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Tour of the Atrial Fibrillation Center at the Ernst Cardiovascular Center, Beaumont Hospital
Beaumont has been a longstanding leader in cardiovascular care and technology. Thanks to the generosity of Max and Debra Ernst and their family, the Ernst Cardiovascular Center became a reality. The new 4,537 square-foot Center, which opened in Fall 2010, offers multidisciplinary clinics for atrial fibrillation, heart valve disease, congestive heart failure, adult and student cardiovascular screening and complex aortic disease.
The concept of the center is innovative as it brings a multidisciplinary approach to diagnosing and treating heart and vascular diseases. In one visit, the patient will be able to see physicians from disciplines like heart surgery, vascular surgery, cardiology, anesthesiology and radiology. The treatment will be individualized and will give the patient an opportunity to hear their treatment plan from their team of doctors.
Conveniently located on the first floor of Beaumont Hospital Royal Oak and contiguous to the Schlaefer Heart and Vascular Center, the center has a welcoming waiting room with a fireplace and coffee machine. Lighting, wall coverings, trim and artwork were all carefully selected to provide a restful, calming environment for the patient. Behind reception, six examination rooms, three consultation rooms, a physician work room and two ultrasound rooms are found. The conference rooms have videoconferencing capabilities that permit the physicians and patients to include family members at long distance to join the conversation, or allow physicians to perform telemedicine consultations.
The center features the latest in cardiovascular imaging options, including 3D cardiovascular ultrasound equipment. “Our goal is to expand Beaumont’s cardiovascular innovations to patients regionally and nationally with expedited, personalized and convenient care,” says Dr. Marc Sakwa, Ernst Center Director. “We specialize in high-risk, complex cases and serve as a referral center for physicians seeking advanced or minimally invasive treatment options for their patients.”
help streamline patient care; it now comprises one of the core services offered in the Ernst Cardiovascular Center. “My desire was to create a concierge-level service for our patients … to help our patients navigate through the complex web of the health care system as well as their complex disease process,” said Dr. David Haines, the AFC Director. The center focuses on patients that are candidates for AF catheter ablation procedures, but patients of all ages and with various stages of AF are seen. The AFC staff coordinates all aspects of AF management including selection, loading and titration of rate-controlling or suppressive antiarrhythmic drugs, selection of the optimal stroke prevention strategy, electrical 
cardioversions, and catheter or surgical interventions. The center gives the patient and their family members a specific contact person to call for all questions related to AF. This often prevents unnecessary trips to the doctor’s office or Emergency Department for the established patient. For example, if the patient is not feeling well, he/she can call the AFC and have the nurse contact the physician with the specifics of the episode: onset of symptoms; heart rate; medications that the patient is currently taking; and how the patient is feeling overall. The physician can then make recommendations. If a patient needs to undergo cardioversion, the AFC nurse makes all those arrangements. If a patient needs to have a new medication instituted, the AFC nurse calls in the prescription and gives the 
patients instructions on how to initiate the medication. If the patient cannot avoid a trip to the emergency department, then the AFC nurse meets them in the ED with a report for the emergency department staff of the patient’s current medications, past treatments for atrial fibrillation, and the physician’s preference for treatment for that patient. If a patient is unsure if they are having an episode but are feeling anxious about their heart rhythm, then they are given the option of coming into the center for an EKG to have it evaluated by their physician.
equipped with an echo lab in the office for the convenience of the patient. The patient is then escorted by an AFC nurse into an exam room, where the patient's history is reviewed and medication list is updated. The physician then enters the exam room to speak with the patient about his or her AF, and flesh out components of the history. After a comprehensive cardiovascular physical examination, the physician comes to his/her conclusions. At that juncture, conversation may continue in the examination room, or shift to a consultation room if off-site relatives or friends are invited to join the discussion remotely. The doctor educates the 
patient about the disease process and rationale for treatment of AF, and puts the case history into that context. A course of action is then recommended, including a discussion of the risks, benefits and alternatives to therapy. If an important treatment option is surgical AF ablation (offered to patients with marked left atrial enlargement and chronic AF), the in-clinic cardiac surgeon will be called into the room for additional consultation. If a patient needs to be started on warfarin therapy, the AFC nurse assists the patient with this process by calling in prescriptions and either enrolling the patient in an anticoagulation management program or contacting their primary care doctor to apprise him/her of the need to monitor this therapy in their patient. The patient is also given education materials and a brief overview of warfarin and the problems and pitfalls of taking this drug.
If a patient followed in the AFC requires a cardioversion, the arrangements are made by the AFC nurse. The nurse makes sure that the patient has therapeutic PT INRs and then works 
with the appropriate physician's office to coordinate the procedure with his or her schedule. When the patient presents on the day of cardioversion, the AFC nurse sees the patient immediately after the procedure, and also calls the patient the following day to check on the patient’s condition and arrange for outpatient follow-up.
If a patient is interested in pursuing an attempted catheter-based curative procedure for their AF, then the physician and nurse each discuss all aspects of the procedure in detail with the patient. If the patient decides to proceed, then the nurse schedules the procedure through the physician's office. The patient continues warfarin through the procedure and afterwards. If they are not on warfarin prior to the procedure, they are started one month preprocedure. The nurse helps guide the patient through the ablation process by communicating with him or her prior to the procedure to answer any questions, to confirm when to discontinue any medications, and to make sure all of the pretesting has been arranged. The nurse then visits the patient in the hospital after the procedure, and calls them at home the day after discharge to assess their progress.
The main focus on this center is to provide convenient, patient-focused care. “Patients with atrial fibrillation have a lot of anxiety associated with their diagnosis,” notes Michelle Mead-Salley, head AFC nurse-clinician. “Having a dedicated nurse in the office that is easily accessed and knows the patient’s history is very comforting for them. They also know that they can have an answer to their question in a timely manner and have tests ordered and completed in the same day if necessary.” The physicians and nurses communicate by phone, email and fax to keep the primary care doctor and any referring cardiologists in the information loop. Communication is emphasized in the center to ensure that the patient and their physician are aware of any medication changes or of any procedures that have been recommended or completed on the patient. Ultimately, the goal of the AFC and Ernst Cardiovascular Center is to fully evaluate and successfully treat the patient, then return the patient back to the care of the referring physician for long-term management and follow-up. Of course, the AFC physicians and nurses are available to assist in the care of these patients at any point in the future should new questions or problems arise. However, developing a strong relationship with referring physicians is dependent upon not taking over their patients. Thus, the patients always return to their referring physicians unless they specifically request otherwise.
Atrial Fibrillation Center
The Atrial Fibrillation Center (AFC) at Beaumont Hospital Royal Oak was created in 2007 to
help streamline patient care; it now comprises one of the core services offered in the Ernst Cardiovascular Center. “My desire was to create a concierge-level service for our patients … to help our patients navigate through the complex web of the health care system as well as their complex disease process,” said Dr. David Haines, the AFC Director. The center focuses on patients that are candidates for AF catheter ablation procedures, but patients of all ages and with various stages of AF are seen. The AFC staff coordinates all aspects of AF management including selection, loading and titration of rate-controlling or suppressive antiarrhythmic drugs, selection of the optimal stroke prevention strategy, electrical 
cardioversions, and catheter or surgical interventions. The center gives the patient and their family members a specific contact person to call for all questions related to AF. This often prevents unnecessary trips to the doctor’s office or Emergency Department for the established patient. For example, if the patient is not feeling well, he/she can call the AFC and have the nurse contact the physician with the specifics of the episode: onset of symptoms; heart rate; medications that the patient is currently taking; and how the patient is feeling overall. The physician can then make recommendations. If a patient needs to undergo cardioversion, the AFC nurse makes all those arrangements. If a patient needs to have a new medication instituted, the AFC nurse calls in the prescription and gives the 
patients instructions on how to initiate the medication. If the patient cannot avoid a trip to the emergency department, then the AFC nurse meets them in the ED with a report for the emergency department staff of the patient’s current medications, past treatments for atrial fibrillation, and the physician’s preference for treatment for that patient. If a patient is unsure if they are having an episode but are feeling anxious about their heart rhythm, then they are given the option of coming into the center for an EKG to have it evaluated by their physician.
Patient Experience
A typical patient that is seen in the AFC experiences a streamlined appointment process. Either a patient calls for an appointment or the referring physician calls to make a consultation appointment for their patient. If the patient has not had an echo within the last year, that study is performed the same day as their AF consultation. The Ernst Center is
equipped with an echo lab in the office for the convenience of the patient. The patient is then escorted by an AFC nurse into an exam room, where the patient's history is reviewed and medication list is updated. The physician then enters the exam room to speak with the patient about his or her AF, and flesh out components of the history. After a comprehensive cardiovascular physical examination, the physician comes to his/her conclusions. At that juncture, conversation may continue in the examination room, or shift to a consultation room if off-site relatives or friends are invited to join the discussion remotely. The doctor educates the 
patient about the disease process and rationale for treatment of AF, and puts the case history into that context. A course of action is then recommended, including a discussion of the risks, benefits and alternatives to therapy. If an important treatment option is surgical AF ablation (offered to patients with marked left atrial enlargement and chronic AF), the in-clinic cardiac surgeon will be called into the room for additional consultation. If a patient needs to be started on warfarin therapy, the AFC nurse assists the patient with this process by calling in prescriptions and either enrolling the patient in an anticoagulation management program or contacting their primary care doctor to apprise him/her of the need to monitor this therapy in their patient. The patient is also given education materials and a brief overview of warfarin and the problems and pitfalls of taking this drug.
If a patient followed in the AFC requires a cardioversion, the arrangements are made by the AFC nurse. The nurse makes sure that the patient has therapeutic PT INRs and then works 
with the appropriate physician's office to coordinate the procedure with his or her schedule. When the patient presents on the day of cardioversion, the AFC nurse sees the patient immediately after the procedure, and also calls the patient the following day to check on the patient’s condition and arrange for outpatient follow-up.
If a patient is interested in pursuing an attempted catheter-based curative procedure for their AF, then the physician and nurse each discuss all aspects of the procedure in detail with the patient. If the patient decides to proceed, then the nurse schedules the procedure through the physician's office. The patient continues warfarin through the procedure and afterwards. If they are not on warfarin prior to the procedure, they are started one month preprocedure. The nurse helps guide the patient through the ablation process by communicating with him or her prior to the procedure to answer any questions, to confirm when to discontinue any medications, and to make sure all of the pretesting has been arranged. The nurse then visits the patient in the hospital after the procedure, and calls them at home the day after discharge to assess their progress.
The main focus on this center is to provide convenient, patient-focused care. “Patients with atrial fibrillation have a lot of anxiety associated with their diagnosis,” notes Michelle Mead-Salley, head AFC nurse-clinician. “Having a dedicated nurse in the office that is easily accessed and knows the patient’s history is very comforting for them. They also know that they can have an answer to their question in a timely manner and have tests ordered and completed in the same day if necessary.” The physicians and nurses communicate by phone, email and fax to keep the primary care doctor and any referring cardiologists in the information loop. Communication is emphasized in the center to ensure that the patient and their physician are aware of any medication changes or of any procedures that have been recommended or completed on the patient. Ultimately, the goal of the AFC and Ernst Cardiovascular Center is to fully evaluate and successfully treat the patient, then return the patient back to the care of the referring physician for long-term management and follow-up. Of course, the AFC physicians and nurses are available to assist in the care of these patients at any point in the future should new questions or problems arise. However, developing a strong relationship with referring physicians is dependent upon not taking over their patients. Thus, the patients always return to their referring physicians unless they specifically request otherwise.
Marketing
Marketing of the AFC and Ernst Cardiovascular Center is multipronged. The most important marketing strategy is providing excellent clinical service and close communication with referring physicians, and returning patients to those physicians at the end of the process. In addition, there are a variety of materials including brochures that are mailed to our tertiary catchment area, direct-to-consumer advertising on local radio, and interesting “infomercials” that are broadcast in a continuous loop to all of the screens in the cardiology waiting areas. The key to effective marketing today is an informative, easy to navigate web site (in ongoing development). The evolving web site design will have a physician portal and a patient portal. General educational material on AF and related conditions will be provided for each portal, but the technical detail of the information will be tailored to the reader. It will provide specific information about procedural outcomes with AF ablation at Beaumont as well as provide references to important publications in the medical literature. Each member of the AFC will be profiled. Important practical information such as contact numbers, directions, and maps will be provided.Research
The final important component of the AFC is the expansion of our knowledge and understanding in this field. To that end, each patient seen in our center becomes part of a longitudinal clinical database. Parts of the data are extracted from the EMR, and the remaining data are entered into the database by the AFC staff. Follow-up data is particularly important to collect accurately. Since most patients are not followed for durations greater than 1-2 years, long-term follow-up is gathered by telephone interviews conducted by the AFC staff. A standardized questionnaire is read to each patient on an annual basis. If there is indication of AF recurrence in the interim, confirmatory information is sought from the referring physician. The database is overseen by the Research Institute. The data are used for ongoing quality initiatives, to provide patients with real-world outcome data from our center, and to perform hypothesis-driven research. Importantly, the AFC at Beaumont is committed to advancing the technology designed to improve AF management. The physicians at Beaumont have been active participants in PROTECT-AF (use of Atritech’s WATCHMAN® atrial appendage occluder to prevent stroke), the ENABLE trial (use of an endoscopically-guided balloon laser ablation system for PVI), Bard’s MESH pilot trial (use of a multielectrode mesh catheter for PVI), the Focus AF trial (use of high intensity focused ultrasound for PVI), as well as a wide range of other technologies in the preclinical setting. Our aspiration is to be able to offer the very latest and most promising therapies to all of our patients.Summary
The ultimate aims of the AFC will be to:- Be a comprehensive educational resource leader for physicians and patients on atrial fibrillation
- Provide the best state-of-the-art treatments for patients with atrial fibrillation
- Have the ability to measure and compare outcomes of different treatment modalities
- Maintain prominence as a national and international leader in the treatment of atrial fibrillation.
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