Growing Stronger: EP Labs Come into Their Own


 Praian Anghiel, MD, a cardiologist specializing in electrophysiology,
works on a patient at Washington Hospital Center.

As cardiology evolves, one crucial subspecialty may be growing in demand far beyond the industry’s present ability to provide highly trained, dedicated technicians: electrophysiology.

Because electrophysiology (EP) technology is not yet a recognized profession, hospitals have found it difficult to find, hire and retain personnel qualified to work in this area; the lack of professional recognition has also made it hard to set and negotiate competitive salaries.

To address the shortage, some physicians and nurses have found it necessary to provide on-the-job, real-time training in EP labs, a less-than-ideal solution that slows the completion of complex procedures and hampers patient through-put.

Some facilities have developed ad hoc programs to train technicians, often recruiting cath lab staff to do double duty; others, like Lancaster General Hospital, an acclaimed 518-bed facility in south central Pennsylvania, have designed comprehensive EP internships for electrophysiology technologists.

Momentum is increasing toward the advanced training and formal certification of these vital staff members. In March, Cardiovascular Credentialing International (CCI)—which issued a call in 2006 for credentialing in the discipline—introduced a new entry-level Registered Cardiac Electrophysiology Specialist (RCES) credential.

Each step that builds strong staff infrastructure in this discipline is a step in the right direction, says Edward V. Platia, MD, director of the Cardiac Arrhythmia Center at the Washington Hospital Center, with one of the top five EP labs in the DC-Maryland-Virginia area.

“There’s a relative dearth of qualified technicians, so frankly we’ve had to train our own, on-site, in the lab,” says Platia. “As you can imagine, given the full facets of electrophysiology training, it’s a rare occurrence when we get someone who is already experienced—that luxury never really occurs to us.”

At Washington Hospital Center—named one of the nation’s best hospitals for heart care and heart surgery by US News & World Report—EP techs new to the job serve as “sort of apprentices,” according to Platia. In the early part of their training, they work alongside senior staff members who shepherd them through their duties—everything from setting up and sterilizing the lab and insuring that supplies are in place, to learning the types and uses of recording and mapping apparatus as well as catheters and computer software.

“Eventually,” says Platia, “they actually put their hands on patients.”

The hospital conducts in-service training both in and out of the hospital setting, and frequently sends techs-in-training to educational seminars (one example: informational sessions held at a Cincinnati-based supplier of cardiac mapping equipment).

“In short, we invest a lot in these people,” Platia says. “Our techs ultimately become so qualified, they go on to take what is, in essence, the national boards (exams by the Heart Rhythm Society and the International Board of Heart Rhythm Examiners). These are credentials you can hang your hat on.”

Nevertheless, physicians would almost certainly prefer to have EP techs walk in on Day One, trained and ready to perform competently in what Platia says are, “in essence, surgical cases.”

How it’s done

EP studies of the heart are performed to analyze cardio-electrical activity, chiefly in patients with heart arrhythmias, a leading cause of sudden cardiac death.

Because arrhythmias are by definition unpredictable and intermittent, they are difficult to isolate through an electrocardiogram; even tests of longer duration, like Holter monitoring, are not dependable tools in the attempt to capture and assess underlying arrhythmic activities.

EP tests, on the other hand, last from one to four hours (in certain cases, including some ventricular tachycardias, the tests have been known to last a full six hours).

Using cardiac catheters linked to sophisticated computers, the electrophysiologist literally provokes arrhythmic activity in a highly controlled and monitored lab environment to determine the precise location of disordered electrical signals. EP studies are used to diagnose as well as treat patients with certain tachycardias or bradycardias, those who have been resuscitated after experiencing sudden cardiac arrest, and those with symptoms like chest pain, shortness of breath, fatigue, dizziness and fainting.

Because potentially lethal ventricular tachycardia or fibrillation may be induced in the lab, EP lab staff must be prepared to defibrillate the patient if necessary. But despite the delicacy of electrophysiologic procedures, they are considered low-risk with a high degree of success. If cardiac ablation is performed at the same time as the diagnostic test, some patients may not even require subsequent medication, and for the most common forms of supraventicular tachycardia, radiofrequency ablation has been successful in eliminating arrhythmias in up to 95 percent of patients.

Investing in technology

In the EP lab of the Heart Rhythm Program at Strong Heart and Vascular Center, located at the University of Rochester, electrophysiology teams perform about 500 ablations, some 4,000 ICD implants and 500 pacemaker implants each year. Director James P. Daubert, MD, agrees that increased formal training and credentialing—which will invariably raise the workplace value of the EP tech—is worth the cost to the profession, the patient and the technicians themselves.

“Yes, it will cost more. When thesefolks get up to a level where they really understand what’s going on and can work independently, it should translate into a relatively high salary for a tech position. They can make some money.”

As at the Washington Hospital Center, Strong Heart and Vascular Center now routinely borrows technicians from the cath lab to fulfill the duties of an EP tech. It works, says Daubert, “because there’s a bit of an understanding of the instrumentation, and the computers are similar. But if they’re not fully trained and all the trained people are busy in other labs, it’s a bit harder and a bit slower. We have to walk them through things, watch everything they’re measuring and doing.”

That said, no one at Strong is trying to speed up the process, Daubert emphasizes.

“We haven’t really tried to make big inroads on reducing the time spent on these cases… Should we take a four-hour procedure and try to get it down to two hours? If maximizing the economic impact was our only goal, we might want to do that. But first and foremost, we want to do [EP studies] well and faithfully, with a high success rate. It’s really a moving target.”

Though lab staff routinely try to “assess and improve” turnaround time between cases, the bottom line that counts is not necessarily a financial statement, but the health of “the one on the table,” he says.

The increasing complexity of EP procedures will almost certainly accelerate demand for skilled EP techs.

“The problem is that a lot of what used to be pacemaker cases now qualify for defibrillation implants and biventricular pacing…It’s a hard thing to get at because every year or two the procedures change a little,” says Daubert. (Industry-wide, atrial fibrillation ablation remains the most consistently performed procedure.)

In the next two years, Strong Heart and Vascular Center will construct a new multimillion-dollar EP lab, replacing its older x-ray equipment, updating its mapping equipment, and acquiring a $1 million state-of-the-art Stereotaxis Magnetic Navigation system. The robotic navigation apparatus utilizes two magnets on either side of the patient, “like MRI, but a weaker magnetic field,” says Daubert. “It enables you to continually realign the direction of the magnetic fields, and maneuvers the catheter in the heart with a joystick. You can do the study from the next room or even remotely.”

Investments of that magnitude (Daubert estimates that Strong will spend $2 million to $4 million on the new lab) are not feasible for some facilities, says Debra Pendergrass Chinnery, RN, director of the electrophysiology lab at Washington Hospital Center.

“Because technology changes so frequently, many hospitals are looking at cost-saving measures by sharing or leasing equipment, more so than purchasing outright. In one organization with five hospitals, maybe one facility is stronger in cardiac and another in neuro, one in cath and the other in EP. It’s all about creatively trying to stay ahead of the game and being cost-effective, for the patient and for reimbursement.”

Pendergrass Chinnery agrees that credentialing EP techs is imperative.

“We have a shortage,” she says. “There aren’t many highly technical personnel, and we’re pulling from a small group of people.”

Credentialing “can only enhance the specialty. It says you are an expert in that area, and it will help in this approaching
age of shared governance. Patients are looking for experienced people to perform these procedures, from the tech to the nurse to the doctor.”

Janet Ford, FNP, director of the electrophysiology department at The Heart Center in Kingsport, Tenn., foresees more educational programs to support the presumed growth in the field.

“I predict that, much like catheter lab techs, educational programs will be cropping up in the junior college setting,” Ford says. “It’s too difficult to train people on the job, and there’s no pool of people to hire from. We’re told there are probably three to five jobs for every EP that comes out of a program.”

A report from the U.S. Bureau of Labor Statistics bears out that contention. According to 2006 BLS projections, employment opportunities for cardiovascular technologists and technicians are expected to increase by 26 percent through the year 2016—much faster than the average for all occupations.

Growth will spike as the population ages, because older Americans have a higher incidence of heart disease and other complications of the heart and vascular systems. Though the demand in the field of electrophysiology is expected to soar, the BLS numbers indicate that fewer EKG technicians will be needed, as hospitals train nursing aides and others to perform basic EKG procedures.

Platia expects gradual, not urgent, growth in the field. “Just oiling the machine might better allow for more efficient through-put. Though some of the procedures are pretty labor- and equipment-intensive, I can’t imagine you’d want to open up labs on every corner…I don’t see it as a crisis in the making. It will increase slowly, incrementally.”

That said, he has a vested interest in retaining seasoned techs at his own facility.

“The competition is out there,” says Platia. “People are always trying to steal our technologists.”


Certifying EP Technologists
Cardiovascular Credentialing International has developed a registry level credential for electrophysiology. This credential—Registered Cardiac Electrophysiology Specialist (RCES)—will be an entry-level credential and supports the current pathway for advanced practice certification through the International Board of Heart Rhythm Examiners. Credentialing establishes recognition of the profession. It assures employers that those individuals who have successfully completed the credentialing process have attained the fundamental knowledge required to work in the field.

(Source: Statement of Need; drafted by Chris Nelson, RN, RCIS, FSICP; Doug Passey, RCIS, NREMT-P; and Letitia P. Esbenshade-Smith, RCIS, NASPEeXAM AP EP & Pacing Testamur)

Cardiac EP—once a small, highly specialized subspecialty—has evolved into a major area of cardiac care, particularly for patients with life-threatening arrhythmias.
Cardiac arrhythmias arise from disturbances of heart rhythm as a result of incorrect impulse generation. With painstaking precision, EP studies collect data about the flow of electricity within the heart, isolating specific areas of heart tissue that give rise to the abnormal impulses. The detailed data enables the physician to formulate an appropriate treatment response.

Although it is more invasive than an electrocardiogram or echocardiogram and involves initiating arrhythmias in a controlled setting, the tests produce data to diagnose the source of arrhythmia symptoms; evaluate the efficacy of certain medications in controlling the disorder; predict the risk of a future cardiac event; assess the need for an implantable device (pacemaker or ICD) or treatment (radiofrequency catheter ablation).

EP studies are performed by a team, led by a physician electrophysiologist with advanced training in the diagnosis and treatment of heart rhythm problems. The physician is supported by a team of specially trained nurses and technicians.