Spotlight Interview: Sentara Norfolk General Hospital

As Hampton Roads’ first Magnet Hospital, Sentara Norfolk General Hospital (SNGH), a 525-bed tertiary care facility, is home to the region’s only Level I Trauma Center, Burn Trauma Unit, and nationally ranked heart program at Sentara Heart Hospital.

In 2013, SNGH was recognized as the number one ranked hospital in Virginia in the 2013-14 America’s Best Hospitals ranking of U.S. News & World Report. In the rankings, the hospital earned two national rankings for its heart and nephrology programs. This is the 14th year Sentara has achieved a national ranking in its Cardiology and Heart Surgery programs, and it is the only nationally ranked heart program in Virginia.

What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab?

We currently have three dedicated EP labs, two of which have biplane fluoroscopy. In addition, we have a hybrid OR lab that we use for laser lead removals and difficult ablations such as epicardial ablations. Plans to build out a fourth EP lab are currently being considered. 

Our staff includes four RNs and eight RCES-certified technicians. RCES credentialing is a mandatory requirement for all newly hired staff. The Sentara College of Health Sciences has a dedicated EP program in which four out of the first five graduates are currently employed within our EP lab.

When was the EP lab started at your institution?

The EP lab was first established in 1989. We initially started out with invasive EP studies to evaluate patients with sustained VT who were resuscitated after cardiac arrest, baseline EP studies on patients with documented VT or VF with specific programmed stimulation protocols to reproduce spontaneous arrhythmias, and serial EP testing to evaluate efficacy of antiarrhythmic drugs (AADs) for suppression of ventricular arrhythmias. We also implanted pacemakers.

ICDs, which were not implanted in our EP lab when it first opened, only delivered shocks at the time. All implant procedures were performed in the cardiac OR, since placement required a thoracotomy, and large devices were implanted in the abdomen. In 1989, the staff consisted of three full-time RNs (we did not have techs). 

What types of procedures are performed at your facility? Approximately how many are performed each week? 

We perform device implantations ranging from biventricular ICDs and subcutaneous ICDs, to pacemakers and loop recorders. We perform a variety of ablations, including atrial fibrillation (AF), flutter and atrial tachycardias, Wolff-Parkinson-White syndrome, and ventricular tachycardias (VT). EP techniques include the use of 3D mapping systems such as Carto (Biosense Webster, Inc., a Johnson & Johnson company) or EnSite (St. Jude Medical). Along with radiofrequency (RF) ablations, physicians use traditional cryoablation, and more recently, cryoballoon ablation. We average about 15-20 devices a week and 9-10 ablations per week. 

What is the primary goal of your program?

Our primary goal is to provide a comprehensive arrhythmia management center for the Hampton Roads area. We aim to care for all aspects of interventional EP, to include diagnostic EP studies, ablation (including complex AF, VT, and hybrid/epicardial), device-based therapy to include cardiac resynchronization therapy and lead management/extraction, and future therapies including left atrial appendage (LAA) occlusion.

Who manages your EP lab? 

Jocelyn Dawes, RN, BSN is the Nurse Manager who manages the day-to-day operations for the Invasive Cardiology Department, which includes Interventional Cardiology and Electrophysiology. Manuel Calayo, RN, BSN, RCES is the Team Coordinator for the EP lab.

How long has the EP lab been separate from the cath lab? Are employees cross-trained?

The EP and cath labs have always been separate. Some of our RCES staff members started out in the cath lab and cross-cover on occasion. We also have RCIS staff members from the cath lab who cross-cover for device procedures. 

Do you have cross training inside the EP lab? What are the regulations in your state? 

In the state of Virginia, RCIS/RCES are permitted to administer medications under the supervision of a physician; however, the RNs in our department are the only staff members who administer medication. We’re currently in the process of cross training our staff to operate the St. Jude Medical EnSite Velocity and Biosense Webster’s Carto 3 Navigation Systems. 

What new equipment and technology have been introduced at your lab lately? 

Adding Medtronic’s Arctic Front cryoballoon has significantly reduced our catheter ablation times for patients with paroxysmal atrial fibrillation. 

We’ve also added Biosense Webster’s Carto system, VisiTag/PaSo Module, and PentaRay NAV Catheter.

Have you recently upgraded your imaging technology? 

We recently installed our second Philips biplane fluoro system with a 56” HD monitor.

Who handles your procedure scheduling? 

We have a full-time EP lab scheduler who coordinates the schedule. We use Epic’s scheduling application called Cadence. Our goal is to maintain superior customer service through collaboration with the physicians’ offices at Sentara Cardiology Specialists to ensure before each patient leaves their office that they have a scheduled date and time of their planned procedure. This feature continues to work extremely well as it allows patients to participate in the decision making process of what date works best for their planned procedure.

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

We are active participants in the NCDR^® ICD Registry^™ and ACTION Registry^®-GWTG^™. We also have a robust EP Committee meeting. Their scope of work includes assessing and evaluating our quality outcomes and developing ways in which to improve. The committee is constantly looking at evidenced-based data to ensure we are applying “best practices” to our delivery care model in the EP lab. 

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

We have a full-time Inventory Team Coordinator, Timothy Henry, who manages the inventory and purchasing of supplies and equipment with the assistance of an inventory analyst. More importantly, our inventory analyst keeps abreast of all supplies that are “near” expiration and actively collaborates with our vendors to rotate out such supplies.

Has your EP lab recently expanded in size and patient volume, or will it be in the near future? 

Our ablations have increased by 35% and our cardiac device implants have increased by 8% in the last twelve months. As a result, we are currently looking at ways in which to reduce variation and streamline efficiency. Our goal is to evaluate the feasibility of a fourth EP lab as we plan for 2014.

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

Similar to other health care facilities, we are challenged with managed care. However, we will continue to provide a service to our community that is based on quality and efficiency. 

Have you developed a referral base? 

To date, we have developed and successfully maintained a comprehensive referral base that includes but is not limited to the Northeast NC region, Hampton Roads, Outer Banks, Eastern Shore, and Franklin County.

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 have embarked on several initiatives to improve efficiency. These have included the following:

• Improving our on-time start
• Reducing our turnover rate
• Changing our patient through-put in the pre-procedure areas
• Adding a mid-level extender to assist the physician with pre-procedure and discharge care.
• These efforts have continued to positively impact our overall efficiency in the lab. Most importantly, it has added great value to our customer satisfaction scores.

Does your EP lab compete for patients? Has your institution formed an alliance with others in the area?

In every market, there is always competition. We look at this positively — competition encourages and fosters continued focus on delivering high-quality care and great outcomes. Our Newport News, Hampton, and Williamsburg markets remain opportunities for us. As a company, we are always open to considering alliances with others.

How are new employees oriented and trained at your facility?

All new employees are required to attend a two-day, hospital-wide orientation. After the two days, employees attend various training classes ranging from learning the hospital EMR system to operating an i-STAT system. Thereafter, employees are placed in their prospective departments for departmental orientation. Typically the EP department orientation is about 6-8 weeks depending on the discipline. New EP employees are assigned to a preceptor and given a department orientation binder. The orientation binder includes departmental policies and procedures, clinical competencies, and learning materials. Much attention is given to return demonstrations during orientation in an effort to validate all competencies.

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

Educational sessions are provided weekly to the staff. One of our EP RNs, Christine Brown, coordinates education for the staff. Topics are presented by fellow staff members, EP physicians, clinical experts, and our vendor companies.

How is staff competency evaluated?

All employees are required to complete annual hospital-wide computer-based training modules. The EP lab staff is also required to complete departmental competencies such as vascular sheath pull and equipment competencies on a yearly basis. This information is documented and logged in each employee’s file.

Do you encourage your clinical staff members to take the registry exam for Registered Cardiac Electrophysiology Specialist (RCES)? How many members of your lab have taken the exam? Does staff receive an incentive bonus or raise upon passing the exam?

SNGH believes in continued education and certifications. All of our full-time EP techs are RCES certified, and our EP RNs are in the process of studying to take the exam. We do provide staff reimbursement for taking the exam. We’re also currently evaluating an incentive program.

How do you prevent staff burnout? In addition, do you practice any team-building exercises?

As a leadership team, we work diligently to prevent staff burnout through various measures. These include:

• Monitoring by employee worked hours and overtime hours to determine if adjustments need to be made;
• Increasing full-time equivalents (FTEs) based on volumes;
• Implementing flexible schedules with staggered shifts;
• Creation of a rotating “late team” so that the same employees are not staying late due to add-ons or emergencies;
• Staff recognition: this is key!;
• Implemented “kudos time” in all of our staff meetings and newsletters;
• Team-building exercises incorporated in our staffing meetings to maintain/enhance positivity in the department.

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

Our staff can participate in the Safety Committee (Safety Coach), Revenue Efficiency, Magnet, and monthly EP department committees.

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

Yes, we are members of Reptrax, which is an online service that tracks and manages facility vendor credentials, vendor activity and vendor behavior.

Describe a particularly memorable case that has come through your EP lab. How was it addressed, and what lessons were learned from it?

An 80-year-old man who presented with near syncope related to severe sinus node dysfunction, prolonged junctional rhythms, and symptomatic bradycardia was referred for consideration of cardiac pacing, but access was an issue.

The patient was dependent on kidney dialysis, with a new and maturing fistula in the left arm and a TDC in the right subclavian. Given the current situation and the likely need to maintain patient upper arm venous access in the future for dialysis as well as the need for cardiac pacing, we chose to implant a dual chamber Medtronic pacemaker via the right iliac vein.

Access of the iliac vein was obtained through direct puncture of the iliac, four fingerbreadths above the groin crease. Using standard SafeSheaths (Pressure Products) and long leads (Medtronic 4076 and 5075), a dual chamber pacemaker was placed with acceptable pacing and sensing parameters. The device was placed just above the rectus muscle midway between the umbilicus and the femoral pulse.

At his one-month check, the patient was doing well with no complaints as to the device location, and with normal thresholds in both chambers.

While not commonly done, femoral venous pacemakers have been reported to be a viable alternative when upper arm access is not available. The long-term stability of the system is very good. Atrial lead dislodgement has been reported, but this seems to be less of a problem when active fixation leads are used.

This technique should be available in all EP labs, particularly in patients with access issues where the only viable alternative may be epicardial leads. One may also consider this approach as a more first-line consideration in dialysis patients, in which preservation of upper extremity access is critical.

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

Currently we do not. However, it remains on our “parking lot” list of things that we would like to adopt in the foreseeable future. 

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?

One member of our EP staff takes call every day. They function as a resource for the cath lab for EP procedures performed after hours and on weekends. Staff members are on call at least seven days, every six to eight weeks. On average, they come in once every two to four weeks. All staff members can function in the resource roll.

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

Yes, our department uses a third-party reprocessing company. In 2012, we saved over $300,000.

Approximately what percentage of your ablation procedures are done with cryo? What percentage is done with radiofrequency?

We do an equal share of both cryo and radiofrequency ablations. 

Do you perform only adult EP procedures or do you also do pediatric cases? Is there cross training for pediatric cases? 

We do adult EP procedures only. Our physicians do partner with the nearby Children’s Hospital for complex cases.

What measures has your lab taken to minimize radiation exposure to physicians and staff? 

Our EP staff is required to complete annual competencies on radiation exposure. We are active participants in the bimonthly Radiation Safety Committee. We also have a hospital Radiation Safety Officer who very closely monitors radiation exposure and dosimeter reports. More importantly, every employee is required to wear their dosimetry badge in every case.

Do your nurses/techs participate in the follow-up of pacemakers and ICDs? If so, how many device visits per week do they handle? Do you use any particular software for follow-up? How many of your ICD/pacemaker patients require a doctor for their visits?

Our pacemaker clinic within the hospital is located on the first floor. RNs follow-up on pacemaker and ICD patients post procedure to check incision sites and device parameters. The clinic staff consist of all RNs. Everyone participates in patient education as well as office and inpatient evaluation of pacemakers and ICDs. The clinic’s RNs also perform remote follow-up of pacemakers and ICDs. The clinic sees an average of 150 patients per week.

We currently use the Medtronic Paceart database. A cardiologist is always available in the hospital. We may need a physician once or twice a week to see the patient. This is usually for a wound evaluation. Otherwise, for rhythm issues we make a follow-up appointment at their office.

What innovative EP techniques are being utilized in your lab?

EP techniques currently being used include Medtronic’s Arctic Front cryoballoon, Biosense Webster’s Carto PaSo and VisiTag, the CardioFocus laser ablation, St. Jude Medical’s EnSite Array Catheter, epicardial VT ablations, and the Impella (Abiomed) for VT ablations.

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

We use the NCDR dashboard to assess the quality of our program. It allows us to identify areas for improved opportunities and also identify areas that the team is doing superiorly. We also use the Outcomes report to benchmark against national averages. Our team continuously uses the data to identify areas that fall outside the national averages and assess why. It also helps us to assess and seek ways to improve our documentation based on NCDR/CMS requirements.

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

Our EHR system is excellent. It puts all clinical information at the fingertips of the health care provider and minimizes the risk of not being cognizant of any pertinent patient information that would be key to the care rendered.

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 see greater streamlining of AF management to include enhanced efficiency in AF ablation/PVI, potential development of LAA occlusion, growth of VT ablation and epicardial ablation, and growth of lead management/extraction.

What about device recalls? How has your lab handled these? 

We utilize RASMAS, which is an alert tracking service that notifies us in “real time” of any recalls. Serving as a backup are our vendors who consistently provide the same information.

Is your lab doing web-based/ transtelephonic device follow-up?

Yes. We perform pacemaker and ICD follow-up with St. Jude Medical, Medtronic, and Boston Scientific.

Is your EP program currently involved in clinical research? 

Yes, our Cardiac Research Department has increased the number of active trials by 25% over the last year. We’re currently enrolled in SAMURAI, CABANA, the Attain Performa Quadripolar Lead Study, the Analyze ST clinical study, the AngelMed ALERTS study, PARACHUTE trial, LAPTOP-HF trial, Accent MRI^™ study, the CardioFocus HeartLight^® trial, Staged DEEP, PREVAIL (CAP2), and the MIRACLE EF Clinical Study.

How is patient education managed? 

We offer an online educational program to all of our patients to view prior to their procedures. We also provide detailed discharge instructions post procedure.

Give an example of a difficult problem or challenge your lab has faced. How it was addressed? 

Staffing has been our biggest challenge over the last year and a half. It’s been a challenge finding experienced EP RNs and techs. The RCES program at the Sentara College of Health Professionals has helped tremendously in bringing techs to our department.

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

Virginia is the gateway to the South. It is also sometimes classified as the heart of the Mid-Atlantic region. Norfolk, Virginia is the proud home of the largest naval base in the world and part of the metropolitan region called Hampton Roads. With a population of 245,803 people, Norfolk is considered Virginia’s second-largest city behind neighboring Virginia Beach, which is roughly about 18-20 miles away. 

Please tell our readers what you consider unique or innovative about your EP lab and staff. 

The EP lab at Sentara Heart Hospital, which is on the campus of Sentara Norfolk General Hospital, provides state-of-the-art technology in each of our EP rooms. It lends itself to automated collaboration with all members of the team due to the architectural design and layout of each of the rooms. The staff is highly motivated, fully engaged, and active participants in providing superior care to all of our patients.