Email Discussion Group: January 2007

New Questions: Stereotaxis Niobe vs. Hansen Sensei I am interested in opinions from clinicians who have experience using the Stereotaxis Niobe 2 system and Hansen Medical's Sensei system. Feel free to express any thoughts regarding ease of use, economics, clinical efficacy, procedure speeds, safety, etc. I am especially interested in those clinicians who have performed human procedures using the Hansen system. anonymous (To reply to this question, please type Stereotaxis vs. Hansen in your subject line.) Working in the USA I am a cardiac physiologist from the UK and am seeking work in the US. I have noted that most jobs are for RNs; is this the case throughout the US? I have 16 years experience in a regional teaching hospital with pacing/ICD and CRT follow-up. I can also run EP lab systems, including CARTO and EnSite/NavX. I hold both NASPExAM/AP exams. I would be grateful if a center is known that employs non-RN staff in CRM. Stuart Allen, Southampton General Hospital, Southampton, Hants, United Kingdom (To reply to this question, please type Working in the USA in your subject line.)    Our lab employs RNs for sedation and technologists for all the other positions in the room. Right now we have one RN who functions full-time as a tech in the room (she does not sedate). A couple of our sedation nurses will occasionally fill "tech" spots in the rooms when needed. The techs scrub in with the physicians, run the CardioLab/CARTO/ESI, work up data, and some even put in lines. Our techs also close pacemaker and ICD pockets. We have an extensive orientation (we call it an internship) process for our techs, and they are able to function at a high level. Susan Deck, BS, RN, EP Educational Coordinator, Lancaster General Hospital, Lancaster, Pennsylvania Combo Lab Our hospital is looking at options for building a second EP lab. This lab will be primarily designed for ablation procedures including atrial fibrillation. However, we are looking at the possibility of it being an EP/Ablation/Cath lab. Has anyone had any experiences combining ablations and caths? anonymous (To reply to this question, please type Combo Lab in your subject line.)   I have had some limited experience with a combo lab for both ablations and cardiac cath, and generally thought it was good. The critical question is: How do your EP docs feel about turning over lab time to other invasive cardiologists because every heart cath is a potential angioplasty? I feel that cath lab-trained RNs and RCIS's are better technically in the EP lab with regard to pressure lines, pericardiocentesis, and emergency temporary pacers, and are a good resource for EP docs with regard to interventional guidewires and sheaths. A steady diet of just EP ablation can get bland at times. I also think it is a good idea budget wise, as your combo lab and staff can be utilized in a diverse way. Dana St. John, RN, HealthPark Medical Center Cardiac EP/Implant Lab, Fort Myers, Florida.  My institution is moving forward with a cath/peripheral/ablation/device room. I'll be happy to discuss any details with you. Contact me at heffernans@mlhs.org. Shawn Heffernan, RN.  We have a combo lab. So far it has been predominantly used for EP procedures (mostly implants), but the capability to use it for cath procedures is there. Susan Deck, BS, RN, EP Educational Coordinator, Lancaster General Hospital, Lancaster, Pennsylvania.  I am a nurse at New York Presbyterian Columbia, and we have one dedicated EP lab and one room we share with cath. The dedicated EP lab will very rarely do diagnostic caths on slow EP days and heavy cath days. Our other room almost always turns to cath once slotted EP cases are done. The "second room" is primarily for devices and EP studies, as having ablation equipment, catheters, etc. may be cumbersome with cath equipment in the same room. Depending upon your cath volume, there is an inevitable "tug-of-war" between cath and EP for available rooms, which can become problematic, especially when EP cases may be delayed or cancelled. There is also the "room turnover" from EP/OR to cath as well. I have worked at another institution where cath and EP are separate entities under the same umbrella, and this seemed to be a more fluid system. Thus, combo labs, in our experience, have the potential to be problematic depending on staffing and time allotment. Again, we are a high-volume institution on both sides, so we may be different from other institutions. Edmund Donovan, RN, Clinical Nurse II, New York Presbyterian Hospital, Columbia University Under Discussion: Quality Assurance We are a new site located in Western Maryland and have started an EP Program. We are in the infant stages of our program. I am the Quality Assurance Nurse and am wondering if there is any official EP Registry out there for data collection and QA. I am also wondering what benchmarking statistics are out there for comparison with other EP labs. I am also wondering what adverse outcomes are being collected for the EP labs and other data collection areas that EP labs are collecting internally for their program. I cannot seem to find any of this information by searching the Web, so I thought maybe I should go straight to the facilities that have this program. Pamela A. Hetrick, RN, Cardiac Data Analyst, Western Maryland Health System, Cumberland, Maryland (Readers, to reply to this question, please type Quality Assurance in your subject line.) I am not aware of any national registry for EP QA. However, at our facility, we do track a long list of outcomes and complications, including infections (for device implants/revisions), pseudoaneurysms, hematomas requiring treatment (blood or evacuation), pericardial effusion/tamponade, death within 72 hours of procedure, MI or CVA within 24 hours of procedure, vascular injury/nerve damage, heart block/arrhythmia, lead dislodgement/reversal, and pneumothorax. We also do monthly sedation QA. We track use of reversal agents, O2 sat < 90% and/or a drop of 5% from baseline for > 1 minute, assisted ventilation or unanticipated intubation, intraprocedural LOC=0, cardiac or respiratory arrest and unplanned admission or higher level of care required secondary to somnolence. Our sedation QA is performed by an RN in the cath lab, and the other QA is done by the hospital's QA department staff. Events are tracked continually and reported quarterly (we track not only the # of each complication, but also who the physician/nurse was, what kind of procedure, other procedure staff, etc.). We have a few senior techs who are able to insert arterial and venous lines and diagnostic catheters (they have all received advanced training and are required to maintain/demonstrate continued competency in these skills on an annual basis), and their outcomes are tracked as well.  We are not an all-RN lab. In our lab, RNs perform moderate sedation, and EP techs perform the other procedural functions. These techs are not "people off the streets." All of our techs have prior healthcare training/experience (paramedic, radiology tech, cardiovascular tech, surgical tech, RN). They have all been through an extensive and rigorous orientation and training program. All staff members receive continuing education and maintain a long list of hospital/departmental-required competencies.  For cardiology in general, our hospital benchmarks the ACC. However, for EP it is a little more difficult you really have to dig for statistics from other facilities. For some complications, our physicians looked at data from other hospitals and then decided what they wanted our target rate to be (usually lower). Our state keeps track of certain complications for hospitals state-wide. That might be a good place to start (at least for things like infection, MI, etc.). Susan Deck, BS, RN, EP Educational Coordinator, Lancaster General Hospital, Lancaster, Pennsylvania Discharge Instructions Post EP Studies/Ablation/ICD and Pacemaker We just started our new EP program. I am searching for discharge instructions for these procedures. If anyone has these documents, do you mind sharing with me so we can tailor our documents to the needs of our patients? Thank you for sharing! Celi Mateo, Director, Cardiovascular, Diagnostic & Treatment Services, Rush North Shore Medical Center, Skokie, Illinois (To reply to this question, please type Discharge Instructions in your subject line.)   I hope that you can find these useful (Homegoing Post EP and Homegoing Instructions Post Device Implant lists provided). We have two EP docs, and these relate to the physician who leaves the Tegaderm dressing in place for two weeks until the office wound check. Kathy Manfull, RN, Affinity Medical Center, Massillon, Ohio *Editor's Note: To obtain a copy of these documents, please email the editor at jelrod@hmpcommunications.com. Thank you.   I would be happy to share the tools we use at my facility. Janice Baker, RN, BSN *Editor's Note: To contact this person, please email the editor at jelrod@hmpcommunications.com. Thank you. Conscious Sedation I would like to discuss with other labs the boundaries, or lack thereof, of procedural sedation and analgesia. For prolonged cases such as atrial fibrillation ablations, which last varying amounts of time between 4 to 6 hours, are the majority of labs resorting to general anesthesia? Or are they attempting to deeply sedate the patient for this length of time? Melissa Forsyth, RN (To reply to this question, please type Conscious Sedation in your subject line.)   I have read that other labs are using Diprivan for atrial fibrillation (AF) ablations, but that is not the practice in our lab. According to our state licensing board, it is out of the scope of practice for nurses to administer this drug. For our AF ablations we do use general anesthesia. The logic here is when crossing the atrial septum, there is a risk of aortic perforation; if this happens, the patient is already prepared for surgery and under general anesthesia. We can move the patient faster to surgery if needed. Another important concept is during RF ablations, a temperature probe can be inserted into the esophagus to monitor the temperature. One of the complications of RF ablation for AF is atrial esophageal fistulas, because the pulmonary veins lay close to the esophagus. By monitoring the temperature, if there is a quick increase, we know we are close to the esophagus and we need to stop burning there. It is easier for the temperature probe to be in place while the patient is under, because no gag reflex interferes with placement. In our experience, it has reduced the risks involved in RF ablations. We do cryo ablations and use general for those as well. Keeping the patient still makes it easier to make deeper and more effective lesions as well. Patients generally go home the same day, but we also have had patients stay. We also have done AFs without anesthesia, but in my opinion, it is better for the patient to be under general. We have not had any major complications with any AFs. Generally nausea, vomiting, bleeding, hematomas, and minor strokes have been the complications we have experienced. Lisa Decker, RN, Davenport, Iowa.  We have recently started doing atrial fibrillation RFAB's, so I would be interested to hear the answer you get. We are currently using versed and fentanyl, and have been discussing general anesthesia. anonymous.  In our lab, we place all of our catheters, perform the transseptal puncture, and begin CARTO mapping prior to calling for anesthesia. All of our AF patients are anesthetized for delivery of RF only in the left atrium. We find the patients tolerate the procedure better, as RF delivery in the LA can be uncomfortable, especially when ablating the right-sided pulmonary veins (PVs) due to close proximity to the esophagus. Also, anesthesia can place an esophageal probe to monitor the temperature in the esophagus when ablating the right-sided PVs as well. We use a CCU monitor to read the probe. If we deem a right-sided flutter line is necessary, we extubate and perform the isthmus line under moderate sedation. We also recommend placing a Foley catheter for better fluid control, both from IV and from ThermoCool (if you are using that technology). Hope this helps. Edmund Donovan, RN, Clinical Nurse II, New York Presbyterian Hospital Columbia University Free-standing EP Labs I am trying to find out if there are any free-standing or stand-alone EP labs in the US. Does anyone know of any? anonymous by request (To reply to this question, please type Free-standing EP Labs in your subject line.)   We looked into doing this a few years ago, but found several roadblocks, and stopped pursuing it after several months of work. I'd be very interested to know if anyone has tried as well, or if there is any free-standing lab in operation. anonymous Pay Scale Differences Since the EP/Cath lab is a multidisciplined venue, we have a multi-talented group that consists of a variety of different credentialed personnel. I would like to recruit answers/input from the EP Lab Digest readers to my question: What is the pay scale(s) or pay ranges for CVT, RCIS, RCIS, and RNs? For example, here is the approximate pay scale we have at our institution: RN: $29.00 - $32.00; RCIS: $25.50 - $28.50; CVT: $23.50 - $25.50; On call: $4.00 per hour. Patricia C. (To reply to this question, please type Pay Scale Differences in your subject line.) RN: $24.00 - $36.90; RAD TECH: $21.98 - $35.12; RCIS: $18.73 - $29.91; CVT: $14.93 - $23.85 anonymous Recycling Platinum Tips I am a new Nurse Manager to the Cath/EP lab, and one of my staff brought to my attention that we could possibly recycle the platinum tips off of the catheters and get some money back for our hospital. Does anyone know anything about this, as far as who do you send them to, as well as the steps involved in doing it? Thanks for any help that you can give me. Brad Massey, Nurse Manager, Little Rock VA Hospital, Arkansas (Readers, to reply to this question, please type Recycling Platinum Tips in your subject line.)  We are also sending our platinum tips to Cascade Refining, Inc. in Salt Lake City, Utah. Their Web site is www.epcatheters.com or you can call them at 800-955-5857. It's a fairly simple process. We cut off the tips of used catheters and save them in a biohazard bag. The company sends you all the forms and mailing materials with instructions. We usually receive the check back in 2 - 3 weeks. Terry Ward, EP RN, Advocate Good Shepherd Hospital, Barrington, Illinois.  We re-sterilize our catheters, however, on those we do not re-sterilize we do cut the tips off. Some of these tips include all ablation catheters, guidewires (from intervention too), Lasso catheters, TZ Medical catheters and others. If you are not re-sterilizing any catheters, I HIGHLY recommend clipping the tips and sending them to the companies previously listed. If you are re-sterilizing catheters, find out from the company you use to see which catheters they do not re-sterilize and then clip them. We use SteriMed to re-sterilize our catheters and cables. We received $3,000 for an envelope of catheter tips we clipped! We used the money for our education fund. It is well worth the time and effort to look into. Lisa Decker, RN, Davenport, Iowa Competency in the EP Lab Can anyone give suggestions on how to start a competency program in the EP lab? We have RNs, CVTs and RTs in the lab. I need to get everyone up to speed on stimulating, scrubbing and troubleshooting. Ronnie Sparrow, RN, CVRN, The Methodist Hospital, Houston, Texas (To reply to this question, please type Competency in the EP Lab in your subject line.)    Our EP program started 18 months ago, and I had to come up with a competency program. I started with an outline of what the EP staff needed to know and/or demonstrate to be competent in performing EP procedures. I then expanded the outline to a competency checklist with educational resources listed as applicable. We are using a workbook from St. Jude Medical as our documentation for each EP staff member as well as the checklist to guide staff through the orientation process. We started the program with one experienced EP RN, and now have a staff of five that can perform almost any procedure independently, although we all are certainly still learning! Terry Ward, EP RN, Advocate Good Shepherd Hospital, Barrington, Illinois Tilt Table Protocol I am starting up an electrophysiology lab and am scheduling the first tilt table procedure. Is there anyone out there that would share any standing orders/ protocols with me? Patti Coblentz, Director of the Cath Lab, Provena Covenant Medical Center (To reply to this question, please type Tilt Table Protocol in your subject line.)  In our lab, we have a physician present during the procedure. We hook the patient up to the LIFEPAK (biphasic defibrillator) and the WITT system for monitoring vital signs and pulse ox. The patient has an IV hooked up to saline. We take baseline vitals with the patient lying down, and then tilt the patient at a 90-degree angle as if they were standing. They have a safety strap around the knees, arms and trunk of body. We then take vitals every 5 minutes and record them on a flow sheet. With an area for comments like "Patient tilted", then at the discretion of the doctor (usually after 15 minutes), if there is no change in heart rate or blood pressure, 0.4 mg SL nitroglycerin is administered and recorded to see if this affects the blood pressure and heart rate. In most cases it does. If the patient becomes lightheaded or fails to respond, we immediately return the patient to the supine position and watch the monitor for pauses while using a pressurized bag of normal saline to build the blood pressure up. We have had patients have long pauses and asystole. We have not had a death since we started these procedures, and if they do have a pause, we immediately prep them for device insertion, since they are already in the EP lab. Most of the tilt tables are done in the office and not in the EP lab, though; for inpatients we do them in the lab. A physician must always be present, along with a RN and RTR. Lisa Decker, RN, Davenport, Iowa Also Under Discussion: Staffing in the EP Lab I am the EP Coordinator at a local hospital. My question is: are there guidelines for the proper number of staff for EP procedures? Currently it is myself, another trained RN, and anesthesia. I have no other staff to cover for sick days or vacation days. Your thoughts would be appreciated. Thank you in advance! Joe Nealis, RN (To reply to this question, please type Staffing in the EP Lab in your subject line.) Noise Interference When Ablating We are currently having a problem with a lot of noise during RF ablations. Whenever we turn on the Stockert RF generator, we begin to see what looks like pacing spikes or sometimes what seems to look like VT. It is present in the surface ECG and the intercardiac signals. It also seems to happen more frequently when we do AVNRT ablations. Sometimes it is so bad that we cannot recognize anything. It does occur during other ablations, but not as bad. We have the GE CardioLab as our monitoring system. Has anyone seen this problem before? What was the solution for the problem? By the way, we have tried everything, including changing all the cables. Any hints or suggestions would be much appreciated. Jerry F. Jones, CVT (To reply to this question, please type Noise Interference When Ablating in your subject line.)