Achieving the New Atrial Fibrillation With EPS Accreditation

In this feature interview, EP Lab Digest speaks with Baptist Health Lexington, the first facility in the United States to receive full Atrial Fibrillation with Electrophysiology Services (EPS) Accreditation status from the Society of Cardiovascular Patient Care (SCPC).

How many EP labs are there at Baptist Health Lexington? How many EP lab staff members and electrophysiologists are there? When was the EP lab started at your institution? 

We have three dedicated EP labs at Baptist Health Lexington. There are four EP physicians, 6 registered nurses, and 5 registered radiologic technologists. The EP lab was started in the fall of 1993. 

What types of procedures are performed at your facility? Approximately how many atrial fibrillation patients does the hospital see annually?

We perform all types of catheter ablations including both FIRM and Stereotaxis-guided AFib ablations. We also implant ICDs, BiV devices, pacemakers (including leadless pacemakers), LAA occlusive devices, and loop recorders. Lead extractions are also performed at Baptist Health Lexington. On average, we perform approximately 50 ablations and 45 device implants per month. 

In 2014, we had approximately 360 patients with a primary diagnosis of AFib seen in our ED and/or admitted to our facility. An additional 800 patients were scheduled for outpatient AFib treatment (external cardioversion or ablation), and another 241 patients were admitted for Tikosyn initiation.

What new technology do you utilize in the lab?

New equipment and device technology includes MediGuide Technology and EnSite NavX (St. Jude Medical), the SmartAblate System (Biosense Webster, Inc., a Johnson & Johnson company), the Topera 3D Mapping System, Arctic Front Cryoablation (Medtronic), and 3D intracardiac imaging. The introduction of these technologies has reduced both procedural and fluoroscopic times as well as improved procedural accuracy.

What else can you tell us about your facility?

We have a truly integrated EP team that is focused on efficacy, safety and providing quality outcomes. We take pride in providing excellent patient care, while staying on the cutting edge of the latest in electrophysiology. The physicians and majority of the EP staff have worked together for a minimum of 10 years. In addition, through our independent research foundation, we have been involved in the most up-to-date device and ablative technologies. Finally, we are fortunate to have the Center for Atrial Fibrillation and Heart Rhythm Disorders, which is an outpatient clinic staffed by APRNs and RNs. The center was started in February 2010 by our EP Medical Director, Dr. Gery Tomassoni, and is the only center of its kind in Kentucky. Patients are often seen in the center prior to evaluation by an EP physician. A patient’s initial evaluation includes testing, development of a treatment plan by an APRN, and in-depth education from an RN and a PharmD about AFib and their medication regimen. Each patient is then scheduled for follow-up with cardiology and/or EP physicians. Patients are also seen in the AFib Center after ablation and/or cardioversion, and as needed for symptom management. Same- or next-day appointments are often available, and patients appreciate the ease of access to clinical staff for phone management.

Baptist Health Lexington is the first facility in the U.S. to receive the AFib v2 Accreditation with EPS status from the SCPC. Describe this certification, and how it differs from the SCPC’s Atrial Fibrillation v2 Accreditation.

AFib v2 was designed to implement evidence-based guideline-driven clinical practice, up-to-date performance measurements, and process improvement across the full continuum of care for AFib patients — from the community, through the ED and inpatient experience, and back into the community. It is available with two designations:

• Atrial Fibrillation Accreditation with EPS (for those facilities that provide full electrophysiology and surgical services)
• Atrial Fibrillation Accreditation (for those facilities that refer their patients to other hospitals for those services)
• To achieve Accreditation with EPS, a facility must meet additional criteria:
• The lead EP must perform ≥100 EP studies and ≥35 catheter-based cardiac ablations (for any arrhythmia on any cardiac site and with any technology). They also must earn ≥30 hours of Level 1 CME credits every two years.
• The facility must provide surgical services to include intra- and extracardiac ablations and LAA excision or occlusion procedures. 

Why did your facility choose to pursue this designation from the SCPC? What was your goal in earning AFib accreditation?

The accreditation helped us align our processes related to the assessment, treatment, and management of AFib patients with evidence-based science to improve the quality of patient care, which also impacts patient satisfaction and cost efficiencies. With the incidence and prevalence of AFib reaching staggering proportions in the next two decades, we will demonstrate our commitment to the care of AFib patients to both our internal and external communities. We hope that by going through this process, the AFib v2 Accreditation will help position our hospital to meet the economic burden of this patient population. 

What was the time frame for accreditation, from start to finish? How long did the process take? 

We previously worked with the SCPC and achieved full Atrial Fibrillation Certification status in December 2012. The SCPC requested we become a beta site for their new accreditation program in 2013. The advantage of a “bricks and mortar” AFib center allowed us to complete the accreditation application process in approximately 4-5 months, where it otherwise would have taken much longer. 

The resources and comprehensive knowledge base of our AFib coordinator was invaluable for the compilation of documents, protocols, and patient data that were required to meet the criteria for the accreditation. 

What members of the staff and hospital (including different disciplines) were involved or in charge of this accreditation process? Was a subcommittee established to organize and enact plans for fulfilling the criteria needed for AF certification? How often did staff members or the subcommittee meet during the accreditation process? 

We have maintained a multidisciplinary approach to managing the AFib patient. For this accreditation we had our AF Coordinator, who is an RN, take the lead on this project. Key members of our team from EP, administration, clinical staff and management, cardiologists, hospitalists, emergency department (ED), and EMS were brought to the table to discuss gaps in care and process improvement. An AFib subcommittee was created within our Chest Pain committee, which meets quarterly. Ongoing communication between meetings also occurred during the accreditation process.

What is the process like for achieving AFib v2 Accreditation with EPS? What are the essential components for demonstrating expertise in AFib v2 Accreditation, and how were they addressed? 

There are 7 essential components built around evidence-based guideline-directed recommendations and best practices to guide facilities through process improvement: 

1. Governance – develop educational AFib programs for physicians, providers, and staff, ensure competencies and skills, and monitor compliance with accreditation goals. We created an online learning module on AFib for staff caring for AFib patients in our facility. Our cardiology and EP physicians are also actively involved in CME offerings and “grand rounds” to staff and peers. 
2. Community Outreach – raise awareness and educate the public, as well as primary and specialty care providers and staff, and integrate the hospital with the community. Our AFib program coordinator provided “Lunch and Learn” sessions on AFib, stroke, and anticoagulation (including the CHA₂DS₂-VASc score) at many PCP offices, spoke to church groups, offered a “Meet the Expert” session with Silver Sneakers, as well as pulse checks and education at several community health fairs.
3. Pre-Hospital Care – integrate the hospital with first responders and healthcare providers, identify measures for process improvement, and educate EMS to better care for AFib patients. EMS participates in our Chest Pain and AFib subcommittee meetings. 
4. Early Stabilization – develop protocols for triage and initial treatment, develop risk assessment strategies, and implement evidence-based guideline-driven care for the early management of AFib patients. Protocols were developed to give ED physicians the option to perform cardioversion in the ED, without the need for prior TEE in patients whose episodes were confirmed to be 48 hours’ duration or less, or were anticoagulated for at least 3 weeks prior. These patients are discharged home with next-day follow-up in the AFib center, rather than being admitted.
5. Acute Care – develop protocols for ED and inpatient management, and guide patient care through rate control, rhythm control, and prevention of thromboembolism. Placing a CHA₂DS₂-VASc calculator on the intranet has raised awareness of the importance of evidence-based anticoagulation. Next steps will be to refine existing inpatient AFib protocols to assist the hospitalist with timing of cardiology consults for external cardioversion.
6. Transitions of Care – develop discharge processes that ensure effective transition of care including educating, improving patient compliance, and providing follow-up. Individualized medication calendars (with medication names, doses, reason for taking, and timing) are created by a PharmD for patients. These are reviewed with the patients by pharmacists and nursing staff. The patients are instructed to bring their medication calendar to follow-up appointments. 
7. Quality Measures – develop processes to capture performance and outcome data, and visualize numerous calculated measures that compare actual performance with facility-determined thresholds and goals. 

Tell us about the ways in which AFib v2 Accreditation with EPS helps hospitals measure patient outcomes and monitor performance. 

Individual patient data entry into the Accreditation Conformance Database is used to automatically calculate established performance and outcome measures. Hospitals can view how these measures are changing in real time as data is entered. All patients who enter the facility through the ED and are discharged with a primary diagnosis of AFib are included in the database. These patients may be discharged from the ED, observation services, or an inpatient unit. Reports can be generated and, as the measures change, improvement can be documented in real time. If the measures are not meeting facility-generated benchmarks, facilities can drill down on the data and implement strategies for improvement.

How has your facility’s approach to atrial fibrillation treatment and management changed since earning this accreditation? Describe some of your protocols established for best practice.

Achieving the designation of AFib with EPS accreditation has significantly increased the awareness of AFib in our overall patient population. We have seen an increase in referrals to our AFib Center from PCP, hospitalists, and our cardiologists, resulting in increased procedural referrals to our EPs. We have a better process to track our outcomes and provide the essential feedback to our providers. Best practice protocols have improved, such as the documentation of the CHA₂DS₂-VASc score and follow-up appointments for ED patients in our AFib Center. We identified early on that same-day or urgent appointments and external cardioversion were essential to meet the needs of our patients.  

What tips do you have for other labs considering or currently going through the accreditation process? 

Obtain the guidelines for AFib accreditation as soon as possible, and perform a gap analysis. Based on the gap analysis, a timeline for the accreditation process can be developed, but expect this to be 6 months or longer. Administrative support and medical staff commitment to AFib is essential.

What does achieving AFib v2 Accreditation with EPS mean for the staff at Baptist Health Lexington? 

The AFib v2 Accreditation helped our hospital provide a coordinated, comprehensive approach to AFib management, which has validated the quality of care and excellent outcomes we provide to our patients. 

Is there anything else you would like to add? 

Accredited hospitals have to demonstrate a higher level of expertise in the treatment of patients with AFib. Image and market differentiation is essential to hospital and healthcare systems. AFib with EPS Accreditation is a competitive advantage that is generating new patients for our hospital system.

Disclosures: The authors have no conflicts of interests to report regarding the content herein.