Considerations for a New EP Lab: Experience at Lenox Hill Hospital

In January 2019, the Lenox Hill Hospital Heart Rhythm Center opened a new EP laboratory, and in April 2019, opened a newly renovated reception area for patients and their families. In this interview, we speak to Nicholas Skipitaris, MD, MBA, Director of Electrophysiology at Lenox Hill Hospital, about the renovation. Lenox Hill Hospital, a member of Northwell Health, is a 450-bed hospital located on Manhattan’s Upper East Side.

What prompted the need for the new additions to the Heart Rhythm Center at Lenox Hill Hospital?

We’re getting busier. Our procedure volumes are increasing, mostly because we have been doing a lot more atrial fibrillation and complex arrhythmia ablations. In addition, our hospital system has been doing many more TAVRs, which has contributed to an increase in implanted device volume, namely pacemakers and CRTs. We’ve also established ourselves in New York as an important arrhythmia center, and so we’re getting a lot of new business.

What was the size of the previous Heart Rhythm Center before the renovation?

On the outpatient side, we have a dedicated, busy clinic space with 4 exam rooms and we see patients there 5 days a week. We also have offsite clinics a few times per month, away from the main campus. We see a lot of patients. The outpatient waiting room and clinic space was updated or “refreshed,” as our outpatient practice has become busier. It wasn’t a complete renovation, as Northwell Health is planning on building a brand-new hospital, a new Lenox Hill-Northwell Health campus if you will, within the next 5 to 10 years, so the hospital administration prioritizes what absolutely needs to get done at this time versus what will be done in the future.

We are also busier on the inpatient side. As a result, our procedural volumes have grown dramatically in the last 5 years and particularly in the last 2 and a half years, prompting the need for another EP laboratory. Previously we had a single full-time EP laboratory and access to a cath lab during the week, but that became difficult to maintain from a volume and scheduling perspective. We were already using the second lab pretty much full-time as well as needing to do other procedures such as extractions in a third (hybrid) room. We needed another dedicated EP lab to keep up. Thanks to a generous donation, we also renovated the reception/waiting area near the new lab to make a beautiful space for families and significant others to gather while waiting for their loved ones during procedures.

What special considerations, design features, or specific technologies were added?

I am sure that you’ve heard this from others, but designing an EP lab can be a challenging process! EP labs are different than cath labs and interventional radiology suites. We have a lot of equipment and have particular intricacies that need to be addressed from the get-go in terms of making sure there is not a lot of electrical noise in the room, specific placement consideration for monitors and equipment for the different types of procedures that we do, and because we work on both sides of the patient (both groins and chest), we needed it to be a very versatile room.

We designed our lab in such a way that wherever you’re standing, you can see everything you need displayed on the high-definition monitors placed on the wall or suspended around the room. This was more complicated than it sounds because the square footage of the room was not particularly large, about 650 or 700 square feet, I think. One of the special features that we incorporated was a third-party video management system that allows us to easily configure what the monitors are going to display at any given time. We do this via touchscreens at the bedside or the control room. We also have placed many video and data ports around the room that allow us to wheel in and display equipment that we don’t use for every case. With all of the different items that are used in an EP laboratory, it's great to have that kind of flexibility.

We have all manner of technology available, and everything that can be is hardwired into the room to avoid cables and things running across the floors. As I mentioned, most everything can be displayed on the monitors and is configurable. In addition to the usual recording systems, we have ultrasound, 3D mapping, and electroanatomic navigation systems. We have also been doing a lot of work with the CardioInsight Noninvasive 3D Mapping System (Medtronic). We also plug in the pacing system analyzer and device programmers so that they can be seen on the large HD monitors during our cases.

How long did the construction process take? Who was involved in the building process?

It took approximately a year and a half to two years in terms of the whole process, from when we made the decision and started the design process. I was intrinsically involved, and we had weekly meetings once construction began. Besides myself, the others involved were our project manager at the hospital, the hospital’s architect, the architect for the contractor, the contractor, our nurse manager, and various other people from the hospital leadership. Periodically, we also involved our industry partners, for example, the recording system and electroanatomic navigation technical people, so that we could cover all of the possible needs for their systems. Then, depending on the phase of the buildout, other subspecialties were involved such as electricians or representatives installing the fluoroscopy.

Just like building a house, at any given time we were concentrating on one feature or the other, but all of these different subspecialties had to work together, because if the fluoroscopy table is not placed in the right location, then you’re bumping into another piece of equipment that you thought wouldn’t be a problem. Frankly, it’s like taking care of a patient — if all the subspecialties seeing a patient aren’t communicating with one other, then it’s a little concerning and can lead to bad outcomes.

The other particular issue that we had was a space constraint. Our second laboratory had previously been a cath lab, which was totally functional from a space perspective, but EP labs tend to have a lot more equipment. Our space filled up pretty quickly. Therefore, in order to maintain the flexibility to have enough room for all of the different procedures that we do, we had to figure out how to make it very functional with all of the different equipment that we use.

What cost considerations were taken into place?

We always tried to keep the costs down as much as possible and stay within budget. Equipment such as the fluoro system makes up the greatest chunk, and can only be controlled to a certain degree. The way that costs begin to escalate, however, is when you don’t spend enough time on the design phase. Believe me, every time that I have built a lab, it’s like the first time anyone has ever done it, so you have to plan very carefully and try to think of everything that you want your lab to do, before the actual construction begins. This is hard. Honestly, the things that cost a lot — and this is advice that I would give to anybody considering building a laboratory — are the change orders. Changes to the design or changes to the placement of things that occur after the construction is underway always cost more when they are added or realized after the design phase. It is critical that as much of the planning that can be done on paper gets done before the physical work begins. This is how to keep costs down and stay within or close to budget. Once construction begins and people are installing things, it becomes much more expensive to change. So, in my opinion, preparation and design are where the great majority of the work should go, and if done correctly and in a thoughtful way, then ideally there will be few change orders during the construction phase, and costs remain as predicted. Good luck with that!

How has the addition of a new lab affected workflow? What additional percentage of cases is your staff able to take on?

Our volume has increased significantly. I would say that our ablation volume has almost doubled recently, which is terrific. The availability of the second resource allows us to schedule things in a timelier fashion and manage this increased volume, so it has been a great addition.

What does the new Heart Rhythm Center mean for the staff and hospital?

I think it gives us greater visibility in our very competitive landscape here in New York. It’s wonderful to have a state-of-the-art facility that we can be proud of, and patients recognize and appreciate that. At the end of the day, it’s all about our staff and physicians who are meticulous and proud of the work that we do. The new facility just reflects the pride that we take in our work. 

Disclosure: Dr. Skipitaris has no conflicts of interest to report regarding the content herein.