Transitioning from EP Diagnostic to Therapeutics: What are the Essential Considerations? by Barbara Sallo, RN, MBA and Marsha MacIntyre, RN, BSN

When hospitals make the decision to expand the cath lab to perform electrophysiology (EP) procedures, it is important to look into the impact it will have on the total cardiology program. Traditionally, hospitals have looked to recognized medical specialist societies to provide insight and direction regarding clinical policy and process. This is no different for EP procedures, which have been routinely conducted in the cardiac catheterization lab setting. When looking for guidance and/or recommendations for EP catheter ablation treatment, the North American Society of Pacing and Electrophysiology (NASPE) and American College of Cardiology (ACC) offer policy statements.

Catheter ablation is one procedure which has transformed the field of electrophysiology. Catheter ablation destroys atypical heart tissue which is responsible for abnormally fast heart rates. Previously, the treatment for many tachycardiac arrhythmias required extensive open-heart surgery. Catheter ablation, through the use of radiofrequency ablation, has, in many instances, made surgery and long-term drug therapy no longer necessary. Therefore, “the number of reported ablation procedures performed annually in the United States has increased from 450 in 1989 to ? 15,000 annually.1 This increase in demand has made the addition of EP services at many hospitals very attractive.

When a hospital is considering expanding cardiology services to include EP and catheter ablation treatment, an assessment of existing clinical services is in order. One of the first questions to address is whether the hospital already has an established open-heart surgery program. While there are no defined regulations that require the “on site” availability of open-heart surgery services when performing catheter ablations, it appears to be an accepted medical practice.

As previously stated, two recognized organizations that provide electrophysiology clinical competency recommendations are the ACC and NASPE. However, the ACC defers to NASPE for specific guidelines. NASPE produces clinical competency recommendations for EP services. Recommended guidelines state “Comprehensive catheter ablation programs require a fully equipped invasive electrophysiological laboratory and ready access to surgical support and facilities. It was felt that full cardiac surgical support was desirable; nevertheless, at minimum, facilities performing ablation should have thoracic surgical backup.”2 The guidelines are not specific regarding the need to have open-heart surgery available “on site,” leaving this open for interpretation.

However, what the NASPE policy statement on catheter ablation, as published in PACE, does present, are equipment and clinical process recommendations. Cine or digital imaging, and hemodynamic monitoring and recording of, at the very least, arterial pressures and O2 saturation are recommended. Standard cath lab radiation exposure precautions must be maintained, especially in extended ablative procedures.

Equipment required for ablations includes an external defibrillator with non-invasive pacing, a radiofrequency current generator with temperature and impedance monitoring capability and a power output of at least 50 Watts. Other desirable equipment includes mapping equipment, and recording equipment capable of monitoring a minimum of three surface leads and at least four intra-cardiac leads concurrently. Hard copies of these recordings also need to be available for cardiologists’ immediate review.

Airway maintenance equipment, such as oxygen, suction and general anesthesia should be available. If your lab is doing pediatric cases, general anesthesia is mandatory.

Staff in cardiac cath/EP labs can differ from hospital to hospital. Members of the EP team for ablation procedures generally will be similar to that of the cath lab. In addition to cath lab training, the EP staff requires experience and ongoing specialization with EP procedures. Ideally, if volume allows, there should be staff dedicated to the EP lab.

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BIO:

Barbara Sallo, RN, MBA is the President of Health Care Visions, Ltd. a cardiovascular consulting firm based in Pittsburgh, Pennsylvania. The firm brings extensive knowledge and expertise in this area of clinical care. Health Care Visions, Ltd. has assisted a multitude of hospitals in all phases of cardiovascular programs from market assessments, program assessments and feasibility studies to business planning and implementation.

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