Spotlight Interview: Easton Hospital

Tell us about your EP program. What is the size of your EP lab facility? 

Easton Hospital is a full-service, acute care hospital that provides inpatient, outpatient, diagnostic, surgical, and emergency medical care for the Greater Lehigh Valley in Pennsylvania. Having recently celebrated its 125th anniversary, Easton Hospital is recognized as a regional leader in cardiac care, earning several accreditations and recognitions, including Chest Pain Center Accreditation, Mission: Lifeline Receiving Gold Plus Center recognition, ACTION Registry Platinum Performance Achievement, and Blue Distinction^® designation.

The Cardiovascular Institute at Easton Hospital is named after Moosa Najmi, MD, one of the chief architects of the cardiac program. The institute is home to two EP labs (one of which is hybrid) and two cardiac catheterization labs. The newest hybrid EP lab was unveiled in August 2016 — part of a $7 million cardiac investment project. 

What is the number of staff members? What is the mix of credentials at your lab? 

The EP lab at Easton Hospital is currently comprised of 14 highly engaged and cross-trained staff members. There is 1 dedicated EP coordinator, 5 full-time RNs, 1 part-time RN, 4 per diem RNs, 2 RCISs, and 2 RT(R)s. 

What procedures are performed at your facility? 

The EP lab performs a variety of procedures, including all comprehensive ablations (atrial fibrillation [AF], ventricular tachycardia [VT]/ventricular premature beat [VPB], and SVT) except epicardial ablation. We perform permanent pacemaker, ICD, CRT, and loop recorder implants. We also perform cardioversions, WATCHMAN implant procedures (Boston Scientific), limited lead extraction, and IVC filter implants. We also implant MR conditional pacemakers and ICDs, as well as subcutaneous devices.

Who manages your EP lab? 

Dr. Koroush Khalighi is the Medical Director of the EP lab, and Dr. Vadim Levin is the EP attending physician. Lori Jones is the Director of Cardiovascular Services, and Shawn Kollar is the EP Coordinator and Lead RN. 

Are employees cross-trained? 

While some positions are dedicated, the entire staff is cross trained for both EP and interventional cardiology. 

What type of hospital is your EP program a part of? 

We are a community hospital that has served our area over 125 years. We celebrated our quasquicentennial in 2015. We also benefit from being connected to a larger health system from which we can access numerous resources and proven models for success. 

What types of EP equipment are most commonly used in the lab? 

We use a variety of equipment. For fluoroscopy, we have a brand-new Philips Allura biplane x-ray system capable of 3D rotational angiography and can also overlap an existing CT scan with a fluoroscopy image. The addition of the Clarity system, which is an optional component of the Philips Allura biplane, helps to minimize radiation exposure for our patients. We use Biosense Webster’s CARTOUNIVU Module (with integrated CARTO 3D mapping), which further reduces radiation exposure. For intracardiac echo, we use Biosense Webster’s CARTOSOUND Module. 

How is shift coverage managed? What are typical hours? 

Staff members work either a 10-hour shift four days per week, or an 8-hour shift five days per week. Our first staff members arrive at 6 am, and our late staff leaves at 5 pm, unless procedures run late. There is a 24-hour service for any emergent procedures.

Tell us what a typical day might be like in your EP lab. 

While no two days are the same, a typical day begins with preparation. The first staff arrive at 6 am, and patients soon follow. Depending on the nature of the case, preparation time varies from 15 to 45 minutes. We are very personable, making patients and their families feel welcome, informed, and cared for. A typical day might include a device implantation, EP studies, and cases treating SVT, VT, atrial flutter, or AF.

What new technology has been recently added to the EP lab? How have these technologies changed the way you perform procedures? 

When we cut the ribbon on the new hybrid EP lab, we were blessed with new EP and ablation equipment as well as 3D TEE and echocardiography equipment. Together, it changed the dynamic for our staff and patients. We are now able to offer expanded services such as the WATCHMAN device, and keep patients with advanced EP issues close to home.

Who handles your procedure scheduling? Do they use a particular software?

Our cath lab unit secretary, with help from the charge nurses and director, schedules most of the procedures using the Cerner system. 

What type of quality control and assurance measures are practiced in your EP lab? 

We pride ourselves on providing quality care, so we use several quality control measures, including case and peer reviews. We also collaborate with partners from nearby EP departments at medical institutions including Temple and Drexel University. 

Have you developed a referral base? 

We are in a competitive marketplace, so our referrals are tied to the relationships we build with our primary care base and the care we provide our patients. We draw patients from across our region. Direct outreach through different local support groups and events helps us share information and engage with potential patients. 

In what ways have you helped to cut or contain costs and improve efficiencies in the lab? 

Cost containment is important in health care, so we are doing our share to minimize expenditures by taking advantage of bundled purchases and rebates. 

How do you ensure timely case starts and patient turnover? 

On-time starts result from coordinating the care process. Some patients are admitted directly to a nursing floor, while others are admitted to our outpatient procedure unit. Cath patients come directly to the lab. From the arrival of our patients and the preparation of our staff, to interactions with our attending physicians and anesthesia department, we strive to create an experience that values patients’ time.

How are new employees oriented and trained at your facility? 

Every new employee follows an orientation process that begins with understanding the mission, vision, values, and culture at our hospital. After that, RNs complete one week of orientation in our nursing education department, and then have a unit-specific orientation. Core competencies at each stage are key to ensuring staff members are prepared to be team players.

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

Device companies have representatives who help keep our staff up to date. Our staff can also join the Heart Rhythm Society; four staff members had the opportunity to attend the 2015 annual conference in Boston. 

How is staff competency evaluated? 

Our staff is evaluated yearly for their ongoing competencies. 

How do you prevent staff burnout? Do you also practice any team-building exercises? 

Our team becomes a second family, so losing a “family member” can be difficult. We work to prevent staff burnout and turnover in a variety of ways. The staff benefits from voluntary late-case participation, and we also provide incentives when cases or work runs late. We know that burnout often occurs because of excessive overtime, so we have created a staffing grid that balances work and home life. 

What committees are staff members asked to serve on in your lab? 

There are several committees at Easton Hospital in which staff members can represent our team. Several of our staff are on these committees, such as the EP lab, nurse practice, safety coaches, radiation safety, and employee satisfaction committees.  

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

All vendors must check in with our materials management team and be assigned a badge. 

Describe a particularly memorable case from your EP lab and how it was addressed. 

We recently had a male patient who was very active. He and his wife would hike, ride trail bikes, paddle kayaks, and travel through China and Europe. Despite these activities, he was often tired and lacked energy. He was later diagnosed with atrial fibrillation. He first visited a different hospital in a larger market for an ablation; however, his pulse was soon erratic again. That is when he met Dr. Khalighi, who implanted a pacemaker as well as performed an ablation here at Easton Hospital. “Compared to the larger-market hospital, my time at Easton was a walk in the park,” he said. He had no discomfort after the procedure, and appreciated the team atmosphere. He is now back in action, working out in the gym five days a week. “I’m 75 years old, but I feel like 25 and act like a teenager,” he says.

Does your lab use a third party for reprocessing or catheter recycling? 

We are committed to this initiative, and are currently looking into catheter recycling programs. 

Approximately what percentage of ablation procedures is done with cryo vs radiofrequency?  

We do not use cryoablation. All ablations are done with RF energy. All complex ablations (VT, AF, and left-sided AFL/AT) are done using a contact force sensing catheter, Biosense Webster’s THERMOCOOL SMARTTOUCH catheter.

Does your lab utilize remote catheter navigation?  

We do not at this time, although we are in the process of starting this approach.

What are your techniques for LAA occlusion? Do you have a primary approach?

Easton Hospital cardiologists and electrophysiologists lead the region in treating atrial fibrillation with the WATCHMAN device. Dr. Levin was among the first physicians in Pennsylvania to perform the left atrial appendage closure implant procedure when the device was approved in 2015. Based on the number of devices implanted, our doctors are some of the most experienced surgeons in the state. 

What are your thoughts on the use of the new oral anticoagulants (NOACs) in patients with non-valvular atrial fibrillation? 

NOACs are the preferable option for anticoagulation in patients with non-valvular AF due to the significantly lower risk of intracranial bleeding and much easier monitoring (does not require INRs and no interaction with food). Warfarin has a role in patients with end-stage renal disease. The biggest concern with the use of NOACs is the price of medications; many patients cannot afford the copay and ask to be switched to cheaper medication, which is warfarin.

Is hybrid epicardial and endocardial ablation of atrial fibrillation performed at your institution? 

No, we use endocardial ablation.

Do you perform only adult EP procedures or do you also do pediatric cases? 

We perform only adult EP procedures at Easton Hospital.

What measures has your lab taken to reduce fluoroscopy time? In addition, what types of radiation protective shielding and technology does your lab use? 

In our new EP lab, we use the Philips AlluraClarity biplane system, as well as Biosense Webster’s CARTOUNIVU system that integrates x-ray with 3D mapping. Compared to our previous system, these new components have significantly improved the amount of milligrays that our patients and staff are exposed to. In fact, we are finalizing a paper on this topic for a journal. We also use BIOTRONIK’s Zero-Gravity system, which allows for radiation protection while eliminating the weight burden of heavy protective apparel for the physician. 

What are your methods for device infection prophylaxis? 

Aggressive pre-procedural management is important. We require patients to wash with chlorhexidine the day before their procedure. On the day of the procedure, we use Sage 2% CHG prep cloths on patients in the holding area. Finally, we use antibiotic wound irrigation and prophylactic intravenous antibiotic therapy during perioperative procedures. Dr. Khalighi also led a study on the role of prophylaxis topical antibiotics in cardiac device implantation (https://bit.ly/2ob7r8S), so we feel we are leading the way in research to ensure our patients are safe from infection.

What are some of the dominant trends you see emerging in the practice of electrophysiology? 

We are excited by many trends, such as the quicker and more automatic activation mapping of complex arrhythmias (already introduced on the market by several companies), the new sources of ablation energy to minimize complications, and non-invasive 3D mapping of arrhythmia (CardioInsight Noninvasive 3D Mapping System). Advancement in the treatment of atrial fibrillation depends on our better understanding of the mechanism of this arrhythmia, earlier intervention in the process of disease, and aggressive risk factor modification (e.g., obesity, sleep apnea, hypertension). We are most energized by the utilization of leadless implantable device technology. 

Is your EP lab currently involved in clinical research studies? 

While we strive to be involved in studies, we are not currently participating in any at this time. In the past, we were part of several prospective clinical studies sponsored by NIH as well as clinical trials such as PainFREE Rx II, MADIT, and SCD-HeFT. 

Are you ACGME-approved for EP training? 

We are in the process of becoming an ACGME-approved lab. 

Does your hospital offer a cardiac device support group for patients? 

Our patients are highly engaged with their decisions, care, and post care. We offer several programs that keep our patients connected. We have a cardiac rehabilitation program as well as three dynamic support groups: a cardiac disease support group, pulmonary disease support group, and stroke survivor support group. Our directors and physicians are involved at every meeting, welcoming new members and strengthening bonds with the “die-hards.”

Does your heart rhythm service offer patients with a suspected inherited arrhythmia a referral to a cardiovascular genetics clinic? 

We have a regional referral center (Hospital of the University of Pennsylvania), and we are working to establish one at our institution in the near future. 

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

Lehigh Valley is a suburban area, with easy access and close distance to major metropolitan areas (including New York and Philadelphia), fabulous beaches, and mountain getaways. Easton is a vibrant city, known for its farmers’ market, public market, festivals, arts, waterways, and entertainment. Interesting fact: Easton doesn’t celebrate the Fourth of July. Instead, we celebrate Heritage Day on July 8th, the day the Declaration of Independence was read in our center square in 1776. Easton is one of only three cities where the original document was read aloud to citizens on that day.

Please tell our readers what you consider special about your EP lab and staff. 

We have an outstanding, dedicated team at Easton Hospital. We are best known for our personal touch. As a small lab, we work very closely with each other. Our patients enjoy the camaraderie. We become family to many patients and caregivers.