, where they are pioneering robotic and minimally invasive approaches to non-pharmacological management of arrhythmias. They have two EP (ablation) labs and one implant lab. There are five RNs and four techs that help with staffing these labs. There are three adult EP attendings and one pediatric EP attending, as well as two nurse practitioners. Complex catheter ablation cases (including ventricular tachycardia, atrial fibrillation, complex congenital cases), pericardial mapping and ablations are also done. They have a busy implant program with several CRT implants a week. In addition to this, they have a steady stream of EPS, AVNRT, pacemakers and regular ICDs. There has been a low rate of complications (major and minor