Spotlight Interview: Florida Hospital Zephyrhills

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 one dedicated EP lab with three staff members, including two RNs and one cardiovascular technologist. We are all EP-certified (RCES) by Cardiovascular Credentialing International. When was the EP lab started at your institution? The EP lab opened in the fall of 2007, one year after Florida Hospital Zephyrhills started its open-heart program. We have two electrophysiologists on staff: Dr. Nadim Khan and Dr. Dilip Mathew. What types of procedures are performed at your facility? We perform all diagnostic and interventional electrophysiology procedures, which include atrial fibrillation ablations and 3D mapping cases. Device implants include loop recorders, pacemakers, ICDs and biventricular devices. On occasion we perform TEEs, cardioversions and NIPS. We have begun to do venoplasty due to the increase in upgrading devices. What is the primary goal of your program? Our goal is to provide a full service EP program promoting and providing clinical knowledge of electrophysiology and its expanding aspects to area physicians, patients and the community. We strive to give personal and professional experiences to all our patients and physicians. Approximately how many are performed each week? We do 30 to 60 cases per month. In total we perform 200 EP/ablations and over 300 device implants annually. Who manages your EP lab? Bonnie McDonald, RN, CEPS (HRS certified), RCES is our clinical coordinator; she has 16 years of EP experience. Florida Hospital Zephyrhills hired her to open and develop the EP lab. She also consults, providing new labs with practical and clinical EP education. Huey Metts, RN, RTR, MBA is our manager of Cardiovascular Services. Gwen Alonso, RN, MSN is our administrative director of Cardiovascular Services. Both are supportive of the staff and the EP program’s needs. Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained? Our EP lab has dedicated staff. We are located within the cath lab area. The EP lab provides support to the cath lab when possible. Members of the cath lab have been trained to scrub all EP procedures; however, the EP staff performs all electrophysiology protocols, stimulation, mapping and recording duties. What new equipment, devices and/or products have been introduced at your lab lately? How has this changed the way you perform those procedures? All new equipment was purchased upon opening. We use the EP MedSystems (now St. Jude Medical) workstation/recording system and NurseMate™ for documentation. We were one of the first facilities in the country to use the NurseMate, which is truly geared for EP documentation. The EnSite (St. Jude Medical, St. Paul, MN) is our mapping system, utilizing NavX and the Array. St. Jude Medical/Philips Healthcare ViewFlex is our intracardiac echo unit. Radiofrequency generators include IBI (St. Jude Medical), Maestro (Boston Scientific, Natick, MA) and Stockert (Biosense Webster, Inc., a Johnson & Johnson company, Diamond Bar, CA). We utilize saline irrigated catheters and pumps including Boston Scientific’s CiruCool 8005, which allows us to perform ablations on congestive heart failure (CHF) patients with fluid intake concerns. We ask our device vendors to use “slave” cables during implants so the physician can view the analyzer recordings. Who handles your procedure scheduling? Do you use particular software? Cases are scheduled through the cath/EP lab unit secretary with the clinical coordinator’s approval. What type of quality control/quality assurance measures are practiced in your EP lab? We pull all our own sheaths to reduce complications, as every sheath removal is reviewed monthly. A Certified Surgical First Assist is provided from the OR for device implant closure as often as possible. Complications, including lead dislodgements, pnuemothorax, infections, perforations, etc., are monitored monthly by the clinical coordinator. Data is presented at cardiology section meetings. The National ICD Registry is completed by EP lab staff for completeness and accuracy. How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? Inventory is managed by the electrophysiology lab coordinator. Acquisition of new equipment is reviewed and approved by the clinical coordinator, physicians and management. Has your EP lab recently expanded in size and patient volume, or will it be in the near future? Since this is a newly developed program, our volume continues to expand and exceed our initial expectations. Plans to build a new EP lab are being discussed, as we presently are in an older cath lab. How has managed care affected your EP lab and the care it provides patients? We are unable to accept some patients due to insurance carriers. What measures has your EP lab implemented in order to cut or contain costs? We have purchased new equipment related to catheter use and bulk buys. Does your EP lab compete for patients? Because of our location, we have no EP competition at this time. Patients are often transferred to our facility for EP-related procedures. What types of continuing education opportunities are provided to staff members? Staff has so far been able to annually attend HRS meetings. All local inservices provided by vendors, healthcare facilities are attended. How is staff competency evaluated? Annual basic and a separate EP lab competency is maintained and evaluated by the clinical coordinator. How do you handle vendor visits to your department? Vendors are informed of cases as they are scheduled. Vendors may come prepare for cases and see the patient pre-procedurally if needed. Inservices must be scheduled. At this time, all device companies participate as directed by the physician. Describe a particularly memorable or bizarre case that has come through your EP lab. What lessons did you learn from it? We treated a 42-year-old African American male with a history of hypertrophic cardiomyopathy, preserved LVF, syncope and family history of sudden cardiac death (SCD). The patient had an ICD implanted in April 2009. He was admitted to a local hospital for six ICD shocks, then was transferred to Florida Hospital Zephyrhills for a NIPS study. Device interrogation showed ventricular tachycardia (VT) as well as an episode of supraventricular tachycardia (SVT). The implanting cardiologist consulted with EP to form a plan to manage the patient’s arrhythmias. However, it was unknown that this patient had an SVT. This is a good example of the complexity of EP and device therapy, how it affects the patients, and the need for staff to know all aspects of EP. How does your lab handle call time for staff members? There is no EP call. The cath lab can do device implants “on call,” but this is a rare occurrence. Does your lab use a third party for reprocessing? We use EPreward (Boynton Beach, FL) for platinum recycling. This provides funds for continuing education resource materials. EPreward has a great website and provides many services. Approximately what percentage of your ablation procedures are done with cryo? What percentage is done with radiofrequency? One hundred percent of our ablations are done with radiofrequency. The cost of cryo and the number of times it would be utilized does not warrant purchasing it at this time. Do you perform only adult EP procedures or do you also do pediatric cases? We do only adult EP procedures. What measures has your lab taken to minimize radiation exposure to physicians and staff? Routine radiation regulations are followed. The use of 3D mapping has decreased fluoro time in complex cases. Do your nurses/techs participate in the follow up of pacemakers and ICDs? We are able to interrogate and reprogram devices. This would be done preprocedurally and/or intraprocedurally as needed. Patients are followed by physicians’ office and clinics. What are some of the dominant trends you see emerging in the practice of electrophysiology? How is your lab preparing for these future changes? As electrophysiology procedures advance technologically, complex EP is the future. Diagnostic EP will require the staff to have a greater knowledge base. We attempt to discuss our findings during the case and encourage our EP physicians to teach us. The increasing number of device implants have impacted EP tremendously. An increased knowledge in device technology and implanting techniques will also be necessary. What are your thoughts about non-EPs implanting ICDs? Hospitals dictate who is credentialed to perform implants. We have eight cardiologists who do implants. We do see referrals to the EPs for complex implants and arrhythmia management. 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 have pamphlets from HRS about EP procedures, ablations and devices. The hospital uses Micromedex® CareNotes® System for patient information. Dr. Nadim Khan provides an online computer video for his patients considering atrial fibrillation ablation. Give an example of a difficult problem or challenge your lab has faced. How it was addressed? As a new program we started out in an older angio suite. At times due to scheduling, we would have to move the EP equipment out of that room, get in an elevator, and then set up in a cath lab that was not busy at that time. This was a challenge, although possible, but I do not recommend it. The staff became experts at setting up and troubleshooting EP equipment. This was a positive outcome, because as we all know, the “connectology” of EP can be difficult. Describe your city or general regional area. How does it differ from the rest of the U.S.? Zephyrhills is a rural community, located north of Tampa, Florida. As Tampa grows outward, the populations are merging. Zephyrhills is also a retirement community whose population triples in the winter months (October to May). This community is seeing rapid growth and is providing services the community needs. Please tell our readers what you consider unique or innovative about your EP lab and staff. All facilities strive and concentrate on patient care and safety, that is a given. We want our patients and physicians to be assured the staff is committed and qualified. All the EP staff at Florida Hospital Zephyrhills have RCES certification. It is a personal and professional goal to achieve certification in your field. If you really believe in and enjoy what you do, get certified! It is the most important thing you can do for yourself and your patients. For more information, please visit: www.fhzeph.org