Spotlight Interview: Memorial Hermann Heart & Vascular Institute-Texas Medical Center

Memorial Hermann Heart & Vascular Institute-Texas Medical Center (TMC) is known for its track record of innovation, outstanding outcomes and exceptional patient care. As the first freestanding heart and vascular hospital in the Texas Medical Center, the Heart & Vascular Institute is consistently ranked by national quality benchmarking organizations as a leader in clinical quality and patient safety. The patient services and amenities available here, coupled with the Institute’s unique design, make it the most modern hospital of its kind in Texas.

The 230,000 square-foot facility houses 147 patient beds, including a 20-bed short stay unit, CVICU cardiology care unit and six cardiac catheterization and electrophysiology labs, as well as access to 11 VIP suites with hotel services and library area. Memorial Hermann-Texas Medical Center has been ranked by U.S. News & World Report as one of the Top 50 hospitals in the nation for heart and heart surgery for 2010-2011. Learn more about the Memorial Hermann Heart & Vascular Institute-TMC at https://heart.memorialhermann.org/locations/about-heart---vascular-institute-texas-medical-center/.

What is the size of your EP lab facility? 

We currently have five rooms that can perform EP procedures. We primarily perform EP in our two biplane rooms and in one of our single-plane rooms. We are also in the planning phase to add an additional OR-hybrid room, which will be utilized by both cath and EP.

When was the EP lab started at your institution?

The electrophysiology program was started at Hermann Hospital (before it became Memorial Hermann-Texas Medical Center) and the University of Texas Health Science Center at Houston Medical School in 1981. 

What is the number of staff members? What is the mix of credentials at your lab?

We have a total of 30 staff members between our cardiac catheterization and EP labs.

Of the 30 total, 23 of those are full-time employees including 17 registered nurses (RNs), three radiologic technologists (RTs) and three registered cardiovascular invasive specialists (RCIS’s). In addition, we have two part-time employees including one RN and one RCIS. We also have five as-needed employees (PRNs), including three RNs and two RTs.

What types of procedures are performed at your facility? Approximately how many are performed each week?

Some of the procedures we perform at our facility include complex and simple ablations (percutaneous endocardial and epicardial); ventricular assist device-supported procedures (TandemHeart, CardiacAssist, Inc.; Impella, ABIOMED, Inc.); hybrid maze ablations; EP studies; implants; LARIAT (SentreHEART, Inc.) left atrial appendage ligation; left atrial appendage occlusion (AMPLATZER appendage occlude, St. Jude Medical); and implantations of left atrial pressure monitors (LAPTOP-HF study).  

We average approximately 10 pulmonary vein isolation (PVI) ablations, more than 10 other ablations, nine implantable cardioverter-defibrillator (ICD) implants, and five permanent pacemaker (PPM) implants each week. 

Who manages your EP lab?

Michael Negrych, RN, and Jeff Dybdahl, RN, CVRN, manage our EP lab and are our EP resource staff. They work together for staff orientation and education, equipment and supply selection, policy and guideline development, and assuring appropriate staff assignments for complex procedures.

Is the EP lab separate from the cath lab? How long has this been?

Our EP lab is not separate from the cath lab. We have two primary resource EP RNs plus three RNs and one RCIS, all of whom are primarily EP-focused staff.

We have had EP-focused staff for about 30 years now. The number of EP-focused staff expanded about eight years ago.

Are employees cross-trained?

Yes, employees do cross-train between EP and cath. The primary EP RNs also spend time with EP-focused and primary cath staff during procedures to educate them about EP.

Do you have cross training inside the EP lab?

Yes, we do cross-train inside the EP lab. Our EP RNs function in all roles including the operation of all of our 3D mapping systems. Other staff members cross-train for scrub, monitor (includes stimulator operation) and X-ray roles.

What type of hospital is your EP program a part of? 

The Memorial Hermann Heart & Vascular Institute-Texas Medical Center (TMC) is located within the flagship hospital of the Memorial Hermann Health System, the largest not-for-profit health system in Southeast Texas. We are affiliated with the University of Texas Health Science Center at Houston (UTHealth) Medical School.

What type of EP equipment is most commonly used in the lab?

Some of the equipment most commonly used in our lab includes St. Jude Medical’s EnSite Velocity Cardiac Mapping System; Biosense Webster’s CartoXpress and Carto 3 Systems; GE Healthcare’s ComboLab Hemodynamic & EP Recording System; GE Healthcare’s Micropace Cardiac Stimulator; Siemens/Biosense Webster’s ACUSON ICE catheters (navigation and non-navigation);  St. Jude Medical’s Swartz braided transseptal catheter sheaths; and diagnostic and ablation catheters from St. Jude Medical, Biosense Webster, Boston Scientific and Bard EP. 

How is shift coverage managed? What are typical hours (not including call time)?

Our shifts are covered in a mix of 10- and 12-hour shifts.

We schedule staff from 7 a.m. to 5 p.m. or from 7 a.m. to 7 p.m. The 12-hour shift covers until scheduled procedures are complete (EP or cath). The 12-hour shift staff members are supplemented with 10-hour shift staff members who are scheduled for late coverage approximately once a month.

Tell us what a typical day might be like in your EP lab.

A typical day in our EP lab will have one or two rooms beginning with anesthesia for PVI or ventricular tachycardia (VT) ablations. Cases are then scheduled on a “to follow” basis. A typical day will have two PVIs in one room, with an implant scheduled in another room for the same physician to perform in between the two PVIs.

What new equipment, devices and/or products have been introduced at your lab lately? How has this changed the way you perform those procedures?

The most recent devices that have been introduced at our lab are the left atrial pressure monitors and the AMPLATZER left atrial appendage occluder.

Our Center for Advanced Heart Failure is excited to have the continuous monitoring of left atrial pressures available for better patient management. The Center also includes our left ventricular assist device (LVAD) and heart transplant programs.

What imaging technology do you utilize?

Our two primary EP labs are Toshiba Infinix-i Biplane utilizing 16-inch frontal and eight-inch lateral flat-panel detectors (FPDs). The single-plane room used most commonly for EP has the Toshiba eight-inch FPD. The remaining two rooms are Toshiba single-plane — one with the 16-inch FPD and the other with the eight-inch FPD.

What is your experience with MR-conditional cardiac devices?

We have implanted them in select patients and have had no negative reports to date.

Does your program utilize a cardiovascular information system (CVIS), picture archiving system (PACS), or cardiology picture archiving system (CPACS)?

We utilize GE Centricity within the department for CVIS. Our images are stored in our Heartlab CPACS. In addition, we are developing a DICOM image server for EP to store outside CT and MRI scans for 3D mapping and eventual case archival from our 3D mapping systems.

Who handles your procedure scheduling? Do they use particular software?

We have a dedicated scheduler for the cath and EP lab. They utilize the Cerner Scheduling Management software used throughout the hospital.

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

We employ a comprehensive, radiation dose-management program, which includes criteria for beam rotation and triggered follow-up for exposure. We assess lab time and supplies used by type of procedure and physician. We also follow standard quality measures for The Joint Commission (TJC) and patient satisfaction.

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

The cath/EP lab has a supply coordinator. The primary EP staff members work with the supply coordinator to establish and maintain supply par levels. 

The supply coordinator places supply and equipment orders based on par levels, and under the direction of the EP staff and management.

Has your EP lab recently expanded in size and patient volume?

Our patient volume has dramatically increased over the last couple of years due to the development of the Complex Arrhythmia Center and Center for Advanced Heart Failure.

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

Managed care has forced our lab to be diligent in controlling expenses for procedures. We have not changed our philosophy, which is providing the best care possible to all of our patients. 

Have you developed a referral base?

Our referral base has been developed along several avenues including but not limited to supporting the needs of the other hospitals in our health system for more complex cases; building and maintaining relationships with cardiologists who completed training at our hospital; receiving referrals for complex procedures sent to our facility and regional referrals due to Memorial Hermann Life Flight, our CAMTS-accredited, critical care, air medical transport service; and most recently benefitting from the addition of our Center for Advanced Heart Failure.

What measures has your EP lab implemented in order to cut or contain costs?

Our primary methods for containment include reprocessing and diligent supply utilization and contract management.

How has the use of reprocessing impacted your lab?

Reprocessing catheters has significantly reduced our procedural expenses, especially for PVI ablations and procedures requiring intracardiac echo (ICE).

In what ways have you improved efficiencies in patient through-put?

The majority of our electrophysiologists have their patients get transesophageal echocardiograms (TEEs) and CT scans for PVIs on the day prior to the procedure. Our holding/recovery area staff contacts all outpatients the day before their scheduled procedure to answer any questions and coordinate a timely arrival. The department has a dedicated anesthesia tech, dedicated housekeeping, and patient care assistants for patient transport. Our holding/recovery area staff prepares patients pre-procedure, including shaving, then performs the sheath removals post-procedure. 

How do you ensure timely case starts and patient turnover?

Timely case starts and patient turnover are thanks to a team effort. Each team member performs a different part of the pre-procedure process: room set-up, emergency checklists, reviewing patient information (obtaining CT scans, labs, TEE results), echo and 3D mapping set-up, etc. 

Has your institution formed an alliance with others in the area? 

We enjoy strong alliances with the hospitals within our system and hospitals that refer to our Institute in the region.

How are new employees oriented and trained at your facility?

New employees attend the campus’s new employee orientation, then are assigned a preceptor in the department for the remainder of their orientation time. We tailor the orientation goals based on the new hire’s experience level.

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

We offer periodic in-services as well as periodic education from vendors, including continuing education opportunities. We support staff attending local educational opportunities and make every effort to accommodate time-off requests for staff wishing to attend out-of-town educational opportunities, such as conferences, workshops and vendor education seminars.

How is staff competency evaluated?

Staff performance is evaluated through annual competency assessments, feedback from physicians, and observations by senior staff.

Do you encourage your clinical staff members to take the registry exam for Registered Cardiac Electrophysiology Specialists (RCES)? How many members of your lab have taken the exam? Does staff receive an incentive bonus or raise upon passing the exam?

Yes, staff members are encouraged to take the registry and certification exams. We have several staff members preparing for the exam.

Achieving registry can be used by staff to advance on the clinical ladder and is required for certain positions higher on the clinical ladder.

How do you prevent staff burnout?

We post work schedules for six weeks at time, enabling staff to plan. We are able to accommodate almost all time-off requests, even those cropping up in the middle of a schedule.

Do you practice any team-building exercises?

We have annual holiday parties, teams for Heart Walk, fantasy football leagues and other staff parties outside of work.

What committees, if any, are staff members asked to serve on in your lab?

The EP lab staff members help with the department clinical practice and education committees. Department staff may also participate in facility or system councils.

Do you contract with vendors? How do you handle vendor visits to your department?

Yes, we contract for ongoing and bulk purchases as well as disposable purchases. All vendor representatives undergo a credentialing process and are permitted access to the facility in line with the terms of our vendor management policies.

Does your lab utilize any alternative therapies to help patients in the EP lab?

We usually have music playing during procedures. We aim to accommodate the patient’s preferences either through our own music library or through online music resources.

Describe a particularly memorable case that has come through your EP lab. What lessons did you learn from it?

We had a patient with inappropriate sinus tachycardia (IST) who had previously undergone three procedures elsewhere before he was referred to us for higher care. The last two had been abandoned by the operators due to the proximity of the phrenic nerve to the target location. Our physician decided to take an epicardial approach. We placed the epicardial sheath, then after mapping with the ablation catheter, he advanced a balloon wedge catheter to the mapped location of the phrenic nerve in the pericardial space. We inflated the balloon to push the phrenic nerve away from the ablation target site. We advanced the ablation catheter endocardially, verified non-stimulation of the phrenic nerve, and were able to ablate the IST. The takeaway was that we learned to think through an identified issue, then plan and develop the best approach to address that issue.

How does your lab handle call time for staff members? 

Call time is distributed among all cath and EP staff. We do not have a separate call time for EP only. 

The size of our staff minimizes the on-call time requirement to approximately one weekend per six weeks and one weeknight per week. The call team is activated an average of 20 times per month. ST-elevation myocardial infarctions (STEMIs) are the primary reason for activation of the call team.

We require a minimum of two RNs on the four-person call team.

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

Less than two percent of our ablation procedures are done with cryo. Ninety-eight percent of our ablation procedures are done with radiofrequency.

Do you perform only adult EP procedures or do you also do pediatric cases?

We primarily perform adult EP procedures. Our sister facility, Children’s Memorial Hermann Hospital, which is collocated on our campus, has its own dedicated cath and EP labs.

What measures has your lab taken to reduce fluoroscopy time and minimize radiation exposure to physicians and staff?

We have programmed a protocol for EP procedures into our X-ray equipment. We also utilize digital zoom to reduce radiation exposure. We have several electrophysiologists who extensively utilize 3D mapping and ICE with minimal fluoroscopic use. These physicians have completed PVI ablations with fewer than 10 minutes of fluoroscopy for some feasibility case studies.

What are your methods for infection prevention?

We adhere to Surgical Care Improvement Project (SCIP) guidelines, which include minimizing traffic into the control room, providing education/teaching on sterile and aseptic techniques, and closely observing staff, vendors, and physicians for sterile field integrity.

How do you use the NCDR Outcome Reports to drive QI initiatives at your facility? 

We review NCDR Outcome Reports in the department, share them with our physicians, and review them regularly with the hospital quality and risk management departments, as appropriate.

What are your thoughts on EHR systems? Does it improve your quality of care?

The hospital is moving toward a complete electronic health record (EHR) system. The medical school and several of our private practice physicians already utilize EHRs in their offices. Challenges with our current EHR strategy include connectivity issues with myriad specialized systems, such as electrophysiology and cardiac catheterization recording systems, and efficient integration of handwritten notes into the EHR. At present, these forms of documentation must be scanned into the EHR system after discharge.

The rapid accessibility to current and previous medical record information allows for better planning and adaptation during procedures.

What are some of the dominant trends you see emerging in the practice of electrophysiology? How is your lab preparing for these future changes?

We foresee the ongoing expansion of complex ablations, especially ventricular assist device-supported procedures, ischemic VT, epicardial approach and hybrid-OR procedures.

We are planning the addition of a hybrid suite within our department, and we continuously review and assess new technology to identify opportunities to further enhance the service we provide to patients. 

How does your lab handle device recalls?

If the recall involves equipment in the department, the device is immediately taken out of service/supply. It is then referred to our biomedical engineering department or returned to the vendor, as appropriate. Departmental, risk management and other documentation are also completed, as appropriate. For implanted devices, we will verify that our physicians are aware of the recall by confirming the company has contacted them regarding their patients.

How is outpatient cardiac monitoring managed?

Outpatient cardiac monitoring is managed through a combination of hospital-based, physician practice-based and medical school-based device clinics.

Are you ACGME-approved for EP training? What are your thoughts on two-year EP programs? 

Yes. Our program is a two-year program, with occasional one-year accommodation granted in special circumstances. 

Give an example of a difficult challenge faced in the lab. How it was addressed?

We had been using only our biplane rooms for PVIs and complex ablations. However, when our volume began to grow rapidly, we frequently encountered the need for a third room for these complex procedures. We worked with our physicians and decided to utilize a single-plane room using a low fluoroscopy protocol and relying on our 3D mapping system with ICE imaging for navigation and mapping. Using these innovative approaches, we can accommodate three complex ablations simultaneously.

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

As indicated in its name, the Memorial Hermann Heart & Vascular Institute-TMC is located in the heart of the Texas Medical Center. The TMC is the largest medical center in the world consisting of 21 hospitals, three public health organizations, two universities, three medical schools, six nursing programs, two pharmacy schools, a dental school, eight academic and research institutions, and 13 support organizations.  The largest employer in Houston, the TMC is home to the largest concentration of medical professional and experts anywhere; one of the first, and still the largest, air ambulance services – Memorial Hermann Life Flight; a very successful inter-institutional transplant program; three Level 1 trauma centers; and more heart surgeries than anywhere else in the world.

Please tell our readers what you consider special about your EP lab and staff.

Several factors make our EP lab special. For one, we have a highly experienced team with a total of more than 70 years of experience among us (two members with more than 20 years each). This experience level provides extraordinary versatility. Our team members have a genuine interest in EP and seek supplemental learning opportunities. We function well as a team, supporting each other and our physicians. Our outstanding reputation brings referrals not only locally, but regionally and nationally as well. We are able to provide superior service to our patients, and have provided 3D mapping support without prior scheduling or as a discovered need, regardless of vendor support, since 2003.