Spotlight Interview: Edward Hospital

Edward Hospital is part of Edward- Elmhurst Health, which is one of the top 10 health systems for cardiovascular care in Illinois and ranked in the Top 15 Health Systems in the nation by IBM Watson in 2019 and 2020. Over 40,000 heart and vascular patients are treated annually by this system’s supportive, experienced multidisciplinary team of board-certified physicians, cardiac nurses, and x-ray technicians. Using the latest technology, Edward Hospital applies advanced therapies and diagnostics to deliver rapid, lifesaving interventions to its patients. Edward Hospital has been expanding care for patients with heart rhythm disorders, coronary artery disease, heart failure, valve disease, and peripheral vascular disease. 

The cardiac specialists participate in research studies as well as serve to train other physicians in new and innovative therapies. First and foremost, Edward-Elmhurst Health fosters a culture of a team approach to provide safe, seamless and personal care to its patients and families.

When was the EP program started at your institution? By whom?  

The EP program was started by the Midwest Heart Specialists approximately 20 years ago. 

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

We have 2 fully functional EP labs located within the cath lab department. One of the labs is dedicated to EP daily, the second lab flexes with the EP schedule to accommodate high EP, cath, PV, and/or Structural Heart volumes. We are very fortunate to have a flex lab and staff.  

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

We have 25 staff members, 16 RNs, and 10 RT(R)s. All RNs and RT(R)s scrub, circulate, and document. We have 2 Specialty Leaders and 2 educators included in our EP staff. The EP program has 3 core staff members: Angie Hill, RT(R), Kirstie Krauth, RN, and Mitchell Katz, RN. We have a total of 25 staff members, which includes 16 RNs and 10 RT(R)s. Aside from the core EP staff members, all staff are cross trained to scrub, circulate, and record within all areas inclusive of EP, cath, PV, and Structural Heart.

What types of procedures are performed at your facility? What types of complex ablations are performed? 

We perform ablations for SVT, ventricular tachycardia (VT), Wolff-Parkinson-White, atrial flutter, and atypical flutter. We use Impella (ABIOMED) for VT if needed. We also perform cryoablation for atrial fibrillation (AF) as well as offer fluoroless ablation. We use multiple transseptal approaches. We have a lead extraction program in place. We deployed 66 WATCHMAN devices (Boston Scientific) last year. We implant pacemakers, ICDs, BiVs, and His bundle pacemakers. Over the past 2 years, we have successfully coordinated a same-day discharge program for implants. 

What would you consider to be the most common arrhythmia seen in your clinic? 

Atrial fibrillation is certainly the most common arrhythmia we encounter.

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

With the first surge, we divided our staff into Team A and Team B. These teams worked alternate days to limit exposure to one another. We cancelled all elective cases, and only performed procedures that were absolutely required. We have returned to doing all elective cases, and continue to get caught up on cases that were delayed during the surge. All inpatient and outpatients now have to be tested for COVID-19 before coming to the EP lab. We are grateful to be working, busy, and providing the very best care to our patients!

Approximately how many catheter ablations (for all arrhythmias), device implants (ICD, pacemaker, ICM, ILR, etc.), lead extractions, and LAA closures are performed?

In 2019, we performed approximately 400 ablations, 533 device implants, 44 lead extractions, and 66 WATCHMAN implants.

What percentage of your lab’s device implants use MR conditional pacemakers or ICDs? What percentage of implants use subcutaneous or leadless devices? 

All devices implanted are MRI conditional. Edward Hospital is a referral site for non-conditional MRI devices. We are supported in this program by our vendors, hospital APNs, and our own radiology team.

Who manages your EP lab? 

Moeen Saleem, MD, is the Director of EP Services, MaryLou Habryl, BSN, RN, RCIS, is the Director of Interventional Cardiology (IC), and Angelique Hill, RT(R), RCIS, is the EP Specialty Leader.

Are employees cross-trained? 

We have 3 core EP team members, but all staff are cross-trained. We offer a Phase II EP orientation for those who desire advanced, hands-on training.

Tell us about your device clinic. 

We run a separate device clinic that is staffed by RNs. 

Do you utilize telemedicine? Tell us about your approach. 

Yes, we use telemedicine. This has increased more recently due to the pandemic. It was previously utilized primarily for routine follow-up and post-op visits, including wound checks for devices. It is also now used for new consults as well as for utilizing data from other digital technology modalities, such as the Kardia app (AliveCor, Inc.) in cases of atrial fibrillation evaluation. 

What type of hospital is your EP program a part of? 

Edward Hospital is one of 4 Illinois hospitals in the large community hospitals category. 

Has your EP lab recently expanded in size? What changes have you seen in patient volume? 

For years we only had one EP lab, but as volumes grew, we added a second EP lab in 2016. We have seen an approximate 10% increase in our ablation volumes in the past year.

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

For operational consistency, our 2 EP labs are equipped with Allura Clarity imaging technology (Philips). EP-specific technology includes the WorkMate Claris System (Abbott), EnSite Precision Cardiac Mapping System (Abbott), Cool Point Irrigation Pump (Abbott), and the CryoConsole Cardiac Cryoablation System (Medtronic). 

How do you manage vessel closure? 

Safe and effective vessel closure starts with safe access for which we rely predominantly on an US-guided approach. We use mostly a manual approach for venous access. We also utilize figure-of-eight sutures with the stop-cock technique. Arterial access can be closed with ANGIO-SEAL (Terumo Medical Corporation), Perclose ProGlide (Abbott Vascular), or the MYNX Vascular Closure Device (Cardinal Health).

What new initiatives or technologies have recently been added to the EP lab? 

For ablation, we have taken an initiative for doing fluoroless cases utilizing 3D mapping and intracardiac echo. Intracardiac echo has also been applied to LAA occlusion procedures as well as lead extraction cases. In regards to device implants, we now offer His bundle pacing as an option for physiologic ventricular pacing and leadless pacing with both Micra and Micra AV (Medtronic).

How is shift coverage managed (typical hours)? How does your lab handle call? 

For shift coverage, there is one team of 4 from 0600-1630, one team from 0900-1730, and the rest are from 0700-1730. Call is from 1730-0700. Most staff take approximately 5 days of call per month and 3-4 late days per month. Late staff work beyond their scheduled hours only to cover procedures until the call team can manage on their own.

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

We perform a mix of ablations and implants (approximately 4-8 cases) each day.

Who handles procedural scheduling? 

The Specialty Leader or Charge RN in EP for the day handles scheduling.

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

We use an inventory system called Insysiv. This is used in conjunction with Lawson.

Our inventory process is overseen and managed by an Advanced Specialty Leader, Lisa Brought RT(R). She closely collaborates with Angie Hill, EP Advanced Specialty Leader, to coordinate inventory needs, orders, par levels, and implementation of new technology/equipment.

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

We measure first case on-time starts, SCIP protocol infection rates, documentation accuracy, and metrics in our same-day discharge program.

What are the best features of your EP lab’s layout or design? What would you include on a “wish” list? 

One of the nice features in our lab is the markings on the floor to indicate your proximity to radiation source. We would love to have more space, but who wouldn’t? The best feature of our EP lab is our team spirit and team development.

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

We order in bulk when possible. We also utilize consignment and participate in a resterilization program.

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

Staff turnover and clean their own rooms. Often, the procedure team transports a patient from the lab to recovery, and a second team will expedite room turnover. We utilize housekeeping for terminal cleaning of rooms for multidrug resistant organism (MRDO) or COVID-19, and with patient transport equipment. Our team is committed to providing an efficient and seamless transition between cases and during lunch coverage.

How do you ensure timely case starts and patient turnover? 

We have a departmental dashboard that is monitored monthly and physicians receive an individualized scorecard quarterly. Pertinent data is reported quarterly at a CV business meeting. Our daily schedule is executed by an Advanced Specialty Leader or Charge Nurse. 

How are new employees oriented and trained at your facility? 

All staff members orient for approximately 6 months. They scrub, circulate, and document in the cath, EP, and hybrid labs, as well as in the Structural Heart Center.

How do you manage continuing education opportunities for staff? 

We rotate staff to provide everyone an opportunity to receive outside education. 

What options for continuing education are available to your mid-career staff? 

CEU/ASRT credits are provided by vendors during live or virtual presentations. We also provide options for the staff to participate in webinars in their free time. From September through May, our cardiologists provide a biweekly Cath Conference (where both IC and EP cases are presented for discussion) in which prior or new cases are reviewed and discussed amongst the MDs, CVOR and ECHO teams, APNs, and cath/EP lab staff.

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

Staff competency is evaluated with orientation checklists. Annual raises are dependent on performance evaluations.

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

We offer monthly staff meetings, weekly staff huddles with the Specialty Leaders, the biweekly Cath Conference, Cardiology Grand Rounds, a monthly staff education hour, and planned monthly social events outside of the hospital (such as our softball team and annual bowling outing). Staff are empowered to think outside the box and bring ideas for efficiency.

What committees, if any, are staff members asked to serve on in your lab? 

Committees include the QA Committee, Pharmacy Committee, and Professional Development Committee.

How do you handle vendor visits to your department? 

Due to COVID-19, we are currently restricting vendors to only the cases they are required to support.

How is patient education managed? 

Patient education is managed on multiple levels. Education begins in the office. The patient also receives instruction during their pre-admission call, when they arrive for their procedure, post procedure, and before discharge. The patient’s family or care companion are also included in the education. We also utilize MyChart messages.

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

We have had many memorable, even transformative cases over the years. What makes a case memorable is how we see ourselves serving the community of this hospital. It starts with taking the approach of building a relationship with a patient and family. We realize that we are not treating an arrhythmia, but rather a person who may be someone’s spouse, parent, or child. Someone who is now facing their own mortality and they are faced with a situation of putting trust in us to manage and treat them. Last year, we had a patient present with VT storm that resulted in multiple ICD shocks. We went through the usual approach of admitting to the CCU, starting IV medications, and performing routine cardiac workup to look for other treatable causes of VT. The patient was eventually brought to the EP lab for an ablation. As many EP teams are aware of, one of the challenges of VT ablation is the hemodynamic instability that occurs with arrhythmia induction. We decided on arranging for Impella (ABIOMED) placement for hemodynamic support. This required collaboration with our IC colleagues. Together with IC, anesthesia, and our staff, an Impella was placed for the ablation. We then induced VT. The hemodynamic support allowed the patient to remain in VT for 45 minutes while we worked with an EnSite mapping (Abbott) technician to map the circuit and eventually terminate the arrhythmia. After the case, Dr. Saleem went out to talk with the family. The patient’s family members were in tears over what had transpired over the week, and were relieved that there was a favorable outcome within sight. He reviewed the procedure and talked about the patient’s expected recovery. We discussed the emotional trauma and understandable anxiety that accompanies receiving multiple ICD shocks, and talked about both the cardiac and emotional recovery that was needed. Both required time and support extending beyond his time in the hospital. In what has become a customary approach, Dr. Saleem described the procedure and outcome with a hand-drawn illustration (Figure 10). (He also uses this approach on medical mission trips, where patients often bring back their drawing during follow-up visits, including a refugee who reappeared 3 months later.) Patients and families will now often take a picture of that drawing for reference. Later that evening, our nurse practitioner sent over a picture taken of Dr. Saleem reviewing the illustration along with a note from the patient’s family member. It turned out that our NP and the family member were close friends, and the family had reached out to our coworker for support during the week. The patient was later discharged home, and is now back to living a normal life, participating in mild exercise, and is functional NYHA Class 1. This case represents our team spirit, our team effort on every level, and our commitment to our community! 

Does your lab use a third party for reprocessing? How has it impacted your lab? 

Yes, it’s a huge cost savings and ecologically sound. We use PremierPro Reprocessing Services.

Approximately what percentage of ablation procedures are done with cryo vs radiofrequency? Why? 

For paroxysmal AF, we use cryo for the first procedure, as we focus on PVI. For redo AF or advanced persistent AF, we use RF ablation with consideration for additional lines or posterior wall isolation. For all other ablations, RF ablation is used. 

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

Yes, when using RF ablation for AF, contact force is used. This is the same for VT procedures. 

Do you have a primary approach for LAA occlusion?

Yes, we use the Watchman FLX LACC Device (Boston Scientific). We participated in the Amulet Study in 2017, 2018, and 2019. We were the first site in Illinois to perform a commercial Watchman FLX implant (Figures 11 and 12). 

What are your thoughts on the use of NOACs in patients with non-valvular AF? 

We favor NOACs if patients are able to afford them. Patients are instructed to hold NOACs on the morning of an ablation procedure and for 24-36 hours prior to a device implant. 

Is hybrid epicardial and endocardial ablation of atrial fibrillation performed at your institution? 

Not specifically; however, we have a good relationship with our CV surgeons and often recommend AF ablation and, when indicated, LAA amputation or ligation at the time of surgery. If additional ablation is needed after surgical recovery, EP consultation is readily available. 

Discuss your methods for lifestyle modification as therapy for your patients with atrial fibrillation. 

We are working towards setting up an AF clinic. We envision a hub-and-spoke model in which patients with atrial fibrillation are appropriately referred for evaluation of sleep apnea, weight loss to optimize blood pressure control, and glucose control to optimize diabetes (in collaboration with PCPs). 

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

We use a hybrid dual-operator approach for lead extraction that utilizes femoral traction, intracardiac echo, and either laser or rotational cutting tools from above. 

What approaches has your lab taken to reduce fluoroscopy time? 

Our physicians and staff aim to minimize fluoro time and exposure. Low-fluoro settings are used as a default.

What percentage of cases are done without fluoro? 

For some operators, 100% of cases are done without fluoro; for others, the percentage is closer to 50%.

What types of radiation protective shielding and technology are used? 

We use radiation badges, mobile and hanging lead shields, RADPADs (Worldwide Innovations & Technologies, Inc.), and floor markers indicating 6 feet from radiation source. A radiation safety officer maintains and monitors badge levels.

What are your methods for device infection prophylaxis? 

We follow the SCIP Protocol utilizing cefazolin or vancomycin; the use of a TYRX Absorbable Antibacterial Envelope (Medtronic) is determined by the performing physician.  

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

We participate in many of the NCDR clinical data registries such as the ICD Registry as well as the CathPCI, Chest Pain-MI, PVI, and LAAO Registries. We review our data frequently, and it is shared with our CV service line leaders and physician leaders. Participating in these registries allows us to identify where we excel as well as where there are opportunities for improvement to better the quality of care for our patients. 

Is your EP lab involved in clinical research studies? 

We are participating in the His-SYNC trial, Amulet IDE trial, OPTION trial, and ASAP-TOO trial, and clinical trials evaluating the remedē System (Respicardia) and Cardiac Contractility Modulation (Impulse Dynamics).

How do you see social media changing the field of healthcare? 

We see it being utilized to market both available and upcoming procedures, as well as to network with other programs around the country. 

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

We are located in suburban Chicago. Therefore, we compete with the large educational institutions in downtown Chicago, but we are also able to provide the same procedures with exceptional patient care, without the stress of the city.

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

We were among the first to implant the Micra leadless pacemaker (Medtronic). We were also among the first to perform LAA occlusion, including recently being the first to perform a commercial Watchman FLX implant in Illinois. 

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

What makes Edward-Elmhurst special is our philosophy of teamwork. The African proverb “If you want to go fast, go alone, but if you want to go far, go together as a team” embodies our culture. There is a sincere team spirit among staff, cardiology, CV surgery, and our administration. How we treat our patients starts with how we treat each other as a team. We treat one another like family, and enjoy team outings to sporting events or bowling nights. Together, we share an enthusiasm for innovation as we are participating in several research studies. This spirit of collaboration inspires us to serve our community with the highest quality of care. Our amazing team of staff and physicians go above and beyond every day to provide safe, seamless, and personalized care to patients.