Spotlight Interview: The Richard M. Ross Heart Hospital at The Ohio State University Wexner Medical Center

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

The electrophysiology lab staff is comprised of 5 radiologic technologists (RTs), 3 cardiovascular technologists (CVT), and 31 registered nurses (RNs). Three of the full-time RNs are dedicated to reviewing patient records prior to each procedure to ensure that all preoperative testing has been completed and reviewed by the electrophysiologist. They also assist the charge nurse with reviewing and coordinating the flow of inpatient procedures through the lab on a daily basis. 

Clinical staff has been cross trained to handle coding, billing, inventory control, registry data collection, and quality assurance reporting for the department. We are currently in the process of recruiting registered nurses and a radiologic technologist to join our team. 

What is the size of your EP facility?

The Richard M. Ross Heart Hospital at The Ohio State University Wexner Medical Center (OSU) is a 150-bed, 225,000 square foot, state-of-the-art hospital dedicated to providing complete care to patients whose condition arises from cardiovascular disease. 

The electrophysiology lab is located on the second floor of the Ross, and has 6 dedicated EP labs and one procedure room. Each EP lab is equipped with identical equipment to facilitate patient scheduling. In early 2016, construction will begin on a new hybrid EP/OR suite, which will be located within the EP lab and be solely dedicated to electrophysiology needs. 

How is shift coverage managed? 

The EP lab is staffed from 7 AM to 7 PM, Monday through Friday. The unpredictable and fluctuating volumes in the procedural areas make staffing a daily challenge. The work-life balance is important at OSU, and staff members are usually assigned to work either 4 ten-hour shifts or 3 twelve-hour shifts per week. Early and late shifts are also employed to facilitate predictable workday schedules. Additionally, two staff members are scheduled to be on call for a week at a time. Call is Monday through Friday from 7 PM to 7 AM, and 24 hours over the weekend. On average, staff is usually called in once per week. The call rotation consists of either a registered nurse and a radiologic technologist, or two registered nurses. Additional team members include the EP fellow on call and the assigned EP attending on call.

What types of procedures are performed at your facility?

At OSU, we perform a broad spectrum of procedures. These include complex ablations such as ventricular tachycardia (VT), atrial fibrillation (AF), atrial flutter, atrial tachycardia (AT), supraventricular (SVT), and AV nodal ablations. Device implants include biventricular implantable devices, pacemakers, implantable cardioverter-defibrillators (ICDs), and implantable loop recorders. Tilt table studies are also part of the daily schedule in our procedure room. We are also involved in many clinical trials, and perform a high volume of extractions as well as left atrial closure procedures.

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

Each week, the OSU EP team performs approximately 170 procedures including ablations, device implants, generator changeouts, extractions, tilt table testing, cardioversions, and Reveal LINQ insertable cardiac monitor (Medtronic) implants. On average, there are 27 ablations (AF, VT, and SVT) and 35 new device implants per week.

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

The Ohio State University Wexner Medical Center is one of the largest and most diverse academic medical centers in the country, and is the only academic medical center in central Ohio. The health system includes six hospitals: University Hospital, James Cancer Hospital and Solove Research Institute, OSU Harding Hospital, Richard M. Ross Heart Hospital, University Hospital East, and the Dodd Hall Rehabilitation Services. The OSU Brain and Spine Hospital will be opening in 2016. With the exception of OSU’s University Hospital East, all of the hospitals reside on one central campus, allowing for a smooth transition in patient care as well as a rich culture of shared innovation. The electrophysiology lab is located in the Richard M. Ross Heart Hospital. 

The Ross Heart Hospital just celebrated its 10-year anniversary and was recently awarded its third Magnet designation status from the American Nurses Credentialing Center (ANCC). The EP service line is located within the Ross Heart Hospital and has its own dedicated inpatient nursing unit, along with 23 invasive prep and recovery beds. 

Which clinical research studies is your EP lab currently involved in?

Research in our EP lab is thriving under the direction of Dr. John Hummel. We are currently participating in a total of 33 studies that span all the core aspects of electrophysiology — AF, VT, and devices. Atrial fibrillation studies include those evaluating the latest catheters (e.g., VICTORY AF and SMART-SF) and technologies (REAFFIRM — rotor modulation). We are also involved in critical management trials such as the CABANA (Catheter Ablation vs Antiarrhythmic Drug Therapy for AF) trial. Device trials include all aspects of device-related care, from implantation to follow-up. We are involved in the WRAP-IT study, which is evaluating an antibiotic envelope that may prevent/reduce device-related infections. In addition, we are involved in trials looking at quadripolar left ventricular leads (NAVIGATE study) and leadless pacemakers (Micra CA study). 

Our medical center is also developing expertise in neurocardiac modulation. Dr. Ralph Augostini is a leading authority on transvenous phrenic nerve stimulation, and we are currently involved in a study looking at cardiac autonomic nerve activation to increase contractility. Our past success includes having the highest enrollment in North America for the clinical study of the S-ICD System; Dr. Raul Weiss, director of the electrophysiology fellowship program at OSU, played a key role in this experience and was the lead author of the study published in 2013 in Circulation. 

Finally, we have ongoing collaboration with other centers, including the University of Michigan (e.g., Cardiac Sarcoidosis Registry). Given our dedication to research, we are often the first to have access to new technologies that are in the pre-clinical phase.

Are you ACGME-approved for EP training? What are your thoughts on two-year EP programs?

The Ohio State University Wexner Medical Center has a very progressive ACGME-approved clinical cardiac electrophysiology fellowship program. For the last decade, we have had a two-year EP fellowship program. Prospective candidates apply from across the country as well as internationally for one of two spots as a first year fellow. First and second year fellows are exposed to an array of procedures including research studies, complex ablations, and lead extractions. Fellows work under the direction of some of the most accomplished electrophysiologists in the country.

In addition to their work in the lab, the fellows also rotate every fourth week through the inpatient EP consultation service. This provides them with a solid foundation of the management of patients with arrhythmias in a clinical setting. Because the service covers the University Hospital, Ross Heart Hospital, and the James Cancer Hospital, the fellows are exposed to a variety of patients with arrhythmias and complex underlying comorbidities. This program structure allows the fellows to develop collaborative skills and relationships with other subspecialties in the care of patients with arrhythmias.

With the attending electrophysiologists, fellows also see patients in the follow-up clinic, device clinic, genetic clinic, and arrhythmia clinic.

Dr. Weiss requires the fellows to attend EP conferences, EP didactic lectures, and intracardiac tracing rounds each week as well as quarterly morbidity and mortality meetings. Fellows are encouraged to attend national and international scientific meetings to present their research projects. Dr. Weiss ensures that fellows are provided regular feedback as to their progress during the two-year program. By the time the fellows graduate, they will have been exposed to a robust research experience rich with cutting-edge EP technology. The rigors of the fellowship are demanding, but the success rate on the EP board has been 100% for the past several years. Moreover, recent graduates have secured positions in full-fledged EP programs across the country.

What innovative EP techniques are being utilized in your lab? 

Under the direction of Dr. Hummel and Dr. Steven Kalbfleisch, the WATCHMAN Left Atrial Appendage Closure Device (Boston Scientific) and LARIAT Suture Delivery Device (SentreHEART, Inc.) procedures are being performed for left atrial appendage closure. Dr. Hummel is also working in collaboration with the OSU cardiothoracic surgeons to perform the Convergent procedure for those patients with persistent atrial fibrillation who have failed traditional AF ablation procedures. 

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

OSU’s EP lab participates in the NCDR ICD registry, our own pacemaker registry, and the Get With The Guidelines atrial fibrillation registry provided by the American Heart Association/American Stroke Association. A compliance process has been implemented to screen new device procedures for compliance with the NCDR guidelines. All implants are reviewed prior to procedure to ensure indications are met, supporting documentation is accessible, and that the program is in compliance with all state and federal regulations. 

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

The EP quality committee meets monthly to review all adverse events related to procedures. The committee reviews data for possible trends and implements process improvement initiatives as necessary. An EP scorecard has also been developed and is given quarterly to each physician. The scorecard tallies the physician’s procedure history and any associated adverse outcomes. Dr. Kalbfleisch, medical director of cardiac electrophysiology, reviews the overall scorecard data for each physician before presenting the individual results. 

Information collected from the registries and EP quality committee is used to identify process improvement (PI) projects. Each year, the service line is asked to participate in a system-wide PI project in which we identify a key patient safety indicator related to our practice. Once the key indicator is identified, a PI plan is developed and implemented. Outcomes are tracked and reported out annually. In 2014, the service line implemented a protocol to decrease our incidence of pneumothorax post-device implant and found a 21% decrease as a result of the newly developed protocol. The 2015/16 PI project will be evaluating lead dislodgment post-device implantation. Simple maneuvers have been implemented to verify lead stability and positioning. These maneuvers have had an impact on our incidence of lead dislodgement and our overall adverse event rate (Outcome Report Metric #13). 

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

At the OSU Wexner Medical Center, continuing education and advanced degrees are strongly encouraged. OSU offers tuition assistance for those full-time employees who wish to attend the university. The assistance covers 10 credit hours per semester. Nursing staff is given 5 paid education days per year to attend off-campus conferences and lectures. Wexner Medical Center also sponsors a number of continuing education seminars on a variety of topics each week. Many of these seminars include accredited continuing education units (CEUs) for the staff. 

Within the service line, the EP attending group also provides additional educational opportunities with accredited CEUs for staff members during their weekly conference. Four times a year, the EP attending group brings in nationally renowned speakers to discuss EP topics at Wexner Medical Center’s grand round conference. 

Tell us what a typical day is like in the EP lab.

Each morning starts with a 10- to 15-minute team huddle led by the charge nurse. Team assignments are given, along with a brief overview of the daily caseload. This quick check-in allows staff the opportunity to ask questions or discuss concerns in an open forum. 

Staff then disperse to their individual labs and proceed with gathering supplies and equipment required for the day’s work. Each lab is staffed with a combination of 2-3 RNs and 1 RT depending on the anticipated procedure. With the exception of the role of the sedation nurse, all staff rotate between circulator, documenter, and scrub roles. Depending on the type of sedation used during the procedure, patients are brought into the lab 20-40 minutes prior to the scheduled start time. The first case typically starts at 8 AM. The case documenter notifies the charge nurse when the procedure is approximately 20 minutes from completion, and the next room assignment is given. The sedation nurse returns with the patient to the prep and recovery area or nursing unit, and provides a detailed bedside handoff to the primary RN. The staff switch roles and begin the prep for the next case. Often, members of a different lab will step in and assist at the start or end of a procedure to ensure a timely start and decrease room turnover time. In general, the procedural volume in our EP lab is incredibly large and diverse. Staff may start with an extraction, then have a device implant case, and end the day with a VT ablation. The challenging variety of procedures engages the staff throughout the day, and we function as a strong, unified interdisciplinary team.