Quality Improvement in an AF Ablation Program
- 1. Dr. Jose Osorio Improving Efficiency While Enhancing Quality and Patient Experience in an AF Ablation Program
- 2. Disclosure • I have received financial support/grants from: • Boston Scientific: advisory board, consultant, research and educational grants • Biosense Webster: advisory board, consultant, research and educational grants • Abbott: research grants • Epix: research grants • Medtronic: research grants • I will not discuss off label use and/or investigational use in my presentation
- 3. CAGR 2013 – 2023 AF 16.51% VT 7.01% AFL 3.85% SVT 2.91% ALL 10.8% 178,010 193,930 213,060 235,800 262,480 293,170 327,830 366,000 407,130 450,330 494,740 0 50,000 100,000 150,000 200,000 250,000 300,000 350,000 400,000 450,000 500,000 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 ©2015 Millennium Research Group, Inc. All rights reserved. Reproduction, distribution, transmission or publication is prohibited. Reprinted with permission. As these estimates are from a third party source, Biosense Webster does not make and hereby disclaims any and all representations or warranties relating to the sufficiency and/or accuracy of the information provided by Millennium Research Group and shall not in any way be liable for the same. U.S. Ablation Volume
- 4. • Clinical Inertia • Efficacy • Efficiency • ~6000 EP labs worldwide • Long procedures • Procedures/day AF Ablation: Barriers to Market Penetration
- 5. AF Ablation Program: Optimizing the Process EP Referrals New Afib Patients Afib Ablations Follow Up Where should you focus?
- 6. • Lean •Toyota •Focus: Eliminating Waste • Six Sigma •Motorola •Focus: Reducing error and variability • Synergistically •Reduce waste and improve process efficiency and quality Quality Efficiency Reproducibility Lean Six Sigma in Healthcare
- 7. Improving Lab and Procedural Efficiency: Room Utilization Cleaning Getting New Patient Anesthesia Prep EP Prep Patient Out of Lab Patient Out of the Lab Room Turn Over Time Procedure Starts Procedure Ends EP study Mapping Merge/ICE/FAM Ablation Validation 3 hours Recovery Patient leaves Lab Groin Care Extubation Room Turn Over Time Afib Ablation Procedure Time Recovery Starts 1 hour 1 hour
- 8. • Standardization •Protocol • Ablation • Anesthesia •Repetition • Eliminate waste and improve flow •Duplication and non-value added steps •Root Cause Analysis for outliers •QI meetings • Similar gains by addressing: •Procedure •Room Turn Over Time Improving Lab and Procedural Efficiency: Lean Six Sigma in EP
- 9. Room Turn Over Time
- 10. Variables Affecting TOT • Recovery • Cleaning • PACU • Patient Transport • Prep time •Anesthesia •EP Prep • EP doc Cleaning Getting New Patient Anesthesia Prep EP Prep EP doc Extubation Recovery Groin Care Patient Leaves Lab Procedure Ends Procedure Starts Improving Lab and Procedural Efficiency: Room Turn Over Time
- 11. Improving Lab and Procedural Efficiency: Room Turn Over Time Cleaning Getting New Patient Anesthesia Prep EP Prep EP doc Extubation Recovery Groin Care Patient Leaves Lab Cleaning Getting New Patient Anesthesia Prep EP Prep Extubation RecoveryGroin Care Patient Leaves Lab Procedure Ends 2 hour Procedure Starts Procedure Ends 1/2 hour Procedure Starts
- 13. 1. Minimize instrumentation 2. Patient Prep 1. Anesthesia and EP together 3. Sedation 1. Propofol only 2. Minimize paralytics 4. Recovery 1. Start with isuprel infusion 2. Ventilator changes 3. Sheath removal 5. Post Anesthesia Recovery 1. At CATH/EP LAB Area Anesthesia Protocol For AF Ablation Cleaning Getting New Patient Anesthesia Prep EP Prep Extubation Recovery Groin Care Patient Leaves Lab Procedure Ends Procedure Starts Median time to extubation 9 min 1st and 3rd quartile = 6-13 Anesthesia is not a bottleneck
- 14. AF Ablation: Efficiency, Efficacy and Safety
- 15. 2010 •Mapping system: 3D reconstruction •Intracardiac Echo 2016 • EP Lab Efficiency • Anesthesia Protocol • Databases • QI 2014 • Contact Force Sensing • Workflow • Integrating CF • Visited Several EP Labs Optimizing Efficiency and Efficacy Standardizing AF Ablation Standardized Afib Ablation Workflow NumberofAFAblations/Year 0 100 200 300 400 500 600 700 800 900 1000 2010 2011 2012 2013 2014 2015 2016 2017 2018 Fluoroscopy Reduction
- 16. 1. 40-45Watts 2. CF 10-15 g 3. Time: 1. 10-15s posterior wall 2. 15-20s anterior wall 4. Validation Protocol 1. Lesion set analysis 2. Adenosine and isuprel Follow up • 3, 6 and 12 months • 4-day Holter at 6 and 12 months • Event monitoring PRN AF Ablation WorkFlow Standardizing the Procedure and Follow Up
- 17. Efficiency and Predictability in Paroxysmal Atrial Fibrillation Ablation with Contact Force Catheter and Stability Module Integration Osorio J et al. Europace, Vol 19, Issue sppl_3, june 2017, page iii371 84.8% 9.8% 5.4% 15.2% (N=112) Success Repeat Ablation 1 year Success Rates - Single Procedure
- 18. A Comparison of Paroxysmal Atrial Fibrillation Ablation Efficiency and Clinical Outcomes Across Technologies in a High-Volume Center Osorio J et al. Europace, Vol 19, Issue sppl_3, june 2017, page iii371 0.50 0.55 0.60 0.65 0.70 0.75 0.80 0.85 0.90 0.95 1.00 0 100 200 300 400 500 600 700 800 ProportionwithNoReablation Days After First Ablation Cryoballoon SmartTouch ThermoCool SF Freedom from Reablation
- 19. • Should be the end result of • Protocols and standardization • Operator experience • Efficiency is not the opposite of efficacy • Safety • Most important consideration • Operator experience • Ongoing data analysis and QI Improving Lab and Procedural Efficiency AF Ablation Efficiency In-Hospital Complications Associated With Catheter Ablation of Atrial Fibrillation in the United States Between 2000 and 2010, Volume: 128, Issue: 19, Pages: 2104-2112, DOI: (10.1161/CIRCULATIONAHA.113.003862) Complication Rates and Operator Volume
- 20. Cleaning Getting New Patient Anesthesia Prep EP Prep Patient Out of Lab Patient Out of the Lab Room Turn Over Time Procedure Starts Procedure Ends EP study Mapping Merge/ICE/FAM Ablation Validation 3 hours Recovery Patient leaves Lab Groin Care Extubation Room Turn Over Time Afib Ablation Procedure Time Recovery Starts 1 hour 1 hour Cleaning Getting New Patient Anesthesia Prep EP Prep EP study Mapping Merge/ICE/FAM Ablation Validation Procedure Starts Recovery Patient leaves Lab Groin Care Extubation Recovery Starts 15 min 90 min 15 min Improving Lab and Procedural Efficiency EP LAB Use Time / procedure Afib Ablations / Day 4-5 hours 2-3 hours 2-3 3-4
- 21. Conclusion •AF ablations will continue to increase • EP Community • Efficiency solutions • QI / Lean Six Sigma Concepts • Standardization • Reducing waste Increased number of ablations/day End Result Reproducible Efficiency Efficacy Safety
- 22. Focus on the customer. Identify and understand how the work gets done. Manage, improve and smooth the process flow. Remove Non-Value-Added steps and waste. • Redundant Steps Lean Six Sigma in Healthcare 1 2 3 4 Manage by fact and reduce variation. • Protocols and Standardization Involve and equip the people in the process. Undertake improvement activity in a systematic way. 5 6 7
Editor's Notes
- #7: Lean elimination of the eight kinds of waste defects, over-production, waiting, non-utilized talent, transportation, inventory, motion and extra-processing. Six Sigma identifying and removing the causes of defects (errors) and minimizing variability in (manufacturing and business) processes. Synergistically reduce waste and improve process efficiency and quality.