Welcome to the panel session on Achieving Excellence in AFib Patient Care. This is a panel discussion. We have our wonderful panelists here, but we're trying to keep this casual and interactive, so if you do have a question, come on up to the mic or send it through the app. My name is Kathy Wood, and we're really glad you're here. I think this will be a very interesting session. We'll start off with questions that we've pre-designed for the panelists, and then the last half an hour we'll open it up to the audience for questions. Our panelists today include Professor Jeroen Hendricks from Maastricht, Netherlands, Dr. D. Varghese from Emory University in Atlanta, Megan Struer from University of Washington in Seattle, Tracy Shannon from Westchester Medical Center in Valhalla, New York, and Linda Otobani from Stanford in Palo Alto, California, and our patient representative we're thrilled to have, Liz Greer. So we'll get started with the first slide for Dr. Hendricks. So the question is, can you discuss the practical application of using an integrated care approach to patients with AFib? Thank you very much for the kind introduction, and so no slides, which makes it a little bit more tricky, but let's see how we get here. So I think before answering this question, I think it's important to look into what is integrated care, because there's a lot of different meanings towards that. And I just looked at a definition that comes from the Association for Cardiovascular Nurses and Allied Professionals through Europe, through the EAC, which says, this is a coordinated organization of a continuum of care delivery responsive to the needs of patients and aligned with guideline recommendations to improve quality of care, but also improve outcomes for patients and clinical outcomes. And I think that is really important to keep that in mind so that we're looking into a whole-of-system approach where we put the patient in the center and then try to deliver comprehensive care delivery. And with that, I think I'll touch already on four important pillars that fuse together, form the integrated approach. So first of all, that is a patient-centered approach where we put the patient in the center and organize the care around him or her. Secondly, an interdisciplinary team approach where we collaborate together with the patient and their carers to improve their outcomes. Thirdly, comprehensive care and treatment. And finally, technology to support this integrated approach. Now, I only have five minutes, but I would like to highlight two pillars of that, and one is an interdisciplinary approach. So if you look at the prevalence of atrial fibrillation that is rising continuously, and it is expected that in the U.S. alone, by 2030, there will be approximately 12 million individuals with atrial fibrillation. So that's huge. We see an aging population. The prevalence of multimorbidity is rising as well. So care is getting more and more complex. So the question is, is one single healthcare professional, can they appropriately address this complex care? Or should we think out of the box and work collaboratively together with physicians, nurses, allied professionals, and patients and their carers? And I think that is really an important aspect if we think of that the number of nurses in the near future is reducing, and allied professionals as well. So we need a bit of a redesign of healthcare. The other aspect is the engagement with patients and involving patients in their care process. I think given the prevalence issues, that is really an important one. So if we want to have our patients actively involved in their care process and make them an active member of the interdisciplinary team, we need to prepare our patients for that. So it is really about engaging with them to see, like, what do they need? What do they want to achieve? And it's also in the language. It's not about, like, what's the matter, but what matters to you, and how can we help you to reach your goals? Now, I think I always use the 3E rule, engagement, education, and empowerment. So I think we need to prepare patients for their active role to be incorporated in the team and that they know what is expected from them. And a very important aspect of the treatment and the care is around risk factors and lifestyle modification. So I think we as healthcare professionals can do whatever we want, but if the patient is not on board, it will be really difficult to make any changes. So education of our patients, I see that more or less as an educational trajectory where we talk about what is atrial fibrillation, how do you recognize your symptoms, what do you do in case you have an episode of AF in the home situation, how do you manage that yourself to really improve that self-care. And then also what I said before, like, risk factors and lifestyle modification is an important one that patients should take the lead on, so take their responsibility. And I think if we do it like that, if we redesign it like that, we can keep our patients safely out of the hospital and also deal with the healthcare burden around the increasing prevalence of atrial fibrillation. So that is, I think, an important one, patient-centered approach. The second pillar, interdisciplinary teams where there's increasing important roles for nurses and like professionals, comprehensive care and treatment, and then technology to support this approach. Thank you very much. Our next speaker is Dr. Dee Varghese, and her question is, how can allied professionals drive improvements in AFib patient management from inpatient settings to outpatient clinics using remote and digital platforms? Thank you, Gabrielle. AFib management is often fragmented. Jaron did an excellent job talking about using the integrated care approach to help with this. A lot of times detection's delayed, guideline-directed therapy's inconsistent, and patients are not given clear goals about managing atrial fibrillation. This disconnect between the inpatient setting and outpatient care is real, and that's exactly where we as allied professionals come in and can make a meaningful difference. Why? Because we're not confined to one setting. Many of us work in the inpatient setting, some in the outpatient, and many like me work between both settings to really provide care across the entire continent. In the hospital, we're stabilizing patients with rapid rates and initiating antiregulation. Then in the clinic, we're managing recurrence, supporting ablation and post-procedure recovery, titrating antirhythmics. Once these patients are stabilized, we're coaching them on lifestyle risk factor modifications, assessing treatment efficacy, and really reinforcing adherence to medications and the risk factor modification. We're everywhere that patients are, and that's exactly where our strength lies. To bring structure to this workflow, exactly what Jaron talked about, and really incorporating the ABC pathway that was mentioned recently in the AFib guidelines, A is standing for avoiding stroke, B for better symptom management, and C for cardiovascular and comorbidity optimization. So we're starting these patients on antiregulations while they're in the hospital. Then in the outpatient setting, we can use mobile health technologies, patient portals, even remote monitoring to track AFib burden and really guide early antiregulation initiation, sometimes even making the case for appendage closure procedures. Asking the patient what quality of life means to them. That conversation is just as important as rate and rhythm control. And these days, really using wearable technologies, smart watches, a live core, and having the patients upload that to their EMR to kind of monitor AFib burden and adjust treatment in real time. Patients love this because it's proactive and personalized care. In the hospital, we're also starting the conversation about lifestyle risk factor modification. And then in the outpatient setting, referring them to the sleep clinic, helping them manage their diabetes, referral to endocrinology, managing hypertension. So a lot of times, we as EPs are involved with that, sometimes referring them back to their cardiology provider. And in the outpatient setting, also having them use tools like a digital blood pressure log, virtual weight loss coaching, and really putting all of it together. We're the thread that holds prevention together, so reducing things that fall through the cracks. Here's where the data gets exciting. So there was a mobile AFib application trial, a mobile platform that applies the ABC pathway, which showed a reduction in stroke, re-hospitalization, and mortality by over 60% across all ages and all risk groups. Another study was the AFib Virtual Ward, which managed atrial fibrillation and atrial flutter, particularly in patients with rapid rates, safely in their home using wearable technology and virtual rounds. 24 admissions were avoided, 25 readmissions were prevented, and there was 100% patient satisfaction. These are all AP-led models, so high touch, low burden. That's actually scalable and efficient. I recently completed a DNP quality improvement project where we built a post-ablation protocol for our AFib patients. Very simple. All these patients received follow-up call within three days, standardized discharge instructions, and resources to digital education platforms. Patients felt more supported, engaged, and we used the AFib effect on quality of life questionnaire scores that reflected a significant reduction in symptom burden and improvement in quality of life. The bottom line, we don't have to wait for AFib patients to show up in crisis. We can be proactive by using digital tools to create a seamless transition between the inpatient and outpatient care. Thank you so much. And our next question for Dr. Megan Schroer is, can you describe your approach to implementing guideline-driven AFib patient management, including lifestyle modification, within our healthcare system? Try to get this to short person level. Thank you for inviting me here. I'm Dr. Megan Schroer. I'm a nurse practitioner, and I also teach in a DNP program at the University of Washington, and I actually got to help write the most recent atrial fibrillation guidelines, so I'm going to talk to you about my approach to implementing those guidelines in practice. I work one day a week clinically, managing mostly atrial fibrillation patients, and I think that when you look at a lot of the research, especially around lifestyle modification, which I was asked to focus on today, a lot of that research came out of European or Australian centers, and so it is great evidence, and we know that we need to do it, but in terms of nurse-led or allied professional-led approaches, we don't have as much data on implementing that within the U.S. health system. But I think some of the main takeaways when you look at all of that research is something that's already been touched on by one of the other panelists, which is early and often high touch. So if we're going to make a difference on lifestyle and risk factor modification for patients who already have developed atrial fibrillation, so secondary prevention, we have to see them more often than we would for just managing their pre- and post-ablation care. So a lot of times I'm not seeing folks until a pre-op appointment. They're already planning to have their ablation, and I'm just getting them ready for ablation, so I might not have a lot of time at that appointment to talk with them about lifestyle and risk factor modification. A lot of times I'm not seeing them as an APP until after their ablation, but I have found that that's a very great time to start introducing lifestyle and risk factor modification if it hasn't already been something that's been prominently addressed with their electrophysiologist, because if people are feeling good post-ablation, they want to continue to feel good. And so a lot of times I find this a time period where folks are really receptive to change, and so I just go step by step through the comprehensive lifestyle and risk factor modification section of the guideline. I kind of have it laid out in my head, so I talk to them about everything. So even if they don't have diabetes, even if they haven't received a diagnosis of high blood pressure, I walk them through all these things that they have control of, because how many people have had an AFib patient that comes in and wants to know, what triggers my AFib, what caused it? I think every single one of us has been asked that question. Almost every patient wants to know what they can do for themselves to control it, and these are the things that they can do, and so we give them some control back in a diagnosis that feels completely out of control. So I just walk them through, like, if you had diabetes, here's what I'd be talking to you about. So if anyone ever brings that up, like, get on it really quick. You know, if you had high blood pressure, we would need to be doing this, and then if they do have high blood pressure, going through what is optimal control, looking at their recent readings. I talk to them about weight loss and exercise, and I talk about those at almost every appointment, and I make sure that they know that there is independent benefit of exercise. So even if you exercise and don't lose a pound, that is independently beneficial to your reduction of AFib burden or progression. And then I talk to them about weight, and I do this often, and I make sure that people know I care about them. This is a very sensitive subject, and people have to know that you're actually saying it because you care. You can't just talk about weight and throw it out there and then move on. So, and really paying attention to nonverbal communication and people's reactions when you bring up these topics, particularly weight. And then there's other things like sleep apnea. It's a little lower on my priority list, but if they haven't been evaluated and they are open to it, then for most folks I will get them evaluated, but the evidence there isn't quite as strong. It's more of a correlation rather than a causation, but for some folks it makes a big difference. So if they're telling you things like my AFib onset is at night, I always wake up with AFib after a night where I feel like I didn't get good sleep, then those are clues that for that person maybe it's a little more important. Did I hit them all? Let's see. Diabetes, high blood pressure, weight, exercise, smoking, obviously we always have to talk about smoking. So I'll stop there because I only have 34 seconds, but in terms of weight management, there is a lot more that we can do now. I don't always, I don't feel comfortable prescribing those medications, but if you're assessing somebody for readiness, then you can either refer them back to their primary care if they have a good primary care relationship. We have a weight loss center that I will refer people to so they can get a more comprehensive evaluation and offerings from our weight loss center. But if it comes from us, I find if I bring it up often, if people know that I care, I have had a lot of success. I've had people come back with 60 pounds of weight loss and they said, well, you told me that you were going to really get on my case if I didn't do it. And I don't remember saying that, but I think I had seen that person probably six or seven times before they came back and did that. So I think just early, often, and hopefully we can get some more evidence within the U.S. health care system. Thank you. Thank you so much. Our next question is for Tracy Shannon. And this is, you've got the long question. Hopefully not too long an answer. But there's so much involved with this. Please describe your process of AFib patient education about the treatment options, including risks of recurrent AFib post-ablation. Does this also include discussion of AFib ablation success rates and possibility of a second procedure? And who educates referring physicians about this information? Thank you. Thanks to HRS for inviting me to be part of the panel. It's really nice to be here with you all. You know, APPs are really instrumental in driving high quality patient care and filling those gaps through education and effective communication, shared communication, decision making, and being a resource. Currently at our center, we have a total of three APPs. So we are not a huge center. I have the luxury of actually working in a hybrid type of position. So I see patients both on the inpatient and outpatient side. On the outpatient side, usually the first appointment is an EP consult with the physician. And the physician starts that conversation about AFib and management and talks in detail about, you know, the specific pillars of care from risk factor modification, stroke prevention, weight control, and rhythm control. And when they do, they talk about, you know, the specific antiarrhythmic options that might be appropriate for that patient, as well as obviously ablation and discuss the risk benefits and also success rates of both of those. We APPs typically have the fortune of a one-hour appointment prior to their procedures. And at that appointment, it's a lot of teaching. You know, at first I said, what am I going to do with that hour? But it never seems to be enough. We'll reinforce, you know, everything that the physicians already reviewed from doing a full H&P EKG, discussing their medications, medication reconciliation, talking to them about basic cardiac anatomy and electrogenesis of AFib, the progressive nature of AFib, and again, review the indications for rhythm and rate control and talk in detail about the procedure. We get written consent for the procedure at that time and provide lots of written information for them to go home with about what medications to stop, why it's so important to continue anticoagulation. And we'll give them an entire folder full of information about that. You know, AFib is increasingly complex. It's a difficult disease. And it's really not important to just review the risk benefits of the procedure. You know, I often started, when I first started, focusing just on the procedure. But we really need to talk further about why rhythm control is beneficial for them, not just for symptom improvement but also for the long-term, their long-term heart health. Knowing procedure success rates in advance really is crucial to help set realistic expectations because patients need to know that they may need more than one ablation. We also have to note for some patients who come back with recurrent highly symptomatic AFib, persistent AFib, success for them may not be defined as total freedom from AFib. It may mean that, you know, they have a significant reduction in their burden and resulting in, you know, less frequent and more manageable symptoms. And again, overall, better heart health. And, you know, we also talk about the subject for the potential for both early and late recurrences of AFib and the drivers of AFib recurrence. So, you know, talking about the three-month blanking period in the inflammatory process that takes place so we can help proactively manage expectations, especially if somebody were to come back post-ablation in persistent AFib and they may need a cardioversion. So we'll talk about medications that we prescribe to help with that inflammation, help with the promote healing and scarring over their lesions, and indication for short-term antiarrhythmics for some patients just during that blanking period to help them through and reduce symptoms. And always, you know, encourage our patients to reach out. You know, all patients are called post-op day one after the ablation and then they're scheduled to see us in the office for follow-up. You know, in follow-up, we do talk about long-term recurrence of ablation, you know, that pulmonary vein reconnection can occur. Patients can have other atrial arrhythmias that were either seen or not seen during the ablation. And we talk about our long-term monitoring process, which involves either, you know, monitoring them through their implantable devices or wearable monitors that they wear. We send them at three, six, and 13 months post-ablation. We talk, you know, talking about long-term management, we obviously talk about risk factor modification. And it's a lot more than just saying, hey, need to work on, you know, getting tested for sleep apnea or losing weight. It's more about talking about how that actually affects their heart health. You know, untreated sleep apnea can really increase atrial size and cause remodeling and contribute to recurrence. I know I've gone over my time. So, knowledge is power. If we can educate them, give them the resources to consistently manage their comorbidities, they feel more in control of their health and they're empowered to change them. Just on the last question, insofar as referring physicians, it's crucial to keep your referring physicians throughout the entire process. They need to be kept abreast of your outcomes, how their patient's procedure went, what are the research protocols that are going on. Give them notes, give them follow-up, and our physicians will even talk to them about, you know, how that procedure went, were there any findings that went on during that procedure that may put their patient at risk, such as, you know, incomplete pulmonary vein isolation and, you know, just keeping it in the loop so we are a cohesive team working together to help their patient. Sorry, it took so long. Thanks so much. Our next question is for Dr. Linda Odubani, Stanford. Describe your approach to shared decision-making conversations with AFib patients when anticoagulation, left atrial appendage obturator procedures, and other treatment decisions are being made. Thank you for inviting me for this panel. I think we're all struggling to get our atrial fib centers of excellence up to a standard of excellence. So I work in a practice that has nine providers, our faculty, and 16 APPs. So that might sound wonderful or it might sound ridiculous. So our shared decision-making process kind of varies by the literature standards, which is there is a lack of standardization, and it varies by provider. I think sometimes the shared part of the decision-making is left out, and the decision is already made before the provider goes into the room, and then they convince or persuade the patient to meet the goal of their visit. So I typically start the visit with, what are your goals of our visit today? Like, what would you like to accomplish in the time that we have? And then at the end, I typically conclude with, you know, based on our discussion, what are you willing to commit to doing? And their commitments often are not even recognizable to the conversation that we've had, but it gives me some sense for what they've heard. And I think a shared decision-making process should include goals of the consult, explain the pros and cons of the different decisions or the treatments, explain the needs for their participation in that decision, and then explain the, get an explanation from them on what their preferences are, what their values are, what's important to them, and then make the shared decision and implement. So you can see that that probably shouldn't happen in a single visit, because as Jerome and others have explained, the education piece is not in and of itself is what's going to empower them and allow them to be engaged. And if you try to do that all in a single visit, they can't see the deer from the headlights. So I think frequently see them often and try to get some information. I think most of the research that has been looked at in this patient population is around oral anticoagulation, and it was initiated in the time when patients had to be on INR monitoring and oral anticoagulation was not a simple tablet for patients to take. I think for patients that want to be very active or extreme sports people, it's still a big decision for them because they have to balance doing that with being able to continue their lifestyle and keeping themselves from having a stroke. So I think in most of the literature that we have to fall back on, it's in an era where maybe it doesn't look exactly like it does now, but we need to adhere to guidelines so patients need to hear that information. I think we're in an evolving field that's moving very quickly, so our information to patients needs to be updated on a regular basis, and that's why I think standardized information that you provide to patients by each provider in your group is really expensive and essential, and it is expensive. But I think it is essential, and I think the clinicians, patients, and also administration needs to buy into the value of shared decision making because it does take time, and it does take resources for the patient. I innovate, or I went to a bio-design conference on Wednesday, so I'm all about AI after all those talks, but I envision that in the future we'll be able to pull up their medical record and then pull up some of the data from their medical record and actually personalize their best decision or best preferences or treatments for them. I think that would just allow us to have so many more resources than we do now as far as adding to their personalized approach for what might be the best for them. I think we also don't have a good way to measure whether or not patients have felt engaged in, there are some measures, a decisional conflict questionnaire and decisional regret questionnaire, so hopefully we'll start to use some of those in a time out of time. So, thank you. Thank you. And our last panelist is Liz Greer, our patient representative, and her question is what does excellence in AF care mean from a patient perspective? Hi, I'm Liz. Just a little disclosure on me is I was an EP nurse for many years here at the San Diego VA, and I retired in 2018. I was the device nurse there, so I do, I've seen both sides. So, after I retired in 2018, I became the patient. So, I thought I was done with EP, and then I got AFib, so now I'm a patient of theirs forever, I guess. Excellence in AFib care, I mean, I was really lucky. I knew all the EPs, and I have their cell phone numbers, and I can go to them with any question I have, but it's still super different being a patient. I spent a lot of time educating patients and telling them what to do for their AFib and what signs to look for after an ablation, but when I became the patient, it was totally different. I was like, oh my God, I can't breathe when I'm walking up a hill, and I've only been two months after, and I didn't know what was going on, and luckily I called on the cell phone. I'm like, what's going on? Oh, let's get you some diuretics. So, I was really lucky, but I have a lot of neighbors and friends who've been through the same situation, and they say to me the same symptoms I had, they can't get anybody to return their calls. Or, you know, I've gone through the portal, and I've told them what's going on, and they say they'll get back to me in 48 hours. Well, so I think excellence in care is being able to get answers to your immediate questions without being told go to the ER for everything, and I used to tell patients go to the ER if you don't feel well, so now I've been on this side, and I'm like, oh gosh, I really don't want to do that. So, being able to communicate with your health care team, so if you're not there, you're the main contact, somebody else can get your portal messages, and just something in a timely manner. That would be really important. Talking about anticoagulation, I know these are joint decisions now, but that's a really, really hard one, too, because, you know, there's some things I really want to be interactive with and make decisions on my own, but that one's a hard one. I almost wish at times my docs would say, you need to be on it. I mean, because they're like, well, you know, you were CHADS 1 because you're a female, but then when I turned 65 a couple years ago, they're like, oh, well now you're a CHADS 2. I'm like, okay, well that means I need to be on anticoagulation, and they're like, well, it's really your call. I mean, that's right, you're not diabetic, and you're not this, and you don't have all the risk factors, and you don't have sleep apnea, so you don't have mechanical things, so it's really your call, and I'm like, oh my God. So, I'm still debating, and I think I'm going to lean toward anticoagulation, because the stroke risk, to me, outweighs my queasiness of being on a drug. So, I think just, you know, being communicative with your docs, and your nurse practitioners, and your team, and that's my main points. Okay? Okay, well, we've got some questions online, and please approach the mic if any of you have questions. We'll open it up now to the audience for questions. There's one. We have one for the whole panel. Do you have dedicated risk factor visits for AFib patients, and if not, how do you manage time constraints for risk factor discussions during a brief 20 to 30 minute clinic visit? Can you hear me? Oh, okay. That's loud enough. We don't have a, yet, a structured format for our risk factor management visits, but we do have a lot of freedom as APPs on our team. So, yes, I do schedule risk factor management appointments. So, whereas post-ablation, we have a very structured approach. We see folks at, post-AFib ablation, we see them at 3, 6, and 12 months. But if someone comes to that three month appointment, and I realize we have a lot of work to do on risk factors, then I'll schedule them to come back six weeks later, if they want to and they're willing to. So, yes, sometimes I will see folks as often as every six weeks to see if they're making progress. If their blood pressure is really poorly controlled, they don't have a PCP yet, or a general cardiologist yet, and I know I'm going to have to manage it in the interim, then I'll see them more frequently. So, under certain circumstances, yes, I do. I do. I think that we need more evidence around what is the right structure within our U.S. system, so all of the research and the randomized clinical trials that have looked at integrated care or comprehensive care, the successful approaches had frequent visits that were at least 30 minutes in duration. So every six weeks to three months and 30 minutes or more. So as we expand on our current staffing and our center, that's kind of the model that we're hoping to adopt, which is actual follow-ups at those three, six, and 13 months, rather than just a phone call about what their monitor showed. And using that as an option to identify other learning opportunities and talking about risk factors as well. And maybe just to add to that, so with my hat from Australia on, we have a dedicated risk factor clinic there, and there's like time intervals, like three, six, nine, and so on a month. But what we do in the beginning especially, we'll ask patients to come in more frequently, so almost every two weeks, to really get them started on their risk factor management and their lifestyle modification, because that is the crucial time that you want to do between brackets change management. So that's how we do that there. We have a question for Tracy. When you review post-procedure care, do you also discuss wearable personal monitors instead of the mailed short-term monitors if the patient asks you? Yes, many patients obviously are using wearable monitors. We currently don't have a method to, they haven't been true tested against extendable holters, so we do still stick with our holter protocol. But certainly if patients are having concerns or findings on their wearables, they send them to us either through the portal or we'll just talk to them after reviewing them on the phone. I'd like to add that I think it's really important to understand the difference between the PPG monitoring that you get with a Apple Watch or a wearable device and the ECG monitoring. So PPG is monitoring the pulse, not the heart rate, whereas the ECG is monitoring their heart rate. So when patients are reporting that they have, my heart rate's consistently less than 100, that can often be erroneous, especially if they're in a persistent or permanent AFib, if their pulse is, if they're in an RBR. So you're gonna get undercounting if the pulse is weak because the PPG is not gonna effectively account the pulse in that situation. So it's really important to educate patients about the difference between PPG, ECG, and to still, if you determine it's needed, still do some sort of clinic-based holter or CAM monitor. And then show that data to the patient. Pull up on their phone their same PPG period where it says your range is no higher than 120 and you show them the CAM and it's like up to 170. So that can help kind of like, you can actually pull up their Apple Health app if they have an Apple phone and show them for the same week and time. So I've found that helpful and a lot of folks don't understand the difference there. I mean, patient, from the patient perspective, non-EP nurse patient. And we have another question for Megan. How do you discuss all of the modifiable risk factors for AFib without overwhelming the patients? That's a great question. I just kind of touch on like, here's the things I would be talking about if you had diabetes and high blood pressure, we'd talk about that, but you don't have that, right? You know, so I just kind of like put it all out there so that they, I think they like the comprehensiveness of it to a certain degree. Of course, it's again, reading the patient, understanding each patient's ability, their health literacy, what might be too much for one person wouldn't be for another person. And sometimes you have to do it over multiple visits. But I like to hit on all the areas briefly so that I can assess their readiness. Now, I don't use a form or a specific readiness tool, but just trying to get verbal feedback, non-verbal feedback from the patient to see what they might be ready to address. So if they had two or three things that needed to address, the one I forgot to mention was alcohol. Shame on me, that's like one of the things I talk about the most, actually, is reducing alcohol. So if they needed to reduce alcohol, they were maybe exercising, but only three times a week for 30 minutes, and I want them to get up above 200 minutes a week, and they needed to lose some weight or something, then I'm gonna see which one they seem ready to change. If they're not gonna talk about alcohol, then I'm not gonna even push that, but I'm still gonna bring it up so that they know. Because then when they go home, they might think on it, they might contemplate on it. And then the fourth or fifth time I bring it up, then maybe they're ready to address that one. So I think it's just kind of briefly touching on all the things we could do to help you get control of this thing that feels out of control, and then working together with them, shared decision-making on what they might be ready to address, if that answers the question. Thank you. Okay, we have time for one last question. This is for the whole panel, so anybody, please chime in. What are your recommendations for a patient who has AFib with RVR if you're trying to avoid an ER visit? How do you handle that? Sometimes we'll actually bring them into the office and see if we can manage at that point. Sometimes those office visits do end up turning into an elective cardioversion, but it depends upon where they are after their ablation, because sometimes they just need more time to heal. If it's something that we can't manage in the office, we will, unfortunately, bring them to the ER to get admitted under our service. I think, too, it's important that they recognize that being in a rapid heart rate is not life-threatening. It is life-scary. But I think giving them some tools or strategies to help bring their rate down. I do a lot of deep breathing, meditation, and I tell them that they should practice that when they're not in Atrial Fib, so that it's a tool that they would be able to access when they need it. I think they should have discussions about maybe pill in the pocket or rate control strategies that they can try before they automatically go to the emergency room. So I think their first time they go into Atrial Fib with RVR, they're not on any medications. So that first visit to the ED is imprinted in their memory. And you need to help them identify that they're now on a different medication regimen, and so it's unlikely that's gonna be repeated. But give them some very specific reasons why they would go to the ED, chest pain, shortness of breath. Otherwise, they can wait it out. So I think just giving them some strategies is really important. I think, Linda, to add to that, I think that's a really important point that you just raised. Also an important aspect of self-care and education for patients to how to recognize what can I do myself. In Australia, we worked with personalized action plans for people that they could follow during an episode of AF, which gave patients, it reduced anxiety, and especially what you just said, it's not a life-threatening emergency that you have to go to ED, because in Australia, we were dealing with ramping at ED. So that was the other issue, to keep them safe out of hospital. So what we taught them is that if you recognize your symptoms from a previous episode, then follow your action plan, see what happens, what Linda just said, sit it out. If that doesn't work, you can still contact a hospital, but in first instance, we try to prevent hospitalization. And just by the way, that's exactly what my doc did with me. ER the first time, he said, if you go to the ER more than two more times, I'm gonna refer you for ablation. I said, well, I'm not going two more times. So he said, okay, then we're gonna do pill in the pocket. And that worked until I went for ablation. That was a great approach. I actually love, Liz, that you said an excellent AFib care is when you get an immediate response before you go to ED from your team. I think that gives us all something to strive for, because the healthcare systems are getting more and more difficult to actually access a person. So I think we just need to remember that. That was a great point for me. Okay, maybe we can get another question in. We have a question I'll throw out to the whole panel, or D, maybe you wanna take a tab at this. How do you best utilize your RNs in an outpatient clinic setting? Are they seeing patients in the clinic? So in our current practice, the nurses, we do have some nurse visits, specifically pertinent to the question that was just asked, for, we do have assigned nurse visit slots. Recently we had a patient who, she was elderly, 80 plus. She had been out of rhythm for at least two days. We have actually several patients who live very far from Atlanta, so from the city. And she drove to her sister's, and then finally came to clinic. In that case, so we do encourage walk-ins in our clinic. And if there's no time on a provider's schedule, they automatically get put on the nurse's schedule. So we did an EKG. We actually can give some oral medication in the clinic. If that obviously doesn't work, then we send them to our outpatient procedure area. She ended up getting a cardioversion the same day, so. It's a little tricky because our center is in the city, and we have several patients who live miles away. So sometimes, if all else fails, you have to send them to the ED, to their closest ED, to get that immediate care. Do you have nurses that are designated as the clinic appointment nurse for the day? So they kind of have that time set aside. They're not like, or is it just like, it's just like an app. It's just like they have to drop everything in. Yeah, we have two dedicated EP nurses. But yeah, they are triaging all the messages that come through our call center. Yeah, so they don't have dedicated. We actually have a couple extra minutes, so we're gonna keep going through these questions because we have a lot of good ones here. Do any of you use group patient visits in your practice, especially in regards to lifestyle modification like diet and exercise? What I know of is that in Sweden, for example, in Europe, they have edufibrillation education classes, but that is like broader than only lifestyle. That's really talking about what is edufibrillation, what does that mean for the patient, but also for the carers? What can you expect regarding treatment and these kind of things? But that is specifically general education information, so to speak. All right. So many good questions, it's hard. All right, here's another good one. As an RN in general cardiology, how can I support patients while they're waiting for EP? General cardiology is often the first to diagnose AFib. Any recommendations? Give them a plan for what to do if they go into AFib so they can avoid the ER. Like maybe work with the general cardiologist to come up with a PRN metoprolol tartrate or diltiazem approach that the patient can use if they have paroxysmal or even persistent. And then every system's different on how long it takes to get a cardioversion. But I don't like to send people to ER for cardioversion because you never know if the ER docs are gonna actually wanna cardiovert. It really varies by hospital and even by provider within the same hospital. So I think just giving them some planning, even bringing up some of the lifestyle things. Making sure that their blood pressure is optimized because that's within the scope of general cardiology. Smoking cessation, and I mean diabetes, that's not really in your scope as much as high blood pressure. But I doubt you have the time in general cardiology as an RN, but any of the lifestyle stuff. I think the more people hear it, the more people they hear it from, the more likely folks are gonna realize how important it is. So and the earlier we can introduce it, the better. And just utilize all of the educational resources that you have at your institutions. There's a lot of AFib management, shared decision-making tools that are available. Medication information packets. So arm them with knowledge so that, again, they can work towards managing that and understanding it and feeling more in control of it while they're waiting to see someone in electrophysiology. I think to that point, too, there's a lot of good information on the web and there's a lot of bad information on the web, but most patients are going to the web to look for information. So even giving them reputable sources for information, web-based information, to prepare for their EP visit. So encourage them to visit the American Heart Association website, obviously the HRS website. I send people to Mayo Clinic's website a lot because they have a lot of good patient-facing education materials. So they can prepare and be more knowledgeable before their appointments. To piggyback of that, I'd like to give a shameless plug for Upbeat TV. We're coming out with Upbeat, well, there's the website already, but Upbeat TV is a separate YouTube channel that will have patient-friendly education. So I think it should launch, I want to say July of this year, and our first topic will be AFib. And how do you manage patients who are non-compliant when they show to follow-up? Yeah. Reinforce, repeat, re-educate, and support, and try to identify what's causing them to not want to work on whatever that is that they need to work on. Yeah, and I think trying to use some motivational interviewing with them, like what are the barriers keeping you from achieving your goals, or are they still your goals? So helping them redefine what's important, because they kind of lose motivation, and so you have to remind them of the value, but then also work within, maybe like eating is a big social family event, so trying to then maybe get the entire family to make some changes. But you gotta meet them where they are. I think, too, motivational interviewing is so important, and the trauma-informed care approach, so a lot of folks who would get labeled as non-compliant, they might have a lot of trust issues with the healthcare system, they might have other barriers in their life, social determinants of health. I currently am working with a patient who has a lot of mental health concerns and traumas in her life that have led to some of those, and so we've been meeting every six weeks because she has been non-compliant with heart rate controlling medications, and her heart rates are constantly like 150. But her goal is to be able to go to Orange Theory, where they flash your heart rate up on a public screen, and she gets embarrassed, so she won't go, because she doesn't like how fast her heart rate is. So that's the goal we're working on, is getting her heart rate down, and understanding that that's her motivation. We've made a lot of progress over four, or five, or six visits. She's finally consistently staying on a beta blocker. We had to take an alternative approach and use digoxin, because she's just not willing to go higher, but she still wants her heart rate down. She has low ejection fractions, so I can justify trying to digoxin for her with the heart failure history. So personalizing your approaches, understanding their goals, and also considering that sometimes, like trauma and prior negative experiences with healthcare providers can really be barriers to people trusting you and trusting your advice. Okay, before we wrap up, I just want to bring to everyone's attention, this was put online today out of Heart Rhythm, the criteria for the establishment of an AFib center of excellence, and key operational standards. So this may be very helpful in those of you who are trying to set something up, improve your standards. I think that brings us to the end of our session. Thank you so much for attending. Appreciate it. Panelists. Thank you.

Atrial Fibrillation

Patient-Centered Care

Integrated Approach

Digital Platforms

Patient Engagement

Lifestyle Modification

Shared Decision-Making

Patient Education

Healthcare Collaboration