Spotlight Interview: Lenox Hill Hospital

What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab? When was the EP lab started at your institution? What types of procedures are performed at your facility?

We perform the full complement of electrophysiology procedures, from pacemaker and ICD implants, routine ablations, biventricular device implants and complex ablations, including atrial fibrillation ablation procedures.

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

We perform about 45 cases (on average) every week. The vast majority are electrophysiology studies and device implants. The complication rates are very low.

Who manages your EP lab?

We have a nurse manager as well as an administrative manager.

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?

There is no cross training. 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 use a LocaLisa navigation system (Medtronic Inc., Minneapolis, Minnesota) on many of our ablation cases. Drs. Skipitaris and Zweibel were the first electrophysiologists in New York to use LocaLisa. We find it easy to use, inexpensive (can use catheters from any manufacturer), and very helpful. It is especially beneficial to see the location of our catheters in two different views at the same time without using fluoroscopy. We recently purchased a Biosense Carto system (Biosense Webster, Inc., Diamond Bar, California), which we use for more complex ablation cases (i.e., focal atrial tachycardias and AF ablations).

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

The lab is completely filmless.

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

The physicians enter their schedules into Microsoft Outlook the day before. Given the limited amount of time to do cases in our lab, the physicians are usually on time.

What type of quality control and quality assurance measures are practiced in your EP lab? How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies?

The nurses, along with a technician, keep track of equipment and supplies used and are responsible for ordering. We do not use any specific program or software to control inventory.

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

The lab has consistently expanded in volume yearly since it opened. Plans are underway to build two new EP labs within the next six months.

How has managed care affected your EP lab and the care it provides patients? 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 have been using re-sterilized catheters in an effort to contain costs. Administration has aggressively negotiated with the device manufacturers for improved pricing. We are trying to increase our patient through-put by increasing lab time and space, thereby reducing the waiting time for procedures.

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

In addition to competing within our own hospital with another EP group, there are many EP labs in New York City that we compete with for patients.

What procedures do you perform on an outpatient basis?

We perform cardioversions, DFT testing and non-invasive programmed stimulation (NIPS), diagnostic EP studies, and occasionally, pacemaker generator changes on an outpatient basis.

How are new employees oriented and trained at your facility?

They are trained by the existing staff members. The new nurses are usually placed with one of the more experienced nurses for a few weeks until they are ready to be left on their own.

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

The electrophysiologists give ongoing lectures to the nursing staff (usually after-hours once a month). At least one of the nurses each year attends the Heart Rhythm Society Meeting (formerly NASPE).

How is staff competency evaluated?

New staff are evaluated by the more senior nurses until competency is demonstrated to fly solo.

How do you handle vendor visits to your department?

There is more or less an open-door policy to vendors. Physicians meet with them as time allows, e.g. between cases. For more specific matters, vendors contact the physicians prior to visiting. For devices or cases that are utilizing new technology, the physicians contact the vendor of choice.

Does your lab utilize any alternative therapies?

No.

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

Recently, we performed an ablation on a young gentlemen with WPW syndrome. His ECG revealed a left lateral accessory pathway (AP). During the diagnostic EP study he had antidromic AVRT down the left lateral AP and up a different septal AP, as well as orthodromic AVRT utilizing both the septal AP and another left posterior AP. We successfully ablated the left lateral and left posterior APs. He still had orthodromic AVRT utilizing the septal AP (only on Isuprel). Given the proximity of the septal AP to his AV node, we opted to treat him medically and bring him back at a later date for recurrent/breakthrough SVT.

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 call for our EP lab. The hours are Monday through Friday, 7:15 am to 7:45 pm.

Does your lab use a third party for reprocessing?

Yes.

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

We do not use cryo for ablations. We utilize radiofrequency energy 100% of the time.

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

We only perform adult electrophysiology procedures.

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

We have surgical backup available, if necessary, by special arrangement for specific cases. There is not an on call OR per se.

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

We envision more biventricular ICD implants for CHF, and more atrial fibrillation ablations.

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

We are involved in the EMPIRIC Trial (Medtronic), which compares electrophysiologist-guided ICD programming with empiric ICD programming, as well as the INTRINSIC RV Trial (Guidant), which compares two different ICD programming methods to avoid RV pacing (VVI at 40 vs. DDDR 60 with AV Search Hysteresis).

Does your lab undergo a JCAHO inspection?

Yes.

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 have an ICD support group, which was formed by Dr. Jeffrey Matos; this meets twice a year. Patients of Arrhythmia Associates of New York can also visit their website at: www.heartbeatmd.com.

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

Since we have two groups of physicians using the same laboratory space, a relatively complex schedule outlining the times each group has access to the lab was devised. There have been some difficulties with this setup, but overall it has worked well. When another electrophysiology lab is built, this should not be as much of a problem.

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

We are located in the middle of New York City. We see a very wide mix of patients, including a decent number of out-of-town visitors. Many of our patients are very sophisticated and come prepared with questions about their conditions. They also have easy access to a second and third opinion given the large number of electrophysiologists in the area.

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

Our lab is unique in that two very busy private practice EP groups manage to work together to perform over 2,000 cases in a single laboratory with a fixed schedule. Our EP lab staff is composed of motivated, dedicated, experienced and hard-working nurses who make this lab situation possible.