The Added Value of Advanced Practice Clinician-Led Care in Atrial Fibrillation

Podcast discussion with William Cho, PA-C, and Monique Young, ACNP

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In this episode of The EP Edit podcast, we share a discussion with William Cho, PA-C, and Monique Young, ACNP, on the benefits of advanced practice clinician (APC)-led clinical care for atrial fibrillation (AF), including in managing the risk of bleeding in AF patients, using nurse practitioners (NPs) and physician assistants (PAs) to help with staffing challenges, and managing burnout. 

This podcast episode is also available on Spotify and Apple Podcasts!

William Cho, PA-C: Hi, my name is William Cho. I've been an electrophysiology (EP) PA for over 13 years. I initially started my career in New York City at Lenox Hill Hospital. I did a short stint at New York-Presbyterian Brooklyn Methodist Hospital before moving back to Salt Lake City about 10 years ago. I currently work at the University of Utah, where I serve as the APC section lead in EP and also have been helping manage all the PAs and NPs in cardiology. 

Monique Young, ACNP: I'm Monique Young. I'm an advanced acute care NP. I've been in advanced practice for 13 years, and 2 and a half of those have been in EP. My former employer was a general cardiologist. I work for the University of Tulane and also take the lead as the advanced practice coordinator of 6 attending electrophysiologists and 1 advanced practice NP. 

William Cho, PA-C: Thank you for joining us today. I think we'll dive into our first topic, which is benefits of PA- and NP-led care for AF. I'll get started. I think AF recurrences can be rather unpredictable. As we know in clinical practice, physicians are not always as readily available compared to their APC counterparts, as they may be tied up in procedures, rounding on the inpatient side, or in meetings. So, I think PAs and NPs can certainly serve as an extension of the physician and can improve access to health care. Most of all, PAs and NPs can help reduce the time to treatment as well as reduce emergency department (ED) visits, particularly during the AF blanking period, when a lot of unpredictable things can happen. Patients can become worried about chest pain-related pericarditis, some oozing at the groin site, or even recurrent AF, which is not totally uncommon, but for uneducated patients, it may cause panic. I think that's where we can step in to reduce that time to treatment so that they feel reassured and taken care of. 

Monique Young, ACNP: I agree. The partnership between the physician and the APCs is crucial to keeping patients out of the ED. I tell my patients that I don't want to see them in the ED, but if I send you to the ED, you need to be there. The educational portion and relationships that APCs have with their patients is vital to the transitions during the blanking period, because when these procedures are done, it can cause inflammation. We can send reassurance to patients who have had prior blockages, who feel chest pain and are concerned they are having a heart attack. So, the education and preparation pre and post case is crucial to educate these patients. The time that we can take to explain how they may have worked out too hard but they are not having a heart attack, and being readily available for these patients makes their journey throughout much more comforting. That is our niche as APCs—that is what we do. The physicians can then focus on the next best treatment and the next best process for these patients. Both of us being through a university, we have to ask if every ablation is worth it, the same, and needed. Also, we don't want to jam up the EDs with something that we can see in clinic. Because if the patient goes to the ED, they're going to have added laboratory tests and medicines. With the rising cost of health care, it's cheaper to treat them in the clinic than in an ED setting.

William Cho, PA-C: Let’s move on to our next topic, which is factors in managing the risk of bleeding in AF patients, such as use of shared decision-making and medication adherence. 

Monique Young, ACNP: So, this is another thing that I think education helps with for patients with a Watchman (Boston Scientific) or left appendage occlusion device. With the rising costs of medical care, patients should be involved in their care, so it’s important to engage them, their family, and the providers. When I transitioned from the cardiology field and came to EP, one of my attendings told me I had such a great relationship with my patients. We're sometimes getting these patients from the ED setting, so we have a big referral base who comes into our practice that is not always everyday seen. We may have a provider sending us a patient who possibly needs an AF ablation. The patient cannot be on anticoagulants, so we have to allow for shared decision-making. Some are clear-cut cases as they've had major bleeds, so this is what they need and it’s our job to educate them. But as an EP practice, we cannot make the decision by ourselves. There is a lot of communication and collaboration between the APCs in EP as well as the general cardiologists or their APCs and staff. There is paperwork that needs to be filled out and registries that need to be kept up. All of this is shared decision-making.

William Cho, PA-C: We get a lot of referrals for Watchman in patients who do not want to take a blood thinner, so we have these shared decision-making conversations. Some patients don't qualify for a Watchman, but we get a lot of patients who are very active and ski or cycle at a high level, and for that reason, they don't want to take a blood thinner. These patients oftentimes inquire about a Watchman. In the patients who should be on a blood thinner according to guidelines but don't want to be, we use a shared decision-making tool. The Mayo Clinic website has a great one where it includes all the CHA2DS2-VASc questions and then calculates an annual stroke risk. You can even calculate a 5-year predicted stroke risk. It also compares someone who has taken a blood thinner versus not taken a blood thinner. So, it gives 2 different perspectives that you can then discuss with the patient and then we move forward in that direction. We want our patients to do what they want to do. So, having this shared decision-making conversation is very important.
 
Monique Young, ACNP: Yes. The tools definitely help explain to patients, even those with low CHA2DS2-VASc scores of 1 or 2. I had one this week. I've had multiple conversations with the gentleman regarding that he didn't need an anticoagulant, but his stroke risk based upon his CHA2DS2-VASc was less than 1% at 1.9. But he still waxes and wanes and vacillates between does he take it or does he not take it. But, you know, they either must stay on it or get off of it. So, you lay out all this information such as the HAS-BLED and CHA2DS2-VASc score, because I'm sure like me you have had patients with a CHA2DS2-VASc of 0 who unfortunately had a stroke. This was in my old practice, and the patient didn't require one, but there are no guarantees. 

William Cho, PA-C: So, moving on to our next topic of how PAs and NPs can help with staffing challenges. I'll start off on this one. I think PAs and NPs can be very versatile. We can be providers in clinic. We can help with follow-up items such as answering patient questions or getting back to the patients with test results, etc. If trained, we can interrogate pacemakers and defibrillators. We can assist in the EP lab as well as take night and weekend call. But I think most importantly, we can act as an extension of the physician and improve access to patient care, because the physician is not always going to be available to see a patient or call a patient back. So, PAs and NPs can definitely relieve stress and open up throughput in the clinical setting. We have a lot of support staff at the University of Utah. We have 6 attendings, 7 PAs and NPs, and 2 registered nurses (RNs) who also help with follow-up work and a plethora of medical assistance. So, the APC role really serves as a bridge between the physician and the rest of the support staff, and it turns into a well-oiled machine. What have your experiences been, Monique?

Monique Young, ACNP: I agree. We're the bridge or the connection between the patient and the physician. The physicians are in the hospital either rounding or doing procedures, and they definitely rely on us to bring everything together and gather all the pertinent stuff. For example, where is that monitor? Where is the electrocardiogram? As far as staffing, you're right. There are a multitude of levels. It has the physicians, the APCs, to either licensed practical nurses (LPNs) or RNs, and then medical assistants (MAs), to field those calls of when the patient is not feeling well and to train the staff to gauge how escalated this needs to be and if the patient needs to come in. So, as far as staffing challenges, we're still building our team. That possibly leads into our next topic of burnout. I think if you have a good “under staff,” as in, staff under you, who can bounce around and understand what the next step is and think one step ahead, that is where the APCs come in. You should educate everyone that is underneath you to say, “this is what I need” and have open communication between the whole team, because the EP world is not just a physician, not just an APC, not just a nurse, MA, or a front desk person—you rely on all of them to make a team. It is very much a team approach. So, to avoid burnout from any level of your staff is to have delineated roles, responsibilities, and teach each team member what is expected of them going forward. I always say to my team, what if this was you calling our office? What if it was you calling this office for your mom or your dad? Give that same care back. That is where the APCs come in, as well as the staff under you. I always tell my patients, we may sound like we're cavalier about doing these procedures, but we understand they're very high-level procedures that we do every day with our providers. We often have to walk into a room and tell a patient they need an ablation, so turn that role around and put yourself in that chair, with someone coming to you and telling you that your 80-year-old mother needs an ablation. I always try to educate my staff on that.

William Cho, PA-C: Yes, that is a good segue into our next topic, which is managing burnout as an APC. As you had mentioned, we have a large APC staff at the University of Utah. I will admit that it has been nice, because it allows some flexibility between the APC PAs and NPs. If somebody has to use vacation time or is out of the office, we can all flex and cover for one another. So, from that standpoint, having a larger APC staff is great. Another thing that we've done with our RNs is protocolized things and created care pathways. For instance, if you have a patient with AF calling in, we have a list of things that our MAs or RNs will ask the patient, such as, when did you go into AF? What are your current AF medications and symptoms? Have you had a recent ablation or cardioversion? They send us a message and then we get back to them and relay our message onto the patient. So, that saves a lot of time. We also like to educate our patients during these clinic visits. So, you might have a patient who does pretty well on his flecainide, but maybe requires a cardioversion every once in a while. If we can educate him and tell him that at the onset of AF, he can take an extra dose of flecainide to try and help convert him, that provides the patient with a little bit of reassurance of knowing what to do and not to panic or go to the ED if he's feeling like he can tolerate it. If he converts back on his own, it saves another encounter that may not have been totally necessary. One thing that has been huge for me is just getting my notes done in clinic and not going home with notes. I like to write brief notes. If I have anything very specific to write, it's all down in the plan. So, I think that is a big factor. Once you get behind on your notes, everything else just seems to blow up a little. At the end of the day, you have to realize you can only do what you can do and you have to take care of yourself, because you still have to be there for the patients. 

Monique Young, ACNP: Yes, I agree. It's a 50/50 deal with the notes—sometimes I'm successful and sometimes it does take a little while. But I like that statement that you must take care of yourself. You must love what you do. You can make all the money in the world, but you must enjoy your profession because it reflects on your patient care and at the office. So, you must take care of yourself and have outlets. I think that helps decrease the amount of burnout—to enjoy what you're doing, know you're making a difference, and have a team support behind you. 

William Cho, PA-C: Alright everyone, well thank you for joining us today. That concludes this podcast and hopefully we’ll see you guys next time!

Monique Young, ACNP: As well. Thank you for joining us, and I hope y'all enjoy the Western AF Symposium! We greatly appreciate you as the APCs of the EP world! 

The transcripts have been edited for clarity and length.