In this feature interview, we speak with Darryl Elmouchi, MD about the Spectrum Health Atrial Fibrillation (AF) Emergency Department (ED) Clinical Pathway and AF Clinic. Dr. Elmouchi is the Medical Director of Cardiac Electrophysiology at the Frederik Meijer Heart & Vascular Institute, Spectrum Health in Grand Rapids, Michigan.
When were the AF clinic and pathway established? What prompted this need?
The Spectrum Health AF Clinic was started in 2011. Its inception was the result of a clinical pathway we created to care for patients presenting to our ED with the chief complaint or symptoms of AF. In 2010, we created the Spectrum Health ED AF Pathway as a means to effectively treat patients in the ED with new onset or worsening symptoms of AF in an evidence-based manner that ultimately allowed for safe discharge from the ED, avoiding hospital admission. This pathway was (and is) very successful; however, early on it became apparent that patients being discharged from the ED needed close follow-up of their AF. As a result, the AF clinic was conceived.
What is the purpose of the AF clinic?
The AF Clinic was designed to deliver evidence-based, but personalized, care of patients with AF in a timely and customer-service oriented manner. Our goal has always been to see patients within 72 business hours of the initial request. It was initially developed to see patients who passed through the ED AF protocol; however, it has grown to the point where it now sees urgent referrals from outside primary care doctors, self-referrals, and internal referrals within our large cardiovascular group. A prime example of the latter are device clinic patients. We follow over 6,500 device patients, and it is quite common to discover new (often asymptomatic) AF on a device check. These patients are quickly referred to our AF clinic for further evaluation and timely institution of appropriate anticoagulation. Ultimately, while treatment and evaluation of new or worsening symptoms of AF are addressed in the clinic, we believe the most important goal is patient (and family) education about the disease and what it will mean to them going forward.
Where is the clinic located?
The AF Clinic is located within our main outpatient practice site. This site is a very large (>60,000 square feet) outpatient building dedicated solely to cardiovascular care. It is located approximately 5 miles from Spectrum Health Hospital. The building is organized into “Pods” and the AF clinic is housed within the EP Pod.
What is the mix of staff and EPs at the clinic? Approximately how many AF patients do you see per week?
The AF Clinic, much like the ED AF Pathway, is organized based on a clinical guideline document drafted with the help of EP, general cardiology, and ED physicians. We have also sought input from local primary care physicians. The AF Clinic is staffed by specially trained Advanced Practice Professionals (APPs which are either NPs or PAs). The primary APPs who staff this clinic are not only specifically trained on the AF Clinic algorithm, but they are housed within our EP division and see only EP patients (inpatient and outpatient). The APPs are supervised by a board-certified EP physician. All patients who are seen in the AF Clinic have scheduled follow-up with either an EP or a general cardiologist (based on pre-specified criteria). The AF Clinic generally sees between 2 to 4 patients per day Monday through Friday.
Discuss some of the unique protocols in place for evaluating, treating, and managing AF patients.
There are many unique aspects to the AF Clinic, and some of these tie into the ED treatment they receive via the AF ED Clinical Pathway. First, for patients who presented to the ED within 48 hours of the onset of their AF, the goal of ED treatment (barring unusual clinical circumstances) is restoration of sinus rhythm. A flowchart directs the ED physician to “pill-in-the pocket” chemical cardioversion if a patient meets clinical criteria. Chemical cardioversion is effective in >70% of patients who receive this therapy. Once these patients present to the AF Clinic, the knowledge that the patient was safely cardioverted this way is quite helpful, as they can now be treated with a “pill-in-the-pocket” approach in the future should their episodes be sporadic. In addition, all patients who present with more persistent AF to the AF Clinic are considered for cardioversion. While the AFFIRM/RACE trials led much of the medical community to believe that a long-term rate control strategy is equivalent to a rhythm control strategy, a deeper dive demonstrates that this is for asymptomatic patients and with effective anticoagulation strategies, rhythm control might still be associated with lower long-term complications. As a result, nearly every patient who presents to the AF Clinic still in AF is scheduled for a cardioversion to determine if sinus rhythm can be restored and if the patient actually feels better in sinus. It is amazing how many “asymptomatic” patients in AF feel much better once you restore sinus rhythm.
What other tips have you found to be beneficial in the creation of this clinic?
We have learned many things from our AF Clinic. First, patients who leave the ED or even a PCP office with a new diagnosis of AF are often frightened and confused about what the diagnosis means. Of all the things that are done in the AF clinic, patient education is likely the most important. Having a sub-specialized and highly trained APP to explain the natural history and treatment options has proven invaluable to most patients. As a matter of fact, we received a grant to study the combination of our AF ED Pathway and Clinic, and we found that patient satisfaction with their care was incredibly high. We hope to publish these results in the near future. Further, at first we only opened the clinic to ED and PCP patients. However, the subsequent need to address AF found on device reports or other forms of monitoring in a safe and timely fashion led to expanding the AF Clinic to these patients. This has been incredibly effective and allows us to protect our patients from the thromboembolic complications of AF in a time-compressed manner.
Tell us about the costs and costs savings associated with the clinic.
As it turns out, this clinic is incredibly cost-effective. We try to keep 2-4 slots per day depending on availability. However, if an AF Clinic slot isn’t filled 48 hours ahead of time, it is filled with an EP patient on our waiting list. This allows us to keep our APPs busy but flexible. Obviously, the cost of an APP seeing patients in the office is lower than that of a physician. In EP we tend to be very backlogged with patients, so the AF Clinic allows us to “expand our reach” and get patients into our office sooner. This effectively increases our access, drives up satisfaction and drives down costs. As for global costs, we believe the combination of our ED AF Clinical Pathway and AF Clinic is far more cost-effective than a traditional admission to the hospital for the acute care of AF. We hope to study this soon, but have found it difficult due to the success of our efforts — we cannot find a well-matched local control group.
What methods for patient education are offered?
The primary education that patients receive is verbal. That is, our APPs educate patients and their families in the office on the diagnosis of AF and specifically what it means in the context of the individual patient’s life and other medical problems. At the end of the visit, patients are given pre-printed material on AF which describes mechanisms and treatment options in lay terms. We do have a detailed description of ablation options for AF, but reserve this for future visits with the EP physicians.
Are there plans to achieve Atrial Fibrillation Certification?
We have been discussing the idea in the recent months. We have yet to determine if this is the appropriate path for us to follow, as we would not want to alter our ED AF Clinical Pathway or AF Clinic unless we felt it would benefit our patients.
Is there anything else you’d like to add?
Ultimately, our Spectrum Health AF ED Clinical Pathway and Spectrum Health AF Clinic were borne out of a need. We felt that the acute treatment of AF in the ED very often was haphazard and led to needless hospital admissions. We fashioned our approach in a multidisciplinary fashion and continue to adjust it over time as new ideas and needs are introduced. This pathway has proven quite effective, and we hope that pathways like this ultimately become the standard of care for the treatment of AF.