Advanced Arrhythmia Management in Conemaugh Health System

Background

Conemaugh Health System (CHS) was established in 1889 and has been serving the communities of Cambria and Somerset Counties and our neighboring areas since that time. Conemaugh Memorial Medical Center (MMC), the flagship hospital of Conemaugh Health System, is a 550-bed tertiary care regional referral hospital located in Johnstown, Pennsylvania, 70 miles east of Pittsburgh. Advanced cardiac services have been provided by the health system for over 20 years and span the spectrum from prevention and diagnostic care to the latest in surgical treatments and rehabilitation. However, until recently, the hospital system was without electrophysiology (EP) services. With the growth of cardiac care, interventional cardiology, and cardiothoracic surgery, came an increasing need for advanced arrhythmia treatment in the region. 

Prior to the development of Conemaugh’s EP department, the majority of device placement was done by general and cardiothoracic surgeons in the local area. Patients needing other advanced arrhythmia management, including ablation procedures, had to travel to surrounding metropolitan areas for their care. This practice limited not only continuity in patient care but also the ability of CHS to provide comprehensive cardiac treatment.

Concept

CHS has a large network of physicians, both private and as part of the Conemaugh Physician Group (CPG). The idea in originating the EP department was to serve both the private and CPG doctors and their patients to the best of our ability. We wanted to provide outpatient and inpatient consultation, medical management options, and device management,  as well as offer the complete range of EP procedures. 

Forming the Team

The initial clinical staff included an electrophysiologist (myself) as well as Matthew Hodge, PA-C, a certified physician assistant with more than ten years of experience in cardiothoracic surgery and cardiac patient care at MMC. I came to Conemaugh directly after finishing my EP fellowship at the University of Pittsburgh Medical Center. While I was able to bring my knowledge and skills to Johnstown, Mr. Hodge provided expertise from his many years of patient care as well as his clinical interactions within the health system. These complimentary skill sets allowed us to very efficiently integrate the EP services with CHS in both the outpatient and inpatient settings. Mr. Hodge works with EP patients not only in the clinic and on the hospital floors, but also assisting with device procedures in the EP lab.

Outpatient services of the practice are incorporated with the general and interventional cardiology services of CPG. We share office space and office staff with the primary cardiology group, but also make a conscious effort to work closely with the private cardiologists and primary care clinicians that request our services. Outpatient EP services are directed by Danelle Blough, MST, a multi-specialty technologist that works almost exclusively with the EP patients in scheduling appointments, diagnostics, cardiac monitoring, and procedures. She has also had many years of experience working in health care in the region, which has been invaluable to building good lines of patient and referring clinician communication.

Denise Botwright, who previously managed a single cardiology physician practice, now oversees the device clinic for all cardiac rhythm patients within CPG cardiology. She coordinates device clinics in Johnstown and the surrounding areas, ensuring that these patients have consistent device follow-up and that patients have timely referral to our team whenever issues arise.

Of course, the key to creating a comprehensive EP program was to build and staff a lab in Johnstown that would provide patients with the same level of care they could expect at any major metropolitan hospital.

Our Electrophysiology Lab

In January 2012, we began the process of developing Conemaugh’s EP lab. Like many programs, our EP lab staff as well as the lab itself developed as an outgrowth of the existing cardiac interventional department. MMC already had an interventional cardiology suite with four cardiac catheterization (CC) labs (only three of which were in routine use at that time) and a 16-bed holding area. It was the fourth out-of-service lab that was slated to be renovated into an EP lab. 

Given the fact that our hospital architects and construction teams had not previously had the experience of building an EP lab, the process was started by touring other recently constructed EP labs in Pittsburgh and the surrounding areas. Equipment and manufacturer lists were made. The architectural and construction teams began the remodeling process at the same time as equipment purchasing and installation were being coordinated. Our primary project in renovating the lab space was to overtake an existing equipment room, which allowed us to expand the control room and lab viewing area almost threefold. We reoriented that procedure table with the foot of the bed facing the control room to facilitate contact between operators and the staff working in the control room. 

As equipment was installed in the lab, staff members were trained on basic operations and mechanics. Our installation included a new fluoroscopy system, a dedicated anesthesia machine, EP recording, radiofrequency and cryoablation equipment, intracardiac echocardiography, and electroanatomical mapping systems. The staff worked with information technology specialists to build and streamline systems for inventory, recording, and documentation of the EP procedures.

The lab was completed and ready for use in November 2012, but the EP team was already formed and working by that point. Until the lab opened, device placement and very limited EP studies were being performed by our team in one of the previously renovated CC labs.

Staffing the EP Lab

The EP lab staff was primarily recruited from the members of the existing CC lab staff at MMC, most of whom did not have prior experience in electrophysiology. Those members of the CC lab staff who were interested in joining the team had the opportunity to attend lectures, visit other EP labs and work with Conemaugh EP clinicians. Ronald Petrunak, RT(R), (CV), BS was the manager of the MMC catheterization lab at the time the EP division was developed. He acts as manager to both CC and EP staff members, and has worked to oversee staffing and cross training of the cardiac service team. Dennis Sebetich, RN, BSN, CCRN, PCCN, a registered nurse with experience in critical care nursing and the CC lab, took on the role as lead EP nurse and has been with the department since its beginning. He has worked closely with our equipment vendors, information technology department, surgical supply and hospital purchasing to develop the lab and maintain inventory. Over the past two years, we have had some technologists with prior EP lab experience that have worked in the lab and have helped to train our existing staff and grow the department. However, at this point, the team consists exclusively of MMC natives. 

Valerie Berg, RT(R) is a radiation technologist who worked in the CC lab and expressed an early interest in working with EP. She has a very impressive ability to use her knowledge and equipment expertise to resolve unforeseen issues that arise during procedures. In addition to her technical role during procedures, Mrs. Berg has also taken responsibilities in lab inventory and cross training of other CC lab technicians. 

 Jesse Hoffmann, RN, who had worked in the lab intermittently over the past year, was the most recent employee to join the EP team on a full-time basis. Mr. Hoffmann, who has prior experience in catheterization and electrophysiology labs, has taken on a dual role in the lab, both circulating and frequently scrubbing to assist in device and EP procedures.

The secretaries and nurses that manage peri-procedural care for the catheterization patients, including Sherry Walkowski, RN, BSN, played an integral role in creating our system of scheduling and intake for EP patients. Their efforts have improved the efficiency of our program as well as enhanced our patient experience. Aubrey Shuhayda, RN, BSN, PCCN works with both CC and EP patients in the preoperative area. She has also taken on an extensive role in the EP lab, assisting with circulating and charting on many device procedures as well as assisting with EP studies and ablations.

We are continuing to cross train other members of the CC lab staff to ensure adequate case coverage for our procedures and patients. A number of the staff have valued the opportunity to work with and learn from our core EP team and have become an imperative part of our procedure process. In addition to our cardiac staff, the anesthesia department at MMC has been working with the EP program since its inception. They perform preoperative evaluation and case coverage for almost every patient that comes through the lab. Having the input of the anesthesiologists and certified registered nurse anesthetists during lab development and construction has allowed for better sedation management. We also made sure that members of the anesthesia team had the opportunity to shadow in neighboring EP programs prior to beginning our caseload.

Growing the Program

Since the lab first opened, we have been equipped to do the full range of device placement and EP procedures. The lab initially performed EP studies and ablations for supraventricular tachycardias, atrial flutter, and idiopathic ventricular tachycardias. Within the first six months of opening the lab, ablation of atrial fibrillation (AF) was also being done on a regular basis. In our first year with the lab and staff, we performed over 540 procedures, including device placements, EP studies, ablations and tilt tests. Our next area of focus for growth will be in lead management and extraction. As technology is developed, we also expect to do more extensive treatment for our AF and cardiomyopathy patients.

The creation of the electrophysiology department within CHS has fortunately coincided with the overall integration of Conemaugh’s heart and vascular care program. As our EP team and services have expanded, we have also had the opportunity to work more closely with the cardiothoracic surgeons and cardiology clinicians, which will be very valuable in future patient care. AF management is an excellent example of where this teamwork will be advantageous. Those of us in EP already understand the importance of identifying AF patients early, before their arrhythmia burden becomes too great, when ablation will be considered. However, it is also extremely important to consider the potential interplay among AF, cardiomyopathy, and valvular heart disease in many of these patients. Naturally, catheter-based AF ablation in a patient with significant mitral valve disease will only have limited success and certainly might not be the best course of action if that patient is a candidate for valve surgery. Likewise, treatment of uncontrolled AF can potentially negate the need for valve surgery in a patient with tachycardia-induced cardiomyopathy and resultant mitral regurgitation. Determining the best course of treatment for these more complex patients is truly a multidisciplinary process. 

As we continue to develop the heart and vascular program at CHS, the EP team will play an integral role in the management of two large cardiac populations: cardiomyopathy and AF patients. Certainly, we now have the facilities and the technology to perform device placement and ablations in these patients. Our future commitment will be to expand availability of cardiac care to our surrounding communities as well as create more formalized, integrated clinics to diagnose and treat these populations over the long term. 

Disclosure: The author has no conflicts of interest to report relative to the content of this article.