Spotlight Interview: Community Healthcare System

What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab? We have 10 FTEs in the department: 5 Registered Nurses, 2 Radiology Technicians, 1 Cardiac Tech, 1 Data Coordinator and 1 Regional Manager. There are 3 cardiac electrophysiologists and 1 anesthesiologist at St. Mary Medical Center and St. Catherine Hospital. There are 10 cardiac electrophysiologists on staff at Community Hospital. When was the EP lab started at your institution? The EP lab was started at St. Mary Medical Center in 1996. However, in 2001, our institution was purchased by Community Hospital in Munster, Indiana. At that time, the Community Healthcare System was formed. The system includes St. Mary Medical Center in Hobart, Indiana, St. Catherine Hospital in East Chicago, Indiana, and Community Hospital in Munster, Indiana. In October 2003, staff from St. Mary Medical Center became regionalized and started providing services at all three institutions. There are four procedure rooms as well as four clinics across the system. What types of procedures are performed at your facility? All three facilities are capable of doing basic EP work including standard ablations, EP studies, device implants (biventricular, defibrillators, pacemakers), tilts, NIPS and cardioversions. We do complex ablations with a 3D mapping system at St. Mary Medical Center, while laser lead extraction is done at Community Hospital. In addition, we have a regional transtelephonic pacing clinic as well as a program for remote monitoring of ICDs. What is the primary goal of your program (AF ablations, lead extractions, BiVs, etc.)? Our primary goal is to be able to provide a full-service EP program to the population of Northwest Indiana. We want to provide safe, quality care to all of our patients. Our goal is to provide all necessary services so our patients do not have to travel to obtain EP services. Continuity is a priority for us. All staff members are cross-trained to perform procedures in the EP lab and to care for patients in the clinic setting. Because of this, our patients meet the staff at their initial consultations, are cared for by the same staff during their procedure, and then again cared for by familiar staff during their follow-up care. Approximately how many are performed each week? What complications do you find during these procedures? Our complication rate is below national standards. We evaluate every case for any adverse event (AE), such as hematoma, pneumothorax, tamponade, lead dislodgements/device revisions (both chronic and acute) and infection. All AEs are reported to our Cardiac Quality Improvement committee for formal review. Who manages your EP lab? Mark Dixon, DO is the Medical Director of the labs, while Chris Atherton, RN, BSN, MPA is the Regional Manager of EP Services. She has regional responsibilities for the day-to-day operation of all labs and clinics within the Community Healthcare System. In addition, Chris acts as the research coordinator for the research protocols that we participate in. She has 17+ years experience in the management of EP services. Is the EP lab separate from the cath lab? How long has this been? EP labs are separate from the cath labs at St. Mary Medical Center and St. Catherine Hospital. At Community Hospital, we share a room with the cath lab. St. Mary Medical Center has had an independent EP lab since its inception in 1996. Upon regionalization in 2003, St. Catherine has had a room that belongs primarily to EP but can be utilized if not needed for EP by the cath lab. Do you have cross training inside the EP lab? What are the regulations in your state? Staff are cross-trained to the clinic as well as the EP lab so they can perform all functions. RNs are trained to assist at the table in all procedures including device implants. The nursing staff performs all duties relating to the physiologic recorders and clinical stimulators. The RNs maintain competencies in the provision of intravenous sedation. Our EP Rad techs provide technical assistance to the physician during implants and cath insertions. Both RNs and Rad techs operate the ablator. The State of Indiana does not allow the registered nurse to perform any function related to radiology. Our techs or physicians perform any function related to our fluoroscopy equipment. 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’ve added CARTOMERGE (Biosense Webster Inc., a Johnson & Johnson company, Diamond Bar, California) within the past 6 months. This required collaboration with our CT department for precertification issues, protocols, orders, etc. In addition, we have fully implemented LATITUDE (Boston Scientific, Natick, Massachusetts) and CareLink (Medtronic, Minneapolis, Minnesota) into our clinic. CARTOMERGE is great technology that allows us to visualize the actual anatomy of our atrial fibrillation patients instead of having to do prolonged mapping procedures. With time, we hope to decrease our fluoroscopy time as well as procedure times. We will also evaluate each patient for use of CARTOMERGE especially those with potential congenital defects. LATITUDE and CareLink are very useful tools to have in the department. It has taken some creativity to establish guidelines that work for both the staff and physicians when responding to alerts found within the system. We have also assumed the responsibility of doing LATITUDE and CareLink for clinics not associated with the Community Healthcare System, which presents a whole different set of issues, as these patients are not normally seen in our clinics. Who handles your procedure scheduling? Do you use particular software? We currently utilize an electronic scheduling program to schedule all clinics, procedures and remote ICD monitoring. The staff has open access to the program and can do scheduling from all three of our sites. The program is fully utilized at St. Mary Medical Center, and will be added in 2008 to St. Catherine Hospital and Community Hospital. What type of quality control/quality assurance measures are practiced in your EP lab? We currently participate as a Premier member in the ACC/NCDR ICD database. We have incorporated the proposed metric that are currently under review into our quality improvement program. We review incidence of any adverse event, hematoma and lead dislodgement as well as beta blocker and ACE/ARBs prescribed at discharge for patients with an EF ? 40%. These will be reported to our Cardiac QA committee. How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? A software program is utilized for the purchase of supplies in the departments of the different facilities. The radiology techs are assigned the responsibility of inventory, stocking and ordering, and have a good working relationship with our Materials Management Department. Since we are regionalized, we work under the same cost center as well as account numbers at all three facilities. We also have standardized supplies at all three institutions to ease the process of keeping an appropriate inventory level as well as keeping staff familiar with stock items. Has your EP lab recently expanded in size and patient volume, or will it be in the near future? It is expected that within the next year we will increase services at Community Hospital, so there will be designated staff at that facility. This is done as a result of adding physicians and changing referral patterns of the medical staff. This will require the addition of RN and EP Rad tech staff. Current staff will continue to support all clinics and procedures at St. Mary Medical Center and at St. Catherine Hospital. How has managed care affected your EP lab and the care it provides patients? We continue to provide all services needed to our patient population. We have worked extensively with our managed care offices to develop contracts that address hardware as well as components related to the complex ablations requiring 3D mapping. Our manager alerts the managed care personnel to any issues that may affect our contractual arrangements. Have you developed a referral base? We have an excellent working relationship with the cardiologists at St. Mary Medical Center as well as internal medicine and family practice. Our EP physicians are very good at communicating any patient interaction back to the referring physician. The relationship is good because each specialty recognizes and respects the other. The EP physicians deal with the arrhythmia issues only and return the patient to cardiology/internal medicine for any other issues. It is an excellent collaborative environment. What measures has your EP lab implemented in order to cut or contain costs? We do bulk buys on a regular basis for some of the more expensive items utilized in the departments (e.g., devices, leads, specialty catheters). In addition, because of the standardized stock at all three facilities, there is no need to have unused quantities of supplies at any facility. Staff carries equipment/supplies to other facilities if needed. We constantly evaluate contracts with our device and catheter vendors. In what ways have you improved efficiencies in patient through-put? Our main efficiency is the standardization of supplies, protocols and staff between the three facilities. We have well-trained staff that has no other focus other than EP-related issues. Our staff are well-trained, very competent and efficient because of the standardization. Does your EP lab compete for patients? Has your institution formed an alliance with others in the area? Yes. There are programs at every hospital in Northwest Indiana. Our labs always have been in the forefront when it comes to new technologies and procedures. Our physicians trust our staff to undertake new endeavors, which then benefit our other labs. We are on a first-name basis with most of the labs in the area. We will never let competition interfere with patient safety. However, we must always remember that we are in a very competitive environment and we want to retain our market share. What procedures do you perform on an outpatient basis? All patients are admitted as outpatients; their status is evaluated post-procedure as to whether they will be discharged same day or be admitted for further observation. How are new employees oriented and trained at your facility? The most successful component of orientation for most employees has been the on-the-job training received in the department. Our physicians are excellent instructors and assist in the orientation process. New employees start in the clinic setting, progress to the basic procedures and then proceed on to full responsibility for the patients undergoing complex procedures. What types of continuing education opportunities are provided to staff members? Our device and catheter vendors are very good at providing clinical education. In addition, utilization of online education is encouraged. How is staff competency evaluated? Staff are evaluated yearly for general hospital and safety competencies. In addition, competencies are evaluated with the initiation of each new procedure in the department. How do you prevent staff burnout? Because of the small number of staff in the department, we try to maintain a close relationship with each other. We often spend more time with each other than we do our own families! We’ve all learned to deal with the different personalities and respect each individual. We attempt to have at least one social occasion per month in order for the staff to maintain a good relationship. In addition, by periodically changing our routine, we have been successful in keeping positive attitudes on the job. The addition of new technology and procedures keep staff updated and interested in what they are doing. What committees, if any, are staff members asked to serve on in your lab? We have recently initiated the Studer principles into our work environment as part of our healthcare system’s Operation Excellence goals. Our staff participates in the Outpatient Satisfaction and Ambulatory Patient Satisfaction teams. How do you handle vendor visits to your department? Do you contract with vendors? Our vendors are aware of the times that are busy in the department and make every attempt not to disturb staff and physicians during those busy times. Appointments for meetings/inservices are made in collaboration with the lab/physician scheduled. We have contracts with device vendors as well as the catheter companies. These are done in collaboration with the EP manager and the Materials Management Department. Does your lab utilize any alternative therapies? No. Please describe one of the more interesting or unusual cases that have come through your EP lab. A 30-ish registered nurse familiar to the department complained of symptomatic palpitations post partum. An EKG revealed an isthmus atrial flutter. This was ablated successfully utilizing an irrigated tip catheter. Six months later, she began to complain of symptomatic palpitations again. During an EP study, it was found that she had an atrial tachycardia located in the area of the crista terminalis; it was Carto mapped and successfully ablated. Again, approximately six months later, she again reported symptomatic palpitations. This time, atypical AVNRT was found and a curative ablation was done. In addition to the mentioned arrhythmias, this patient also had a right bundle branch block and a PFO. She has been arrhythmia-free for over approximately two years now. How does your lab handle call time for staff members? How often is each staff member on call? How frequently do they have to come in, on average? Is there a particular mix of credentials needed for each call team? We have one RN on call for emergencies. We studied the need for emergency procedures after hours, and the occurrence is very rare. However, with 1,000+ patients in the clinic, the RN provides phone triage for patients after hours and on weekends/holidays. Because of the numerous clinics at three facilities, we increased the call pay to encompass the responsibility. The nurses are on call one week at a time from Monday to Monday. They rotate call every 4-5 weeks, depending on specific schedules. Only RN are needed for the call teams; our Rad techs do not take call. Staff rarely has to come in for any patient issue. In 2006-2007, we had only to respond four times to needs after hours and on weekends. Does your lab use a third party for reprocessing? No. Approximately what percentage of your ablation procedures are done with cryo? What percentage is done with radiofrequency? Cryo is not utilized in our labs. Radiofrequency is used 100% of the time. Do you perform only adult EP procedures or do you also do pediatric cases? We care for patients aged 12 and above. Anyone younger than that is referred to a pediatric cardiac electrophysiologist elsewhere. Do your nurses/techs participate in the follow up of pacemakers and ICDs? If so, how many device visits per week do they handle? Do you use any particular software for follow up? How many of your ICD/pacemaker patients require a doctor for their visits? Our RNs work in the clinic under physician supervision. All are trained to do the basic interrogation of the devices we utilize. Changes to parameters are made only under physician order. An EP Cardiac Technician manages the transtelephonic pacing clinic as well as the LATITUDE/CareLink programs. They handle 50-60 device visits per week. PaceArt is used for the transtelephonic pacing program, and LATITUDE and CareLink are used for defibrillators. We tried doing RN-only checks, but the patients prefer to see physicians. With the advent of ICD remote monitoring, the physician sees the patient only twice a year, and the rest of the checks are done remotely. Pacing patients are also seen only twice a year. What trends do you see emerging in the practice of electrophysiology? How is your lab preparing for these future changes? According to Dr. Mark Dixon, the Medical Director of our department, Interventions will become increasingly complex and involve higher risk patients. The therapeutic technology will continue to evolve. St. Mary’s department has expanded to a two-lab facility, one for ‘simple’ cases such as pacemaker and defibrillator implants, tilts, cardioversions, NIPS and basic EP studies, and a second lab, known as the interventional lab for biventricular ICD implants and complex ablations. Our nurse manager works tirelessly to meet with hospital administration to budget for state-of-the-art upgrades and expansions. What are your thoughts about non-EPs implanting ICDs? Do you train such individuals? Dr. Dixon writes, I have a strong opinion against this practice. While the technical procedure is achievable by a good cardiologist, the knowledge base to adequately program, test and optimize these devices is not gained in a cardiology fellowship. There is no significant shortage of EP physicians in most areas, so this practice should be strongly discouraged! What about device recalls? How has your lab handled these? We were impacted significantly by the device recalls over the past few years. We have followed the recommendation of the vendor for patient follow-up. Our physicians were very good about talking with patients about the various recalls. They provided needed reassurance to our patients, which resulted in greater patient understanding and acceptance of the information that was being broadcast by the media. Is your EP lab currently involved in any clinical research studies or special projects? Which ones? We have done research with both Guidant (Boston Scientific) and Medtronic over the past 10 years. We have participated in many clinical research studies involving leads/devices as well as post-market release studies. In the past, we participated in SCD-HeFT and COMPANION. We currently are involved with MADIT CRT. In addition, we are in the follow-up phases for the REASSURE AV Registry, EASYTRAK EP, EASYTRAK 3 Downsize, RENEWAL 3 AVT, APL and OMNI studies. When was your last JCAHO inspection? Our last inspection was more than two years ago. We are expecting a visit early next year. Are you ACGME-approved for EP training? What do you think about two-year EP programs? We are not ACGME-approved for EP training. According to Dr. Dixon, The discipline of cardiac EP has evolved over the years from a predominately diagnostic modality to a highly interventional diagnostic and curative modality of treatment. Given the complexity of the procedures, I feel that a two-year fellowship should be mandatory. 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? We provide a support group for patients with implantable defibrillators. This group meets every two months. Topics of discussion include any new technology or treatment related to their devices, as well as pharmacological, nutritional and congestive heart failure information. Staff members assume responsibility for the set-up of the meetings (e.g., obtaining the speaker, planning refreshments, etc.). Sponsorship is sought from our device manufacturers. Give an example of a difficult problem or challenge your lab has faced. How it was addressed? One of our biggest challenges was anesthesia services. During the complex, lengthy ablations, it was not suitable for a patient to receive intravenous sedation administered by the staff nurses, due to the prolonged nature of the cases and the limited number of meds that could be administered. Our in-house anesthesia department was unable to meet our needs with coverage often dictating time of day/day of week, etc. that the cases could be done. This was not an acceptable situation to our physicians. St. Mary Medical Center recognized the need, and in order to solve the problem, contracted outside anesthesia services for utilization at St. Mary Medical Center and St. Catherine Hospital. The solution has worked well. Although this was a pricey solution, the benefits outweigh the cost. We have anesthesiologists who are available to us 24 hours a day. In addition, the working relationship with the group is impressive. These anesthesiologists are very familiar with every case we do in the department, including the level of sedation needed and the EP preferences. We started using them for all cases requiring a deeper level of sedation, such as biventricular and implantable defibrillator implants, cardioversions, NIPS and ablations. The anesthesiologists also follow us from one hospital to another. Of the utmost importance is our patient satisfaction. Patients are very satisfied because of the level of sedation they receive during these extended procedures. Describe your city or general regional area. How does it differ from the rest of the U.S.? Hobart, Indiana is located in the northwest corner of the state, approximately 38 miles from Chicago. It is a growing community of newly developing subdivisions and industry. The area was historically built on the success of the steel mills that are located in the area. During the past 10 years, the steel industry has suffered greatly, which leaves many of our patients with issues of healthcare coverage. Because Indiana is not a certificate of need state, there are many freestanding hospitals and diagnostic and surgery centers within 10 to 15 minutes of our facility including one right across the street. While many other smaller and community-based hospitals may have difficulty keeping up with larger competitors in their areas, St. Mary Medical Center and its sister hospitals of Community Healthcare System have grown strategically to bring in new technology, new procedures and new services, so patients do not have to travel great distances to get the very best in care. Together, the three hospitals of Community Healthcare System operate the region’s largest cardiovascular treatment program, with the electrophysiology lab at St. Mary Medical Center sharing its expertise and research studies with its two sister hospitals and vice versa. Please tell our readers what you consider unique or innovative about your EP lab and staff. The most innovative and unique characteristics of our department are those of autonomy and standardization. This staff does it all! The staff are proficient at performing procedures and running the clinic at all three facilities. Procedures, policies, equipment and staff are standardized for the entire system. We even do our own internal registration of clinic patients so they can avoid waiting in the Admitting Department. We feel that there is a greater level of satisfaction among all involved because of these characteristics. We are providing a full-service EP program! For more information, please visit: www.comhs.org