Spotlight Interview: Dayton Heart and Vascular Hospital at Good Samaritan

What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab? Good Samaritan Hospital has two dedicated state-of-the-art EP laboratories, measured at 715 square feet each. Additionally, we share an OR-ready endovascular suite for laser lead extractions. Staff currently consists of 3 electrophysiologists, 4 full-time registered nurses (RNs), and 2 registered radiology technicians (RRTs). With our merger with Dayton Heart Hospital, an additional RN and RRT will be added to our staff. When was the EP lab started at your institution? Dr. Wase established the EP program at Good Samaritan Hospital, Dayton in 1994. It was the first EP lab in the Dayton area. We have been a dedicated EP lab for 15 years. What types of procedures are performed at your facility? Approximately how many are performed each week? We perform all interventional electrophysiology procedures, which include radiofrequency ablation of complex arrhythmias (including atrial fibrillation ablation) and all complex device implantations, including some in complex congenital heart disease patients. Our yearly volume includes about 250-300 ablation procedures and 600 device implantations. We perform head-up tilt tests and elective cardioversions in the cardiac diagnostics lab. What is the primary goal of your program? Our primary goal is to provide comprehensive electrophysiology services utilizing state-of-the-art technology in a patient-focused environment with particular attention to cost containment. We are fortunate to have a team of electrophysiologists, Dr. Abdul Wase, Dr. Kevin Kravitz, and Dr. Sameh Khouzam, who lead us to excellence by providing quality patient-focused care. Who manages your EP lab? Susie Mayabb, RN holds a joint position as Manager of the cath and EP labs. Her background as an EP lab nurse for 7 years gives us a unique advantage, as she understands our needs in upgrading our technology and keeping an adequate inventory. Susan Sacksteder, RN is our team leader who deals with day-to-day handling of personnel/scheduling issues. Rich Gulling served as our Director until May 2009. Joel Halladay now serves as Director of the cath and EP labs. Is the EP lab separate from the cath lab? How long has this been? Are employees cross trained? Our EP lab has dedicated EP staff. We are also conveniently adjoined to the cath lab, so that additional staff is available to help if needed. There is some limited cross training that occurs, so that personnel can serve as an extra set of hands when the need arises. We are fortunate to have a large group of professionals who work well together for the main goal of providing excellent patient care. Do you have cross training inside the EP lab? What are the regulations in your state? Our EP lab staff is trained to perform any task necessary within the lab, with the exception of giving medications, which is the responsibility of our nurses; Sue Sacksteder, RN, Hope Shaffer, RN, Melinda Gillon, RN, and Julia Ralston, RN are credentialed in procedural sedation and function as scrub techs under the guidance of the physician. For deep sedation during ICD implantation, we have the anesthesiologist administer propofol. 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 have recently updated our equipment to include CartoSound and CartoMerge (Biosense Webster, Inc., a Johnson & Johnson company, Diamond Bar, CA); this has enhanced our ability to perform more complex ablations. We have recently started a lead extraction program and have purchased a laser in order to perform lead extractions; we also use non-laser technology to assist in complex cases. The laser is shared with our interventional colleagues in the endovascular suite. In addition, we have 2 new state-of-the-art Siemens (Malvern, PA) biplane rooms with the GE CardioLab (GE Healthcare, Chalfont St. Giles, UK). We also have AcuNav (Siemens) intracardiac echo available to us. Who handles your procedure scheduling? Do you use particular software? All scheduling for the EP and cath lab is coordinated through a dedicated scheduler using Epic OpTime (Epic Systems Corporation, Verona, WA). What type of quality control/quality assurance measures are practiced in your EP lab? Fluoroscopy times are monitored and recorded on each case. Anesthesia and procedural complications are tracked for each case. We have instituted procedural standing orders (protocols) for consistency in patient care. All patients will receive a patient satisfaction survey, and we take the suggestions we are given to “heart”. We also have quality goals for the year based on areas to improve upon according to the Joint Commission’s recommendations for patient safety. Currently we are tracking labeling of all medications, syringes, and bowls, and completing a verbal time out with all 11 aspects of a complete time out addressed. Major complications are also presented in our weekly cath/M&M conferences. How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? Inventory is managed with the help of CIMS, in which a barcode is scanned and automatically reordered when an item falls below a certain par level. However, we will be changing our current system to the Lawson system in late 2009. We also order devices in bulk from vendors in order to remain competitive while keeping costs at a minimum. 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”? In September 2008, Good Samaritan opened its Heart and Vascular Hospital; this is a tower dedicated to heart care with a patient-centered approach. In June 2008, Good Samaritan expanded its size and volume when it acquired The Dayton Heart Hospital. The complete merging of the two hospitals is scheduled for August 2009. We are currently under renovation to accommodate the increase in patient volume. By August 2009, we will have 2 new EP labs and 5 cath labs. We feel fortunate to welcome Julie Officer, RN and Sherrie Ford, RT(R) into our EP lab family. How has managed care affected your EP lab and the care it provides patients? Managed care has not affected the way we provide patient care. We apply the same standards of care to every patient regardless of their ability to pay. 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? It is our newest unit project to contain costs by looking at all current supplies and vendors to see if a sheath or catheter can be obtained from an alternate company at a lower cost. The physicians will have the ultimate say in any product change, as we would never want to compromise patient or physician satisfaction. We do bulk buys in order to contain costs of frequently used devices and leads, and to create some “friendly” competition. We are currently developing a data set that we can track supply expense by provider and hope to benchmark against best practice to provide the best cost-effective care. With the opening of the Heart and Vascular Hospital, the Day Patient Unit and Cardiac Hold Area were created. This serves as a same day surgery unit for cardiac outpatients and a pre-op area for inpatients, and has greatly improved patient through-put. Our newest labs were built utilizing Lean and user center design principles, which result in a better working environment for staff, patients, and physicians. Does your EP lab compete for patients? Has your institution formed an alliance with others in the area? Because we are a member of Premier Health Partners System, we collaborate rather than compete with our sister hospitals, leveraging the strengths of our partnerships for the well-being of everyone we serve. Currently we have captured the largest market share for EP services in the Dayton area. What procedures do you perform on an outpatient basis? The majority of our procedures are performed on an outpatient basis. EP studies and radiofrequency ablation patients will typically go home 6-8 hours after the procedure. Device patients will be dismissed the following day. In-house patients may be added to the schedule if needed. How are new employees oriented and trained at your facility? We feel it takes at least a full year to train a new employee in the EP lab. We are fortunate to have staff members who have a strong cardiology background prior to coming to the EP lab. We provide hands-on training and inservices, and have many resources available to our employees, including physicians who are willing to teach staff members during procedures to provide a better understanding. Our employee turnover rate is very low. What types of continuing education opportunities are provided to staff members? Our physicians are very knowledgeable and enjoy teaching the staff on a daily basis. We are also fortunate to have vendors who are willing to share their knowledge with us. Recently the hospital and Dr. Wase arranged to have Dr. Andrea Natale come to our lab to share his expertise of atrial fibrillation ablations. We also attend the Heart Rhythm Society’s scientific sessions as budget allows. Dr. Khouzam recently started a quarterly program of case reviews and advanced EP tracings as well. How do you prevent staff burnout? In addition, do you practice any team-building exercises? We are not required to take call, and we have a very supportive administration who appreciates that we have lives outside of the hospital. Our EP lab celebrates every birthday with a cake. We have an employee of the month incentive within the Therapeutic & Diagnostics Cardiology Division. We honor the employee with a complimentary parking pass for one month and a luncheon. What committees, if any, are staff members asked to serve on in your lab? We have a wonderful team of nurses who are driven to excellence. Each of our RNs serve on at least one committee, which includes unit council, professional development, clinical ladder committee, and magnet committee. Involvement in these committees is not a requirement, but it does exemplify the types of nurses who work at Good Samaritan and in the EP lab, and the strong role they have in the shared governance at the hospital. How do you handle vendor visits to your department? Do you contract with vendors? Vendor visits to the hospital are arranged through the lab, and all vendors are required to sign in through the purchasing department where they are given a badge. This badge is to be visible at all times, indicating who they are and that all required paperwork is on file with the hospital. Does your lab utilize any alternative therapies? We provide music for our patients and stay close by the patient as much as possible to talk with them if needed throughout the procedure. Describe a particularly memorable or bizarre case that has come through your EP lab. What lessons did you learn from it? We have several memorable cases during our 15 years in interventional EP. One particular case that comes to mind is that of a patient who had a Glenn Shunt and was the survivor of cardiac arrest. She needed an ICD. Literature review revealed no cases had been reported in any peer-reviewed journals in English language. First, we utilized a long sheath into the subclavian vein over a glide wire. Next, venography was performed, which was used as a road map. We utilized a single coil ICD lead and introduced it through the superior vena cava (SVC) into the shunt and via the right pulmonary artery retrograde into the main trunk of the pulmonary artery, and advanced it through the pulmonary valve into the right ventricular apex. She was placed on long-term anticoagulation. The lesson learned from this case was that we have to be prepared for any eventuality while performing an EP procedure. We now routinely have a single coil lead in stock that comes in handy in right-sided implants and left-sided persistent SVC cases. How does your lab handle call time for staff members? We do not take call. We have 10- and 12-hour shifts. Twelve-hour shifts were formed to accommodate later cases, and have improved physician and employee satisfaction. Does your lab use a third party for reprocessing? We are no longer using a third party for reprocessing. We are now a single-use facility. Approximately what percentage of your ablation procedures are done with cryo? What percentage is done with radiofrequency? All of our cases are done with radiofrequency ablation. With current technology using cryo, we feel the recurrence rates of arrhythmias are higher. Do you perform only adult EP procedures or do you also do pediatric cases? We only perform cases on adult patients. What measures has your lab taken to minimize radiation exposure to physicians and staff? We use the RADPAD® (Worldwide Innovations & Technologies, Inc., Overland Park, Kansas) on every case to minimize staff exposure. We minimize the use of radiation time as much as possible. We keep the fluoro at 7 frames per second, which is adequate for most of our needs. We shield the reproductive organs of patients of childbearing age. With the assistance of Chandra Blake, RT(R) and Tiffany Martinez, RT(R), the quality of our lead aprons is assessed according to hospital guidelines. Lead glasses, thyroid shields, and aprons are replaced as needed. Our radiation safety personnel monitor the total exposure by mandatory wearing of radiation badges. 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? We do not participate in the follow up of devices. However, we occasionally receive calls from patients, and are willing to assist them with any questions or problems they may have. What trends do you see emerging in the practice of electrophysiology? How is your lab preparing for these future changes? Atrial fibrillation ablations are definitely the wave of the future. We hope the length of time required to perform the cases will decrease as new catheters and techniques are developed. We will look at emerging technology such as navigation systems as well as alternate ablation energy sources such as cryo, which may hold promise in the future. What are your thoughts about non-EPs implanting ICDs? Do you train such individuals? Given the increased complexity of devices and programming options, we truly feel that only electrophysiologists should implant, program, and follow up on ICDs. What about device recalls? How has your lab handled these? Our physicians assess the needs of patients whose devices/leads have been recalled. Generally we follow the advice of the manufacturer and regulatory agencies. In a recent lead recall, we have assumed a judicious approach, and are only explanting leads that show signs of fracture by increased impedance with oversensing of signals as ventricular fibrillation, leading to inappropriate shocks. If a procedure is needed, the vendor assumes some or all of the cost. Is your lab doing web-based/transtelephonic device follow-up? No. The physicians do this independently through their offices/clinics. Is your EP lab currently involved in any clinical research studies or special projects? Which ones? Dr. Wase is involved in clinical research. He has studied the relationship between renal failure and DFTs, and for the first time demonstrated that with progressive worsening of renal failure, there is an increase in DFT. He has also studied the relationship between propofol administration by an anesthesiologist versus an electrophysiologist. When was your last inspection by the Joint Commission? We passed our most recent Joint Commission inspection in October 2007. Are you ACGME-approved for EP training? What do you think about 2-year EP programs? Currently, we do not have an EP fellowship program. Until recently we had a cardiology fellowship program that was directed by Dr. Wase. The cardiology fellows were routinely scrubbing in most cases and were certified in pacemaker implantation if they completed a minimum of 25 implants in a satisfactory manner. 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 for pacemaker or ICD patients? All patients are given educational material regarding their procedure preoperatively and postoperatively. Our staff is dedicated to answering any questions our patients may have both preoperatively and postoperatively. Our staff and patients participate in an annual area-wide holiday dinner supported by local hospitals and device vendors. Give an example of a difficult problem or challenge your lab has faced. How it was addressed? Our most recent challenge has been the upcoming merge of two quality hospitals into one. Each facility will bring positive aspects of patient care, and we look forward to combining our forces to become the best hospital in the area. Describe your city or general regional area. How does it differ from the rest of the U.S.? Dayton, Ohio is home to 166,179 people. Dayton is situated within the Miami Valley region of Ohio, just north of the Cincinnati metropolitan area. Good Samaritan is a non-profit hospital that primarily serves the north and west areas of Dayton. We also serve as a tertiary referral center for rural areas to the north and west. We are currently celebrating 50 years of heart care in Dayton. We have a 560-bed facility employing more than 35 primary medical and surgical specialties. We are a multi-campus operation and a leading provider of inpatient and outpatient health care services. Good Samaritan Hospital has a commitment to the underserved by providing quality patient care to all. Please tell our readers what you consider unique or innovative about your EP lab and staff. We are fortunate to have a very dedicated staff that is willing to go the extra mile in order to achieve patient satisfaction. We strive to minimize our patients’ anxiety by meeting with them preoperatively to discuss and alleviate any fears they may have. Our team has an exceptional working relationship. Each member of our team is constantly looking for ways to grow professionally and educationally, as evidenced by most of our staff serving on various committees throughout the hospital in order to be involved in the decision-making process. For more information, please visit: www.goodsamdayton.org/