Heart Rhythm 2023 Highlights

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Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of EP Lab Digest or HMP Global, their employees, and affiliates. 

EP LAB DIGEST. 2023;23(7):18-19.

In this article, we feature discussions with various presenters at Heart Rhythm 2023, which took place May 19-21, 2023, in New Orleans, Louisiana.

The Role of Advanced Practice Providers in Practice Improvement

Tara Mudd, MSN, APRN, NP-C,

Norton Healthcare, Louisville, Kentucky

I am presenting as part of the practice improvement track, focusing specifically on creating a high-functioning care team. One of the challenges that we face in the hospital setting is when we see patients as a collaborative team, what does that look like from a billing standpoint? There have been some changes that are coming out through the Centers for Medicare & Medicaid Services, beginning in 2024, that focus on how to bill visits in the hospital when the patients have been seen by both the physician and advanced practice provider. We know that patients are best treated through a multidisciplinary care team, so we first and foremost want to do the best thing for the patient. But we also must make sure that we have created an operational plan to make that efficient from a business standpoint. So, the goal of my presentation is to take some time to explain what split/shared billing is, and what that means and does not mean. As those changes are being proposed to be implemented in January 2024, what are some opportunities to align your care team around that new ruling to ensure adequate, high-quality care for patients? Some of that may look like the compensation models for paying your providers need tweaking, or ways to create a non-competitive environment from a compensation standpoint. That is really the crux of the issue when you get into who is billing for what and you have compensation models that are driven by productivity—those numbers matter to the provider. So again, how can we continue to deliver great care to our patients, but also make sure that we are operationally setting up the team for success? When our team is set up for success, our patients are also set up for success.

Cryoballoon Ablation for Atrial Fibrillation With Lead-Free Zero Fluoroscopy Approach Integrating Pulmonary Vein Hemodynamics, Intracardiac Echocardiography Imaging, and 3-Dimensional Mapping

Brandon Doty, BSN, RN, OMS-II,

Arrhythmia Research Group, Jonesboro, Arkansas

Cryoablation has been around for a while, but historically, we have always utilized fluoroscopy to complete this procedure. But using fluoroscopy comes with its own issues, whether it be prolonged radiation exposure to the operator and patient, or operators and people in the lab having to wear lead aprons, which comes with possible injuries to the spine with prolonged use. So, efforts were made to pioneer techniques where we did not have to use fluoroscopy anymore and to find ways to verify placement of the cryoballoon during the procedure. We are outlining a 4-year retrospective analysis of our patients using a technique that was pioneered by my research mentor, Dr Devi Nair, where she used a 3-pronged approach utilizing pulmonary vein hemodynamics, intracardiac echocardiography with color flow Doppler, and 3-dimensional mapping. We did a 4-year retrospective analysis of approximately 430 patients and found we were able to use these techniques and that it did not increase adverse events or complications. The complication rates were consistent with standards and did not increase procedure times. As a matter of fact, it maybe shortened them slightly. Also, we did not have increased cryoballoon times and it did not increase left atrial dwell time. So, we were able to do the same procedure without increasing risk to the patient in any way.

Early Conversations About Cardiovascular Implantable Electronic Devices and End-of-Life Care: How to Be Proactive With Your Patient and Family

Heather Ross, DNP, PhD, ANP, FHRS

Arizona State University, HonorHealth Cardiac Arrhythmia Group, Scottsdale, Arizona

When placing implantable cardioverter-defibrillators (ICDs) in patients, one of the things that we know as clinicians is that we may also eventually need to talk about deactivating the device-shocking capability. Patients often do not know that. As clinicians in Western medicine, we have generally been trained to prioritize saving lives. When it comes to the end of a person’s life, that focus on saving life may not be appropriate any longer, and it may be more appropriate instead to keep a patient comfortable and help them have a good death. However, a lot of us in the Western world are oftentimes not comfortable talking with our patients about that. It is a real struggle for the heart rhythm team and our patients and their families to figure out how to talk about the very tough topic of end-of-life care. It is also difficult for us to figure out when to talk about it. We do not want to spring this discussion on a patient at the end of their life. Indeed, we have all seen patients who have a lot of stress at the end of their life because they do not know we can turn off the ICD—no one has ever talked to them about it. Some patients do not want to talk about it ever, while other patients do want to talk about it at some point toward the end of life. In addition, there are other patients who say they wish they had known this information all along because they had been harboring this fear about what happens at the end, and if somebody had told them, it would not have been a question mark and they could have been comfortable knowing that they had the choice to make when the time was right.

With that in mind, there is not a lot of research evidence to guide exactly what to do. The research, as you can imagine, is quite qualitative—it is about how people feel. You cannot really do a randomized, controlled trial on this kind of thing. In general, we are not as good in Western medicine about synthesizing qualitative research like we are with quantitative research. There have been some studies that have started to be put together. While there is not a single definitive answer, we do have some evidence-based guidelines from a variety of national and international associations. One guideline is a class I recommendation to inform patients about ICD deactivation if it is consistent with their goals and preferences. The guideline recommends doing this at a variety of times across the continuum of care, including before implant at the time of consent for implantation of a device, at the time of generator change, and during advanced care planning, which may come up when a patient’s overall health condition changes. There is another guideline for heart failure (HF), as most of our patients who have an ICD also typically have heart failure. The class I recommendation is for patients with HF and life-extending therapies such as an ICD, to have the option of discontinuing those life-sustaining therapies, including in an anticipatory way before it needs to be done, and that this should be done across the continuum of care for HF. So those are our 2 guidelines that are based on the existing, largely qualitative body of evidence.

As members of the heart rhythm team, we want to know best practices for how the team can talk with patients. There are a few things to keep in mind. The entire heart rhythm team who is caring for the patient at different points in their continuum of care should really feel prepared, educated, and ready to talk with patients about ICD deactivation. It is not just up to the physician, the palliative nurse, or the technicians and nurses who are caring for that patient throughout the life of their defibrillator (and maybe multiple defibrillators!). To that end, it is a good idea to make sure that your whole team is educated. For a lot of us, we are not taught in our training about how to talk with patients and families about end-of-life care and ICD deactivation, so that can feel just as scary for us as it can feel for some patients. Therefore, education is key to feeling prepared and feeling like we have the self-efficacy to talk with our patients and their families.

Another thing that can help us all be successful in talking with patients about tough conversations like ICD deactivation, or frankly any other health conversation, is to be aware of health literacy. It is important to remember that if we hand a pamphlet to a patient, the most current surveys on literacy in the United States suggest that about 1 in 8 people will not be able to read and understand it. About 55% of the population may be able to read it, but they may not be able to exercise good health literacy, which means to read, understand, and apply that material to their own health. Therefore, it is important that we are thoughtful about how we communicate. Some ways we can do that are to use simple language and pictures in whatever literature we give or show to our patients and their family members. We need to be mindful of the patient’s language, whether they have low English language skills, or maybe English is a second, third, or fourth language for them. Maybe Spanish, Polish, Ukrainian, or Swahili is their first language, so we need to be thoughtful of that. We also need to be thoughtful about patient culture. Different cultures have very different practices and beliefs regarding end-of-life care, so we should know a little about that. This is part of where our education comes in. If you do not know, look it up or ask somebody a few things.

Also, please do not use jargon. As clinicians, we use many terms that are specific to heart rhythm care. Our patients do not understand that. We must speak in clear and simple language, and using an alphabet soup is not going to get that done. So, be thoughtful about how you would explain this to your grandmother, for example, and use those words, not jargon.

Finally, when you are talking to patients and their family members, it is always a good idea to use a teach-back method. Ask the patient to explain back to you what you just told them—that is one way you can make sure that they really heard you and processed that information. You will know if they tell you back what you told them, and they did not jumble it around. It also gives you an opportunity to clear up any misconceptions, so always ask questions. What else do they want to know or are they wondering about? Make sure, above all else, that you have an open door for your patients and their loved ones to ask the questions they are wondering about.