EP Tips & Techniques

Achieving Milestones in Lead Management, Atrial Fibrillation, and Accreditation: Experience at Winchester Medical Center

Daniel V. Alexander, DO, FACC, CCDS
Winchester Cardiology and Vascular Medicine, Winchester Medical Center
Winchester, Virginia


Daniel V. Alexander, DO, FACC, CCDS
Winchester Cardiology and Vascular Medicine, Winchester Medical Center
Winchester, Virginia


Winchester Medical Center (WMC) is a 455-bed regional referral medical center located in Virginia. Established in 1903, the medical center forms the flagship facility of the Valley Health System, which is comprised of six hospitals within the Shenandoah Valley of Virginia and extending into West Virginia. The Valley Health System provides care to a region underserved by medical assets, allowing patients to obtain local, high-quality care without the difficulty of traveling great distances. 

Winchester Medical Center has taken the lead in bringing innovation to a rural, underserved medical region. In this article, we discuss our efforts to reintroduce a lead management program, build an atrial fibrillation center, and achieve accreditation.  

The Team

The cardiac electrophysiology program at WMC began in 2009 under the leadership of Dr. Ejaz Khan. It was the first in the region. Dr. Khan also instituted a comprehensive lead management program, offering a service that was not commonly available. I joined WMC in February 2016 and am part of a group called Winchester Cardiology and Vascular Medicine, a private practice entity with a close relationship to WMC. 

WMC utilizes a clinical council leadership team to manage our EP service. This council is composed of myself, Heather Hostetler, BSN, as well as three implanting cardiologists who are very active in our council: Dr. Daniel Reese, Dr. J. Dixon Brown, and Dr. Ajay Virmani. Heather and I manage the clinical, business, and technology aspects of the cardiac electrophysiology program at WMC; this dyad between clinician and hospital service line coordinator allows for great collaboration between clinical mandates as well as the realities of the hospital budget and financing. Our council has been able to make significant changes to the EP department at WMC, including accreditation by the Intersocietal Accreditation Commission (IAC) as a certified electrophysiology laboratory, as well as ushering in new technologies and procedures for our department. 

The EP team at WMC also has a dedicated staff, including lead technologist Debbie Jenkins, CEPS, lead nurse Peter Schieve, BSN, clinical specialist Cindy Kettner, BSN, and two technologists, Sara Tusing, RCIS and James Blocker, RCIS. Lisa Behneke, PA and Elizabeth Robinson, PA (Figure 2) manage our device clinic and outpatient electrophysiology. The device clinic team is comprised of three device specialists and two additional ancillary staff members. The device clinic at Winchester Cardiology and Vascular Medicine manages over 3000 patients, including a robust remote device monitoring clinic. 

Collaboration in Lead Management and Atrial Fibrillation

Collaboration is often discussed as a positive force for larger programs; however, it is an absolute necessity in a smaller program with a single electrophysiologist. We are experiencing successful collaboration with our projects for a lead management program and atrial fibrillation (AF) center. 

When Dr. Khan left WMC, we lost an experienced lead extraction specialist. My previous program did not perform lead extractions, and my last experience with extraction had been six years prior, during fellowship training. Given the need for lead management in our community, I decided to reintroduce the lead management program at WMC. Prior to Dr. Khan’s departure, I tried to re-orient myself with the extraction process during as many cases as possible. I decided to have one of our cardiac surgeons, Edward Kofsky, MD, FACS, become fully involved as a lead extraction specialist, and together, we began rebuilding the program. In many extraction centers, the cardiac surgeon simply waits for an emergency to occur. At WMC, the electrophysiologist and surgeon serve as a co-management team. Every case is performed either in our hybrid laboratory (Figure 3) or in the operating room. Our plan is to build a comprehensive lead management program, bringing a much-needed service to the Shenandoah Valley. 

In conjunction with our Chief of Cardiovascular Services, Basel Ramlawi, MD, we are also in the planning stages of developing a comprehensive AF center that would open in 2018. Our conventional endocardial approach to atrial fibrillation has served well for paroxysmal as well as early persistent AF patients. We have a significant number of patients who continue to have symptoms related to persistent and longstanding persistent atrial fibrillation. WMC is involved in the registry for the AtriClip (AtriCure) for left atrial appendage occlusion. Additionally, we are working toward an endocardial left atrial appendage occlusion program in collaboration with our structural heart disease specialist, Omar Ali, MD. 

Having recently added cryoablation for the management of paroxysmal AF has provided for increased efficiencies in both time and effectiveness. Development of a workflow strategy for AF ablation has been crucial to the efficiency of our program. This requires synergy between cardiac anesthesiology, nursing staff, outpatient scheduling, and the recovery room. Our approach to paroxysmal AF has been to utilize a cryoablation strategy with suitable anatomy and clinical characteristics (distinct pulmonary vein ostia, atrial size <5.5 cm, and relatively low burden of atrial fibrillation). 

Achieving IAC Accreditation

In April 2017, the Valley Health Heart & Vascular Center at Winchester Medical Center (WMC) received the Intersocietal Accreditation Commission (IAC) Cardiac Electrophysiology accreditation. Debbie Jenkins, CEPS spearheaded this initiative. The process involves submitting data from our lab of case volumes, continuing education and training for our laboratory staff, quality assurance programs, and continuous process improvement. Frank Vermeiren, MS, RT(R)(CV), RDCS, Director of IAC Accreditation, Cardiac Electrophysiology, was instrumental in facilitating the accreditation of our laboratory. We are very proud to be a smaller, community-based program that has sought and obtained national accreditation, and judged on the same standards as larger institutions in the country. We were the first in Virginia, and one of only a handful in the U.S., to receive IAC accreditation; other labs in the state are now looking at having their own labs certified in the same way.

In addition, we are seeking Atrial Fibrillation Accreditation by the American College of Cardiology. Kayla Roberts, RT(R) (CI), who heads our educational initiatives program at the Heart and Vascular Center, took the lead on this program, and we hope for accreditation in the first quarter of 2018. Evaluation by nationally recognized external organizations allows us to maintain best practices, and ensures that quality is represented by each member of the cardiac electrophysiology team. Hospital-wide accreditation ensures that all of the providers at Winchester Medical Center maintain best practices in the management of atrial fibrillation.

Disclosure: The author has no conflicts of interest to report regarding the content herein. Outside the submitted work, Dr. Alexander reports personal fees from Winchester Medical Center.