Spotlight Interview: Carilion Clinic

What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab? We currently have 3 electrophysiologists: Dr. William Welch, Director, Dr. Terry May, and Dr. Alex Vigh. Our staff includes 1 RN Manager, 3 RNs, 1 flex-time RN, 3 cardiovascular techs (all radiology techs at present) and 2 scrub techs. When was the EP lab started at your institution? Dr. William Welch came to Carilion Roanoke Memorial Hospital in the summer of 1991 from the Medical College of Virginia. What types of procedures are performed at your facility? We do 1,000 invasive procedures annually, including ablations, EP studies, and pacemaker, loop recorder, AICD, and Bi-V implants. We also do tilt table testing and DC cardioversions. Approximately how many are performed each week? What complications do you find during these procedures? We do a total of 20-35 procedures weekly. Complications are rare; our complication rate is lower than the national average. Who manages your EP lab? Charlene Cole, RN, MBA is the senior director of invasive cardiology, and the EP lab manager is Brenda Rechtman, RN, BSN. Brenda has been in the position of supervisor/team leader/manager since being hired in 1991. Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained? The EP lab has always been independent from the cath lab. We do occasionally cross train a tech or RN from the cath lab for backup assistance. Do you have cross training inside the EP lab? What are the regulations in your state? Our nurses provide procedural sedation for our patients. Other than physicians, only registered nurses in the state of Virginia may administer IV sedation drugs. RNs and CVTs circulate implants. Our CVTs operate the stimulator during EPS/ablation and scrub implants, along with our 2 scrub techs. What new equipment, devices and/or products have been introduced at your lab lately? How has this changed the way you perform those procedures? We just upgraded both of our EP MedSystems as well as a Boston Scientific ablation system. The EPIC electronic medical record went live in July of this year. Who handles your procedure scheduling? Do you use particular software? The manager and charge personnel schedule outpatient cases through our newly installed EPIC electronic medical record. Interface between all Carilion physician practices and the medical center eliminate scheduling conflicts in our electronic medical record. Several departments, including the outpatient recovery area, echo and the EP lab, can be scheduled with one phone call, limiting unnecessary calls and scheduling errors. What type of quality control/quality assurance measures are practiced in your EP lab? We monitor Joint Commission patient safety goals. The biomedical department monitors all patient care and monitoring equipment in the lab. We monitor safety issues, including Pyxis (computerized medication administration system), expiration dates, refrigerator temps, crash carts and defibrillators, and O2 tanks. Our maintenance department monitors fire and safety equipment. We are also beginning a post procedure phone call to patients to assess the hospital education process. How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? The manager is responsible for inventory and monitoring all device inventory. All staff assists in alerting her to needs in the department. She also contacts vendors for equipment pricing and makes suggestions for purchase in cooperation with physicians and administration. Has your EP lab recently expanded in size and patient volume, or will it be in the near future? An addition to the electrophysiology staff is planned for the future. Carilion Clinic has a large invasive and noninvasive cardiology department, including cardiac surgery. Have you developed a referral base? Our electrophysiologists and hospital have a large referral base extending into West Virginia, southwest Virginia and North Carolina. 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? Our hospital limits the number of device vendors. We also reprocess some diagnostic catheters and use the money for continuing education of lab staff. In addition, we schedule our patients through our new EMR, which identifies conflicting appointments for patients. How are new employees oriented and trained at your facility? New RN employees attend the procedural sedation class at Carilion. They work for 6 months to a year with a senior employee to learn skills particular to the EP lab. We also send all employees to outside training provided by vendors and other sponsors. Topics include: use of stimulators, interpreting electrograms, tachyarrhythmias, ablations, pacemaker and AICD devices, and interrogation. Device reps provide weekly in-services. Staff are required to present an in-service at least once yearly. What types of continuing education opportunities are provided to staff members? Device and catheter reps provide weekly in-services to our staff. All staff had the opportunity to attend the SASEAP conference in Myrtle Beach in September. We try to send at least one employee to Heart Rhythm Society in May, and to educational offerings provided by vendors and other sponsors. Several employees attended the annual Heartnet Convention in Roanoke sponsored by Carilion Clinic. How is staff competency evaluated? Annual performance evaluations, with competencies observed by peers, are required. Manager/employee conferences help assess the employee’s individual education needs. Job-related education hours are required per hospital policy. How do you prevent staff burnout? In addition, do you practice any team-building exercises? Yes, we regularly offer a team-building activity during a staff meeting. During a lightly scheduled day, we will plan an outside luncheon for our staff meeting. We give movie tickets for birthdays, and ice cream socials and chocolate for a variety of occasions. We celebrate birthdays with a carry-in lunch custom-prepared for the individual. What committees, if any, are staff members asked to serve on in your lab? We have a safety meister, as well as committee members on nursing outcomes, support group meetings, procedural sedation, patient education, the American Heart Association, United Way, Epic, and others. We have a focus group of all staff responsible for research and evidence-based practice. How do you handle vendor visits to your department? Do you contract with vendors? Device vendors are in the lab each day. We have the same vendors cover each implant. Catheter reps must schedule in advance, allowing only one catheter vendor in the lab each day. Does your lab utilize any alternative therapies? A music therapist/massage specialist visits our patients prior to their EP procedure. How does your lab handle call time for staff members? We do not take call. Our staff works Monday through Friday from 7:30am to the completion of the last case. One of the most difficult issues in the lab is the lack of control over schedule. Our staff alternates working late evenings. Planning personal time can be difficult with multiple add-on and prolonged cases. Does your lab use a third party for reprocessing? Yes, we use Ascent Healthcare Solutions. Approximately what percentage of your ablation procedures are done with cryo? What percentage is done with radiofrequency? We are not using cryo for ablations. Do you perform only adult EP procedures or do you also do pediatric cases? We perform only adult procedures. What measures has your lab taken to minimize radiation exposure to physicians and staff? We use lead aprons, lead shielding for physicians and staff, the RADPAD® (Worldwide Innovations & Technologies, Inc., Overland Park, Kansas), and lead eye glasses. We encourage staff to place themselves as far from the x-ray as possible during patient care. Do your nurses/techs participate in the follow up of pacemakers and ICDs? Pacemaker clinics are now held in physician offices. What trends do you see emerging in the practice of electrophysiology? How is your lab preparing for these future changes? We realize that atrial fibrillation ablation will be on the increase for some time. At present, we perform mini-Maze procedures in our cardiac surgery department. EP lab staff assists with testing during these cases. However, we do not perform atrial fibrillation ablations at this time. What about device recalls? How has your lab handled these? We replace recalled devices according to physician order. The patients are monitored through the electrophysiologists’ offices. Is your EP lab currently involved in any clinical research studies or special projects? Not at present. When was your last inspection by the Joint Commission? Our last inspection was done in January 2007. 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 hospital provides a large selection of educational handouts to patients. We have an active AICD support group that meets 3 times yearly. Our nurses recently developed a new AICD educational program. They completed a literature search on the subject and put together a pre-op and post-op educational booklet for patients. They spend time with the patient prior to and following surgery. The nurses also give a follow-up phone call to these patients after discharge. Give an example of a difficult problem or challenge your lab has faced. How it was addressed? Staffing shortages are difficult to manage. Searching for new EP staff takes a great deal of time, and, minimally, a year of training once hired. As a backup plan, we are training two RNs from the cath lab to work with our electronic medical record and procedural sedation. Describe your city or general regional area. How does it differ from the rest of the U.S.? Metropolitan Roanoke, Virginia includes several counties, has a population of about 300,000 persons, and is the business center of southwest Virginia. A larger population of primarily rural developments populates the surrounding area. We have access to snow skiing, mountain climbing, beaches, and cities like Atlanta and Washington, D.C. within a few hours drive. It has been listed as one of the best places to live in the U.S. Carilion Clinic, the largest employer in Roanoke, is a multiple hospital and physician provider health system. Please tell our readers what you consider unique or innovative about your EP lab and staff. Our lab and staff are a mix of awesome professionals who demonstrate each day how important our patients are. We work with physicians who respect their talents and dedication to electrophysiology. They are impressive as a working team, supporting each other in and out of the lab. For more information, please visit: www.carilion.com