Spotlight Interview: Scott & White Healthcare

What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab? There are 3 invasive EP labs with 1 single-plane lab, 1 biplane lab, and 1 single-plane Stereotaxis remote navigation lab. There is an additional noninvasive lab for tilt table testing in the outpatient holding area. The lab is supported by a 15-room holding area shared with the cath lab. Our EP staff consists of 5 full-time faculty attendings and 1 part-time attending. In addition, there is 1 EP fellow (ACGME accredited) and 1 rotating cardiology fellow participating in EP procedures each month. A full-time physician’s assistant supervises the Pacemaker Clinic and works with the EP team. Patient care staff is made up of RNs and EP techs. When was the EP lab started at your institution? The EP lab was opened in 1990 with 1 single-plane lab. An additional single-plane lab was added in 2000. In August 2007 we moved into a brand new facility as was described. What types of procedures are performed at your facility? We perform comprehensive EP studies, 3D mapping (using Biosense Webster’s Carto and St. Jude Medical’s EnSite systems, Stereotaxis navigation), catheter ablation of various arrhythmias including atrial fibrillation, pacemaker and ICD implants and generator replacements (including CRT-P and CRT-D), cardioversions, tilt table testing, ILR implants, and lead extractions (mostly in the operating room). Approximately how many are performed each week? What complications do you find during these procedures? Approximately 30-35 procedures are performed each week with a low complication rate (What is the primary goal of your program? The primary goal of our program is to provide the best diagnostic and therapeutic service to our patients in the Central Texas region and from remote locations. Scott & White in Temple is a tertiary care medical center and a major teaching institution of the Texas A&M University Health Science Center. As a result, we are committed to providing an environment suitable for training medical students, residents and fellows. In addition, we are actively engaged in research to advance our program in a more academic setting. Who manages your EP lab? Shoei K. Stephen Huang, MD is the Director of EP/Pacing Section and Lab; Nancy Ellis, RN, is the manager of Cath/EP labs; Jenelle Durbin, RN, is the EP Lab Asst. Nurse Mgr. Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained? Yes, it has been this way since 1990. We have employed RNs separate from the cath lab for many years. This past year we added permanent, full-time EP techs. Do you have cross training inside the EP lab? What are the regulations in your state? Yes, our EP staff is cross-trained. RNs and techs function in all roles except those requiring licensed staff such as assessment, medication and sedation administration. What new equipment, devices and/or products have been introduced at your lab lately? Our new EP monitoring and recording system is the AXIOM Sensis XP by Siemens. Imaging equipment is Siemens’ Artis zee system. Currently, we have updated our Carto and EnSite 3D mapping systems, and radiofrequency and cryoenergy generators with various ablation catheters including an irrigation system. We installed the Stereotaxis remote navigation system in our third EP lab in October 2008. How has this changed the way you perform those procedures? With all of the sophisticated mapping and ablation equipment, we are able to more precisely localize the arrhythmia focus and enhance our ability to perform atrial fibrillation ablation with both anatomical and electrical approaches. It improves the efficacy and safety of the procedures. Who handles your procedure scheduling? Do you use particular software? Clerical staff performs the scheduling functions using no particular software. What type of quality control/quality assurance measures are practiced in your EP lab? We do follow-up on outpatients and inpatients for identification of complications, success and patient satisfaction. We keep a log sheet to track the procedure results. We have several in-services and fixed meetings with the staff to review outcomes and quality control measures throughout the year. How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? The cath/EP lab has a material management technician to assist with ordering and inventory. Much of the process is still manual at this point. Has your EP lab recently expanded in size and patient volume, or will it be in the near future? Yes, we have recently expanded our EP lab volume by extending our coverage to several satellite hospitals, including University Medical Campus Hospital in Round Rock and Metroplex Hospital in Killeen. Our EP lab is not part of a separate “heart hospital.” How has managed care affected your EP lab and the care it provides patients? Managed care does not seem to have much effect on our patient care. Have you developed a referral base? Our EP referrals come primarily from the general cardiologists and primary care physicians from our own healthcare systems and from the surrounding communities. 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? The hospital utilizes Novation contract pricing and vendor contract pricing for devices and EP catheters. We use an outside vendor for catheter reprocessing. We are currently looking at all of our processes for opportunities to increase through-put. Examples include transferring the cardioversions to the outpatient staff, performing TEEs in the outpatient area immediately prior to cardioversion, and expanding the use of pre-printed orders. Does your EP lab compete for patients? Has your institution formed an alliance with others in the area? We cover the areas that are not competitive to our EP patients. We do not form an alliance with others in the area. What percentage of procedures are performed on an outpatient basis? In addition, what EP procedures are generally only considered inpatient? In 2007-2008, approximately 40% of our procedures were performed as outpatient. In general, any new device implantations, complex arrhythmia ablations, or any procedures with immediate complications are considered an inpatient procedure. How are new employees oriented and trained at your facility? New employees are assigned a mentor to shadow until independent. Length of orientation may depend on prior EP lab experience. Education through vendor-provided teaching is also provided. What types of continuing education opportunities are provided to staff members? Institution- and industry-based opportunities are provided throughout the year. In addition, bi-weekly serial didactic lectures and exercises related to EP/pacing topics are rendered by EP attendings and staff. Scott & White’s research and teaching environment provides many opportunities through our Staff Education and Ambulatory Care Nursing departments. How is staff competency evaluated? Both nursing (including sedation) and equipment competencies are performed annually. New this year in Ambulatory Care Nursing is a competency fair that will serve to assess competency and standardize on 80% of what nurses will require. Staff is encouraged to get certified through the IBHRE competency exam for the allied professional or the RCES credential. How do you prevent staff burnout? Our biggest job satisfier has been to allow staff to work 4 ten-hour days. We continue to have staff meetings with all cath and EP lab employees. Employees rotate staying late if needed. What committees, if any, are staff members asked to serve on in your lab? Every cath and EP lab employee participates on an Action Team. There is a mix of staff from each area. We have an Employee Satisfaction Team, Safety and Infection Control, and Patient Education committee, to name a few. How do you handle vendor visits to your department? Do you contract with vendors? Scott & White uses Vendor Credentialing Services to screen and track vendor representatives. We do have vendor contracts. How does your lab handle call time for staff members? How often is each staff member on call? How frequently do they have to come in, on average? Is there a particular mix of credentials needed for each call team? Currently, lab staff is on call Saturday and Sunday and any holiday from 8 am to Noon for emergency pacemaker implants. The lab call team consists of 2 RNs and 1 EP tech. Callback procedures are very, very infrequent. Because our EP staff is separate from the cath lab, we no longer rely on the cath lab for the rare weekend/holiday implant procedure. Does your lab use a third party for reprocessing? Yes, we use Ascent Healthcare Solutions. Approximately what percentage of your ablation procedures are done with cryo? The percentage of cryoablation procedures is less than 1%. Do you perform only adult EP procedures or do you also do pediatric cases? The lab has an occasional adolescent pediatric case. However, no pediatric cases are under the age of 12. What measures has your lab taken to minimize radiation exposure to physicians and staff? The imaging system is equipped with shielding on the procedure table and a moveable lead shield. The physicians wear lead eye glasses. Utilization of the biplane room and utilization of 3D computer mapping and Stereotaxis remote navigation for complex cases are other measures. Do your nurses/techs participate in the follow up of pacemakers and ICDs? Do you use any particular software for follow up? Device follow ups are performed exclusively by our device clinic staff consisting of 3 RNs and one CVT, plus a physician's assistant as the supervisor. We use Paceart software. What are some of the dominant trends you see emerging in the practice of electrophysiology? How is your lab preparing for these future changes? We believe ablation of atrial fibrillation and ventricular tachycardia as well as implantation of CRT-Ds are some of the dominant emerging trends. What are your thoughts about non-EPs implanting ICDs? Do you train such individuals? We feel that non-EP trained physicians should not implant ICDs. We do not offer training for such individuals. What about device recalls? How has your lab handled these? We follow the guidelines issued by both HRS and the company statements. Is your lab doing web-based/transtelephonic device follow up? Yes, and it is followed by our device clinic. Is your EP lab currently involved in any clinical research studies or special projects? Yes, we are involved in several industry-funded multi-center studies as well as intramural grant supported self-generated projects. When was your last inspection by the Joint Commission? Our last Joint Commission inspection occurred in January of 2009. Are you ACGME-approved for EP training? What do you think about two-year EP programs? Yes, we offer an ACGME-accredited CCEP fellowship program. There is no question that the fellowship program should be two years. 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 (e.g., for pacemaker or ICD patients)? Patient education booklets are available in our cardiology/EP clinic and outpatient areas. Patients are provided with written discharge instructions with our contact information 24/7. The Pacemaker Clinic offers quarterly ICD patient support group meetings. Give an example of a difficult problem or challenge your lab has faced. How it was addressed? Currently staffing is a challenge. Texas is faced with a nursing shortage similar to other areas of the country. We are currently supplementing staffing with agency RNs while recruiting and training full-time staff. Having dedicated EP techs has helped provide stability. Describe your city or general regional area. How does it differ from the rest of the U.S.? We cover a region with a population of more than 200,000, midway between the large metropolitan areas of Dallas and Austin. Temple has a population of 55,000 with a large medical community as well as many industries. Please tell our readers what you consider unique or innovative about your EP lab and staff. We have a beautiful new, spacious lab in a new hospital. Although we have experienced staffing challenges, the management team (with a combined Scott & White tenure of 67 years) remains dedicated to the Scott & White Mission and Vision: Our Mission is to provide the most personalized, comprehensive, and highest quality health care, enhanced by medical education and research. Our Vision is that Scott & White will be the most trusted and the most valued name in American health care. For more information, please visit: www.sw.org.