Novel Pathway for Earlier Treatment of Arrhythmia Patients

Scroll to the end of the article to see video commentary by author Jessica Bower, MSN, RN, CCRN, RCIS!

Managing atrial fibrillation (AF) and other arrhythmias for patients in California’s Central Coast community is a top priority for the staff at Marian Regional Medical Center (MRMC), whose response is critical for optimal community outcomes. A MRMC electronic medical record (EMR) review of ICD-10 codes with a primary diagnosis of AF from 2019 demonstrated that 4100 patients visited the MRMC emergency department (ED) at least twice for AF, as evidenced by more than 8200 insurance claims for the ICD-10 code diagnosis according to the MRMC finance department. This data was used to demonstrate the need for better follow-up with these patients and other arrhythmia patients earlier in their diagnosis. A pathway was developed to encourage interspecialty communication and coordination for diagnosing and treating arrhythmia patients at MRMC, as well as to provide community education and awareness. The arrhythmia team at MRMC has currently assessed, contacted, or reviewed over 2000 arrhythmia patients. Nearly one-half of these patients were receiving education about their arrhythmia and treatment options for the first time, and numerous referrals were made to our primary care physicians, cardiologists, and our electrophysiologist for treatment and intervention. Herein we discuss pathway implementation using an arrhythmia nurse navigator for patient education and appropriate referral within 72 hours alongside stakeholder buy-in cultivation and measurable outcomes.

Intervention Overview

Technology is ever-changing and improving in the management of AF, and it is of the utmost importance that physicians and nurses stay up to date. Efficiently and adequately educating and caring for the community fits within MRMC’s mission, vision, and values.

To better reach this targeted population, MRMC developed a process to ensure patients were being followed by the correct specialties and educated about their disease process and options. Focal goals for this project were establishing diagnostic and treatment communication along with coordination of care for MRMC arrhythmia patients, while also creating community education and awareness. The first step was to work with physicians and nurse teams outside of electrophysiology (EP) who cared for patients with arrhythmias, and provide them with guideline updates. The second step was to assist patients with self-advocacy and awareness.

Educating the community on the signs and symptoms of arrhythmia helped identify patients earlier in their diagnosis and provided a more practical approach for their treatment. Identification of stroke risk and symptoms was essential, since AF is the cause of 1 in every 7 strokes.¹ Other risk factors, such as obstructive sleep apnea (OSA), alcohol consumption, and smoking, can also increase a patient’s risk for AF.^2,3 Arrhythmia staff used MRMC’s Octavia data tool to search and query EMR data and find patients with established or new-onset arrhythmia diagnoses listed through ICD-10 codes and CPT codes to identify patients in need of education and intervention. The arrhythmia team then provided presentations to affected units as well as clinics within the community. The ultimate goal for all providers was to advocate for the patients affected and their communities, and provide the best possible care at MRMC.

Current Evidence

One in 4 adults over the age of 40 is at risk for AF.² Since many of these patients are still very active, AF can have a direct impact on their quality of life. According to Masoudi et al,⁴ AF affects more than 6 million individuals in the United States. Half of these people struggle to tolerate rhythm and rate control medications, or do not respond to the drugs at all.⁵ Only an estimated 27,000 of these patients are treated with catheter ablation,² which is the number one treatment option after attempted drug therapy according to the American Heart Association (AHA) and American College of Cardiology (ACC) guidelines.⁶ Approximately 750,000 patients are hospitalized, and there are as many as 160,000 deaths each year, costing the US health care system an estimated $35,700,000,000 annually.² These patients are also 5 times more likely to develop heart failure (HF) or suffer a stroke.⁶ In addition, 35% of patients with AF are over 80 years.⁶ AF may occur without underlying heart disease because of cardiac structure changes and function due to aging, including increased myocardial stiffness.⁶ Symptoms are also frequently atypical among older patients (eg, palpitations are less common), and guidelines caution they are more prone to heart block, especially with amiodarone and digitalis.⁶

Over 1 million US patients with AF progress from their first episode of AF to persistent AF (defined as an AF episode that lasts continuously for more than 7 days) within the first year of diagnosis.² MRMC is striving to more quickly diagnose and treat this patient population. The national success rates for treating paroxysmal AF and other common arrhythmias with catheter ablation is 95%-97%, and 80%-91% for more complicated arrhythmias such as premature ventricular contractions and atrial tachycardia.⁷ The success rate for treating persistent AF and longstanding persistent AF is lower, termed variable by most studies, in patients undergoing pulmonary vein isolation (PVI) at around 59% after 18 months in some studies.⁷ This demonstrates the need for earlier diagnosis and treatment as well as alternative ablation techniques, including hybrid convergent procedures.⁷

Guidelines for AF management recommend that catheter ablation be the first-line therapy used prior to any class I or III antiarrhythmic agent trials for symptomatic paroxysmal or persistent AF.⁵ The latest data demonstrates a significantly improved quality of life after AF ablation than with drug therapy.⁴

Existing Health Policy and Guidelines

Transitional Care

A specialized AF clinic for transitions of care is associated with improved adherence to ACC and AHA clinical quality and performance measures for adults with AF, including proper assessment and treatment for stroke prophylaxis.⁵ Twelve percent (or roughly 66,000 people) currently taking anticoagulants for AF have a CHA₂DS₂-VASc score of 0, meaning they do not need anticoagulation.⁵ Related risk factors such as OSA and alcohol and tobacco use are also commonly undertreated.⁵

The ACC’s Hospital to Home (H2H) Initiative is an effort to reduce hospital readmission rates by improving the transition to the outpatient setting for patients with congestive HF and acute myocardial infarction.⁴ One well-tested approach that consistently demonstrates effectiveness in addressing the needs of complex populations while reducing health care costs is the Transitional Care Model (TCM). This is a nurse-led intervention targeting older adults at risk for poor outcomes as they move across both the health care clinician and environment continuum.⁸ Six categories are associated with negative outcomes in these older adults transitioning to post-acute settings and homes, including lack of patient engagement, adequate communication, physician team collaboration, follow-up, and continuity of care, leading to poor patient satisfaction and further decline in health status.⁹ Components of the TCM model include screening, staffing, maintaining relationships, engaging patients and caregivers, assessing and managing risks and symptoms, providing education about and promoting self-management, collaborating, promoting continuity, and fostering coordination.⁸ The TCM model, which has been refined multiple times over the years, is adapted for each facility and has evidence-based backing through randomized clinical trials to demonstrate the capacity to improve experiences, health, and quality of life outcomes as well as reducing rehospitalizations and total health care costs.⁹

Cardiovascular Care Leader

Questions regularly arise regarding who should lead care of cardiovascular teams and patients. The ACC’s stance is that the ultimate leader of the cardiovascular care team is an informed patient, in consultation with their family, when directing and determining goals of cardiovascular care.⁸ That leadership should be flexible, reflecting the patient’s specific needs at a particular time and setting.⁸ Examples include a nurse or pharmacist leading a chronic anticoagulation clinic, or a registered nurse or advanced practice nurse (APN) leading a team and coordinating transitions of care. The leader should be the team member that possesses the greatest knowledge, experience, and qualifications for the leadership task at hand.⁸

Importance of Stroke Risk Assessment and Prevention in AF

If the bleeding risk is not high, evidence supports using chronic anticoagulation with warfarin, direct thrombin, or factor Xa inhibitors for primary stroke prevention in nonvalvular AF patients due to an increased risk of stroke from the left atrial appendage.⁶ The ACC and AHA recommend using the CHA₂DS₂-VASc score to estimate stroke risk and the HAS-BLED tool to calculate bleed risk scores.⁶ Many patients abandon their anticoagulants or are dosed inappropriately. Education on the most up-to-date treatment guidelines for AF and other arrhythmias is needed for physicians and clinics outside of EP to mitigate these losses. The BRIDGE trial assessed bridging vs no bridging in nonvalvular AF patients requiring periprocedural interruption of warfarin therapy; the absence of bridging was found to be equal to bridging with low-molecular-weight heparin for prevention of arterial thromboembolism, decreasing the risk of bleeding.² However, bridging anticoagulation may only be appropriate in patients (on warfarin) with a very high thromboembolic risk.²

Pathway Components

The Cardiac Catheterization Services Department (CCSD) at MRMC took part in developing this arrhythmia pathway for this patient population. The pathway involves physicians, APNs, nurses, and ancillary staff in the ED and inpatient entities. It also involves the care transitions team for the outpatients that are discharged with a diagnosis of AF or atrial flutter. Additionally, process innovation to aid patient referrals and develop a more effective collaborative relationship between primary care physicians and hospitalists with specialty providers, cardiologists, and electrophysiologists is evolving. As the process grows, it will include an open communication line with the neurology team to include cryptogenic stroke patients. In addition, the pathway will assist patients with other arrhythmias, including supraventricular tachycardia and ventricular tachycardia.

The role of the arrhythmia nurse navigator is to educate patients and ensure they are referred appropriately within 72 hours. The advantage of a transitional care clinic is that it creates broad generalizability across various settings, reducing inappropriate AF admissions and improving care quality.⁵ Nurses working in nurse-led models of care undertake comprehensive assessments, provide timely patient-centered care, offer education and support, maintain continuity of care, and connect patients to other health professionals and services.⁵

This pathway results in a referral to an arrhythmia nurse navigator after the physician diagnoses the patient in any pertinent arrhythmia per 12-lead electrocardiogram. After the physician addresses the patient’s symptoms, the arrhythmia nurse navigator is notified and ensures follow-up, education, and proper referral to each level of care.

The key to achieving this pathway was obtaining physician and health care staff buy-in prior to implementation. Staff established open communication lines with department heads and medical teams to help achieve buy-in. Providing presentations to affected units as well as clinics within the community was essential. Ultimately, staff measures patient outcomes through registry data and procedure data is kept by the CCSD.

Because of the success with this pathway structure, many hospitals within the Dignity Health network have reached out to us for guidance in getting started. A consulting project is being developed in partnership with Biosense Webster to help other area hospitals develop and implement similar arrhythmia pathways. Findings from a recent study presented at Heart Rhythm 2022 suggest a single intervention of appropriate EP consult directed from the ED led to better outcomes and removed some hurdles associated with navigating patients through the system.¹⁰ The study demonstrated that using a TCM approach, ED evaluation to EP consult was reduced from 128 days to 1 day.¹⁰ This demonstrates how the pathway can be transferred to other care settings or contexts, including chest pain and cryptogenic stroke. This process has opened many doors and created lasting change for both the unit and MRMC.

Conclusion

Our staff have been pleased with the outcomes of the follow-up pathway. Not only did the pathway increase EP volume at MRMC, it has brought physicians together across specialties. It has also empowered nurses and staff by giving them a voice and support for aiding patients’ transitions throughout the health care journey. Finally, it has helped us better educate our patients about their condition and their options for the best care, allowing them to make fully informed health care decisions. 

Disclosure: The author has completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Ms Bower reports participation on an advisory board, support for attending meetings and/or travel, and consulting fees from Biosense Webster for a cardiovascular administrator advisory board meeting.   

Author Jessica Bower, MSN, RN, CCRN, RCIS comments on her article published in the August 2022 issue of EP Lab Digest.

References

1. Atrial fibrillation. Centers for Disease Control and Prevention. September 27, 2021. Accessed May 19, 2022. https://www.cdc.gov/heartdisease/atrial_fibrillation.htm

2. What is Afib? Biosense Webster, Inc. Accessed May 19, 2022. https://www.getsmartaboutafib.com/afib-education/what-is-afib

3. Morillo C, Banerjee A, Perel P, Wood D, Jouven X. Atrial fibrillation: the current epidemic. J Geriatr Cardiol. 2017;14(3):195-203. doi:10.11909/j.issn.1671-5411.2017.03.011

4. Masoudi FA, Calkins H, Kavinsky CJ, et al. 2015 ACC/HRS/SCAI left atrial appendage occlusion device societal overview. J Am Coll Cardiol. 2015;66(13):1497-1513. doi:10.1016/j.jacc.2015.06.028

5. Abadie BQ, Hansen B, Walker J, et al. An atrial fibrillation transitions of care clinic improves atrial fibrillation quality metrics. JACC Clin Electrophysiol. 2020;6(1):45-52. doi:10.1016/j.jacep.2019.09.001

6. Heidenreich PA, Solis P, Estes NAM 3rd, et al. 2016 ACC/AHA clinical performance and quality measures for adults with atrial fibrillation or atrial flutter: a report of the American College of Cardiology/American Heart Association task force on performance measures. J Am Coll Cardiol. 2016;68(5):525-568. doi:10.1016/j.jacc.2016.03.521

7. Kirchhof P,  Calkins H. Catheter ablation in patients with persistent atrial fibrillation. Eur Heart J. 2017;38(1):20-26. doi:10.1093/eurheartj/ehw260

8. Brush JE, Handberg EM, Biga C, et al. 2015 ACC health policy statement on cardiovascular team-based care and the role of advanced practice providers. J Am Coll Cardiol. 2015;65(19):2118-2136. doi:10.1016/j.jacc.2015.03.550

9. Hirschman KB, Shaid E, McCauley K, Pauly MV, Naylor MD. Continuity of care: the transitional care model. Online J Issues Nurs. 2015;20(3):1. doi:10.3912/OJIN.Vol20No03Man01

10. Stiles S. Early arrhythmia-specialist consult, ordered in the ER, a boon to AF outcomes: ER2EP study. Medscape. May 2, 2022. Accessed July 6, 2022. https://www.medscape.com/viewarticle/973250