Modular EP Units: Are They Possible? One Hospital’s Experience

Background
La Porte Regional Health System (LRHS), a Clarian Health Partner, is comprised of La Porte Hospital, a 227-bed community hospital; La Porte Regional Physician Network, made up of 19 physician practices; and La Porte Hospital Foundation, a philanthropic arm that supports the health system. La Porte Hospital was the first hospital in northern Indiana to achieve Magnet™ recognition, an award that is given to an elite group of hospitals for exemplary nursing leadership and quality patient care. The facility has experienced significant growth over the past few years. The cardiology program has grown to include a successful interventional program as well as cardiothoracic surgery. In an unprecedented spirit of partnership, physicians are working together in ways that are unique and creative for extraordinary patient care. Doctors and clinicians from a broad spectrum of specialties have come together to form the Heart & Vascular Institute in order to screen and treat patients, as well as educate the community about heart disease. In the past, La Porte Hospital was able to provide care to all cardiovascular patients except for those needing cardiac electrophysiology (EP) services. Patients in need of EP services had to be transferred to hospitals in surrounding areas for treatment. It was decided that every effort would be made to obtain EP services for the patients in our community. Cardiac electrophysiologists would be recruited, as well as a director of electrophysiology services (at which time I was hired). Dr. Mark Dixon and his partners, Drs. Scott Kaufman and Raghuram Dasari, joined the medical staff in order to provide EP services.

The Options
The decision to provide EP services was an easy one. Where those services were going to be provided was not quite as simple. There were three alternatives for this relatively land-locked facility: shared space with the cath lab, new construction, or utilization of a temporary building. Sharing space with the cath lab would not be ideal, as there was only one cath lab in the facility. The current lab was already very busy — doing multiple interventions and diagnostic cases per day. To add multiple EP cases to this already busy lab would not be a satisfactory solution. The full compliment of services added would include electrophysiology studies, catheter ablations, and implantation of pacemakers, defibrillators, and biventricular devices. Besides the obvious problem with routine scheduling, there would be issues of what to do with emergent cases requiring intervention when the lab was already being utilized. Patient safety would be a prominent factor in the evaluation of this option. In addition, in order to share space, a new hemodynamic monitoring system would have to be purchased and the lab would have to be shut down during installation. This would require the facility to go on bypass for any cardiovascular emergency and on hold for the scheduling of elective cases during the installation period. Building a new EP lab was also not an ideal option. As with many healthcare facilities, space is at a premium at La Porte Hospital. There was no space available for construction of a new lab. It would also be a very costly option — not only for construction but also for the cost of the equipment. Future plans may call for the construction of new cath lab/EP suites; however, timing did not allow for the appropriate planning and development of this new area. The goal of the facility was to begin EP services by the second quarter of 2008, and new construction could not occur within that time allotment. The last and most viable option was to evaluate the possibility of utilizing a temporary building. La Porte Hospital had previously utilized a mobile cath lab for a short time during construction of the new cath lab, so we looked into the possibility for doing this for EP as well. Modular Devices Incorporated (MDI) of Carmel, Indiana was contacted and an evaluation of temporary options was undertaken. MDI could provide two options for the EP lab. One option was for a mobile lab, and the other option was for a modular lab. Both units were turnkey labs that included a complete X-ray system, hemodynamic system, contrast injector, a cine capture system, and digital archiving (PACS) capabilities. Both units had procedure and control rooms. However, there were differences between the two units that would affect our decision. The mobile lab had an approximate size of 8’ x 48’. The patients would enter the procedure room via a hydraulic patient lift capable of lifting 1,500 pounds. This unit would not be attached to the current facility, so patients would have to be transported out of the hospital to the mobile unit. In comparison, the size of the modular lab could be 12' x 48' or 14' x 48’, providing needed additional space. Patients would be transferred in from ground level, so no lift would be needed. With added construction on site, there could be seamless integration from the modular lab to the permanent structure of the hospital. The modular is a completely self-contained unit designed to function just like a permanent in-house lab. Both units provide lead-lined rooms, intercom and stereo systems, an automatic light dimming system for cine runs, monitors for live and playback review, as well as hemodynamic monitoring, narcotics cabinet, and in-room storage for supplies. The heating and cooling system was designed to meet the requirements necessary for a surgery suite so devices could be implanted. A scrub sink with foot-operated controls was also available. The units could also be wired so the in-house computer networks could be utilized in the modular. MDI would also provide support of the modular and the contained equipment at all times. Preventative maintenance would also be performed if the modular would be used for an extended period. After careful consideration of all options, the decision was made to lease the modular unit. Our decision was based on the intent that the unit would be primarily utilized for EP, but would also serve as a backup to the cath lab if there were the need. A combination hemodynamic system would be needed so both entities could be supported. The unit was delivered in late 2007, and during January 2008, installation was completed. Construction was done to integrate the module into the current facility. Additional hallways and storage areas were added to the area in order to make the transition to the module seamless. Work was done to the exterior to provide a finished look to the addition, so a shell was built around the module to accomplish this. The hospital computer network and LAN were integrated into the module to provide computer services and the PACS system. Hook-ups to power and water were also finished. Major construction was completed, but there was still considerable work to be done before the first cases could be performed.

Additional Needs
The modular unit came equipped with a Mac-Lab/CardioLab 7000 system (GE Healthcare, United Kingdom). With plans to provide complex ablation services within the first year of operation, an upgraded hemodynamic system would be needed to support a 3D mapping system. It was felt that the 7000 would not meet the needs of the program. Instead of upgrading the system after a few months, a new hemodynamic monitoring system was purchased at the onset of the program. This unit would remain the property of La Porte Hospital and would be moved to the permanent location of the lab upon completion. Another consideration was that a stimulator was not provided with the modular. A compatible unit would have to be purchased so studies could be performed. In order to meet all needs, a new GE Mac-Lab/CardioLab IT system with a Micropace stimulator (Micropace EP Inc., Tustin, California), a 128-channel amplifier, and a Carto interface (Biosense Webster Inc., and Johnson & Johnson company, Diamond Bar, California) was purchased and installed within a five-week period. The 7000 was removed from the modular once the IT system was ready for installation. Representatives from the hospital biomedical engineering department, engineers from GE, and the engineer from MDI worked together to pull cables, install monitors, and ready the unit for operation. In addition to a new flat panel monitor on the boom, a flat panel "slave" monitor was installed for utilization by caregivers at the head of the patient during procedures. This monitor allows easy visualization of the patient's vital signs and electrograms. The new GE Mac-Lab/CardioLab IT unit was networked into the DMS system so all functionality would be available to the EP lab. Additional capital purchases that were required for operations included two defibrillators, IV pumps, a cautery device, ablation devices, supply carts, procedure tables, portable "C" lockers, a suction canister system, lead protective wear, and patient transport devices, as well as a dictation system, fax/copy machine, computers, and a network printer. Simple modifications to the unit were also needed. The contrast injector was removed from the swing arm system and replaced with a surgical light that was needed for device implants. The contrast injector could be placed on the table when needed for cath lab backup. Additional can lighting was installed to provide better task lighting during procedures. Modifications also had to be made to the oxygen and suction outlets to match those of the hospital. Adaptors were then utilized to standardize the outlets for efficiency of use and patient safety.

Future Considerations and Final Thoughts
All of the concentrated efforts paid off, and our goal was accomplished. The first cases were successfully completed in the modular right on schedule. There were no major issues with the modular, construction, or equipment. Patients, staff, and visitors have told us that they cannot tell where the hospital ends and the modular begins, as the transition is seamless. We will continue to refine the process and modify how we are going to set up cases and utilize space. This will be an ongoing evaluation as we settle into our new area. It is anticipated that we will be utilizing the modular for a period of 18 to 24 months. During that time, as stated previously, we want to include complex ablations and 3D mapping. We will need to refine the space in order to accomplish this, as upgrades may be needed to the X-ray equipment and monitoring system. We may utilize anesthesia services for complicated cases, which will lead us to issues with shared space. With growth will come the need for additional inventory and equipment. Again, we will have to be creative in order to provide an ergonomically correct, efficient workspace for the patients and staff. So will a modular unit work for an EP lab? Yes — it was the best option for our program. Will a modular unit work long-term? Yes it will, if we continue to involve our physicians and staff in decisions concerning the space and how to best utilize it. Our group is very creative, and we will continue to work together to provide an environment that can assist us in providing excellent care to our patients.

For more information, please visit: www.modulardevices.com.