Spotlight Interview: Spectrum Health

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

There are five board-certified cardiac electrophysiologists at Spectrum Health in Grand Rapids. We have three dedicated EP labs within the cardiac catheterization department. To staff the procedure rooms, we have seven registered nurses and seven EP technologists. Often, we use anesthesiologists for deeper sedation during complex procedures. Occasionally, we perform high-risk laser lead extractions in a hybrid room of the OR. 

What is the mix of credentials at your lab?

There are seven RNs and one RT(R) in the EP lab. Everyone is BLS certified. The nurses are required to be ACLS and PALS certified. The technologists are strongly urged to be ACLS and PALS certified. We also encourage anyone to become RCES, RCIS or IBHRE certified. We have one technologist that is IBHRE certified.

When was the EP lab started at your institution?

Dr. Alan Woelfel started the EP program in May 1991. 

What types of procedures are performed at your facility?

We routinely perform ablations of atrial fibrillation, ventricular tachycardia, premature ventricular contractions, atrial flutter, and supraventricular tachycardia. We have both Carto 3 (Biosense Webster, Inc., a Johnson & Johnson company, Diamond Bar, CA) and EnSite Velocity (St. Jude Medical, St. Paul, MN) three-dimensional anatomical mapping systems. Two of our physicians perform epicardial ablations. In addition, we offer a full line of device implantation services including implantable loop recorders, pacemakers and defibrillators, as well as CRT devices. We are also a referral center for laser lead extractions.

Approximately how many are performed each week?

We average 50 procedures each week; this includes a variety of ablations and device implantations. Typically, two of the EP rooms are scheduled for a full day’s work (7:30am to 5:30pm), with the third room reserved for the inpatient service line.

What is the primary goal of your program?

We strive to take the best care possible of all cardiac rhythm abnormalities, with a particular emphasis on complex ablations.

Who manages your EP lab?

Anne Beekman manages the cardiac catheterization lab. Two individuals, Kim Umlor, RN and Matt Jackson, RT(R), share the day-to-day leadership of the EP team, coordinating resources and schedules.

Is the EP lab separate from the cath lab?

The cath and EP labs share a nine-procedure lab area. There are three dedicated EP labs, two peripheral labs, and four coronary labs. Our EP lab shares a registration area and prep/recovery area with the cath lab.

How long has this been?

The Kresge Catheterization Lab has been in the Fred and Lena Meijer Heart Center since the completion of construction in 2005.

Are employees cross trained?

We have many staff members who began their career in the cath lab. Generally, when we hire new staff, they are from a nursing floor. Cross training to coronary catheterization is not a part of the orientation process.

Do you have cross training inside the EP lab?

Cross training has been a desire of the nursing staff in EP. We have not been able to accommodate the training program for the nurses, though. We have been understaffed due to our rapidly growing service line.

What are the regulations in your state?

We are a certificate of need state.

What new equipment, devices, and/or products have been introduced at your lab lately?

One of our newest technologies is Medtronic’s Arctic Front® cryoballoon; we have performed a few PVI procedures using this new technique. We also have three Carto 3 systems, one is RMT, (Biosense Webster, Inc., a Johnson & Johnson company) and one EnSite Velocity (St. Jude Medical). The Carto 3 systems have recently added the ACCURESP™ Module. When we built the third EP lab in 2009, Stereotaxis was installed. Recently we have used the Impella 2.5 VAD (Abiomed, Danvers, MA) for VT ablations. All three EP labs have the EP MedSystems’ (now St. Jude Medical) recording systems and EP-4™ Cardiac Stimulators (St. Jude Medical). There are two ZeroGravity lead shields (CFI Medical Solutions, Fenton, MI) available for the physicians to use. We also recently acquired the Baylis NRG™ RF Transseptal Needle (Baylis Medical, Montreal, Quebec, Canada). We have been at the forefront of the newest pacemaker and defibrillator technologies. St. Jude Medical has introduced the DF4 and IS-4 leads to our facility. We have been implanting Medtronic’s MR-conditional pacemaker system here as well. The majority of our lead extractions are performed with the Spectranetics laser system.

How has this changed the way you perform those procedures?

We have been able to offer our patients all of the newest technologies and products, which allow us to treat arrhythmias more effectively and efficiently.

Have you recently upgraded your imaging technology?

Since the opening of the Meijer Heart Center in 2005, we have maintained the imaging technology. Each lab is equipped with Philips FD10s or FD20s (Philips Healthcare, Andover, MA), and we have one Philips FD10 biplane system.

Who handles your procedure scheduling?

The cardiology office schedulers and hospital schedulers coordinate the scheduling process. The hospital schedulers notify vendors of procedures and anesthesiology of MAC or general anesthesia cases.

What software is used?

The cardiology office uses NextGen EMR and the hospital uses Cerner.

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

There is a monthly quality meeting in which processes are fine tuned and statistics are tracked. We track infection and complication rates. We also discuss and implement ways to improve our outcomes.

How is inventory managed at your EP lab?

Inventory is managed with Pyxis in conjunction with an inventory control specialist. We keep a close eye on regularly used products, and perform manual counts weekly. There is also a yearly audit.

Who handles the purchasing of equipment and supplies?

We have a finance department responsible for negotiating contract pricing and authorizing equipment purchases. 

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

Since 2004 we have added four electrophysiologists. The EP lab has added weekend on-call time (for devices and urgent ablations), and expanded from one procedure room to three procedure rooms. In addition, the cardiology group is looking to add one more physician and an additional EP lab.

Is your EP lab part of a separate heart hospital?

The heart hospital for Spectrum Health is the “Fred & Lena Meijer Heart Center,” part of the Frederik Meijer Heart & Vascular Institute.

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

Managed care has not affected access to the EP lab; however, length of stay has been shortened. We make every reasonable effort to discharge patients undergoing simple ablations and device implants on the same day of their procedure.

Have you developed a referral base?

Yes, we receive referrals from most of West Michigan. Patients come from as far north as the Upper Peninsula and as far south as the border with Indiana. There are no other ablation facilities in or near the greater Grand Rapids area.

What measures has your EP lab implemented in order to cut or contain costs?

We have contracted with Stryker to resterilize catheters. We have very competitive contract pricing with the cardiac rhythm management vendors in order to keep product costs low. The physician leadership sits in on all contract negotiations in an effort to drive down costs yet keep access to the newest technology.

In what ways have you improved efficiencies in patient through-put?

In order to accommodate inpatient volumes, we have dedicated a physician and lab to get more urgent procedures completed sooner. We schedule our procedure rooms to the maximum capacity for outpatient procedures. Our AF patients have their transesophageal echo procedures the day before the ablation. Often we have patients on a “standby” list to come in on short notice.

Has your institution formed an alliance with others in the area?

Spectrum Health has many clinics, multiple community hospitals, and a one large multi-specialty hospital. There are many physicians groups that have aligned with Spectrum Health.

How are new employees oriented and trained at your facility?

New hires have a three- to six-month orientation in which a preceptor facilitates the learning process.

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

The physicians conduct a monthly case conference where we discuss and diagnose interesting cases. The cath lab also has a yearly conference, with topics from the cath lab and EP. The vendors often invite staff to attend conferences off site to get more in-depth training.

How is staff competency evaluated?

The staff is responsible for keeping up with annual hospital competencies. There is a yearly clinical competency cruise where we have to demonstrate regularly used skills. We also have regularly scheduled vendor in-services.

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

Staff members and physicians often attend happy hours, cookouts, and get-togethers with each other. We also have annual beach and Christmas parties. The staff attends concerts and other social events together.

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

There is an EP quality, radiation safety, and shared leadership committee that the staff serves on.

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

The hospital uses Reptrax for vendor credentialing and tracking. The vendors support our procedures and are at the hospital almost every day. They will perform follow-up checks on device implants that stay overnight, and assist with mapping arrhythmias.

Describe a particularly memorable case that has come through your EP lab.

In the past year, we have had two patients with recurrent VF from malignant PVCs. Both had incessant VF that was unresponsive to multiple antiarrhythmics and rapid pacing. This was in spite of a normal QT interval. The first patient had 43 external shocks in less than four hours. Ironically, both patients came to the EP lab on Sundays and had emergent ablation of their PVCs. Both have done very well. 

How does your lab handle call time for staff members?

We have a three-member team that covers “late” finishing procedures during the week. We also take Saturday and Sunday call from 7am to 5pm for devices and ablations. Emergent weeknight devices are covered by the STEMI team. The STEMI team is composed of cardiac cath lab members. There is a night shift that covers this during the week, and an on-call team for the weekends.

How often is each staff member on call?

Each staff member is assigned one or two “late” nights per week and one weekend per month on call.

Is there a particular mix of credentials needed for each call team?

When we assign a team, we must have one RN and one tech. The other team member can be either a tech or RN.

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

Currently our cryo use is minimal. However, with Medtronic’s cryoballoon for atrial fibrillation, we have increased our volume to three to four cryo procedures per month. The other 99% of cases are done with radiofrequency.

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

We perform pediatric ablations on patients five years old and up. Rarely will we have a pediatric patient for a pacemaker implantation.

Is there cross training for pediatric cases?

All of our EP staff is able to perform adult and pediatric procedures. We utilize a pediatric anesthesiologist or a pediatric sedation team (MD, RN, and nurse tech) to provide safe and effective sedation.

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

To minimize staff and physician radiation exposure, the EP recording and mapping systems have been installed in the control room. For the majority of our ablations, the physicians routinely use 3D anatomical mapping. The Philips imaging systems have been programmed to default to an extra low fluoroscopy dose of 1 mrem/min. To further protect the physicians, the EP lab provides ZeroGravity lead aprons and lead-lined glass screens.

Do your nurses/techs participate in the follow-up of pacemakers and ICDs?

No, the cardiology medical group has a device clinic that follows all of their patients. The device clinic follows all of the post-procedure visits. Our device clinic follows over 6,000 patients with implanted cardiac devices, with over 3,500 of them followed via remote monitoring.

What innovative EP techniques are being utilized in your lab?

We routinely perform AV node ablations from the pacemaker/ICD pocket. We place the ventricular lead and attach it to the pacemaker, then ablate the node through an additional sheath. Once complete, the catheter is removed and an atrial lead may be placed or the sheath may be removed. The patient may sit up immediately after the procedure.

We also perform “permanent/temporary” pacemakers. We place a permanent pacemaker lead through the right internal jugular vein or subclavian vein, and attach it to a “re-sterilized” pacemaker outside the body. We do this for patients that we extract for infection and are dependent, awaiting re-implantation. We save pacemakers that were extracted for upgrades and have ample battery longevity.

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

We are seeing same-day discharges for procedures, more epicardial ablations, and research involvement.

How is your lab preparing for these future changes?

We have arrangements with the CRM vendors for home monitoring devices to be available the same day as the procedure.

We have been more aggressive with treating VTs that have been unsuccessful with an endocardial approach. Rather than referring out, we are performing more and more epicardial procedures.
Our physicians are included in many trials and studies. We have also received grant money to study a novel atrial fibrillation protocol at our institution.

What are your thoughts about non-EPs implanting ICDs?

Given the recent publications regarding complications being lower for patients implanted by board-certified EPs, we feel that it is in the best interest of the patient to have EPs implant ICDs.

Do you train such individuals?

No. There are interventional cardiologists that implant pacemakers at our hospital, often in the general cath lab. These physicians do not implant defibrillators at our institution.

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

We work with the physicians to determine the patient need, and partner with the vendor to ensure appropriate charging.

Is your EP lab currently involved in any clinical research studies or special projects?

Yes, we are currently involved in the MADIT-RIT (Boston Scientific), ALERTS (AngelMed Guardian System), aCRT (Medtronic), Analyze ST (St. Jude Medical), IRASE AF (St. Jude Medical), SaferICD (Spectrum Health), and EDIT-AF (Spectrum Health) trials.

Are you ACGME-approved for EP training?

No.

What do you think about two-year EP programs?

In order for fellows to be adequately trained in complex ablations, two-year EP programs are a must.

Does your staff provide any educational materials for patients who may have additional questions about their condition or a procedure?

The hospital provides educational materials for procedures and conditions; however, staff members are also able to answer questions that the patients still have.

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

With our increased volumes and desire to strive for cost-effective and efficient health care, we were needed for off-hours coverage. The EP physicians were fighting for lab time with the interventional cardiologist on the weekends and off hours. Initially, we added Saturday 8–12 coverage. Over time, our need grew to provide additional coverage from 7am–5pm on both Saturday and Sunday.

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

Metropolitan Grand Rapids has a population of nearly 800,000. It has been well known for its furniture manufacturing, but is an emerging healthcare destination. Grand Rapids has been fortunate to have a strong legacy of philanthropic giving. We contribute the healthcare buildup as a result of this generosity. Grand Rapids is also the home of ArtPrize, the world’s largest art competition, and is the birthplace and home of the late former President Gerald R. Ford. 

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

We have a group of staff and physicians that promote quality and efficient health care. We are able to perform a volume of procedures that is unparalleled for our program size. Often, we are able to perform 6–8 procedures in a single lab. We are able to do this by utilizing efficient turnaround times.