Performing Electrophysiology Services in an Ambulatory Surgery Center

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EP LAB DIGEST. 2024;24(10):1,7-9.

David N Kenigsberg, MD, FACC, FHRS
Clinical Cardiac Electrophysiologist, Medical Director and Co-Founder, Florida Heart Rhythm Specialists & Fort Lauderdale Heart and Rhythm Surgical Center; Medical Director, Cardiac Electrophysiology, HCA Westside Hospital, Plantation, Florida; Governor & President Elect, Florida Chapter, American College of Cardiology; Treasurer, Arrhythmia Intervention Society

During the COVID-19 pandemic, patients requiring cardiac implantable electronic device (CIED) replacement or de novo implantation were typically kept out of the hospital to reallocate resources for higher acuity and sicker patients as well as to prevent hospital-acquired COVID-19 infection. Retrospectively, this situation resulted in the realization of cost savings, improved efficiencies, and increased patient and physician satisfaction. Experience gained from the pandemic reinforced the benefit and importance of transitioning outpatient electrophysiology (EP) procedures to an ambulatory surgery center (ASC) setting.

The Fort Lauderdale Heart and Rhythm Surgery Center of Broward County, Florida, opened in February 2019 and has remained operational on weekdays ever since. The center houses a spacious 1-room operating room with fixed fluoroscopy. The adjacent area has 6 pre- and post-operative private patient bays. CIED procedures that are routinely performed at the center include implantation of de novo permanent pacemakers (PPM), implantable cardioverter-defibrillators (ICD), cardiac resynchronization therapy devices, cardiac contractility modulation devices, and implantable loop recorders (ILR), as well as generator replacements for all device types.

The main operators at the center are 2 electrophysiologists who have been practicing for over 15 years each and account for over 90% of the total ASC volume and revenue. In addition to the physician owners, National Cardiovascular Partners, a subsidiary of SCA Health, co-owns and manages the center. Every member of the clinical staff who works at the center, including nurses and technicians, has over 25 years of experience in the cardiology space. 

Over the past 5 years, nearly 1800 cases have been performed at the center. Our safety record in the ASC is exemplary, including only 2 hospital transfers, no pneumothoraces, no pericardial effusions or tamponade, and no patient deaths. The incidence of CIED infection at the center is less than 1%. 

The mission of the ASC is to provide high-quality patient outcomes, encourage patient satisfaction and overall experience, and reduce health care costs. Cost transparency is a primary focus for many patients, as many are typically responsible for 20% or more of their health care financial responsibility. In addition to cost savings, efficiency and satisfaction are key factors that contribute to the overall experience. 

At our center, there is on average a 25%-30% cost savings to the Centers for Medicare and Medicaid Services (CMS) for procedures as compared

to the hospital outpatient department (HOPD) setting. For example, in 2021, the CMS National Current Procedural Terminology (CPT) procedure rate for an ICD implantation (CPT 33249) in the HOPD was $32,838.89 and $26,732.74 in the ASC. For a de novo PPM implant (CPT 33208), the HOPD rate was $10,400.15 and ASC rate was $7,897.23. For ILR implant (CPT 33285), the HOPD rate was $8,152.58 and ASC rate was $7,046.17. 

A success factor is teamwork both within the ASC and with the physician’s office. The ASC’s chief executive officer (CEO) and office CEO must have a strong working relationship with one another and have the same goals to achieve the highest level of patient satisfaction and best outcomes. Since the opening of our ASC, both CEOs have engaged in weekly phone calls as well as meet regularly with the schedulers to debrief on all aspects of the scheduling process to continually identify opportunities for improvement. In our early years, meetings were monthly, but as time has passed, they have moved to quarterly or when necessary. 

This teamwork is the foundation of creating the best patient experience. Over the past 5 years, our ASC has maintained a patient satisfaction rating higher than 98% (Figure 1), according to Press Ganey patient satisfaction scores for our center. The data show that patient satisfaction scores have remained higher than 97% consistently for the past 6 quarters (Figure 2), keeping us in the 99th percentile. 

We attribute that to several factors, including open communication between patients and the ASC team. Our scheduler is proficient and compassionate with the patient during the entire process, including scheduling, insurance verification, and any expected out-of-pocket balances, and also provides crucial patient information such as a brief overview of the procedure and medications required before their procedure. Optimal team communication occurs through regular staff meetings and meetings with the Quality Council, Governing Board, and Medical Advisory Committee, which have been facilitated by our limited number of people in administration. 

Patients also appreciate the ease of the experience and pleasant environment. For example, the ASC is easily accessible, with onsite parking

available for patients and staff. The décor of the center is modern and aesthetically pleasing, creating an inviting experience. Patients also appreciate the consistency of engaging with the same staff members prior to their procedures. 

Performing cases in the ASC is also efficient for physicians. Block scheduling is crucial to facilitate efficient physician office scheduling, including information accuracy and urgent case posting. Prompt dictation is facilitated with available templates and the option to edit the dictation live so that accurate details are captured and submitted to coding on the day of the procedure. The ASC CEO has worked to streamline processes such as order sets, discharge instructions, and dictation templates to be utilized specifically for each physician’s patients. 

Patient selection is imperative for the success and outcomes of ambulatory EP care. All patients are seen in the office and assessed for appropriateness based on height, weight, neck circumference, sleep apnea risk assessment, and review of comorbidities. Other socioeconomic factors, such as if the patient lives alone or has a support system, play a key role in determining ASC appropriateness. The ASC’s Governing Board and Medical Advisory Committee have established admission criteria with annual review to ensure that all agree on best patient selection to support patient safety. Of course, patients choose the site of service for their procedure. If a patient or family member is unsure about ASC care, we facilitate the opportunity to tour the ASC prior to care. This hesitancy was more common before COVID-19; most patients are now open to using the ASC as the place of service, as many patients and their families do not prefer to be in a hospital setting if they do not have to be there. 

Over the years, our biggest hurdles have been establishing contracts with insurance providers and overcoming the stigma that these procedures

must be done in the hospital. Improving public opinion and public confidence about the safety of having procedures performed in an ASC is still an ongoing challenge. Importantly, our referring physicians must have faith in the evolution of transitioning patient care to the outpatient setting. 

Another significant challenge is access to anesthesia providers. Medicare reimbursement for anesthesia providers is significantly lower than for other professions and ultimately prices out the feasibility of having an anesthesiologist provide sedation. ASCs that have a high Medicare case mix warrant the discussion of nurse-administered moderate sedation versus CRNA-administered monitored anesthesia care sedation. Many of the procedures, especially generator replacements, can be safely performed using moderate sedation and adequate use of local anesthesia. This sedation approach can facilitate shorter case times and faster recovery times; however, some patients would rather be sedated with propofol. 

For the past 5 years, the Fort Lauderdale Heart and Rhythm Surgery Center has persevered through adversity, COVID-19, and corporate changes, all while remaining relevant. It will be a pivotal moment for ASCs to provide the best electrophysiological patient care in the ambulatory care setting. 

Disclosure: Dr Kenigsberg has completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. He reports a Medical Director Fee from National Cardiovascular Partners and owns a portion of Lotus which owns a portion of ASC.