Spotlight Interview: Mercyhealth Heart and Vascular Center-Janesville

Mercyhealth is a regional health system with over 700 employed physicians, 5 hospitals, and 80 facilities throughout 50 northern Illinois and southern Wisconsin communities. The EP lab at Mercyhealth Heart and Vascular Center-Janesville was established in August 2016 by Imdad Ahmed, MD, FHRS, FACC, FACP, a board-certified electrophysiologist.

What is the size of your EP lab facility? 

We have one lab at our facility. The lab is used for both ablations and device implants. There is a separate lab for cardiac catheterization.

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

We have a total of 10 staff members that rotate between the EP and cath labs. This includes 5 RNs and 5 x-ray techs. Eight staff members work each day to cover both labs. 

What types of procedures are performed at your facility? 

Procedures performed include device implantations (e.g., pacemakers, ICDs, biventricular devices, subcutaneous ICDs, and His bundle pacing) and EP studies/ablations for SVT, ventricular tachycardia, and atrial tachyarrhythmias (e.g., atrial fibrillation, atrial flutter, and atrial tachycardia). We perform both radiofrequency ablation and cryoablation. We plan to start using the Micra Transcatheter Pacing System (Medtronic) and CardioMEMS HF System (Abbott) in early 2018.

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

We perform approximately 3-5 ablations and 5-8 device implants per week. This past year, we did 138 ablations and 235 device cases.

Do you have cross training inside the EP lab?  

Yes, we cross train all staff to rotate through the EP lab. 

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

We are a community hospital. 

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

We use the CARTO Mapping System (Biosense Webster, Inc., Johnson & Johnson company) and Micropace Cardiac Stimulator (GE Healthcare). We also implant MR-conditional devices and subcutaneous ICDs.

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

We recently moved to 10-hour shifts to cover Dr. Ahmed’s busy schedule. He has 2 and a half days in which he does EP ablations. For the 2 full days, we staff his room from 6:30 am – 5:30 pm. He also does early cases on his non-EP scheduled days, so we bring in staff at 6 am to get his devices scheduled. 

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

On a typical day, the first patient is in the procedure room by 7:30 am. Once that procedure is done, the team and our dedicated environmental services tech turn over the room and prepare for the next patient’s arrival. We often complete 3 or 4 procedures per day, with the procedures being a mix of ablations and device implants. 

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

We are planning on utilizing the UNIVIEW Module (Biosense Webster, Inc., a Johnson & Johnson company) to enable low-fluoroscopy procedures. Our current fluoroscopy time for AF ablations averages approximately 5 minutes.

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

We use a shared calendar (Microsoft Outlook) between Dr. Ahmad’s clinic RN and the staff. After the clinic visit, patients are added to the cath lab schedule. The cath lab staff then schedules the patient through the EPIC Radiant tech worklist.

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

We routinely perform timeout procedures with the entire team, reviewing case durations and fluoroscopy time. Procedural complications are reviewed in structured morbidity and mortality conferences.

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

We have 2 cath lab staff members that manage all inventory. The cath/EP lab supervisor is in charge of helping to obtain all new equipment and supplies requested by Dr. Ahmed.

Have you developed a referral base?

We have developed a wide referral base within the 5 hospitals and 80 facilities of Mercyhealth. The niche of our program is to innovate with new technologies, and we are the only hospital to perform complex ablations within this health system.

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

By continuously evaluating reprocessing opportunities and service contracts, we are able to provide excellent cost-effective care to patients.

How do you ensure timely case starts and patient turnover?

On-time starts and delays are some of the metrics that we discuss during our morning department huddles. Any issues are reported during our weekly VP huddle, in front of the executive team. This helps to quickly identify, address, escalate, and resolve issues. 

How are new employees oriented and trained at your facility? 

We have a departmental orientation checklist for new RNs and techs. A preceptor is assigned to assist with the orientation. 

How is staff competency evaluated? 

We perform yearly core competencies using a hands-on group discussion approach. 

What types of CE opportunities are provided to staff members?  

The vendors have been very helpful with offering continuing education opportunities. We are in the process of sending two of our EP staff to advanced atrial fibrillation courses in Los Angeles and Las Vegas. Our staff are also invited to other one-day EP courses offered by vendors in our area. 

How do you prevent staff burnout? 

We are still in the growing pains of creating a new program that has expanded so fast. We did not expect the program to quickly become so busy! Our staff has worked incredibly hard over the last year, and half are working overtime hours on a weekly basis. We have recently added 3 new staff members, and are in the process of adding a fourth. With the addition of extra staff, we should be staffed much better and staff should not experience as much overtime. 

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

Our staff members are involved with the Nurse Practice council monthly meetings, the Sedation committee, and the Radiation Safety committee.

How do you handle vendor visits to your department? 

Our department is very open and provides easy access to vendors. Vendors set up appointments with our cath/EP lab supervisor. We have a vendor in the lab almost daily for cath or EP equipment/supplies. 

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

 We performed a fascicular VT ablation in a 22-year-old patient who had previously failed ablation at a different facility. This was our first VT ablation case, and it was a great learning experience for our staff. The ablation was successful, with no arrhythmia recurrence.

How does your lab handle call time for staff members?  

Our call teams consist of 3 staff members. Teams are comprised of an ACLS RN that circulates, an RT(R) that scrubs, and a third staff member who uses the Xper IM (Philips). Our teams take call one night a week and every fourth weekend. Our call staff begins call at 4:30 pm and covers until 8 am the next morning. Of the 10 staff members currently in our cath/EP lab, 2 pool staff members rotate through our call rotation.  

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

We do not reprocess our catheters. We send in all of our EP catheters for platinum recovery. 

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

Ninety percent of our ablation cases are performed with radiofrequency; the other 10% is done with cryo.

Do you utilize lifestyle modification as therapy for your patients with AF?

We utilize a comprehensive management approach for AF that includes medication management with anticoagulation, ablation, sleep apnea evaluation for appropriate patients, weight loss counseling, smoking cessation, and aggressive risk factor modification. We make appropriate referrals based on the patient’s need.

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

We utilize very low fluoroscopy; our average fluoroscopy time for AF ablations is 5 minutes. We wear lead aprons and glasses during procedures. Staff wear badges to check for accumulative radiation exposure. The circulating nurse and physician utilize a moveable lead shield for ablations. We also use the RADPAD (Worldwide Innovations & Technologies) and lead gloves during biventricular device implants.

What are your methods for device infection prophylaxis?

We utilize very strict prophylaxis measures, starting from the pre-operative area until the procedure is complete. All patients are carefully prepared and receive a pre-procedure IV antibiotic. The device pocket is irrigated with antibiotic solution. High-risk patients are screened for MRSA and prescribed a post-procedure antibiotic.

What are your thoughts on EHR systems? 

Mercyhealth utilizes EHR in all its hospitals, clinics, and urgent care locations. We use Epic electronic records. EHR has tremendously improved patient care and efficiency.

How is outpatient cardiac monitoring managed?

There is a device clinic at the main hospital, as well as a satellite device clinic at the Mercyhealth Hospital and Medical Center–Walworth. 

Describe your city or general regional area. 

Janesville, located in southern Wisconsin, is the largest city of Rock County. Our EP lab is the only one performing complex ablations in Rock County and surrounding Walworth County, a combined total population of over 200,000.

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

We are proud of our hardworking EP lab staff. This new program, established in August 2016, was only possible with the extraordinary effort of each and every EP lab staff member.