Atrial Fibrillation Certification Program at Porter Adventist Health Care System

The Society for Cardiovascular Patient Care (SCPC) began certifying hospitals for atrial fibrillation in 2011, with the primary goal of assisting healthcare facilities to better evaluate and manage patients with atrial fibrillation (AF). In addition, the SCPC sought to improve the quality of AF care by encouraging education regarding atrial fibrillation for both healthcare providers and patients. 

Our interest in this process began after reading about the Genesis HealthCare System, which was featured in 2012 in EP Lab Digest^® for achieving the first AF certification in the United States.¹ Recognizing that Centura Health was committed to these very same goals, providing quality cardiac care and improving education with all aspects of heart care, including atrial fibrillation, we began to plan for certification. Porter Adventist Hospital, one of the hospitals in the Centura Health care system, had previously demonstrated their commitment to such optimal levels of care, achieving both Heart Failure Accreditation and Chest Pain Center Accreditation from the SCPC in 2012.

Centura Health consists of 15 hospitals in Colorado and Western Kansas. Seven of the 15 hospitals are located in the Denver Metro area. Centura Health care facilities and hospitals in the greater Denver metropolitan are integrated with the goal of developing systemwide approaches for the optimization of cardiovascular care. To facilitate integration of individual hospitals into a single overarching system, physician directors from each subsection of cardiology were appointed. Sri Sundaram, MD, FHRS, with South Denver Cardiology, was appointed the systemwide director of clinical cardiac electrophysiology and put in charge of improving the quality of electrophysiology care provided at Centura hospitals in the Denver area. 

The AF certification article in EP Lab Digest^® prompted us to contact the SCPC to discuss the certification process. Recognizing that this certification would showcase our expertise in the care of atrial fibrillation, provide a unified systemwide approach for AF care, and consequently improve quality at all Centura hospitals while also allowing for cost savings, we approached the Centura Health Cardiovascular Council with our plan. The council consists of chief executive officers from each of the individual hospitals in the Denver Metro area, as well as cardiovascular service line directors, cardiac cath and EP lab directors, cardiovascular nursing leaders, and other key physician leaders. We felt it was critical to obtain the cooperation of all potential involved parties to achieve the certification. AF certification can only occur at hospitals with advanced state-of-the-art electrophysiology labs. For this reason, Porter Adventist Hospital was chosen as the site to pursue atrial fibrillation certification. 

Porter Adventist Hospital has a very active electrophysiology department. There are four cardiac electrophysiologists that practice primarily at the hospital. In 2013, approximately 500 EP cases were performed at Porter in two full-time electrophysiology labs. One lab has a Carto 3D mapping system (Biosense Webster, Inc., a Johnson & Johnson company) while the other has a NavX 3D mapping system (St. Jude Medical). Of these 500 cases, approximately 250 were various ablations, 100 of which were AF ablation procedures. The volume of cases is increasing every year, and this trajectory is projected to continue as a result of strong physician leadership, excellent team cohesion, and superior patient outcomes. In addition, a state-of-the-art hybrid operating suite and cardiac catheterization lab are also being utilized for device implantation. Porter currently has 11 lab staff members who are all trained in both cardiac catheterization/intervention and electrophysiology; however, due to the industry migration from diagnostic and interventional cardiology to EP, the associated staff has become much more focused on EP advancements. Part of the reason for the increase in volumes at Porter is the result of high-quality care, and in particular with the outcomes of our patients with atrial fibrillation. Achieving certification has been a journey to demonstrate and enhance the superior quality AF care at Porter Adventist Hospital and establish ourselves as a leader in AF care in Colorado.

Steps to AF Certification

A multidisciplinary subcommittee was first established to organize and enact our plans toward fulfilling the criteria needed for AF certification. Porter Adventist Hospital’s cardiovascular service line director chaired the subcommittee, which also included emergency medicine physicians and ER charge nurses, nurse managers from the main cardiac telemetry units, Porter Adventist Hospital’s EP lab director,  Dr. William Choe, and individual members of the EP lab staff. Monthly meetings were utilized toward the goal of completing one component of the Key Elements of certification every month. 

The SCPC requires achievement of ten Key Elements to qualify for certification. For example, one Key Element pertains to the treatment of AF patients in the emergency department. ED triage algorithms are delineated in detail, requiring a collaborative approach between the emergency department physicians, the electrophysiologist, and ICU and telemetry unit nurses. Criteria were established for four possible dispositions: discharge home with cardiology follow-up, admission to telemetry, admission to regular medicine floor, or admission to an ICU. Another Key Element was ED integration with emergency medical services (EMS). To address this, the ED physician on the subcommittee, Mark Prather, MD, presented educational didactic sessions to EMS personnel. In addition, interactive question and answer sessions focused on atrial fibrillation were organized between attending electrophysiologists and EMS. Another Key Element addressed was global education. The electrophysiologists discussed the AF protocols with nursing staff on the individual hospital units, using interactive lunch time sessions. Grand rounds on the topic of atrial fibrillation were also presented by the EP attending. Multiple in-service sessions were provided to the EP lab staff about the triage decisions and the eventual decision to perform AF ablation. 

The certification process also addressed process improvement as a Key Element. In order to appreciate the areas of improvement that were needed, outcomes of patients admitted with a diagnosis of atrial fibrillation began to be tracked and then reported on a monthly basis. Prior to this, the data was not regularly reviewed. By reviewing this data, areas of improvement could easily be targeted. 

These approaches to patient care established as the standard of care as part of the certification process were applied broadly, not just at Porter Adventist, but to all hospitals in the Centura system. The certification process also calls for guidelines for care for patients in the emergency department. For instance, early cardioversion in the emergency department can lead to significant improvement in co-morbidities that may be associated with atrial fibrillation. Patients that present within 48 hours of the onset of atrial fibrillation, and with appropriate CHA₂DS₂-VASC scores, can be cardioverted immediately in the emergency department, rather than waiting for three to four weeks to achieve therapeutic anticoagulation. This allows optimal patient care and satisfaction, as they do not have to suffer longer with atrial fibrillation symptoms, but rather can be treated sooner to optimize their quality of life. With the application of these guidelines, patients received ideal care at all of the hospitals in the Centura system in a more timely manner. 

Another example rests on harnessing the power of a common electronic medical record (EMR) among all hospitals in the Centura system. Physicians on the subcommittee representing multiple hospitals developed detailed order sets for stable and unstable atrial fibrillation with therapeutic options based on national guidelines. Rate control agents and appropriate, high-yield tests were featured prominently on the order set. Other order sets developed included transesophageal echo, cardioversion, pre and post ablation, pre and post device implant, and tilt table testing to allow for uniformity of optimal care. This process was set in place not just at Porter Adventist Hospital, but also at the other hospitals without active EP labs. As such, a systemwide approach to atrial fibrillation was formulated based on the guidelines for care provided in the certification process. 

Implementation of such systemwide approaches to AF care can also result in cost savings for the healthcare system. For instance, early triage decisions based on guidelines can lead to more timely treatment. Rate control agents can be started in the emergency department and be continued on arrival to the hospital floor. This frequently leads to achieving rate control and even conversion back to normal rhythm prior to evaluation for a cardiologist. Cost savings from $2,000 to $25,000 per patient have been estimated with this approach.^2,3 In addition, anticoagulation that was driven by the CHA₂DS₂-VASC scoring system has also led to sooner treatment and likely to fewer strokes.

After approximately 18 months of regular monthly meetings, all of the Key Elements required for certification were completed and the application was submitted to the SCPC. Within one month of submitting the application, a decision was rendered and certification was achieved. However, our work is not done; further quality measures will continue to need to be monitored and adjusted throughout the years in order to stay up-to-date with the most recent evidence-based practice and to maintain certification.

Disclosure: The authors have no conflicts of interest to report regarding the content herein.   

References

1. Atrial Fibrillation Certification Program at Genesis Health Care System. EP Lab Digest. 2012;12(2):1,10.
2. Saccheti A, Williams J, Levi S, Akula D. Impact of emergency department management of atrial fibrillation on hospital charges. West J Emerg Med. 2013;14:55-57.
3. Cohn BG, Keim SM, Yealy DM. Is emergency department cardioversion of recent-onset atrial fibrillation safe and effective? J Emerg Med. 2013;45(1):117-127.