Atrial Fibrillation Certification Program at Genesis HealthCare System

Atrial fibrillation (a-fib) is the most common cardiac arrhythmia and has become recognized as a health concern that may lead to stroke and possible death. More than 2.5 million patients in the United States have a-fib, and the numbers are rapidly increasing as our population ages. A-fib patients use more healthcare services and have much higher healthcare costs than those without the disease.

Based on these statistics, the Society of Chest Pain Centers (SCPC) developed an Atrial Fibrillation Certification with the goals of assisting facilities to better evaluate and manage the patients with this disease more effectively, improve their outcomes, and educate both patients and healthcare providers to more efficiently provide care.

Genesis HealthCare System is committed to providing advanced and quality heart care within the community: “Close to Home and High Quality Too.” Previously accredited from the SCPC as a Chest Pain Center with Percutaneous Coronary Intervention (PCI) under the direction of Dr. Albirini, Genesis HealthCare System was the first hospital in Ohio to receive full Heart Failure Accreditation from the same organization. Based upon their demonstrated quality of defined criteria during that accreditation process, the SCPC selected Genesis HealthCare System as one of five hospitals in the nation to participate in beta site testing for the forthcoming Atrial Fibrillation Certification. 

Once the beta testing was complete, the SCPC finalized and made available the Atrial Fibrillation Certification. Genesis HealthCare System was the first facility in the United States to receive this certification by demonstrating expertise and commitment to quality patient care by meeting or exceeding a wide set of stringent criteria and undergoing a comprehensive review by SCPC. This article, based upon interviews with members of the Genesis Atrial Fibrillation Committee and SCPC, will review the certification process, key elements, and how they addressed them. This information may be helpful to other facilities applying for Atrial Fibrillation Certification.

Why did your facility choose to pursue the SCPC Atrial Fibrillation Certification?

We are a quality-driven institution. We felt that preparing for this certification process would create the opportunity to improve outcomes for a high-risk group of patients — those with suspected or known a-fib. Our goals were to develop a protocol-driven and systematic approach to patient evaluation and management. Additionally, we wanted to reduce time to treatment and risk-stratify patients to decrease their length of stay in the emergency department and hospital.

Why did SCPC select Genesis HealthCare for Atrial Fibrillation Certification?

Phil Beckley, PhD, Atrial Fibrillation Clinical Specialist for the SCPC, offered, “Genesis HealthCare has had a long history with both Chest Pain and Heart Failure Accreditations as offered by SCPC. It has been able to experience the benefits of examining and improving care processes for these two groups of patients and was eager to apply these same principles for a-fib patients. By comparing current processes in the assessment, treatment, and management of a-fib patients with those that are nationally recognized and recommended by the Society, Genesis HealthCare System has been ultimately able to improve patient care and better meet the needs of its staff and community. They understand that undertaking an evaluation of processes that affect patient outcomes is crucial to meeting the challenges of healthcare efficiency and reform.”

What was the process for applying for certification?  

A facility must meet certain eligibility requirements before applying for Atrial Fibrillation Certification. They must be an Accredited Chest Pain Center and have performed a minimum of 50 on-site catheter-based ablation procedures. Each principal operator must be a physician specifically trained in invasive cardiac electrophysiology studies. Genesis HealthCare System has been an Accredited Chest Pain Center with PCI since 2009. With the addition of electrophysiology services in 2009, we had the full spectrum of cardiac care in place. In 2010, Dr. Magdy Migeed, Director of Genesis HealthCare’s electrophysiology (EP) laboratory, performed 131 cardiac ablations.

To begin the certification process, the Society of Chest Pain Centers was contacted and an application manual was purchased. This manual contained instructions for completion, the facility information booklet, the certification tool that contained all of the key element requirements, and application paperwork. Our Chest Pain/Heart Failure Coordinator served as the Atrial Fibrillation Certification project leader. A multi-disciplinary team was formed with representatives from Emergency Medical Systems (EMS), the Emergency Department (ED), nursing units, cardiac diagnostics and rehabilitation, community education, the EP laboratory, pharmacy, quality management, and education services. For the initial meeting, the key elements and facility information requirements were distributed to each member for review. A gap analysis was performed using the certification tool as a guide. Ideas were generated as to how our current a-fib process worked and what improvements could be made. Each team member took responsibility for looking at the process from their departmental perspective and developing ideas on process improvements. The team met monthly, and as key elements were met, supporting documentation was given to the Chest Pain/Heart Failure Coordinator. The supporting documentation was compiled in a binder and was the evidence to show how the key element requirements were completed.

Once the group felt that they had met all of the requirements for Atrial Fibrillation Certification, the necessary paperwork was completed and the binder was submitted to the SCPC for review. Following a brief consultative phone call, a conference call was scheduled with the Genesis HealthCare Atrial Fibrillation Team and representatives from the SCPC. During this time, the application was reviewed, supporting documentation was discussed, and questions were answered. Within the week, Genesis HealthCare was notified that they were awarded the first Atrial Fibrillation Certification from the Society of Chest Pain Centers in the country.

Key areas in which a facility with Atrial Fibrillation Certification must demonstrate expertise include:
 
• Emergency Department Integration with EMS
At Genesis, we have an EMS CQI Consultant who is involved with many of the hospital initiatives, thus providing a crucial link between hospital activities and EMS. This integrated relationship recognizes that the EMS is an extension of the care provided to the patient in the ED. The local EMS agencies have existing protocols in place for cardiac arrhythmias and atrial fibrillation. Dr. Migeed provided education to the EMS in the form of a newsletter. One aspect of this education was to request for EMS to obtain a 12-lead EKG prior to any treatment, providing the patient is hemodynamically stable. This provides valuable information to the electrophysiologist or cardiologist in determining the presenting rhythm and long-term treatment options.

•  Emergency Assessment of Patients with A-Fib
Our Emergency Department is highly adaptive and flexible. Over the past few years, they have worked to achieve Chest Pain Center Accreditation, Heart Failure Accreditation, Level 3 Trauma Center, Atrial Fibrillation Certification, and are currently working toward becoming an Accredited Stroke Center. The ED staff receive frequent education and training regarding the current practices and protocols. An a-fib computer-based learning module and several “medical minute” updates were provided in their bed huddles, which reviewed changes to the current order sets, triage protocols, and reminders on the importance of getting 12-lead EKGs. We have an experienced ED registered nurse in the clinical educator position who has been the driving force in the provision of education to the frontline staff. 

•  Risk Stratification of the A-fib Patient
With Dr. Migeed’s input, the CHA2DS2 VASc risk stratification tool was incorporated into the Cardiac Dysrrhythmia and Atrial Fibrillation order sets. With the upcoming Stroke Accreditation, this was a perfect opportunity to provide a tool that would benefit a-fib patients while decreasing their risk for stroke. Risk factors such as congestive heart failure, hypertension, age, diabetes, previous stroke, vascular disease, and gender could be taken into consideration to help determine patients’ risk for thromboembolism. Thorough risk stratification can help assure that patients are directed to the most appropriate treatment options. In addition, current policies regarding transesophageal echocardiography (TEE), assessment and reassessment of the patient, and response to treatment policies were reviewed and updated as needed.

•  Treatment for Patients Presenting to the Emergency Department in A-fib
Genesis HealthCare System has Guidelines of Care for the cardiac arrhythmia patient which recommend nursing care and interventions for the assessment and treatment of symptoms associated with cardiac arrhythmias. These guidelines aid in reducing anxiety and promoting comfort. Examples contained in the guidelines include asking patients and family members about anticoagulation therapy, last known dose, and exploring rate control versus rhythm control options. Patients are also provided education regarding invasive procedures and discharge instructions. Inpatient order sets for a-fib were developed, which reflect a pathway of treatment, risk stratification, and management relative to rate control and rhythm control options. In addition, a pharmacist performs an ongoing reassessment on patients receiving warfarin to ensure that PT/INR monitoring is completed and appropriate therapeutic adjustments are made. Consults to ancillary departments such as pharmacy, clinical nutrition, cardiac rehabilitation, and social services are frequently made as deemed necessary by health care personnel.

•  A-fib Discharge Criteria and Patient Education
Prior to discharge, each facility must have a well-documented process regarding education on the a-fib disease process, follow-up physician/clinic visits, medications, and lifestyle modifications. From the time of admission, assessment of the patient’s discharge needs must be an ongoing process. This includes physical needs, functional status, psychosocial support system, financial resources, cultural and ethnic background, level of education, and barriers to care. To enhance the current process regarding this requirement, the idea of a combination Stroke/Atrial Fibrillation Navigator position was generated. This health care professional would see each stroke and atrial fibrillation patient in the hospital and evaluate their personal needs to ensure that they receive comprehensive treatment. The Navigator would also participate in performance improvement initiatives, collaborate with the health care team, and provide education to the various departments regarding this specific patient population.

•  Personnel, Competencies and Training
All staff, whether it is the physicians, nurses, technicians, EMS, and other health care personnel, need to have ongoing education and training to keep current with standards of care, best practices, and changes in technology.

Genesis HealthCare System has an excellent education department in place that recognizes education is essential in the success of an organization.

Educational presentations are regularly offered to keep staff engaged and informed. Since the addition of the EP department, Dr. Migeed has been providing education and in-services on cardiac arrhythmias and their treatment to staff of all levels. One area where we noticed that we could improve was in having more atrial fibrillation specific education for the cardiac nursing teams. The education department worked to develop a computer-based learning module that was specific to a-fib. The disease process and pathophysiology, signs and symptoms, treatment options, and precipitating factors were discussed, and a short quiz was given at the end. All nurses caring for cardiac patients were required to have this education in an effort to increase the depth of their a-fib knowledge.
 
•  Process Improvement
In working through the Atrial Fibrillation Certification process, a gap analysis of our current state was performed. Items that needed addressed prior to submitting for Certification were discussed with the Atrial Fibrillation team, and methods for completion were determined. This became our “map” of how to get where we were wanted to go. Each member of the team took responsibility for working within their department to accomplish our goals. The summary of our process improvement plan and accomplishments was submitted to the SCPC. The Atrial Fibrillation team was very beneficial in evaluating the care of this population. This team developed into an Atrial Fibrillation Committee. The committee will continue to meet on a quarterly basis to examine our processes, flowcharts, and data to ensure that we are continuing to meet the needs of our patients and their families.

•  Organizational Structure and Commitment
At Genesis HealthCare System, our administrative team and medical staff recognize the importance of continuous quality improvement.

As the leader for heart care in Southeastern Ohio, we are committed to providing quality care to the residents of Muskingum and surrounding counties. The Heart and Vascular Program has made a continual effort to improve processes and deliver evidence-based care to the patients we serve.

Having already been recognized by the SCPC as an Accredited Chest Pain Center with PCI and an Accredited Heart Failure Center, we recognize the importance of the accreditation/certification process. Achieving these accreditations has enhanced the already high-quality services we provide, and having the support of our administrative team made the process improvement changes we were making easier to implement.
 
•  A-fib Community Outreach
Community outreach includes both the public at large and the external health care providers in this area. This is highly valued at Genesis, and we recognize the importance of reaching out to our community and showing a commitment to provide education and resources for them related to disease processes, treatment options, and wellness care. We try to use a variety of media outlets, such as website, radio and television material, written publications distributed through the mail, and visits by health care providers who provide education and screenings at health fairs, occupational visits, and at local schools. We are also involved with the national HeartCaring Spirit of Women program. This program ascribes to the highest standards of excellence in women’s health, education, and community outreach. Many of our local primary care physicians are “HeartCaring Physicians” and also receive the educational literature for their offices and staff regarding cardiovascular health issues. As part of the Certification process, an educational packet specific to a-fib was put together for distribution to our HeartCaring physicians. This packet contained information and treatment options that may be needed to manage this patient population.

Another service that Genesis HealthCare System offers to the community and local physicians is our Anticoagulation Clinic. A clinical pharmacist manages this clinic. Patients are seen by referral from their physician and receive education on their disease state, the role of anticoagulant therapy, medication interactions, importance of compliance, and the procedure to follow in case of bleeding. The patient receives laboratory monitoring of their PT/INR by fingerstick, and dosage adjustments in medical therapy are made at that time. Clinic visit report summaries are sent to each referring physician office along with any concerns related to treatment.

Summary

By going through the Certification process, we put our whole atrial fibrillation program under a microscope and examined it. We found areas that were functioning very well, areas that needed improvement, and additional areas that needed developed. The final result of the certification process was a higher understanding of what an ideal a-fib program should look like. We are striving to be that ideal program every day. By having a team approach, we have staff in every department who realizes how important it is to have comprehensive care for an atrial fibrillation patient. They can serve as the mentor and teacher to the people around them. It is by having high-quality people actively involved in process improvement that the facility as a whole can become better.