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Establishing an Effective, Comprehensive, and Customized Electrophysiology Team Training Program
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EP LAB DIGEST. 2024;24(8):1,8-10.
Naushad Shaik, MD, Medical Director, Electrophysiology Program1; Melanie Reynolds, BSN, RN, RCIS, Director, Cardiology Education1; Denys Mosquera, MSN, RN, Senior Nurse Manager, Cardiology Education1; Amber Arnold, BSN, RN, RCIS, Senior Nurse Manager, Invasive Cardiology2; Michelle Keith, MLS, BAS HCA, RCIS, VA-BC, Senior Manager Cardiovascular Services3; Danielle Wilson, BSN, RN, Invasive Laboratory Supervisor Electrophysiology2; Oria Jordan, BS, RCIS, Lead Tech Electrophysiology Education2
1AdventHealth Central Florida Division; 2AdventHealth Orlando, Orlando, Florida; 3AdventHealth Celebration, Celebration, Florida
AdventHealth Central Florida Division’s Electrophysiology (EP) Program began at its Orlando campus in the 1980s and was expanded to its Celebration campus in 2018. Our services include a variety of device implants, EP studies, all levels of ablations (atrial fibrillation, ischemic ventricular tachycardias, and epicardial), and structural heart procedures. Several of our other campuses offer minor EP procedures such as pacemakers and implantable cardioverter-defibrillators (ICDs).
In all, our Orlando and Celebration EP teams have over 48 members, including registered nurses, registered cardiovascular invasive specialists, registered respiratory therapists, registered radiology technicians, and advanced paramedics, who support 8 dedicated EP laboratories.
Within the EP program, each team member is cross-trained to perform all roles for every procedure, including documentation, scrub assistance, pacing protocols, circulating, monitoring, and measuring electrical signals. Comprehensive education has been essential to growing a collaborative team that supports one another and all our facilities. In 2010, we added an educator to our EP team who has worked closely with our leadership and physicians to create a customized, 8-month EP orientation and training curriculum that has evolved over the years. This educational addition has helped our program achieve remarkable success, especially in terms of retention and fostering a high EP knowledge base among team members. The EP Training Program is in place at AdventHealth Orlando and AdventHealth Celebration. Educators in charge include:
• Oria Jordan, RCIS, AdventHealth Orlando EP Educator
• Pauline Maldonado, RCIS, AdventHealth Celebration EP Educator
• Melanie Reynolds, RN, RCIS, Director, Cardiology Services Education, Central Florida Division
With strong engagement from the EP physicians and team, the EP Training Program is designed to cater to each orientee’s individual learning style and ability, progressing through the concepts with continual evaluation. Stages include the following: hospital orientation and onboarding, implant training, introduction to ablation concepts, ablation rotation, and a final 2-week rotation/refresher period prior to completion as well as an “EP University” for continual education. In this article, we outline each aspect of our EP Training Program.
Setting the Stage for Success: Onboarding and Preceptor Assignment
The initial 2 weeks of the EP Training Program focus on hospital orientation and onboarding as well as learning more about individual personalities and learning styles, which is essential to effectively matching and assigning preceptors to each new team member. The married preceptor/preceptee model has been critical, promoting successful progression while providing continual support and instruction delivered in a manner the orientee can retain.
The initial onboarding process focuses on sterility concepts, radiation safety, fire safety, patient and procedural safety, an introduction to policies and standard operating procedures, pharmacology education specific to invasive cardiovascular care, airway assessment, hemodynamic monitoring, cardiac anatomy review, and advanced electrogram review. The orientee is assigned observation time in the procedure room to learn team dynamics and various procedural roles. We also provide the orientee one-on-one time with their supervisor and our EP educator to learn about quality expectations and service standards.
Implant 101 Training: Understanding Roles, Equipment, Sterility, Procedure Flow, and Safety
In the third week of EP orientation, the orientee transitions into Implant 101 training. Device procedures are introduced for 1 week, focusing on the different devices, the various procedures, and the 3 roles in the procedure room (scrub, circulating, and documentation). We emphasize sterility, draping of the patient, sedation safety, and documentation. This introduction also helps orientees learn about the devices, system components, functions, indications, measurements, and terminology they may hear in the procedure room. Our team utilizes demo devices, leads, and other components to provide hands-on learning and simulation opportunities.
All EP roles are discussed in detail as orientees also spend time in the supply area, where they become familiar with where implant equipment is stored. We review pacemaker trays and instruments, including their indicated use. Team members are expected to know each instrument and the intended use so there is no delay when a physician requests a specific instrument as well as how to recommend instruments based on situational needs. Instrument passing, suture loading, and blade loading are demonstrated and practiced in a classroom setting before training at the scrub table.
During the sterility portion of the implant training, the sterile back table, front table, and patient draping are demonstrated and practiced repeatedly in a classroom simulation setting. The orientee must maintain sterility throughout table and patient setup prior to progressing.
Once the employee can demonstrate competence with sterility, we focus on procedure flow from the scrub role perspective, walking them through every step of the procedure to allow better understanding of how to anticipate the physician’s needs. This is repeated for each implant procedure performed in the laboratory. Additionally, vendors are scheduled to provide in-services on their specific devices. A simulation room (Mentice Simulator) is utilized to simulate a device implant procedure in which the orientee performs the procedure from the role of the physician and then again from the role of the scrub technician. This technology allows for procedural safety and technique re-enactment and features components that mimic the cardiac catheterization and EP laboratory environment but do not expose the operator to radiation. This approach assists with solidifying procedural flow.
Next, the circulating role is introduced by discussing patient transition to the procedure table and reviewing monitoring devices to be attached to the patient. We also provide a sedation review, emphasizing frequency of vital sign monitoring, Richmond Agitation-Sedation Scale (RASS), airway assessment and management, and steps to improve patient safety. Online training modules combined with virtual reality goggles enhance the sedation safety instruction.
For airway instruction, our team provides hands-on training using a manikin. Orientees must demonstrate airway opening, insertion of airway adjuncts, head tilt, chin lift, jaw thrust, and proper use of the bag valve mask device.
To conclude Implant 101 training, we review proper patient interview techniques and documentation as well as complications that can arise. Orientees observe procedures and receive educational resources to promote continual review and to provide guidance for implementation in the procedure room.
We require the orientee to perform each role repetitively for 4 weeks to foster independent performance before proceeding to the next role, starting with the scrub role, then the circulating role, and finally, the documentation role. Competencies on certain equipment are completed during their procedure exposure. Preceptors are tasked with completing weekly evaluations to monitor the orientee’s progress, provide future goal expectations, and suggest additional exposure needed to achieve independence. We also complete weekly check-ins with the educator, preceptor, and orientee to discuss what is going well and any improvements needed. If difficulties are encountered, adjustments are made for teaching strategies, timeline, preceptors, and one-on-one coaching. If necessary, a growth plan is developed. From day one, we encourage preceptors and orientees to maintain open communication with their educator regarding successes and concerns. Once the orientee is independent with implants, we transition to EP 101 to introduce ablation concepts.
EP 101: Introducing Ablation Concepts
For this section, we start with an in-depth, 12-lead electrocardiogram (ECG) review. It is important for new employees to understand intracardiac cell properties and how we gain leads and intracardiac signals. Our trainers discuss all leads, polarity, anatomical location, and deflections, and then proceed to demonstrating and practicing ECG lead and patch placement. They then introduce the 3 hybrid ablation roles and review expectations. During live procedures, we also teach and review cardiac anatomy, catheter placement, fluoroscopy views, and how to perform an EP study. Our team utilizes pacing equipment for a hands-on approach with pacing protocols performed during the EP study.
To help prepare them for troubleshooting, orientees are provided a thorough review of how all the equipment functions and is connected. Using posters and a heart model as visual aids, we discuss all tachycardias treated and mechanisms of action and then demonstrate how ablations resolve these circuits. It is important that orientees understand the biophysics of ablation and cardiac mapping as well as the tools utilized during treatments and the associated risks.
Transseptal puncture and intracardiac echocardiogram (ICE) are simulated using the Mentice simulator to ensure orientees understand procedure flow and steps to anticipate during ablation procedures. We also introduce and have orientees practice ablation table setup and patient draping with non-sterile demonstration equipment. A trip to the supply room allows for a review of ablation supply items. We also review the mapping companies, including the cables and connections for each, and the vendors and educators teach connectology for each mapping system. Additionally, trainers provide instruction on the biplane fluoroscopy equipment and options to improve images and radiation safety. The week concludes by reviewing ablation documentation and potential complications. During this week, orientees continue to spend observation time in the laboratory during actual procedures.
Ablation Training: Procedure Rotations and Ongoing Evaluation
Upon completion of EP 101, a new preceptor is assigned for the ablation rotation, since we have found that rotating preceptors helps decrease their fatigue and burnout. Ablation rotations focus on one role for 5 weeks, and we continually assess the employee’s progress, learning retention, and engagement to determine the best path for the next training. We may start with scrubbing and pacing, then move to circulation and monitoring, and finish with documenting and circulating. Equipment competencies are completed during procedure rotations. We continue the same approach of weekly evaluations and progression monitoring during the ablation rotation until an orientee reaches independent performance in all roles. Monitoring is the most difficult role to learn. Preceptors are expected to continuously review procedures with orientees to facilitate the learning process with EP measurements. Ablation training typically takes about 15 weeks.
Reviewing and Refreshing EP Knowledge and Skills
Once an orientee completes ablation training and is deemed competent to function independently in all roles, we provide 2 “free weeks” where they can rotate through procedures and refresh their skills with other roles. If additional exposure is needed, we ensure this is provided before an employee’s orientation is complete. The supervisor and educator meet frequently to review the orientee’s exposure to procedures and various physicians, and the orientee’s progression is tracked and documented throughout the entire orientation process.
Celebrating Completion and Ensuring Continual Education Through EP University
After an orientee completes EP orientation, we celebrate their “official initial” status with a certificate and picture, which we share in the hospital newsletter. Fully trained employees are identified on our daily schedule by their initials, while orientees are identified by their first name. We schedule newly trained employees in rooms with stronger staff to continue solidifying their EP education. If there are any concerns with concept retention after orientation, we introduce a mentorship program where the employee is paired with a senior team member. Our goal is to ensure all team members can perform all roles and be relied upon during every procedure.
EP education continues throughout a team member’s career at AdventHealth. Once they have been in the procedure room for a year, they can attend EP University to further solidify EP topics they are encountering during procedures. This is a 5-month program, offered 1 day each month, and includes advanced concepts as well as a hands-on heart dissection lab in which employees can identify structures and key components to better understand their work. The goal of EP University is to provide standardized, sequential, and consistent training to small groups to improve our employees’ clinical, epidemiological, and technological understanding. It consists of 5 topics: EP 101 (Products, Setup, Anatomy with a Heart Dissection Lab, Workflow Basics), EP 102 (Complex Workflows, ICE, Navigation Tools, Pacing Maneuvers, EP Laboratory Troubleshooting), EP 201 (Rhythm Focus, Arrhythmia Diagnosis and Differentiation), EP 202 (Advanced Rhythm Focus, Understanding Mapping, Mapping Interpretation), and EP 301 (Pharmacology, Ventricular Tachycardia Physiology and Procedural Workflow, Advanced Anatomy, and Advanced ICE).
Outside of EP University, physicians also take an active role in educating our employees. They lead monthly, hour-long educational classes that include beginner, intermediate, and advanced topics. Team members are encouraged to rotate through these classes based on their current knowledge level. Furthermore, vendors host biweekly in-services on different EP concepts to maintain equipment competency and introduce new equipment or procedures. We also utilize our team members who have been deemed “super users” to provide additional training to employees and assist with annual competency assessments of individual team members. Finally, our educators host classes and provide 1:1 instruction as needed.
Supporting Expansion
In addition to these ongoing efforts, AdventHealth Orlando and AdventHealth Celebration continue to provide training to our sister facilities as they grow their EP programs. The goal is to expand our treatment options to the communities we serve throughout Central Florida.
As an organization, AdventHealth values education and is committed to ensuring team members have the tools and training needed to optimize the quality of care provided to patients. New EP employees, program vendors, and physicians regularly praise the thoughtful, thorough approach we have taken to EP orientation and training.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest and report no conflicts of interest regarding the content herein. Dr Shaik reports he is a consultant and speaker for Boston Scientific, Medtronic, Abbott, Biotronik, and Biosense Webster; he also reports payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events for Boston Scientific, Medtronic, Abbott, Biotronik, and Biosense Webster.
