Spotlight Interview: Medical Center of the Rockies

What is the size of your EP lab facility? 

The electrophysiology program at Medical Center of the Rockies (MCR) currently has two EP labs. One is a dedicated EP lab, and the other is a hybrid EP lab/special procedures room. In the hybrid EP lab, we can perform simple EP studies up to complex atrial fibrillation (AF) cases and laser lead extractions. Open-heart surgeries can also be performed in the hybrid room if the need arises. Once our second fully dedicated EP lab opens in late April, we will move the EP equipment from the hybrid room to the new room. Our hybrid room will still continue to support complex EP procedures.

When was the EP program started at your institution?

Our EP program was started in 1999 at Poudre Valley Hospital (PVH), 17 miles away. On February 14, 2007, Medical Center of the Rockies opened and our EP program was moved over from PVH. We still perform pacer implants and generator changes at PVH, with more complex EP/CRM procedures being transferred to MCR. This program has grown to be one of the largest EP programs in Colorado.

What is the number of staff members? What is the mix of credentials in the EP lab?

We currently have nine dedicated EP staff members and four EP physicians, with a fifth starting in March 2016. In 2015, our patient volume increased 17% from the previous year, and as we grow our service, we will continue to expand our staff. Of the nine dedicated staff members, two are CVTs and seven are RNs.

Has your EP lab recently expanded in size and patient volume?

Our volume in electrophysiology has boomed since 2007 to the point of having to bring additional staff, physicians, and rooms on board. Since July, our growth in EP is up by 22%.

What procedures are performed at your facility? Approximately how many catheter ablations (for all arrhythmias), ICD implants, and pacemaker implants are performed each week?

Our lab performs a wide variety of EP procedures, including simple EP studies, ablations (AV node, AF, atrial flutter, atrial tachycardia, AVRT, and ventricular tachycardia), generator changes, permanent and biventricular pacemaker implants, subcutaneous ICD (Boston Scientific) implants, permanent and biventricular ICD implantations, and laser lead extractions. Left atrial appendage procedures utilizing the WATCHMAN Device (Boston Scientific) will be starting in February of this year. Our pre/post nurses also assist our cardiologists in performing TEEs, tilt table testing, cardioversions, and loop recorder implants.

We perform approximately 11 ablations, 6 pacemaker implantations, and 3 ICD implantations each week. 

Who manages your EP lab?

The EP lab is managed by Carol Mackes, BSN, NE-BC. Douglas Roderick, CVT is the EP team lead.

Is the EP lab separate from the cath lab? Are employees cross trained? 

Although EP is not separate from the cath lab, we have our own dedicated rooms and staff. Our cath lab staff are cross trained to work as a circulator or to scrub in the EP lab. There is cross training within EP, so each member of the team can perform in each role (with the exception of techs not designated to administer medications). We are in the process of looking into sending our techs through a medication certification course.

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

We are a community hospital that is part of the University of Colorado Health System. Currently there are five hospitals in our system, with a sixth under construction in Longmont, Colorado.

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

Our lab uses the following equipment: EnSite System (St. Jude Medical), Carto System (Biosense Webster, Inc.), Maestro 3000 Cardiac Ablation System (Boston Scientific), Stockert generator and SmartAblate System (Biosense Webster, Inc.), and the Ampere RF Ablation Generator (St. Jude Medical). We also perform cryoablation (Medtronic), laser lead extractions (Spectranetics) and ultrasounds (Siemens Healthcare). We implant CRM devices from St. Jude Medical, Boston Scientific, and Medtronic. 

What imaging technology do you utilize?

When the new lab opens, we will have two Philips FD20/20 biplane imaging systems.

How is shift coverage managed? What are typical hours (not including call time)?

We have a master schedule that follows a six-week rotation. Our staff arrives at 6:30 am, with first case start time at 7:30 am. EP staff members rotate, as the need arises, to cover late cases. Typically, most cases are done by 5:00 pm. No on-call is required for the EP team.

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

A typical day starts at 6:30 am. Upon arrival, we check our “board” for assignments, run x-ray quality control, perform equipment checks, ensure rooms are stocked, research patient information, pull product for cases, and prep the rooms. Once cases start, the staff will rotate through for lunch and break coverage. Patients are prepped in our pre/post area and recover there. All intubated patients recover in PACU, and those that need acute care will go directly to the CICU. After the last case is done, staff will clean and restock prior to leaving for the day. 

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

This past year, we trained and started performing laser lead extractions. In doing so, we are able to offer this service to our patients without having to refer them to Denver for this procedure. As of February 2016, we will start implanting the WATCHMAN Device (Boston Scientific).

Do you implant MR-conditional pacemakers or ICDs? 

Yes, we use MR-compatible pacemakers and ICDs from Medtronic. 

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

We have cardiovascular schedulers who utilize the Epic software to schedule our EP patients’ appointments and procedures.

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

Our lab is involved in many quality control measures. We currently perform QAs on our equipment (e.g., Philips systems and ACT machines). Audits are performed on our charting, handwashing techniques, sterile techniques, radiation dosing, lead quality, and nursing quality improvements. 

How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies?

We have a product buyer from the purchasing department who is dedicated to the cath/EP lab. He handles the daily order entry after all cases and completes the purchasing orders from the different companies. Ordering is determined by usage, and par levels are set up accordingly and monitored with regular cycle counts. Our product buyer works closely with vendors and physicians in acquiring new equipment, and facilitates contracts with all vendors.

How has managed care affected your EP lab and the care it provides patients?

Managed care has had a minimal effect on the clinical management and care of our patient population. One change that has occurred is an increasing trend toward same-day discharges (when deemed appropriate). We have also utilized LEAN process improvement to find ways to improve efficiency of our labs; however, we do not compromise patient safety or care, regardless of insurance or reimbursement. 

Have you developed a referral base?

We have a massive outreach program that is a huge part of our referral base, with 17 locations servicing northern Colorado, western Nebraska, and southern Wyoming. This encompasses an area of about 50,000 square miles. The clinics saw approximately 74,000 patients in 2015.

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

Our system has committed to system contracts with vendors and negotiates for best price. The bulk of our equipment in the lab is on consignment instead of being purchased. We reprocess much of our EP equipment to help contain costs, and the tips of our interventional wires are sent for metal recycling. As mentioned above, we also utilize LEAN process improvement strategies to improve the efficiency of our lab. 

How do you ensure timely case starts and patient turnover? 

We are currently tracking, auditing, and evaluating our “patient in room” times and “case start” times and delays, in an effort to improve upon our processes and on-time case starts. 

How are new employees oriented and trained at your facility?

New employees go through an interview process that incorporates at least three of our current staff members. Upon hire, they are required to go through a week of house-wide training before they start orientation on the unit. Once they get through the hospital-wide training, they are paired with one or two staff members that remain with them throughout their unit-specific orientation. This process is individually tailored depending on the needs of the new hire. The average orientation process takes approximately three months. They are required to complete both house-wide and unit-specific testing and comps. If a new hire feels that their orientation is not complete or does not feel comfortable on their own, they can ask for an extension of their orientation.

Does your EP lab compete for patients? Has your institution formed an alliance with others in the area? 

The cardiology practice has been very proactive in outreach and we are considered a regional hub, with our services extending to three states (northern Colorado, Wyoming, and Nebraska). Competition with other hospitals in our area is done through excellence in patient care. MCR has been listed as one of the top 100 hospitals (U.S. News & World Report), and has received Magnet hospital status. We are constantly striving to meet and beat our customers’ expectations. 

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

We have many company representatives who provide educational in-services carrying CEU credits. In 2012, we hosted an RCES review course at Medical Center of the Rockies, which was the first time a course like this has been offered west of the Mississippi. We hold an EP conference once a month, during which physicians go over complex cases or topics of interest. This February we will host a cardiac symposium, where physicians will give lectures on their areas of expertise. The staff is encouraged to participate in both in-house and outside educational opportunities.

Have members of your staff taken the registry exam for the Registered Cardiac Electrophysiology Specialist (RCES)? Does staff receive an incentive bonus or raise upon passing the exam?

We currently have one staff member who is IBHRE certified. The majority of our staff holds a certification in either CVRN and/or RCIS. We are encouraging our staff to work toward obtaining the RCES certification.

Our hospital offers a bonus for certifications if they are not part of your job requirement. The bonus is given out on a yearly basis, and increases with each certification that is held.

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

Staff burnout is something all facilities must acknowledge and be proactive in combating. Our EP staff members meet as a team on a monthly basis. Open communication is encouraged, and team building is often obtained during educational opportunities such as EP conferences. Involvement in holiday and special event parties is also encouraged to foster team relationship building. 

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

We have many unit-specific committees that staff work on, such as being involved in the LEAN process, sterile equipment transport, ICD registry, and educational committees, just to name a few.

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

All of our vendors are under contract. All cases that are scheduled with specific vendors are contacted either by the scheduler, physician, or charge nurse.

Once a quarter, vendors are allowed to schedule an educational opportunity. All vendors must be invited to observe in our rooms by the physician as well as sign into Reptrax. 

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

We currently only perform EP procedures on adults (starting age, 18 years old).

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

The Philips imaging system allows for EP imaging at 3.75 frames/sec, which dramatically decreases the amount of fluoro dosing during a case. We also utilize the biplane for long, complex cases. We use lead mobile shielding and personal protective lead. Fluoro dosing is measured on monthly dosimeters, and we get return data on a quarterly basis. Staff is required to take a yearly radiation competency. We document and follow the air kerma of all patients for potential overexposure. 

What are your methods for device infection prophylaxis?

We give antibiotics (typically cefazolin or vancomycin) to all device patients within 30 minutes of incision time. This is a quality measure that is tracked. Pre-op antiseptic prep of the skin and attention to sterile technique are adhered to; irrigation with an antimicrobial solution to the device pocket is implemented for infection prevention. Patient education for infection prevention starts at the pre-op physician visit and continues through the patient’s post-op office visit for incision check. 

Do you use the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) or any other outside data collection registry? 

We do participate in the ICD registry. One of the EP employees enters all of this data, which takes approximately 40-60 hours/quarter.

How do you use the NCDR Outcome Reports to drive QI initiatives at your facility?

NCDR outcome reports are evaluated and utilized to identify trends and areas in need of process improvement for both the EP lab and the physicians. 

What are your thoughts on EHR systems? Does it improve your quality of care?

We use the Philips Xper for our case charting, and utilize Epic (EHR) to look up information about our patients. Epic is also used for prep/recovery/discharge documentation of patients in our pre/post area. Utilizing an EHR has improved data accuracy, legibility, accessibility of patient information, communication between providers, and has allowed for a more comprehensive picture of patient care. 

How does your lab handle device recalls?

When a device recall occurs, the vendor sends letters out to the implanting EP physicians. The severity of the recall is evaluated and a determination of appropriate action is made. Depending on how severe the recall is determines whether or not the patients are asked to have their device changed out.

How is outpatient cardiac monitoring managed?

All cardiac monitoring outside of the hospital is done by our device clinic. If the patient is hospitalized, monitoring is done by the nurse practitioners and checked as needed by the device representatives.

How is coding and coding education handled in your lab? 

Our facility utilizes specialized coders to make sure that all coding and billing is correct. Our lab only enters the product charges into the Epic system.

Is your EP lab currently involved in clinical research studies? Which ones?

Dr. Gary Luckasen is the director of the Cardiac Research Department. Our cardiac research program is very active, and is involved in many studies. We are currently enrolled in the VICTORY AF clinical study and in the AdaptResponse clinical trial:

VICTORY AF: The purpose of this clinical study is to evaluate the risk of procedure- and/or device-related strokes in subjects with persistent or longstanding persistent AF undergoing ablation with the Phased RF System (Medtronic).

AdaptResponse: Comparing market released CRT devices which contain the AdaptivCRT^® (aCRT) algorithm to standard CRT.

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

The patient population is comprised of farmers, students, mountain vacationers, migrant workers, and a large retirement community, among others. Being on the Front Range serves as a challenge, due to the fact that many of our patients must be sent by helicopter or fixed wing from the mountains and outlying small communities and other states. Having an airport next to the hospital helps outreach patients get here in a timely manner. We are unique in the fact that we are a tertiary hospital based in a community setting.

Does your lab utilize any alternative therapies?

We provide a choice of music for our patients to listen to during procedures.

What other innovative EP techniques are being utilized in your lab? 

One innovative approach that we are using with cryo/PVI procedures is the utilization of pressure lines in an effort to minimize or eliminate contrast usage. In addition to the benefits of decreased exposure to contrast for the patient, this also results in less fluoro exposure time for the staff, patient, and physician. 

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

We are fortunate to have a talented and compassionate group of physicians and staff working in our lab. One of the qualities noted is the cohesiveness of our team, all with the common goal to provide patients with the best outcomes and a positive experience.

Although we are one of the largest EP labs in Colorado, we are able to maintain and deliver personal and caring services to our patients while utilizing advanced and current technologies to ensure best possible patient outcomes.

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