Spotlight Interview: Tampa General Hospital

Tell us about Tampa General Hospital.

Tampa General Hospital (TGH) is the primary tertiary care institution on the west coast of Florida and the primary teaching hospital of the University of South Florida. Cardiac services provided at TGH encompass the full spectrum of cardiac care, including a busy heart failure, ventricular assist device, and cardiac transplantation service (the fifth busiest heart transplant service in the United States). Tampa General Hospital received Atrial Fibrillation Accreditation by the Society of Cardiovascular Patient Care (SCPC), an institute of the American College of Cardiology (ACC), in 2016. 

How is the EP service currently organized at Tampa General Hospital? 

The EP program at TGH is a state-of-the-art arrhythmia service that provides the full spectrum of cardiac electrophysiology procedures. EP services are currently being delivered by 7 board-certified electrophysiologists and 3 additional cardiologists proficient in device implantation. 

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

The EP labs are currently part of the cardiac catheterization laboratory and interventional radiology suite located in our new Bayshore Pavilion, a 6-story, 340,000 square foot hospital that opened in 2007. There are currently two fully equipped EP labs and a hybrid surgical lab with EP capabilities on the third floor. The addition of a third dedicated EP lab is currently being discussed. 

Ablation procedures have been performed at TGH since the mid 1990s. We have had an organized EP service since 2001, and have been performing atrial fibrillation (AF) ablation procedures since 2002. 

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

We perform approximately 400 ablations and 400-500 pacemaker/ICD implantations per year. We also recently implemented a dedicated lead management and lead extraction program. Our ablation volume is focused on complex ablation procedures for ventricular tachycardia (VT) and AF. We perform epicardial VT ablation, VAD-assisted VT ablation, and highly complex ablation procedures in patients with congenital heart disease and after heart transplantation. 

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

We have 9 dedicated EP staff; this consists of 4 nurses, 5 technologists, 1 charge personnel, and 1 clinician.

Are employees cross trained? Do you have cross training inside the EP lab? 

We do cross train staff to encourage the growth and learning of each individual, as well as to enhance the patient experience.

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

Our labs are covered with 1 or 2 nurses and 1-3 technologists, for a total of 3 staff members per room. Our shifts begin at 7:30am, with alternation for late coverage for nurses and technologists.

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

Staff arrive at 7:30am, and meet and review cases for the day. Staff work together to set up the procedure room and retrieve the patient from the pre-procedure unit. Once the patient is in the room, the team sets up the patient as a unit, with precise communication to ensure the best outcomes and experience for the patient. We typically perform 4-6 cases daily in our EP suites.

Who handles your procedure scheduling? 

Scheduling is routed through our dedicated centralized scheduling department, who coordinate our daily schedules along with arrange anesthesia and echo cardiology support.

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

We currently have a single-plane imaging system from Philips. We use the CARTOUNIVU Module (Biosense Webster, Inc., a Johnson & Johnson company) and intracardiac ultrasound technologies to minimize radiation exposure. Our mapping systems include the CARTO 3 with CONFIDENSE (Biosense Webster, Inc., a Johnson & Johnson company) and more recently, with Ripple Mapping software, as well as the EnSite mapping system (Abbott). Intracardiac echo is utilized with the ACUSON SC2000 (Siemens). We use three different vendors for catheter ablation: Stockert and SMARTABLATE (Biosense Webster, Inc., a Johnson & Johnson company), the Ampere RF Ablation Generator (Abbott), and Arctic Front cryoablation (Medtronic) for AF procedures. We use the Excimer Laser System (Spectranetics) for lead extraction.

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

We have recently started to utilize electroanatomic mapping systems with both the CARTOUNIVU Module (Biosense Webster, Inc., a Johnson & Johnson company) and intracardiac ultrasound to perform minimal fluoroscopy (and completely fluoroless) procedures, particularly for AF. This has allowed our lab staff to minimize their time wearing lead, which also lessens fatigue, musculoskeletal aches and pains, and cumulative radiation exposure. We have recently acquired CARTO with Ripple Mapping technology (Biosense Webster, Inc., a Johnson & Johnson company), which has improved and simplified our mapping of complex arrhythmias in patients with extensive myocardial scar. 

What is your routine approach for ablation of paroxysmal and persistent AF? 

For pulmonary vein isolation procedures, we are using either a wide area circumferential radiofrequency ablation (WACA) approach with an irrigated force sense catheter or cryoballoon ablation. For patients with paroxysmal AF, where only PV isolation is anticipated, cryoballoon ablation has gained popularity and is now the standard first procedural approach. For redo procedures, and if additional flutters or linear ablation is anticipated, radiofrequency energy is the preferred ablation technique. For patients with persistent AF, we routinely perform extensive substrate mapping, preferentially in sinus rhythm, but also in AF if needed. Mapping is geared towards definition of myocardial scar in sinus rhythm followed by scar modification, or towards mapping of more organized atrial arrhythmias followed by activation map guided ablation. If AF persists, empiric cavotricuspid isthmus (CTI) ablation is performed; left atrial linear ablation is less often performed, and ablation of high-frequency CFAEs is rarely performed. We have not explored the option of rotor ablation. We are achieving excellent long-term results using the organized approach described here. 

We have MRI scar mapping ability using the Merisight system (Marrek). MRI 3D reconstructed image integration is an option and is frequently performed. In addition, we are participating as a center in the DECAAF II trial. As mentioned earlier, we have also recently acquired CARTO with Ripple Mapping technology (Biosense Webster, Inc., a Johnson & Johnson company), which appears to be advantageous for mapping myocardial activation of channels in patients with large amounts of myocardial scar. 

We refer patients for surgical ablation when there are other indications for surgical intervention, such as the need for valve surgery or CABG. Due to our relative comfort to deal with advanced forms of AF in patients with structural heart disease, we have not seen major advantages in primary surgical ablation techniques. 

Describe your experience with ablation procedures performed in patients with complex and advanced heart disease.

As a tertiary care center with a major heart failure, heart transplant, and ventricular assist device program, we are frequently performing VT and PVC ablation procedures in patients with advanced LV dysfunction. We routinely perform epicardial VT ablation procedures and VT ablations in patients with ventricular assist devices, and occasionally perform procedures under temporary hemodynamic support. We also have solid experience with ablation procedures in patients after heart transplantation and in patients with corrected congenital heart disease. 

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

As with any lab, radiation safety is very important. The imaging protocols are default to the lowest settings. Additionally, we try to utilize intracardiac echo and 3D mapping technology as well as the CARTOUNIVU Module (Biosense Webster, Inc., a Johnson & Johnson company) as often as possible to reduce exposure. Tracking fluoroscopy times for individual procedures has dramatically reduced fluoroscopy times. Some of our operators are now able to perform AF ablation procedures routinely with 2-3 minutes of fluoroscopy time. We are making a special effort to introduce these low fluoroscopy techniques to our fellows and trainees. 

Please share with us your innovative approaches for device implantation, including His bundle pacing.

We have always paid careful attention to hemodynamic optimization of cardiac resynchronization therapy (CRT) in our advanced heart failure patients. Over recent years, we have developed our own electrocardiographic and echocardiographic optimization strategies. We are increasingly utilizing the option of His bundle pacing in patients who require long-term ventricular pacing, and are now considering this technique as an alternative or adjunct to CRT, and in patients who require AV junctional ablation procedures.

In addition, TGH is utilizing the newest generation excimer laser technology for laser lead extractions as well as all commercially available mechanical cutting sheaths. Our team is comfortable with both standard subclavian approaches and transfemoral approaches to lead removal. To date, Dr. David Wilson and Dr. Raymond G. Cutro have performed more than 150 procedures with a proven record of safety and efficacy.

What are your techniques for LAA occlusion? Do you have a primary approach? 

We currently implant the WATCHMAN device (Boston Scientific), as well as offer surgical and robotic ligation.

Tell us more about your use of MR conditional devices.

We implant both MR conditional and traditional devices. Our MRI team has innovated protocols that are MR safe under supervision for any type of device.

What are your thoughts on the use of the new oral anticoagulants (NOACs) in patients with non-valvular atrial fibrillation? 

We routinely use NOACs before and after AF ablation. In conjunction with our stroke team, our cardiology department is performing an investigator-initiated study of early administration of apixaban in patients presenting with acute stroke and atrial fibrillation (AREST Trial). 

What other clinical trials is your EP lab currently involved in? 

We are currently one of the enrolling centers in the DECAAF II trial. Patients with persistent AF are randomized to either a conventional PV isolation approach versus conventional PV isolation plus DE-MRI guided scar modification. We are also involved in the GENETIC-AF trial, comparing pharmacogenetically targeted bucindolol with metoprolol for the prevention of symptomatic AF. We have several investigator-initiated studies involving patients with heart transplant-related arrhythmias, and arrhythmias in patients with left ventricular assist devices. 

What academic institution is your ACGME-approved EP fellowship program affiliated with? 

The University of South Florida (USF) is an academic teaching program that is committed to advancing patient care, clinical innovation, and basic, clinical, and translational scientific research. The USF EP fellowship program recruited their first EP fellow in 2007. Our fellowship program was recently extended to two years. Fellows currently alternate rotations at TGH and at the James A. Haley VA Veterans’ Hospital. 

Have you developed a referral base? 

Our mission is to innovate with new concepts and cutting-edge technology, which enables us to tackle difficult cases. We have developed a wide referral base throughout Florida’s Central West Region. We maximize procedural outcomes through an individualized and innovative approach tailored to the often complex disease process. We avoid inappropriate procedures and put a lot of emphasis on careful aftercare. 

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

We routinely perform timeout procedures with the entire team, and review case durations using OpTime. Procedural complications are reviewed in structured morbidity and mortality conferences.

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

Inventory is managed by the Cardiovascular Imaging Laboratory (CVIL) business manager, as well as by three dedicated inventory specialists. We use QSight (Owens & Minor), an electronic inventory control system that interfaces with EPIC, our electronic medical record (EMR), and the McKesson system. This system increases traceability using lot numbers, expiration dates, and product recalls, which increases patient safety, reduces inventory, and limits supplies to a just-in-time basis. During a case, the product is opened and then immediately scanned, which impacts par levels and ordering status. The CVIL has a combined inventory. When we switched over to QSight, we were able to cut waste by 1.5 million.

The CVIL utilizes a value analysis model to evaluate new products and implement cost-saving initiatives. The CVIL has their own committee, but can refer large-scale items to an executive committee, if necessary.

How do you ensure timely case starts and patient turnover? 

We analyze patient schedules and workflow on a daily basis, and have recently developed an efficiency process to improve on-time starts and room utilization in the labs.

For example, our pre/post procedure department streamlines the preparing of each patient. A multiple department status board is used to communicate where each patient is in the process as they prepare for their procedure.

We also have a visual management board where we track and report first case start time, turnaround time (wheels out to wheels in), room productivity, and reasons for delay. The previous day’s data is available the next day for staff, physician, and senior management to review. This information is also discussed at our ‘huddle’, which allows us to recognize, address, and resolve issues.

How are new employees oriented and trained at your facility? 

New employees are partnered with a senior member of our team for 12 weeks of orientation. Our unit-based educator meets biweekly with the new member to give and gain feedback, as well as to review competency-based orientation (CBO) paperwork. This is a dedicated list of skills each new employee and preceptor must sign off on together, ensuring both members agree on proficiency. These meetings also improve communication between the staff and management team.

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

Tampa General Hospital provides learning opportunities by sponsoring staff to go to conferences as well as bringing vendors to our facility for additional educational opportunities.

Does staff receive an incentive bonus or raise upon passing the exam for the Registered Cardiac Electrophysiology Specialist (RCES)?

Tampa General Hospital will reimburse staff who sit for and earn their RCES. In addition, we have a clinical ladder (1, 2, 3, and 4) compensation plan for specialists that meet criteria. Each specialist can earn a 4.5% raise with each level earned.

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

The department has a shared governance committee with multiple subgroups, which allows staff members to participate in an area that interests them. The subgroups include patient satisfaction, efficiency, patient safety, education, and recruitment and retention. Each subgroup meets at least monthly and is sponsored by a member of our management team.

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

The staff works closely with our vendors and have an interconnected relationship.

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

Preventing burnout and maintaining morale directly affect retention of staff. The EP department has been working on an efficiency project for the past year. The goal of this project is to improve efficiency in the lab and allow for timely completion of the workday in a way that supports work-life balance. Gathering together outside of the hospital setting also increases morale and unity. For the past two years, our entire department has met for a cookout, bonfire, and swimming; this event was graciously provided by one of our physicians. The department (family members included) also rented a pavilion for a beach day that had plenty of games and food. We will continue planning fun events in the future to maintain camaraderie among the team.

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

EP care at Tampa General Hospital is highly individualized and tailored to the patients’ needs. We are taking care of very complex and ill patients, and pride ourselves to go the extra mile for our patients. We are proud of our advanced VT and AF ablation programs, and our experiences with CRT optimization and His bundle pacing.