Spotlight Interview: Advocate Illinois Masonic Medical Center

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

Advocate Illinois Masonic Medical Center currently has one dedicated, leading-edge EP lab. Funds have been approved for the renovation of a current cath lab to accommodate both cath and EP procedures. We also staff an outpatient device clinic three days a week. We have seven dedicated nurses, ranging from full time to registry, and one full-time radiologic technologist. All staff members are ACLS certified. The hospital has earned Magnet designation and our nurses all have critical care and cardiology backgrounds, with credentials including ADN, BSN and MS degrees, as well as some CCRN and CVN certifications. We also have one inpatient research nurse and one outpatient clinic nurse who work closely with physicians to manage patient care. Our physicians are board certified in clinical cardiac electrophysiology.

When was the EP lab started at your institution?

Richard Kehoe, MD and Terry Zheutlin, MD started the cardiac electrophysiology program at Advocate Illinois Masonic Medical Center in 1989, moving their established practice from one of the university-based hospitals in Chicago. Since then, the lab has grown to its current level of five full-time electrophysiologists, with several additional electrophysiologists maintaining privileges. Dr. Kehoe is the medical director of the program, Dr. Zheutlin heads the outpatient clinics, and Dr. Mansour Razminia is the medical director of the EP lab and interventional electrophysiology. We also have a dedicated ACGME-certified EP fellowship program training two fellows each year under Dr. Kehoe’s direction.

What types of procedures are performed at your facility?

We perform radiofrequency ablations for many types of complex arrhythmias, with an emphasis on atrial fibrillation and atrial tachycardia. The group has extensive experience in cryoablative techniques for the treatment of AV nodal reentrant tachycardia (AVNRT) and septal accessory pathways. Referrals are seen from throughout the Midwest. The lab is also active in the implantation of pacemakers, loop recorders, defibrillators and biventricular devices. Other procedures include tilt table studies, non-invasive EP testing, transesophageal echocardiogram (TEE) and direct current cardioversion (DCCV), and drug infusion studies.

Approximately how many are performed each week?

Each week we typically perform four to five ablations, four to five implants, three to four TEE/cardioversions, 1 to 2 tilt table tests and occasional NIPS and drug infusion studies.

What is the primary goal of your program?

Since our procedure volume is heterogeneous, covering ablations and device implants along with noninvasive interventions, our primary focus is on improving the quality of life for our patients. Our patients tend to have similar complaints of fatigue, shortness of breath, chest heaviness, and dizziness, though the mechanisms driving those complaints are varied, according to their clinical diagnosis. Whether it is by radiofrequency ablation or device implantation, we hope to optimize their lives.

Who manages your EP lab?

The EP lab is managed by Kathleen Magurany, BS, RT(R), RDMS. In addition to EP, Kathleen manages the cardiac catheterization labs, non-invasive Cardiology and Neurophysiology services. The EP lab has a designated clinical team leader, Emily Tschappat, ADN, RN, who coordinates the lab on a day-to-day basis and is responsible for issues such as staff scheduling, equipment and supplies, and patient flow. Emily is known by the team to be the head cheerleader who keeps them motivated with a ready smile and upbeat attitude. Kathleen and Emily have an excellent partnership, offering a complement of both nursing and radiological safety perspectives.

Tell us about the separate EP and cath labs. How long have the labs been separate? Are employees cross-trained?

The EP and cath lab each have their own nurse team leader and distinct staffs, though we are geographically located next to one another. The staff assists each other, as needed, with admitting/recovery and overflow device cases in the cath lab. The labs were established independently and have remained separate since the inception of the EP lab in 1989; however, with a new lab on the horizon, we will be utilizing existing staff for EP and cath and will require more cross training. Two of our EP nurses have prior cardiac catheterization lab experience and can cross-cover, if available and needed for cath procedures.

Do you have cross training inside the EP lab?

Some nurses are cross-trained to the outpatient device clinic and develop a familiarity with all aspects of device programming. Other nurses and our radiologic technologist are cross-trained in the electroanatomical mapping system and play an important role in assisting with the three-dimensional mapping.

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

We attempt to keep pace with the latest technology enhancements. Currently, we are using St. Jude Medical’s EP-WorkMate and EnSite mapping systems, and have just upgraded to their Velocity system. Our ablation systems include both radiofrequency and cryoablation, and our physicians are extremely proficient in the use of the ACUSON ultrasound system for both vascular access and intracardiac applications. Our reliance on 3D mapping, supplemented by intracardiac ultrasound, has greatly minimized our dependence on fluoroscopy, to the extent that the vast majority of our cases can be performed without radiation.

The lab’s fluoroscopy imaging became digital in 2005. Other equipment, such as the ACUSON ultrasound system, is upgraded as available.

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

Our cath lab secretary is responsible for scheduling the cases. She relies on SharePoint to assist in scheduling, and coordinates the scheduling of anesthesia if needed.

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

Being a Magnet-designated hospital with a patient safety and quality outcomes focus, our team shares a multi-disciplinary approach to quality outcomes as well as nurse-sensitive quality indicators. Each nursing unit has been asked to identify important clinical outcome indicators and self evaluate the unit’s performance. For example, the EP lab has been focusing on improving procedure start times, fluoroscopy reduction, and the prevention of procedural complications, such as DVTs, fluid overload and electrolyte imbalance, hypothermia and infection.

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

We use an automated storage system to store and inventory our supplies. It is set up to re-order as supplies are used. It’s overseen by the charge nurse and the radiologic technologist. Other equipment purchases are handled by the charge nurse and manager.

Has your EP lab recently expanded in size and patient volume, or will it be in the near future? In addition, is your EP lab part of a separate “heart hospital”?

Our patient volume continues to increase, so much so that the renovations planned for the new procedure room include rendering it capable of fully supporting all EP and interventional activities. We do not maintain a separate heart hospital, as we approach care in a collaborative and coordinated manner through our Heart and Vascular Institute, partnering with Cardiology, Radiology and Cardiovascular Surgery on high quality outcomes.

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

Managed care has not had a great impact on the functionality of the EP lab, other than time spent on obtaining pre-procedural authorization for diagnostic tests and procedures. Our outpatient nurse coordinator has been essential in negotiating some of these barriers.

Tell us about your referral base.

We do have a developed referral base. Our lab relied early on developing the capability of readily and safely obtaining left atrial access for ablating left-sided accessory pathways. This expertise enabled us to become comfortable in techniques such as pulmonary vein isolation and ablation of left atrial tachycardias, which represented the bulk of our ablations, at the time. As this expertise developed, the lab also developed a strong reputation for the advanced application of intracardiac echo (ICE).

Another area of expertise that has helped develop a referral base is the lab’s early reliance on cryoablative techniques, dating back to our participation in the initial FROSTY multicenter clinical trial.

We receive a number of referrals from laboratories that are not cryo-equipped, and we apply this technology for ablation of arrhythmias such as AVNRT or septal accessory pathways. For the last seven years, we’ve successfully used this technology in more than 90 percent of cases and have encountered no instances of persistent AV block.

We also place a priority on communicating the therapeutic plans and procedural outcomes back to the referring physicians. Successful communication has also been an important component of the lab’s development of a referral base.

What measures has your EP lab implemented in order to cut or contain costs? In addition, in what ways have you improved efficiencies in patient through-put?

We send many of our diagnostic catheters for resterilization, including intracardiac ultrasound catheters. Those catheters that cannot be safely resterilized, including those with electrodes, are processed to harvest the metal from the electrodes.

Our hospital is part of Advocate Health Care, a 12-hospital system in Illinois and one of the top 10 health systems in the nation. This alliance has enabled us to negotiate better pricing with vendors and identify exact devices at time of schedule, holding representatives accountable for follow-through. Patient through-put is enhanced by focusing on prompt procedural start times and staggering staff scheduling, enabling us to cover cases when volume demands force the lab to operate past the usual closure time of 5 pm. 

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

The Chicago health care market is extremely competitive, with numerous award-winning hospitals, physicians and systems vying for patients within a limited geographical area. Our program competes effectively throughout Chicagoland by emphasizing successful outcomes, minimizing complications and providing safe, companionate care to all our patients.

How are new employees oriented and trained at your facility?

Orientation consists of a one-year period of on-the-job-training, with one-on-one mentoring for the first few months. Staff members must be able to prove competency on the use of all EP equipment.

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

We encourage staff members to participate both in HRS- and industry-sponsored educational programs. Staff members also attend monthly nursing grand round sessions, and EP and cath conferences as time allows. Advocate Illinois Masonic Medical Center also has a STEPs program, a four-level direct caregiver staff nurse clinical ladder system that recognizes and rewards excellence in clinical practice, from beginner to expert, through career development opportunities and the enhancement of professional fulfillment.

How is staff competency evaluated?

Advocate Illinois Masonic holds an annual competency fair for all nurses and technologists to review their skills and update practice techniques. Successful completion of computer-based learning modules is required to attend the fair and to meet Advocate Health Care’s continuing education requirements. For EP-specific competencies, staff members evaluate each other’s performance on key clinical indicators at least once a year.

How do you prevent staff burnout? In addition, do you practice any team-building exercises?

Shared scheduling allows staff to be more flexible in rotating coverage for early and late shifts. Members of the EP team work together, accommodating each others’ needs for time off and special circumstances. This teamwork and flexibility is what helps prevent burnout in our lab.

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

Currently, staff members are involved in numerous hospital- and system-level committees, including the Clinical Informatics Committee, the Nurse Advisory Council and the Clinical Advancement Board. They have also been involved in the Conscious Sedation Committee, as needed.

Does your lab use a third party for reprocessing?

Some equipment is sterilized in-house, such as cables and surgical instruments. We use a third party for reprocessing of our diagnostic catheters, which has allowed us to lead our institution in savings.

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

The most dramatic change to our day-to-day function has been eliminating fluoroscopy through the use of 3D mapping and intracardiac ultrasound for invasive EP studies and ablation procedures. The use of the EnSite mapping system in conjunction with ICE has enabled us to minimize the amount of fluoroscopy used during ablation cases to zero. Mansour Razminia, MD has developed the method, now performing 100 percent of ablations without a second of fluoroscopy. Our physicians and staff don’t even wear lead for these cases anymore.

We’re currently looking at ways to implant cardiac devices without the use of fluoroscopy. For those procedures requiring radiation, personnel have protective lead garments and work closely with our radiation physicist to assure the team is educated and exposure levels are tracked. 

Do your nurses/techs participate in the follow up of pacemakers and ICDs? If so, how many device visits per week do they handle? How many of your ICD/pacemaker patients require a doctor for their visits?

Four of our EP nurses are cross-trained to work in the outpatient device clinic. They typically see 35 to 40 pacemaker and ICD patients a week, with approximately half of these patients requiring a physician consultation during their visit. The information collected at these visits is recorded into our EP database.

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

A clearly dominant trend for us is improving patient and staff safety in the EP lab by eliminating the use of fluoroscopy. The benefit to the patient in terms of reduction in lifetime radiation exposure speaks for itself. Additionally, benefits for the EP lab’s staff include performing procedures without cumbersome lead aprons, jackets and protective eyewear. The expectation is that the EP physicians and laboratory staff may thereby minimize the risk of orthopedic injury — a notorious occupational hazard. Secondary benefits include minimization of fatigue and improvement of mental fitness in challenging, lengthy procedures. In addition, the emergence of the fluoroless technique enables us to perform catheter-based procedures on pregnant patients, if needed, without injury to the fetus.

What are your thoughts about non-EPs implanting ICDs? Do you train such individuals?

We currently do not support training non-EP physicians in the techniques of implanting ICDs or CRT devices. Findings from the examination of recent NCDR registry information, as well as data from other sources, strongly suggest complication rates are higher and patient outcomes are poorer when non-EP physicians implant ICDs.

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

The nurses routinely working in the device clinic have established a system to track patients found to be involved in a device recall. These patients are followed closely according to recommendations of the device company, the FDA and HRS consensus statements.

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

We are currently involved in the multicenter IMPACT clinical trial, which is evaluating the use of intense remote monitoring as a guide for anticoagulation strategy in patients with atrial fibrillation. We are also interested in validating long-term success in patients who have undergone cryoablative therapy for AVNRT, as there seems to be some doubt in the EP community at large as to whether cryoablation is as effective as radiofrequency ablation. In addition, we are interested in determining the extent to which ICD and CRT-D patients treated in the real-world setting replicate the beneficial outcomes that have been reported in randomized control clinical trials.

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

Advocate Illinois Masonic is a teaching hospital with two ACGME-approved EP fellows annually. Because ACGME only approves a 12-month EP training period and no CMS finding is available beyond the first year, the majority of fellows entering training seem to prefer two full years to facilitate learning of more complex ablation procedures and device implants. Intermittently, we have been able to offer certain fellows two years of training by relying on intramural and external sources of funding. The consensus within our program’s key faculty is that the optimal training interval for EP fellows is between 18 to 24 months.

Does your lab provide any educational or support programs for patients who may have additional questions or those who may be interested in support groups?

Our outpatient nurse coordinators provide patients with information on their disease process and procedures that may have been recommended. The clinical nurse specialist rounding in-house with the physicians each day is responsible for making certain all patients receive necessary information and discharge instructions.

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

With the emergence of long and complex ablation procedures, such as atrial fibrillation ablation, radiation exposure to patients and staff has presented a challenge. The focus on lifetime radiation reduction strategies nationally has exposed the public to this safety concern, in addition to several of our EP attending physicians, fellows and lab staff who have developed cervical and lumbar-sacral spine injuries from the need for wearing lead aprons during procedures. Our ability to utilize a fluoroless technique for the majority of these lengthy procedures has impacted patient and staff safety, and should help to greatly minimize the risk of problems in the future.

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

Chicago, the Windy City, is an internationally renowned destination, known for culinary delights, an ample theater scene and championship sports teams. Once and current home to President Barack Obama, Oprah Winfrey, Michael Jordan and Studs Terkel, no other Midwestern city has the glamour and star power of Chicago. Advocate Illinois Masonic is located just east of Lake Michigan and the famous Lincoln Park in the city’s Lake View neighborhood. Just down the street from the world-famous Wrigley Field, home of the Chicago Cubs, the hospital sits in the heart of one of the most diverse urban neighborhoods in the country. Patients and staff speak more than 40 different languages and come from countless cultural backgrounds.

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

Advocate Illinois Masonic Medical Center in Chicago is one of only a handful of facilities nationally that has established a program for eliminating the use of fluoroscopy in diagnostic EP studies and catheter ablation procedures in the adult population. Fluoroscopy use has not been used in more than 50 consecutive procedures performed at the hospital by Mansour Razminia MD — procedures that have included a mix of atrial fibrillation/tachycardia, ventricular tachycardia, atrial flutter and SVTs. With no fluoroscopy  used, the entire EP lab staff is able to work comfortably in a safer environment, free of heavy, cumbersome lead shielding aprons. Dr. Razminia continues to refine his fluoroless technique, with our EP fellow and lab staff active participants in the process. It is our hope that by expanding the fluoroless approach to the ablation of arrhythmias, we will enhance patient safety and improve the quality of life for patients, EP physicians and staff members.

Dr. Razminia is happy to share his knowledge and serve as a mentor for the fluoroless technique he uses at Advocate Illinois Masonic Medical Center. To inquire, please email our assistant, Charity Lemke, at charity.lemke@advocatehealth.com  

For more information about Advocate Illinois Masonic Medical Center, please visit https://www.advocatehealth.com/