The Levinson Heart Hospital at CJW Medical Center-Chippenham Campus

When was the EP lab started at your institution? The Levinson Heart Hospital at CJW Medical Center opened its first electrophysiology lab in January of 1990 by Dr. Roosevelt Gilliam. CJW Medical Center was the first private hospital in the area to open an EP lab, with the first electrophysiology study performed in March of 1990. In 1997, Dr. Gilliam was the first electrophysiologist to implant Guidant’s dual-chamber automatic cardioverter defibrillator. In 2008, Dr. David Gilligan was the first to implant the Medtronic Reveal DX insertable cardiac monitor. We recently also added a new entry to CJW Medical Center’s timeline. On August 4, 2008 at 6:37 AM, Dr. Gilligan implanted Boston Scientific’s COGNIS, the first newly released CRT device implant in the United States. Tish Snider, RTR is our EP lab historian; her records date back to September 1979, which was the opening of CJW Medical Center’s first cardiac cath lab. What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab? CJW Medical Center Chippenham and Johnston Willis campuses share 758 beds. The HCA Richmond Heath System is Richmond’s largest and most comprehensive healthcare provider and largest employer in Central Virginia. The cath/EP labs share the same area with 4 cardiac cath/peripheral suites and 2 dedicated EP labs. The lab is located on the third floor of the Levinson Heart Hospital, which opened in May of 2003. The EP lab has eleven dedicated staff members; 3 RCIS’s, 2 RTRs, 1 CVT and 5 RNs. What types of procedures are performed at your facility? We perform implantations of Boston Scientific, Medtronic and St. Jude Medical pacemakers, ICDs and CRT devices; diagnostic EP studies; and SVT, VT and complex ablations, which include atrial fibrillation ablation in the 2 EP labs. TEEs, cardioversions, and tilt table studies may be performed in the lab or in one of the twelve beds in the cath/EP lab’s recovery rooms. Next-day ICD testing is also done in the recovery area. The EP lab averages over 1,800 procedures a year. What is the primary goal of your program? Our goal is to provide comprehensive EP services to the Richmond tri-city area. We now have 4 dedicated electrophysiologists servicing our lab: Dr. David Gilligan and Dr. Charles Joyner from Virginia Cardiovascular Specialists, and Dr. Anthony Caruso and Dr. Matthew Ngo from Cardiovascular Specialists of Virginia. We would like to become an educational site for training EP staff members as well as become an Atrial Fibrillation Ablation Center. Who manages your EP lab? The administrator of the Levinson Heart Center is Lee Higgenbothem, the director of Invasive Cardiovascular Services is Steven Genger, and Howard Carter, RCIS is the clinical coordinator of the EP lab. Is the EP lab separate from the cath lab? How long has this been? Are employees cross-trained? The EP and cardiac cath labs have separate staff dedicated to each specialty. The EP staff is cross-trained to help in the cath lab if needed. Cardiac cath staff can perform pacemaker implants in their area if the EP labs are performing procedures at the same time. Do you have cross training inside the EP lab? What are the regulations in your state? Yes, most staff members can perform the majority of the EP procedures. Since EP studies and ablations require extensive knowledge of EP, only the staff members trained with GE’s Cardiolab, the Micropace EPS 320 Cardiac Stimulator and St. Jude Medical’s EnSite 3D Mapping System can operate this equipment. The state of Virginia requires the physician to be trained in radiation exposure and for staff to operate the x-ray equipment under the direct supervision of the physician. What new equipment, devices and/or products have been introduced at your lab lately? Has this changed the way you perform those procedures? We recently purchased the Baylis RFI transseptal system, St. Jude Medical’s Cool Path Ablation System, and a second St. Jude Medical EnSite Mapping System (Version 8.0). We also upgraded our original EnSite Mapping System to Version 8.0 with Fusion. With the addition of the second St. Jude Medical EnSite Mapping System, we are able to perform two ablations concurrently. Who handles your procedure scheduling? Our cath/EP lab secretary, Rita Lee, handles the scheduling of all cases and inputs the patient list into GE’s Centricity Data Management System. What type of quality control/quality assurance measures are practiced in your EP lab? To ensure patient safety and access our patients’ cardiac function, we started to perform transthoracic echos pre- and post-CRT implantation and ablations. There was one incident when a pericardiocentesis was emergently performed in our Recovery area upon arrival, after a technically difficult LV lead insertion. We deduced that if the pericardial effusion had been seen prior to taking the patient off the table, then the pericardiocentesis could have been performed in a more controlled environment. Sel Batir, CVT and Howard Carter, RCIS are trained in Echocardiography, increasing the procedural time by 10 to 15 minutes. How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies? Our dedicated inventory specialist, Al Macklin, controls the purchasing of supplies. During each case, supplies are entered into the GE Cardiolab supply list by the person monitoring the case. This information is sent to the GE Data Management System for reorder. The hospital’s New Products Committee reviews and approves all new equipment and new supply items for use in the EP lab. Has your EP lab recently expanded in size and patient volume, or will it be in the near future? With the addition of our new electrophysiologist Dr. Matthew Ngo, our second St. Jude Medical EnSite Mapping System was added and the number of EP procedures has increased. The EP lab is part of Levinson Heart Hospital at CJW Medical Center – Chippenham Campus. Levinson Heart Hospital was dedicated to the memory of Dr. Harold Levinson, a prominent cardiac surgeon who was well respected in the community. How has managed care affected your EP lab and the care it provides patients? We continue to provide the same excellent patient care, and our patient outcomes continue to be above the national average. In fact, we are proud to be the #1 Heart Hospital in Virginia according to Health Grades. CJW Medical Center and HCA Henrico Doctor’s Hospital, Richmond have been named by Health Grades as one of “America’s 50 Best Hospitals” in 2007 and 2008. We are one of the first hospitals in Central Virginia to earn the distinction of being the first fully accredited Chest Pain Center. Have you developed a referral base? Yes, our physicians educate the primary care physicians in the Richmond tri-city area. There are several hospitals in the area that do not provide EP services. These hospitals refer their patients to the Levinson Heart Hospital’s EP lab. 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? In times with low patient census, staff volunteers to leave early, cutting down on the manpower hours worked. The stock levels are also well maintained by the inventory specialist. In addition, by recycling the catheters, cost are kept down. Does your EP lab compete for patients? Has your institution formed an alliance with others in the area? Yes, Richmond is a highly competitive market, with two major hospital systems and an academic medical center that compete for patient services. HCA Health Systems have 4 hospitals in the Richmond tri-city area. There is not a true alliance outside of this system, since the cardiology groups service many of the hospitals in this area. What procedures do you perform on an outpatient basis? In addition, what EP procedures are generally only considered inpatient? Approximately 85% of the patients who come in as an outpatient to our pre-op holding area turn into inpatients. They become an inpatient if their procedure requires a newly implanted device, a device upgrade, or an ablation of their arrhythmia. Most generator changes, tilts, and cardioversions are done on an outpatient basis. How are new employees oriented and trained at your facility? New employees are assigned a mentor to coordinate their orientation to the lab. Christine Reoch, RCIS is the Clinical Educator for the EP lab who provides educational material and further training. Each staff member plays an active role for training on a designated piece of equipment or role. Each lab also has a “room leader.” Sel Batir, CVT and Angie Rodriguez, RN are the room leaders who coordinate the training of new employees according to the procedures done on that day. Vendors provide additional in-services as well as additional training opportunities. One of the best sources of education continues to be our EP physicians, who dedicate their time and expertise. What types of continuing education opportunities are provided to staff? Two staff members are sent to the Heart Rhythm Society’s annual meeting every May. Two other staff members attend the SASEAP meeting in September in Myrtle Beach. Several of our staff members have attended Order and Disorder: The Basics and Beyond the Basics. In July 2008, St. Jude Medical provided a one-day seminar for many Virginia hospital EP staff members who recently started to work in the EP field. All but three of Levinson’s EP staff attended. Boston Scientific, Medtronic, and St. Jude Medical continually provide educational opportunities for the EP staff. How is staff competency evaluated? The hospital requires yearly competency exams on Healthstream to maintain proficiency. All staff members are required to have their BLS/ACLS and adhere to the Joint Commission guidelines. How do you prevent staff burnout? In addition, do you practice any team-building exercises? We haven’t experienced staff burnout. We rotate staying late with the late night cases. We all have responsibilities in the daily functioning of the lab. Our lab is very team-oriented and each member plays a critical role in ensuring the successful operation of the EP lab. What committees, if any, are staff members asked to serve on in your lab? Clinical coordinator Howard Carter, RCIS presently attends the EP Departmental monthly meeting and serves on the (IRB) Interventional Research Board. An educational committee is in the planning stages. How do you handle vendor visits to your department? Do you contract with vendors? Vendors schedule their lab time with Rita Lee, our lab’s secretary. HCA Hospitals contract with the vendors, and once the products clear with the New Product Committee, they are then permitted to be used in the lab. The device rep is always present during implantation of their product. Does your lab utilize any alternative therapies? Both labs have music available for the patients, including satellite radio. There is Sirius Radio available in lab 6. Two of our nurses also have beautiful voices, which adds “live entertainment” during the patient’s prep! Describe a particularly memorable or bizarre case that has come through your EP lab. What lessons did you learn from it? A recent bizarre case involved a dual-chamber ICD generator change using a remote wireless system. The case progressed in a timely manner until the new implant was placed into the pocket and interrogated. The impedance of the RV lead was greater than 1,000 ohms. The ICD was removed from the pocket, the leads were disconnected and reconnected, and then placed back into the pocket. The RV lead tested to be greater than 1,000 ohms. We all were perplexed over the situation and the device rep offered the physician a new device with the intention of sending the first device back to the company for the engineers to evaluate. The second ICD’s interrogation was uneventful. At that moment the rep realized he had two ICDs in the room, and he realized he had actually programmed the second ICD instead of the first at the time of the first device being implanted. Lesson learned — keep only one ICD in the room at the time of implant and confirm the serial numbers! 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? What mix of credentials are needed for each call team? Our EP staff is not required to take call. They can take call in the cath lab, mostly weekend call. An RN is only allowed to administer medication in the EP lab according to our hospital policy, so an RN is the first person on call; the second and third positions can be an RN, RCIS or an RTR. Does your lab use a third party for reprocessing? We presently use Ascent Healthcare Solutions to reprocess the EP catheters. Approximately what percentage of your ablation procedures are done with cryo? What percentage is done with radiofrequency? The majority of our ablations are done with radiofrequency. The lab utilizes both irrigated and non-irrigated catheters. Cryo tends to be utilized on the posterior left atrium, when the esophageal temperatures rise during atrial fibrillation ablations, and on accessory pathways close to the AV node. Do you perform pediatric EP procedures? Levinson’s EP lab does not perform procedures on pediatric patients. What measures has your lab taken to minimize radiation exposure to physicians and staff? One of our labs has the recording system behind a lead-shielded wall; the other has two freestanding lead shields separating the patient from the monitoring systems. All staff have their own lead glasses and appropriate lead aprons. Both sides of the table have lead aprons and the physician has a moveable lead shield. Do your nurses/techs participate in the follow up of pacemakers and ICDs? Device follow ups are done by each company’s device rep in the physicians’ offices. 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 are treating more heart failure patients whose life has been extended by the drug-eluting stent era. I can see implanting more CRT devices as technology continues to evolve. With these devices and patients requiring upgrades to their existing pacemakers/ICDs, Spectranetics’ laser lead extraction system will be utilized in more complex cases. The EP lab is presently working with the OR staff in the Levinson Heart Hospital to create a protocol to improve on our efficiency and patient safety during these extractions. We are presently looking into putting a 220V outlet in the OR suites to be able to perform laser lead extractions in the OR. Excellent patient outcomes are our goal. This year at Heart Rhythm’s annual meeting in San Francisco, at a dinner meeting sponsored by Spectranetics, electrophysiologists from Cleveland Clinic spoke on creating new guidelines and credentials required by the Heart Rhythm Society, to perform these procedures. The lab is also preparing staff members through additional training and new equipment purchases to meet the needs of our community to perform more complex VT and atrial fibrillation ablations. What are your thoughts about non-EPs implanting ICDs? I personally feel that only an electrophysiologist should implant and provide follow up to patients treated with an ICD or CRT device. What about device recalls? How has your lab handled these? The electrophysiologist assesses each patient and their risk factors. Once the decision is made to excise the old device and/or leads, the vendor absorbs some or all of the costs associated with the exchange and the hospital fees. Is your lab doing web-based/transtelephonic device follow up? Web-based follow up is being done in the physicians’ offices and from the patients’ homes. Boston Scientific’s LATITUDE, Medtronic’s CareLink and St. Jude Medical’s Merlin all provide this kind of follow-up care. Is your EP lab currently involved in any clinical research studies or special projects? Which ones? Dr. David Gilligan provided a comprehensive list of the Virginia Cardiovascular Specialists’ research studies done at CJW Medical Center. Two ongoing studies are the Rhythm ID Going Head-to-Head trial (RIGHT) (Boston Scientific/Medtronic; 2006-ongoing) and the REASSURE-AV Study (Guidant; 2005-ongoing). We participated in the EASYTRAK3 study (Boston Scientific; 2006-2008) and EASYTRAK4 study (Guidant; 2005-2007), the Concerto AT Study (Medtronic 2006-2007), ULTRA Study (Boston Scientific; 2006-2007), PEGASUS CRT Study (Boston Scientific; 2005-2007), EnTrust Study (Medtronic; 2004-2007), TRENDS Study (Medtronic; 2004-2006), REFLEx Study (Guidant; 2004-2006), Contak Renewal: Heart Failure-Heart Rate Variability Registry (Guidant; 2003-2005), Data Logger Study (Guidant; 2002-2004), SAFE 1-year data study on FDA-approved pacemaker (2002-2004), Clinical evaluation of bipolar fixed-screw, lead model 3830 (Medtronic; 2002-2003) and RELIANCE Gore Defibrillator Lead Study (Guidant; 2002-2003). When was your last inspection by The Joint Commission? Our last inspection was in the fall of 2006. We expect a visit again before the end of 2008. Are you ACGME-approved for EP training? What do you think about two-year EP programs? We are not an ACGME-approved training site for electrophysiology. We have several staff members interested in education. I can see our lab being a future training site. The web has provided an abundance of educational material and continuing education for those who dedicate their studies in electrophysiology. Does your staff provide any educational materials for patients who may have additional questions about their condition or procedure? Pamphlets on all of our procedures are available in our recovery room area where patients go for pre-op and post-op care. Videos are also provided pre-procedure if they don’t receive information at their doctor’s office. The EP lab staff have discussed the possibility of starting an ICD support group if the need arises. Give an example of a difficult problem or challenge your lab has faced. How it was addressed? Our present challenge is with anesthesia during ICD/Bi-V implantation and post-patient care following general anesthesia. The nurse anesthetists/anesthesiologists are not hospital employees. Our procedural times vary and often go into the early evening hours. There is the occasional conflict of the nurse anesthetist/anesthesiologist not being available for coverage at a specific time or if two procedures are occurring at the same time. Earlier coordination and communication between departments is providing some resolution of this issue. We are presently recovering post general anesthesia patients in the PACU (Recovery in the OR) and providing a nurse from our recovery area to pull sheaths. Describe your city or general regional area. How does it differ from the rest of the U.S.? Richmond is located in Central Virginia. The Blue Ridge Mountains are two hours away heading west on I-64. Virginia Beach is two hours away heading east on I-64. There is a lot of local history in Virginia, with many Civil War sites to explore, as well as Jamestown, Yorktown, Colonial Williamsburg and Washington, D.C. within a two-hour drive. There are three main healthcare systems competing for patients in a 100-mile area. A new facility was recently built in Petersburg, Virginia in July 2008; however, they do not have an EP lab. VCU is an urban college campus with a medical school and state-owned hospital. Richmond and its surrounding community continue to increase in population, especially with the addition of 10,000 military personnel and their families at Fort Lee, located in Petersburg, Virginia, by 2010. Please tell our readers what you consider unique or innovative about your EP lab and staff. Our physicians and staff have an excellent working relationship. We operate as a team, with staff members flexible in their work schedule. There is never a problem with staying late or starting earlier than scheduled. We accommodate our physicians’ requests and are often praised for our dedication and professionalism. We are committed to growing our EP program to accommodate the outlying communities, continually searching for ways to meet the needs of our physicians and patients in a highly competitive market. Through continuing education and evolving technological advancements, we continue to grow and meet the needs of our community.