Porter Adventist Hospital

This electrophysiology lab is the newest addition to the cardiac program at Porter Adventist Hospital. The EP lab is also only the second in the state to acquire the Biosense Webster, Inc.'s CARTO Electroanatomical EP Navigation System. Read about what they consider to be the strengths of their lab.

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

Porter Adventist Hospital has one EP lab and one implant room. We are located in the same vicinity as our cardiac cath lab. We have just completed a remodel of our EP lab, that included the installation of an Omega bi-plane imaging system. In order to continue doing EP cases during the remodel, a storage room was temporarily turned into an EP lab (sounds familiar doesn't it?). Now that the remodel is complete, we have a large EP lab, with lots of room and storage. The storage room/EP lab has now been converted to an implant room for other cardiologists to use for implants during lengthy EP procedures. The implant room will continue to use the C-Arm for imaging. We have three EP lab staff. One is a paramedic with extensive experience in an EP lab before moving to Colorado. There are also two RNs: one has a background as an EP nurse with a private practice physician along with a Critical Care background, and the other has Critical Care and unit manager experience.

When was the EP lab started at your institution?

Our EP lab at Porter Hospital started about 12 years ago. It initially began with medical staff from a nearby university hospital. It continued with University Hospital Medical Staff, until private practice electrophysiologists came in about 10 years ago. Our EP lab Director Dr Roger Damle and his partner Dr William Choe provide us with most of our patients.

What types of procedures are performed at your facility?

Procedures performed in our lab are tilts, cardioversions, pacer/ICD interrogations and re-programming, EP studies, ablations (SVT/VT and atrial fibrillations) and implants of pacers, ICDs and biventricular devices. We are hoping to begin doing patent foramen ovale (PFO) closures also. Due to having staff that are experts in conscious sedation and have critical care skills, we also assist with transesophageal echocardiography (TEE) and stress echos.

Approximately how many are performed each week? What complications do you find during these procedures?

Currently we perform about 50 procedures per month. Each year it seems that our volume is increasing. Our continuous quality improvement (CQI) process involves tracking patients for groin complications, post-implant pneumothorax, lead dislodgements, and site infections.

Who manages your EP lab?

We are managed by the cath lab manager. She is a recent addition to our facility, and is greatly appreciated for her cath and EP lab experience.

Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained?

Our EP lab is separate, but together, with the cath lab. Our lab is located in the same area as the cath lab, but we have separate cost centers, inventory, and staff that work primarily in the EP lab. We are required to float to the cath lab when needed, and take call for the cath lab. The three EP lab staff are the primary staff, just for EP. We are responsible for maintaining inventory, communicating capital needs to our manager, troubleshooting problems in conjunction with our Biomed Department, and tracking and reporting our own CQI processes.

Do you have cross training inside the EP lab? What are the regulations in your state?

Colorado does allow non-licensed personnel to administer medications under the direct supervision of a physician. We do have cross-training in our cath lab. It is our EP director s preference that RNs provide conscious sedation for procedures in the EP lab. This has lead to having RNs with a lot of experience in providing sedation, thus there is an extremely low complication rate. We assist our physicians by providing conscious sedation for all procedures, including ICD implants and testing.

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?

We have just completed the installation of a bi-plane digital imaging system, manufactured by Omega Medical. We are very happy with its size, image quality, and ease of use. It s a big improvement over our 12-year-old C-arm. We can actually see the poles on the catheters now! Other recent acquisitions are an upgrade to Carto XP, and the purchase of the Chili Tip system.

Is your EP lab filmless, or does it plan to become filmless in the foreseeable future?

Our EP lab is all digital.

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

Scheduling is done by our cath lab secretary. The hospital does have a software scheduling program, but the cath and EP labs maintain a separate schedule. Physician timeliness is not an issue in our lab. Our physicians are respectful of our time and of our patients time. Our volume is such that overtime is rarely an issue.

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

The physicians and staff work with the hospital-wide Quality Improvement Department to maintain the high standards the hospital requires. We have ongoing QI processes for groin sites, post-device implant infections, lead dislodgements, and post-implant pneumothorax. Our complication rates are extremely low.

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

We use the Lawson inventory system for both par level supplies and purchase order requisitions. EP lab staff are responsible for maintaining an appropriate inventory of supplies. The hospital is currently assessing the need for an inventory specialist to share between the Cardiac Cath Lab, EP Lab, and Radiology.

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

As noted previously, we recently remodeled. Along with the installation of our new Omega Medical Imaging System, we also choose to add additional storage space for supplies and counter space for the RNs. We converted some of our monitors to flat screens, so that the physicians would be more comfortable and have more desk space. We are very pleased with the ergonomics of our new lab.

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

Managed care has affected where a patient can be admitted or have outpatient procedures performed. This has limited access to electrophysiologists in our community because the patient frequently will require a referral from a primary care physician that may not be aware of the procedures an electrophysiologist can perform. This limitation obviously can and does affect our patient volume. The level of care provided once the patient enters the electrophysiology realm does not seem to be affected by managed care.

What measures has your EP lab implemented in order to cut or contain costs? In addition, in what ways have you improved efficiencies in patient through-put?

We work with our vendors to purchase in bulk in order to reduce cost, and our hospital is a member of a larger parent corporation (Centura Health, a combination of Adventist and Catholic Health Care organizations) that does enter into purchasing contracts with our vendors, without limiting which vendors the physicians can utilize.

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

Porter Hospital was a part of Adventist Healthcare Systems that combined with Catholic Healthcare to create Centura Health. Centura Health is the largest health care system in Colorado. There are two EP labs within the Centura Health system they are both located in the metro area. There are eight EP labs in the Denver/Boulder metro area, so there is competition for electrophysiology patients.

What procedures do you perform on an outpatient basis?

All of our elective procedures can start as outpatient procedures. Many of our patients are admitted for less than 23 hours. Ablations and new device implants do spend the night in the hospital, but are discharged the next morning.

How are new employees oriented and trained at your facility?

The turnover in the EP lab has not been an issue. Of the new staff that has arrived, they have come with extensive experience, so there has not been an official orientation developed other than hospital-based orientation. Employees are mentored by another staff member until they are ready to work independently.

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

EP lab staff are encouraged to pursue outside educational opportunities such as attending NASPE and other local electrophysiology society meetings.

How is staff competency evaluated?

We have annual certification and evaluations conducted by our manager. We are required to test annually on conscious sedation and airway management as well as maintaining ACLS credentialing. We are encouraged to seek certifications, such as NASPE exams, for EP and Pacing.

How do you handle vendor visits to your department?

Vendors visits are limited to invitation only. The device reps at our hospital attend implants and offer technical support.

Does your lab utilize any alternative therapies?

No, we do not use any alternative therapies. However, we did recently install a Denon receiver, with a five-disc CD changer and overhead speakers we suppose that could be called patient-related music therapy, but it was really just staff therapy. We are rapidly increasing our music library as well. So far we have Sting, Roxy Music, AC/DC, Clapton, Eagles, Van Morrison, and a wide range of other jazz and rock CDs.

Please describe one of the more interesting or bizarre cases that have come through your EP lab.

We recently had an interesting ablation case of a patient with upper loop atrial tachycardia. We also did a VT ablation in a patient with an ICD post generator replacement. The patient had never received therapies prior, and then developed frequent sustained monomorphic VT that was responsive to VT ablation.

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?

There is no EP lab call. EP Lab staff are required to cover call for the cath lab along with the cath lab staff.

Approximately what percentage of your ablation procedures are done with cryo? What percentage is done with radiofrequency?

Cryo is not utilized, but we do use Chili Tip and conventional radiofrequency.

Do you perform only adult EP procedures or do you also do pediatric cases? Is there cross training for peds cases?

We perform procedures on adolescents and adults. However, we are not currently doing true pediatric patients.

Does your lab provide surgical backup for procedures (such as biventricular implants)?

We have an active open-heart program, with surgeons on sight, and we are just a few steps away from the operating room. We do not have surgical backup for our procedures or anesthesia backup for our implants.

Is your EP lab currently involved in any clinical trials or special projects?

The private practice physicians that utilize our lab the most have their own research department within their practice. Our lab has not been involved in any research projects or clinical trials.

Does your lab undergo a JCAHO inspection?

We had a JCAHO inspection two years ago, and are expecting another this year. We plan to continue to be compliant with JCAHO standards, and do not expect much, if any, disruption due to the upcoming JCAHO inspection.

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?

We do provide patient education material to assist with pre- and post-procedure education. We also use NASPE material, and encourage our patients to visit the NASPE website. There are local support groups that we can refer to for those patients that are interested in seeking others with similar diagnosis.

Give an example of a difficult problem or challenge your lab has faced. How it was addressed?

Our Cardiovascular Service Line Director and cath lab manager left within two months of each other, leaving the department to run as a self-governed unit for nearly six months. The strengths of each staff member were demonstrated during this period, as we continued to function normally, to interview new staff, and to complete the remodel of our EP lab. Our hospital administration allowed us to independently make the decisions required to continue and improve on the services we provide. Physician satisfaction improved, and patient satisfaction has remained high. Our search for a new director and manager has yielded two exceptional leaders.

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

Porter Hospital is located in the South of Denver City. The city of Denver has a population of about 500,000 people, with about 1.5 million in the greater metropolitan area. The front range, or eastern side of the state, is arid, about 15 inches of moisture a year. The eastern slope typically gets about 300 days of sunshine a year.  The western side of the mountains offers plateaus, with fruit orchards and vineyards. The population of Denver/Boulder, in general, leads a very active lifestyle. There is an overabundance of seasonal recreational activities available. Everyone knows of the wonderful ski areas nearby, but those same areas are fantastic mountain biking areas in the summer. The snow-capped peaks feed wild streams that offer great flyfishing and rafting. The streams feed lakes that offer boating and fishing opportunities. There are wonderful hiking trails in those same mountains, and climbers find the front range filled with places to climb. The miners of the 1800s left behind a lot of dirt roads that offer a chance to get away for a quiet forest drive or for a rugged four-wheeling trip. The Ride the Rockies bike ride is a chance to see 400 miles of the Rocky Mountains from the seat of your bicycle every summer.