Aggregation of EP and AF Patients: Revisited

Introduction

Atrial fibrillation (AF) is the most common heart rhythm disorder in the world. It is estimated that three million Americans carry the diagnosis of AF, with the majority between 65 and 85 years of age. As the U.S. population ages, the incidence is expected to increase to 8-12 million over the next 30 to 40 years. Patients with AF are known to have a 5% greater risk of stroke than those without the arrhythmia, and strokes associated with AF tend to be more devastating than those attributed to other causes.^1-3

AF is the primary diagnosis for more than 460,000 hospitalizations a year in the U.S. alone, and contributes to the deaths of 80,000 Americans each year. Patients frequently have one or more comorbid conditions, which can contribute to both the development of the arrhythmia and complicate its treatment.³

In September 2011, Lancaster General Hospital (LGH), a 623-bed community hospital in Lancaster, PA, opened an arrhythmia unit (AU) dedicated to the care of electrophysiology (EP) patients, with a particular focus on patients with AF. At the time, approximately 1,000 AF patients were admitted to LGH annually, with patients located throughout the hospital’s cardiac telemetry units. AF treatment modalities and regimens were as variable as the physicians prescribing them. The average length of stay (LOS) for a newly diagnosed AF patient was 4.47 days, and readmission rate was close to 13.6%. Private practice physicians limited the organization’s ability to standardize care. 

Using LGH’s highly successful heart failure unit as a model, a multidisciplinary team created an arrhythmia unit to aggregate AF and arrhythmia patients and drive standardized treatment. The ultimate goals of the project were to find ways to decrease barriers to timely diagnostic and interventional EP procedures, decrease LOS, hospital cost, and readmission rates for AF patients, and to improve patient outcomes and satisfaction. 

Unit Organization

The team for this 20-bed inpatient unit developed standardized AF admission and discharge order sets, and discharge instructions specific to each physician group. Working with the admitting office and nursing supervisors, the team established criteria for AU admission. EP sedation nurses and AU staff created education binders personalized for each patient; the binders included information about medical condition(s), medications, diagnostic/interventional procedures, labs, and treatment team members. All AU staff members received additional education and training specific to the EP patient population. In addition, twice-weekly AF education sessions provided AU patients with more in-depth education as well as the opportunity to ask questions and compare their experiences with other arrhythmia patients. As described in a previous EP Lab Digest^® article in 2012, initial outcomes trended favorably.⁴ This article will discuss the progress to date with a concentration on our results with AF patients. 

Other Elements of the Arrhythmia Unit Organization

Antiarrhythmic, anticoagulant and other medication therapies are the norm for this patient population. These patients have atrial and/or ventricular arrhythmias, and frequently a variety of co-morbidities as well. Therefore, constant patient monitoring is essential to recognize negative effects on the EKG, signs and symptoms of inappropriate dosing or side effects, medication interactions, and/or renal or hepatic complications. A Pharm.D. with a specialty in cardiology is now present on the unit three days a week to evaluate provider orders, monitor lab results, consult with nursing and providers on new or existing medications, and assist with patient and staff education. This resource has been a welcome addition to the professional team and is proving to be an important patient safety feature. 

To expand the new nurses’ knowledge and enhance relationships with physicians and nurse practitioners (NP), each new RN orientee spends a day rounding with an experienced EP NP after successful completion of the hospital’s Arrhythmia Interpretation course. The RNs visit arrhythmia patients both in the AU and throughout the house. The bedside nurse and his/her preceptor interact daily with physicians and NPs, which is essential to honing their critical thinking skills. Rounding with the NP, however, allows the nurse to focus specifically on rhythms, medications, case types, and interventions without being challenged by the need to address questions and concerns about their assigned patients. It also provides an opportunity to learn practice patterns that influence clinical decisions and reinforces what they experienced while observing procedures in the EP lab. AU and EP lab staff periodically collaborate on Grand Rounds events that highlight interesting and new technologies, patient scenarios, and procedures. 

EP and AU staff also collaborated on the creation of a wide variety of short educational documents that support the educational needs of patients regarding diagnoses, procedures, medications and lifestyle changes. This very current, evidence-based information is on the AU unit website and available to caregivers throughout the hospital. The website provides free and easy access to the educational materials by all hospital employees to use for patient teaching and for their own educational needs. In addition, the documents can be copied and pasted into the patient’s electronic medical record to validate patient education, and be incorporated into their discharge instructions. 

Metrics with Aggregation

Since the unit’s inception, a total of 1,019 AF patients have been admitted to the AU. For fiscal year (FY) 2010 and 2011, the average LOS for AF patients was 4.47 days and 4.44 days, respectively. For FY 2012, following unit aggregation, average LOS decreased to 3.74 days (age and gender adjusted p<0.001).⁵ Through the fourth quarter of FY 2013, LOS for AU patients has decreased further to 3.35 days. In contrast, average LOS for all AF patients (including those patients who were not on the AU unit) was 3.84 days for FY 2013 (Table 1). Aggregating AF patients has also impacted hospital cost, with average cost reductions seen for patients in Diagnosis Related Groups (DRG) 308 (cardiac arrhythmia and conduction disorder w/major comorbidities or complications within DRG classification (MCC), 309 (cardiac arrhythmia and conduction disorder w/CC), and 310 (cardiac arrhythmia and conduction disorder without CC). Readmission rates within 30 days of hospitalization have not changed significantly. Our readmission rates within 30 days have averaged between 11.5% and 13.7% for FY 2013. In FY 2011, the readmission rate within 30 days averaged 12.94 days. However, given that the national average for 30-day readmission for non-valvular AF patients is currently 18%, Lancaster General was already outperforming in this area.⁶

The AU has also had a significant effect on patients’ satisfaction with their physician’s care. According to Press Ganey patient satisfaction data, 75% of AU patients in FY 2011 felt their physician treated them with courtesy and respect. By the fourth quarter of FY 2013, that percentage had increased to 84.4%. Similarly, 61% of patients in FY 2011 felt their physician explained their condition in a way they could understand; by the fourth quarter of FY 2013, that percentage had increased to 68.9%. Satisfaction with nursing care has remained flat through the same period (Table 1). We reported these AU metrics as an allied professional oral abstract at the Heart Rhythm Society’s Scientific Sessions in May 2013⁵ as well as at the LGH annual patient safety fair. 

Other Care Trends

Because the AU has a large concentration of arrhythmia/AF patients, treatment trends and variances have become more evident. For example, several AU nurses noticed a large number of patients on IV amiodarone with infiltrated IVs. On further analysis, the RNs discovered that many physicians, mainly cardiologists (EP and non-EP) but also some internists, were ordering IV amiodarone for control of AF even in stable patients. After reviewing the data collected by the AU nurses, the physicians worked together to revise and strengthen the IV amiodarone protocol and improve compliance checks. AU staff, physicians, and NPs also began questioning a variety of current processes, many of which have existed for years and have been followed without question because “it’s always been done that way.” 

In recent months, physicians have been exploring more outpatient treatment options for patients with AF. Practitioners are eliminating non-essential testing (echocardiograms, labs, etc.) and working on treatment pathways for newly diagnosed AF patients so that treatment is streamlined and more efficient. By examining barriers to care and identifying treatment algorithms that are most effective, we hope to continue to positively impact our patient outcomes. 

Recently, AU nurses have begun to take a more active role in the bi-weekly AF education classes. Using an educational video and a variety of other teaching tools, the nurses are helping AU patients to better understand their disease and treatment options. Teaching patients, families and significant others strengthens the nurse/patient relationship, and helps keep nurses up-to-date on current treatment modalities.

Outpatient Initiatives

Patient education continues in the outpatient environment. One cardiology practice provides shared medical appointments (SMA) with an EP NP for AF patients. Patients are given the option to participate in the SMA while still hospitalized. The SMA allows the NP to educate multiple patients at a time, and helps patients share frustrations and experiences. It also reinforces previous teaching and has been positively received by our patient population.⁷ Other outpatient initiatives are planned, specifically, nurse practitioner-directed patient follow-up in an organized Atrial Fibrillation Center. 

Ongoing interactions and discussions amongst the nurse manager, EP director, lead NP, and EP educator, while essential, are not enough. Physician leaders have attended AU Governing Council meetings to address mutual concerns, build trust and brainstorm solutions. The council is composed of several RNs and two support staff. Other staff members are invited to participate depending on the agenda. This provides an opportunity for rich dialogue, goal setting and the ability to dispel misconceptions. The manager attends the EP department’s performance improvement committee meetings, and the AU Steering Committee meets quarterly to evaluate progress and address issues.

Although aggregation has demonstrated an initial positive impact, patient aggregation continues to be a work in progress. Getting appropriate patients admitted to the unit on a consistent basis has been an issue from the beginning. The majority of AU patients are admitted to an EP service; many have EP procedures during the week and are discharged home the day after the procedure. During periods of high census, and especially on weekends, the AU routinely receives patients without a cardiac or EP diagnosis simply because the unit has empty beds. Prioritizing admissions to the AU to patients of a large cardiology practice has helped somewhat, but inappropriate admissions still occur and continue to be a source of frustration for AU staff and physicians. 

Physician practice still varies from group to group, and sometimes from physician to physician within groups. Efforts to further engage physicians in the process include having AU representatives at cardiology/EP service line and performance improvement meetings, and one-on-one discussions with the unit’s nurse manager regarding unit-specific issues. These conversations have increased physician and staff relationships as well as compliance with unit policies. Physicians and NPs are using published AF treatment guidelines from the Heart Rhythm Society⁸ to help them create standardized treatment regimens for AF patients. Treatment standardization has also been assisted by greater acceptance of ablation therapy as a primary treatment modality for AF by both practitioners and third-party payers.

Multidisciplinary rounds (MDR), which include nurses, providers, care managers, and pharmacists, are an effective way to promote collaboration and communication among team members. We have found a main patient concern is outpatient pharmaceutical costs, specifically, novel anticoagulants and antiarrhythmic medications. The AU has processes in place to help address these patient concerns. However, we are still exploring the most efficient way to create a multidisciplinary rounding process to further address holistic patient needs for optimal patient outcomes and patient satisfaction. 

Conclusion

Since its inception in 2011, aggregation of atrial fibrillation patients on the AU has had a positive impact on LOS, cost and patient satisfaction at our institution. We have accomplished much over the past two years; however, we continue to explore ways to improve processes, collaboration, and outcomes. The difficulties associated with AF will continue to grow given our aging population and health care resource challenges. Aggregation, standardization of care processes, and a focus on patient engagement and education are strong tools to improve care metrics.

Acknowledgement: The authors wish to acknowledge the AU and EP lab staff for their many contributions that have made this initiative a success.

Disclosures: Ms. Deck, Ms. Riefenstahl, and Ms. Thompson have no conflicts of interest to report; Ms. Repoley reports that outside the submitted work she received payment from Medtronic for development of educational presentations including service on speakers’ bureaus (for teaching of allied health professionals regarding heart rhythm disorders).

References 

1. Tu HT, Campbell BC, Churilov L, et al. Frequent early cardiac complications contribute to worse stroke outcome in atrial fibrillation. Cerebrovascular Dis. 2011;32:454-460.
2. Hong HJ, Kim YD, Cha MJ, et al. Early neurological outcomes according to CHADS2 score in stroke patients with non-valvular atrial fibrillation. Eur J Neurol. 2012;19:284-290.
3. Heart Rhythm Society Atrial Fibrillation Fact Sheet. Available online at https://www.hrsonline.org/News/Fact-Sheets/AFib-Facts#axzz2YqmpQYBX. Accessed July 12, 2013.
4. Riefenstahl A, Deck S. Aggregating EP/Arrhythmia Patients to Improve Outcomes. EP Lab Digest. 2012;12:1,15.
5. Repoley JL. Aggregation, standardization and education – powerful tools to improve care for the atrial fibrillation patient. Heart Rhythm. 2013;10:S1.
6. Johnson BH, Smoyer-Tomic KE, Siu K, et al. Readmission among hospitalized patients with nonvalvular atrial fibrillation. Am J Health Syst Pharm. 2013;70:414-422. 
7. Tergesen A. Tired of waiting for a doctor? Shared medical appointments could be the answer. Wall Street Journal online. Published May 30, 2012. https://online.wsj.com/article/SB10001424052748703811604574533460290578596.html. Accessed August 15, 2013.
8. Wann LS, Curtis AB, Ellenbogen KA, et al. 2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (update on dabigatran): a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol. 2011;57:1330-1337.