Coming up next, we're going to look at the importance of the partnership between the EP team and anesthesiology. Let's dive into that a little bit more. Welcome back. In this segment, we're going to be focusing on the critical importance of a partnership with effective communication and practices between the EP team and anesthesiology. I'd like to welcome, in addition to our EP faculty, Dr. Bob Henry, an anesthesiologist here at Grandview. Thank you very much. Can you tell me a little bit about the experiences you've had in working with Dr. Osorio's team? Well, I think Dr. Osorio has just been great. We met five or six years ago, I don't know exactly the date, but we met at what we call the old place, the Trinity Montclair Hospital, before we moved to this current hospital. And he basically requested a meeting with the anesthesia department, and we started talking from there. That's kind of started the ball rolling. We discussed kind of what he wanted and what he expected. I think, you know, cardiology and anesthesia, as we all know, has always had differing views of each subspecialty. I consider anesthesia to be a service subspecialty, and so I do think it's important for the anesthesiologist to know what the cardiologist actually, what they plan and what they want and what they want delivered. So I don't know how far right now you want me to just keep, because I can talk on this for quite some time, but I'll just go ahead and elaborate a little more. Dr. Sorio gave us some ideas that he was wanting to be efficient, have a real schedule. What I call a real schedule meant, because we'd never done that in our previous cardiology department, we pretty much with the EP folks, and for just like TEE and anything else we would sedate for, we would just get a phone call and say, hey, can you come over? Or we would have, if we had an EP study or an ablation to be done, it would be 8 o'clock in the morning and it might happen somewhere between 8 and 1 o'clock in the afternoon. So we had no firm schedule, nor did we start and we weren't, we didn't pre-op patients. We would come in and it would just be kind of like, well, we didn't know anything about it and now we do. So with Dr. Sorio, it was, we're not going to do it that way, I don't want to do it that way. And so Jose and I got together and we started talking and said, and from my perspective, we like to pre-op patients, we like to have a full schedule, and we like to start at the, for us at this hospital, we like to start at the first of the day and then try to finish up sometime within an eight or especially no more than a 10 hour day. And I think that with that in mind too, I'll just go into that a little bit too, Chris here right beside me can elaborate on that some, but I think it's important for the staff, the staff, not just the anesthesia staff, but the staff too, to believe that there is going to be an end to the day, you know. So I think too with that, we agreed that we were going to finish up at a certain time a day and we weren't going to load any patients in the room at a certain time. I think ours was four o'clock, but you can make it any time as long as it's consistent and the staff believe that you're going to be finishing. So, but back to the anesthesia, I think it's really important for us to know that when the cardiologist says that they're going to start at seven o'clock or eight o'clock, just name your time, 6.30. One time we were closer to 6.30, now we're closer to seven o'clock, but we all know what basically that when it's posted, that's what time they mean to start. And before we, before Dr. Sorio came along and said, we want to have a full schedule, two or three electrophysiologists up to four rooms a day, that we would be busy enough to staff those rooms. We would just, we didn't even, we never even talked to the cardiologist in a formal sit down after 20 something years. I was chief for anesthesia at the current hospital. I'm no longer the chief now, but nevertheless, I gave that up a couple of years ago. But I was a chief when we started this and we wanted a real schedule that you started when you said you were going to start. And like I was saying that we never talked about that before and it was just kind of like, well, we just would go in and hope for the best. It'd be kind of like two ships passing in the night and hopefully you met somewhere in the middle and things got done. But currently, we all know that if we have three cardiologists down there and four rooms, we're going to run four rooms and it's going to be efficient enough where you're not going to sit around and wait for three or four hours or no one's going to be running clinic in the middle of it. And then you come back and if Dr. Sorio says, I've got eight rooms, I mean, eight cases and expects to have two rooms, we agree that we're going to try to have two CRNAs down there and an anesthesiologist that's dedicated to that area. And I just think it's important, you know, the dialogue goes both ways. If he doesn't like what I'm doing, he can tell me. If I don't like what he's doing, I can tell him. And it's happened both ways. He's let us know that some things, hey, I don't quite like it this way. Then if there's some give, then I say, well, this is what we're willing to do. And if we can work it out, and if it doesn't work out, then we find a compromise. So what I think I'm hearing you say, based on the description of how things were before Dr. Osorio, is that things really changed for the better. Changed immensely and definitely for the better. So what facilitated that change from the way it had been before Dr. Osorio? The whole thing is communication. It's absolutely communication. And then when you communicate, then you have to deliver. If I tell Dr. Osorio I'm going to have three CRNAs there on Tuesday morning at seven o'clock, and I show up routinely with one, he's not going to be happy. And if he tells me he's going to have, you know, three cardiologists and we're going to run a schedule, and then two cardiologists show up at 10 or 11, and one shows up at seven in the morning, and so it works both ways. And so everybody has to say, all right, I'm going to schedule this, and I'm going to be there, and I expect, you know, unless some rare circumstance, that you all will provide what you're saying, and you all will do what you say, and we're going to run a real schedule. And that changed a great deal. Very interesting. One thing that, honestly, I hadn't even ever thought about this, what you just described, how this communication certainly improved patient care significantly, also because it's now giving you the chance to pre-op the patients. You can see the patients and prep a recovery before, rather than just meeting the patient who's on the table, come here, sedate this patient. And I hadn't even thought about that being a consequence of what we started. But the communication, along the lines of everything else we've talked with the AP staff, and giving the chance of people to voice their concerns, and you act, I think it's paramount for the safety and success of everything we're doing. Excellent. Now, I'm curious for both of you to hear more, having gotten to watch the case this morning, about the protocols that you've worked out for delivering anesthesia, and ventilation in particular, at key points in time. Can you tell me about both the process of how that evolved, and what specifically you're doing? So I've been very fortunate to work with Bob, and the other anesthesiologists, and Julie as the lead CRNA, and the EP lab to develop the protocol that we use today. So what's being published, they were, my colleagues are drafting this. So I think we have to understand how important proper sedation of our patients is today, right? Having a patient paralyzed will improve the entire procedure. You don't want a patient coughing. There is enough data that suggests that patients done having a fibroblast under general anesthesia have better outcomes than patients done under conscious sedation. There are, there's other data suggesting that more stable patients, for example, works showing that high frequency stimulation, pacing faster during the ablation improves outcomes. So with that in our mind, and also thinking that during mapping, the requirements are different, with the protocol we developed focused on a few things. One, the sedation is propofol-based. I think that's an important discussion today because the anesthesia literature overwhelmingly shows that propofol, you have less nausea. You are more likely to have same-day discharge. So this is before the EP literature. So we do, we start with propofol, succinylcholine for short-acting paralytics. We use some Versed and fentanyl because with propofol, one of the concerns they voiced to me was the patients were going to have awareness during the case. So particularly as you're paralyzing the patients, we use a BIS monitor, so bispectral index monitoring to reduce the chances. So a little, some Versed, some fentanyl. And then immediately, we have the patient put at 16 breaths a minute for the gating in the beginning of the procedure for mapping systems that require gating. And once we are transeptal, and we're going to start the process of mapping. So some mapping systems use gating, some use compensation. The ones that use gating, it is important, you will improve the efficiency of the mapping having a prolonged expiratory phase. So that's why we then switch to eight breaths a minute with one to four IU ratio to prolong the expiratory phase. So you will have much faster mapping. Around that time, we map where the phrenic nerve is. We will tag the phrenic nerve. Once tagged, we give rocuronium. So we give long-acting paralytics. As we switch to ablation, we make another change. We go to 30 breaths a minute and a tidal volume of 200, which will decrease significantly the respiratory base cardiac motion. So you're going to have a much more stable catheter, and at the same time, stimulate at 500 milliseconds. As we complete ablation, and we always do about 15 to 20 minutes of isoproteranol, our protocol is halfway into the isoproteranol infusion. We will cut the dose of propofol in half and continue to decrease it. At some time towards the end, we'll switch to SIMV to allow patients to start building some CO2 and promoting spontaneous ventilation. At the same time, if I'm 10, 12 minutes into the isoproteranol infusion, there's no evidence of any arrhythmias induced, we will use the neuromuscular stimulation to see if the patient is going to require reversal. And if so, we typically use Sugamidex for reversal. With this, what we have accomplished in our lab is once we complete the procedure, once we say we are done, we have on average a time to extubation of 6 to 7 minutes. And we've shown that across thousands of patients. In the study we did, out of 1,200 patients, we had one patient re-intubated due to congestive heart failure. So we haven't had any anesthesia-related complications using this protocol. So it has, I think it's a protocol that we did jointly with the anesthesia department that focuses on our requirements during mapping, improving the efficiency and outcomes of ablation by having the patient more stable, and ultimately improving the turnover of your time and the efficiency by shortening the time to extubation. Right. You know, what's really remarkable to me, actually just being in the lab and seeing your team work together, is all that, what you just told us now, you don't say that all the person in the lab, they just know what you're thinking and what to do next. So you've obviously set up this collaboration or this, you know, partnership from the beginning, and that's, you've related to the respective teams, and I think that's so important. I mean, they knew what you wanted before you even asked for it. You didn't even have to ask for most of the things today, am I right, or, you know, they're just so aware of it. I did not have to. But I will say, I mean, I'll just interject here. This is because Dr. Sorrell did take the time at the very beginning to kind of say, we want to do this, and we didn't always do it exactly that way. We kind of improved it and touched on it. And then one thing I'll say, too, about it is, if we think this patient's not really tolerating, you know, the SAT's dropping, or there's something, you know, then we can kind of back up. It's not just, we're going to do it this way, and we're going to charge it, you know. There is some dialogue occasionally. So I just think, once again, it's, to Dr. Sorrell's credit, it's a communication. He doesn't mind, you know, if he's, let's say, in fact, he wants to know. Pressure's down, you know, the patient's not quite tolerating this ventilation. Let's back up and then ease into it a little bit better, adjust it just a little bit to where, like you say, get the work done, but not have to, in any way, compromise patient care. And I have to say, I'll be first to admit, I wasn't really sure that it would be as tolerated as well as it has been when we first started. Setting up those standard protocols and modifying it to meet the patient's needs. Yeah, because some of the ventilatory parameters that we're using are not just right out of, you know, what everybody's kind of grown up with, so to speak. So it does take a little bit, and you have to say, well, yeah, we can keep playing with it and tweaking it. And so it does take, and there is a little bit of, well, actually, a considerable amount of individual, you know, individuality when it comes to some patients. But again, as a general rule, it is pretty much the protocol that we try to achieve with every patient. Yeah. And as an outside observer, just as Andrea said, it came across as very well choreographed, you know, clearly coordinated. So one of the problems I can perceive in a lot of labs, including my own, is we're working with not the same people every day. And there's 25 anesthesiologists in the group we work with. And any given day, I may be with any one of them. And so how would you go about that if you're an electrophysiologist in a lab with? You know, we have about 14 anesthesiologists here that routinely work at our hospital. And probably over the last year, we've probably had another five or six to rotate through. Now, not everybody will go to the cath lab. So that's one thing. We don't have everybody rotating through the cath lab. And we do also have one particular CRNA and maybe two or three that really are down there frequently. And I do think it is important to have at least some level of consistency. And if nothing else, have someone that if, and I'll be the first to admit, not every anesthesiologist gets along with everybody. And the same thing with every cardiologist or anyone. So I think it's important to have someone that you can say, you know, all right, Chloe, I'm gonna, you know, I'll just pick out one of our anesthesiologists. Chloe, I won't say her last name, but never mind. Chloe, so you need to be able to talk to Chloe and say, we need to get this done. We need, you know, this particular anesthesiologist isn't really wanting to do like, and if he's that uncomfortable, then maybe we need to talk about it or get something. Fortunately, I don't know that we really had it to go that far, but I could see in instances in the past that some are not gonna be that comfortable with some of the protocols. And if they're not, then we, you do have to be able to call someone and, you know, get things adjusted. So you're suggesting we have at least a point person. That's right, a point person. It doesn't have to be the, you know, the anesthesia chairman for the EP, but just a point person is exactly right. Some of the programs even have a hard time even convincing anesthesiologists you don't need an A-line. And again, I think it does come down to communication and expectations of what the EP doctor wants and what anesthesia wants and what's really needed. Well, and I'll be glad to touch. We have such a good relationship with our cardiologists now that if we really felt strongly that the patient needed an A-line, we could tell the cardiologist and cardiologist, it's fine, you know. But, and that does take, you know, I guess some experience and also too, as long as you, as long as we would say to the cardiologist that we needed an ART-line, they'll either put it in or we'll put it in, all right? And so both of us usually agree, but if, you know, it is so rare now that I think we need an ART-line when the cardiologist does it because we work together enough and both sides understand that, you know, this patient's sick enough to where we need some sort of a, you know, invasive monitor that we don't normally use. Well, and something basic, we took the time to explain what intercardiac echo is. And, you know, let me, look, if there's gonna be an effusion, we will tell before you see a blood pressure change. That's simple communication point that makes that conversation of, do we really need it much easier. I just heard you talk about communication, which is so key and I think that just rings, you know, it rings a bell even at home. And it's even before the patient gets to the lab. So it's, and it involves, so not just the physicians communicating, but also the Chris's, you know, the managers is trying to, if you have cases going on other places, right? So you're not often, you have many cases going on at the same time, getting people ready and in sequence. So having, you know, the communication and having a team and everyone communicating to each other. And I'll bring Chris into this because he knows real well that sometimes if we're busy and we're seeing a patient and Chris happens to be by, will you say to Chris, hey, as Dr. Sorio or Dr. Gindre, they mentioned that this patient's sicker than usual and they'll say, oh, sure. You know, they're aware or well, what's your concern? And then he can either go talk to him or we'll talk to him directly. Sometimes Chris will speak to him before we will and they already know. So I think it's very important to have someone and Chris will be the first to tell us if there's a, you know, that this patient's real, this patient's sick, this patient needs, he's gonna need, you know, something maybe out of the ordinary, whatever that may be, you know, so. Yeah, the communication has built enough trust in what we do, how we do in each other that that facilitates the flow now. And I'd like to piggyback off of Josh's last question regarding, you know, the universal adoption of a standardized practice. I'm coming from an academic institution where there's a lot of learners coming through our laboratory, including with our anesthesia team. So how would you suggest that communication be made to the learners so that all the learners are, you know, knowledgeable about what we're doing in the EP lab? You know, that's a real good point because we don't have any anesthesia residents at this institution, they're all CRNAs. But once again, we have new CRNAs that rotate through. And I still think that it's very important not only to have a port person, but to kind of explain why you're doing it. And most anesthesia residents, they'd be able to pick it up very quickly once they know, especially if someone said, here's the protocol, you must read this before you go in and it's, you know, at least have some basic parameters and here's why we do it. You know, we're not just doing it but, you know, just to irritate you. We're doing it because there's reason and it's for better patient care and for efficiency, things of that nature that I think everybody would understand and go along with, especially when they see a reason for. It might even make coming to the EP lab more exciting. Yes, doing new things, right? We've had, typically when there's a new CRNA or one who's in training that is shadowing another CRNA, we'll take the time to explain, this is what an afib ablation is. This is what intracardiac echo is. This is what pulmonary vein isolation is. I think, as Bob said, when they understand why I've asked them to do 30 breaths a minute and 200 tidal volume, they're our partners in patient care. They're not just doing because we are antagonizing them. There's a reason why we're doing it. There's a clinical reason and everybody's on the same team. We're all for clinical reasons to do things. And these standardized protocols, I'll point it, really, it's about standardization efficiency, but it's really about the patient, right? That's really what this is all about, making the best outcomes, keeping them safe, which I think you've just shown dramatically. Pretty impressive. And I'll touch on another thing that was somewhat unique and I kind of already brought it to it, but I think it's very important. Just from the very beginning, Jose said, if the pressure's down, if there's a change, let me know. Don't just start doing stuff, and whether it's fetal efferent or whether you're starting to give epi or anything, let him know, let her know up there. Don't just be, and I just think, as long as you're communicating, then the electrophysiologist may tell the anesthesia department, I know why the pressure's down. This is why, and you need to do something with it or you don't, I'll correct it right now. And so that just eliminates a lot of misunderstanding and then as things ratchet on down, now you're trying to correct something that didn't need to be corrected. So Bob, Jose, I'm hearing that certainly for your relationship, communication has been the real key in all of this. Yes, I tip my hat to Dr. Osorio. I think it was great to hear today before we started this, just chatting with Bob that I had forgotten that this really started before this hospital started. Just, it started with an hour meeting that I requested to have with the physicians that I knew I was gonna be working with for years to come. And when me and Chris met with Bob and Dr. Spivak, I mean, that was the beginning of it. It was the beginning of, I think, I mean, don't wanna put words in your mouth, but it made them comfortable with the process that, okay, we're gonna, we understand why we're doing things and how we're gonna be doing things and they could voice their side of the story. So it's interesting that requesting a meeting was just really the beginning of a long and successful work relationship for us. He still remembers that meeting even now. Oh, I really, it was. It impacts. Absolutely. And I think too, we no longer really think of the cath lab, even though it is technically a peripheral site, but we don't really think of it as a peripheral site because we staff it fully every day. And we pretty much know if we're gonna need three CRNAs for three rooms or two rooms or however many rooms that we, we usually run two to four rooms, five days a week. And generally it's three to four rooms, five days a week. And with that, it's just real important to have that level of consistency. And for the folks at smaller institutions or just don't have as, aren't as fortunate as we are to have this many electrophysiologists, even if you just ran two days a week, if you ran two days a week, but you did it consistently, you could do just as well and have just as good a program as long as it's consistent and you, and everybody knows on Tuesdays and Wednesdays, we're gonna be in the EP lab and expect to staff it. So Bob, I wanna ask you a question because I think it's important that other electrophysiologists understand this. For us to, we've been discussing to along this conversations today about to be a, to have a successful lab, you need to consider all stakeholders, right? So what is your opinion on how do you see, for example, a lab that you're gonna be called for one procedure and it may be a 9 a.m., it may be a 10, it may be a 3 p.m. What is the impact for your anesthesia program if that's the type of relationship you're gonna have with the electrophysiologist service? The relationship will never be good. You might be able to get the job done, but it's just, with, in the anesthesia world, it's, we try to run on a schedule. It's all about trying to, it's trying to have the appropriate staff with appropriate rooms and running on a schedule. And that's one thing that I think it's very important if you can get everybody to say, we're gonna start at 7 o'clock, or you can even say, we're gonna start at 10 o'clock and we could try to do that, but it's much more difficult when you get in the middle of the day. But if you say you're gonna start at 7 o'clock and you don't start till 10 o'clock, that's even the worst. And then you get later on in the day and it gets worse. So anything like that just makes it more and more difficult. Yeah, and it's interesting, because you brought that up, because we used to initially do that, just thinking the anesthesia didn't wanna cover even other cases like pacemakers and ICDs and we thought we were being nice by just saying, cover this. I mean, while I have our nurses giving IV sedation, it takes a long time to recover. And we didn't like it and it wasn't probably the best thing for the patient. And then all of a sudden covering all the cases actually, I don't know if that's how you would feel too, is just to be able to staff your people. It's much better for us to have consistency and to start at the beginning of the day, because then we can have our CRNAs and a dedicated anesthesiologist there to where they know that's gonna be their place, as far as for the day or for even half a day. So you're talking about alluding to the model of using anesthesiologists and CRNAs to sedate all patients that come to the EP lab. So we did do that. And I don't know, I didn't actually ask you this before, but I don't know if you're utilizing anesthesia support for other types of cases. 100% of our cases. So that's what we do now too. And it's so much better for the patient. So much better. So much better for us as a provider. We've found the same thing. And again, it all started with a meeting and we have to have meetings regularly, especially initially. And you said now you don't need meetings with Jose. I found the same thing. And once you get those lines of communication going, then you can work out all the details. And we found the same thing. Our anesthesiologist told us we wanna start the day there and we wanna stay there all day. They don't wanna come for a case, go up and do an endoscopy and then come back and do another EP case. It's much better for them to just schedule out. Yeah, yeah. And now, just for clarification, we don't do routine casts. We don't select routine. I know that that's not what you alluded to, but I just wanna make sure that anybody watching this realizes that it's all... We do devices and any of the EP work, but I don't know that anyone's really doing routine casts. We don't do that. And we've done the same. We've gone to fully scheduling our block days, all day, even if it's just pacemakers and ginseng. Yeah, yeah, yeah. Those two. So we haven't yet. I'm sorry to interrupt, because I'm wondering for all of you, actually, a question for all of you, how did you have that supply of anesthesia providers so you can meet the demand in the EP lab? I think that's what other programs like myself, like our program, we might struggle with. Well, but once you know the demand and you have a discussion about this is our demand, x many cases, x many procedures, this many times a week, they can plan. They can hire more people. They can work around that. I agree with that. When we first started talking about doing all devices, we didn't have enough people to supply the four rooms, five days a week, but we hired up. When you do hire up, and same thing with the anesthesiologist, at one time, when we first got started, the anesthesiologist kind of did the cath lab and maybe a room somewhere else, you'd like to say, but now it's pretty much the cath lab. You're pretty much at the cath lab, and you may have a bronc just down the hall or something like that next, where our bronc lab is next, if the cath lab's light on any given day, but most time, it's pretty much, you're running the cath lab, and you hire up, and if it's consistent, then it works fine. It's just that when it's really inconsistent, that's when you kind of get in trouble from the anesthesia world. But then it all comes back to the communication. If you can communicate that this is the anticipated need that we're going to have, that's going to fill up. Well, that's been a consistent message that I've been hearing from both of you. I was just going to say, in the summer, it's because it's slower. It might be slower because people are on vacation, but then anesthesia takes vacation, too, so it works out. That's right. Well, I want to thank you all for a very robust discussion. Thank you. That was great. Bye.

communication

partnership

EP team

anesthesiology

EP lab

patient care

efficiency