Journey to an Atrial Fibrillation Center of Excellence

Background

Cone Health is a 1,254-bed hospital system located in Greensboro, North Carolina. Cone Health is an integrated not-for-profit health care network serving 6 counties in North Carolina. The community has a very active and physician-led Accountable Care Organization (ACO), Triad HealthCare Network, which encompasses Cone Health’s employed physicians as well as the broader independent provider community.

Atrial fibrillation (AFib) care in the community has historically been managed by a variety of healthcare providers, including primary care, cardiology, and electrophysiology (EP).

Because of the growing atrial fibrillation patient population, as well as rising costs of atrial fibrillation to the healthcare system, our team (Figure 1) initially sought to understand how atrial fibrillation patients presenting to Cone Health were being managed in the hospital setting.

Determining Our Baseline

A report was created through our EMR (Epic), which allowed us to identify patients that were admitted with a primary diagnosis of atrial fibrillation over a six-month period. We found that only 50% of patients admitted with a primary diagnosis of atrial fibrillation were evaluated by cardiology while admitted. The other half of patients were managed by the internal medicine or family practice teaching service alone. There was a significant variation of care delivered to these patients.

We recognized that standardization of atrial fibrillation management across our healthcare system was necessary. In addition, it was felt that outpatient follow-up of atrial fibrillation patients was suboptimal, with not all patients receiving follow-up post hospital discharge within 30 days.

Adherence to metrics outlined in the American Heart Association’s (AHA) Get With The Guidelines^®-AFIB (GWTG-AFIB), including documentation of CHA₂DS₂-VASc score, INR follow-up scheduled at discharge, as well as statin initiation were also determined to be suboptimal. At initial assessment, CHA₂DS₂-VASc score was calculated 40.3% of the time, INR was scheduled 83.3% of the time, and statins were prescribed at discharge 71.8% of the time.

There was significant opportunity identified for patients presenting to the emergency room (ER) with atrial fibrillation. In our healthcare system, all AFib patients have historically been admitted for inpatient care. We felt there was opportunity to send a percentage of patients home from the ER using a standardized protocol and ensuring close outpatient follow-up.

The opportunities for standardization of patient care that were identified within the Cone Health system included the ER pathway, AFib order sets, stroke risk assessment, patient education, peri-procedural issues/bridging, AFib clinic referral, and anticoagulation reversal. (Table 1)

In order to address all of these opportunities, we realized that a multidisciplinary team approach was appropriate and needed. We also included all stakeholders in the decision-making process in order to be successful.

Establishing a New Design and Multidisciplinary Model

Our atrial fibrillation standardization team is consisted of electrophysiologists, cardiologists, hospitalists, ER physicians, neurologists, administration, ACO representation, quality, IT, and research. We initially met twice per month as we were building the program and identifying areas of potential improvement. Without assured positive return on investment, administration’s buy-in was key in our efforts to decrease variation in the care of patients with atrial fibrillation. Therefore, being able to present our baseline data with plans for improvement was essential for administrative buy-in.

Our system utilized an atrial fibrillation nurse navigator role to help educate providers and floor nurses about the process to standardization as well as the rationale behind why this was important to the care of patients in our community. The quality department devoted a full-time employee to help manage the left atrial appendage occlusion (LAAO) database as well as the AHA GWTG-AFIB database. We achieved gold recognition in atrial fibrillation management from the AHA through the intentional efforts of our quality nurse and our AFib nurse navigator’s work with providers on improving metrics. Our CHA₂DS₂-VASc documentation was one specific area where we were able to quickly make marked improvement, taking documentation rates from 40.3% to 97%. Other key strategies to improvement included frequent education, auditing of patient charts during admission, EMR notes to providers reminding to document, and thank you notes to providers when work was done well.

We successfully created an early discharge protocol for patients presenting to the ER with stable atrial fibrillation. In our protocol, patients were either rate controlled or underwent cardioversion in the ER, with close outpatient follow-up. In the first year of implementation, 273 patients were discharged from the ER with no 30-day complications.¹ Part of our ER protocol success is due to engaged ER physicians as well as a robust partnership with pharmacy. Pharmacist presence in the ER allowed for patients to be discharged on appropriate OAC therapy, with free 30-day copay cards when needed to help facilitate compliance.

It quickly became clear that we would need improved access for patients with atrial fibrillation; therefore, we created a model for a nurse practitioner (NP)-led atrial fibrillation clinic. Based on previously published data showing significant reduction in hospitalization and cardiovascular morbidities with a nurse-led clinic,² as well as knowledge gained by visiting Jill Schaeffer, NP and the team at The Heart Group at Penn Medicine - Lancaster General Health, our AFib clinic opened in 2015.

Our AFib clinic was intentionally created to be independent from the cardiology practice within Cone Health. Nurse practitioners are the sole care providers in the atrial fibrillation clinic. Support is provided by a full-time RN and CMA. Electrophysiologists are available for support, but do not routinely see patients in the clinic. Because of the complexities of the atrial fibrillation patient, we chose to hire a nurse practitioner who would work solely in the AFib clinic and not rotate to other EP advanced practice provider coverage.

In order to get community buy-in for patients to be seen in a nurse practitioner-led clinic, extensive educational efforts were carried out with various stakeholders. We employed a variety of methods, including journal clubs and presenting at cardiology, emergency department, and hospitalist section meetings. Data sharing was also a crucial element in successfully launching our NP-led clinic. We focused on opportunities for standardization of care within the healthcare system and the fact that the clinic was designed to augment standard of care, not replace physician visits.

Our clinic is structured to allow for up to 13 office visits per day. There are appointment slots held for same-day and next-day appointments, as needed. Triage phone calls are prevalent, with many patients needing advice from a healthcare provider in addition to office visits.

To further enhance care, electrophysiology and neurology also formed a partnership to evaluate and manage cryptogenic stroke patients. After appropriate neurologic consultation, patients with embolic stroke of unknown source were evaluated by electrophysiology and had an implantable loop recorder placed according to our protocol.^3,4 Approximately 26.7% of patients were found to have atrial fibrillation documented at 32 months. After atrial fibrillation is detected, these patients are followed in a standardized fashion to ensure appropriate anticoagulation and management. Collaboration between our device clinic and AFib clinic has been essential in this process.

Patient-Focused Care

We have found that atrial fibrillation patients seen in the clinic often lack general education about their disease process. Navigating the system of referrals and medications can also be a challenge for patients. In building our AFib program, we sought to build relationships with the service lines most often included in the management of atrial fibrillation patients. These include bariatric surgery, nutrition, pulmonary, advanced heart failure, pharmacy, cardiovascular surgery, and ER teams. By creating a model where the AFib clinic functions as the hub of patient management, patients are able to have a centralized location to receive information and augmented care.

Because of the large part that lifestyle plays in the management of atrial fibrillation, we now offer free nutrition classes monthly to our AFib patients and are looking into the possibility of offering yoga classes as well.

There is a large focus on education and empowering patients to be involved in their care. We often stress that patients can affect the trajectory of their AFib journey by being active participants in lifestyle modification and self-monitoring.

Learning From Others

It is also important to note that an essential part of our success has come from collaboration with others. Although recent guidelines⁶ have begun to highlight the importance of multidisciplinary management of atrial fibrillation patients, there were previously few centers of excellence in AFib — perhaps the earliest example was the study published by Hendricks et al in 2012.² In 2015, Dr. Carl Timmermans and the team at Maastricht University Medical Center was gracious in allowing our nurse practitioner, Donna Carroll, to visit their atrial fibrillation clinic, where she learned many nuances of standardization in AFib management. Subsequently, five of our standardization team members were able to visit The Heart Group at Penn Medicine - Lancaster General Health to learn about the use of EMR to better manage atrial fibrillation, as well as visit their arrhythmia ward.⁷ Dr. Jose Osorio and his team at Grandview Medical Center were also helpful to us in demonstrating efficiencies that can be realized in EP.⁸ In addition, recent dialogue with Dr. Anish Amin⁹ and his group from Riverside Methodist Hospital as well as Dr. Andre Gauri¹⁰ from Spectrum Health have provided great perspective on multidisciplinary AFib patient care.

Summary

Creating an atrial fibrillation center of excellence requires a multidisciplinary team, administrative buy-in, and system-wide support. As a result of the creation to our AFib clinic, we have seen a reduction in ER visits as well as increases in cardioversion, ablation, and ancillary referrals.⁵

Disclosures: The authors have no conflicts of interest to report regarding the content herein. Outside the submitted work, Ms. Seiler reports personal fees for consulting from Medtronic and Biosense Webster. Dr. Allred reports personal fees for consulting from Medtronic and Biosense Webster, and fees from Janssen, outside the submitted work.

1. Seiler A, Young S, Carroll D, Peck K, Nanavati A, Allred J. Use of a Dedicated Emergency Room Algorithm for Early Discharge of Atrial Fibrillation Patients. J Am Coll Cardiol. 2018;71(11 Supplement):A514.
2. Hendriks JM, de Wit R, Crijns HJ, et al. Nurse-led care vs. usual care for patients with atrial fibrillation: results of a randomized trial of integrated chronic care vs. routine clinical care in ambulatory patients with atrial fibrillation. Eur Heart J. 2012;33(21):2692-2699.
3. Seiler A, Biby S, Sethi P, Allred J. Use of a Dedicated Protocol and Implantable Loop Recorder to Evaluate for Atrial Fibrillation in Cryptogenic Stroke Patients: Real World Validation of Crystal AF. Circulation. 2015;132:A14805.
4. Milstein NS, Allred J, Seiler A, et al. Atrial Fibrillation Incidence in the First Month After a Cryptogenic Stroke as Detected With an Implantable Cardiac Monitor. Circulation. 2018;138:A13051.
5. Seiler A, Carroll D, Booth S, Lundy R, Allred J. Abstracts from the 2018 Atrial Fibrillation Symposium. J Cardiovasc Electrophysiol. 2018;29(4):657-678.
6. January C, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. Circulation. 2019; Jan 28:CIR0000000000000665. [Epub ahead of print]
7. Deck SA, Riefenstahl AM, Thompson EJ, Repoley JL. Aggregation of EP and AF Patients: Revisited. EP Lab Digest. 2013;13(10):1,8-10.
8. Cooper C, Breland J, Kolaczek R, Osorio J. Spotlight Interview: Grandview Medical Center. EP Lab Digest. 2019;19(1):1,12-16.
9. Robinson A, Swinning J, Amin A. Developing a Multidisciplinary Model for Atrial Fibrillation Management. EP Lab Digest. 2019;19(1):1,8-11.
10. Gauri AJ, Sanders V. Contemporary Atrial Fibrillation Management: Spectrum Health’s Comprehensive AFib Program. EP Lab Digest. 2019;19(2):1,11-13.