Key Considerations for Designing an Electrophysiology Laboratory in a Community Hospital

Holy Cross Hospital is a community-based hospital operating two dedicated electrophysiology (EP) laboratories, with staff that are cross trained in both EP procedures and cardiac catheterization. The labs are predominately utilized by practicing electrophysiologists in the community and cardiothoracic surgeons. Recently, Holy Cross Hospital had the opportunity to redesign its two EP laboratories.There are several key considerations requiring careful planning and thought which will ensure that any EP lab renovation project moves smoothly. The purpose of this article is not to serve as a treatise on EP lab design; rather, it is intended to highlight salient points that may prove useful for other community hospitals as they undergo renovation projects of their own.

In this article, we will outline the key steps taken at Holy Cross Hospital in redesigning our laboratories. Topics covered will include design buildout, vendor selection, sterility, cables and electrical noise.

Design Buildout

The design challenge starts with identifying the various members needed to discuss the layout of the new EP laboratory. These members include end-users of the equipment (physicians and medical lab staff), healthcare architects, hospital engineering representatives, hospital administration, construction team members and third-party equipment vendors. At Holy Cross Hospital, regularly scheduled meetings were held with various members of the design buildout team during the construction process to ensure the project’s success. The following design elements were addressed: 

1. Unobstructed views between the control room and the procedure room
2. Ample space on both sides of the table to allow for a variety of procedures
3. Sufficient clear floor space to easily transfer a patient from a stretcher to the EP lab table
4. Enough storage in the procedure room for catheters and other related equipment; in the event that storage space is minimal, consider keeping routinely needed items such as catheters, wires and medications within the EP labs and less-utilized equipment such as intracardiac echo machines and cryoablation machines in separate detached storage space
5. Adjustable lighting
6. Appropriate amount of flexible workspace for the physicians and lab staff
7. Reducing unnecessary background noise for the patient and staff
8. Placing noise-generating equipment in a separate room

While this list is certainly not exhaustive, it provides a tangible framework from which to move forward for any team undertaking an EP lab renovation project. There are a lot of moving parts in an EP laboratory. We found that a 3D-rendered video clip which demonstrated all the moving parts prior to construction start was the most useful in ensuring there were no collisions or design flaws.

Vendor Selection

In our laboratory we had to purchase an entirely new fluoroscopy system. We are fortunate to be at a time in electrophysiology when traditional x-ray vendors are starting to offer bundled EP lab package deals. To a certain extent, these deals allow hospitals to purchase an entirely new lab without having to individually source every piece. There are cost savings to be realized when buying in bulk. As with any hospital system, we bid the job out for vendors to compete. The following considerations went into our final decision: cost of equipment, physician preferences, warranties, knowledge of the sales team regarding the applicability of their equipment for EP procedures, track record for the equipment provider to service the equipment, ability of equipment to interface with our current computer image archival system, company pipeline for future product development as they relate to EP procedures, and the ability to group equipment acquisition with other capital improvement projects ongoing at our hospital institution for further cost savings. Certainly each hospital system will have its own unique circumstances that influence final vendor selection. As long as there is a systematic process to equipment selection that involves input from end-users (i.e., physicians and lab staff), one can rest assured regarding appropriate equipment selection.

Sterility Considerations

The fundamental driver regarding health facility building requirements for sterility depends on whether the EP lab is designated as a surgical operating room by your hospital building code inspector. If the EP lab is designated as a surgical operating room, your architect will have a stringent set of building code requirements to fulfill. Historically, percutaneous procedures such as catheterizations or diagnostic EP procedures do not require the higher level of sterility as seen in operatories. However, device implantations do merit more attention to sterility concerns. A few guiding principles are put for consideration:

1. Insist that no one enters the EP lab area without sterile head covers, shoe covers and scrubs. This is easily enforced by having conscientious physician and lab staff always practicing sterile techniques.
2. Separate the scrub sink into a sub-sterile environment prior to entering the EP lab.  
3. Employ positive pressure ventilation AC equipment when feasible.
4. Employ High-Efficiency Particulate Air (HEPA) filters with the AC equipment.
5. Flooring of an EP laboratory should have no seams in order to prevent entrapment of liquids or bodily fluids.    
6. Routinely have Environmental Services perform “deep cleaning” at the end of a procedural day to keep moving parts free from dust that settles, as well as to allow the dust that is disturbed to resettle prior to the next procedural day. 

Cable Considerations

There are three inescapable truths in life: death, taxes and lots and lots of cables in the EP lab. Every piece of equipment in the EP lab has corresponding cabling. Some cables are particularly delicate, such as the fiber optic cables that connect to 3D mapping equipment. While these cables are necessary, they can represent a design nightmare. A number of design options exist to sensibly address the problem; these options include laying cables on the floor, hanging cables from the ceiling or running them through conduits under the floor.

With modern day design innovations such as mobile stackable equipment racks, no EP lab should have to settle for laying cables on the floor. The foremost problem with this has to do with moving equipment across cables, which hastens premature cable failure. There are a few guiding principles with the remaining design solutions. Hanging cables from the ceiling is feasible and simple to perform, especially if one does not have the ability to break into the subflooring of the EP lab. However, there may be numerous unsightly cables hanging overhead in the EP lab, which may also not be acceptable. If the possibility of a recessed ceiling exists, as is the case with most EP labs, one could run most of the cables behind removable ceiling panels and have strategically located cable drops.

The biggest concern with running cables through conduits under the floor has to do with cable replacements. If you are designing an EP lab from the floor up, consider having a raised flooring system with flooring access panels; this will enable cable repairs or change-outs to be easily performed. It is important to never run cables that may need repair/replacement where they cannot be easily accessed. 

In our lab, we employed a combination of techniques. The oxygen, suction and anesthesia gas lines were routed through the ceiling with drops located at the head and foot of the EP procedure table. Equipment wires were, in most cases, routed under a raised flooring with easy access in the event repairs were needed. Additionally, do not forget to route cables for future upgrades. For example, if you operate a lab with only St. Jude Medical’s EnSite Velocity mapping system but are contemplating purchasing similar 3D mapping equipment from alternative vendors, incorporate the cables into the EP lab design. At a later date, when alternative 3D mapping equipment is procured, one can simply plug in the equipment without having to perform a minor renovation.

Electrical Noise Considerations

Another problem that can occur in the lab is electrical noise. All cables used in an EP lab generate an electrical field that surrounds the cable along its entire length. While this field is weak, it can cause problems when these fields interact over a sufficient area. A few simple guidelines can help minimize in-line noise:

1. If cables need to cross one another, have them cross at right angles to minimize electrical field interactions.
2. Make sure each system is properly grounded. 
3. Keep systems that periodically emit large amounts of energy separate from other systems in the lab. Specifically, place your RF generators on a separate cart away from electrical recording equipment. 

If employing a mobile stackable arrangement, be sure to not place RF generators directly below the EP recording equipment. Frequently, the underside of the RF generator is shielded but not the top side. Our lab employs a stackable equipment rack and has found that electrical noise is minimized by placing the RF generators at the top of the equipment rack and EP recording equipment at the bottom. 

Summary

The design of an EP laboratory is a challenging project. With a dedicated team, routine project update meetings, and definitive leadership, the task can be expertly navigated toward a successful completion.