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Achieving Atrial Fibrillation Accreditation: Interview with Dr. Derek Rodrigues
The Bob and Patty Edwards Arrhythmia Center at Overlake Medical in Bellevue, Washington, was recently the first on the West Coast and only the ninth in the nation to receive national accreditation by the Society of Cardiovascular Patient Care (SCPC). In this feature interview, we speak with Derek M. Rodrigues, MD, FACC, who started the Electrophysiology program at Overlake Hospital, about the accreditation process.
Tell us about the Arrhythmia Center at Overlake Medical Center.
Our EP program was created in 1996, and there are now 3 electrophysiologists, including Jeffrey Fowler, MD and J. Alan Heywood, MD. We have 2 dedicated, state-of-the-art EP labs that are equipped to do 3D mapping, and we use both St. Jude Medical’s EnSite and Biosense Webster’s CARTO systems.
Last year we were the only Seattle-area hospital and one of the few regional hospitals to use FIRM-guided therapy using the Topera Rotor Mapping Solution (Abbott) for more complex atrial fibrillation (AFib) patients; we have had about 9 months’ experience with that software and mapping system, with encouraging results. We were also the first in the northwest region to use contact force sensing for ablation; we did our first cases with this technology in April 2014, and we think it has really been revolutionary in terms of improvement in outcomes and safety.
Approximately how many AFib patients does the hospital see annually?
We receive our AFib cases through our primary care network and through the Emergency Department and urgent care clinics. On an annual basis, we see over a thousand novel atrial fibrillation cases. When we went through the AFib accreditation process, we became familiar with the number of ways that AFib patients come into contact with our healthcare system.
Why did your facility choose to pursue this designation from the SCPC?
In 2001, Dr. Heywood and I began performing AFib ablation. Our initial focus was mainly on safety and not so much with the length of the procedure. As a consequence, we’ve had a remarkable safety record for a growing AFib ablation program, and have now completed about 2,000 AFib ablations. During this time, we realized that we wanted to have a much more robust approach in the care of our patients, and we wanted to bring the excellence we achieved in the EP lab in terms of safety and success to the program in general. We also wanted the care of our AFib patients across the hospital system to be excellent and consistent with practice guidelines. For example, we found that there wasn’t clear documentation of stroke risk score in our AFib patients; physicians were taking account of a patient’s stroke risk, but there wasn’t documentation of what that risk was. When we looked at appropriate anticoagulation in patients, it wasn’t always clear to us why the patient with a high risk score was not being anticoagulated; the reason for the absence of anticoagulation may well have been compelling, but again the documentation wasn’t always clear. Therefore, we decided that if we were going to achieve excellence for the institution, there would have to be a widespread, systemwide, multidisciplinary approach in the care of these patients. We looked into the SCPC and thought they had a very rigorous model for evaluation of programs, performing gap analysis, targeting areas of variance and building action plans with application of policies and protocols that were guideline driven or reflected best practice. They’ve been around for a while and have done good work with designating Chest Pain Center Accreditation. At the time, the SCPC was also the only organization addressing arrhythmia care in this fashion. We were well into the accreditation process before the announcement was made about the merger with the American College of Cardiology (ACC), but it was still a validation for us, because the ACC had probably concluded the same thing we had, which is that the SCPC is a leader in helping transition institutions to the next level of care.
What was the time frame for accreditation, from start to finish?
The accreditation process took a little over a year. I think what we all liked about this program is that it held our institutional “feet” to the fire, in the sense that there were timelines by which tasks had to be completed, and if those deadlines weren’t met, there were financial penalties. From a clinical standpoint, I appreciated their approach because it was not punitive but encouraging. In other words, their timelines reflected a knowledge of how institutions work and helped avoid inertia. From an institutional standpoint, having a timeline was very helpful because it moved the process along quite rapidly and helped us accomplish tasks on time.
Who was involved in this accreditation process?
Although I was the clinician lead on this, we needed an individual to be almost full-time dedicated to this task. The hospital hired a nurse practitioner, Roxanne Bliss, ARNP, and designated her the EP navigator. This job function was created to mimic a similar role utilized in the cancer field, which has had a navigator role for midlevel providers for some time. The notion is that after a significant diagnosis, management of treatments can be quite complex for some patients, depending upon which treatment strategy they choose. Having a navigator helps guide patients through the process and allows for excellent care delivery, ensuring issues don’t fall through the cracks, and in turn, the patient feels educated and supported. For example, a patient needing an AFib ablation will need to be counseled as they might be initiating anticoagulation for the first time, and we need to make sure this goes smoothly. Patients starting an antiarrhythmic medication will need proper monitoring, etc.
The care process involved in these patients is quite complex and, in some ways, similar to a patient with a cancer diagnosis: how do you successfully lead your patients and help their treatment be a comfortable process for them? The navigator role helps fulfill this important function. At Overlake, we have Roxanne and Mary Hall, ARNP in this important role.
Roxanne’s first task was to assist us in becoming a designated Arrhythmia Center of Excellence, and help shepherd the process.
What can you tell us about the process for achieving AFib Accreditation?
One of the systemwide changes we made during the accreditation process is that patients entering our system with AFib are now immediately given a stroke risk assessment. We chose to use the CHA2DS2-VASc score because it has been the most widely adopted. The hospital had also recently introduced the Epic system into our outpatient and inpatient environment, so we used this as an opportunity for this documentation to be in the electronic medical record. We worked with our hospital’s Epic team and had representation from the Emergency Department, hospitalists, and nursing staff to adopt this stroke risk scoring system. Since documentation is increasingly becoming a burdensome requirement by providers, it was important to include these additional disciplines because they would be most impacted. We wanted to have them create and understand a tool they felt their departments would accept and embrace. As a consequence of this multidisciplinary collaboration, we were able to create a very innovative tool. If you look at other centers nationwide, they use a very cumbersome and manual process to come up with a patient’s score — that certainly interferes with workflow and reduces compliance. We wondered, why couldn’t we make this process automatic? Since the patient’s information already resides in the medical record, why not have the EMR system automatically come up with the score? So our in-house Epic team created this, with input from our multidisciplinary team. Once a patient has a diagnosis of atrial fibrillation, it will now automatically scan the record to generate a CHA2DS2-VASc score. Some components are obvious in the record, such as age and gender, but it also scans for the presence of coronary artery disease, prior stroke, hypertension, diabetes, etc. We found that as we tested it, the automatically derived score was very accurate. We extended the model to reflect appropriate treatment. If the CHA2DS2-VASc score is greater than 1, then anticoagulation is recommended or documentation is provided for why treatment is inadvisable. The patient record is scanned to find whether an appropriate anticoagulant is in the patient’s medication list, and if not, the system would alert the clinician to say their AFib patient with a CHA2DS2-VASc score of 3 was not on an anticoagulant, giving them the option to easily prescribe one by providing a set of choices to select from. If the clinician is aware of any reason why the patient shouldn’t receive an anticoagulant, there is an opportunity in the system to select high-risk bleeding, patient refusal, etc. It’s a very automatic, clinician-friendly process that ensures an accurate stroke risk assessment, appropriate anticoagulation based on that stroke assessment, and the ability to prescribe anticoagulants or provide documentation for non treatment. The advisory also informs the provider of the patient’s estimated annualized stroke percentage, which can be helpful in counseling. We set it to update every 6 months to a year, so every year the clinician has the tools to go back and make sure the patient’s score and clinical circumstances haven’t changed.
It’s a great tool that we’re very proud of. We were even complimented by the SCPC because they hadn’t seen anything like this used at any other institution. Creating this tool took a number of meetings as well as a significant amount of investment and time. However, it now serves as a model for other conditions, by providing automatic clinical guideline assessment and Best Practice Advisories. It has improved our documentation rate from about 15-20% to 98%, well in excess of what the SCPC needed in order to demonstrate excellence!
What are some of the other ways your facility’s approach to AFib treatment and management has changed since earning this accreditation?
In addition to stroke risk assessment and appropriate anticoagulation, we also had to ensure policies, procedures, and protocols were followed in the outpatient and inpatient environment, so order sets were created for clinicians to confirm that patients admitted with AFib were receiving appropriate care. For example, we created order sets to ensure that persistent AFib patients have good rate control and that clinicians have what they need to help achieve that goal.
Education was a big factor as well. An educational program was built into the system to help educate our nursing staff who manage AFib patients. Nursing administration has made it a requirement for nurses to complete this educational module, and it’s updated every year or so. There is also an educational outreach requirement for clinicians. Therefore, we produce educational resources and participate in educational symposia to help educate our medical community on arrhythmias and current arrhythmia care. We also present talks to the community. Finally, we created an educational website in which patients could access information about their condition and learn about the resources we have to offer.
What tips do you have for other labs considering the accreditation process?
Organizations that are engaged in AFib work and have a desire to go to the next level should look into accreditation — we certainly have found this to be a very holistic and robust program. However, it is important to note that accreditation does require a lot of commitment on the part of hospital administration to provide the resources. Care providers must also be committed because they have to give up their time. It is important for everyone to understand that this is a time-limited process, meaning that there are intense work requirements to be able to achieve this. It’s also an ongoing process, not a one-time deal. We agreed that a thoughtfully done accreditation was less a one-and-done project and more about an ongoing journey. For 2-3 years following accreditation, you have to show that your institution can remain engaged in this. The assumption is that after an institution is engaged in this process for 2-3 years, it becomes part of their DNA and what they do. This process is supposed to be meaningful and deep, and not something superficial. It impacts the institution at an administrative level as well, because they have to make this a strategic objective. It helped that our hospital CEO, Michael Marsh, was very supportive with this program initiative. We’ve also worked with the SCPC to make the accreditation process less onerous on the part of the institution — hospitals have a desire for clinical excellence and are looking for a process that will be easy for them to adopt.
What does achieving AFib Accreditation mean for the staff at Overlake Medical Center?
From both an institutional and clinical standpoint, we can look at what we’ve been able to achieve and feel more satisfied that patients entering the system with a diagnosis are getting better evaluational assessment. This is reflected in the medical record, with automatic reminders sent to address any care gaps. This also has affected the patient care experience, in that patients are able to feel they have been educated about and understand their condition, and feel comfortable and supported with the care path that they have chosen. As clinicians, we have pride that we’re doing a better job and that patient care has been enhanced. There is also a systemwide level of awareness that we’re providing better resources for our patients. In addition, it reflects the knowledge that measured performance positively influences outcome.
Is there anything else you’d like to add?
There are other components that facilities might like as well. For example, since some of our AFib patients end up on amiodarone, we’ve developed a similar Best Practices Advisory tool for ensuring that amiodarone follow-up guidelines and recommendations are built into the system. On an acute, 6-month, or annual basis, our system alerts clinicians on the need for either lab or pulmonary function testing, because with about 600 of our patients on amiodarone, we needed a better way to ensure that patients were getting guideline-based assessment in a timely fashion.
We’re also engaged in both retrospective and prospective AFib ablation outcomes. AFib ablation outcomes were not a requirement — it was a recommendation that the institution be engaged in this process. However, as we looked into what constituted excellence in a program, we thought this was a very important component.
Once the SCPC provides an organization with the goals they need to meet, they have to figure out how to make it work and what they are going to do to achieve it. The SCPC allows the organization to figure out for themselves how to do this, because what works for one organization might not work for another. For example, based on our experience, the SCPC’s recognition of our clinical tool for stroke risk assessment was something they were very impressed with, but you would have to figure out if it would be a good fit for your program as well. There are certainly various pieces of the process, and the SCPC tries to present institutions with different options based on their experience working with a number of institutions.
