Spotlight Interview: Salem Hospital

The Salem Cardiovascular Center electrophysiology lab, located at Salem Hospital in Salem, Oregon, serves more than 360,000 people in a two-county region, and more from the Pacific coast to the Cascade Mountains. EP patients benefit from low employee turnover, new state-of-the-art facilities and award-winning cardiac care.

What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab? Salem Hospital’s EP lab moved last year to a new $220 million patient-care tower. Two of the seven new, 650-square-foot cath lab rooms are used primarily for EP procedures. However, we have access to other cath lab rooms for device implants if necessary. Our new rooms are 30 percent larger than the rooms in our previous space and have all new equipment. The Salem Hospital EP lab has three full-time employees and one part-time employee. We have two RT(R)s, one RN RCES (registered cardiac electrophysiology specialist) and CEPS (certified cardiac electrophysiology specialist), and one part-time RT. In addition, all 16 cath lab RTs are utilized in the EP lab for scrubbing and device implants. Our eight cath lab RNs rotate through the EP lab, managing patient care and sedation.

When was the EP lab started at your institution? Salem Hospital opened its EP lab in June 2002.

What types of procedures are performed at your facility? Approximately how many are performed each week? At Salem Hospital, we perform about 30 procedures a week. Some of the more common procedures include diagnostic and therapeutic EP studies, AV node ablations, VT ablations, pulmonary vein isolations, SVT ablations, atrial flutter ablations, and pacemaker, implantable cardioverter defibrillator (ICD) and biventricular ICD implants.

What is the primary goal of your program? Our goal is to provide our patients with excellent care, offering the most technologically-advanced treatment options for their medical needs in a patient-centered environment. We focus primarily on the combination of EP studies and device implants.

Who manages your EP lab? Bryan Sprague, RT(R), supervises both our EP and cath labs. He was an RT(R) for 20 years in the Salem Hospital cath lab prior to becoming the lab supervisor. Lori James-Nielsen, RN, is the director of cardiovascular services. She helped start the EP program.

Is the EP lab separate from the cath lab? Are employees cross-trained? No, our EP lab is part of the cath lab. The cath lab technologists do assist the EP team with scrubbing duties, and our EP RTs rotate to cath lab rooms, where they scrub, control and circulate. RNs circulate, sedate and monitor, but currently do not scrub in.

Do you have cross training inside the EP lab? As part of our four-month orientation process, every employee is rotated through the different cath and EP labs. New employees learn the basics of each of the positions in which they will participate. One week of orientation is devoted to training for scrubbing devices in the EP lab. Our employees are monitored until they are confident in their role and have achieved competency.

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’ve begun using intracardiac echocardiography (ICE) for most trans-septal punctures. There are clear imaging benefits from visualizing the atrial septum from within the heart, particularly the image of the inferior rim of the septum. With the additional imaging quality, trans-septal puncture and pulmonary vein isolation under ICE guidance is performed with lower radiation doses and shorter procedure times. We also frequently use 3-D mapping (NavX, St. Jude Medical, St. Paul, MN) for our more complex cases, which shortens procedure times and decreases radiation doses.

Who handles your procedure scheduling? Do you use particular software? We have a full-time scheduler for the cath and EP labs. We use Epic software (Epic, Verona, Wisconsin) for scheduling.

What type of quality control/quality assurance measures are practiced in your EP lab? Salem Hospital has a strong focus on patient safety and quality. The entire EP lab team, including all our physicians, has gone through a four-hour course on communication and teamwork and implemented communication tools that are having a positive impact on patient safety. This includes implementation of the WHO Surgical Checklist with physician-led timeouts. We also apply evidence espoused by the Surgical Care Improvement Project (SCIP) in order to prevent infections and ensure positive outcomes for our patients by making sure antibiotics are administered and discontinued at the appropriate time and that the correct antibiotics are selected.

How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? The EP lab team uses an inventory management system to keep close control on our equipment levels. Wayne Amende, RT(R), manages all inventory purchases and restocking of supplies for Salem Hospital’s cath and EP labs. Wayne’s 30+ years of knowledge and experience in Salem Hospital’s cath lab make him a valuable resource for us. Salem Hospital’s EP labs are equipped with a workstation where the RN or RT(R) scans any product being used into our IntelliShelf Supply System (McKesson Automation, San Francisco, CA) for billing and reordering purposes. The McKesson system automatically interfaces with Epic, our hospital computer system, and populates the patient bill, eliminating manual entry.

Has your EP lab recently expanded in size and patient volume, or will it be in the near future? Yes. In 2009, we completed and moved into our new tower. The cath lab as a whole increased from three 450-square-foot rooms to seven rooms averaging 650 square feet in our new space. The EP portion of the lab grew from one to two rooms that are 200 square feet larger than in our previous space. Every staff member in the cath and EP lab was given the opportunity to offer input and review the blueprints. The end result is a beautiful, state-of-the-art space with large rooms and current technology. Our local population continues to grow, and we believe the space will continue to meet our needs and growth expectations well into the future.

Have you developed a referral base? We have a large referral base established with both Salem area physicians and surrounding communities. Our EP doctors have fostered relationships with physicians and general practitioners in the outlying community, educating them on why and when to refer patients to the EP lab. Salem Hospital is located in the heart of the Willamette Valley with the two closest major cities (Eugene and Portland) located nearly an hour away. Because of our location in Oregon, patients from as far as 100+ miles to the east and a 50-mile radius to the west, north and south, will come to us for EP procedures.

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 through-put? We work directly with Supply Chain Services to contain costs. In addition, we have begun reprocessing EP diagnostic catheters, which could result in substantial cost savings. To improve patient through-put, we recently opened an extended recovery unit for patients to stay overnight as they recover from their procedures.

Does your EP lab compete for patients? Has your institution formed an alliance with others in the area? EP procedures are rarely emergent. Due to the proximity of Salem to Portland and Eugene, we compete with some facilities in those two metro areas. We offer all of the same types of procedures. However, we also have 3-D mapping and are the most sophisticated EP lab in the Salem area.

How are new employees oriented and trained at your facility? All new RNs and RTs undergo a four-month on-the-job training and orientation program. During the orientation process, every employee is rotated through the different cath and EP labs. New employees learn the fundamentals of each position in which they will participate. One week of orientation is devoted to training for scrubbing devices in the EP lab. Competencies are assessed at the completion of each training session.

What types of continuing education opportunities are provided to staff members? We schedule bi-weekly lectures on subjects pertinent to electrophysiology. Our EP doctors present on topics such as the physiology of the cardiac cell, pacemaker and ICD indications, complications that can crop up with EP studies or device implants, and pathophysiology of cardiac rhythm services. We discuss how and why we do procedures. Salem Hospital provides in-house, ongoing training opportunities and various online educational opportunities. Salem Hospital also encourages us to attend medical conferences and participate in further educational opportunities, such as additional certifications. The hospital offers a reimbursement program for expenses associated with continued education.

How is staff competency evaluated? Evaluating competencies is truly a daily process. We are always trying to refresh and assess what we know or think we know. We have designed an orientation manual to evaluate baseline skill levels. We orient an employee to each of the skills required in the EP lab. Then, our electrophysiology coordinator, Tom Segoria, RN, RCES, CEPS, evaluates their skills annually. In addition to our department evaluation, all employees must meet a list of required hospital competencies. Our cath lab supervisor, Bryan Sprague, RT(R), provides these annual evaluations of skills and proficiencies.

How do you prevent staff burnout? In addition, do you practice any team-building exercises? Since emergent cases in electrophysiology are so rare, we don’t have on-call hours. But what is even more important is that we are a cohesive unit, which makes people enjoy working here. The culture here is very much a family atmosphere. We often plan team building activities, such as bowling, a summer picnic, golf trips and this summer’s ropes course adventure. Those relationships outside the workplace foster strong friendships and teamwork within the workplace.

What committees, if any, are staff members asked to serve on in your lab? We have several committees on which staff members may participate. Our specialty practice team (SPT) is a peer group that concentrates on patient satisfaction and best-practices projects. The SPT meets regularly to discuss ideas for improvement, standards for practice, any employee concerns, or lab issues. The SPT then shares those ideas with other staff members. Three of our four EP employees are on the 10- to 12-member SPT. Tom Segoria, RN, RCES, CEPS, EP coordinator, is a member of the management advisory council to stay informed of hospital initiatives and management best practices.

How do you handle vendor visits to your department? Do you contract with vendors? Vendor visits are scheduled with Bryan Sprague, RT(R), our cath lab supervisor, or with Tom Segoria, RN, RCES, CEPS, EP coordinator. All vendors must have an appointment and sign in before arrival to the cath and EP labs. A call is placed to the lab prior to vendor arrival for approval. We contract with vendors when appropriate.

Does your lab utilize any alternative therapies? We offer music to our patients, with an iPod in every room. We provide Bair Hugger warming blankets (Arizant, Eden Prairie, MN) that provide temperature control for our patients from their feet to their shoulders.

How does your lab handle call time for staff members? The EP team is limited to staying for late cases. We have on-call cath lab personnel who are cross-trained to handle any emergent EP or device cases.

Does your lab use a third party for reprocessing? To realize savings, we just started contracting our catheter reprocessing.

Approximately what percentage of your ablation procedures are done with radiofrequency? One hundred percent of our ablation procedures are done with radiofrequency.

Do you perform only adult EP procedures or do you also do pediatric cases? Is there cross training for pediatric cases? We perform mostly adult EP procedures. We occasionally handle pediatric cases for patients who are close to the size of an adult, such as a mid- to late-teen.

What measures has your lab taken to minimize radiation exposure to physicians and staff? To reduce our radiation exposure, we use lead aprons, the RadPad (Worldwide Innovations & Technologies, Inc., Kansas City, KS), and lead shielding. In addition, Salem Hospital employs a radiation safety officer who checks equipment and monitors radiation exposure of staff, physicians and patients.

Do your nurses/techs participate in the follow up of pacemakers and ICDs? No. Monitoring of devices is handled through the physician’s office.

What are some of the dominant trends you see emerging in the practice of electrophysiology? We expect continued growth in our EP caseloads, as community physicians better understand the value of and need for electrophysiology procedures. We also think that advancements in technology, equipment and medications over the next five years will result in industry-wide changes on how patients are treated. Specifically, we believe technology advancements in remote navigation (robotics) will allow patients more flexibility in selecting a doctor. For example, physicians will be able to drive catheters from a remote location. The patient will be able to have the procedure at their local EP lab with access to the doctor of their choice, potentially worldwide. The doctor will benefit from decreased fluoro time. Also, we think advances in pulmonary vein isolation for atrial fibrillation will decrease the need for medications and risk of congestive heart failure and stroke.

How is your lab preparing for these future changes? In our EP lab, we are already doing 3-D imaging. We hope to get remote navigation in the future.

Is your EP lab currently involved in any clinical research studies or special projects? Yes. Currently, we are participating in two BIOTRONIK studies — CELESTIAL and GALAXY. These are FDA-mandated lead efficacy, safety studies. The purpose of CELESTIAL, a post-approval registry, is to confirm long-term safety and successful biventricular pacing for BIOTRONIK’s Corox OTW(-S) B Pleft ventricular (LV) pacing leads as used in conjunction with any BIOTRONIK CRT pulse generator (CRT pacemaker [CRT-P] or CRT defibrillator [CRT-D]). The evaluation of safety will be based on the analysis of Corox OTW(-S) BP LV lead related adverse events. The CELESTIAL post-approval registry will provide data to permit characterization of any LV lead failures contributing to patients losing CRT. Additionally, acute and chronic LV lead parameters for pacing thresholds and impedance will be evaluated. The GALAXY study is designed to be a post-implant (office-based) registry, and patients are meant to be seen according to each institution's standard of care, but not to exceed a follow-up time frame of every six months. At least 2,000 patients will be enrolled in this registry, and each patient will be followed for five years post-implant. Safety will be evaluated based on the analysis of the overall incidence of lead-related adverse events that require additional invasive intervention to resolve. In addition, each individual adverse event will be separately investigated. Lead parameters for sensing, pacing thresholds and impedance will also be evaluated. An independent clinical events committee will review and adjudicate all adverse events that occur during the study according to the protocol definitions.

Does your staff provide any educational materials for patients who may have additional questions about their condition/procedure? In addition, does your hospital or lab staff have a device support group? Yes, we have a general pamphlet on electrophysiology studies and what to expect. We always interview a patient prior to his or her procedure to answer any questions and address any concerns. If we are unable to answer a question, we make sure the physician meets with the patient again. We also give the patient a cardiac resource guide with more detailed information about what they will experience with their procedure, and tips for when they go home. It includes a cardiac patient education video with sections focused on various heart procedures, as well as information on heart disease and healthy living. This DVD was just completed and includes patients sharing their stories so that future patients have a better idea of what to expect before they arrive. The DVD was made using our own staff and providers, so patients will hopefully recognize a familiar face on the day of their procedure. To see a small segment from the resource section of the video that introduces team members, as well as a segment on patients’ thoughts of Salem Hospital, go to EP Lab Digest’s Web site and link from this story. Our Healthy Hearts Educational Support Group is a great resource for cardiac patients and their friends and family as well. Every month, attendees can listen to a speaker on topics such as diet and heart failure, vitamins and herbs, depression, stress and heart disease, rhythms, home exercise programs, and more. The support group is an opportunity to ask questions from cardiac experts — cardiologists, nurses, dietitians, pharmacists, and others — and to talk with other people with similar experiences.

Give an example of a difficult problem or challenge your lab has faced. How it was addressed? With our ongoing growth, we are always looking for experienced staff members to join our team. Our cardiologists face the ongoing challenge of educating general practitioners about what EP services are and when or why to use them.

Describe your city or general regional area. How does it differ from the rest of the U.S.? Oregon is a beautiful state with environmental and cultural diversity. Salem, Oregon’s capitol, benefits from its central location. Salem is in the heart of Oregon’s nationally renowned wine country. It is located two to three hours from Central Oregon’s high desert amenities (skiing, hiking, rock climbing, fishing, rafting, etc.) and is an hour drive from the Pacific Coast. Most people who live in Oregon embrace its natural beauty and its diverse outdoor opportunities.

Please tell our readers what you consider unique or innovative about your EP lab and staff. One thing that sets us apart is our space and equipment. With the move to our new facility a year ago, EP lab patients and staff enjoy current equipment. The rooms are large and designed to make everyone’s job easier and the patient more comfortable. Our staff is more like a family than just co-workers. We are friendly, professional, bring humor to the workplace and truly enjoy working together. We are a very integrated team. As a result, we have minimal turnover and our patients benefit from our highly experienced staff.

For more information, please visit www.salemhospital.org.