Denver Health Medical Center

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EP LAB DIGEST. 2025;25(5):1,15-17.

Benjamin A Steinberg, MD, MHS, FACP, FACC, FHRS, EP Director; Christopher Barrett, MD; Amy Unteutsch, BSN, RN; Jenn Forristall, RN; Jocelyn Legner, BSN, RN; Richard Roberts, RCIS; John Nichols, CEPS, RCIS; Anissa Phothiboupha, RCIS, AART; Aaron Seidler, BSN, RN; Eric Smith, RCIS  
Denver Health Medical Center, Denver, Colorado

Describe your city or general regional area. What specific challenges does your hospital face given its unique geographic service area? 

Denver Health is located in the heart of the city of Denver, enmeshed among the population we serve. It is a historic, safety-net hospital, the health system primarily responsible for care of the under- and uninsured of Denver, including a large immigrant population. Many patients struggle with mental and substance abuse disorders, often complicated by and complicating arrhythmia care. Frequently, acute care encounters might be our only opportunity to intervene in a process that could have devastating long-term consequences. Fortunately, the staff across the health system embraces this mission.

What is the size of your EP facility? 

We currently have 1 primary EP room for ablations and devices, with overflow into a second lab for device procedures as needed.

What is the number of staff members? 

Across the cardiac catheterization and EP labs, we have both a clinical manager (MSN, RN) and clinical educator (BSN, RN) to help ensure a balance between overseeing day-to-day operations and providing ongoing education and support to the staff. 

Our staff are the crown jewel of the program. They are highly skilled in EP and all float between the EP and cath labs, including ST elevation myocardial infarction (STEMI) and vascular call. 

Our primary clinical staff includes 7 nurses (1 ADN, RN; 5 BSN, RNs; 1 BSN, MS, RN), and 5 certified tech specialists (3 RCIS’s; 1 ARRT(R), RCIS; 1 RCIS, CEPS). There are also 2 charge nurses (1 BSN, RN; 1 BSN, RN, RCIS), and 1 inventory specialist.

What types of procedures are performed at your facility? 

We are largely full-service EP, including all manner of catheter ablations, device implants, and left atrial appendage occlusions (LAAO). However, the lack of onsite cardiac surgery largely precludes routine lead extraction or epicardial ablation at this time.

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

For ablation cases, we primarily use catheters and mapping from Johnson & Johnson MedTech, including the ThermoCool SmartTouch SF catheter, QDOT contact force-sensing ablation catheter, and SoundStar ultrasound catheter. Transseptal access is usually achieved with powered needles from Baylis Medical Technologies.

What are some of the new technologies and techniques recently introduced in your lab? How have these changed the way procedures are performed?

Using the latest Carto nGEN generator, QDOT ablation catheter, and SoundStar ultrasound catheter (Johnson & Johnson MedTech) has routinely enabled minimal- and zero-fluoroscopy ablation procedures. We have upgraded to Carto V8 and anticipate including pulsed field ablation this year.

Discuss your techniques for preventing esophageal injury during atrial fibrillation (AF) ablation.

We routinely monitor esophageal temperatures during ablation, modifying in response to elevations. As more sophisticated technologies have not clearly been shown to improve outcomes, we have not felt them worth the cost.

How is inventory managed in your EP lab?

We have taken on an active inventory management approach, with live tracking of everything used. This has greatly minimized expired equipment. Additionally, with 2 primary operators, we are able to harmonize equipment and minimize the variety of shelf stock, simplifying inventory and clinical flow.

Can you describe the extent and use of vascular closure devices in your EP program? Tell us about your approach for same-day discharge (SDD). 

We have embraced vascular closure devices where appropriate—that is, in settings where the benefit outweighs the cost. This includes patients eligible for SDD, those with high-risk vascular access, difficulty with bed rest, or other considerations. As many of our patients struggle with housing instability, SDD is often not a reliably safe option. However, in addition to inpatient observation stays, we sometimes have access to other destinations, such as temporary respite care.

Tell us about your device clinic, including its staffing model, day-to-day function, and tools/software used.

As a relatively smaller program, we are reliant on a critical partnership between our device nurses and an online device monitoring platform to assist with data acquisition, preliminary interpretation, and routing. This has allowed us to be relatively nimble in effectively and efficiently managing our unique patient population.

Discuss your approach to remote monitoring of arrhythmias, including management of data deluge from cardiac implantable electronic devices (CIEDs). 

We have partnered with a commercial platform that integrates data from all the major manufacturers. They have helped us streamline processes for routine checks while maintaining control over more serious and uncommon transmissions and alerts.

How do you ensure timely case starts and patient turnover?

To ensure timely case starts and efficient patient turnover in our EP laboratory, we rely on a combination of staff ownership and accountability as well as continuous improvement strategies. Outliers, such as turnover that is slower than optimal, are routinely reviewed to identify controllable variables that can be improved.

How does your lab schedule team members for call?

Scheduling team members for call in a combined catheterization/EP lab remains a challenge due to the need to balance the different demands of both cath and EP procedures. Staff are given the autonomy to self-schedule their on-call shifts based on their availability and preferences. This helps staff members manage their work-life balance while ensuring that the lab is adequately covered during both elective and emergent procedures. Our staff understand the demands of a combined lab setting and work together to support each other during busy periods or when unexpected changes arise. Team members step up to cover shifts and willingly collaborate to help determine solutions when coverage is required at short notice.

Do you have flexible or multiple shifts? How do you handle slow periods?

Staff are encouraged to proactively schedule their paid time off (PTO) in alignment with the lab’s block schedule and provider availability. This ensures that the workflow is balanced and resources are optimally utilized, especially during high-demand periods.

During periods of low case volume, we offer “low census” opportunities, which allow staff to adjust their hours or shifts accordingly. This helps maintain a flexible workforce, ensuring that we have the right number of staff available when demand increases and reducing unnecessary labor costs during slower periods.

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

The ‘geography’ of our EP lab is highly advantageous in that the control room is shared with interventional cardiology and vascular medicine. Additionally, all labs are close in proximity to the physician offices, allowing for easy collaboration among all invasive cardiology teams and ready access to other operators. As we prepare for the replacement of our fluoroscopy equipment in the next 2-3 years, we are focused on maximizing efficiency, safety, and flexibility for optimal patient care delivery in our EP laboratory redesign.

What measures has your lab implemented to cut or contain costs?

This is an area of great interest and attention for us, given our unique, safety-net hospital status. In addition to contract negotiations for materials, we are attentive to inventory status, opportunities for reprocessing, supply chain changes, and which products are opened during cases. The guiding principle is to balance cost versus potential benefit to the patient for various technologies, ensuring we maintain a high quality of care.

What works well in your lab for onboarding new team members?

As a small group, we commit the primary EP staff specialists to provide guidance and mentorship to any staff interested in learning EP.

What continuing education opportunities are provided to staff members? 

Our unit-based cath/EP lab educator (BSN, RN) and EP specialist (RCIS, CEPS) coordinate weekly vendor-supported education with the staff. 

Discuss your program’s approach to conduction system (CS) pacing. 

We have embraced the use of left bundle pacing for most standard pacing implants and indications, as well as “bailout” for CS leads that are not feasible or optimal. Given the acute setting might be the only opportunity to care for our patients, providing a pacing solution with the lowest risk of a downstream cardiomyopathy is particularly appealing.

Discuss your program’s approach to lifestyle risk factor modification for reduction of AF. 

Our unique patient population often includes challenges with housing and food instability, as well as drug and alcohol addiction. Often, an observation or inpatient stay provides opportunities to engage addiction medicine specialists and social resources to address these major social determinants of health.

Tell us about your primary approach for LAAO.

Given our unique patient population, we often consider LAAO in perhaps less traditional settings. Nevertheless, we have maintained a “right patient, right time” approach, including thoughtful shared decision-making around the approach to stroke prevention in AF.

What are your thoughts on recommendations from the 2023 guideline for the diagnosis and management of AF, and how has it impacted your clinical practice?

Among the major advances in this version of the guidelines is the acknowledgement that risk stratification for stroke goes beyond the CHA2DS2-VASc score. Additional considerations, such as AF burden, atypical risk factors, and/or social determinants of health allow us as clinicians to better tailor the approach to individual patients, including the latest evidence on AF-related stroke risk factors. Again, given our unique patient population, acknowledging this heterogeneity of risk and treatment effects is essential to effective and efficient care.

Discuss your approach to treatment of AF in patients with heart failure.

Supported by the latest evidence and guidelines, we have taken a relatively aggressive approach to rhythm control among patients with AF and heart failure. This is particularly valuable in our patient population, where follow-up may be a challenge. This complicates the use of the limited antiarrhythmics that can safely be implemented in patients with heart failure (eg, amiodarone, dofetilide), which require frequent clinical monitoring. Therefore, catheter ablation has become a major tool to improve outcomes in these patients.

What approaches has your lab taken to reduce fluoroscopy time? What percentage of cases are done without fluoroscopy? How do you record fluoroscopy times/dosages?

We are continuously working to minimize radiation in the EP lab. More than half of our ablations are performed with zero fluoroscopy, thanks to Dr Chris Barrett’s pioneering efforts in the space. In fact, our staff have come to expect this!

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

We are fortunate in EP to benefit from immense technological innovation and progress in short periods of time. This allows us to more effectively and safely treat heart rhythm disorders every year. However, this is balanced with a responsibility to be good stewards of the resources, and understanding the incremental cost-benefit of new technologies is essential to responsible implementation, particularly in a health system such as ours. We have approached innovation as an opportunity to understand the tradeoffs of cost versus clinical benefit to the patient and/or system, and factor that into whether we ultimately implement new approaches.

What is considered historic about your EP program or hospital? 

Denver Health has been Colorado’s primary safety-net hospital, in one form or another, since 1860. There is a long-standing commitment by the staff to the “mission” of Denver Health—serving any and all, including people experiencing poverty, uninsured, pregnant teens, those suffering from addiction, victims of violence, and unhoused populations. For some, it is even a family affair—for example, Dr Steinberg is a second-generation Denver Health physician!

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

We have some of the best all-around staff—all the EP team members also cover cardiac cath cases and take STEMI call. Despite this breadth of responsibility, they have mastered EP and have been key in the high-quality care of a sometimes very challenging patient population. 

Acknowledgement. We are grateful for the support of Denver Health cardiology leadership, including Brian Stauffer, MD, Casey Grant, RN, and Heather Shockley, MSN, RN.