In this interview, we speak with Karen Martinelli, RN, CCRN, Atrial Fibrillation Nurse Navigator, Narendra K. Kanuru, MD, Michael J. Riley, MD, FACC, and Bryan T. Piedad, MD, FACC, FHRS, about the Atrial Fibrillation (AFib) Clinic at WellStar Health System in Atlanta, Georgia. The other clinicians located here are John Dercola, PA-C, Cesar A. Egoavil, MD, MBA, FACC, Jacob N. Blatt, MD, Anand Kenia, MD, and Mohammad Kooshkabadi, MD.
When and why was the AFib Clinic created?
We started the designated AFib Clinic in 2014. We had been performing atrial fibrillation ablations since 2005, but it was clear that our patient population and our procedures needed to be approached in a more structured and systematic manner.
Importantly, we wanted to be able to track procedural results so that we could use this information to improve process and outcomes. Our initial goals for this clinic were: (1) to establish a designated clinic day to allow for patients with atrial fibrillation to be evaluated and treated without long wait times for appointments; (2) to ease the referral process in order to provide patients with atrial fibrillation quicker access to electrophysiologists; (3) to give our patients and their families a support system based on personalized care; and (4) to promote awareness of the disease process and provide structured educational opportunities for our patients, community, and staff.
Who is a part of the AFib Clinic team? Are other subspecialties included as well?
Our AFib team is made up of members of our Cardiac Electrophysiology department, including 7 electrophysiologists, 4 APPs, 4 RNs, and a dedicated AFib Nurse Navigator. We practice as part of a comprehensive health system, which includes integrated access to multiple subspecialties, including Bariatric Medicine, Sleep Medicine/Pulmonology, Anesthesiology, Endocrinology, Nephrology, Neurology, Advanced Heart Failure, Cardiology and Cardiac Surgery, among others. We have developed pathways within our own institution for referrals and collaboration between disciplines. Some examples include our pathways for patients with cryptogenic stroke to undergo timely evaluation for atrial fibrillation monitoring, or for patients who are candidates for surgical or Convergent ablation to be evaluated and treated by our cardiac surgeons.
How many patients do you treat at the clinic?
On a weekly basis, we evaluate over 20 new atrial fibrillation patients. Although most are seen in the AFib Clinic, some new patients are still seen in the standard EP clinic as well. Approximately 450 patients are seen each year in our designated AFib Clinic.
Describe the types of services you utilize in your treatment of AFib.
Risk factor modification is a vital part of our preoperative strategy. We engage with a multidisciplinary group of physicians to optimize patients’ non-arrhythmia conditions prior to consideration of an invasive approach. We perform cryoballoon pulmonary vein isolation (PVI), radiofrequency catheter ablation, complex atrial arrhythmia ablation, endocardial left atrial appendage closure, and hybrid ablation utilizing both epicardial and endocardial approaches (Convergent ablation).
In the past, were AFib patients at WellStar admitted as inpatients? What changes were made in standardization of patient care? Describe the protocol for AFib patients presenting to the emergency department.
We have worked extensively with our cardiology colleagues as well as emergency department (ED) physicians and hospitalists to streamline treatment of atrial fibrillation. Our primary goals in the ED are to provide proper anticoagulation, as well as to ensure rate control and symptomatic relief. If this can be achieved in the ED, then we typically discharge the patient with both expedited follow-up and further cardiac testing, as would be appropriate. If the patient was not seen by Electrophysiology, then an expedited appointment in the AFib Clinic is made. Since our new patient clinic occurs weekly, the patients are always able to be seen in consultation within one week of either hospital or ED discharge.
Using EPIC, our EMR system, we have established an outpatient referral order for the AFib Clinic to ease the process of MD referrals to the clinic. An EP scheduler monitors this work queue on a daily basis to ensure the patients are contacted with an appointment date and time.
We utilize portions of all our physician cardiology meetings, as well as hospital medicine, pulmonary critical care, CTS, section meetings, and grand rounds formats to discuss our program, procedures, and referral process to ensure that the specialties are aware of the clinic.
Karen, discuss your role as a Nurse Navigator.
At WellStar, this role was developed as a clinical position and structured to improve overall patient safety and satisfaction throughout the ablation process. The Navigator position provides consistent support from the electrophysiologists, nursing staff, APPs, designated EP procedure scheduler, EP appointment scheduler, and EP lab staff. We have designated resources to provide education and support. The continued growth of our comprehensive AFib Clinic is directly related to the ongoing processes and continued improvement of providing a patient- and family-centered approach to this disease.
The Navigator role evolved from our desire to have a “champion” for the AFib Clinic that focused on promoting awareness and coordinating the best possible care.
Responsibilities of the AFib Navigator at WellStar include managing pre- and post-procedure patient relationships as well as developing educational programs for patients, families, community, and staff. This is accomplished by developing staff in-services for cardiac educators, so they can better educate the patients utilizing EP-directed, post-procedural discharge instructions. We also provide ongoing educational programs and clinical updates for ICUs, Acute Rehabilitation Unit (ARU), and step-down unit staff.
We took the additional effort to develop AFib support groups as well. These groups include current patients, those recently diagnosed, and other stakeholders who have an interest in learning more about the disease. The support groups, led by the Navigator, meet 3-4 times annually. The support groups are augmented by community outreach programs in which multiple physician specialties discuss the risk and management of AFib.
Of particular importance, the Navigator incorporates data collection and sharing of our outcomes with the providers of our organization. This facilitates continuous process improvement and improves patient management strategies.
How have outcomes changed or improved since the creation of the AFib Clinic?
By careful review of the procedural outcomes, we have been able to identify issues and improve both short- and long-term success while reducing complication rates. We have also been able to better identify patients for whom the procedure may pose higher than average risk. In addition, we have been able to standardize patient education, which has improved communication between patients and all members of the team.
What key components can be attributed to the success of WellStar’s AFib Clinic?
I believe that our success is due to our outstanding and dedicated team members. We are dedicated to seeing patients as individuals who have a unique set of issues. This allows us to formulate a more customized plan which, in turn, results in better outcomes. Although large-scale trials suggest what outcomes could or should be, we cannot know if we are even achieving or exceeding these metrics without a structured approach, which includes assessments of success and complications. Similar to databases that track ICD implants, every center performing atrial fibrillation ablations should strongly consider starting a clinic and engaging in a structured approach to these patients, including maintaining a registry to track success rates and complications.
Why is it important to offer a comprehensive (versus a traditional) approach to treating atrial fibrillation?
A comprehensive approach improves procedural success, reduces peri-procedural complications, quickly identifies process issues that can be resolved, aids patient education, and allows our patients to benefit from consensus-driven best practices. It allows us to provide more personalized care and improve overall patient satisfaction within the EP practice.
Is there anything else you’d like to add?
WellStar’s AFib Clinic is the first and only comprehensive and dedicated atrial fibrillation clinic in Georgia. This has allowed us to better serve patients as well as utilize our own data to improve procedural outcomes and overall patient satisfaction.
Disclosures: The authors have no conflicts of interest to report regarding the content herein. Outside the submitted work, the authors report the following: Ms. Martinelli reports personal fees as a consultant for AtriCure, Dr. Riley reports personal fees as part of a speakers’ bureau for Johnson & Johnson, and Dr. Piedad reports personal fees from Medtronic, Abbott, Boston Scientific, and AtriCure.
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