St. John’s Regional Medical Center (SJRMC) is a 230-bed hospital operated by Dignity Health, along with its sister hospital, the 180-bed St. John’s Pleasant Valley Hospital (SJPVH) in Camarillo, California. SJRMC was founded in 1912. St. John’s Regional Medical Center and St. John’s Pleasant Valley Hospital offer comprehensive medical services, and together, they represent the largest acute-care health organization in Ventura County. St. John’s hospitals serve all of Ventura County and beyond, including the cities of Camarillo, Moorpark, Oxnard, Port Hueneme, Ventura, and Somis.
When was the EP program started at your institution?
The first modern EP procedure, an atrial fibrillation ablation, was performed in 2013 at SJRMC.
However, it wasn’t until the last quarter of 2016 that the EP service started to become more active, implanting the first leadless pacemaker in Ventura County in September 2016 and performing the first cryoablation for atrial fibrillation (AFib) in Ventura County in November 2016. Progress rapidly continued into 2017 when we added a lead extraction program. In 2018, a WATCHMAN program (WATCHMAN Left Atrial Appendage Closure Device, Boston Scientific) and a hybrid epicardial-endocardial ablation (Convergent) program for AFib were created.
Our EP program became official last year, with Dr. Sovari named as medical director.
What is the size of your lab? Is the EP lab separate from the cath lab?
SJRMC has three catheterization labs, and SJPVH has one catheterization lab. The cath and EP labs are not separated — one of the cath labs at SJRMC currently has all the EP equipment, and is used for EP cases (875 square feet). The other cath labs are available for device implantation if needed.
What is the number of staff members? What is the mix of credentials at your lab?
There are a total of 32 employees in our combined EP and cath labs. During an EP procedure, there are typically four staff members to a team, including two RNs, one cardiovascular technologist, and one radiology technologist. An additional technologist is sometimes present if in training for an advanced procedure.
Who manages the EP program?
Our EP lab is managed by the medical director of EP services, the cath lab nurse manager, and a charge nurse for day-to-day operations.
What types of procedures are performed at your facility? What types of complex ablations are performed?
At SJRMC, almost all types of complex EP procedures are performed. SJRMC has successful programs for performing cryoballoon ablation, the Convergent procedure, lead extraction, and WATCHMAN device implantation. Leadless pacemaker implants, His bundle pacing, and all conventional device and ablation procedures, including VT and PVC ablation, are also performed at SJRMC.
Approximately how many catheter ablations for all arrhythmias, device implants, lead extractions and LAA closures are performed each week?
The total number of weekly procedures varies between 10 to 20 cases. While the majority of cases are device implantations, there are also 4-5 EP cases. We have two designated WATCHMAN implantation days each month, and on each of those days, 3-5 procedures are performed.
The mission of our EP program is to provide comprehensive care using all available treatment and procedural options to patients. Our successful program at SJRMC has had an extremely low rate of complications, which has brought us recognition in the region.
What types of EP equipment are most commonly used? What imaging technology is utilized?
We are the only hospital in this area to have the ultra-high resolution RHYTHMIA HDx Mapping System (Boston Scientific). We also utilize the CARTO System (Biosense Webster, Inc., a Johnson & Johnson company) and EnSite Velocity Cardiac Mapping System (Abbott) at SJRMC. A variety of catheters are available for use, including multielectrode catheters such as the INTELLAMAP ORION Mapping Catheter (Boston Scientific), contact force ablation catheters, and ablation catheters with additional sensors such as the INTELLATIP MIFI Ablation Catheter (Boston Scientific), as well as many other irrigated and non-irrigated ablation catheters. We also use the Arctic Front Advance Cryoballoon and CryoConsole (Medtronic). The Vivid i system (GE Healthcare) is used for intracardiac echocardiography. The WorkMate Claris Recording System (Abbott) is used for our recording system, and an additional LABSYSTEM PRO EP Recording System (Boston Scientific) is being purchased.
What percentage of your lab’s implants use MRI conditional, subcutaneous, or leadless devices?
Currently, almost all pacemaker and ICD implants are MR conditional devices. SJRMC implanted the first leadless pacemaker device (Micra transcatheter pacing system, Medtronic) in the region in September 2016. Since then, a total of 38 leadless pacemakers have been implanted. Subcutaneous ICD implants are performed, but make up only a small percentage of total ICD implants.
What new initiatives or technologies have recently been added to the EP program? How have they change the way procedures are performed?
Within the last two years, SJRMC has initiated several advanced EP programs that have revolutionized the level of cardiovascular care at the hospital and made SJRMC a hub for advanced EP care. Increasing our volume and the type of procedures performed has required hard work and collaboration from our staff and hospital administration. Further plans to expand the EP lab at SJPVH is under review.
What is a typical day like in your lab?
A typical day in the EP lab may consist of performing two AFib and/or atrial flutter ablations, followed by a third catheter ablation (either SVT or AFib). There may be a device implant as well.
How is shift coverage managed (typical hours)? How does your program handle call?
Typical shift hours are staggered from 6 AM to 5:30 PM. We have one team on call after routine hours for all urgent or emergency procedures needed in the lab.
Who handles procedural scheduling?
An administrative assistant at the cath lab location handles the scheduling of the EP and cath lab cases.
How is inventory managed? Who handles the purchasing of equipment and supplies?
A designated EP tech coordinates with our inventory specialist to ensure that the inventory is kept up to date. Vendors also coordinate with our inventory specialist.
In what ways have you cut or contained costs and improved efficiencies in the lab and device clinic?
We have focused on two main areas to improve efficiencies: 1) we try to minimize our turnaround time between cases, and 2) we train staff members for each particular procedure to increase their efficiency and speed during procedures.
How do you ensure timely case starts and patient turnover?
The charge nurse is the main person to coordinate and communicate with the pre-op area, anesthesiologist, electrophysiologist, and staff members, to make sure we have the patient in the room on time and that we are preparing all required supplies. There is routine communication between the operator and staff regarding having the required catheters and supplies for the case before each procedure starts. The type of anesthesia affects turnaround time. In general, we have less than one hour for turnaround before the next patient is in the room.
How are new employees oriented and trained at your facility?
New EP employees receive training by more experienced staff as well as in-service training by industry. They participate in our EP conference. Following this, they begin participating in EP cases as the second scrubbed technician until they are comfortable with that particular procedure.
What types of continuing education opportunities are provided to staff?
Mandatory educational case reviews of EP procedures are attended by all staff members and presented by the medical director of EP services. In addition, there is regular in-service training provided by industry to train and re-train staff members on both new and advanced procedures. Any unusual measures, findings, or complications during procedures may be followed up during a briefing session between the physician and staff. It may also be reviewed by medical directors for further action.
How many of your staff members attend medical conferences each year?
Last year, four of our staff members attended the Heart Rhythm Society’s annual scientific sessions, and there is an effort to provide support for staff to continue attending these type of meetings.
How do you prevent staff burnout and turnover?
This topic has become very important for us, particularly because of our recent expansion. Staff members are protective of break time and vacation time. Our need to employ more technicians and nurses has been discussed with the hospital administration, and is under consideration.
We have also designated one or two technicians to each advanced program (such as for WATCHMAN implants), to ensure adequate staff preparation and supply availability for those particular procedures. This has given a sense of ownership of certain programs to staff members.
Describe a particularly memorable EP case, and how it was addressed.
We recently had a 78-year-old male with a history of persistent AFib, coronary artery bypass grafting (CABG), transcatheter aortic valve implantation (TAVI) (valve on valve), and recent tricuspid valve (TV) clips who was referred for syncope and long pauses requiring pacemaker implant. Conventional pacemaker implantation could have caused tricuspid regurgitation, for which the patient recently had undergone tricuspid valve clipping. In addition, there was a possibility that an interaction between the lead and tricuspid valve clips would result in an insulation break long term. Leadless pacemaker implantation would avoid these complications. The procedure was performed successfully and without complication. The same patient was later brought to the EP lab and received a WATCHMAN device because of a contraindication to long-term anticoagulation therapy (Figure 3). Use of TAVI, TV clips, a leadless pacemaker, and WATCHMAN device in this patient with prior CABG is a great example of how new advances in cardiovascular technologies can help patients. Performing any of those procedures with a conventional surgical approach can be associated with much higher morbidity, longer recovery, and perhaps higher cost to the healthcare system.
In a different case, a 95-year-old female who was pacemaker dependent was referred to us with pacemaker pocket infection after generator change. She had restrictive cardiomyopathy with moderate mitral regurgitation, tricuspid regurgitation, and aortic insufficiency, and moderate pericardial effusion. In this case, the 20-year-old pacemaker leads were extracted successfully and safely using a hybrid extraction approach (removal from superior approach with snaring from inferior), and a leadless pacemaker was successfully implanted to minimize the chance of infection.
Approximately what percentage of ablation procedures are done with cryo energy versus radiofrequency?
The vast majority (>90%) of our AFib ablations are done using the cryoballoon. For other types of ablations, radiofrequency is the primary method.
What are your thoughts on the use of NOACs in patients with nonvalvular AFib?
NOACs are increasingly recognized as an alternative to warfarin, and in many cases, are a better option. They are easier to use (which helps increase compliance), have a steadier anticoagulation state, and there is a potential benefit in patients with PCI and cardiac stents.
Do you utilize lifestyle modification as therapy for your patients with AFib?
Lifestyle modifications, including weight loss and avoiding known triggers such as excess alcohol and caffeine, is routinely discussed with our AFib patients. Planning in this regard is individualized based on the patient’s need. Nutrition counseling is also available.
What approaches has your lab taken to reduce fluoroscopy time? What percentage of cases are done without fluoro?
Three-dimensional electroanatomical mapping and intracardiac echocardiography are extensively used to minimize fluoroscopy. Fluoroless ablation of AVNRT and AFib has been performed by Dr. Sovari and Dr. Brett Gidney. Overall, only a small percentage of fluoroless cases are performed; however, this has become a focus and goal for the near future.
What are your methods for device infection prophylaxis?
Routine practice of intraoperative antibiotic and sterile procedure is practiced and monitored carefully. Absorbable antibacterial envelopes are available for use in select high-risk patients.
How do you use the NCDR Outcome Reports to drive QI initiatives at your facility?
We are planning a quarterly QI meeting for EP procedures, in which we will use those data.
What are your thoughts on EHR systems? Does it improve your quality of care?
EHR systems are double-edged swords! On one hand, EHR improves the ability for documentation of patient data. On the other hand, extensive documentation has made it difficult to retrieve the most important and relevant information on the patient. Perhaps current EHR systems require extensive revision to improve the ability of more easily retrieving pertinent data. Maybe there will be a role for AI in future EHR systems!
What are some of the dominant trends you see emerging in the practice of electrophysiology?
An important change in EP has been the introduction of new and advanced pacing technologies such as the leadless pacemaker and His bundle pacing. It is exciting to have these emerging pacing technologies after decades of using the same conventional pacemaker systems.
AFib continues to be the main challenge in EP because of both its complex pathophysiology and increasing incidence. AFib patients have different pathologies. In fact, they are so different that the only thing some AFib patients have in common is the irregular heartbeat of their left upper chamber! For example, a 90-year-old patient with AFib and hypertension has a very different underlying pathology than a 30-year-old patient with a family history of AFib. I believe that recognizing this issue, focusing research efforts on categorizing AFib patients based on their underlying pathology, and offering treatments accordingly, will be a critical to improving our understanding and treatments for AFib.
Do you utilize remote monitoring of CIEDs?
Yes, we utilize remote monitoring for the majority of our patients. This is a critical technology that allows for earlier and more accurate detection and diagnosis of arrhythmias. However, we have found that it does require extensive time and resources, and is not particularly financially beneficial to our practice at this time.
Do you utilize digital tools or wearable technologies for patients?
Yes, we individualize these tools depending on the patient and their needs.
Is your EP lab involved in clinical research studies?
There are two physician-initiated research protocols under review in our young EP program. We are keen to join larger clinical studies in the near future.
Does your EP program have plans to expand?
Yes, plans for further expansion are currently being reviewed. This includes providing EP mapping and ablation equipment for the cath lab at SJPVH.
How do you see social media changing the field of healthcare?
Social media plays an important role in getting information out, exchanging ideas, and discussing difficulties in practice at all levels. The hospital has been active on social media platforms such as Twitter, Facebook, Instagram, and LinkedIn. Since social media platforms are easily and commonly used, we believe they will play an even bigger role in education in science and medicine, particularly in the EP field.
Describe your city or general regional area.
Our hospital is located in Ventura County, which is very diverse with multiple types of communities, such as beach communities, tourist areas, rural and agricultural areas, as well as a military base.
Please tell our readers what you consider special about your EP lab and staff.
Our EP program is proud to offer comprehensive EP care — from conventional device implants and EP ablations, WATCHMAN implants, lead extraction, leadless pacemaker implants, cryoballoon ablation for AFib, complex atypical atrial flutter ablation, hybrid epicardial-endocardial AFib ablation, His bundle pacing, to fluoroless catheter ablation — a wide range of complex procedures are performed successfully in our EP lab. We safely provide these services to our patients, and our complication rate remains very low.
Lastly, our elderly patients are the center of our focus and attention. We believe in providing procedural options to our elderly patients, who are the majority of our patient population. We have successfully implanted a leadless pacemaker in a 103-year-old patient, performed lead extraction in a 95-year-old patient with clear infection of the device, successfully implanted a WATCHMAN device in a 92-year-old patient, and safely performed cryoballoon AFib ablation in a symptomatic 91-year-old patient.
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