Spotlight Interview: Sanford Health

Sanford Health is an integrated health system headquartered in the Dakotas. It is one of the largest health systems in the nation, with locations in 126 communities, 9 states, and 4 countries.

Sanford’s USD Medical Center in Sioux Falls provides leading care for patients from across the Midwest. As the largest hospital in the state and a teaching hospital for the Sanford School of Medicine at the University of South Dakota, we are proud to offer the latest in innovative care. Our highly skilled medical teams are renown for their passion, leadership, and dedication to their patients and to their specialties.

Our leading cardiologists and specialists provide advanced cardiac care, surgery, prevention, emergency and rehabilitation, and the latest in technology. But while we provide some of the most advanced heart care in the country, patients choose Sanford Heart because we understand that it takes courage, connection, and compassion to choose a path that leads to better heart health.

At Sanford Heart Hospital, the patient is always our first thought. We are experts at understanding the intricacies of their heart and creating an experience focused around their comfort and well-being.

What is the size of your EP lab facility? When was the EP program started at your institution?

The EP program really took off when Dr. Scott Pham joined Sanford Health in 2003, and later increased in volume in 2010 once Dr. Christopher Stanton joined. We have 2 dedicated EP labs where we perform ablation procedures and device implants. We have 1 hybrid OR room where we do laser lead extraction. We can also use any of the 6 cardiac cath labs for device implants if needed.

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

We have 6 dedicated EP members and two electrophysiologists. The dedicated EP members include 4 RCES, 1 RCIS, and 1 RN. We currently use members from the cardiac cath lab (25 RN and 16 RCIS) to help staff cases.

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

We perform a wide variety of EP procedures, including diagnostic EP studies, ablations (AVNRT, AVRT, AV node, atrial tachycardia, atrial flutter, PVI, RVOT, and ventricular tachycardia), generator changes, loop recorder implants, permanent and biventricular pacemakers/ICD implants, subcutaneous ICD implants, laser lead extractions, and left atrial appendage closure (LARIAT Suture Delivery Device, SentreHEART, Inc.). We were recently approved for the leadless pacemaker implant (Micra Transcatheter Pacing System, Medtronic). We perform approximately 80 PVI ablations, 160 SVT ablations, 10  VT ablations, 300 PPMs, 160 ICDs, 60 biventricular device implants, 6 subcutaneous ICD implants, 13 laser lead extractions, 6 left atrial appendage closures, and 120 loop recorder implants every year.

Who manages your EP lab?

Our EP team’s lead RCES, Jamie Shores, works closely with our 2 electrophyiologists, Drs. Pham and Stanton, as well as with manager Kyah Broders, RN, BSN and director Bridget O’Brien-Johnson RN, MSN, CNML, to make sure that day-to-day operations run smoothly.

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

Our EP lab is not currently separate from the cath lab; however, we do have dedicated rooms and staff. The cardiac cath lab staff is cross-trained to circulate, monitor, and nurse for all device cases. In addition, our EP staff is cross-trained to circulate, scrub, monitor, and nurse for cardiac catheterization cases. Our dedicated EP team members are the only ones who can scrub device and ablation cases as well as operate the Bloom stimulator (Fischer Medical Technologies), CardioLab Recording System (GE Healthcare), and ablation generators.

Do you have cross training inside the EP lab?

The EP team members are expected to perform all the roles during electrophysiology cases including scrub, circulate, monitor, run the Bloom stimulator, and operate the Stockert/MAESTRO/Cryo generators and CARTO 3 system (Biosense Webster, Inc., a Johnson & Johnson company). The RN in the room is the only one who can administer conscious sedation.

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

Sanford USD Medical Center is part of a larger health system. The care we provide our patients has become more integrated as several of our communities have expanded their focus across the Health Services Division to include the clinics, hospital, and network. We have an extensive outreach program. Our physicians and staff travel to 27 different outreach sites in South Dakota, Minnesota, and Iowa over 100 times each month. In 2012, Sanford Heart Hospital partnered with the University of South Dakota to implement a fellowship program. This program is the only one of its kind for cardiovascular training in the region, and is one of 193 cardiovascular fellowship programs approved for development in the United States. 

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

The most common equipment used in our EP lab is the Bloom stimulator (Fischer Medical Technologies), CardioLab Recording System (GE Healthcare), Xper Information Management (XIM) system (Philips), Stockert ablation generator, CARTO 3 mapping system with SMARTTOUCH module (Biosense Webster, Inc., a Johnson & Johnson company), MAESTRO 4000 ablation generator (Boston Scientific), cryoablation (Medtronic), and laser lead extraction (Spectranetics). We implant CRM devices from Medtronic and Boston Scientific.

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

We have varying shifts with a 4-week rotation schedule. The first set of staff arrives at 5:30 a.m., with the first case starting at 6 a.m. The EP lab performs cases until 5:30 p.m., with the cardiac cath lab being open until 7 p.m. We have one person on call during the week and the weekends to scrub device cases as needed.

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

A typical day starts at 5:30 a.m., when staff come in to check their room assignments and patient status board to see what cases are scheduled. All the rooms are turned on, an equipment check is done, and supplies are pulled for cases. All our outpatients arrive in our Short Stay Unit, where they are checked in, accessed, and prepped for their procedure. If we have an inpatient, the floor nurse will get IV access; obtain consent and the rest of the prepping is done in the EP room. Our electrophysiologists have block days where they run 2 rooms during a certain time frame. We run our rooms with 4 staff members. Typically, most cases have 1 RN to 3 technologists — some cases will have 2 RNs and 2 technologists. Once the procedure is complete, the physician will speak with family in the waiting room, and then proceed to his next case in the other room. The staff will turn over the room and transport the patient to their room. We recover our pacemaker and diagnostic EP study patients in our Short Stay Unit; all other patients are recovered on the floor. All intubated patients are recovered on the floor as critical care status. Once the cases are done for the day, the staff stocks and terminal cleans the rooms. If cardiac cath lab cases are still going on, the EP staff will help where needed. 

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

In last few months, we changed our dressing for device implants to an AQUACEL Dressing (ConvaTec). This has allowed the patient to be able to take a shower and not have to worry about doing dressing changes during post-op care. In the last year, we added Biosense Webster’s SMARTTOUCH module to our CARTO 3 system. This has allowed us to be more efficient in our atrial flutter cases by knowing the direction our catheter is pointing and how much force we are applying during ablation. Also, we will be starting training on implantation of the leadless Micra pacemaker (Medtronic). This will allow patients who need a single-chamber pacemaker to not have a generator placed in their chest.

What imaging technology do you utilize?

In both of our EP labs, we have the biplane Artis zee (Siemens Healthcare) for imaging.

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

Our EP cases are scheduled by the physician offices through the hospital’s PAC, which utilizes the One Chart (Epic Systems Corporation) software.

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

We measure our patient satisfaction through Press Ganey. We perform monthly audits on x-ray lead quality, proper shielding for nurses during cases, handwashing techniques, wasted supply management, and charting. On a daily basis, we perform QA on our ACT and avox machines.

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

Inventory is managed through a barcoding process built within the Philips XIM system that is managed through Lawson. We have a supply chain staff assigned to us that manages Lawson on a daily basis and assesses which products need to be ordered. Our lead RCES works closely with the supply chain to make sure inventory stays on track and supplies are ordered. The staff does a full count of inventory in the rooms every week. We utilize a 2-bin system for minor supplies used on a daily basis, which is managed by the supply chain.

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

Our EP procedures have shown a steady increase since we opened our 2 labs in the heart hospital. We continue to adapt to the busy workflow and look to add new members to our team.

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

With the changes in the healthcare landscape, we have worked toward decreasing our observation hours with all patient populations. As an organization, we have evaluated the observation days on all units and worked with Utilization Review as well as Case Management to shift their focus with observation patients to prompt discharge while ensuring all patient needs are met. After reviewing the department observation hours, it was determined the best option for low-risk observation patients would be the Short Stay Unit. The patient population would be in close proximity to CVS/NUC testing, the cardiac cath lab, and the staff is used to the fast-paced environment and trained in the care of the cardiac patient.

Have you developed a referral base?

Our 2 electrophysiologists do outreach 1-2 times a week, which is a huge part of our referral base. Sanford Health has 225 clinic locations, and this allows our physicians to more easily reach our rural patients. 

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

As an enterprise, we look at many ways of cutting cost. We are committed to system contracts with vendors and negotiate for best price. We purchase some of our supplies in bulk to allow us the best price available. We also reprocess most of our EP supplies to keep costs down. We work closely with physicians and staff to prevent wasted products.

How do you ensure timely case starts and patient turnover?

We utilize block scheduling, in which each case is scheduled for a certain amount of time, to ensure on-time case starts. During the physicians’ block, they utilize 2 rooms. This process helps with turnover: as when one room is turning over, the physician is working in the other room.

How are new employees oriented and trained at your facility?

New employees go through 2 interviews: one with HR, and the other with the manager and a few current staff members. Upon hire, they do a 2-day hospital orientation and then are scheduled with an experienced staff member to be their preceptor for at least 12 weeks. They use a skills checklist to meet their competency, and meet weekly with the manager and clinical educator to go over their progress. If at 12 weeks they do not feel they are comfortable to do their skills independently, then their orientation can be extended. 

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

Once a month we hold EP case conferences, in which the electrophysiologist will go over interesting cases that were done or topics of interest. In addition, we do a video conference once a month with the Mayo Clinic in Rochester along with other hospitals to discuss complex device cases. Each year we send one member of the EP team to the Heart Rhythm Society annual conference to be able to take in the vast amount of education offered during the convention. Our device representatives will provide educational in-services for us to attend or offer individual training if needed. As staff, we try to hold educational sessions during our downtime to help prepare staff taking the RCES or IBHRE exam.

How is staff competency evaluated?

Staff do yearly competency through their Sanford Learns. We also hold validations twice a year on certain topics, and staff is checked off monthly on their skills and equipment. 

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 4 team members who have their RCES. It is highly encouraged to take the RCES after the first year of being on the EP team. Once completed and passed, staff are reimbursed on the cost of the test. They are also moved into a different job classification with compensation in pay.

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

We make great strides in preventing staff burnout by rotating staff through the different positions during cases, allowing staff not having to do the same thing over and over. We offer mental breaks when needed from our busy case schedule. We have a retention and recruitment team that works on fun ideas for events to build up staff morale. We celebrate birthdays and cardiovascular professionals’ and nurses’ week, as well as welcome new hires and staff milestones (e.g., years of service, new babies, marriages, etc.).

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

All staff is encouraged to be involved in department committees. The EP and cardiac cath lab staff join together to form the department committees. The types of committees we have are retention and recruitment, staff scheduling, radiation, stocking, and terminal cleaning. One RN serves as the representative for the whole department at nurse senate and performance improvement.

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

All vendors have to make an appointment through our manager, and when they arrive to the hospital, they have to sign into Reptrax. Our device vendors are required to be present at all cases. We have contracts with vendors for supplies.

Does your lab utilize any alternative therapies to help patients in the EP lab? 

We offer warm blankets from our blanket warmer in our pre/post area and in the procedure room. The patient can select what type of music they would like to listen to during their procedure to help relax them. Our staff is wonderful with talking to the patient during the EP study, and are effective at calming their nerves.

How does your lab handle call time for staff members?

We have one person from the EP team on call every night and weekend to scrub device cases. When we are called in for a device, 3 members from the primary cardiac cath lab call team join to perform the case. We have a 20-minute response once we are paged.

Does your lab use a third party for reprocessing or catheter recycling? How has it impacted your lab?

Yes, we use Stryker to reprocess a good majority of our diagnostic EP catheters, cables, and intracardiac ultrasound catheters. Reprocessing has had a positive impact on our lab, as it has allowed us to save money.

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

We do about half cryoablation and half radiofrequency. All of our PVI ablation cases and a good majority of our slow pathway ablations are done with cryo. 

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

We recently decreased the use of contrast in our PVI ablation cases, and are instead utilizing pressure waveform to verify occlusion. This has been beneficial to the patients, as they are receiving either no contrast or very little contrast. We have also incorporated compound motor action potentials (CMAP) into our PVI ablation cases, in which we monitor any phrenic nerve damage by placing the right and left arm EKG leads across the diaphragm. During phrenic nerve pacing, we watch for a reduction in the amplitude in lead I. If there is a 35% reduction, we would come off cryoablation. This is just another tool to use to ensure that there is no phrenic nerve damage when ablating the right pulmonary veins. 

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

Once a month, Dr. Ian Law from the University of Iowa comes to Sanford Heart Hospital to perform pediatric EP cases.

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

All of the staff and physicians wear lead aprons and glasses during the procedure. We do random checks to make sure staff and physicians appropriately hang up their lead apron to prevent wear and tear to the lead. We also check the lead aprons annually for any cracks and holes. During a procedure, the physician, CRNA, and nurse will utilize our moveable lead shields for added extra protection from radiation. A daily report on radiation exposure is generated during procedures, and anything that is over 3000 mGy is flagged. The information is then sent to our radiation physicist. A radiation safety committee meets monthly to go over any radiation concerns. 

What are your methods for device infection prophylaxis?

Once the patient is in the procedure room, we start IV antibiotics on all device implants. The antibiotics are started within one hour of cut time; in general, they are started within 30 minutes of cut time. We inspect the area of implant and remove any hair or adhesive. We also place a mask over the patient while we clean the area, and remove it after the drape is on. Before we scrub the chest with chloraprep, we first wipe it with a chlorhexidine cloth. As a team, we hold everyone accountable in the room for sterile technique, which includes not opening the table until everyone has all proper attire on (including a mask and hat), staying in the room once the table is open, and maintaining a distance of 12 inches from the sterile table. We irrigate all device pockets with an antibiotic solution to help prevent any infection. After the case, we dress the area with an AQUACEL Dressing, which has silver in the pad to help with the healing process and reduce the chance of skin infection. We properly educate our patient on their dressing and how to care for it post-op. After about 5-9 days’ post-op, the patient will have a wound check in the office, during which time the dressing is removed.

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

Our ICD data recently has been at or near 100% for several quarters, so we continue to monitor our outcomes. Three years ago, we had issues with pre-op antibiotic administration that fell far below the national average. The problem was addressed and a resolution of the issue occurred, with now the pre-op antibiotic administration metric being 100% in most quarters. 

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

We use Philips XIM for our procedural case charting and the One Chart for EMR. As with everything, EHR has its pros and cons, but overall, we think it does help to improve our quality of care. 

What are some of the dominant trends you see emerging in the practice of electrophysiology?

At Sanford USD Medical Center, we have seen an increase in the use of a variety of technologies to help reduce CHF symptoms. Some of the procedures we perform in the EP and cardiac cath labs to help CHF patients are biventricular device implants, PVI ablations, LAA closures, TAVR, the CardioMEMS HF System (St. Jude Medical), mitral clips, and many others. We have a very specialized team here at Sanford Medical Center to help treat CHF. 

We have also seen an increase in lead extraction, not only for infections or recalls, but to decrease the amount of hardware in a patient. 

How does your lab handle device recalls?

When a device is recalled, in most cases a letter is sent out to the patient and the device clinic from the vendor. The device clinic will make sure that the patient is notified either by phone or letter. The device clinic will document in the patient’s chart that they have been notified of the recall. The severity of the recall will determine whether action needs to be taken. 

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

Named for the Big Sioux River falls in the heart of the city, Sioux Falls is the largest and most diverse city in the state of South Dakota. With over 170,000 residents and a quarter of a million people regionally speaking 60 different languages, Sioux Falls has recently been called “a modern-day boom town” by our Mayor Mike Huether. Our “best little city in America” is constantly being hailed as a great city for business, families, and retirees, as well as the number 1 up-and-coming city for recent college graduates. With over 70 parks spanning our 73 square miles, a steadily growing population, low unemployment rate, and an economic boom like no other, Sioux Falls is poised for continued success and innovation on the prairie.  

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

Since we are such a small group, we give great meaning to the word “teamwork.” We rely on one another to help each other out, such as staying late or coming in early, or switching call or shifts with each other. Our 2 electrophysiologists are eager to teach us, and the whole team is eager to learn. We work as a very cohesive team, and feed off each other’s strengths to get the work done in an efficient manner. We are all dedicated to the work of health and healing. We look at ways of improving the human condition through exceptional care, innovation, and discovery.