Improving Electrophysiology Lab Efficiency: Collaboration With Anesthesiology is Well Worth the Time

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EP LAB DIGEST. 2023;23(6):16.

Obtaining efficiency in the cardiac electrophysiology (EP) laboratory is what many of us strive to achieve. Not only does an efficient laboratory equate to increased quality and timely patient care, but it also improves job satisfaction for both staff and providers. In the setting of COVID-19–era resource limitations, an efficient laboratory also minimizes disruptions in care. Specifically, the COVID-19 pandemic placed significant strains on supply chains and health care resources alike. Unpredictable availability of medical equipment and medications, health care worker attrition from retirement and burnout, and increased hospital bed occupancy all stressed the health care system and resulted in the need for laboratory efficiency to minimize disruptions in patient care. Further, considering the recent ruling by the Centers for Medicare & Medicaid Services to decrease reimbursement associated with catheter ablation of atrial fibrillation (AF), the need for optimizing laboratory efficiency is heightened.

Many of the efforts to improve laboratory efficiency require close collaboration with our colleagues in anesthesia. Osorio et al¹ outlined a standardized anesthetic protocol that was designed with the intention of improving effectiveness of lesion formation during AF ablation while also improving efficiency and ensuring patient safety. Success of a standardized anesthetic protocol is largely reliant on close collaboration between EP and anesthesia with a combined focus on data-driven quality improvement. Following a trip to the Arrhythmia Institute at Grandview Medical Center and working with their staff on a recent laboratory efficiencies webinar,² we were motivated to implement several changes at our institution at the University of Wisconsin.

Building a strong and sustainable relationship with anesthesia is imperative to EP laboratory efficiency and begins with open communication. First, we appointed a cardiac anesthesiologist to serve as the primary liaison between anesthesia and the EP team, including the lab manager and EP director. Together, we then identified an anesthesia physician to help facilitate add-on cases and adjustments to our daily schedule. They coordinate scheduling and availability of care teams, when possible, to aid in optimizing lab scheduling.

Once the patient is in the room, anesthesia and EP hold a detailed huddle prior to induction of anesthesia to review patient management objectives. During this approximate 2-minute huddle, we discuss case details such as use of medications (eg, neuromuscular blocking agents), hemodynamic monitoring concerns, tips for minimizing use of unnecessary administration of intravenous (IV) fluids, post-procedural disposition, heparin administration, and ventilator management techniques. Our academic medical center structure has EP fellows, rotating anesthesia residents, and certified registered nurse anesthetists. This process ensures that providers who may be less familiar with EP practices understand the procedural plan and have an opportunity to ask for clarification.

Most notably, implementation of a high respiratory rate, low-tidal-volume mechanical ventilation strategy³ in conjunction with paralytic use has improved catheter stability and decreased ablation (and other) procedural times. Simultaneously, we also initiated a new bladder management algorithm to avoid unnecessary placement of urinary catheters. Our patients recover in the post-anesthesia care unit; therefore, it was critical to work with our anesthesia partners to ensure a streamlined transition of care. With this collaboration, our center has been able to obviate the need for ubiquitous urinary catheterization by minimizing unnecessary IV fluid administration.

Furthermore, placement of arterial lines for AF ablation patients was standard practice at our institution. While this practice is not employed at all AF ablation centers given widespread use of intracardiac echocardiography, our anesthesia and EP physicians preferred continuous beat-to-beat monitoring as the EP patient populations become more complex. Specifically, this patient population is at risk for hypotension due to the vasodilating and negative inotropic effects of standard inhaled anesthetic agents (sevoflurane). Additionally, the AF patient population with hypertension treated with antihypertensives, as well as elderly patients, are at increased risk of hemodynamic instability under general anesthesia. However, standard placement of arterial lines often led to increased periprocedural time and exposed our patients to potential risks of procedure-related vascular complications such as hematoma. Implementation of a noninvasive finger cuff that provides continuous blood pressure monitoring has helped minimize those risks and time expenses, with an average time savings of 19 minutes, as well as contributed to an overwhelmingly positive response from the perspective of both the EP and anesthesia teams. While the noninvasive finger cuff is used for most of our EP patients undergoing general anesthesia, arterial lines remain to be utilized when the patient is deemed at increased risk of hemodynamic compromise from induction of general anesthesia (pulmonary hypertension or reduced left ventricular systolic function). This is a joint decision, though the final decision is at the discretion of the supervising anesthesiologist.

Patient safety and timely care are at the forefront of an efficient laboratory. Adopting these changes in our approach has helped us achieve our goals, with the main emphasis on changes to hemodynamic monitoring, IV fluid administration and subsequent bladder management, and most importantly, the ventilation strategy to allow improvements in catheter stability. Building and reinforcing relationships with our anesthesia colleagues has unlocked the true potential of quality improvement with a positive return on investment. Regardless of your stage on the path to EP laboratory efficiency, engagement with the anesthesia team is a critical step that will be well worth the time. 

Those interested in lab efficiency are encouraged to view the detailed webinars with transcripts available free-of-charge from the Heart Rhythm Society (HRS): https://tinyurl.com/4e58xt92

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Wright reports consulting fees from Biosense Webster, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from Biosense Webster and Edwards Lifesciences, and support for attending meetings and/or travel from Edwards Lifesciences. Dr Osorio reports research grants or contracts from Abbott, ArtiCure, Biosense Webster, Boston Scientific, and Medtronic, consulting fees from Abbott, Biosense Webster, Boston Scientific, and Medtronic, payment for speaking/teaching from Boston Scientific, and membership on advisory committees/review panels for Biosense Webster and Boston Scientific. Dr Silverstein reports honoraria from Biosense Webster, Impulse Dynamics, Medtronic, and Volta Medical. Ms Smith reports support for the manuscript from the BMS-Pfizer Alliance, which provided support to the HRS for the QI activity.

References

1. Osorio J, Rajendra A, Varley A, et al. General anesthesia during atrial fibrillation ablation: standardized protocol and experience. Pacing Clin Electrophysiol. 2020;43(6):602-608. doi:10.1111/pace.13928

2. Osorio J, Varosy PD, Cooper C, et al. EP lab efficiences. Heart Rhythm Society webinar. Accessed February 10, 2023. https://www.heartrhythm365.org/Public/Catalog/Details.aspx?id=EFw86P4zBdpwp7DS7N54vw%3d%3d&returnurl=%2fUsers%2fUserOnlineCourse.aspx%3fLearningActivityID%3dEFw86P4zBdpwp7DS7N54vw%253d%253d 

3. Osorio J, Varley A, Kreidieh O, et al. High-frequency, low-tidal-volume mechanical ventilation safely improves catheter stability and procedural efficiency during radiofrequency ablation of atrial fibrillation. Circ Arrhythm Electrophysiol. 2022;15(4):e010722. doi:10.1161/CIRCEP.121.010722