Index
Ep Defined | Getting Started | Working in the EP Lab
Right Atrium | Right Ventricle | Left Atrium | Left Ventricule | Cardiac Conduction | Cardiac Cell Properties | Action Potential | Sympathetic or Not | Med Page
Electrograms Defined | Recording Modes | Electrode Spacing | Filters | EGM Interpretation | Arrhythmia Analysis
The Physical Lab | Tools of the Trade
Setting Up | Catheter Placement | Baseline Measurement | SNRT | Conduction Study | Arrhythmia Induction | Pacing Protocols | Ablation | Tilt Table | Secrets to Success
Bradycardia | Atrial Tach | Atrial Flutter | Atrial Fibrillation | AVNRT | AVRT | Ventricular Tachycardia
Surface ECG's | Intracardiac Questions | Med Challenge | Advanced

The Physical Lab - Are You Dedicated?

Dedicated or Not?

          One question that confronts every EP program early in the development stage is that of the dedicated lab. Should the EP Lab be a dedicated room? How this question is answered can have a major impact on the success of the EP program. This section attempts to address this question and provide some guidelines on what choice to make.

          During the time that I have worked in this field, I have witnessed a variety of different approaches to EP Lab design and set up. The lab I started out in was a hybrid lab that was used for both cardiac cath and EP procedures. I was the only Tech who was even interested in electrophysiology and as such, did all of our cases at first. The scrub and circulating positions were filled by other cath lab staff as availability allowed. As new duties provided me the opportunity to assist with procedures in labs across the country, I was able to see how different facilities had set up their EP programs. I began to realize that how a program was set up could have a significant impact on the long term success of that program.

          There are two aspects of the dedicated lab that must be addressed in any facility, that of the dedicated room and the issue of dedicated staff. Both of these issues can have a huge impact on an EP program and both should be considered careful before a decision is made.

The Dedicated Lab

          Cross over or hybrid labs were common in the early days of cardiac electrophysiology and are still often used in facilities starting up EP programs. Because of procedural similarities, they are usually associated with the cardiac cath lab, though I have seen EP labs affiliated with the radiology department. As this field of medicine grew, many facilities built labs specifically for EP procedures. Today we find that electrophysiology is an integral part of any cardiac program and a necessity for any cardiology practice to remain competitive. Hospitals that are considering adding an EP program will have to tackle the decision as to whether or not they should build a procedure room specifically for EP.

          As a temporary solution, the hybrid lab may make sense. Adding a new service is often considerably easier than adding a new room, at least until a new lab can be added to the facility. The key point is that the hybrid lab is only a temporary solution that should be utilized for the least amount of time possible. One of the worst mistakes that can be made is to set up a cardiac EP program with no plans for having a dedicated lab within 18 to 24 months. This is a direct indication that you are not planning for success, you are setting yourself up for failure. It is also something that will be picked up by your physicians, your staff, your patients and your competitors.

          When you look at the field of EP and the impact having a solid electrophysiology program can have on a facility, a dedicated lab becomes the only viable long term solution. The investment is simply too great to be relegated to a part time status. Scheduling conflicts will be the first of many problems that present themselves. When should the hybrid lab be scheduled for EP and when is it used for other procedures? What is the protocol for dealing with an emergency case when the EP patient is draped and on the table? What happens when the case goes long as often occurs in a lab that is learning the ropes? How much time should be allocated for EP utilization of the hybrid lab? Plans on how to deal with these issues and more should be decided prior to implementation of a cross over lab. Consideration of how these issues may impact the function of the lab should be sufficient motivation to plan for a more permanent solution.

Dedicated Staff

          Another very important consideration regarding a dedicated EP program involves the staff. No matter what decision is made on what type of lab to use in the first stages as an EP provider, it is absolutely essential that the staff who work in EP be dedicated to that field from the very beginning. Before I elaborate, I wish to provide you with some basic information regarding my background. The purpose of this is to hopefully establish my qualifications as an informed source regarding this subject. I do this not to “toot my own horn”, but rather to try to convince you, the reader, that my thoughts on this subject are born from extensive experience with the subject matter presented.

          My overall medical experience started in 1981 and has involved cardiac care since that time.   From the Cardiac Telemetry ward to Critical Care, ER, Non-Invasive Cardiology and the Cardiac Cath Lab, I spent over 20 years working in a hospital environment. Thirteen of those years were spent running a Pacemaker / ICD Clinic and the last two years included working as the primary EP tech. In 1997, the first version of this web site was launched in an attempt to provide some resource for allied professionals who were seeking to learn more about this field. I achieved Testamur for the NASPE Exam in EP for Allied Professionals in 1999 and followed that up with successful completion of the Pacing / ICD exam the next year.
In 2001, I accepted a position as a Clinical Engineer with an EP based company. Over the next four years, my work in the field presented me with the opportunity to assist with EP procedures in close to 100 different labs around the country. I have had the opportunity to contribute to the set up and design of a few new labs and have encountered a wide variety of mistakes and strong points in lab design. Over the last two years, my primary responsibility has been to set up and deliver education regarding advanced EP concepts. The information that I present regarding most subject on this web site is based upon personal experience. Of all those subjects, there is none that I have more passion for than the need to provide appropriate EP education for the staff who work in this field.

          Cardiac electrophysiology is a complex field with a steep learning curve. There are few education programs and most EP training occurs on the job. Despite similarities to jobs found in other aspects of cardiology such as the cath lab or ECG lab, the field of cardiac electrophysiology places initiates into an environment that is sufficiently alien to anything they have previously experienced that it requires extensive repeated exposure to comprehend. In essence, the only way to get good at electrophysiology is to do it over and over again until it begins to stick.

          If you do some investigating regarding how those of us who have walked this path before made it to where we are today, you will find that it took time and repeated experiences to grasp the basics of this field. Getting the basics down is only the first step in the long journey to mastering EP. First comes the simple understanding of how the equipment is set up and how it functions. This is followed by a very basic knowledge about the purpose of each step in an EP procedure. The understanding of why each step is performed begins to open the door to the first simple steps in interpreting the data collected. This can only be achieved with a sound understanding of the cardiac anatomy combined with a small amount of physiology thrown in. Once this point has been achieved, the initiate will have the necessary knowledge foundation required to build a true understanding of cardiac EP. For a person with little or no experience to reach this point requires 18-24 months if the exposure is on a consistent basis. If their experiences with EP are limited to an on again / off again approach, it may takes as long as five years to reach this level.
The final piece of the puzzle to keep in mind regarding dedicated staff in the EP lab is the difficulty in finding education in this field. There is little formal education available, and what is available is either insufficient or requires 1-2 years dedicated to the classroom. This requires that most EP staff learn on the job. Unfortunately, most of those who already have significant experience in EP have already gone to industry and are not available to teach newcomers. With this in mind, give serious consideration to having at least a dedicated core group for you EP program.

Final Thoughts

          When the time comes to set up an EP program, there are a number of things to keep in mind regarding the lab and lab staff. EP can be a huge money maker if the program is set up correctly, and it can be a difficult proposition if it is based on a poorly designed plan. Considering the investment in both time and money required to establish an EP program, the wisdom of ensuring that your program gets off to a good start should not be difficult to see.

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