Early Ambulation and Same Day Discharge: Creating Efficiencies in the Electrophysiology Lab and Improving Patient Satisfaction

Interview With Benjamin D’Souza, MD

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In this episode of The EP Edit, we feature a discussion with Benjamin D’Souza, MD, from Penn Presbyterian Medical Center in Philadelphia, on how an early ambulation program can enable same day discharge, create efficiencies in workflow, and improve patient satisfaction.

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What vascular closure methods were you using for cardiac ablation patients before you started to use the VASCADE MVP^® venous vascular closure system, and what was that previous experience like for you and your staff?

We are a very high-volume center for ablation for atrial fibrillation (AF) at the University of Pennsylvania - Penn Presbyterian Medical Center in Philadelphia. Our previous experience with vascular closure was essentially not to do anything for closure. We would have the staff hold pressure for a certain amount of time and have the patients lay flat for a few hours. One of my colleagues would typically use a tape ball in which they would wad up tape and tape it to the patient’s skin, which would invariably pull off the patient’s hair and be uncomfortable. We did use some figure-of-8 stitches for patients but struggled with either pain related to the site or bleeding afterward. There were not any options for a closure device that allowed for closing of multiple venous puncture sites on both sides of the groin. This was the reason we decided to start working with Haemonetics and begin using VASCADE MVP for closure. In our previous experiences, we had used a bunch of methods that we were not happy with but tried because we needed to. Once we initiated an early ambulation program for our program to expedite discharges to same day for AF ablation, we took off in terms of our use of VASCADE MVP.

Why did you originally want to implement an early ambulation program and how did the VASCADE MVP system help you to accomplish your objectives?

Our group at Penn had an interest in ambulating and getting patients out of the hospital early, especially for same day discharge. But at the time, no one was really sending home patients same day from an AF ablation. Looking back, overnight stay for AF ablation patients was largely considered the standard of care across the United States. However, when the COVID-19 pandemic happened, we did not have any beds in the hospital. If we were planning a procedure on a patient, we needed to have anesthesia support, which was a struggle because of COVID, and we were not able to admit these patients to the hospital. 

Interestingly, the pandemic pushed us to revisit some of the things that we thought were the standard of care and what we thought was best for our patients. What ended up being a luxury became a necessity in terms of being able to get patients out of the hospital sooner. We started the process at Penn. Once we began to ambulate patients earlier and were able to get them up out of bed, making sure that they were doing okay, we were sending the patients home same day. This has now become pretty much the standard of care in our practice and with my patients. I send more than 95% of patients home the same day. The hospital is thrilled because I saved those beds, and the patients are also thrilled. Getting patients out of bed early was very important to us. 

There are multiple areas in the hospital where the patients can go after a procedure, but the area for our outpatient procedures is nicknamed “the bowling alley” because it is a long alleyway. However, the bowling alley is not staffed after 6:00 PM. So, if we cannot get patients out of bed in an appropriate timeframe, we cannot get them home. Traditionally, if we admit them to the hospital, they stay in the hospital. So, the ability to ambulate a patient early became the key point in getting patients out of the hospital, so that if I finish a procedure in the mid-afternoon, I do not have to admit them to the hospital for 4-6 hours of bed rest. I can get them up, make sure that they can urinate, ensure they feel alright, and then get them home the same day. That was very transformative for our program. We developed a center of excellence for same day discharge for AF ablation, and that has grown throughout the health system and region as well.

What does the VASCADE MVP system learning curve look like? Who closes in your facility?

The VASCADE MVP is very easy and straightforward to use. When we first started the program, I was doing the closure, but then we trained our nurses and technicians. We are largely a nurse-driven hospital system, so in our EP laboratories, the nurses do the closures. I rarely do it, and for the most part, the nurses are very comfortable doing it. Haemonetics has been very supportive in terms of growing the program. We are also using this as part of our magnet status for nursing, demonstrating that we were able to build a program in which the nurses are more involved in the program.

It has been wonderful for them, because they are more involved with procedures and are more actively involved in the care of patients. It is nicer for me as well, because I can start to work on some of the other things related to getting the patient home, whether that is talking to the nurse practitioners about orders, talking to the family, getting the procedural notes finished, or talking to the referring physician. So, it allows me to multitask and enables the process of getting that patient home same day, which requires multiple steps. Every second matters to me in terms of my productivity. It has also increased the satisfaction of our nurses in the lab.

There have been reports of staffing shortages in health care, which could potentially affect post-ablation workflow in the EP lab. How have you navigated staffing and workflow concerns in your EP lab at Penn Presbyterian Medical Center?

Unfortunately, there have been health care shortages in multiple areas across the country, whether on the inpatient or outpatient side, and EP labs are not immune to that. We have had good retention of staff at Penn, and I think part of that is addressing their concerns and making sure that they feel that they are a part of the process with the patients. This has very much helped with that. Beds are an issue at any hospital, and Penn also struggles with patient beds. So, our EP lab nurses were not thrilled when they previously had to stay late to secure a patient a bed in the hospital and not be able to go home.

If we can finish our procedures on time and get them home to their family, they are happier and want to come to work. I think all these things were a strain prior to COVID and got even worse afterward. So, keeping your staff happy, whether that is through having them remove their lead, do fluoroless procedures, or not having to stay late, has been a large part of us being able to retain our staff.

What does your PACU nursing staff say about your early ambulation program? What do they see as the biggest benefits of this program?

In addition to the patients, probably the people who are the most thrilled are our outpatient staff, who also want to go home and see their family. It can be a struggle if you are getting the patients up a few minutes before a staff member finishes their shift to make sure they can go home. You should know about any issues as early on in the process as possible, which is why ambulating the patients as early as possible is key. When I used to come into the lab each morning, I cannot tell you how many times my outpatient nursing staff used to ask me if we were closing our patients so they could be discharged and everyone could get home. So, this was a very large part of it.

Again, as beds are a struggle everywhere in most health care systems, the sooner that we can free up the PACU or the “bowling alley” bed for another patient, whether it be an outpatient or someone who needs to stay, it takes a lot of stress off the situation. The ability to let my outpatient nurses get home on time and get my patients home without having them take up a hospital room has been key. Same day discharge for patients post AF ablation has been transformative for our program.

Did your hospital administration or supply chain leaders initially have concerns over added costs for vascular closure? How did you guide these discussions with your new product committee? 

This continues to be a struggle in terms of hospital administration, supply chain, and the new product committee. They need to make sure that we are financially doing well and continue to keep the lights on. Finances are important. Haemonetics has been very gracious and supportive. They developed a workflow calculator, which was created with a third-party consulting firm, that essentially looks at cost per case. This is very much a hot topic in the EP field, and it is something that we continue to look at as the cost of health care and new technology continues to increase. This workflow calculator looks at time to ambulation, overnight stay versus same day discharge, resource utilization, staff, and the PACU. I presented that information to our new product committee to justify the cost of the device. This has been looked at time and time again, and has shown cost savings for the hospital and the University of Pennsylvania. Further, we told the new product committee that we would start by looking at the same day discharge experience. Haemonetics was very helpful. They brought their clinical people in, and we tracked and recorded all our data. We brought this information to Penn and showed that based on this subset of patients, we had saved this amount of money to the hospital system. It was then easily approved for use on all our patients. We published this data with the Heart Rhythm Society as well. It has shown to be a true quality improvement story for our hospital. We celebrate that we can use something like this to get our patients home and save money for the hospital.

Tell us about same day discharge for AF ablation in your lab. What percentage of patients do you typically send home the same day and how does that compare to before you began your early ambulation program? Why do you same day discharge your post-AF ablation patients, and which patients do you NOT same day discharge?

It is interesting looking back on the history of this. The conversation on same day discharge at the time of the pandemic was very different. We looked at the data and talked to other folks across the country who were already doing this to figure out what the barriers were, because getting patients out of bed as early as possible was one of the major barriers for us. So, prior to COVID, we essentially went from doing 0% same day discharge of patients at the University of Pennsylvania, to now more than 95% of my patients are sent home same day. It has really changed our program. Across the country, this has largely become the standard of care at many programs. Why do it? These patients now have the ability to sleep in their own bed, spend time with their loved ones, and not be in a hospital, which is largely the worst place you could ever try to sleep. 

Regarding all the constraints that we had in terms of getting patients into the hospital, including bed and nursing availability, etc, we looked at the data and evaluated which patients bounced back to a local emergency department (ED). Currently, I am in Philadelphia taking care of patients at the University of Pennsylvania, but I see patients as far as 100 miles away in some of our satellite clinics, and they are coming in far away from home. We have a pretty consistent workflow where our advanced practice providers and nurses and staff make sure we have all the check boxes for what we think is appropriate for patients to go home and then we follow up with them after.

Through our nursing protocol, we have an automated call system that contacts the patients next day and goes through about 10 questions, such as “Do you have this?” or “Do you not have this?” and “Are you doing okay?” This triggers to our nurses a protocol that calls them and makes sure they are doing okay. We want to confirm that they are not having any issues and that we can address them as an outpatient if needed. All those things together have allowed us to enroll patients in the same day discharge protocol here.

When it comes to same day discharge, are there any different considerations for persistent versus paroxysmal AF patients? Dr Zayd Eldadah published on same day discharge in AF ablation in the Journal of Cardiovascular Electrophysiology in 2022.¹ 

This study had approximately 350 patients, which included about 57% of patients with persistent AF and 43% of patients with paroxysmal AF, and essentially there was not a difference between the 2 groups. Therefore, it is not so much about the duration of AF that keeps us from being able to send home a patient same day.  

Initially, we thought there might be some subsets of patients who should potentially be allowed to stay. There are multiple factors to consider, the social factor certainly being one of them. If you have a patient who lives far away from the hospital and lives alone, you may want to reconsider sending that patient home same day.

But it is important to continue to pay attention to your patient profile and try to identify if there are limiting factors in terms of getting those patients out of the hospital. We continue to grow our process and do better. Physicians who would never, ever send a patient home same day from an AF ablation 3 or 4 years ago are now routinely doing it. So, it goes to show that sometimes we have to reevaluate what we think of as standard and continue to push the field forward so that we can do what is best for our patients.

How would compare VASCADE MVP system against figure of 8, considering peer-reviewed published clinical data, reproducibility, complication rates, and patient satisfaction? Do you have patients who express concern about their previous method of vascular closure, and if so, what do they say after they have had VASCADE MVP closure for their latest procedure? What do your patients have to say about their overall patient satisfaction and post-procedure recovery using the VASCADE MVP system?

We went from doing essentially no version of closure, with manual pressure, tape, and manual compression, to using a stitch and figure of 8, and now we are almost universally using VASCADE MVP for our patients. While the figure of 8 is a stitch and can certainly be used in patients relatively quickly, the data is limited in terms of randomized or prospective, multicenter trials, and it is largely based on single-center data. There was a publication in the Journal of Interventional Cardiac Electrophysiology in 2021 that looked at patient satisfaction and use of pain medications with figure of 8, and it showed that there was not a significant improvement in patient satisfaction compared to manual compression and suture-mediated closure.² Looking at the figure-of-8 publications, they reported a major complication rate ranging anywhere from 0 to .4% and a minor complication rate ranging anywhere from 0 to 9%.

When putting in a stitch with a needle, a big concern is hitting another blood vessel such as an artery. That is not possible with the VASCADE MVP. There is ease of use because there are no needles or stitches; the only thing left behind is a collagen plug. So, it really does change the experience. Based on the Press Ganey patient satisfaction surveys at Penn, I can tell you that prior to us rolling out a closure system for our patients, the number one complaint was groin pain and groin-related issues. Those stitches work acutely when closing the groin, but they can hurt because you are literally tying down tissue. So, those patients can be very uncomfortable, and then you must cut that stitch. If there is bleeding when you cut that stitch, then you must decide what to do in terms of bed rest protocol, so it ends up being more complicated. In terms of our data as well as anecdotally, our patients are thrilled. They tell us they did not even know that we did a procedure in their groin, which is a main deterrent of many patients undergoing AF ablation. They have had a catheterization before or have heard from another person about sandbags and clamps and lying flat for hours. A lot of our patients have chronic back issues or comorbidities where they cannot lay flat for a long period of time.

When I educate patients on the process and let them know they will be up in 2 hours or less, they are going home same day, and that there are no stitches, clamps, or sandbags, it changes their perspective about the procedure. By discussing what may be considered as the “worst” part, which is groin access for a procedure, and making it a nonconcerning factor for patients, they are much more inclined to move forward with an ablation if they know they will not have that level of discomfort. When I see these patients about a month out post ablation, they tell me it was not a big deal at all. That makes me very happy, because I do not want them to be uncomfortable or remember anything negative from the procedure. Being able to send patients home same day and no longer having any concerns related to the catheter insertion site has been a game changer for us at Penn, and we have transitioned 100% to using VASCADE MVP for all those patients. 

References

1. Eldadah ZA, Al-Ahmad A, Bunch TJ, et al. Same-day discharge following catheter ablation and venous closure with VASCADE MVP: a postmarket registry. J Cardiovasc Electrophysiol. 2023;34(2):348-355. Epub 2022 Dec 21. doi:10.1111/jce.15763 

2. Mohammed M, Ramirez R, Steinhaus DA, et al. Comparative outcomes of vascular access closure methods following atrial fibrillation/flutter catheter ablation: insights from VAscular Closure for Cardiac Ablation Registry. J Interv Card Electrophysiol. 2022;64(2):301-310. doi:10.1007/s10840-021-00981-5

3. Natale A, Mohanty S, Liu PY, et al. Venous vascular closure system versus manual compression following multiple access electrophysiology procedures: the AMBULATE Trial. JACC Clin Electrophysiol. 2020;6(1):111-124. doi:10.1016/j.jacep.2019.08.013

4.  Al-Ahmad A, Mittal S, DeLurgio D, et al. Results from the prospective, multicenter AMBULATE-CAP trial: reduced use of urinary catheters and protamine with hemostasis via the mid-bore venous vascular closure system (VASCADE^® MVP) following multi-access cardiac ablation procedures. J Cardiovasc Electrophysiol. 2021;32(2):191-199.

5.  AMBULATE VASCADE MVP Same Day Discharge Retrospective Registry: NCT04538781. ClinicalTrials.gov. Accessed November 17, 2023. https://www.clinicaltrials.gov/study/NCT04538781?term=NCT04538781&rank=1

We would like to thank our sponsor, Haemonetics, and their VASCADE MVP Venous Vascular Closure System. VASCADE MVP is simple and easy to use, with 0% major complications^* in 1223 patients in 5 EP clinical trials.^1,3-5 To learn more, please visit: hospital.haemonetics.com/vascular-closure/vascade-mvp 

^*Major venous access site closure-related complications through the follow-up period

This content was published with support from Haemonetics. Dr D’Souza has had past or present engagements as a consultant and/or clinical investigator with Haemonetics. The views, opinions, and experiences in this podcast are those of the speaker. Please consult product labels and instructions for use for indications, contraindications, warnings, precautions and adverse events. See VASCADE MVP IFU 3972. 

© 2023 Haemonetics Corporation. Haemonetics and VASCADE MVP are trademarks or registered trademarks of Haemonetics Corporation in the U.S., other countries or both. 11.2023 USA. LIT 0128 Rev AA 

The transcripts have been edited for clarity and length.