Spotlight Interview: Texas Cardiac Arrhythmia Institute at St. David’s Medical Center

The Texas Cardiac Arrhythmia Institute (TCAI) at St. David’s Medical Center is led by internationally recognized cardiologist Dr. Andrea Natale and staffed by a team that includes some of the most prominent physicians and researchers in the field, as well as highly trained and competent support staff. In addition to caring for patients suffering from cardiac arrhythmias, the Institute is dedicated to furthering the understanding and treatment of this disease and serving as a primary educational resource for physicians around the world. What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab? We have four labs and a training facility at St. David’s Medical Center. The staff at TCAI include: 9 electrophysiologists, a director of EP services, a nurse manager, a charge nurse, 10 registered nurses, 4 EP techs, 1 patient care tech, 1 administrative assistant and 1 research coordinator. We also have a Center for Arrhythmias and Atrial Fibrillation, which employs 6 registered nurses. In addition, we have 4 research fellows that are employed by the hospital. When was the EP lab started at your institution? The EP lab was started in January 1996. What types of procedures are performed at your facility? Approximately how many are performed each week? Our lab is involved with performing complex ablations, including atrial fibrillation (AF), ventricular tachycardia (ischemic, idiopathic), ventricular fibrillation, atrial tachycardia (AT) and inappropriate sinus tachycardia (IST). The lab also implants biventricular devices, ICDs, pacemakers and loop recorders. The average number of procedures performed in the lab is between 45 and 50 cases per week. What is the primary goal of your program? TCAI has been primarily focused on complex ablation procedures for conditions such as atrial fibrillation and ventricular tachycardia/ventricular fibrillation (VT/VF). Our lab has also been a leader in the use of remote navigation systems, and has further cemented this position with the opening of our second Sensei (Hansen Medical, Mountain View, CA) lab in addition to our existing Sensei and Niobe (Stereotaxis, St. Louis, MO) labs. Another area that differentiates our lab is the use of alternative ablation procedures, primarily using epicardial access. TCAI was the second lab in the country to perform the convergent AF ablation procedure, in which a cardiovascular surgeon creates an epicardial lesion set, which is then completed by an electrophysiologist using traditional endocardial catheters. In addition to the convergent AF ablation, our lab has performed multiple epicardial ablations for PVCs, VT/VF, AT and IST. While TCAI’s primary focus has been complex ablations, we still have a strong presence in the CRM area. This will continue to be a growth area, with the recent openings of our third and fourth EP labs along with the addition of laser lead extractions. Who manages your EP lab? EP services operate under the direction of Barbara Thomas, Director of Texas Cardiac Arrhythmia Institute. She is supported by a management team that consists of a nurse manager and charge nurse, who coordinate the daily operations of the EP lab. Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained? Our lab is separate from the cath lab. We have been independent from them for about two years. The staff is not cross-trained to perform procedures outside of the EP lab. Do you have cross training inside the EP lab? What are the regulations in your state? It is a goal to have all staff trained to each role within the EP lab. Initially all nurses are trained to circulate. After the nurse has a comfort level to EP, they are gradually trained to monitor and eventually scrub. Techs are trained to scrub procedures, and eventually learn to monitor. The law in Texas states that techs cannot administer drugs, which is why they are not trained to circulate cases. What new equipment, devices and/or products have been introduced at your lab lately? We have a Stereotaxis Niobe lab and 2 Hansen Medical Sensei labs. We utilize CartoSound (Biosense Webster, Inc., a Johnson & Johnson company, Diamond Bar, CA) and EnSite Velocity™ Cardiac Mapping System (St. Jude Medical, St. Paul, MN). On November 3, 2009, we were the first lab in the United States to use the Carto® 3 System (Biosense Webster, Inc., a Johnson & Johnson company). Our staff is trained in the use of all new equipment that is introduced into the lab. Who handles your procedure scheduling? Procedural scheduling is performed through the offices at the Texas Cardiac Arrhythmia Institute. We are in the process of hiring a nurse scheduler whose duties will be to optimize patient care and facilitate flow of procedures performed in the lab. This person will act as a liaison between the patient, physician and other departments to provide information or convey appropriate instructions. How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? At the present time we do not have a specialized inventory system. We are working on improving this process with the help of one of our EP techs in the lab. The purchasing of equipment is done through our purchasing department, while our supplies are ordered by one of our techs. Has your EP lab recently expanded in size and patient volume, or will it be in the near future? Within the past year the EP lab has expanded from two to four dedicated labs. We have also hired six nurses, a PCT, and administrative assistant to help accommodate the addition of these labs. How are new employees oriented and trained at your facility? New employees start with a formal orientation that is provided by St. David’s Medical Center that introduces the policies and practices of the hospital. After the initial two days of hospital orientation are completed, they proceed with comprehensive training in the EP lab. Depending on the progress of the new staff member, the length of orientation is scheduled to be about six weeks. We have a dedicated orientation system that involves learning the basics of electrophysiology. Competencies must be completed that are specific to EP procedures, and training of the equipment is an ongoing process for each new employee. What types of continuing education opportunities are provided to staff members? We have the fortunate opportunity to send our EP employees to various conferences that are held throughout the year. This allows them not only the opportunity to learn more about the field of electrophysiology, but to become associated with fellow EP staff from various labs throughout the country and world. Just recently, we sent 6 nurses to Venice Arrhythmias 2009, where they were given the opportunity to present in the Allied Professionals Program. How is staff competency evaluated? We have annual competencies in the lab that are specific to EP training as well as computerized learning that is assigned by the hospital. Training is evaluated and documented in each employee file for formalized monitoring. How do you handle vendor visits to your department? Do you contract with vendors? Starting November 15, 2009, we will be handling all of our vendors through a formalized system called VendorClear. VendorClear is a web-based vendor access service utilized by healthcare facilities to monitor all Healthcare Industry Representatives (HCIRs) associated with their hospital. HCIRs electronically store all the necessary credentials online, which can be accessed by St. David’s Healthcare to verify their qualification and association with the facility. How does your lab handle call time for staff members? There is no call team assigned in the EP lab. Does your lab use a third party for reprocessing? Yes, we use a third party to process our diagnostic catheters and recycle our platinum catheter tips. Do you perform only adult EP procedures or do you also do pediatric cases? The majority of the procedures performed in the lab are on adult patients. Occasionally we perform ablations on patients who are considered within the pediatric population. It is important for us to communicate with anesthesia, PACU and the nursing units to facilitate the appropriate pre-, peri- and post-op care needed for these patients. Do your nurses/techs participate in the follow up of pacemakers and ICDs? Our EP lab does not participate in any follow up of any procedures that are performed in the lab (i.e., pacemakers and ICDs). Patients either follow up with the offices of the Texas Cardiac Arrhythmia Institute or their hometown facility. Is your EP lab currently involved in any clinical research studies or special projects? Which ones? As a part of our commitment to clinical research, we are heavily involved in clinical trials as well as publishing abstracts and papers. TCAI is currently involved in over 22 clinical trials exploring new ablation energies, combined surgical approaches and comparing ablation for AF to traditional drug therapy. In addition to the clinical trials, we strive to contribute to the knowledge base for electrophysiology through the publication of abstracts and papers. In 2009, TCAI had over 40 abstracts accepted by conferences, including 20 for HRS, and had 18 papers published in several prominent scientific medical journals. Led by our executive medical director, Dr. Andrea Natale, TCAI has also contributed significantly to the publication of four books exploring topics from the current state of ablation techniques to treating patients who have experienced sudden cardiac arrest. Please tell our readers what you consider unique or innovative about your EP lab and staff. In addition to providing patients with cutting edge care, the Texas Cardiac Arrhythmia Institute also strives to advance the field of cardiac electrophysiology through education and clinical research. To further the education portion of our mission, TCAI houses a state-of-the-art multimedia training center. The International Training Center (ITC) allows visiting physicians, EP lab staff and industry personnel to observe procedures from a comfortable conference room while still being able to interact with the operating physician and lab staff. This is accomplished with multiple remote control cameras in both the ITC and labs, full audio integration between the labs and ITC, and with the use of our Odyssey Cinema system. This combination of systems allows visitors to feel like they are in the lab, and at the same time, provides them with a better perspective than if they were actually in the lab. In addition to local viewing, the International Training Center allows TCAI to broadcast both live and recorded cases around the world, both over the Internet and through traditional satellite broadcasts. Over the last several years, TCAI has utilized this capability to demonstrate several new technologies, including Hansen Medical’s Sensei system and CoHesion module and Biosense Webster’s CartoSound, during live procedures at HRS, the Boston Atrial Fibrillation Symposium, and ACC meeting. What else can you tell us about the EP team at St. David’s Medical Center? The Center for Arrhythmias and Atrial Fibrillation is comprised of six registered nurses who are specifically assigned with electrophysiologists at TCAI. The primary goal of this group of nurses is to provide guidance for the patients before, during and after treatment. The nurse provides information regarding arrhythmias as well as guidance in setting up a consult with an electrophysiologist. All pre-consultation essentials are clearly explained to the patients, including any testing that may be required. To enhance continuity of care, the nurse joins the patient in the consult and reviews any treatment plans discussed. This is an ideal opportunity for the patient to bring up any concerns, as the role of the nurse is to answer questions and assure that they clearly understand the diagnosis and treatment recommendations. The Clinical Research team is a key element in the structure of Texas Cardiac Arrhythmia Institute. This group of individuals brings to TCAI experience in clinical cardiac and electrophysiology studies, data analysis, and statistical modeling. Strong backgrounds in academic and clinical research settings provide the team with a solid foundation for conducting sophisticated electrophysiology studies. Their works are published in medical journals, and team members frequently present their research findings at professional meetings. For more information, please visit: www.tcainstitute.com