Spotlight Interview: Huntsville Hospital

What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab? Our dedicated EP lab has four RNs, 1 RT, and 1 multidisciplinary tech. Several of these staff members have worked in cardiology for more than 20 years. We have two full-time cardiologists who specialize in electrophysiology; each has over 10 years experience.

When was the EP lab started at your institution? The EP lab opened in our institution July 1, 1996, under the supervision of David Woodard, MD, upon the completion of his cardiac electrophysiology fellowship at the University of Florida in Gainesville, Florida. Six years later, Jay Dinerman, MD joined the staff, relocating from Jacksonville, Florida, where he developed the EP program at Baptist Medical Center upon the completions of his fellowship at Johns Hopkins Hospital. He currently serves as the program director. Drs. Woodard and Dinerman originally met during Internal Medicine training at Shand's Hospital in Gainesville, Florida.

What types of procedures are performed at your facility? We currently implant pacemakers, defibrillators, biventricular devices and event recorders. We also perform a variety of ablations including atrial flutter, atrial fibrillation, AV node, reentrant tachycardia, right- and left-sided accessory pathways, atrial tachycardia, and RVOT ventricular tachycardia. Some of these ablations require the use of the EnSite (St. Jude Medical, St. Paul, Minnesota) 3D mapping system. Cardioversions are also performed in the lab.

What is the primary goal of your program (AF ablations, lead extractions, BiVs, etc.)? We serve the general EP needs of a large portion of patients from the Northern Alabama/Southern Tennessee area. We try to provide a comprehensive set of services so patients can be treated relatively close to home.

Approximately how many are performed each week? What complications do you find during these procedures? On average we perform 20 - 25 procedures per week. Our complication rate is low; we have had occasional hematomas, lead dislodgements, and incision infections.

Who manages your EP lab? Our EP lab is managed by Patricia Bailey, RN, BSN. She has over 15 years experience in the Cath lab. The EP lab Medical Director is Jay Dinerman, MD, FACC.

Is the EP lab separate from the cath lab? Are employees cross-trained? Although physically located adjacent to the Cath labs, the EP lab runs and is staffed as an independent entity. Do you have cross training inside the EP lab? We try and involve as many Cath lab personnel working in the EP lab as possible, and often recruit dedicated EP staff from those Cath lab members who both show an interest and also have special skills necessary to function in the EP lab.

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 recently acquired St. Jude Medical's EnSite mapping system for assistance with diagnosis, localization and ablation of a variety of arrhythmias. In June 2006, our lab was equipped with a state-of-the-art digital bi-plane fluoroscopic unit by Omega Medical Imaging (Sanford, Florida). The bi-plane system allows us to reduce procedure and fluoro time.

Who handles your procedure scheduling? Do you use particular software? We have department secretaries that schedule inpatients and outpatients (through the cardiologist's office) using the Surgical Information Systems software.

What types of quality control/ quality assurance measures are practiced in your EP lab? Hematomas, handwashing, and physician documentation are three quality assurance measures that we practice.

How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? Huntsville Hospital utilizes SIS and Lawson for in-house communication, patient scheduling, billing and inventory control. Our department employs two full-time Materials Management staff members: 1 RN and 1 RT. Their responsibilities include: Maintaining current par levels Identifying par level needs change Replacing expired products Coordinating all purchasing requisitions for daily supplies Participating in all supply contract negotiations Helping in labs as needed and taking call Supplies utilized during procedures are entered each day by the Materials Management staff into SIS, which interfaces with Lawson to generate an itemized patient bill, deducts from our inventory, and orders supplies according to par levels. When physicians express interest in new products, our Materials Management staff is responsible for completing the New Product Request Form, which contains all pertinent information related to justification and costs, and presenting it to the Clinical Operations Committee. This approach has proven to be successful for Huntsville Hospital.

Has your EP lab recently expanded in size and patient volume, or will it be in the near future? Our EP lab has not expanded in size, although it has significantly increased in volume. Our caseload has steadily increased over the past three years. We have no immediate plans to enlarge our EP lab area.

Have you developed a referral base? We have a large referral base from the northern Alabama/southern Tennessee region.

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 throughput? Our entire staff is very cost conscious, including our Medical Director. The Cath/EP lab manager, materials management staff, purchasing director and medical director all work together to decide on a maximum purchase price allowed to insure the best price. If the company does not agree to these terms, their inventory is removed from the hospital. With this policy in place, along with a JIT warehouse and a well-trained staff that doesn't open a product until ready to be utilized, we have seen a significant reduction in costs.

Does your EP lab compete for patients? Has your institution formed an alliance with others in the area? There are two cities within a 100-mile radius that offer EP services. There is a strategic alliance between Cardiology Physician Group (The Heart Center), Huntsville Hospital, and Huntsville Cardiothoracic Surgeons.

What procedures do you perform on an outpatient basis? All implants and lead revisions are admitted to the hospital for overnight observation. Generator changes are done on an outpatient basis. Most ablation procedures are done on an outpatient basis. AV junction ablations, transseptal procedures, and any patients with complications from an ablation procedure are admitted.

How are new employees oriented and trained at your facility? Employees from outside the hospital system receive a general hospital orientation. They are also tested to assess their basic cardiac knowledge. All new employees receive an EP lab orientation from our clinical specialist, who schedules appropriate classes on an as needed basis and assists the preceptor in skills and knowledge assessment. Each employee is precepted one-on-one by selected, experienced personnel for at least 120 days, or until they are proficient in the scrub/monitor or scrub/tech position. Current state RN licensure/ARRT is required. All licensed staff members are ACLS and BCLS certified.

What types of continuing education opportunities are provided to staff members? The hospital has a variety of classes and seminars available to staff hospital-wide. The Cath/EP lab has monthly in-services arranged by our clinical specialist, Mr. Jamie Fortenberry, RN, and are presented by vendors and hospital personnel. They are held from 7 - 8 am one Wednesday per month, delaying the case start times for that particular day. There is also an annual cardiology conference organized by The Heart Center. Ms. Ame Bradford, an EP RN, coordinates additional EP in-services with vendors as the need and opportunities arise. Additionally, two staff members are sponsored to attend the Heart Rhythm Society conference on an annual basis.

How is staff competency evaluated? Staff competency is evaluated first at the 30-, 60-, 90-day periods during their probationary period, then on an annual basis unless a problem is noted during the interim. Evaluations are conducted by the manager.

How do you prevent staff burnout? Everyone participates in decision making and problem solving. There is a great rapport and respect between staff members and physicians, and we are able to openly discuss and solve problems. We also listen to music during procedures, and plan social events outside the work place.

How do you handle vendor visits to your department? Do you contract with vendors? Product and pharmaceutical representatives are welcome to visit by appointment through our materials manager. Due to HIPAA guidelines, we require reps to follow Corporate Compliance policies and sign in with the Pharmacy or the Purchasing departments to pick up a vendor identification badge before entering the facility. Vendors are allowed in the procedure rooms when invited by a physician.

Does your lab utilize any alternative therapies? We use no alternative therapies, although many members of our staff are adept at using empathetic touch and speech to calm and reassure our patients.

How does your lab handle call time for staff members? How often is each staff member on call? How frequently do they have to come in, on average? The EP team does not take call, although they participate in a stay late rotation on designated days.

Does your lab use a third party for reprocessing? No.

Approximately what percentage of your ablation procedures is done with cryo? What percentage is done with radiofrequency? All are currently done with radiofrequency. We are not yet using cryo.

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

Do your nurses/techs participate in the follow up of pacemakers and ICDs? Lab staff does not participate in follow-ups. It is done in the Pacemaker Clinic utilizing pacer clinic staff and clinical representatives from pacemaker companies.

What trends do you see emerging in the practice of electrophysiology? We see an increase in biventricular ICDs due to a large CHF population. We also see an increase in three-day mapping usage for ablations to reduce the use of fluoroscopy.

What are your thoughts about non-EPs implanting ICDs? Do you train such individuals? We feel that in locations where EP physicians are available they should be performing the implants. We would be willing to train individuals under appropriate circumstances; however, in general, currently designed scenarios emphasizing brief hands-off training do little to actually advance competency.

What about device recalls? How has your lab handled these? We approach these on a case-by-case basis.

Is your lab doing web-based/transtelephonic device follow-up? No, the hospital lab does not participate in follow-up; The Heart Center conducts all patient follow-up.

Is your EP lab currently involved in any clinical research studies or special projects? Which ones? We are involved in a number of clinical research products including REVERSE and several post-release studies.

When was your last JCAHO inspection? Our hospital passed the JCAHO inspection in November 2005; the EP lab did very well. The staff emphasis was on handwashing, time-outs, and charting details. The environmental focus was on clean/uncluttered work areas and in moving supplies from boxes to plastic bins.

Are you ACGME-approved for EP training? No.

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? Education and support programs are provided through the cardiologists' office and pacemaker company representatives. We have found that recent changes in vendor sponsorship guidelines (AdvaMed) have significantly hindered our ability to provide educational opportunities for our staff.

Give an example of a difficult problem or challenge your lab has faced. How it was addressed? In December 2005, our existing EP lab fluoro system needed to be replaced. We needed to continue to provide EP services, so our entire lab was moved into one of the Cath labs. The EP staff worked both after hours and between patients to move supplies and also worked with the BioMed department to relocate and install EP equipment in a cath lab. Using a combination of temporary and unfamiliar equipment in a room designed for caths instead of EP procedures was challenging for both staff and physicians. However, due to hard work and perseverance, the temporary situation worked well, and in approximately six months, we were happily back in our own lab with new equipment. After working the bugs out of our new lab, we are excited to be doing EP procedures at home again.

Describe your city or general regional area. How does it differ from the rest of the U.S.? Huntsville, nicknamed The Rocket City, is located in north central Alabama in the foothills of the beautiful Appalachian Mountains. It is home to Redstone Arsenal and Marshall Space Flight Center, which support a large high-tech professional population. Huntsville Hospital is the largest non-governmental employer in the area. The Arsenal is home to the U.S. Space and Rocket Center, which is the top tourist attraction in Alabama. Its Space Camp Program draws adults and children from all over the world. Other area attractions include numerous museums and historical sites; minor league and college sports teams; community music, theater, and dance leagues; touring Broadway shows and big-name concerts. This is small-town living with big city amenities.

Please tell our readers what you consider unique or innovative about your EP lab and staff. Our lab and staff strive to be as diverse as the community that we serve, offering a full range of high-tech, professional services with the feel of a close-knit, small-town community. We strive to have a relaxed, caring, yet professional atmosphere for both the staff and our clients.

For more information about Huntsville Hospital, please visit www.huntsvillehospital.org.