Spotlight Interview: Duke University 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? As an adult EP department, we currently operate 2.6 EP labs per day. During our construction/renovation phases, we are sharing one EP lab with the pediatric EP department. Our staff consists of 8 MD attendings, 8 RNs, 5 techs, 1 clinical lead and 1 equipment specialist. When was the EP lab started at your institution? The Duke EP Program began seeing patients in 1970. What types of procedures are performed at your facility? We perform all types of EP procedures. A large part of our service is focused on complex procedures, such as lead extraction, catheter ablation for atrial fibrillation (AF), atrial tachycardias and atypical atrial flutters, Bi-V device implantation, and catheter ablation for ventricular tachycardia (VT) in the setting of structural heart disease. Approximately how many are performed each week? On average, our adult EP lab team performs approximately 27 cases per week, and our EP physician team completes approximately 170 clinic visits per week. What is the primary goal of your program? While a primary clinical focus is cutting-edge catheter ablations for atrial fibrillation and ventricular tachycardia, our program is evenly split between device therapy and complex catheter ablation services. We are experiencing significant growth in the area of catheter ablation and are opening a new Atrial Fibrillation Center. Who manages your EP lab? The day-to-day operations are facilitated by Medical Directors Dr. Patrick Hranitzky and Dr. Ruth Ann Greenfield, as well as an RN Clinical Lead (currently a vacant position). From a service line perspective, our senior administrative director and senior clinical operations director manage our hospital-related tasks. Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained? The adult EP labs have always been separate from the adult Cath labs. The adult EP and Cath lab staff are not cross-trained to perform procedures within both departments. However, the clinical team that provides services in our pre/post recovery department are cross-trained to care for both EP and Cath patients. Do you have cross training inside the EP lab? What are the regulations in your state? The majority of our staff members are cross-trained to perform the various roles (i.e., team lead, scrub, circulator, etc.) within the EP labs. A portion of our staff serves as room-specific experts in the ablation and device rooms. What new equipment, devices and/or products have been introduced at your lab lately? How has this changed the way you perform those procedures? Hospital administration has been very supportive of our equipment needs, and we have recently added remote catheter navigation using Hansen Medical’s Sensei Robotic Catheter System to the EP labs. There are plans in place to add the Stereotaxis Magnetic Navigation System in the future. These systems, together with advanced electroanatomic mapping systems and integration of intracardiac ultrasound, have allowed us to approach complex arrhythmias such as atrial fibrillation and ventricular tachycardia with efficacy and safety. Who handles your procedure scheduling? Do you use particular software? Inpatient procedure scheduling involves our rounding physician and charge nurse, who interface with a hospital-based computerized system. Outpatient scheduling involves the clinic’s scheduling RN and charge nurse. What type of quality control/quality assurance measures are practiced in your EP lab? While our medical director facilitates Morbidity and Mortality conferences, our PI coordinator reviews complication rates and enters information into the ACC-NCDR registry for devices. How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? Our current inventory system interfaces with the hospital’s procurement system. We have a materials management manager and two supply clerks for the EP and Cath labs. Has your EP lab recently expanded in size and patient volume, or will it be in the near future? To accommodate our continued growth in complex EP procedures, two fully-equipped EP biplane labs are scheduled to open in March 2009. During the second phase of construction/renovation, two new EP labs will be completed for a total of four newly constructed/renovated EP labs. While Duke University Hospital does not have a separate building for heart services, our departments function as a complete continuum of care within the cardiovascular service line across our three campuses. Have you developed a referral base? Duke University Electrophysiology has an excellent reputation in the community and around the state. We are privileged to have the opportunity to help patients and referring physicians manage arrhythmia problems refractory to first-line therapies, like AF and VT late after myocardial infarction. 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 have a Value Analysis Team (VAT), which includes a physician, the RN clinical lead, the material management manager, the finance director, and representatives from Hospital Procurement. The VAT meets monthly to discuss new supplies needed and supply cost management. Does your EP lab compete for patients? Has your institution formed an alliance with others in the area? The Duke Heart Network is comprised of 16 clinics and medical centers in the southeast that have formed affiliations with Duke in order to improve cardiovascular care in their communities. The network’s mission is to help members achieve clinical excellence through both clinical and programmatic guidance and services. What procedures do you perform on an outpatient basis? While the majority of device implantations are handled on an inpatient basis, many complex ablations, including catheter ablations for atrial fibrillation, are performed on an outpatient basis. How are new employees oriented and trained at your facility? Each staff member is assigned a clinical preceptor for the first three months of employment. During this timeframe, staff complete their clinical check-offs to show proficiency within their role. We have several online training modules that also assist in getting staff trained on our equipment. What types of continuing education opportunities are provided to staff members? Staff participate in weekly staff meetings, which rotate between educational in-services and departmental updates. A few topics for upcoming educational in-services, which are led by a member of the physician team, include Cardiac Anatomy and Physiology, Basic Pharmacology, and Electrocardiography. How is staff competency evaluated? We have an Annual Skills Fair to review our educational needs. Yearly evaluations also include tracking for staff competency. How do you prevent staff burnout? The Learning and Organizational Development (L&OD) department within Duke University Health System has hosted team-building sessions to aid in achieving the best methods for communication within the labs. These sessions allow staff to interact with each other outside of the daily lab environment. Staff also are directly involved in a Six Sigma Green Belt Project, which is designed to improve overall lab performance by evaluating our daily patient flow within the EP labs. What committees, if any, are staff members asked to serve on in your lab? Staff serve on the Invasive Lab Advisory Council, Heart Center Clinical Practice Council, Patient Education Council, Nursing Magnet Committee, Friends of Nursing Committee, Sterile Processing Committee and Hospital PI Committee. How do you handle vendor visits to your department? Do you contract with vendors? Vendors are required to utilize the Status Blue System, which was implemented system-wide to facilitate the daily credentialing and documentation process. Does your lab utilize any alternative therapies? While we have background music playing softly in all of the EP labs, a Pilot Project is being implemented within the Cath labs to determine the feasibility of providing MP3 players for patients to use during cases to aid in managing their level of comfort. As a result, the clinical team and patient are permitted to listen to different selections during the case. Please describe one of the more interesting or bizarre cases that have come through your EP lab. Recently, a patient returned after AF ablation with an incessant left atrial flutter. This is a relatively rare occurrence in our lab (i.e., How does your lab handle call time for staff members? While our staff do not participate in an on-call rotation, they are scheduled for a late shift approximately six nights per month. A late shift consists of a four-member team that stays beyond the regular day shift schedule until the last case of the day is complete. With the unpredictability of complex catheter ablation procedures, it is challenging to determine which days of the week will require a late team. Does your lab use a third party for reprocessing? We use SterilMed as a third-party partner for reprocessing. We only reprocess EP diagnostic catheters. Approximately what percentage of your ablation procedures are done with cryotherapy? Approximately 10-15% of our complex catheter ablation procedures employ cryotherapy ablation. Do you perform only adult EP procedures or do you also do pediatric cases? Is there cross training for pediatric cases? Adult and pediatric EP cases are performed by two separate clinical teams in separate EP labs. However, there is frequent collaboration between adult and pediatric faculty. While a portion of the adult and pediatric EP staff have worked within both departments and can assist when needed, it is not common practice to cross-train staff to perform procedures within both departments. What measures has your lab taken to minimize radiation exposure to physicians and staff? We have recently reevaluated the fluoroscopy settings and optimized them to minimize exposure. In addition, we use the RadPad (Worldwide Innovations & Technologies, Inc.) to reduce scatter to the operators during complex ablations. We employ table to floor, free-standing, and drop-down lead shields to augment the protection provided by the lead vests and kilts worn by the staff. The new EP labs make use of the most recently developed flat-panel systems that further reduce exposure substantially. Lastly, incorporation of remote catheter navigation systems into the lab and the extensive use of intracardiac ultrasound in conjuction with electroanatomic mapping have both reduced operator exposure as well as actual fluoroscopy times to perform complex ablation. Do your nurses/techs participate in the follow up of pacemakers and ICDs? The current EP lab staff do not routinely participate in device follow-up. There is a separate group of physician extenders who handle this task. What trends do you see emerging in the practice of electrophysiology? How is your lab preparing for these future changes? The most significant trend we have seen is an increase in the demand for ablation of complex arrhythmias. We are positioning our resources through construction/renovation of new EP labs to allow us to manage these cases more efficiently by bringing the latest technologies to bear as we move forward. We are also hiring additional staff to accommodate anticipated growth in patient volume. What are your thoughts about non-EPs implanting ICDs? Do you train such individuals? As a whole, we do not favor having non-EPs implant devices. We have trained one physician at a Duke satellite to implant; he had extensive experience with pacemaker implantation and had taken and passed the former NASPExAM. What about device recalls? How has your lab handled these? Each recall is handled separately after a team of physicians and administrators meet to determine how to best proceed. Is your lab doing web-based/transtelephonic device follow-up? Yes. We have utilized remote follow-up from several vendors, including Medtronic (CareLink), Boston Scientific (LATITUDE), St. Jude Medical (Merlin.net) and Biotronik. In addition, we have been using Raytel (Philips) for a number of years. Is your EP lab currently involved in any clinical research studies or special projects? Which ones? At any one time, we almost always have active research protocols, ranging from site-based research on new catheters and technologies for device and ablation therapy to investigator-initiated projects about the pathophysiology of arrhythmias. The latter category includes studies of genomics, proteomics and metabolomics, as well as studies of disease mechanism at the more ‘macro’ level of the electrophysiology of arrhythmogenesis. When was your last inspection by the Joint Commission? Our last inspection occurred two years ago in 2006. Are you ACGME-approved for EP training? What do you think about two-year EP programs? Yes, we are ACGME-approved. It is our thought that two years of training is required for Fellows to be truly successful independent operators in complex ablation. 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? Upon arrival/admission, our patients receive a Heart Center Patient Resource Guide with specific educational information for the device and ablation procedures. All outpatients are seen in the clinic prior to the procedure and receive education in the clinic setting. Give an example of a difficult problem or challenge your lab has faced. How it was addressed? While we are challenged with recruiting experienced EP staff, just as other EP programs are, we are beginning to think outside the box to partner with various schools within Duke University to enhance our departmental exposure to new graduates who enjoy working in a high clinical and technical environment. If interested in applying, please call our Recruitment Department at 919-684-6339. Describe your city or general regional area. How does it differ from the rest of the U.S.? We are located in the central part of the state known as the Triangle area. We are two hours from the Appalachian Mountains and the North Carolina coast. The Triangle area is one of the fastest-growing areas in the country. Please tell our readers what you consider unique or innovative about your EP lab and staff. We are a very highly technical lab that performs very complex ablation procedures. Duke has extensive experience in managing complex heart rhythm disorders, conducting more than 1,000 EP lab procedures annually. Our primary clinical focus is on cutting-edge catheter ablations for AF and VT. For more information, please visit: www.dukehealth.org www.dukeheartcenter.org