Spotlight Interview: Covenant HealthCare

What is the size of the EP lab facility, and what is the mix of staff credentials?

Covenant HealthCare has two dedicated electrophysiology (EP) labs. One lab is completely upgraded to do Carto 3D mapping (Biosense Webster, Inc., a Johnson & Johnson company, Diamond Bar, CA) and laser lead extractions, and the other lab is Carto equipped. We have one RN coordinator (eight hours), two RNs (ten hours), two RNs (eight hours) and two CVTs (eight hours). Two RNs and one CVT are shared with the catheterization lab. All staff are certified in basic life support and advanced cardiac life support. Our nursing staff are ADN and BSN educated, and work alongside two clinical cardiac electrophysiology board-certified EP physicians and six cardiologists.

When was the EP lab started?

Our lab opened in 1999 with three RNs. As an original staff member, our coordinator has seen many positive changes over the past 12 years. After many transformations, we now have two state-of-the-art EP labs, of which we are very proud.

Who manages your EP lab?

The EP lab is under the direction of the Cardiovascular Services. The leadership team consists of Kevin Birchmeier, Director of Cardiovascular Services, Pam Eimers, Manager of Invasive Cardiology, and Linda Pollard, EP Lab Coordinator.

What types of procedures are performed at your facility?

We perform diagnostic EP studies and ablations for many complex atrial and ventricular arrhythmias. However, our primary emphasis is on pulmonary vein isolation (PVI) for atrial fibrillation (AF) using Siemens’ ACUSON ultrasound (Siemens Medical Solutions, Malvern, PA) and Biosense Webster’s Carto 3D mapping. We implant and replace all devices (BiVs, pacemakers, ICDs, and loop recorders). Laser lead extractions under general anesthesia are performed in our lab. Tilt table testing, TEEs and cardioversions are performed in the noninvasive cardiology area. We average 3–4 PVIs a week, plus other basic EP studies and ablations, two laser lead extractions and ten or more devices. We have six cardiologists who have privileges to implant pacemakers.

What is the primary goal of your program?

Our goal is to provide safe and effective patient care within the established guidelines of medical science, focusing on patients with cardiovascular disease in the east central region of Michigan.

Is the EP lab separate from the cath lab? Are employees cross trained?

The EP and cath labs at Covenant HealthCare have been separate since the inception of the EP lab. Currently, we are developing a cross-training program for staff members in both labs. These staff members will assist with added cases and help in the call rotation for the cath lab. Staff in the EP lab are being cross trained for all roles in EP; however, the CVT staff members do not administer conscious sedation per our hospital policy. All RNs have critical care background and cath lab experience.

What new equipment, devices and/or products have been introduced at your lab?

Our hospital was one of the first in the Great Lakes Bay Region to use Biosense Webster’s Carto for 3D mapping. We have now upgraded to Carto 3. With the use of Carto 3 and intracardiac echo, our physicians have decreased the length of our procedures while using less radiation. Implanting MRI-compatible permanent pacemakers has also been a great addition to our labs.

Have you recently upgraded your imaging technology?

Yes. We have Siemens’ Artis system, which allowed us to use DynaCT. The upgrades to Carto allow us to do PVI without the need for a CT.

Who handles your procedure scheduling?

All procedures are scheduled through central scheduling utilizing Cadence software. If conflict appointments arise, schedulers contact the EP coordinator and issues are resolved.

How is inventory managed at your EP lab?

We have a materials management specialist who manages our inventory through QSight. She works closely with the manager, EP coordinator and staff to ensure equipment is available when needed. In order to help with cost efficiencies, she works with the team to negotiate pricing for supplies and equipment.

How has managed care affected your EP lab?

Managed care has not had an impact on our patient care.

Have you developed a referral base?

Through video communication and educational initiatives, we have developed relationships with hospitals in outlying communities. We currently draw patients from 20 counties throughout Michigan.

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

Covenant HealthCare is part of Novation, a group purchasing organization, to negotiate best pricing of equipment and supplies. The hospital has a value analysis committee that evaluates all new products before they are brought into the lab, to ensure the safest products are used in our labs.

Does your hospital compete for patients?

We are one of four hospitals in our region to offer electrophysiology services. We were the first hospital in the area with Carto 3D mapping with ACCURESP (Biosense Webster, Inc., a Johnson & Johnson company) and Siemens’ DynaCT, and are one of two hospitals in the Great Lakes Bay Region that does laser lead extractions.

How are new employees orientated and trained?

All staff members have a six-month orientation. New staff members are paired with a preceptor who works with them through this period. Orientation is divided into three phases with an in-depth checklist and clinical performance assessment. Our physician feels it takes about a year for a staff member to feel comfortable in the EP lab.

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

All staff members have the opportunity to, and are encouraged to, attend off-site trainings and conferences to further their depth of knowledge in the field. We send several staff members to the Heart Rhythm Society’s annual sessions, and ask them to bring back and share insights gained. We also have in-services brought to our organization through vendors and pharmaceutical representatives.

How is staff competency evaluated?

The department has developed competencies on all equipment and procedures for EP. A written and hands-on evaluation is performed annually for each employee.

How do you prevent staff burnout?

Chocolate, lots of chocolate! All joking aside, we have a primary EP physician who is very proud of the staff he works with. He values their opinions, respects their time and talents, and makes sure to let them know how much they are appreciated. This constant communication results in very satisfied staff that is committed to our program.

What committees are staff members asked to serve on?

There are a variety of committees available throughout the medical center. However, many of our staff are actively involved in the value analysis committee, customer service committee, and cardiovascular section committee.

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

All representatives must check in through RepTrax and wear a photo ID when entering the hospital. Representatives are present for all devices and frequently present for 3D mapping. They are invited through e-mail by the attending physician’s office.

How does your lab handle call?

The EP lab is open five days a week, closed on holidays and weekends, and does not take call. We do have two RNs that pick up every fifth weekend call for the cath lab. The EP lab staff works until all the cases for the day are completed. Urgent/emergent weekend cases are supported in the main operating room. 

Does your lab use a third party for reprocessing?

Covenant uses Stryker for reprocessing select items following FDA guidelines. We are negotiating with a company to purchase supplies at a price that would be comparable to reprocessing and use new at all times.

What percentages of your ablations are done with cryo vs. radiofrequency?

Radiofrequency ablation with a Stockert generator is done about 99% of the time in our lab. Cryoablation is used on our younger patients or with patients who have pathways close to the AV node.

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

Our second lab was built with a control room. The use of Biosense Webster’s CartoSound with ICE has decreased the amount of radiation to patients, staff and physicians. However, per policy, we use all the standard lead aprons with thyroid collars, and lead glasses are offered to all staff and physicians performing cases. In addition, we have lead shielding around the table and portable lead shielding in the room. We work with a radiation safety committee who reviews all badge exposure. As low as reasonable (ALARA) notices are sent to staff who exceed established doses, with a reminder to increase distance and shielding and decrease time around radiation.

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

Recalls are evaluated by our EP doctors, who make the decision to schedule patients for changeout of devices and/or certain leads. Specific devices can be tracked through our QSight system and verified with the patient and vendor. 

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

With the opening of our second lab, more staff was needed. Our hospital chose to utilize cath lab techs to fill the gap. Two volunteers were sought out and cross trained to work two days a week in the EP lab. One tech enjoyed EP so much that they took the full-time position.

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

Like many states, Michigan has been hit hard by the recent recession as well as the decline of the automotive industry. While this has been reflected in the Great Lakes Bay Region (Saginaw, Bay and Midland counties), we have also seen many positive changes in recent years. The region is home to two globally recognized chemical plants and is emerging as a medical hub, educating and employing thousands of medical professionals each year through local universities and hospitals. Within the region, Covenant HealthCare is Saginaw County’s largest employer, employing more than 4,200 local citizens.

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

We’ve seen an increase in AF ablations, a decrease in device utilization, and a decrease in complex pacemakers. Our lab has prepared for this by having a state-of-the-art 3D mapping system and ablation technology. We do 120 AF cases per year, which keeps our skills high.

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

We do not train non-EPs to implant ICDs. They need formal fellowship training in troubleshooting, programming, and complex implant techniques.

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

Our hospital had the insight to build a pre- and post-recovery area for interventional cardiology called the cardiovascular recovery unit (CVRU). This unit consists of private and semi-private rooms. All outpatient EP patients go to the CVRU to be prepped for their procedures and return there to recover. The staff is knowledgeable of what needs our patients require. Educational videos are shown to patients, and questions are answered before they arrive in EP. Anesthesia is scheduled for all ICDs, BiVs, and complicated ablations. After patients are prepped in the CVRU, they arrive in the OR pre-operative area, where they are assessed by anesthesia before coming to the EP lab. The relationship that the EP lab has with the CVRU unit and anesthesia department creates a smooth transition from admission to discharge, and is a great patient satisfier. We have recently installed an electronic communication board to help keep our patients’ families and loved ones updated on their procedures. This board tracks patients’ flow through the pre-op, procedural area, recovery and back to their room.

For more information, please visit www.covenanthealthcare.com.