A desire for a comprehensive way to manage atrial fibrillation patients has led many hospitals to pursue the concept of an “Atrial Fibrillation Center of Excellence.” This approach allows for the necessary expertise, program focus, and dedication to appropriate care for these patients to be offered in a well-thought-out and systematic way … in essence, having a winning “game plan.”
Putting together a successful atrial fibrillation program is like putting together a championship football team. The team requires the right players and personnel, a nicely appointed stadium, and enthusiastic season ticket holders. The first step should be drafting the right electrophysiology (EP) doctor that will serve as both quarterback and coach. This selection then sets in motion a series of collaborative capital expenditure and personnel decisions.
Many football teams focus on a quarterback’s raw talent. Likewise, new arrhythmia treatment programs often focus on the EP physician’s PVI volume (> 100 cases) and competence. However, of equal or greater importance is their interpersonal communication skill set. They need to possess the coaching ability to motivate all members of the EP team and get them through a tough game or a challenging season. For a program to thrive, the EP quarterback/coach must understand that he/she will be serving as the focal point of the program, serving as the ambassador and salesperson. The ability to engage at the appropriate level with patients and families, primary care providers (PCPs), cardiologists, cardiac cath lab staff, and the medical director of the ACO/Medical home is crucial. The EP physician must also be committed to learning the financial aspects of the EP industry (see recent EP Lab Digest® blog entitled “My Economic Education” by my friend and colleague Dr. Ishu Rao). In this particular subspecialty, financial understanding partnering between the electrophysiologist, facility, and often staff is vital due to the high costs of the technology requirements to remain best in “the league.” This will allow the EP to review a financial spreadsheet and have a constructive conversation with administrators and vendors. While the basics of hospital finance are teachable, the interpersonal communication and coaching skills may not be.
The EP quarterback/coach must be able to interact with the referring general cardiologists and PCPs so that he/she can transform them into enthusiastic, referring season ticket holders. The foundation of this relationship is trust. Trust begins with the referring physician feeling comfortable sending all of their atrial fibrillation patients for evaluation. This avoids any potential or perceived embarrassment if the patient returns and reports that he/she was not an ablation candidate. The EP can be expected to review the full spectrum of options (including anticoagulation), select appropriate PVI candidates, and also provide referring tailored care for non-PVI candidates. Trust will be firmly established if the electrophysiologist can provide realistic PVI patient expectations (such as 60% single procedure success with a 5% major complication rate) and promptly handle complications and/or recurrences without leaving them untreated, only to be handled by the referring doctor. If the EP doctor is genuine in his intent to collaborate, this lays the groundwork of mutual respect that will transform the referring general cardiologists and PCPs into loyal repeat customers, who will fervently support the EP doctor when they speak with their patients/families following the sometimes inevitable complications and recurrences.
The doctors who serve as key defensive players are the interventional cardiologists, cardiovascular surgeons, neurologists, gastroenterologists, and ER staff. Corazon believes these key team members need to be educated on the basic aspects of the PVI procedure so that they understand and accept in a non-judgmental manner that some complications may unfortunately occur. For example, the GI doctor will need to understand the reason for the EP quarterback’s persistent requests for frequent post-PVI GI evaluations or EGDs. Given the life-threatening nature of a left atrial esophageal fistula, it is imperative to make a prompt diagnosis.
These doctors need to function like defensive linebackers, always available on the sidelines with their helmets on, ready to run into the game to play defense if the quarterback throws an interception. Although the electrophysiologist should be capable of stabilizing a tamponade patient, for instance, it is paramount to patient safety that an interventionalist or surgeon be available to help out as needed. In addition, although ER doctors are often the first to see a delayed complication such as tamponade, stroke, or esophageal injury, the education of these doctors is often neglected.
Once your organization is convinced that your EP quarterback meets both the procedural and communication skills requirements, you can move on to the collaborative decisions regarding key personnel and the capital expenditures involved in building a new stadium (e.g., 3D mapping, cryoablation, robotic navigation technology, and biplane system). Most EP training programs offer the opportunity to use several different mapping systems and niche technologies. However, it is reasonable to expect the electrophysiologist to take a lead role in prioritizing which capital expenditures are most important. This initial discussion will provide an opportunity to assess whether your EP quarterback has the ability to participate well in the “huddle.”
The EP quarterback should also be involved in selecting the best offensive coordinator (typically a nurse or PA). This offensive coordinator is one of the most important members of the team, and he or she will be responsible for managing all of the clinical and non-clinical aspects of PVIs (the offensive game plan). The most important responsibilities in this role are handling unanticipated calls from complex pre- and post-PVI patients and triaging calls/pages that arise during the actual procedures so that the electrophysiologist can stay focused on the “play” at hand. Other clinical tasks include pre- and post-PVI education, completing admission and discharge paperwork, and carrying out post-discharge follow-up phone calls to confirm that patients are taking their anticoagulants as instructed and to be certain that they are not experiencing any delayed post-PVI complications. Additional tasks include confirming insurance approval, arranging pre-op testing (CT/MRI), and urgently scheduling post-op testing and evaluation (event monitor/pulmonary vein MRA/echocardiogram/EGD) if there is a suspected complication.
The next collaborative personnel decision is interviewing and selecting the lab personnel that will take the lead on the PVI procedures. These folks are the offensive line, protecting the EP quarterback from blind side hits by keeping an eye on the vital signs, ACT, and ICE images to maintain proper orientation and watch for early evidence of a pericardial effusion. Offensive lineman can get ‘benched’ (take vacation or leave for an industry job), so Corazon recommends having at least one cross-trained cardiac cath lab staff member to fill this void so the unit can keep protecting the EP quarterback. The decision on whether to integrate and rotate the dedicated EP staff with the rest of the cardiac cath lab staff, including STEMI call, is institution specific, but ideally should be prospectively determined. One consideration is that if your non-ablation and STEMI volume is modest, it is likely that your EP staff will be putting in more hours per week than the non-EP staff.
One last consideration is the role of an anesthesiologist or CRNA. When starting a new PVI program, it makes good sense to have a trained professional handle this important part of the procedure. This is not a passive role, as this person needs to understand the challenges and potential complications of PVI. When this medical professional is properly trained and actively engaged in the game, it is like having an experienced assistant coach sitting high above the field watching for any worrisome moves the opposing team is making. They are also your greatest asset when an urgent complication occurs, because they are immediately available to handle the airway and give vasopressors if necessary. This additional oversight position allows the EP physician and staff to concentrate on other critical rescue procedures.
Following these important personnel decisions, the EP team should take a road trip to the electrophysiologist’s training program so that all members of the team (including cardiac cath lab and CV service line directors) can fully understand what is involved with building and maintaining a successful atrial fibrillation program. This trip prevents any misunderstandings or false expectations regarding the global programmatic requirements. The road trip should include extensive documentation related to every aspect of the process, including tips on insurance pre-approval, billing codes, the specifics of ordering every single piece of equipment, and peri-PVI anticoagulation and antiarrhythmic drug management protocols.
Defeating the Opponent: Watch the Scouting Films
The week before a game, the football team views the scouting films of the opposing team. They study their offensive formation, the pattern of how they line up, and this allows them to anticipate what play the opposing team is going to run. During the actual game, this allows them to recognize the pattern and, thus, successfully stop the play. Fortunately we possess the scouting films for PVIs on the basis of the results of several large studies and registries. Defeating complications is an exercise in reverse engineering. Experienced EP teams know how to anticipate the most common complications, and they know the pattern of events that often results in a complication.
The most common problems in our playbook are groin complications, stroke, tamponade, and, although less common, esophageal injury that progresses to left atrial fistula. Championship EP teams know that the offensive formation or pattern for a stroke often starts with a groin complication that requires discontinuation of anticoagulation for a surgical intervention. How do we defend against this play? One possible solution is to use ultrasound to guide venous access so that we do not hit the deep femoral artery — thus, decreasing the likelihood of a groin complication that requires discontinuation of anticoagulation. Another example is delayed tamponade. The offensive formation or pattern for this play is a patient with severe post-PVI pericarditis. Defending against this play involves aggressively treating the inflammation, ordering serial echocardiograms, frequent monitoring of anticoagulation, and making sure that all team members (from the referring doctors to the ER doctors) are watching for this play (complication).
From a hospital program standpoint, there is also a common pattern that precedes a failed PVI initiative. The most frequent scenario is a hospital that wants to “see some results” before budgeting for the necessary building blocks. For example, if the EP quarterback has a weak offensive line (poorly trained or committed cardiac cath lab staff), has no offensive coordinator (nurse or PA), and has to carry the team without a break, he or she will get “injured” in the form of burnout. If the EP knows that the organization is committed to providing these building blocks as well as drafting another EP doctor within 12–18 months to help with the entire EP workload, then they will be less likely to exhibit signs of burnout or even worse, leave employment.
Another worrisome pattern is created by poor planning with a hospital that creates inappropriate financial expectations that could impact both EP and cardiac (non-EP related) revenue. For example, a device implant, when performed efficiently and with aggressively negotiated vendor prices, is more profitable per hour than ablation. Although recent changes in coding/RVU assignment will increase reimbursement for complex ablation, the average contribution margin per hour for PVI is $3,500, compared to pacemakers ($5,000) and ICDs ($12,000). Poor planning in the form of trying to use an existing busy cath lab to do PVI could result in lost EP (device) and non-EP (interventional) revenue due to dissatisfaction from ineffective scheduling and deficient lab capacity.
Maintaining a successful program is similar to reviewing your own game films to see why the offensive line missed a block and the EP quarterback got sacked. For example, in one client scenario, the ACTs were not getting checked often enough and the patient had a stroke. Corazon believes a stellar EP team should meet on a regular basis to review cases and to set corrective actions in motion. If there are any doubts about the integrity of the quality process, then consideration should be given to an outside unbiased review. Tracking outcomes, especially profoundly successful outcomes, can be the program’s most useful marketing tool. Other important considerations include providing continuing education for clinical and billing/coding staff.
Sharing the New Stadium: An Opportunity for Synergy
Atrial fibrillation and structural heart programs have many things in common. They are expensive to start, require cooperation across many disciplines, and ultimately may only generate significant revenue from their “halo effect.” It may be possible to save some money by building a ‘stadium’ in your hospital where multiple teams can share a work space. Hybrid rooms can be used for PVI, ELG, ASD closure, TAVR, and subcutaneous ICD implants. Even if you are not able to build a multi-purpose hybrid room, in order to maximize the productivity of both a structural heart and PVI program, all the major principles should be encouraged and incentivized to work together. This starts with a minimum of quarterly meetings of all physician and non-physician stakeholders. Whereas hospital-employed physicians may display a willingness to adhere to meeting attendance because they may be less concerned about disruption of their referral pipeline, private practice groups can be encouraged to cooperate if they are convinced that the hospital is going to aggressively market the new programs, and thus, grow the size of the entire referral “pie.”
Corazon believes, particularly in terms of highly-specialized programs, the “whole” is oftentimes more than the sum of its parts. Indeed, each team player, as an individual, has something to contribute, but when working together as a team, the contribution and accomplishments for the program as a whole or for the hospital at-large can be so much greater. Coordinating efforts around a central focus, working collectively, setting reasonable expectations, coaching and mentoring team members, and ensuring ongoing communication and collaboration are critical elements to a successful football team and to a successful hospital program as well. Following Corazon’s playbook for program development and maintenance can lead you to a winning season year after year.
Dr. Charles Kinder is the Founder and Director of the Heart Rhythm Program for Heart Care Centers of Illinois and a Medical Expert for Corazon, Inc. He thanks Drs. Delaughter, Kowal, Mehta, Rao, and Tierney for their thoughtful contributions to this article. Marsha Knapik is an Account Manager at Corazon, a national leader in strategic program development for the heart, vascular, neuro, and orthopedic specialties, offering consulting, recruitment, interim management, and physician practice & alignment services across the country and in Canada. To learn more, visit www.corazoninc.com or call 412-364-8200. To reach Dr. Kinder, email CKinder@heartcc.com. To reach Marsha, email firstname.lastname@example.org.