Nebraska Methodist Hospital

Nebraska Methodist Hospital is a 350-bed hospital located in Omaha, Nebraska. It is the busiest surgical hospital in the city and does over 20,000 procedures annually. Methodist Hospital is ranked second in Nebraska in U.S. News & World Report’s 2012-13 Best Hospitals rankings, and has received the Magnet Award for Nursing Excellence as well as the American Heart Association’s Lifeline Bronze Performance Achievement Award. The full range of cardiovascular care, including heart catheterizations, cardiac surgery, peripheral interventions, and electrophysiology, is offered at our institution. Having completed over 530 procedures in 2012, our EP lab is one of the busiest in the city.

What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab?

We are fortunate to have an extraordinarily large electrophysiology laboratory. Formerly a pediatric cardiac catheterization laboratory, when a new children’s hospital was built, the lab was converted to an adult EP lab. We have new fluoroscopy, a new recording system, and the most recent generation mapping system. We have three electrophysiologists, two of whom spend the majority of their time in the Methodist Hospital lab, and one who does a fair amount of outreach as well. There are 10 full-time staff members and five part-time staff members. The mix of credentials includes RNs, RTs, and LPNs. We also work very closely with our anesthesiology staff, consisting of both MDs and CRNAs. It is a busy laboratory, and we are fortunate to have so many individuals with such diverse backgrounds contributing to our success.

When was the EP lab started at your institution?

Methodist Hospital started the electrophysiology program in 1999. Originally situated in one of the cath labs, it consisted of little more than fluoroscopy and a stimulator. It has since evolved into a thriving EP program with state-of-the-art equipment. 

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

We are proud to offer a wide range of EP procedures in our laboratory. This includes a full complement of ablations including SVT ablation, idiopathic and ischemic VT ablation, and atrial fibrillation ablation. We also offer the full spectrum of device services from pacemakers to CRT-D devices. We recently started a lead extraction program as well; this is a joint venture with the EP Service and the Cardiothoracic Surgery service. In calendar year 2012, we implanted 374 devices and performed 157 ablations. The lab generally performs four to five ablations a week, the majority of which are for atrial fibrillation. Over the past year, we have had a consistent increase in the number of ablations of all types. 

What is the primary goal of your program?

Our goal is to offer a full complement of high-quality EP services to our patients and referring physicians. We make every attempt to stay up to date with current advances in technology and techniques in order to stay on the cutting edge of the field. Fortunately, we have a staff that is always eager to learn new procedures and new equipment, which facilitates this goal.

Who manages your EP lab?

Janell Neilsen, who was one of the first EP LPNs in the Omaha area, runs the daily business of the lab. Bonnie Brabec and Karen Cannina manage our Cardiovascular Service Line.

Do you cross-train with the cath lab?

Our EP lab is located on a different floor from the cath and echo labs, and there is a separate family waiting area. Our manager, Janell, is a dedicated EP LPN, but most of the staff is cross trained for work in the cath lab. However, as those in cardiology know, the skills and personalities involved in EP differ substantially from the cath lab, and the employees tend to align more with one than the other. 

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 new equipment that has recently been introduced into our laboratory that has had the most dramatic impact on our procedures has been the Medtronic Arctic Front^® Cardiac CryoAblation System for PVI. In our opinion, this has made PVI safer, more efficient, and possibly more effective. We firmly believe in this technology, and because of the decreased procedure time (we do PVI in one and a half to two hours, which includes a waiting period, after which time we look for persistent entrance and exit block and do isoproterenol testing), we frequently do two in a day. Though we would occasionally do more than one a day with radiofrequency PVI, we can now do two ablations and still have time for any add-on devices that may need to be done as well. We have found our success rates to be superior to RF PVI, outpatients recover more quickly from the procedures, and left atrial tachycardias have become a thing of the past.

Have you recently upgraded your imaging technology?

We did recently upgrade our imaging technology. In 2011 we had a new Siemens system installed. We have been impressed with the quality of images as well as the ability to customize the single flat panel display for different types of cases. 

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

Our office schedulers work with the hospital anesthesia/OR schedulers. Our office used GE Centricity as part of our electronic medical record system for us to keep track of appointments and procedures. 

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

We keep close track of all of our procedures and any complications including infections, hematomas, pneumothoraces, and effusions. These data are presented to entire cardiovascular division on a quarterly basis. We are very proud of our safety record, and strive to make each case as safe and comfortable for our patients as possible. 

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

Our inventory is managed manually. Janell handles the purchasing (it helps that she has a photographic memory!).

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

Our volume has expanded over the past few years. In 2012, we did about 150 more cases than 2011. We now also regularly have a “device” room in use while we are doing ablations in the EP lab. Fortunately, our cath lab is part of the hospital OR suite and has sterile OR air handlers, allowing us a clean lab in which to implant. We are currently in the process of designing a hybrid room as well.

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

Managed care has certainly had an impact on our reimbursement. As most in the field know, device reimbursement was substantially reduced in 2012, and ablations are being affected in 2013. Fortunately, atrial fibrillation ablation finally received its own billing code.

Have you developed a referral base?

We are part of a relatively large cardiology group, and most of our referrals come from within our own group. However, there are independent cardiologists at our hospital as well, and we have a very good relationship with them. We also make ourselves available to the primary care physicians with whom we work, and have a fairly large number of arrhythmia patients that are referred directly from primary care physicians. Any chance we get, we try to give talks to referring physicians and allied health professionals. Our hospital has a good relationship with local television and print media outlets, which allows us to reach out to potential patients as well.

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

To cut costs we have joined an accountable care organization with one of the other local health systems. We use this to negotiate contracts with device companies to help contain costs.

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

Health care continues to be an increasingly competitive field. In order to compete with patients, we proudly tout our high volume and good patient safety record. Additionally, whenever we offer a new procedure we involve the local media. For example, when we did the first cryo PVI, we involved the local television and print media and had a spotlight on the local news health segment. I feel that using the marketing tools offered by the hospital has been invaluable. I have had several patients visit with me after seeing me on the news or in local publications, all of which has been facilitated through the hospital’s marketing services.

How are new employees oriented and trained at your facility?

Our employees
start in the cath lab and then orientate into the EP lab. When they start in the lab, they are extensively mentored by experienced employees. Fortunately, we all enjoy teaching and in the lab we have a fairly relaxed environment that encourages questions and learning.

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

Our staff members are required to complete continuing educational activities and do so enthusiastically. We (physicians and staff) routinely attend the Heart Rhythm Society’s annual scientific sessions as well. Our employees are generally very eager to learn new techniques and to stay up to date with current treatment guidelines. We also have an annual cardiovascular symposium for nurses and allied health professionals. 

How is staff competency evaluated?

Our staff is routinely evaluated by other staff members as well as physicians in the lab. Constructive feedback is also given on a continued basis. As I mentioned above, our staff is eager to learn and to continue providing the best possible care to our patients. Our employees are generally very open to suggestions and opportunities for improvement.

How do you prevent staff burnout? 

This business can certainly result in burnout, particularly the ablation side of it, involving cases that can be hours in duration and fairly intense. To combat this, we like to keep a relaxed atmosphere in the lab. We are quite informal, we listen to music, and we keep things as casual as possible. I feel that this way, nobody is afraid to speak up or yell “OFF!” during an ablation if they see something amiss. 

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

We have EP physicians on both the hospital’s Executive Committee and the Morbidity and Mortality Committee.

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

Our vendors utilize Reptrax, as is required by the hospital. We do contract with vendors and have very good relationships with several companies.

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

We recently had an atrial tachycardia that we ablated from the non-coronary cusp (NCC) of the aortic root. When the patient presented to the laboratory, she was in an incessant atrial tachycardia. The earliest activation appeared to be near the region of the His catheter atrial electrogram. There was a chorus of sighs heard throughout the lab, as most expected a prolonged and high-risk ablation. My staff thought I was crazy when I declared that we would ablate this rhythm from the non-coronary cusp of the aortic valve (aren’t aortic valve tachycardias ventricular tachycardias?). The lab staff did a great job setting up for an angiogram, and after defining the coronary anatomy, we created a beautiful 3D map with early activation in the NCC. A single ablation here rendered the tachycardia non-inducible. 

This case presents several teaching points. The first is to think things through with each case. In EP, we do fairly well with pattern recognition, but that will only get one so far in the lab. We may well have been able to ablate this atrial tachycardia from near the His atrial electrogram, and perhaps we would have been able to do it safely as well. But a thoughtful appreciation of the anatomy of the aortic root demonstrated the proximity of the NCC to the atria and the His bundle region in particular (think of how often we put in pacemakers for heart block in aortic valve disease). Simply targeting the area of earliest activation may well have led to a pacemaker in this patient. 

Another point this case illustrates is the need to stay up on the literature. Case reports of NCC atrial tachycardias have been popping up in the literature (there was a very nice case report of such in EP Lab Digest^® last year), and it was from these case reports that I got the idea of looking in the NCC. The field evolves rapidly, and if an operator simply tries to turn every case into AVNRT, there will be many dissatisfied patients.

How does your lab handle call time for staff members? 

The call team covers any after-hours or weekend cases. The cath lab and EP lab have one team which consists of two RNs and one RT. They are on call two nights a week and one weekend a month.

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

We use cryo for all of our atrial fibrillation ablations, which is the majority of the ablation that we do. All pulmonary vein isolation is done with cryo. Until recently, I used RF for ablation of complex fractionated atrial electrograms and linear lesions in persistent AF, but I have now transitioned to a PVI-only approach, and additional ablations (generally with irrigated RF) are only done if a non-pulmonary vein trigger is revealed with isoproterenol testing. The vast majority of our AVNRT cases are done with cryo. However, if only non-sustained AVNRT can be induced, I frequently use RF for a somewhat more clearly defined endpoint (junctional rhythm with slow pathway RF ablation). For typical atrial flutters, we use both 8 mm solid tip and irrigated RF. 

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

We treat only adult patients in our EP practice. However, we are fortunate enough to have very talented pediatric electophysiologists located just across the street from our hospital. 

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

I feel that minimizing radiation is a paramount but often overlooked aspect of our business. Fortunately, we now have many tools to assist us with this. I always try to be careful positioning the equipment, keeping the patient off the beam and close to the image intensifier. We rely on intracardiac echocardiography for pulmonary vein isolations, and we rely a great deal on the 3D mapping system. On occasion, we will even map the first catheter as we place it in the femoral vein and use that map to place the other catheters, approaching the so-called “fluoro-less” ablations.

Do your nurses/techs participate in the follow-up of pacemakers and ICDs? 

Our clinic is a private practice model, so our clinic employees rather than hospital employees perform the device follow-up. We use the Medtronic Paceart System for follow-up as well as wireless systems such as LATITUDE (Boston Scientific), Merlin (St. Jude Medical), and CareLink (Medtronic). We have three dedicated device technicians that do about 75 checks a week in clinic, and about 100 remote checks a week. 

What innovative EP techniques are being utilized in your lab?

We find the use of cryoablation for PVI very promising. Since transitioning from point-by-point RF to cryo, our success rates have improved and our procedure times have declined. Additionally, we can never get enough imaging! We have the latest generation NavX mapping system, and I feel that this technology fits seamlessly into my cryo-PVI technique. We frequently use the EnSite Array non-contact mapping system as well. This has turned out to be invaluable in some atypical scar-related atrial flutters and atrial tachycardias. In addition to 3D mapping systems, we use ICE for all our PVI cases to assess balloon positioning, occlusion, and optimal transseptal sites. We often use it for  VT as well, particularly those that are LV in origin, both ischemic and idiopathic.

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

The most dominant trend we see is a decrease in device volume, particularly with ICDs. This is being countered with a substantial increase in AF ablation volume. In line with this trend, we now have two electrophysiologists performing AF ablations as opposed to only one, as was the case before. We strive to be one of the first locations in the region offering new technology and techniques. We were both the first site in the city to do cryo PVI and the first site in the Western United States to implant a quadripolar LV lead. We are eager to learn new techniques and expand our procedure repertoire so that we can continue to offer the full range of EP services to our patients and referring physicians.

What about device recalls? How has your lab handled these?

Device recalls are something with which we, and I think all, EP labs struggle. Our device clinic tags the device check of each patient with a recall or advisory. Each case, however, is handled on a case-by-case basis. In the absence of any definitive recommendation from the ACC/HRS/AHA, we base decisions such as lead extraction, lead abandonment, or continued follow-up on the patient’s age, comorbidities, and the nature of the recall. 

Is your lab doing web-based/transtelephonic device follow-up?

Our outpatient device clinic does both transtelephonic and web-based follow-up. As many of our patients come from rural communities that are some distance away, web-based follow-up has turned out to be a very convenient way for us to monitor our patients.

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

Yes, we are currently involved in several device clinical registries as well as research studies. Our office has a dedicated research division.

Are you ACGME-approved for EP training? What do you think about two-year EP programs?

We do not have an EP fellowship program. However, when I trained at Washington University, two years was desired from the fellows. I could not agree more. The increase in the number and scope of procedures that EP physicians do now as opposed to when the one-year fellowship was conceived has unfortunately not been met with a required increase in the length of training. 

Does your staff provide any educational materials for patients who may have additional questions about their condition/procedure? In addition, does your hospital or lab staff have a device support group? 

We always have plenty of written materials to provide patients and family with information regarding the procedures. We have booklets in the clinic and in the hospital, and we carry them around with us as well. The hospital also has videos about the procedures. We make every attempt to involve patients and their family in their care. After every AF ablation, we give patients in pre- and post-ablation the voltage maps of the left atrium. Patients truly appreciate any written information or photos we can provide for them.

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

One of the most difficult challenges our lab faced was taking the step from primarily doing devices and basic ablations to more advanced ablations and even lead extractions. This is when having an interested and thoughtful staff, such as we do, becomes invaluable. Prior to our first AF ablation we had several meetings, both formal and informal, with the EP lab staff. They were eager to proceed and very interested in both the procedure and the follow-up. They learned about the procedural techniques, potential complications and how to deal with them, the new equipment involved, and the follow-up after the ablation. Our first case went as smoothly as it could go, and this has been the case for any new procedure we have introduced. This is also what makes our staff so unique and innovative. They have take up every challenge, every new procedure, and every difficult case with interest, thoughtfulness, and above all else, attention to patient safety. This field expands at an unimaginably rapid rate, and any lab that does not stay ahead of the curve will be lost in the dust. I am confident that our staff can take on any challenge the world of EP can throw our way and eagerly anticipate what the future holds.

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

Omaha is a moderately large city with a population of about 400,000. Including the surrounding counties that comprise the Greater Omaha area, that population expands to about 1.2 million. We have a mix of both urban and rural patients, and it is not uncommon to ablate a patient that works for one of our many well-known financial institutions in the morning, and then implant an ICD on a corn farmer in the afternoon. Our patients tend to be very friendly and down to earth people, regardless of their vocation. We are fortunate to have a very strong medical community, in both the academic and private practice models. The Omaha area remains a wonderful place to practice medicine, with very reasonable compensation (particularly given the low cost of living) and a family-friendly environment. 

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

Like most busy labs, our primary goal is to provide a wide array of EP procedures, and to do so with the utmost regard to patient safety and thoroughness. We strive to provide the same range of complex procedures that are performed at academic medical centers, and work hard to learn new skills and techniques in order to offer truly innovative and quality care. In our field, whether one is attempting to maximize procedure volume or focusing on the complexity of the procedure, the patient often gets lost in the shuffle. In our lab, the patient is always first. Many of our ablations, and all of our complex ablations are done with two EP physicians. Though this takes time away from already taxed schedules, another set of eyes on the electrograms can often improve both the success and the safety of an ablation. As mentioned above, we make every attempt to involve the patient and the family in their care. We have even brought family members into the lab to see the imaging and explain what we did. We are proud to have been the first lab in the city to perform several procedures and are eager to offer even more. However, pride should never become bravado in the EP lab, and patient safety and satisfaction should always be paramount. I feel that although achieving a balance between complex procedures, good outcomes, and patient safety is and should always be a work in progress, we can be proud of the work we have done and look forward to what the future of EP brings.