In this interview, we speak with William Lewis, MD, Chief of Cardiology and Director of the Heart and Vascular Center at MetroHealth Medical Center in Cleveland, Ohio, about being one of the first Gold achievers in the American Heart Association’s Get With The Guidelines®-AFIB program.
Tell us about the EP program in the Heart and Vascular Center in The MetroHealth System. How many EP labs and EP lab staff members are there? When was the EP lab started at your institution?
Our electrophysiology program began in 1991 with one electrophysiologist, and has grown over time to five. We have two electrophysiology laboratories, including a biplane lab and two electroanatomic imaging systems. We have two electrophysiology fellows and five full-time electrophysiologists. Our lab employs 20 staff who cover both the EP and cardiac cath labs.
What types of EP procedures are performed at your facility?
Our electrophysiology laboratory performs the full spectrum of procedures, including subcutaneous and endovascular device implantation as well as diagnostic and therapeutic electrophysiology studies (including complex three-dimensional procedures). MetroHealth was an early adopter of left atrial occlusion systems, including EP lab and OR-based systems.
Approximately how many atrial fibrillation (AFIB) patients does The MetroHealth System see annually?
Annually, we treat over 5000 patients with atrial fibrillation. The MetroHealth System’s market share in cardiac electrophysiology is growing despite a stagnant market size.
The MetroHealth System was one of the first Gold achievers in the Get With The Guidelines-AFIB Registry and recognition program. As GWTG-AFIB Chair, what can you tell us about this program?
Get With The Guidelines is a national hospital-based quality improvement program from the combined forces of the American Heart Association (AHA) and the Heart Rhythm Society. It uses quality improvement tools to increase adherence to guidelines. We share techniques with each other, and collaborate using national webinars and a web-based patient management tool. We just presented our initial experience in adherence to stroke-preventing anticoagulation guidelines at the AHA’s Scientific Sessions in November 2016. We demonstrated that we are providing guideline-recommended anticoagulation to over 95% of eligible patients. That adherence rate has never been seen before in the literature. Because of our partnership with the HRS, we are now benefiting from the expertise of the nation’s largest organization of arrhythmia specialists. Hospitals receive private reports that benchmark their data against national data.
With the recent addition of our atrial fibrillation ablation registry at no additional cost, hospitals can enter their ablation patients with features such as a follow-up form to monitor and benchmark procedural success.
Why did your facility choose to participate?
The MetroHealth System is dedicated to high-quality care. For us, participation isn’t enough; we want to improve and achieve the highest level. We have achieved Gold Plus in the AHA’s Get With The Guidelines Heart Failure program, Gold in the Mission Lifeline program, and Platinum in the ACC’s ACTION Registry. The Atrial Fibrillation program was a natural next step. As the national chair for GWTG-AFIB, I felt strongly we should participate. The pressure was on — I knew that if we “talked the talk”, we needed to “walk the walk”!
What is the process for participating in the Get With The Guidelines-AFIB? What steps are involved?
It is as easy as contacting your AHA affiliate and asking for the Get With The Guidelines representative. They will guide you through the process. There is a contract designed to protect your data and to assure privacy. The Quintiles staff maintains a help desk to assure that the process is smooth.
How long did this process take for The MetroHealth System? What members of the Heart and Vascular Center team were involved?
MetroHealth got on board very quickly. Within two weeks, we had the contract signed and were entering data. Quality improvement is a team game. We involved our quality improvement nurse, our electrophysiology leadership, our lab nursing staff, the pharmacy team, and our nursing education team. The education team was important, because patients with atrial fibrillation are everywhere in the hospital, and the educational process is important for residents and attendings that manage atrial fibrillation — not just cardiology.
What are some of the ways your facility’s approach to treating atrial fibrillation has changed since enrolling in the Get With The Guidelines-AFIB program?
We applied some of the techniques we used in our other Get With The Guidelines programs. For example, we developed order sets and educational programs that were targeted to physicians and nurses in a multidisciplinary fashion.
What were some of the areas for improvement that were identified, and what processes or protocols were modified to ensure they were in line with the Guidelines?
Like most institutions, our attending physicians, fellows, and residents are smart people that understand the guidelines. But quality improvement is not only about education and smart people — it is about implementing processes to ensure all patients get the appropriate treatment and to prevent patients from falling through the cracks. Thus, the order sets, nursing protocols, and educational modules for patients were important. One unique approach was to develop a CHA2DS2-VASc calculator in our electronic medical record. We worked closely with our information systems team to develop this.
How has participating in Get With The Guidelines-AFIB affected your center’s treatment rates and patient outcomes?
I think we all would like to say that by joining Get With The Guidelines-AFIB, we just proved that we were already doing a perfect job. However, when we looked at our baseline data (one of the important first steps in the program), we found that although we were very good, we were not where we wanted to be. We very quickly improved our anticoagulation rates from 85% to 95%.
Why should other EP programs consider taking part in Get With The Guidelines-AFIB?
At the end of the day, Get With The Guidelines-AFIB is about getting better. Registries “register” patients. Quality improvement programs strive to get better. As medical professionals, w]e gave an oath to improve the lives of patients. This is the core of the profession. This is how you get better, and Get With The Guidelines has a proven track record of improvement.
What does participating in Get With The Guidelines-AFIB mean for the staff in The MetroHealth System?
Our staff and physicians take great pride in the fact that the quality of our work is recognized by the American Heart Association and Heart Rhythm Society. Being one of the first two hospitals recognized is the icing on the cake.
Is there anything else you’d like to add?
I want to emphasize that the Get With The Guidelines-AFIB ablation registry is the only national registry with a six-month follow-up form to determine ablation success. Again, the data is private. You compare yourself to aggregate benchmarks, and your outcomes are never shared.