Spotlight Interview: Doylestown Hospital

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

Dr. Rob Sangrigoli started our EP program in a converted space in 2001. Since then, we have grown to 2 dedicated electrophysiology labs and 5 electrophysiologists.

What is the size of your EP lab facility? Has the EP lab recently expanded in size?

We currently have 2 full-time EP labs, and given volume increases, we will need to build/expand to a third EP lab. With exponential growth in atrial fibrillation (AF) ablation, it is likely we will need more space at some point in the future.

What is the number of staff members? What is the mix of credentials at your lab?

We have 17 dedicated EP staff with many years of experience. This includes 12 RNs, 7 CCRNs, 5 cardiovascular specialists with RCIS and RCES certification, our lead EP RCIS, and our EP RCIS educator with MS, RCIS, RCES credentials.

What types of procedures are performed at your facility?

Doylestown Hospital is a high-volume lab providing a full complement of procedures including ablation of atrial fibrillation, ventricular tachycardia, and SVT. We are experienced in endocardial and epicardial ablation techniques, as well as multiple ablation platforms such as cryo and radiofrequency ablation. We routinely perform the full range of device implantations including leadless pacing, cardiac resynchronization, His bundle pacing, and left bundle branch pacing. We perform left atrial appendage (LAA) occlusion in the EP lab in collaboration with our interventional cardiology colleagues. We have a close relationship with our cardiac surgeons for combined endocardial/epicardial ablation of AF in refractory cases. We have also recently added lead extraction capabilities in order to provide the full complement of EP services.

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

We perform approximately 15 ablations per week and a comparable amount of device procedures. We recently started our extraction program 3 months ago, and have a goal to perform 25 cases in the first year. We also perform 1-2 LAA procedures a month.

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

We have 2 EnSite (Abbott) and 2 CARTO (Biosense Webster, Inc., a Johnson & Johnson company) systems for mapping, as well as 2 cryo consoles. We have recording systems from EPMedsystems in both labs and fluoro/imaging equipment from Philips.

Who manages your EP lab?

Our EP director is Michele Clugston, CVT, RCIS, and our clinical manager of EP is April Henrysen, RN, BSN; they also manage interventional cardiology and vascular surgery. John Harding, MD, is the medical director of our EP lab.

Tell us about your device clinic, including its staffing model.

Our device clinics are outpatient based, with no real crossover to the hospital lab. We have 3 separate “pods” under the overarching umbrella of the cardiovascular division and health system that function as separate cardiology practices with separate device clinics.

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

Due to state regulation and local infection rate, we experienced a purposefully controlled slowdown in Spring 2020 to conserve staff and bed utilization, and performed only emergent/urgent cases during that time. This was followed by a rapid return to pre-COVID volumes by mid to late summer as the local outbreak became more manageable. We had already been proponents of same-day discharges whenever possible and have continued this approach throughout the pandemic, which has helped us to minimize hospital resource utilization.

Tell us more about your same-day discharge approach for AF ablation cases.

We typically utilize same-day discharge for our morning AF ablation cases, and the second AF ablation taking place those days will often go home as well. We have been doing this for several years and hope to relay our experience in our recently initiated randomized, prospective evaluation of same-day versus next-day discharge.

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

We have completed EP lab accreditation process through the American College of Cardiology and have been approved for accreditation as of May 2021.

With exponential growth in EP, our monthly departmental meetings are specifically designed to tackle utilization and resource issues. Meetings include all the EP physicians, department managers, and EP staff leaders. We also routinely include the hospital’s vice president of cardiovascular services as well as invited guests from the anesthesia department and nursing supervisors from the cardiovascular units.

This provides us with a unique opportunity to bring in representatives from the entire network of departments involved in the EP program. We discuss everything from future infrastructure needs, budgets, current clinical needs, and patient throughput from arrival to discharge.

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

Our dedicated EP labs are full during the week with ablations and devices. When we need additional space for cases such as device implantations, we utilize the cath labs.

How do you ensure timely case starts and patient turnover?

We keep laser focused on streamlining practices while ensuring safety and quality. We continuously communicate among EP stakeholders to keep cases starting early or on time, and to minimize turnover time throughout the day. We also have 2 dedicated NPs who coordinate pre- and post-procedure evaluation and management, and who provide an additional measure of quality, safety, and consistency to our approach.

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

The new Woodall Center for Heart and Vascular Care, located on the second floor of the Cardiovascular and Critical Care Pavilion, has really enhanced the pre- and post-procedure experience for our patients.

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

We are always looking for ways to reduce equipment costs without sacrificing the quality and success of our program. Our monthly EP meetings with hospital administration help identify areas where we can reduce cost and communicate about the necessary equipment required for our procedures. We reprocess catheters and cables, and also have a dedicated Inventory Coordinator who keeps pars at appropriate levels and looks for price savings.

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

We utilize reprocessing for equipment such as intracardiac ultrasound catheters, to variable results. It has brought significant cost savings to our lab. Annually, we save around $691K a year and divert 4,000 lbs of waste from landfills.

What types of continuing education opportunities are provided to staff? What options for continuing education are available to your mid-career staff?

Scheduled didactics are provided to our lab staff, and there is a dedicated focus to on-the-job teaching. We foster a collegial atmosphere in our labs where every person in the room is expected to contribute to the quality and safety of the procedure. We continuously train our staff members in different aspects of each procedure, including dedicated training in scrubbing/assisting in cases, running the EP stimulator, circulating cases, and using general mapping principles. We also have a good relationship with many EP companies that provide in-house and outside education for our team.

Tell us about your primary approach for LAA occlusion.

Currently, we perform LAA occlusion with the first-generation WATCHMAN device (Boston Scientific), and will soon be implementing the second-generation WATCHMAN. We plan to expand to include the minimally invasive LAA clip via thoracoscopic surgery for patients who are not ideal candidates for endocardial closure.

Does your program have a dedicated atrial fibrillation clinic, or have plans to implement one?

Our AF clinic is in many ways virtual, as our 3 employed cardiology practices function somewhat independently. With the recent construction of a new heart wing and hospital, there will be functional brick and mortar space for an integrated AF clinic. We have dedicated protocols for AF management in the ER (cardioversion protocol), sleep apnea screening, and rapid referral, which are all integral parts of our team-based AF management approach.

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

It is certainly a goal to someday become a completely fluoroless lab. We focus on ALARA principles, with the overwhelming majority of device and ablation cases under 50 mGy. This is achieved through reducing frame rates, field of exposure, and reliance on intracardiac ultrasound and mapping technologies for fluoro reduction. However, there are certain situations in which minimal fluoroscopy aids in safety and quality of the procedure.

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

We have a radiation physicist check all the imaging equipment in the lab on an annual basis. Imaging companies also do routine preventative maintenance. Both our director and manager are on radiation committees to ensure processes are in place in all areas of the hospital.

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

High-density mapping tools have really been a game changer when ablating focal or macroreentrant arrhythmias. They are also useful in highlighting gaps from prior pulmonary vein ablation. Case times are markedly reduced; for example, cases that once took 4-6 hours can be accomplished in a fraction of the time due to these new mapping tools.

It is also exciting to see the expansion of pacing techniques, including His bundle pacing, left bundle pacing, and leadless pacing.

Finally, the explosion of AF ablation and single-shot technologies such as cryoballoon ablation have allowed us to treat more patients in a consistent, effective, and timely fashion. We are very excited to be participating in the coming months in the trials for pulsed field ablation, which we feel will enhance safety and further reduce procedure times for AF ablation.

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

Smartphone apps are becoming ubiquitous and allow us to move to pill-in-the-pocket anticoagulation strategies for many patients post AF ablation.

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

We are a community-based hospital located approximately 45 minutes to Philadelphia and in close proximity to New York City as well. We are a close-knit, growing suburban community with a lot of history and culture, and have a great mix of farms, open space, and restaurants/shops in the Doylestown Borough. We are very close to many distinguished universities.

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

We work hard to provide quality, consistency, and safety to our patients, as we want them to “buy local” for their EP care. We have excellent academic hospitals in the Philadelphia and New York City region, and are dedicated to provide comparable local care.

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

Our team-based approach is a particular strength of our program. Our EP lab functions as a close family, and one that gets along for that matter! Through education, empowerment of all members of the team, and latest evidence-based care, we have a high retention rate and continue to grow.