Workflow for Efficiency and Same-Day Discharge: Experience at Ascension St Vincent’s Medical Center

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EP LAB DIGEST. 2024;24(3):1,8-9.

Saumil R Oza, MD, and Anthony R Magnano, MD, Ascension Medical Group St Vincent’s Cardiology, Jacksonville, Florida

Since 2008, annual atrial fibrillation (AF) ablation volume at Ascension St Vincent’s Medical Center has increased from less than 100 cases per year to approximately 800 cases in 2023. In that time, our program also went from completing 1-2 AF ablations per physician each day to 4-7 AF ablations per physician each day. This growth has required improved efficiencies that have been realized through significant procedural experience and new technologies. Most importantly, regular dialogue among our electrophysiologists and staff has accelerated the learning curve, culminating in our current “St Vincent’s approach” to AF ablation. In this article, we describe the different layers of preprocedural planning, procedure workflow, safety protocols, and follow-up routines that have been implemented at our institution.

Preprocedural Care

In 2019, an AF Clinic was started with a dedicated mid-level provider. The purpose of the AF Clinic is to evaluate patients discharged from the emergency department (ED) as well as provide routine follow-up care. The AF Clinic has been an important avenue for decreasing wait times for AF patients from the ED or referring physicians, as well as existing patients within our practice. Physicians are then able to free up clinic slots for new patients and semi-urgent visits. This, in turn, increases the number of procedures scheduled during each clinic. Prior to scheduling, every patient watches a prerecorded video that uses animation to describe the procedure as well as discuss possible complications. The video is emailed or texted to patients so it can be shared or watched again as needed. Patients also learn what to expect the day of their procedure, including limitations after the procedure and considerations for same-day discharge (SDD). The video is an excellent supplement to our in-person dialogue with the patient, who can also ask more informed questions on the day of the visit.

Preprocedural Transesophageal 

Echocardiography (TEE)

If patients require a TEE, the first 2-3 cases are scheduled in the TEE lab the day before, and the rest are performed on the day of the procedure. For low-risk patients, left atrial appendage (LAA) thrombus is ruled out by placing an intracardiac echocardiography (ICE) catheter in the pulmonary artery, just past the pulmonic valve, to scan the LAA.

Access

We have diligently developed protocols designed to avoid access site complications that could require admission. Every attempt is made to prevent minor postprocedural groin oozing, which could cause the patient to stay in the holding area for more than 2 hours. Ultrasound-guided peripheral venous access is used. Oftentimes, the greater saphenous vein access is useful for one sheath to reduce crowding of sheaths and minimize the risk of venous tears (Figure 1). We minimize the skin “knicks” using only the dilator for skin expansion to minimize minor bleeding. We limit most procedures to 3 sheaths, which are all placed unilaterally, typically in the right femoral vein.

Mapping and Ablation

For our 3 access sites, we generally employ an ICE catheter, a multi-spline mapping catheter (OctaRay, Biosense Webster, Inc, a Johnson & Johnson company), and a SmartTouch Surround Flow (Biosense Webster, Inc) contact-force irrigated ablation catheter. We use a single transseptal technique with a mapping and ablation catheter placed simultaneously through the septostomy. We believe having 2 catheters in the LA is critical to ensuring block across lines that often have numerous epicardial connections that must be severed. A multipolar coronary sinus (CS) catheter may be used for more complicated repeat procedures with multiple organized flutters or cases where more complex techniques are used, such as dispersion mapping. For the majority of atrial flutters, a detailed substrate map and a few well-placed sites of atrial entrainment suffice to elucidate the flutter circuit without the use of a CS catheter. 

Anesthesiologists intubate with a short-acting paralytic, typically succinylcholine, which wears off quickly, allowing pacemapping of the right phrenic nerve on the anterior side of the right pulmonary veins (PVs). After phrenic nerve mapping, the patient is paralyzed with a larger dose of rocuronium to avoid map shifts during the case. During ablation, improved catheter stability is achieved by using a high frequency, low tidal volume ventilatory protocol with the ventilator set at 30 breaths/minute at a tidal volume of 200 cc. The improved map and catheter stability achieved through paralysis and high-frequency ventilation have reduced our ablation time by 23% compared with nominal ventilator settings. Prior to ablation, the location of the esophagus is identified using both radiopaque contrast (gastrografin) as well as echo contrast (Definity, Lantheus). This allows for both edges of the esophagus to be seen and mapped onto the left atrial map using CartoSound (Biosense Webster, Inc) (Figure 2). While paralyzed, we are then able to deviate the esophagus using the EsoSure Esophageal Retractor (EsoSure) and remap the esophagus in the new location. The location of the esophagus can also be confirmed using a few seconds of fluoroscopy after deviation (Figure 3). Because we can be confident the esophagus is not adjacent to our lesion path, power is set at 50W for ablation around the PVs and Visitag (Biosense Webster, Inc) settings are set for an impedance drop of 10 Ohms, which we will target up to an Ablation Index of up to 500 on the posterior wall and 550 on the anterior wall. At the end of the case, the paralytic is reversed with sugammadex. This allows the patient to quickly wake up, reducing the time to extubation. 

Venous Closure

Through our access technique, we have found that the Vascade vascular closure system (Haemonetics) offers the most optimal venous closure. Injection of lidocaine with epinephrine around the Vascade at the end of procedure improves patient comfort and reduces minor capillary bleeding. With these measures, patients are generally able to be ambulated and discharged after 2 hours of bed rest.

Discharge

The holding area has a checklist to ensure patients are safe for discharge following their ablation procedure. In addition to deeming patients medically stable, it is also verified that patients have transportation, adequate care at home until the following day, and live within a 45-minute drive from an ED within the hospital system. Upon discharge, patients are given detailed instructions about appropriate activity levels post procedure. The patient is also instructed on how to handle complications such as sore throat, mild fluid overload, mild pericardial discomfort, and esophageal irritation. 

When scheduled for ablation, patients simultaneously have a live or virtual postprocedural visit arranged for the following day. This postoperative check is usually by telephone if the patient was discharged home, but typically in-person if the patient is staying at an on-campus hotel. Over the following weeks, the AF Clinic remains an integral part of postoperative care and a contact point for the patient should they have any questions or concerns.

The Real AF Registry 

We participate in the Real World Experience of Catheter Ablation for the Treatment of Symptomatic Paroxysmal and Persistent Atrial Fibrillation Using Novel Contact Force Technologies (REAL AF) Registry, a multicenter registry led by Heart Rhythm Clinical and Research Solutions and funded by Biosense Webster of over 100 high-volume electrophysiologists at more than 50 sites. As part of this collaboration, a prespecified protocol is followed in all patients after ablation. At 1-, 3-, 6-, and 12-months post procedure, a physician or mid-level sees the patient in the clinic. A 7-day Holter monitor is performed at 6 and 12 months, followed by a televisit with a mid-level in our AF Clinic. Patients are then seen yearly in the AF Clinic with a 7-day Holter monitor prior. Participation in the registry allows for a summary of our intraprocedural data, such as various measures of procedural efficiency, as well as measures of efficacy, such as first-pass isolation. Clinical outcomes of efficacy and safety out to 1 year can be assessed and results can be compared with others in the registry. Best practices can then be shared throughout the group at quarterly virtual meetings. All members of the registry can access this data as well as the expertise of a statistician to write abstracts and papers. 

The AF Clinic

Shifting the care of routine follow-ups to the AF Clinic allows for more new patients to be seen and for clinicians to work at the top of their licenses. Furthermore, protocol-driven visits by our mid-levels reduce medical errors, ensure regular patient follow-up, and allow the mid-levels to independently see patients. In addition, the AF Clinic allows patients to quickly access a clinician for any urgent visits and is often used in lieu of an ED visit. Mid-levels also partner with our pulmonologists, general cardiologists, and bariatric surgeons to ensure that comorbidities such as obstructive sleep apnea, obesity, or heart failure are addressed appropriately and lifestyle changes can be implemented.

Summary

The journey to achieve SDD has been made by implementing small changes over time to prevent any significant disruptions to workflow while maintaining efficiency. Making gradual changes has also allowed staff to remain comfortable, which promotes safety. Participation in the REAL AF Registry has enabled us to track our results, complications, and efficacy, as well as implement many of these changes to ensure improved quality of life in our patients. Treating every patient in this manner has allowed for protocol-driven care with objective analysis of outcomes used to improve patient care. 

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest, and report no conflicts of interest regarding the content herein. Dr Oza reports consulting fees and payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from Biosense Webster, as well as stock/stock options and leadership or fiduciary role in other board, society, committee, or advocacy group, paid or unpaid, from HRCRS/3PH. Dr Magnano reports leadership or fiduciary role in other board, society, committee, or advocacy group, paid or unpaid, from Medtronic.