Norton Audubon Hospital and Norton Hospital, part of Norton Healthcare in Louisville, Kentucky, recently achieved Atrial Fibrillation (AF) v3 Accreditation with EPS through the ACC Accreditation Services. In this interview, EP Lab Digest speaks with Frank Wilson, RN, nurse manager at Norton Hospital, Sandra (Sassy) Utsey, APRN, nurse practitioner with Norton Medical Group, and Melissa (Missy) Allen from the outpatient Norton Heart & Vascular Institute Heart Rhythm Center (HRC), about this certification.
Tell us about the EP programs at Norton Hospital and Norton Audubon Hospital. Approximately how many AF patients does Norton Hospital and Norton Audubon Hospital see annually?
Frank: Norton Hospital’s EP program is tied in with the cath lab, so we have 2 rooms where EP procedures can be performed.
Missy: More than 12,000 patients were seen in the Norton Healthcare system with a primary diagnosis of AF in 2017.
When did the hospitals achieve accreditation?
Frank: Missy and her team started this process at the beginning of 2012, working with the Society of Cardiovascular Patient Care to achieve Chest Pain Center accreditation in 2013. Norton Hospital and Norton Audubon Hospital then became AF certified in 2014, but the required site visit had not yet been done at that time. Following an initial three-year period of certification (from 2014 to 2017), both facilities became eligible for AF accreditation, which took place in May 2017.
What members of the staff were involved in the accreditation process?
Sassy: I was the lead at Norton Audubon Hospital, and Frank was the lead coordinator at Norton Hospital. Both facilities utilized a multidisciplinary approach, involving cardiologists, electrophysiologists, administration, medical directors, nurses, axillary staff, therapists, and those in the noninvasive cardiology department. A broad-reaching group of people were involved in this process to lend their frame of reference and help improve outcomes.
Frank: In 2012, Missy initiated the plan for the AF Center of Excellence and began working on this process with Steven Conway, system vice president of cardiovascular pulmonary services for Norton Healthcare, and electrophysiologist Dr. Kent Morris with Norton Heart Specialists, the physician practice of Norton Heart & Vascular Institute.
Missy: Yes, when Norton Cardiovascular Associates was acquired by Norton Healthcare in 2011, it became known as Norton Heart Specialists. In 2012, we began exploring the possibility of an AF Center of Excellence, and received approval in 2013 to move forward with this initiative systemwide. Our marketing and public relations teams became involved and helped with what we needed to meet criteria for accreditation, including assessing our needs for education, outreach, and AF support groups.
Frank: Leading into the 2014 certification process, when we received the go-ahead for the AF Center of Excellence, Norton Audubon Hospital utilized an AF coordinator and chest pain coordinator. At Norton Hospital, I served as the AF coordinator and John Vereb, RN, nurse manager of the emergency department, was the chest pain coordinator. In the beginning, our team consisted of Mike Sego and Lesli McDonogh (the directors of the 2 cath labs), staff nurse Ashleigh Ellingsworth, RN (who worked at Norton Hospital), and Vickie Sotkiewicz, RN, clinical information analysis (for data collection). We worked together as a system going into the 2014 certification; however, each hospital had to submit a separate application. For the 2017 accreditation process, Sassy, Ashleigh, and I worked alongside electrophysiologists Dr. Morris and Dr. Robert Schwartz, electrophysiologist with Norton Heart Specialists, the physician practice of Norton Heart & Vascular Institute on order sets, best practices, and procedures. In 2013-2014, we created an AF order set for our patients and put the links in our Epic electronic medical record (EMR) system for CHA2DS2-VASc scoring. After the teams from Norton Hospital and Norton Audubon Hospital met, Missy then helped coordinate the electrophysiologists at both facilities to review order sets and the different nuances for each hospital.
What can you tell us about the process for achieving AF accreditation?
Frank: Each of the components of accreditation is essential. The first deals with governance of the hospital and system leadership. Community outreach is the second essential component. The third deals with pre-procedural policies for each hospital in our system; chest pain and AF are discussed along with other issues on a quarterly basis. The fourth component reviews how an AF patient is managed in the emergency department, from triage all the way to either discharge or being admitted to an observation or inpatient unit. The fifth element involves the hospital stay and order sets. The next component evaluates post-procedure protocols and policies, including transition to discharge, patient education, and follow-up. The last element looks at clinical quality and outcomes in the practice.
Sassy: When I joined the Norton Audubon team about 2 and a half years ago, Missy and Frank were well on their way into the accreditation process. Therefore, it was great because this process helped me gain a better idea of the expectations needed for best practices and set standards. I do not have a traditional nurse practitioner role; I do a lot of staff development and facilitate between staff and physicians. Therefore, learning core components and elements has allowed me to ensure that the nursing staff is intricately involved and helped me understand why the physicians were doing the things that they were doing. We looked at each of the elements listed by the ACC Accreditation Services to figure out if we were adhering to best practice. It was revealing to everyone involved to find out we were ahead of the game. For most elements, we were already doing the work because we hold ourselves at a very high standard. We did come across some suggested but non-mandatory elements that presented opportunities for how to could integrate enhanced practices into our current way of doing things. It was educational to learn about these elements and help our staff understand the process.
Frank: When we began in 2014, there were mandatory, recommended, and innovative categories for different processes. Some of the items in the recommended or innovative category in 2014 became mandatory in 2017, and some new items were added to the recommended or innovative list for 2017. During this process, there were many things we set up, including community outreach with AF support groups and education. In 2014, we created education on chest pain and AF accreditation for all employees at Norton Healthcare, and we update this information every year. In 2017, Sassy recreated AF education for the whole system and changed some of our different criteria. Our system team looks at chest pain and AF accreditation education for staff; however, we also keep track of education for physicians, and whether conferences or CE educational events are provided to physicians and advanced practice providers (APPs). Missy’s team came up with a wonderful advertising and marketing plan about how to keep up the education initiative on an ongoing basis.
Missy: From the outpatient perspective, we implemented some items that are innovative but not necessarily mandatory. For example, we’ve been holding patient support groups since 1996, including quarterly support groups for defibrillator patients. Our AF support groups started in 2012. In addition, we hold quarterly EP meetings for staff including physicians to collaborate on the latest protocols and best practices. We also work with our marketing and public relations team to provide education to our local and regional primary care physicians and their nurse practitioners on the latest protocols and procedures available for AF. We also meet with pharmacists to provide education. Furthermore, we hold quarterly educational events at the hospital for the community, patients, and family members. These are advertised, posted in the hospital, and mailed to patients. These hour-long educational opportunities are presented by our physicians and nurse practitioners in the evenings, with a 30-minute Q&A afterward. Some of the topics discussed include updates on anticoagulant medications and the latest procedures that are available.
Frank: We always try to incorporate EMS staff in our educational events as well. Sassy holds a monthly meeting with a cardiovascular group that provides case studies on topics such as cardiac events or AF. In 2014, we had a cardiologist and nurse give an hour-long CEU/CME presentation on AF; this was entered into our online learning system for our physicians and staff to access on demand at their convenience. We did another continuing education conference during this time period, as well as held a larger conference this past November.
What changes have you implemented in the accreditation process?
Missy: One aspect that we’re still working on, which has been a big undertaking for us, is having the Epic EMR system calculate the CHA2DS2-VASc score for us, rather than having to use a smartlink. It’s important that, regardless of inpatient or outpatient, physician offices are making sure that everything is documented. We are working to get this calculated systemwide.
Sassy: It’s currently not standardized. At Norton Audubon Hospital, we want to make sure the CHA2DS2-VASc score is available in a structured way. It’s done at every consult, with every AF patient. It was brought to our attention that there are many low-risk AF patients managed by their family physician without the supervision of a cardiologist. We changed our process to include primary care physicians in our monthly meetings so that we could disseminate information and provide them with education. Primary care is represented in our monthly cardiovascular care meetings, and I also attend a separate meeting once a month to discuss elements related to cardiovascular services, such as AF and CHA2DS2-VASc, so those groups can participate and meet the standard as well until we are able to put the automatic process in place. Having communication and this multidisciplinary approach helps identify and understand any nuances, and involves the hospital group in the care of these patients as well.
Missy: We have two new AF initiatives that we’re working on. First, we’re finalizing an algorithm in which emergency department (ED) physicians can send AF patients who meet the criteria in that algorithm same day or within 24 hours to the Heart Rhythm Center instead of admitting them to the hospital, where they will be seen by an APP. We’re piloting this at our Norton Brownsboro Hospital emergency department, and will be opening it up to all Norton Healthcare emergency departments once it’s ready. The second initiative is a social media and advertising campaign focused on AF patients. This is a great way for patients to see a Norton Heart & Vascular Institute electrophysiologist. The phone number provided in the campaign goes directly to our dedicated AF line at the Heart Rhythm Center, where we have appointments set aside for those patients (we will also have appointments reserved for the ED patient initiative). Ultimately, both initiatives will be of great benefit for patients who are currently being treated by their primary care physician but want to see an electrophysiologist without a referral, and for those patients being treated at another facility who would like to transfer to Norton Heart & Vascular Institute.
Frank: For those facilities undergoing certification or accreditation for the first time, one of the things that we also had to do was develop an order set to the current guidelines and create a loop process where follow-up can be made whenever changes are made. What you develop for education is also important, because it shows staff what is mandatory for their annual competencies. We created education for both floor staff and EP staff as well as for triage nurses. Information about the signs and symptoms of AF was created, and made available on different units throughout both facilities. This process also involves updating the tracking tool for AF patients. For example, this tracks the percentage of patients that received an anticoagulant on discharge; there is also tracking for the percentage of patients that received education about their medication. The tool also tracks where we’ve improved; we have been able to check CHA2DS2-VASc scoring and see where there has been improvement through the year. While each of us work within our own facilities, we use a systemwide perspective for the AF order set best practices.
Missy: We’re trying to put the focus on educating patients. For example, we have a nurse available who can provide an hour-long visit with patients to discuss diet and exercise, weight and BMI, stress, and other health issues. Before any procedures are done, every single patient must go through an AF checklist — this puts part of the responsibility back on the patient, meaning that they need to do their part to have a successful outcome, whether that is losing weight or seeing a pulmonologist for a sleep study evaluation. We are working towards a multidisciplinary AF clinic, one appointment for that patient where they meet with the AF coordinator, pharmacist pulmonologist, and EP physician.
Has certification resulted in cost savings for the hospitals as well?
Missy: We are looking at the outcome-based measurements that will result in a cost reduction. One of the aspects we are looking at is to reduce hospital readmissions for patients with AF. Once AF patients are discharged, they are seen four days later with one of our nurse practitioners at the Heart Rhythm Center. This is one of the ways we are trying to make sure patients stay out of the hospital and are educated about their medication.
What does achieving this accreditation mean for the staff? Any final thoughts?
Missy: Personally, we knew that we were doing a great job, but achieving this accreditation gave us a new perspective on how well we were doing systemwide. It takes a lot of people to get this done. Without Frank and Sassy, I’m not sure we could have done this, because we all brought something different to the table. This process also helped us improve in a couple of areas, but in general, I think we were ahead of the game. It feels good to know we are providing excellent care throughout Norton Healthcare.
Sassy: Actually, the surveyors were so impressed with the Heart Rhythm Center during the accreditation process and site visits, that they invited Missy and Tara Mudd, APRN with Norton Heart Specialists) to participate on a panel in their annual congress! Missy and her team are exceptional.
Frank: Mandatory, recommended, and innovative elements helped validate each step of the process. Staff involvement and a multidisciplinary team approach were the keys to our success. Our goal was to improve patient care and outcomes, and I believe that is what we have achieved and will continue to strive toward.