Virtual Atrial Fibrillation Center Model: An Effective New Strategy for the Management of Patients With Atrial Fibrillation

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EP LAB DIGEST. 2023;23(10):1,6-7.

Chester County Hospital (CCH), part of the University of Pennsylvania Health System, is a 329-bed hospital offering a wide array of inpatient and outpatient medical and surgical services to patients. In 2015, CCH began the development of a state-of-the-art electrophysiology (EP) program as part of its commitment to provide a full array of cardiovascular services to Chester County. As a result of this commitment to its patients, the hospital saw significant growth between 2015 and 2023 in both the volume and type of EP procedures performed in the hospital.

The goal was to expand on the hospital’s commitment to broaden the scope of care for patients with atrial fibrillation (AF), the most common atrial arrhythmia in the United States. Consistent with the experience of health centers across the US, our hospital recognized that AF accounted for a large percentage of hospital admissions, over 30% in some cases. Nationwide studies have demonstrated that delays in the management of AF, specifically, delays in patient access to advanced therapies, can make antiarrhythmic interventions less successful and more complicated. With this in mind, we pursued the creation of an AF Center at CCH that would utilize novel hospital staffing models and advanced practice providers (APPs) to expedite and improve AF management.

A “virtual” AF Center model was developed, which was well-suited to the private practice environment of CCH. The structure of the center was designed to recognize emergency department (ED) presentations for AF as inflection points in AF management for a majority of patients. Whether an initial presentation for a new diagnosis of AF or a recurrence of previously treated AF, these ED visits represented an opportunity for patient education, risk factor modification, and expedited access to specialty EP care. The model was presented to Kurt Schillinger, MD, PhD, Director of Cardiac EP, and hospital administration, and the model was unanimously approved in 2021. Currently, we have a total of 3 APPs and 3 electrophysiologists involved with the AF Center at CCH. As of 2023, we average 10 admissions to the AF Center per month.

At its inception, the model was based on patient management driven by APPs. From initial presentation in the ED to admission on the observation unit and discharge, the center was designed to have APPs heavily involved in medical decision-making that included developing a comprehensive treatment plan in conjunction with EP physicians, educating patients, scheduling necessary cardiac testing, reviewing the importance of medication compliance, and confirming adherence to guideline-directed medical therapy for stroke prevention. Following this model, education is currently provided to all AF Center patients that includes risk factor modification material, AF treatment options including ablation, and sleep apnea risk assessment using the STOP-BANG questionnaire.

To ensure appropriate patient triage, an admission criteria template (Figure 1) was designed around a patient co-management strategy involving a multidisciplinary team of physicians and APPs in ED, internal medicine, and EP. The admission criteria enabled state-of-the-art, coordinated, and guideline-directed therapy for patients with atrial arrhythmias. These criteria were supplemented with clinical assessment at the time of presentation. Quality metrics for program assessment were determined prior to the initiation and included time to EP consult, CHA₂DS₂-VASc assessment, time to outpatient EP follow-up, and time from presentation to cardiac ablation.

A review of these metrics for the center was performed in 2022, approximately 12 months after the center opened. Results from this review were very encouraging. Time from presentation with AF to initiation of advanced therapy in traditional referral models prior to the AF center averaged 134 days. However, the use of the strategies for patient care in our AF Center model reduced the average time from initial presentation to initiation of advanced therapies to 61 days. This expediting of advanced care was also associated with a focus on care excellence for the patients admitted to the service. A total of 247 patients were admitted to the AF Center over a 1-year period following the admission algorithm. Time to EP consult was less than 24 hours (7.9 ± 7.6 hours). All patients (100%) underwent CHA₂DS₂-VASc assessment and a 100% goal was achieved. Time to outpatient follow-up was less than 14 days (10.8 ± 4.5 days).

Overall, use of a multidisciplinary management team has proven to be an effective strategy for managing the AF patients who met the criteria for admission to the AF Center. The results from our AF Center model show expedited access to advanced therapy, including AF ablation, and excellent compliance with guideline-directed medical therapy based on CHA₂DS₂-VASc assessment. These results also translated into a reduction in hospital readmissions for AF and a decreased length of hospital stay (<24 hours). We are hopeful that this model will allow for future growth of the AF Center, including expansion of the criteria template to include other atrial arrhythmias, such as atrial flutters and supraventricular tachycardias. It is also our hope that the evolution of the AF Center admission criteria will also allow for an increase in admission volumes, including direct admissions from home or outpatient clinics.

Disclosure: The author has completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Ms Pammer reports no conflicts of interest regarding the content herein.