Key Factors for a Successful Arrhythmia Program: Experience at Memorial Hermann The Woodlands Hospital

The Objective

In the spring of 2011, I began discussions with Memorial Hermann The Woodlands Hospital with the goal of instituting a complex cardiac arrhythmia program that would allow me to treat my patients with the same world-class level of care achieved at the Texas Medical Center in downtown Houston. In September 2011, the program was officially launched.

Memorial Hermann The Woodlands Hospital is a 252-bed community-based hospital that serves a growing population in Montgomery County just north of Houston. The hospital’s two current cath labs provide excellent care for interventional cardiology procedures, and one of the labs is outfitted to accommodate basic EP procedures, including EP studies and SVT ablations. Prior to the inception of the program, most electrophysiologists practicing in the greater North-Houston area typically had to transfer their patients out of the local area an hour or more south to the Texas Medical Center to receive complex EP procedures. Therefore, the motivation for developing a complex cardiac arrhythmia program in Montgomery County was simple: benefit both patients and referring physicians by keeping local patients at the local hospital. Patients appreciate the ability to receive care close to home, and referring local physicians appreciate the ability to remain involved in a patient’s care simply by virtue of the patient being treated at a local hospital where they have staff privileges.

An Integrated Approach

Instituting an EP program capable of accommodating complex EP procedures requires a coordinated and integrated effort among the cardiac cath lab staff, CV anesthesia, and CV surgery. It is vitally important to have an open dialogue with each of these service lines to discuss issues relating to routine matters such as scheduling demands and equipment and supply requirements, as well as to clearly identify potential complications and outline protocols that can be enacted should complications occur.

Dealing With Management

Developing our arrhythmia center at Memorial Hermann The Woodlands Hospital was met with enthusiasm and overwhelming support from the hospital’s administrative team. I attribute this to an alignment of the program’s goal with that of the administration: to create an environment that would allow the hospital to keep local patients in the area and avoid the need for patient transfers to the Texas Medical Center.

In dealing with hospital administration with respect to developing a new cath lab program, it is essential to begin a dialogue that is focused on establishing well-defined and practically achievable milestones. Accordingly, the focus in the beginning should not be on procuring “all the fancy toys,” since approaching hospital administration with a list of expensive equipment demands is unlikely to rally much support for any program. Rather, it is important to make use of the hospital’s existing facilities, equipment, and resources whenever possible. As cath lab volumes increase under the new program, it will be easier to justify additional equipment requests as well as garner support from administrators for such requests. Also, it is wise not to forget that maintaining a hospital’s support for a new program will be easier if the new program contributes to the hospital’s ultimate objectives: providing the highest level of care while increasing procedure volumes and avoiding complications.

Also, do not neglect to take advantage of a hospital’s public relations tools and resources. In efforts to promote our new complex cardiac arrhythmia program, Memorial Hermann The Woodlands Hospital has been an invaluable resource for introducing the arrhythmia center to the community. By hosting speaking engagements with different community organizations and promoting the program through the local media, Memorial Hermann The Woodlands Hospital has helped the program gain a great deal of exposure. The hospital also has established a dedicated phone line that allows patients to obtain information about the program and be connected to nurses and other program staff who can answer questions or provide additional information. In addition, lectures and promotional “advertising” in the local media have helped us reach out to our community physician colleagues to inform them about the program so that they are knowledgeable about the new services that are now available to treat their patients.

Ancillary Services

It is mindful not to neglect other hospital support services when developing a program that will introduce new procedures into the hospital setting. As mentioned earlier, a coordinated relationship among the cath lab staff, CV anesthesia, and CV surgery is essential. However, the importance of appropriately educating other hospital staff that may interact with a patient having a “new” procedure also is of critical importance. For example, following a pulmonary vein isolation procedure, a patient was admitted to the hospital for an overnight stay. That evening, the patient developed some chest discomfort, a symptom not uncommon following such an ablation and that usually represents pericarditis or inflammation. The floor nurse responded to the patient’s chest pain with a STAT ECG and then contacted me to ask if nitroglycerin sublingual could be given. While this is certainly an appropriate treatment option for patients with potential ischemic-related chest pain, it is not indicated for patients following an ablation who typically have no underlying heart disease. The point here is to remember to educate staff involved in ancillary services at all stages of care about any new procedures introduced with the institution of a new cath lab program, from staff who will assist with admitting the patient, to floor nurses who will provide post-procedure care.

The Key to Success

The most important factor in creating a successful lab is the staff. Without a motivated team willing to learn new techniques and invest the time and effort necessary to learn to work together efficiently, a lab can never truly excel. At Memorial Hermann The Woodlands Hospital, we were fortunate to have a highly skilled team at the inception of our new complex cardiac arrhythmia program that already worked well together and eagerly embraced the challenges involved in learning new skills and working on new EP procedures. As Leigh Brown, the cath lab’s manager explains, “I’m so proud of my staff. They’ve done a great job of incorporating the new procedures into their skill sets.”

The bulk of the responsibility for staff training comes from, and should come from, the physicians. Invaluable opportunities for training present themselves when physicians are willing to spend time with lab staff during cases reviewing intracardiac electrograms, discussing guidelines and procedure indications, and reviewing scenarios for dealing with potential complications. Additionally, the greater understanding that cath lab team members have with respect to a patient’s condition and the details of a procedure, the more likely each person on the team will feel motivated to stay connected to the case.

Be mindful that training can also come from sources other than physicians. For instance, take advantage of industry representatives who can be present for cases and provide supplemental training to lab staff. Having these representatives present and available to answer questions and troubleshoot with new equipment on the spot can help keep procedure time low and prevent lab staff from becoming unnecessarily frustrated.

Finally, physicians should not hesitate to include lab staff in conferences or other training opportunities presented to physicians. For our program, we were fortunate to secure funding for our dedicated EP/cath lab staff members to attend the 2012 Boston Atrial Fibrillation Symposium along with our program physicians. According to Troy Milliken, one of our EP lab nurses, “The experience was definitely worth it. It helped solidify us as a team, and opened our eyes to the newest and latest technology.”

Future Projection

Currently, the dedicated EP lab for our new complex cardiac arrhythmia program is equipped with a biplane camera and St. Jude Medical’s EnSite mapping system. The lab stocks equipment such as intracardiac echocardiography and different ablation generators to accommodate a multitude of EP procedures including complete EP studies, outflow tract ablations, SVT ablations with a focus on atrial fibrillation, and limited ischemic VT cases.

Expansion of the program is an ongoing project, and as the program develops, we hope to outfit a second lab with full EP capabilities, including the incorporation of a Biosense Webster Carto mapping system in order to accommodate requests from physicians to provide both mapping system options. We also intend to expand our procedure capabilities to include cryoablations, epicardial access approaches to mapping and ablation, and the new left atrial appendage ligation procedure.

Final Thoughts

Obtaining and maintaining the support of hospital administration, coordinating among both essential and ancillary services, and training and motivating lab staff have each proved to be fundamental components in successfully implementing a complex cardiac arrhythmia program at Memorial Hermann The Woodlands Hospital. As medical director, I look forward to guiding the expansion of the program, with the ultimate goal of eliminating the need to transfer patients residing in Montgomery County out of the area for even the most complex of EP procedures.