Spotlight Interview: The International Heart Institute of Montana, Providence St. Patrick Hospital

When was the cardiac electrophysiology (EP) program started at your institution, and by whom?

Our EP program started in the late 1980s to early 1990s with Drs Caroline Goren and Clifford Sheehan.

What is the size of your EP lab facility? Where is the EP lab in relation to the catheterization laboratory?

Our EP lab includes a total of 4 rooms, with 1 dedicated EP lab and 1 cath lab suite that has an EP mapping system but is currently used by both cath and EP for overflow and add-on cases.

The EP and cath labs are separate entities and have been so for at least 4 years. The employees are trained in their chosen specialty.

What is the number of staff members? What is the mix of credentials at your lab? Describe your lab staffing and structure.

Current staff includes 3 EP techs and 4 registered nurses designated to EP. We also have open positions available for 2 EP techs—it’s an amazing opportunity for someone who loves EP as well as outdoor activities! Our typical structure has the techs scrubbing and pacing, with the nurses focused on conscious sedation or assisting anesthesia. We use our resources to cross train nurses and increase the scope of their role in the lab.  

What types of procedures are performed at your facility?

We perform a full array of ablation procedures, including for supraventricular tachycardia (SVT), typical and atypical atrial flutter, and atrial fibrillation (AF). We also perform implantation and follow-up of cardiac implantable electronic devices (CIEDs) such as pacemakers and implantable cardioverter-defibrillators (ICDs). Our devices are almost exclusively MRI compatible. Subcutaneous ICDs and leadless pacemakers represent 5% of our current device business. We previously performed lead extraction and are trying to reestablish this program.

Approximately how many catheter ablations, device implants, lead extractions, and left atrial appendage (LAA) closures are performed each week?

In an average week, we perform 8 ablations and 10 device implantations. LAA closures are performed an average of 4-5 cases per month.

In what ways has the COVID-19 pandemic impacted your hospital, EP lab, or practice?

At the beginning of the pandemic, we restricted procedures to urgent/emergent cases only and observed a decrease in procedures. Due to staff limitations, we also experienced a brief period where cases were limited due to COVID-19-positive caregivers in the department. The most consistent hurdle we experience is inpatient bed capacity and limited procedures that may require an overnight stay in the hospital. We are currently evaluating this on a day-by-day basis.    

Who manages your EP lab?

Management structure for the EP lab includes Timothy Bertrand, ARRT(R)(CI), RCES, EP clinical supervisor; Lindsay Dahlseid, MSN, RN, RN-BC, cardiac clinical manager, and Kristen Petersen, MSN, BSN, CEN, executive director of cardiac and surgical services.

Tell us about your device clinic, including its staffing model, outpatient device management, and tools/software used.

Our device clinic is staffed with 3 RNs and a device technician who have worked together for over 6 years. The clinic has a robust daily schedule of in-clinic appointments and remote checks with charting being done in both Epic and Paceart (Medtronic). Patients can usually be seen within 24 hours of referral. Being rural Montana, we also provide support to 4 satellite locations, covering a geographic area of 200 miles. Clinicians coordinate monthly educational opportunities with company representatives.

Do you utilize telemedicine?

We saw a rollout of telehealth visits with the COVID-19 pandemic. While most visits are in person, we have also partnered with outlying facilities to offer outreach visits for patients in other locations in Montana.

Has your EP lab recently expanded in size or had a change in patient volume?

The population of Western Montana has increased in size since the beginning of the COVID-19 pandemic. We have been trying to expand our EP program and designate 2 labs to EP procedures Monday through Friday. This has taken time due to recruitment and use of travel EP techs.

What type of EP equipment is most commonly used in the lab? What imaging technology do you utilize?

We use Abbott technology for mapping and pacing, along with the Bloom stimulator (Fischer Medical). We have a biplane fluoroscopy system from Siemens Healthineers in our designated EP lab. We mostly use ablation catheters from Abbott, as well as some pacing catheters from Biosense Webster. We primarily use cardiac devices from Abbott, Boston Scientific, and Medtronic.

How do you manage vessel closure?

If no anticoagulation is involved, manual pressure is applied. In cases of ablation with femoral venous access alone and anticoagulation, figure-of-8 sutures are placed at venipuncture sites. For arterial access, we commonly use Perclose (Abbott).

What new initiatives or technologies have recently been added to the EP lab, and how have they changed the way you perform procedures?

We are currently in the process of upgrading our three-dimensional mapping system and finalizing a purchase for upgraded x-ray equipment in one of our labs. We are looking at starting left bundle branch pacing, restarting lead extractions, and looking forward to new technologies and techniques to improve procedures.

How is shift coverage managed? How does your lab handle call?

Our lab currently functions with lab staff scheduled for 10-hour shifts. The EP team does not currently work call hours; however, they are responsible for shift extensions to finish procedures scheduled for the day and any urgent add-ons. The on-call surgical heart team covers any urgent pacemaker needs during the weekend, along with our electrophysiologists.

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

A typical day usually starts with an AF ablation and finishes in the afternoon with an SVT/flutter and/or device case. We utilize the nondesignated EP room for device implants and add-on inpatient procedures.

Who handles procedural scheduling?

Procedure scheduling is managed by our EP clinic nurses, including the scheduler in the cardiovascular lab (CVL) as well as the CVL charge nurse and EP supervisor, depending on complexities surrounding the case. Over the last couple years, the scheduling process has become more difficult as we have had to ensure lab availability, anesthesia, and staff for procedures.

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

The EP clinical supervisor and stock processing and handling (SPH) inventory specialist manage the department inventory. Equipment that is considered a capital purchase goes through a local stewardship committee, and greater purchases may need approval at a system level.

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

The hospital participates in the Joint Commission Resources’ Continuous Service Readiness program and local surveys of departments. Currently, we have a project team applying for a Comprehensive Cardiac Certification through the Joint Commission.

SPH quality specialists review patient procedures and meet quarterly with our electrophysiologists for a morbidity and mortality review.   

What are the best features of your EP lab’s layout or design?

We have a dedicated biplane fluoroscopy system, ample space for anesthesia, wonderful nursing and tech staff, and industry support. The layout includes a control room with a large window looking into the procedure room.

In what ways have you cut or contained costs in the lab and device clinic?

We use reprocessed catheters when possible and complete equipment upgrades through bulk order inventory purchases. We have leased and/or shared equipment within the lab or with other departments. We complete monthly outdates and stock rotation to ensure there is no waste. There is good communication with the physicians on supplies needed for complex cases.

What changes have you made to improve lab efficiency and workflow as well?

Over time, we have worked with both lab and preop staff to improve lab efficiency and workflow. Scheduling improvements have been made around procedure types to ease room turnover.

How do you ensure timely case starts and patient turnover?

We use teamwork to improve turnaround time between cases. Our physicians are always prompt for scheduled start times. Turnover time can sometimes increase when moving from an ablation to a device case due to equipment setup. We have also seen an increase in delayed starts related to preop COVID-19 testing.

Have you developed a referral base?

Providence St. Patrick Hospital has had a robust cardiovascular and cardiothoracic program for a number of years. We are very active in traveling to outreach locations such as Helena, Butte, Hamilton, Polson, and Bozeman. Our patients are located throughout in a 300-mile radius.

Does your EP lab compete for patients? Has your institution formed an alliance with others in the area?

We have some local competition from a community hospital in town. Other EP labs in Montana are located in Kalispell (120 miles), Great Falls (180 miles), and Billings (340 miles). We have formed some affiliations with other health care systems, and we provide some hospitals with a version of our electronic medical record. Above all, the relationships developed by our staff and physicians have been important in ensuring an ongoing referral pattern.

How are new employees oriented and trained at your facility?

New employee orientation is dependent on experience. Our orientation includes coverage of hospital policies, equipment, and electronic health record. We encourage our techs to obtain their registered cardiac electrophysiology specialist (RCES) certification within 2 years of hire. They are provided access to EP Academy (Springboard Healthcare) for continued education as well as our library of other resources for education. Our physicians are excellent teachers who are willing to provide education and/or in-services for staff. Staff members are also able to participate in case reviews and cardiac rhythm management meetings.

What types of continuing education opportunities are provided to staff? How is travel time to conferences managed?

The small size of our department makes it difficult for our team to travel to a medical conference at the same time. Professional development funds are offered by Providence for travel and continuing education.

How is staff competency evaluated? Does staff receive a bonus based on performance?

The department has specific competencies that are role specific and need to be completed during orientation or with new equipment/workflows. We do not have a bonus structure for performance, but we do have a yearly merit process based on performance and have utilized retention bonuses in the past.

How do you prevent staff burnout and turnover? What approaches do you use for team building?

Recruitment has been difficult over the last couple years. We have not had many EP tech applicants for our positions. These recruitment difficulties, combined with some lab turnover and an increase in procedure volume, has made burnout a serious concern for the lab. For over a year, we have operated with at least 1 EP tech traveler in the department. This helps staff not have to work extra days and balances overtime demands. The travel assignments have also assisted with vacation requests for staff. The team collaborates well together, and the supervisor works hard at maintaining a positive atmosphere both in the EP lab and with the cath lab group. There are also social gatherings scheduled outside of work for people to enjoy time together. The team works hard and really enjoys what they do.   

How do you handle vendor visits to your department?

We have a handful of EP-specific representatives that are part of our daily scheduled procedures. They follow hospital policy and register onsite when assisting with procedures.

Describe a particularly memorable case from your EP lab and how it was addressed.

Our toughest cases are usually the most memorable. On Wednesdays, we try to schedule more complex cases (eg, ventricular tachycardias, complex premature ventricular contractions, atypical atrial flutters, redo AF ablations). Our physicians typically set aside time to perform these procedures together in an attempt increase efficacy and safety. It is not unusual to find an interventional cardiologist collaborating with one of our electrophysiologists when attempting a procedure such as venous balloon dilation.

Does your lab use a third party for reprocessing?

We use Medline for reprocessing catheters. They have developed workflows for our facility to collect and process used catheters.

Approximately what percentage of ablations are done with the cryoballoon vs radiofrequency?

All our ablations are done with radiofrequency.

Does your lab use contact force sensing technology during radiofrequency ablation of AF?

Yes, our standard catheter for this is the TactiCath Contact Force Ablation Catheter (Abbott).

Do you have a primary approach for LAA occlusion?

The Watchman device (Boston Scientific) is used for LAA occlusion procedures in our cath lab.

What are your thoughts on the use of novel oral anticoagulants (NOACs) in patients with nonvalvular AF?

NOACs have been a welcome addition to our armamentarium. These medications have been well tolerated and have helped our patient population in more rural areas avoid travel to warfarin clinics.

How is patient education managed?

There are numerous individuals who provide education to our patient population. The education typically starts with the physicians and can also include physician assistants (PAs), physician extenders, and nursing staff from the clinic, cath lab, and inpatient units.

Discuss your methods for lifestyle and risk factor modification for your patients with AF.

Our physicians and PAs provide education on weight reduction, abstinence from alcohol, increased exercise, and screening for and treatment of sleep apnea. Providence offers bariatric surgery seminars that our patients are encouraged to attend. We have a robust group of nutritionists available for consultation.

Do you offer multidisciplinary care for AF?

We are in the process of implementing a model of care that will rely more on focused nursing education and standardization of care for patients with AF before rhythm control strategies via pharmacology or invasive procedures.

What other innovative EP techniques are being utilized in your lab?

We are actively involved in clinical research and hope to be able to enroll patients in pulsed field ablation (PFA) trials.

How do you manage radiation quality checks of the imaging equipment?

A physicist performs an annual x-ray evaluation on our CVL equipment.

What are your methods for device infection prophylaxis?

We have a strict protocol for prep in the lab. Our facility managers frequently assess the air handling system. For patients at risk of infection, including those with a high PADIT infection risk score, we implant the Tyrx Absorbable Antibacterial Envelope (Medtronic).

How do you use the NCDR Outcome Reports to drive quality improvement initiatives at your facility?

We have been involved in the ICD registry for more than 10 years. We are also collecting data for the AF and LAA occlusion databases.

What are your thoughts on electronic medical record (EMR) systems? Does it improve your quality of care?

All clinical documentation occurs in Epic. We have a different hemodynamic system (McKesson). Also, we are not able to connect the recording and mapping systems. Right now, we use manual image capture to integrate maps and electrograms in the procedure note. Providence is working on a comprehensive Epic module that will integrate most of our systems. I am not sure that EMRs improve quality of care, but they have standardized our procedure notes.

Do you use remote monitoring of CIEDs? What clinical and economic benefits have you seen?

Remote monitoring has been extremely helpful to our patients. Western Montana is quite vast, so driving hundreds of miles in the winter on icy roads is not ideal. Having the opportunity to remotely check devices saves time as well as increases patient satisfaction and safety.

Do you utilize digital tools or wearable technologies in your treatment strategies?

We encourage the use of wearable devices. We advise patients about forwarding their tracings so they can be included in the EMR and in their clinical notes.

How are digital technologies changing the field of EP?

Technology has always played an important role in the EP field. New mapping systems and high-density catheters have helped us take better care of our patients.

How is social media changing the field of health care?

Social media has enabled collaboration with world leaders and experts. It has become more common for us to have social media referrals from patients that relocated to Montana from other states.

What trends have you seen in your procedures and/or patient population?

Patients are more empowered with knowledge and often cite their preference toward procedures that they have researched online or via social media. This trend is a significant departure from traditional care delivery.

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

Clearly, there has been an increased volume of ablations. We hope that the advent of PFA will improve patient care, reliability of lesion duration, and workflow.

Describe your city or general regional area. How is it unique from the rest of the US?

Missoula is a college town surrounded by mountains and areas of low population density. We pride ourselves in having a touch of diversity in an otherwise very homogeneous state. Most Montanans have a passion for land conservation, outdoor activities, and privacy.

What specific challenges does your hospital face given its unique geographic service area?

Many of our patients come from other rural areas in the state, often located hours away. While we reach some through outreach clinics, many are referred from providers in other facilities. We have faced challenges and workflow changes in order to get patients here for their procedures and safely discharge them home.

What is considered historic about your EP program or hospital? Has your program or hospital recently experienced any “firsts”?

We have had many firsts over the years, including our first AF ablation, subcutaneous ICD implantation, and leadless pacemaker implantation. Our hospital hosts a renowned CT surgery symposium (www.rockymountainvalvesymposium.org) every year. We are also very proud of having had Dr Carlos Duran, a pioneer of CT surgery, on our staff.

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

Come visit to find out! 

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