Spotlight Interview: Ascension St. Vincent’s Riverside Hospital

When was the cardiac electrophysiology (EP) program started at your institution? By whom?

Our EP program was started in late 1990 by Dr J. Timothy Walsh, who implanted devices in the operating room (OR) as well as performed EP studies outside of the OR. Dr Jay Patterson joined Dr Walsh in 1992 and performed our first supraventricular tachycardia (SVT) ablation in a vacated cath lab. The Heart and Vascular Center at Ascension St. Vincent’s Riverside Hospital opened in 2003 with 3 dedicated EP suites and 4 cath lab suites. Drs Anthony Magnano and Arne Sippens-Groenewegen joined our EP department in 2006 and performed our first atrial fibrillation (AF) ablation. Dr Saumil Oza joined the EP team in 2008. We currently have 4 EP labs.

Are employees cross-trained?

We have dedicated staff in the cath and EP labs. About 80% of our EP techs also have some cath lab experience.

Who manages your EP lab?

Heather Lewis is cardiology director and Cassandra Dunn is the EP clinical program coordinator.

What is the number of staff members?

We have 6 electrophysiologists, 6 registered nurses (RNs), 6 cardiovascular technologists, and an EP clinical programs coordinator.

What types of procedures are performed at your facility?

We perform all EP procedures, including tilt table testing, cardioversions, left atrial appendage (LAA) closures, and ablations for AF, SVT, premature ventricular contractions, complex ventricular tachycardia (VT), epicardial VT, and VT using Impella (Abiomed) support. Approximately 99.5% of ablations are done with radiofrequency energy. We also implant pacemakers and implantable cardioverter-defibrillators (ICDs), loop recorders, and Watchman (Boston Scientific) devices. We implant subcutaneous ICDs and leadless pacemakers in a select group of patients. We use 100% magnetic resonance (MR) conditional pacemakers/ICDs on new implants. We also perform His bundle pacing (HBP) and left bundle branch pacing (LBBP).

Approximately how many catheter ablations (for all arrhythmias), device implants, lead extractions, and LAA closures are performed each week?

On a weekly basis, we perform 24 ablations and 20 device implants. We perform 16-24 AF ablations per week. We also perform 25-30 LAA closures per month.

What types of EP equipment are most commonly used in the lab?

We have the CardioLab and MicroPace Stimulator (GE Healthcare) in all 4 EP labs, x-ray systems from Philips and GE Healthcare, and 2 ultrasound systems from GE Healthcare. We have 3 Carto 3 mapping systems (Biosense Webster, Inc, a Johnson & Johnson company), which we heavily rely on for performing fluoroless ablation. We also have 1 EnSite Precision Mapping System (Abbott). We implant cardiac devices from Medtronic, Abbott, and Boston Scientific.

How do you manage vessel closure?

We primarily use the Vascade venous closure device (Haemonetics).

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

During the onset of the pandemic, we were limited in securing personal protective equipment, so all nonemergent cases were canceled or rescheduled. During the surge, we saw a 90% decrease in our EP outpatient volumes. EP performed only emergent procedures, increasing our use of groin closure devices and discharging 90% of our patients home the same day.

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

We have 1 device nurse and 3 remote monitoring techs to help monitor about 8000 devices. We use PaceMate for our cardiac rhythm management software and Holter monitoring. Our heart failure clinic helps monitor our OptiVol (Medtronic), HeartLogic (Boston Scientific), and CardioMEMS (Abbott) data.

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

The EP lab’s hours of operation are Monday through Friday from 7:30 AM to 5:00 PM, with an assigned late team to cover until all daily cases are completed. We have a call team in place on weekends and major holidays. Minor holidays are covered at the electrophysiologists’ request.

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

We average 6-7 ablations and 5-6 device implants per day. Most days, we have 2 electrophysiologists on hand, with 7:30 AM and 8:00 AM start times. Our anesthesia-supported cases are scheduled first. The first EP team arrives at 7:00 AM and the patient is in the room by 7:30 AM. The second EP team arrives at 7:30 AM and the second patient in the room by 8:00 AM. The third and fourth EP teams arrive at 8:00 AM and 8:30 AM. Our room turnover times are 15-20 minutes.

We are also in the process of becoming a Biosense Webster Training Expertise Center to help other electrophysiologists streamline their processes and procedures. One to 2 times per week, Dr Oza is provided with 2 anesthesia providers and completes 6-7 AF ablations on those days. Otherwise, each physician generally performs 4 AF ablations per doctor, per room.

How do you ensure timely case starts and patient turnover?

The EP coordinator reviews the next day’s procedure schedule to ensure all equipment, anesthesia, vendor support, and adequate staffing are available for a timely start. Our team works well together, keeping the lines of communication open between RNs, technicians, and physicians. Our EP team is dedicated to meeting our goal of a 15- to 20-minute room turnover time.

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

The Resource Group manages EP inventory. Our EP resource representative works with the EP coordinator on all EP inventory, doing daily supply inventory checks and reordering to par as needed. Capitol EP equipment and supplies are purchased at the direction of our cardiology and resource group directors.

What type of quality control and assurance measures are practiced?

We have a quarterly meeting on complications and quality management that is attended by our physicians and dedicated EP team. Drs Magnano and Oza are also part of the REAL AF Registry, comprised of high-volume, low or zero fluoroscopy AF ablationists from around the country. They are able to compare their procedural efficiency, safety, and efficacy with other high-volume doctors around the country. They meet quarterly to discuss new techniques and present new ideas to the group. 

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

Three of our 4 EP labs do not have control rooms, allowing everyone to participate in the procedure and be available if an emergency occurs.

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

We are a part of the Ascension Health Care System, the largest nonprofit health care system in the country. As part of a large nonprofit system, we are able to treat all patients irrespective of their ability to pay, including Medicaid and uninsured patients.

Have you developed a referral base? Has your institution formed an alliance with others in the area?

We are recognized as a center for advanced ablation in the region. We have a large cardiology practice, spanning 3 (soon to be 4) hospitals. We travel to South Georgia for outreach clinics and have relationships with practices throughout the region. We also draw a significant volume of patients from Daytona Beach and surrounding areas through our relationships with several groups in that region. Our referral base includes patients from within our practice as well as from other cardiologists and electrophysiologists within a 150-mile radius of Jacksonville.

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

Dr Oza recently started using VX1 software (Volta Medical) for his patients who present with recurrent AF. This is an artificial intelligence-based software that assists with real-time identification of specific abnormal electrograms, known as dispersed electrograms. We will also be the first in Northeast Florida to begin using electroporation to perform AF ablation as part of the AdmIRE trial. Dr Patterson has begun implanting the remedē System (ZOLL Medical) for central sleep apnea.

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

One of the ways we have improved lab efficiency and workflow is by creating a Watchman implant day each month for our 3 electrophysiologists who perform these procedures. If more than 5 Watchmans are scheduled, a second anesthesiologist and EP team are used. Dr Oza has completed 12 Watchman procedures in less than 7 hours. He is leading a multicenter trial to evaluate the safety and efficacy of a large-volume Watchman day approach.

Do you have a primary approach for LAA occlusion?

We mainly perform the Watchman procedure, but also perform the Lariat (SentreHeart, Inc) procedure when needed. Our surgeons use the AtriClip (AtriCure, Inc) when doing hybrid convergent ablation. We perform the convergent procedure in our persistent and long-standing persistent AF patients. Dr Oza is the first in the country to routinely perform the convergent procedure along with electrogram-guided catheter ablation from Volta Medical.

How are new employees oriented and trained at your facility?

We have an onboarding process with our education department. New staff are assigned an EP mentor, who mirrors their schedule for 12 weeks. Our vendor support clinicians work together to ensure that our staff are trained on specific equipment.

How do you handle vendor visits to your department?

Our resource group manages the vendor policies. All vendors are required to check in daily and have a current date visible on their vendor badge when in the department.

Does your lab use a third party for reprocessing or catheter recycling?

Yes, we use third-party reprocessing for our diagnostic catheters and in-house sterilization for our cables.

Tell us about your approach to conduction system pacing.

Three of our electrophysiologists perform conduction system pacing (previously HBP, and now mainly LBBP) using technology from Medtronic and Boston Scientific. We also perform endocardial left ventricular pacing using an ultrasound-based pacing system from EBR Systems, Inc, as part of the SOLVE-CRT Trial.

Is your EP lab involved in clinical research studies?

We are involved in the CHAMPION, SOLVE-CRT, TAILORED-AF, AdmIRE, CONFORMAL, CONVERGE, and OPTION trials, along with nearly 30 other studies. Due to our high volume, we are generally among the highest enrolling sites in most of the studies we participate in.

Does your program have a dedicated AF clinic?

Our AF clinic is run by a nurse practitioner. They follow up with our same-day discharge patients as well as complete routine follow-ups and urgent visits.

A written handout is used to discuss lifestyle modification with all patients. We also work closely with our bariatric surgeons and sleep medicine physicians.

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

We use advanced esophageal imaging using a Definity Gastrografin solution to visualize the esophagus on intracardiac echocardiography and fluoroscopy. We then use the EsoSure Esophageal Retractor (EsoSure) to deviate the esophagus. This has increased both efficiency and efficacy as well as the safety of our AF ablations.

What approaches has your lab taken to reduce fluoroscopy time? What percentage of cases are done without fluoroscopy?

Most of our ablations are done without fluoroscopy. A few seconds of fluoroscopy are needed when esophageal deviation is required. Dr Oza has not used fluoroscopy for any of his AF, VT, or premature ventricular contraction ablations for almost 10 years now. Dr Magnano also uses minimal fluoroscopy.

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

Pulsed field ablation will change the way we perform ablation procedures and likely make it both faster and safer. We also need better technology to help us evaluate where to ablate in patients with persistent AF and refractory AF. Learning registries such as REAL AF (Biosense Webster) and DYNAMIC AF (Abbott) will help spread best practices and assist with the quicker adoption of new technology. It will also help identify centers of excellence by standardizing outcomes data between centers.

How do you see social media changing the field of health care?

Social media, such as Twitter, allows physicians to share ideas faster than ever before, leading to the spread of best practices and improved access to new technology.

Are there plans to expand the EP program?

We have just added a sixth EP physician, and we have plans to remodel and update one of our labs to better suit ablation procedures. We are in the process of acquiring Avail recording systems, which will allow us to record and broadcast our EP procedures.

Describe your city or general regional area.

For a medium-sized market like Jacksonville, we have a very large number of electrophysiologists (around 25). We have a very large medical community with 5 major health care systems and over 11 hospitals in the area.

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

The main strength of our EP lab is our dedication to patients, our shared love of EP, and our respect for one another. We have focused on lab efficiency and safety in order to perform a very high volume of cases in only 3 active EP labs. We have well-trained staff, most of whom have worked together for more than 10 years in the EP lab. Our staff is able to quickly learn new procedures as well as the workflows associated with them to stay on the forefront of our field. We have maintained a high retention rate and continue to grow and look forward to what’s next in the evolving field of EP.