Empowering Care to the AFib Patient
Saturday, April 24, 2021
Hospitals need to consider new strategies for the large and growing population of AF patients, especially given the impact these patients have on the clinical, operational, and financial aspects of a cardiovascular service line. A comprehensive AF program provides a collaborative approach to evaluation and management of patients with AF.
Please join us for a live streaming educational session with James Allred, MD and Amber Seiler, NP from Moses H. Cone Hospital in Greensboro, NC.
The Cone Health Atrial Fibrillation Clinic is a hospital owned NP-led clinic that was built in 2016 out of the need to have improved coordination and rapid follow up with AF patients discharged from the hospital. It is staffed by a dedicated, multi-disciplinary team and is located within the Heart Failure Clinic at the Cone Health Heart & Vascular Center. Their clinic has been profiled by Advisory Board as a Best in Class AF Program and their outcomes have been published in the Journal of the American College of Cardiology.
The clinic’s founders, James Allred, MD and Amber Seiler, NP will discuss the following:
The presentation will be followed by a live Q&A session. Anyone is welcome to join, as this is a great way to gain momentum on developing a comprehensive AF program.
Thank you for joining today's product theater hosted by bison's Webster. My name is Tiffany, Durant says and I will be your moderator and we are happy to have dr James allred in amber Seiler. Coming to you live from north Carolina. Today's session is tiled empowering care to the patient and they will discuss how to implement a comprehensive program. The session will be recorded after the presentation. There will be a question and answer session. We will monitor the chat throughout the presentation so please submit your questions by using the chat feature, the cone health Atrial fibrillation clinic is a hospital owned nurse practitioner led clinics that was built in 2016. It is staffed by a dedicated multidisciplinary team and is located within the heart failure clinic at the cone Health, heart and vascular center. The clinic has been profiled by advisory board as a best in class a fit program and their outcomes have been published in the Journal of the American College of Cardiology. Now, let's get the session started with Dr James, Al Red and Amber Seiler. Thank you Tiffany. It's it's really great to be with you today. Amber and I are very excited for this presentation. Here are our disclosures. Yeah, as we begin today, let's look at our objectives. So today we were talking about management of atrial fibrillation patients looking at what a comprehensive atrial fibrillation center looks like. We'll talk about collaboration with the emergency department as well as other practitioners within the health care system. And we'll talk about the overall impact of this collaborative approach at cone health. So when we think about patients with atrial fibrillation, we know that there are a lot of patients with atrial fibrillation. Currently about five million cases in the United States and that is expected to more than double over the next 25 years, many of these patients present to the emergency department and Over 467,000 admissions yearly are due to a primary diagnosis of atrial fibrillation. The problem is that these patients don't just have atrial fibrillation. As you can see from this slide. Many of our patients have other co morbid conditions such as diabetes, obesity, hypertension, stroke, coronary disease, sleep apnea, and the list goes on and on. But for most of these patients, their admission will be due to exacerbations of their atrial fibrillation. And so when you look at data looking at 2010-2014, you'll see that two thirds of patients who presented to the emergency department and were diagnosed with atrial fibrillation were admitted and that leads to lots of emergency visits and hospitalizations every year. For patients with atrial fibrillation, the costs associated with this are tremendous. And so as you look at the breakdown of a fib annual costs, which can be lots and lots of dollars, you'll see that most of these costs are inpatient costs. When we talk to our patients often they complain about their costs related to an anti arrhythmic medicine or to anticoagulants care. But when you look at this slide, you'll see that the cost of medicine are only about 4% of the overall cost to these patients. When we look at our health care system, the majority of the costs are due to and patients stay and direct and indirect costs related to that. And so if we can reduce hospitalizations for these patients, then we can substantially reduce costs to the health care system. So when patients present with atrial fibrillation, what are our treatment goals? Initially, we want to stabilize the patient? Certainly, if that patient comes to our emergency room with sepsis or a pulmonary embolism, unstable angina, we need to stabilize that patient, admit that patient and take care of their immediate needs. But many patients present in a stable condition with symptomatic atrial fibrillation for these patients, We want to determine why they're in atrial fibrillation. We want to improve their symptoms. We want to reduce the risk for stroke and then we want to reduce progression of their disease. And I think that's an important part of health care to pay for patients that an electrophysiology we're just now starting to look at and to embrace. But it's certainly important. We're all familiar with rate control, rhythm control and treating underlying ideologies. And so for patients who have sleep apnea, making sure that that is treated, making sure that diabetes, thyroid disease and all these other things are also managed for these patients at cone health. We have a protocol for our patients when they present to the emergency department. And we've talked about that protocol many times But this is not a new concept when you look you'll see data in the emergency room literature going back to the 1990s that talks about ways that you can safely cardioverter patient in the emergency room and ways that you can protocol care to discharge patients rapidly to avoid long-term hospitalizations. Amber Seiler will now talk to you more about our own health protocol. Perfect. Thanks so much. So thanks again for joining us this morning. I know for some of y'all that's very early um in north Carolina we got to sleep in a little bit but um as we started putting our atrial fibrillation program together and we really do feel like this is a program. Um The E. D. Protocol was very quickly identified as an important piece of that when we looked at our baseline data, some of the things that we collected were how many patients come to the hospital, how many come through the emergency room, what happens to those patients when they hit the er And so it was really obvious from the very beginning that we had a big opportunity for our patients that were seen in the emergency room with atrial fibrillation. And so when we started thinking about how are we going to tackle this and what does that look like? We got together a group of people, lots of different stakeholders to put this protocol together. And in a few more sides we'll talk about what that standardization team looks like and who I was involved in that process. But importantly you know the er physicians were involved are pharmacists were involved, you know lots of different stakeholders. Again just trying to make sure we're doing the right thing for patients and that we were taking really great care of them but also reducing health care costs. So for our patients if they come to the hospital to the emergency room with atrial fibrillation or flutter if they're unstable. So any of those things that dr already mentioned you know sepsis acute and my acute this compensated heart failure. Any of those things those patients aren't qualified to participate in this protocol and they are automatically excluded but if they're you know presenting rhythm is a fib and that is their primary diagnosis and they really don't have other things going on then the er physicians can use this protocol to triage and treat those patients. And we wanted this to be an E. R. Treatment protocol as opposed to an E. R. Cardioversion protocol. We do cardio cardio for patients in the emergency room. But our ultimate goal was just to get them home not have them admitted and then follow up in our atrial fibrillation clinic. So if we walk through this protocol um so if it does come in with a fib or atrial flutter If it's a new diagnosis and they're stable that our new onset and they're stable. So the two questions that are asked or with the onset less than 48 hours ago and or are they appropriately anti coagulated. And we have a lot of questions come up about well how do you know the 48 hours? And a lot of that is just really due to patient history and how confident the provider is in the patient's history for when that atrial fibrillation episode started. If the episode started longer than 40 hours ago. Or if they've missed doses of their anti coagulation but they're still stable then the plane would be to either start or reinitiate their anti coagulation and rate control them if able orally and then send them home from the emergency room will follow up in our atrial fibrillation clinic. The other option is to cardio birth those patients if the violence that was less than 48 hours ago or if they were appropriately and track coagulated once again follow up in our atrial fibrillation clinic. And so these are posters that we put all around our emergency room and the physician and um and pia and nurse practitioner work rooms. So they sit right behind their computer screens. And the clinic phone number is on the bottom of all of these posters which has been really helpful to just improve communication so that there's a question you know, should we do you know send the patient home, are you able to see them? Things like that? It works out really really well. The other thing that we started when we did this protocol was initiated an order set for our patients who come in through the emergency room with atrial fibrillation. And we have epic in our health system. And so in that order set is an automatic referral to the eighth of clinic that's pre checked. And in the 8th of Clinic team works that work to you every morning whenever they come in. And so even if patients don't get that appointment before they leave the emergency room, they're going to get a phone call from our clinic team the next business day to follow up and make that appointment. We've also created some queries within Epic so that we can pull the number of patients that were admitted to the emergency room um and discharged. You might not have had that orders that use or might not have had that referral place. And we also follow up with all those patients when they go home. So you know, at the end of the day our goal is to send these patients home but to ensure that they had closed outpatient follow up in our fifth clinics. So we started this protocol back in 2017 and this was our first years data um of of what we found whenever we put this together. So the average age of our patient that presented to the er was 67 56 or female. Average Chad's basketball was three. About 30% of the patients had new onset atrial fibrillation but the others had known a fib that was an existing condition which is interesting, you know? And my uh at least I thought that a lot higher percentage of those patients would have been new onset atrial fibrillation. But this was really a story for us and a lesson for us that patients with domination of also present to the emergency room. And there are there opportunities that we have with our atrial fibrillation clinic or just outpatient world to educate them and give them the tools they need to manage their eighth episodes at home without coming to the emergency room. And we'll talk about that a little bit later too. Average Bmi was right at 31 average age at time of er visit is very consistent with age of a fib patients um that we see in our clinics and this is the data from folks that were discharged from the emergency room. So one of the concerns we put this protocol together from cardiology was that they were going to get called for all of these patients, which was an interesting concern as we were pitching this idea because Historically they were called for 100 of these patients and they said, you know what? We're putting this protocol together, You know, do we really need to be call or not? And so in that first year cardiology was consulted 46 of the time, which we felt really good. About 77 of our patients were anti coagulated and discharge. And again, this isn't a cardioversion protocol is an er discharge protocol. And so some of our patients weren't candidates for anti coagulation or had left atrial appendage occlusion devices or had other reasons why they didn't need to be anti coagulated. 70 of the patients left the emergency room in Sinus Rhythm And 81 of those patients followed up within 30 days. And our goal for that was much higher than that, right. Our goal is 100 to have fallen within 30 days, but we can't always control when our patients come back. So this is a little bit of a busy slide and I apologize for that. But the blue bars are patients who were discharged from the emergency room. The red bars are total a fib admissions for the hospital. And then that green line is the percent discharged from the emergency room. And so if we would have taken this back to december of 2000 and 16, that green line would have been at zero because we did not send anyone home from the emergency room with a fib. We admitted every single one of them. And over the last year, especially during covid the numbers of patients who came to emergency room went down, which I think is probably consistent with what a lot of other practices I've seen, but our percent discharge significantly went up mostly because of hospital bed utilization and trying to make sure that we were getting everybody out that could be out um and not admitting anyone that didn't need to be admitted. This is our any discharge volume from January of 17 to January of 21, so averaging right at 30 patients a month that we sent home from the emergency room who present with atrial fibrillation and then this is our cardioversion volume. So, you know, average between six and eight patients a month that we're cardioverter. So again, it's not a cardioversion protocol is just your discharge protocol. So folks who came to the emergency room and we're carney inverted, these were representing Rhythm. So 20 of those um we're new onset atrial fibrillation, 52 of those were paroxysmal, which makes a lot of good sense, right? 24% 24 persistent and four had atrial flutter. And when we look at our patients who came back to the er so one of the concerns was, well, if we send them home, are they going to come back? Right, and we better just keeping them in the hospital for three days. Like we have done historically, our patients do okay if we send them home. So we wanted to look at that. And so for patients who came back to the emergency room, they were more likely to be older females, which makes sense. You know, those are the folks who call our clinics and are just really nervous and need somebody to kind of helped talk him off the ledge and tell them everything's gonna be okay. And this is a population that we want to give specific education too, for when they have recurrent atrial fibrillation and make sure that they have tools at home to manage that arrhythmia without having to come back to the hospital. Another concern that folks had whenever we're putting this protocol together was that it was going to increase emergency room length of stay. Our er physicians as most are are have metrics around throughput and what things look like. And so we wanted to specifically look at that to see if we were increasing length of stay in the emergency room but implementing this protocol. And so when we look at this patients that were admitted from the er for atrial fibrillation, their average length of stay with four hours and 51 minutes, which makes sense. You know, you got to get a cardiology, consult, somebody's got to come down to that patient, write the orders and we've got to wait on a bed if they were discharged from the emergency room and did not undergo cardioversion. Their average length of stay with four hours and 33 minutes. If they were cardio voted in the er their average length of state was two hours and 16 minutes. And so this was just reassuring to all of the teams emergency rooms. You know cardiology hospital administration that we were not going to increase emergency room length of stay by using this protocol. And this is proven to be true year over year. So when we think about you know why to put an E. R. Protocol together and what that looks like. I think it's really important to to understand current state in your healthcare system and know what problem you're trying to solve for us. We felt like some of the benefits of early discharge from the emergency room or improve patient outcomes if we can have follow up in a dedicated atrial fibrillation clinic where they're going to get specific education around atrial fibrillation, make sure they're plugged in where they need to be plugged in. We felt like that would be helpful. We wanted to reduce hospitalizations which we've done. People do go home from the emergency room, we wanted to reduce er length of stay which we just talked about reducing patient cost is is real and it's a it's a challenge for our patients. And wanted to be sure that we're um you know optimizing their care without utilizing inappropriate resources by keeping them out of the hospital. Well one of them to have improved access to sinus rhythm, you know, um with without this protocol in place they would be admitted and their cardioversion would likely happen two or three days into the admission as opposed to within two hours of being seen in the emergency room and then improve patient satisfaction and dr alright, I know you've got a story about that patient on christmas Eve, you don't know if you want to tell them about that real fast. Absolutely, so this was christmas Eve, a patient came in with atrial fibrillation a few years ago and christmas Eve happened to fall on a friday and things were really quiet around the hospital and the plan was, you know, a heparin drip, Dill ties um drip and let's watch him until monday. And this was an elderly gentleman who had family in town and was really excited about the holidays and was really upset about the idea of not not being able to be with his family. And um uh this was kind of one of the referring hospitals to us not directly part of our system. And one of the er doctors who was working in the E. R. That day just happened to be part of our system. And he had heard about um this patient, he said why don't you just cardioverter and sent him home. And so he stepped in. He worked with the team they were able to discharge the patient and I continue to follow this patient today. It's been several years and he still talks about being able to spend christmas with his family and how meaningful that was for him. And so the quality of care to these patients. Uh it's a tremendous thing that you can offer and I'll have patients who go out of town now on vacation and maybe they're at the beach and they go into atrial fibrillation and they get to experience those three days in the hospital. And when we come back to me, they're like, oh my goodness, you know, can you can you please help other people understand that patients can be safely discharged from the er and so that's a lot of why we do this is to help our patients when they're traveling in other places, uh not be in the hospital for three days because you know, as we found out when you keep a patient in the hospital for three days, um the readmission rates are exactly the same as the readmission rates when you send patients home the same day. And we followed our safety Um an adverse event profile very carefully and we have not seen any adverse events in this patient group. And so it really is something that can be done safely. Again. The literature goes back to ear data from the 1990s out of Ottawa and they've been doing this a long time. And so I think it is something for everyone to think about awesome. And I know we talked briefly earlier about all the focus on our team, but I know dr always going to go into this and who we included as we put this protocol and our program together. Right. I think you're right amber, when you say this is a program, not a protocol and that's what we want to spend the rest of the time this morning talking about is the rest of the program because an aha moment we have a lot of folks that come to the cone health to visit our program, lots of cardiologist, electro physiologist, administrators, a. P. P. S. And one of the biggest takeaways that I frequently here is I can't do this by myself and I realized I co own health that it's a team sport. And when they walk away and start to put that into practice their programs just go into great, you know, great productive over overhauls and it's really great to see and and it's been great to experience, you know, when we first started at kind of health, you know, seven or eight years ago and are a fib journey. It was largely myself and maybe one or two people in this picture, this is our standardization team. And over the course of time our team has gotten bigger and bigger and we've included more people and it's been really exciting to see what our team can do. Um As an electro physiologist, I have a lot of energy but I only have so much and it's really great to have other people that will come alongside of me and and to help extend my reach and grow the program and ways and honestly I could not do so that we have a call every month with our standardization team and to hear from different team members about what they're doing. So here's a list of the people on our team. We have pharmacy, we have our representative um cardiology, the emergency room team, electrophysiology are a fib clinic team which includes are a fib nurse are nurse practitioners. The rest of the team our research quality and I. T. Partners are all part of our team. And so we titled This Talk Today Empowering care to a fib patients. And that's what we want everyone to hear today is that this is a team sport. There are a lot of people that can come alongside of you. And and if you allow these people to be part of your team, you're going to see results that you you couldn't imagine the synergy can be really, really great. Um and so for example, you know this month we're talking about looking at our post operative cabbage patients and a fib in this patient group and and what can we do specifically for them and seeing quality. Already looking at some of the data we have and partnering with them and and the a fib clinic, talking about how these patients could land and our pharmacists, looking at ways that we can do things. It's really amazing and it's exciting when we try to take care of these patients. And so um we recognize that patients with atrial fibrillation impact lots of lots of areas and you can see in this slide, the patient with atrial fibrillation is in the center but they're surrounded by all of the touch points to the emergency room. Primary care patients with stroke and a fib landing and neurology, other specialties pulmonary and integrate other groups. Um These patients need lots of resources so they need dieticians, they need pharmacists, they need the sleep clinic, they need weight loss clinics, they need outpatient procedures such as cardioversion, they need rehab, they need exercise, they need anti coagulation clinics and so many different things. And so empowering these people to be part of your team is going to be what allows your team to succeed. And so when you look at patients with atrial fibrillation who present to the emergency room and then fall to cardiology or electrophysiology for treatment thereafter I think a huge opportunity is to use the nurse practitioner model actually use physician assistance in taking care of your patients. And that's what we've done at health with our a fib clinic. And so we have an a fib clinic that um is stand alone from our cardiology practice. It's in a separate location. We have a nurse practitioner and a p a. A nurse. And to medical assist who see patients every single day with atrial fibrillation and they are able to reach out to these patients again in ways that otherwise we would be limited with our capacity. And so part of the reason our E. R. Protocol works for example is that patients who leave the er are seen within our a fib clinic within 33 to 5 days. And so you know if we told an er doctor to rate control of patient we try to get him into the office in two or three months it wouldn't happen. And if you told my practice that James you have to see this patient in two or three days every time they leave an er with a fib. That probably wouldn't happen either. And so a great opportunity to have a comprehensive approach to taking care of patients with atrial fibrillation is to include nurse practitioners, physician assistants and others into the care of these patients. And I think this is a really great place for these patients to receive their care. When you look traditionally at patients who leave an E. R. With a diagnosis of a fib. About 40% of these patients only follow up with primary care. About 40 of these patients follow up with cardiology. About 10 of these, 10 of the patients don't follow up with anyone and then about 10 follow up with electrophysiology. But with our approach now with our clinic, what happens is when all of these patients leave leave the er or if they leave the hospital after hospitalization. We have those patients follow up in our a fib clinic within 3 to 5 days and they continue to follow these patients so they become part of their care team. They start talking to them about weight loss, they start talking to them about the importance of exercise reduction of alcohol compliance with anti coagulation and all of these other things. And then these patients are captured so that if they have recurrent episodes of atrial fibrillation, we have opportunities to keep them out of the er with very close follow up in the clinic. Were able to start anticoagulants very soon, were able to start anti arrhythmic drugs early and then once the patients fail anti arrhythmic therapy, then those patients who have frequently a class one indication for ablation can come straight to electrophysiology for those conversations. And so we feel like the patient who could either have spent several years in a fib through no follow up or primary care alone or cardiology hopefully are getting treatment earlier. And we all know that there's a lot of recent data and energy looking at early treatment of atrial fibrillation because we know that these patients will do better long term. We also know that by using our comprehensive approach to taking care of patients with atrial fibrillation, hopefully we can prevent progression of their affair disease from a paroxysmal intermittent state to a more persistent state which which can be harder to cleat to treat and carries a higher co morbidity for that patient. So this is our ecosystem on this slide at cone health and you can see that there are lots of interactions for patients with atrial fibrillation. We have just if you think back to that puzzle slide where you have the patient in the middle and everything else around them in our ecosystem slide we take that patient we put them in the A. Fib clinic and we partner with that patient and then we have everything else around us. So patients with advanced heart failure can be seen in the heart failure clinic which is right next door, patients who have obesity can be treated very aggressively for that. Patients with sleep apnea can be followed closely. There's also a partnership with our device clinic so that patients who have long term monitoring can be found or can be managed closely with our affiliate clinic patients who have been part of our crypto genic stroke protocol and have a fib detected can very quickly come into our atrial fibrillation clinic as well. And then his ambulance to stay. All roads lead to the E. P. Lab. And so for patients who meet criteria for ablation we often see these patients a bladed as well. And so as you think about a program what are opportunities for standardization? Here are a few, here's some some that we have used it can health that we've been successful with but you'll find that there are lots of other opportunities as well. And so certainly we have presented our er pathway. Today we have a fib order sets to guide our emergency doctors are cardiologists in our hospitalists and taking care of patients with atrial fibrillation were allowed you know opportunities to standardize stroke risk assessment, patient education, um peri operative management and bridging of anti coagulation if necessary. That has been a standardized approach and there's really a lot of great data to guide um that type of care referrals to our a fib clinic who are patients who are appropriate to be triaged or a fib clinic and who are patients that might not. And then even standardization in the way that we would reverse anti coagulation should this be required? Mhm. Perfect. So this is some data that was presented through the advisory board and so some of you might have seen this. But as we put our clinic together, we really wanted to track outcomes and and know what benefit we were providing to our patients and honestly to the health care system. There were again, a lot of stakeholders involved and creating this program and investing a lot of time and energy and financial resources and getting this up and off the ground. And so One of the things again that we wanted to do was just just see where things were going. And so this is our 1st 12 months of our clinic being up and running. And that time we saw 538 individual patients and scheduled 68 cardio versions, 27 8 revelations and there were 100 and 21 avoided er visits due to a chip clinic availability. And we measured that by saying, you know, if a patient called in and said I'm having a lot of trouble should I go to the hospital or you know what should I do? And the at the clinic was able to say why don't you just come on over here and see us instead? And those patients we counted as avoided er visits because without the a fib clinic we and our cardiology practice do not have availability to see these patients um same day or next day. And so that's how we captured that. Some questions that we get asked about, you know, how do you how do you how do you fund this and what do you need to make it happen? And it's a really good question. Our clinic is located within the hospital walls which is very expensive real estate, but we did that intentionally to try to wrap in all the patients in the community without being associated with the physician practice. Um and so we built that proforma off of about 4-5 visits a day and two additional eighth of ablation is a year. And so as you can see, we blew that out of the water and we like to say this is a little bit of if you build it, they will come, the patients are there, they're desperate for education. Again, a lot of them really just need a place to go. Like when they go into a fib they need a place to land and this is a really great way to make that happen and take really good care of patients. So we think about an eighth of clinic and what that looks like, you know, what do we think those benefits are again, improve patient outcomes. We do think is real, patients are getting offered the treatment they need when it's appropriate to be offered the treatment, you know, historically patients get referred to ep after they've been in 1/5 for two years and their own embryo and they failed for cardio versions, right? And those are the patients that we can help, you know, we want them much earlier and their disease process so that we can intervene and hopefully have a much better long term results for those patients, improve their quality of life. And the procedure today is so much different than it was 11 years ago. We started our program at cone with abrasions. And so I do think, you know, a big part of our clinic is being able to offer them the treatment options they need when it's appropriate for those patients, reducing er visits and hospitalizations. We've talked a lot about and we've been very successful with that reducing length to say a patient calls again. Improved access to ablation is a big one. You know, just like your GPS ours are busy, right? And so they need to be sent patients who are appropriate for a procedure and patients who aren't appropriate for a procedure who can be followed by other physicians or other folks. That makes really good sense for those patients as well. Um um improve procedure outcomes. You know, just by the sheer fact that we're getting these patients when they are paradoxes will not win. their persistent were able to intervene on things like sleep apnea, weight loss really. Get them tuned up before they get on the table. We do think that that helps with procedure outcomes. And then again patient satisfaction is is a big one and are a fib clinic. Our patients really see it as a V. I. P. Clinic. You know there's a direct phone number to that clinic is answered by an eighth of clinic staff member. There is no phone tree. You know the person who answers that phone knows who the patient is and knows what they need you know in their eighth of care. And so um it really is seen as an extra adult service for these patients. You know the eighth of clinic doesn't typically own patients, they're usually co managed but it's just a nice adjunct way for patients to get care when they need it. Again a lot of it is that same day, next day availability doctor already anything to add there. I can't say enough. I think you'd add improved physician um quality of life and said well you know before the A fib clinic you know I was a bleeding about one out of 10 consults that I saw. The other folks either didn't want the procedure or they had in high risk comorbidities or other things. Um But they didn't want to necessarily go back to other providers because I was the A fib guy, right? Um And that's a lot of the reason we put our affect clinic together. But over time as things have evolved now it's probably about four out of five consults that are I feel appropriate for ablation and the patients are engaged and ready to do that. And so um we're able to oblate patients um quicker as you said, which means they are also more likely to be paroxysmal than they used to be. They haven't felt, as you said for anti arrhythmic drugs. And so um I think there's huge value to the physician which we should probably add to the slot. That's awesome. Um So are we have an accountable care organization and greens through And I know a lot of people have these organizations are a Ceo has been a huge fan of our clinic. Arrhythmia calls. Does dr allred said at the very beginning of this presentation is incredibly expensive and the A. C. A. Recognizes that. And so they are excited about any ways that they can help to intervene um to take really great care of patients and not spend unnecessary dollars but you know for our A. C. O. It really is to take really great care of patients first you know and the savings has come as an add on bonus. And so um for example are a ceo when we were starting this emergency room protocol we said you know we really like to get the er doctors and all the cardiologist together and let's have a journal club and let's talk about it and you know go through while we think all of these things are really important for our patients and trying to figure out how does that get paid for and what happens in the A. C. O. Says you know what we'll cover it. You know if if this is the right thing for patient care then we've got it and then you know a year after we started that protocol we said would really be nice to get together again and you know really talk about our data and share what we've been able to do for our community and they said no problem, we will cover it, you know? And so how are the Ceo also funds things like Y. M. C. A. Scholarships for our patients and our patient education brochures. And so they've been a really strong strategic partner um and ar atrial fibrillation clinic. And I would encourage you to reach out to your local players because this data is real the patients benefit and it's called saving to the insurance carriers. And so Um in our first year we saved them $1.2 million $2.7 million dollars and avoided hospital admissions. We did do more procedures which you know negates a little bit of that cost savings. But overall this was extremely positive for everyone. You know putting this program together, we call it a win win win, right? The patient's win, which is most important. The systems went and the pears win. So everybody wins, putting these types of programs together. And so we often get asked well where do you start? Um and we like to say you got to know where you are before you can decide where you want to be. Um I encourage people to think about, what problem are you trying to solve by putting together your affiliate program. Right? So um it's more than on Fridays. We're going to see a fib patients and it's more than we're just gonna flip this side around or you know, do this different on this day. It really can meet its maximum potential whenever you got dedicated staff, a dedicated space a fib. All those people do when you do it all day every day, you get really, really great at a fib. And so again, determining the need, What problem are you trying to solve? Um knowing what your baseline data is and then having a plan to track that data longitude only as you institute protocols and pathways and figure out better ways to take care of your patients, establishing goals goes right along with that, generating by in doctor or do you want to take that one and talk about that again, as we empower care, you know, to those providing character patients with this is a big deal. You need buy in, you know, I talked to electro physiologist all the time who really want to do this, but they're exhausted. They're working hard all day and they need help. Um I talked to nurse practitioners pa's who are excited about this, but they can't get their docks to listen. Um you know, and then you see sometimes they both have it together and everything's great but then you have administration that that you can't get bought into things. And so you know, I always say to start small and find one success, you know, whatever that is, what is your practice struggling with with a fib care and work together as a team to solve that problem. And then once everyone sees success, success will breed success, right? And so then you have buy in and then you move to the next level and the next and the next. You know, with our er protocol, we had lots of cardiologist who felt like our protocol needed to be 200 pages long at least. And we had lots of er doctors who said if it's more than one page, I'm not looking at it. And so how do you get by in its little by little and working with them and partnering to empower everyone to take care of these patients better, yep. Absolutely, So what can you do now to get started? You know, like we talked about collecting those key data points, it's really, really important. Um think about protocols, you know, we've talked a lot about standardization, I think as you think about your population, um there's a lot of things that are done differently by different practitioners, you know, by different subspecialties, lots of different things, guidelines have changed, you know, and so just making sure that your hospital system is has protocols in place, that that reflect current guidelines, um and then get patients the opportunity to be treated at the right time by the right person. We feel like it's really, really important and a coagulation is a really easy place to start, you know, that one that one everybody can get really fast by and for and kind of all nod their heads around the table that yes we need to do this. Um Thinking about order sets. You know on our border sets, there are no I. V. Medications. You know we're trying to get people to think about what anticoagulant are you going to let this patient walk out the door on whenever they walk in the door. Um And then what oral rate control agent makes the most sense for this patient. We're trying really hard to stay away from the Taj, some drips and and heparin and all of those things and figuring out who your core team is. You know people who are going to be on your team and be all in and be willing to drive this with you. Um It's often um stressful and it's a big push. It's a it's a long road to hoe right? It's a it's a lot of work to do and so you need people who are gonna be all in and be with you to the end of that process. Um and then having those early conversations with people who are excited about taking care of patients in new and different ways and have that energy needed to help enact change. We feel like it's really, really important. Anything to add their doctor already. Okay, awesome. So we're about to spend the next 10 minutes or 15 minutes and answering your questions. We want this to be interactive. And so if you still have questions go ahead and put those in in the chat now um so that our moderator can get through the questions in the next 15 minutes or so. Um as we finish up, I do want to let you know that cd remote Solutions is a company that Amber Seiler and I have that that we used to partner with clinics with hospitals with providers to help uh and taking care of these patients and so we can help with consulting and thinking about putting together performance for your team. We can help you think about how you're going to collect your data and how you're going to present that and we can help you put your team together and so um just reach out to us on that end. Otherwise I think at this point we will proceed with questions Amber and I have our twitter handles there and so you can always message us with any questions throughout the year, we have um you know, it's so great to partner with really great clinics across the country and we have really amazing providers that reach out to us and we're able to just collaborate, work together. And so we would we would love to collaborate with your team and help out any way we can and so feel free to reach out to us. Twitter is always a good way to do that. At this point, I'll turn things back to Tiffany, our moderator for questions. Hi, I'm back. Um we have several questions in the chat. So the first question is I know dr are red and amber, you talked about initial buying from the administration. Can you talk a little bit more about that? And what data did you share with? Administration, yep. So, absolutely, So I'll take this one first. So I think administration right now is very interested in when we started a program is very interested in standardization, right? And reducing variation and so for us that was an easy way to say, this is a good reason why we should put some of these protocols in place. Another thing that helped us was just looking at the data. So in this picture is sharing young who is who now works on our epic team but went back when we started all of this was our quality one of our quality nurses and she went through and pulled six months of hospital data, looking at length of stays and who saw the patient and what procedures are they getting hospital and where they sent home on anti regulation and a lot of those quality things and data speaks right. And so for us getting administrated by in was again a lot about reducing that variation of care. But knowing what our baseline was and having a clear plan to improve where we were to get where we want it to be. Absolutely. And I think when we started, we put together a slide deck, as Amber says, where we had, you know, across the four or five hospitals in our system here is where the majority of a fib patients land. We even went by hospital floor according to our hospital, they're more likely to be on this floor, this floor, this floor. When they come in with atrial fibrillation, we looked at our average length of stay, we looked at our readmission rates and we had all of this on power point and then we kind of put together a proposal of some things we wanted to do, such as how do we get them out of the er and how do we help prevent the hospitalizations? And so we just put together some ask and it showed that we were engaged and we were, we had bought into the process so that what happens is you present this to several of your partners who say, wow, this is great. We need to get you in front of the lead and you get in front of lead and they're like, wow, this is really great. We need to get you in front of this team and then the quality team and the next thing, you know, everyone is excited about the opportunity. And I think by in isn't always overnight and it isn't always easy. Um and the hard part is were often very busy and overworked in other areas. But yeah, I think you have to be willing to put the effort. I think if you just say administration, we think this should happen and we want you to do it, that doesn't come across quite as well as you know, here's the need that we have here is some opportunities and let's partner together to do it. Yeah, great. Well, the next question says in the presentation, I noticed that cardiology was only consulted 46% of the time using the protocol in cases where cardiology was not consulted. Were there any hurdles as far as training in the er with getting patients to follow up in the a fib clinic after discharge? So, so, you know, this protocol again has evolved over time and initially we wanted those, those conversations with cardiology. But I think as time went on, a lot of the emergency room providers realized they were very comfortable in taking care of these patients. And so we've had lots of conversations and education with our our team. We have again, it's all about your team members, Right? So we have amazing uh emergency room physician who is basically quarterbacking from the er side and he's working with his partners regularly, talking to them about the process and ways to safely take care of these patients. Um For our er docs we do have an order set and part of that is um the referral to the A. Fib clinics so we feel very comfortable that those patients are going to land there. We also have an eighth of a navigator who basically goes back, you know, every week at the end of the week and looks at all the patients who were in the er with the primary diagnosis of a fib and looks to see how they landed. And so mostly to make sure they landed safely, right? And so we call these patients to make sure that they have the follow up that they are anti coagulated um and answer any questions that they have along the way. And this navigator also will send messages to some of our er providers to say hey Mr jones came in and I noticed you admitted him but but he would have been a good candidate for the protocol you know? And so again it has been a learning process along the way. The next question is you guys spoke about the importance of treatment. Does cone health have any special protocol for early detection of a fib? So that's a hot topic right now. Uh We do not have a specific protocol for early detection of a fib. I will tell you what we do have are a lot of patients calling in saying my Apple watch said this right. And so what we've done is we've tried to intentionally divert those patients to the clinic because those are two providers who have extensive experience with a fib and are able to help with education and you know, get patients again plugged in where they need to be when they need to be there. And so we are not doing any kind of systematic early screening for a fib outside of any research trials that we have going on right now. But we have Um encouraged anybody who calls in with that. My Apple Watch said kind of thing to be seen in the 8th of Clinic because they are the best people to educate patients and again get them where they need to be. Exactly. I think again this is an opportunity to standardize. I worry when you have 40 providers taking care of patients of various ages and there is data coming from a wearable, how do you standardize 40 cardiologist and how they're going to manage wearables in 2021? I think it's coming but it's not here today. And so if you can direct those patients to one or two providers who have, as Amber said extensive experience with these products and they use them every day and they're collaborating and using it in patients every day, then we feel like we're going to give a better solution to those patients. We do have an early detection of a fib protocol for our cryptid an extraordinary. So if you have had a crypto genic stroke or symbolic stroke of unknown source, then those patients um typically receive an electrophysiology consult before they leave the hospital and have an implantable loop recorder placed prior to discharge. And we do follow those patients incredibly closely through our device clinic. And if a fib is detected, those patients are started on anti coagulation and refer directly to the clinic. The next question we have is how did you calculate how many mps slash ps were needed? You were starting out and how did you convince administration to stop it that way? Yeah. So that's a good question and it's a little bit of know what you can ask for and what's going to be acceptable, right? And we wanted this to be really successful and we wanted this to be financially positive for the hospital. We're not trying to spend money. That doesn't make sense or do things that don't make sense. I mean, this really is a collaborative effort within the system um to try to make sure that everybody is getting what they need. And so we asked for one to start and one nurse which we felt like was a very reasonable ask. And again we built that Proforma off of four or five clinic visit today and two additional revelations a year, which is not a lot. Um and then as that clinic grew over, what was it after? Only the first couple of three years we recognize that we needed another to add another provider. It was just too full and we were losing our ability to do those same day, next day add on appointments and that at the point that we requested that second A. Pp. And then I think you look at opportunities to share resources as well. So you know for example are administrative support team we share with heart failure and so we have a whole kind of registration desk and you know folks to check patients in and schedule appointments and do things that is a collaboration with heart failure. Uh And and so we are able to share resources with them and also with structural, you know when we look at things like Watchmen and some of the other things that we have that we need navigators for, we're able to share resources and that helps extend our ability to care for these patients. Next question we have is does the current scheduling system that your hospital used to deliver a fit patients to the A fib clinic? Do they perhaps call a main scheduling number or if a primary care person sends a patient as a referral? Do they go right to the f clinic? That's a really great question. So are a fit clinic has a dedicated phone line that rings straight to them. There's no phone tree, there's there's no you know, it's somebody in that outfit clinic is going to answer that phone or you can leave my voicemail and they'll call you right back. And so primary care is a great example of that. So historically patients would show up in their primary care office with new newly identified atrial fibrillation potentially going very fast. But the patient was asymptomatic and those patients were always sent to the emergency room. And now the primary care providers in our community just call the a fib clinic and say, you know, I'm gonna start him on eloquence and a little bit of partisan, can you see them later, today or tomorrow? And the answer is always yes. We're always happy to see those patients, but it does not go through the hospital system. It's a dedicated phone line. You know, all of that. We've tried to keep very tight around the clinic and around people who understand that schedule and are able to move things around so that patients can be seen. And it's the most efficient work day. And also within the hospital basically they can use epic to directly uh send a request to the work queue. So for example there on the cardiology service or the hospital services are going home, they can put that patient into the work queue and then monday it's on the weekend. You know, let's say on monday morning the clinic team would come in and pull that work queue and schedule the patient from that. Yeah. Next question we have is how did you estimate the number of patients that would go through the clinic as you were starting out? So that's a great question. You know, when we first started putting this together, honestly my clinic was I had so many patients that I couldn't have followed. You know, because of bandwidth. You know, I mean I wanted to be in the electrophysiology lab, my administration and practice wanted me to be in the E. P. Lab But I could have been in the Office eight days a week and I still could have seen everyone you know things like following their tickets in to make sure they're getting frequent follow ups and the appropriate labs, amiodarone these other things. And so to begin with I actually said well okay if I shift all of my you know tickets and follow up to this clinic you know here's a known volume of patients and if I just take my routine follow up patients and shift them to the A fib clinic there's a known volume. Um I used to only see my post defibrillation patients three months after the ablation. I said well you know would be nice to have those patients seen by someone four weeks after the ablation. And so every oblation patient we're seeing in the A fib clinic at four weeks after to just follow up you know that's a known volume of patients. And so so we started it, you know, not saying well is that we are going to send these patients or the hospitalist we already knew even if they didn't, we had a ton of patients within our practice that we could have seen in this clinic to keep our uh our nurse practitioner busy at the time. The next question we have is did you produce your own educational materials to give to patients? Or do you utilize material from another source such as HRS or a A J. You know, I think there are some really great resources out there and I'll let Amber tell you about our current resources and how we got them. But you know, I mean by a sense Webster, you know, J and J has has great resources for patients and for practices these days, american Heart Association is really working tremendously, you know, with lots of efforts to to direct to patient educate as well as the heart rhythm society. And so I think those are three really great resources that we have today um that you should use and I love to use those resources. But if you tell them about how we got started with ours. Absolutely. So we got started a big focus of our clinic was that lifestyle modification piece. Right? You know, helping patients understand that they do have control over this disease state. And like many others, you know a fib is something that they can directly impact with weight loss and exercise and sleep apnea treatment and diabetes control of hypertension control. And so We we did not find a lot of resources that were geared toward the 8th of patient for that lifestyle modification piece. And so there was a master nursing student who needed a project to do at one of our local colleges. And so we tapped her help us put together our own native clinic brochure. And so what it has is, you know, general information about what a fib is, you know, common medications coming procedures. But then there's a whole section dedicated to lifestyle modification. And one of the messages that were really trying to send to patients is you do have some control over this, right? You you do have um a way to help prevent progression of this just on your own. And and it's a really unique position for patients to be in. Like we talked about empowering patients. You know, that message of you can do something about this, you know, and it's not going to make it go away completely, but you can certainly alter the course of this disease state. Things like giving them tools at home like, you know, pierre pill in the pocket, like an odd or some partisan to take when they go out of rhythm, things like that, just to help empower them to have control over their own health care. And so we wanted to include all of that in those patient education resources which um for us was better served. Um doing that internally. The next question we have is what protocol do you have for new onset um A fib on the weekend, if you're a fib clinic is only for monday to friday. So a lot of these patients, you know, if they land in the emergency department or the hospital um then they'll they'll follow up in the a fib clinic in 3 to 5 days. You know, those patients actually aren't seeing the same day by our a fib clinic team are a fib clinic team does not go to the er to assist in the process. And so they would see that patient again in 3 to 5 days after they left the er or left the hospital. You know we do not have um you know I think there's an opportunity to keep patients out of the hospital on the weekends. Certainly we know during the week patients go into a fib and they call the a fib clinic and the clinic does say come on over and that absolutely keeps people out of the hospital and out of the er I tell patients you know this is a V. I. P. Service for you. Unfortunately it's monday through friday and we talk about you know if you have atrial fibrillation, what do you do on the weekends? How do you know it's all about taking the power away from a fib and giving it to the patient because these patients are really afraid and that fear is the reason they land in the er and um and that's the biggest thing are a fib clinic nurses are doing is they're they're talking these patients off the ledge there saying you know what you're fine, you're gonna be okay, come on over, we'll help you out, you know and they orally control a lot of these patients to keep them out of the er And so um you know we have conversations on the front end for patients to say if you have a fib on the weekend, what is your action plan? And we talked to them about the things that would the reasons for them to go to the er Refractory chest pain, they're passing out, they can't breathe, go to the er but if it's you know I'm in a fib but I feel okay I'm just a little scared. You know you're going to do this you're going to do this and you're going to call this first thing on monday morning and for many patients that's enough to keep them at home and safely at home. Problem. Well I'll say our last question because we're running up to time but um if you could speak briefly on how do your M. P. S. And P. S. Effectively manager at the patient and remote monitoring. So are you know we've got like a minute a half left so we'll talk quickly about this one. But our device clinic is completely separate from our atrial fibrillation clinic. They do work closely together and we have worked intentionally to try to improve that data flow between our device clinic and are atrial fibrillation clinic. And so typically what happens is the device clinic will get that alert for new persistent a fib or a new onset atrial fibrillation. And they refer those patients over to the clinic. We have put things like you're like express marijuana man, middle manager and our eighth of clinic so that they have the opportunity to interrogate those devices and they've been trained to know how to read those reports and then our device clinic is always available if they have any questions about those interpretations. Well thank you DR. Allred and Amber for being here today for this informative session. Thank you to all the attendees for joining today's product theater empowering care to the patient. Have a great day and enjoy the script symposium.
