Aggregating EP/Arrhythmia Patients to Improve Outcomes

Background

The Electrophysiology & Pacing (EP) lab is part of the Cardiovascular Service Line at Lancaster General Hospital (LGH). Located in Lancaster, Pennsylvania, LGH is a 623-bed community hospital that achieved its third Magnet designation in 2011.

Hospital reporting structures are such that nursing reports through the nursing hierarchy and the procedural areas (including the EP lab) report to the Vice President of Operations, Cardiovascular and Pulmonary Services.

About two years ago, the EP Section Chief and the Vice President of Nursing met to discuss opportunities for aggregating EP/arrhythmia patients on a defined nursing unit. The hospital has a proven record of success with patient aggregation with the CHF population, and the EP population seemed to be a prime target for a similar initiative. At the time, EP/arrhythmia patients were housed in the general telemetry population, and the nurses and caregivers unfamiliar with EP were unsure of how to care for patients and their families. In addition, physician practices were widely disparate, especially in regard to the use of antiarrhythmic drugs (AAD) and anticoagulants. Just as importantly, we had no idea how satisfied — or dissatisfied — patients and families were with their care.

There are four cardiology groups that admit cardiac patients to LGH. Aggregating heart failure patients on one nursing unit (5 West) resulted in standardized patient care, eliminated inefficiencies, and increased staff satisfaction and retention. The nurses who work on 5 West are experts in the care of CHF patients, and consistently provide the best care for CHF patients and their families. Due to the nature of the disease and the propensity for frequent readmission, the staff is able to establish trusting and respectful relationships with patients and families. The nurse manager on the unit believes the unit’s success is a result of the staff taking ownership of the unit goals and extreme pride in their work. Our goal is to use the CHF model as a template and attempt to reap some of the same benefits for EP/arrhythmia patients.

Aggregating EP patients is supported by the observation that atrial fibrillation (AF)/arrhythmia patients often exhibit a similar pattern of complexity, chronicity, and frequent readmission seen in the heart failure population. A review of the hospital census revealed that on any given day, there were about 40 EP/arrhythmia patients scattered throughout the hospital, many of whom carried the diagnosis of AF. Armed with this knowledge, we felt there was a critical mass of patients to support this initiative and designated 6 East, a 20-bed cardiac telemetry unit, as the new EP/Arrhythmia unit. Nursing administration and the 6 East nurse manager, Liz Thompson, were enthusiastic and supportive of the designation. The EP and Pacing Committee, chaired by the EP Section Chief, Dr. Douglas Gohn, approved the concept and the various components of the plan were delegated to the Patient Aggregation Subcommittee. Subcommittee members (Figure 1) were responsible for developing the structures, processes, and metrics that would be used to implement the plan and measure its success.

The committee’s first step was to perform a literature search to determine if other hospitals had attempted a similar plan and, if so, to learn what issues or successes they experienced. We quickly determined that an EP/arrhythmia unit was a relatively new concept, and thus provided LGH with a great opportunity.

After completing the literature search, the subcommittee’s first task was to determine how to best implement EP patient aggregation at LGH. The subcommittee identified the following goals:

• Increase physician, patient and staff satisfaction
• Reduce length of stay (LOS) and costs for AF 
• Reduce the AF readmission rate
• Achieve better management of complex arrhythmia patients
• Decrease complications related to treatment. 

The subcommittee identified strategies for achieving these goals through review of Press Ganey surveys and HCAHPS results, in addition to the results of the annual internal Employee Opinion Survey (EOS). A critical element to the success of the aggregation initiative was the involvement of the EP physicians’ office staff; to increase continuity of care and increase staff satisfaction, we solicited their input throughout the planning and implementation process.

The subcommittee held its first meeting in May 2011, with the bulk of the time spent building relationships among the subcommittee members and discussing ways to make the concept a reality. Once the subcommittee  had an idea of where they wanted to go, they incorporated their ideas into a working document that outlined what needed to be accomplished and when. The target date for opening the 6 East EP/Arrhythmia Unit was set as September 6, 2011.

An overarching goal of the aggregation plan was strengthening staff relationships and building a more cohesive team, which would ultimately result in a better experience for everyone. The group identified a wide range of tactics designed to support their strategy, including:

• 6 East RNs shadowing nurses in the EP lab
• EP techs shadowing 6 East nurses on the unit
• Creating a 6 East and the EP lab liaison 
• Providing EP-specific education, led by EP staff members, for 6 East RNs and patient care assistants (PCAs)
• Communication to key stakeholders (cardiology and internal/family medicine physicians/office staff, ED staff, admitting office staff, nursing leadership from other telemetry units, nursing and cardiology administration)
• Hosting a “meet and greet” for all interested parties prior to “Go Live” on September 6.

The shadowing experiences became a great opportunity to forge stronger relationships and greater understanding between the 6 East nursing staff and the EP lab staff. RNs from 6 East were paired with one of the EP lab sedation nurses for an entire day. Our hope was that the experience would give the nurses a better idea of what happened to their patients when they sent them off to the EP lab. We were gratified to see many “Aha” moments in which the 6 East nurse suddenly made the connection between what was happening in the lab and what they were doing on the nursing unit. It was wonderful to see them truly understand what happens in a procedure or finally understand why antiarrhythmics are held for some procedures but not others.

The subcommittee appointed Louise Gaydon, one of the more experienced EP nurses, as the EP/6 East liaison. Louise works with the 6 East nurses in a mentoring and helping role, which supports 6 East staff members in a more personal and non-threatening way, and helps them to become more comfortable with EP/arrhythmia patients and physicians. Louise attends a weekly huddle on 6 East, in which they discuss ongoing issues and challenges.

Another important goal identified by the subcommittee was to provide EP education to the 6 East staff. Working with the 6 East nurse manager, the EP educator created a pre-intervention Computer-Based Learning (CBL) module to assess the level of EP knowledge held by the 6 East RNs. The results of the assessment provided the template for an eight-hour EP education session. The focus of the education sessions was pre- and post-care of the EP patient. In addition, EP lab staff, EP nurse practitioners, and device manufacturer reps provided the nurses with a broad overview of EP procedures and terminology (Figure 2). Most attendees have been from 6 East, but nurses from other telemetry units and cardiac research have attended as well. Three classes have been held thus far, with follow-up sessions planned in the next six to eight months to reinforce and expand upon the knowledge gained in the initial classes. Future sessions will build on previous learning and subsequent experience, and will begin to explore some more complex EP topics. The 6 East Patient Care Assistants (PCAs) attended a two-hour education session, led by the EP educator, where they learned about EP and how to help the RNs care for patients with rhythm problems.

The subcommittee also developed a communication plan to make sure all stakeholders got the necessary information. The nursing supervisors were a critical link due to their responsibilities for patient placement. Initially, we did not transfer existing 6 East patients to other telemetry units in order to make room for EP patients (in the CHF template, this is standard practice). As a result of our early experience, we plan to address that issue in the near future.

On September 1, 2011, the subcommittee hosted a “meet and greet” in the 6 East conference room, complete with refreshments and communication updates about the patient aggregation initiative. Subcommittee members developed posters that showcased the new A-fib admission orders and cardiology discharge orders; every attendee received a list of 6 East admission criteria. Representatives of other cardiovascular nursing units and procedural areas were invited, as well as primary care physicians and members of their office staff. Invitations were also extended to the nursing supervisors, pharmacy, admitting office, and emergency department physicians and staff. Approximately 150 employees and physicians attended the event.

In order to facilitate success, the subcommittee proposed a more focused approach — concentrating on one specific patient type — for the initial months of the initiative. The committee chose AF patients because of their high volume (about 1,000 patients annually) and readmission rates (12.4% at 30 days, all cause) for this patient population. The AF patient population is diverse in regards to disease onset, cause, duration, and treatment strategy. The aggregation team developed admission criteria and AF admission order sets to help clinicians (particularly non-EP physicians) identify appropriate 6 East patients and guide them toward appropriate treatment (Figure 3). To further increase standardization of care, the team also attempted to decrease the complexity and variety of post-hospital care by developing standard discharge orders and processes.

The subcommittee’s next goal was to develop an educational program for patients and their families. The key goals of the program were to create better healthcare consumers and to address issues that resurface every time an AF patient is admitted. The subcommittee decided to give every AF patient an education binder to house all the materials the patient received during their stay. EP RN Dave Sechler developed the educational materials for the patient binders. Each patient’s binder contains information specific to his or her diagnosis, medications, and physician group. Only 6 East patients receive a binder, but the material is available to other telemetry nursing units via the 6 East intranet site.

The education sessions, scheduled for Tuesday and Thursday afternoons, debuted on October 27, 2011, with 13 patients and family members attending the first two classes. The topic for the first session was Living with A-Fib. During the sessions, facilitators explain the importance of the patient binder and how to use it for best effect. To make sure every patient gets the same information, the sessions are scripted, which allows several people to facilitate the classes. We encourage patients to keep all pertinent information and questions regarding their medical care or treatment in their binders, and to take it to all medical appointments. As there are several cardiology and internal medicine practices that admit patients to 6 East, we provide practice-specific information for each patient. Anecdotally, patient and family reviews of the education binders and sessions have been extremely positive. So far, the most common request has been for more information about medications. (See Figure 4 for the EP binder welcome letter.)

Where Have We Been?

• Outcomes. The EP patient aggregation initiative is an exciting opportunity for LGH. Thanks to the input and efforts of many people, the initiative is slowly gaining acceptance; however, we are still fine-tuning the process. While we cannot control all the variables (such as patient census), there are definitely things that we would do differently. When the EP/Arrhythmia Unit opened on 6 East, the average daily census dropped dramatically. Subsequently, the unit census did not reflect a truly homogenous group of EP/arrhythmia patients on the unit. Although the census has improved, appropriate patient placement is still a challenge at times; thus, it has been difficult to report and track the metrics. As the census has improved, we have been able to work through many of the placement issues, and hope to be able to obtain accurate data over the next six months.

The majority of patients undergoing TEE/cardioversion are housed on 6 East. The subcommittee identified an opportunity to standardize the care and treatment of those patients. One of the biggest issues we encountered was that the definitions of acceptable therapeutic INRs, labs and antiarrhythmics varied greatly among the different physician groups (and among the individual physicians in each group). Working through the structured processes of the EP and Pacing Committee, we were able to reach a consensus with all the physicians and define a standard for the therapeutic range for the INR (we are still working on some of the other issues). We also used the EP and Pacing Committee to standardize the administration of aspirin prior to device procedures; the new expectation is that aspirin will be held for five days prior to device procedures. We are now working with the physicians’ offices to develop a process to ensure that occurs.

• Staff and Physician Satisfaction. One of our biggest challenges was, and continues to be, the volatility of the EP patient population. During the week, the EP lab volume helps to keep the 6 East EP patient census more or less stable, which has had a positive impact on patient and staff satisfaction. Also, the EP physicians like having their patients being housed in one location (as opposed to scattered all over the hospital), as it makes rounding, admissions, discharges, and answering questions easier and more efficient. However, over the weekends, house volume and the need for telemetry beds results in a wide variety of patients (some EP, some cardiac, some not) being admitted to the arrhythmia unit. This creates a great deal of dissatisfaction for both 6 East staff and the EP physicians.
• Multi-Disciplinary Rounds (MDRs). MDRs have been used with great success in the heart failure model. Bringing multiple caregivers (physicians, nurses, pharmacists, care managers, social workers, etc.) together to define treatment goals and implement care has improved efficiency, outcomes and patient satisfaction. Early on, the aggregation team identified the implementation of MDRs as one of the goals of the initiative. However, we are currently struggling with both the rounding structure and how to identify the patients who will get the most benefit from the process. Due to time constraints of busy schedules, it has been difficult to get all the required parties to participate, and there are differing opinions about how to document the rounds. Despite these issues, MDRs remain a priority for the subcommittee, and they continue to identify and explore viable options. 

Where Do We Go From Here?

The 6 East EP patient aggregation initiative has made considerable progress over the last seven months, but there is still much work to do. The Patient Aggregation Subcommittee recently developed the following goals:

• Revise/refine the processes for patient placement to maintain a stable EP patient population on 6 East.
• Work with the Performance Improvement department to report outcomes by the end of June 2012.
• Continue to build upon 6 East RN and patient care assistant education over the next 12 months. 
• Complete shadowing experiences for all 6 East and EP lab staff.
• Develop and implement rounding with purpose for the 6 East manager and EP director. 
• Develop and implement rounding with purpose for the EP Section Chief.
• Improve continuity of care by improving the patient discharge process and communication between the hospital and physicians’ offices.
• Expand AF education sessions to AF patients hospital wide.

Despite the many challenges, the 6 East EP/Arrhythmia Unit has achieved a great deal in the past seven months. We have improved communication between the 6 East staff and the procedural area. EP/Arrhythmia Unit nurses have used their increased knowledge base to better prepare their patients for procedures, resulting in fewer delays. And our patient education sessions appear to be working — physicians are reporting that discharged patients are arriving for office appointments with their binders in hand.

Over the next six months, we will continue our efforts toward the creation of a stable EP patient population on 6 East. With that hurdle behind us, we will finally be able to collect and report tangible data. However, like most things in life, this initiative is a process. There will always be room for improvement as we work to provide our EP patients with a truly extraordinary experience.