Good morning, and again, thank you guys so much for joining us, and thank you to Atricure for putting this amazing program on. I am an EP nurse practitioner by training, but recently I've transitioned to the dark side of administration, so I wear both hats, and that's given me a different appreciation for programmatic development, certainly. But this morning, we spent a lot of time talking about the hybrid procedure and patient selection, and we're going to continue to spend a lot of time talking about that, but I think we would be remiss if we didn't stop for a moment, come up a little bit for air, and recognize that this procedure is an amazing tool to offer our patients, but we have to determine the best way to get patients through our system if we're going to make our program successful and have efficient throughput. So we're going to spend a little bit of time talking about how we at Norton Healthcare have developed an algorithm for optimization of patient care, and I think any time that you're talking about optimizing something, you have to have a very frank realization that something that you're doing is suboptimal. So really what you're looking at is identifying what is the problem that we are trying to solve, and sometimes it's not just about identifying the problem, but also recognizing there's a lot of things around that. So really, when you're trying to identify what is this problem that we have, but also from a strategic standpoint, how does solving this problem align with what our strategy space is? Do we have a strategic initiative that says we need to improve throughput of our patients through our ambulatory clinics, through the hospital, from a care pathway standpoint, and aligning those things to bring it into more of your opportunity space. What is the opportunity that we have to improve something? And in that frame of mind, going towards your solution space. So from a strategy space, what is your health care system business goals, strategic vision? Do you have KPI and symptoms that you need to look at? What are those metrics and targets that you're trying to improve, and how does that align with what your problem statement is? Who has the issue? What is the goal? And why is it no longer acceptable to continue status quo? And then looking at, okay, we need to solve this problem because what is the value that we're trying to improve? And what are those? It may not be a problem, it may be a design challenge. Maybe that care pathway design is suboptimal. But it's important to not only think about from a provider standpoint, from a staff standpoint, from a health care system standpoint, what is in it for you to solve that problem? And that aligns with your strategic vision, your metrics, things like that. But also, what is in it for those with the problem? And I think as a clinician, that clinician hat that I wear, is that's what's to me the most important, is we have patients and a continuing growing volume of patients that have this disease state. And what is in it for them, or my family member too? Are we getting them through the process well and efficiently? And so, for us, we had to take a very hard look at what we were not doing well. And we had a lot of ineffective care pathways surrounding our patients with AFib. Biggest issue was prolonged wait times for appointments. Our patients were coming to us and we were saying, great, we are happy to see you. You can get an appointment in four to six weeks. And that was not very palatable to the patients, nor to us who are trying to improve access to care. We also are identifying that there are a lot of unnecessary admissions to our emergency department for patients with otherwise stable AFib. We want to treat their AFib, certainly, but do they truly warrant admission for a diagnostic stress test and an echo? So what were our opportunities to help reduce that? But really taking a frank look at who was at fault for that. I think a lot of times it's easy for us to blame that on our emergency medicine colleagues, but recognizing that perhaps we have not provided them with the guidance of the best way to treat these patients. So it's not just you all need to do better, but also how can we help you do better and how can we help partner with you at the elbow and educate you on how to get patients through the system or how to refer their patients appropriately and not necessarily admit them. But we recognize that because we did not have an established emergency medicine protocol for AFib patients, that's why so many of them were getting admitted unnecessarily. So what we did was, Dr. Kent Morris, who you guys will hear from later, is our EP physician champion, as well as myself, and working with the emergency medicine colleagues to identify, okay, what do you feel like are the gaps and what are your concerns and reservations? And matching your protocol to the aggressiveness that your ER physicians are willing to accept. In our minds, we had this brilliant, great multi-page protocol that addressed everything, but then recognizing that they may not be as aggressive as we would be necessarily with this because they're not as comfortable with it. So we don't want to make a protocol that's super aggressive that they are then not going to implement because it's too aggressive, too long. We learned one page is best. You got one page, one shot to do that. And then also bringing them again to the table when we're talking about this process. But you also have to engage general cardiology. I think a lot of us come from systems where we have multiple facilities and multiple hospitals and why we would like to be able to be available all the time in every facility. That's just not reality. And a lot of times with emergency medicine colleagues, their instinct is going to be to pick up the phone and call the cardiologist because that's who they typically do. So if the cardiologists don't buy into this idea and this pathway, it's going to take a couple of phone calls to the doc before they say, okay, well, they're not even agreeing with what their own partners are doing. So I'm just going to throw this protocol in the trash can. But really what this and laying the groundwork for this did for us was it helps to get direct to EP referrals for AFib. We were trying to eliminate that step where patients with AFib go and sit on amiodarone for years and years and years without an attempt of actual ablative therapy. So we really wanted to try to open that door between our emergency department and then further down the road primary care to get patients directly to EP for that. So creating this AFib protocol and launching this with our emergency department is really what paved the way for us to develop an atrial fibrillation clinic. Now there's been a lot of great work. I love this study that came out of Ohio Health with Riverside and looking at a dedicated AFib clinic and how much impact that has on your diagnosis to ablation time. What was so interesting about this was one, not just the data and the significant reduction of diagnosis to ablation time using an AF clinic pathway versus your traditional EP clinic pathway is that it's the same players. You largely have the same team members staffing your general EP clinic and your AF clinic. So it's the same people. We know the same data. The difference is care pathway. You've designed a more streamlined pathway for that patient to get into your EP program and delineate that patient to the most appropriate therapy. Now while this looked at catheter ablation, one thing that we know is that as we continue to grow our AFib patient volume and we start to strategize them to treatment, catheter ablation, that also introduces then hybrid ablation because the more AFib patients we identify and we start treating, then naturally we're going to feed our hybrid program as well with these patients that need and deserve this therapy. So I'm going to now turn it over to Dr. Peterson, our cardiothoracic surgeon, to kind of talk about from his standpoint what's been helpful in that throughput for hybrid patients. Hi. Good morning. You can tell Tara's already been part of the dark side because she has all the verbiage from administration. From a more clinical standpoint, I know that's the only reason why I'm here because you could give this whole talk without me and better. But part of this was we were trying to figure out the best way that we can help manage these patients, get them in to see me, so we start talking about hybrids, doing convergent back in 2016, 2017. So we're at the point now where we want to make sure that we have scheduling coordinators and one of the pathways was, and for patient satisfaction, was making sure that they all had their appointments scheduled, that they came in to see me, that some of these procedures, kind of the standard stuff like CT or MRI for even if they've had multiple previous ablations, basic stuff about getting TETs or TEEs to diagnose to make sure they don't have severe structural issues or something else. We get ischemic. A lot of that stuff is already taken care of now before they even come to see me. For some patients, depending on their symptoms, I may want to order a couple extra things if I'm worried about it or a specific type of testing. But generally, there's been a great job of trying to put all these patients in a bow so when I see them, we can get them straight through my office, get them scheduled for surgery in a reasonable time period so that then the long delays of two to three months are kind of avoided. So you can see some of the basic stuff we do is EKGs. This is all kind of routine stuff, the basic PrEP labs and anticoagulation status. And kind of tying back into what someone had mentioned earlier this morning, you know, to me, one of the best things about taking the left atrial appendage as part of this, we've been doing it from the very beginning, was theoretically we can get them off their anticoagulation. Most of the patients that come to me are like, well, this is great, but can I get off my blood thinners? Can I get off some of these meds? And we have a long discussion that this is not something that will happen emergently or immediately, but within hopefully six to nine months as a combined decision-making process with the patient and their EP docs who see them back in follow-up, that hopefully if, you know, if they're in sinus rhythm, if on the secondary TEE during the endocardial portion the clip is in a good place and everybody's happy, that yes, you may be able to get there. So for what we are now is generally, although we have had some self-referrals that show up in my office, the majority of our patients come through the electrophysiologist. And when I say, when we have EP here, that really means EP and APP, because I would say now that we have the initiation of our AFib clinic, probably 60% of those patients now are seen primarily by their APPs who have the approval from their EP MDs that they work with and to go ahead and make these initial referrals instead of having them see the APP, then have to see the MD EP, and then come see me. So that has really tightened up our process. So you see, I get to see them in the office. We schedule their first stage, the epicardial stage, because I've kind of gotten away from using first stage because even though we do a lot of de novos, you know, sometimes they've already had an endocardial portion. So in my verbiage and my notes and stuff, I now call it epicardial stage just for that reason, even though, you know, for us most of the time it's the first stage. We also then set up their four-week follow-up with my PA who's back there hiding in the corner who does 90% of these cases with me. So he gets to see them on their first post-op visit to make sure all their incisions, everything's healing up. And part of his workup is also to make sure that they have their follow-up appointments scheduled, that they've been checking their MyChart, et cetera. So we then get the EP follow-up in six weeks, and that's usually MD, always MD. Then they get the endocardial stage, and the TE at that point to confirm that, yes, I did put the clip in the right place, and we didn't theoretically knock out the circumflex. They then have their follow-ups at six weeks, 12 weeks, and then ongoing EP follow-up following that. These little marks is where we were having the problems, as I kind of discussed, as far as getting people into the system. One of the first initiatives we kind of discussed, one of the big holdups was trying to get these folks from EP in to see me in a timely fashion. I think we've kind of addressed that already. And then a lot of times, depending on who was sending them, whether they were coming from the APPs or coming directly from the MDs, there were some issues as far as getting some of our pre-op testing. That was another hurdle we were able to overcome. Initially as we were first kind of getting this program set up, one of the things was we were getting the first or the epicardial stage scheduled in the operating room. The four-week follow-up wasn't a big deal, but we weren't getting the second or the endocardial stage scheduled appropriately, and so sometimes if there was a delay in getting their EP follow-up, then all of a sudden their endocardial portion was being pushed out even further. And so that was one of the big things that we, as a team, sitting together on our conference, was working out is like, how can we make this better? What can we do differently? So that was a big, big improvement. So this is kind of where we started was our plan, and you can see we had a lot of pitfalls. Part of what we're going to try to talk about now is how we overcame that stuff. So I think, and to go back to this slide here, as it relates to that efficiency of patient throughput, like not only does this help keep the procedures in line with kind of what you clinically want the patient to come in with a certain period of time, but also from a patient satisfaction standpoint, just so that they know kind of what is next. As Dr. Peterson mentioned, initially we would just schedule the endocardial stage, and then like once that was done, then we'd work on everything else. And our EPs are very busy, and that was causing a lot of delays. And so I will always give credit to Karen Martinelli and her team, who you'll hear from here after we're finished, about basically getting all of this scheduled on the front end. So the minute that that first stage is scheduled, then you have all of the subsequent follow-ups scheduled as well. It really helps eliminate a lot of the kind of confusion from the patient standpoint. It's a huge patient satisfier and helps eliminate some of the call burden to the office for patients calling and asking, okay, I had this done, what's next, what's next, what's next? So this was a huge patient satisfier from our standpoint. But you know, to kind of go back to the beginning and what we talked about as far as like identifying what are our opportunities to improve AF care, which led to the development of our ED protocol, which then led to the development creation of a dedicated APP-run AFib clinic that is a direct feeder into our hybrid program. It makes it sound like that's the order that we did it in and it was all perfect and happy and it was great and everyone won. And that is not at all how it went. We actually did this completely backwards. We launched our hybrid program and then we thought, okay, we have some opportunities to improve patient throughput here. And one of the things that we were recognizing was that there was a significant, you know, we launched and then we just were a bit stagnant and we weren't getting that volume and growth that we knew we had the patients for. So that's when we really had to take a step back and say, I don't know that we've optimized how our patients are getting into our system and how we're getting them through their AFib treatment journey very well. That's when we had to come back to the table and say, okay, this isn't working very well. We need to create these pathways and protocols to get the patients. And then when we did that and executed that, that's really when the volume of hybrid referrals really started to increase significantly. Now, that doesn't mean that we kind of built the plane and threw it in the air and never had to do anything for it again. It is a continual process of having touch points and conversations around what's working, what's not working. And the fire alarm is working today. But I think that really when we did that and we created those pathways is really when that volume started to increase and our hybrid program grew significantly. And I'm going to turn it back over to end with Dr. Peterson. I would love for him to speak briefly on the importance of that cross-disciplinary collaboration and the benefit of that. So two things. One, I think one reason for some of our success is that from the very beginning we sat down as a team, myself, my PA, and the EP docs and their APPs and talked about how we wanted to build this program, what we thought was important, how it was going to go, et cetera, and have continued to have these meetings where not only do we sit down and discuss pathways and stuff, but we actually discuss patients. We put up maps, which as a surgeon had never really seen before. To me, they all look like Russia. So I like to see Russia when they put my part up because I feel like, okay, I did a really good job. But in the beginning, you put up and it looks like a teeny little triangle and you're just like, huh, I need to do more. I need to do this better. I need to be more precise and have a better understanding of what it is I'm doing besides sucking a catheter to the back of the heart and running us and then telling jokes for 90 seconds. So that was a huge big deal for us as a collaboration, just being able to speak at the same language and understand their language as a surgeon because I didn't really get it. I mean, I loved AFib, but until you sit down in these conference and really start having more communication and more understanding, they kind of understand, like they'd never seen pericardial reflection. So we put that up and they're just like, oh, wow, that's why it looks like a witch's peak or sometimes it looks like a square. I get that now. So I think those were really important. Secondly, for us, I think the success also is we spent a lot of time educating our cardiology and APP and primary care partners in our, as part of Norton Healthcare because for a long time, as we all know, there really wasn't much to do for longstanding persistent AF. And then all of a sudden we're like, hey, wait, send us all your longstanding persistent or your persistent AF. And so that was an education process. We started doing these cases and a lot of the general cardiologists and even the interventional cardiologists are like, wow, you did this epicardial ablation and it failed this patient's back in AF. And it was a de novo patient. It's like, well, yeah, he still has open circuits. Of course he's still in AF. So they would call it, say, oh, well, this was a failure and we're like, no, it's not a failure. He's just not, hasn't had the second part done yet. So there was a lot of education that had to take place. I think we all as a team spent time in front of our partners doing slideshows and presentations in the evening and dinners and all that stuff at department meetings saying, here's what we're doing, here's what it's working, and educating them as well as what does it mean to have a convergent or a hybrid ablation. So I think those were the two big things that really kind of helped push us along because then once we had more buy-in from the other APPs, from the other cardiologists, you know, that stream of patients coming directly into AF clinic, you know, dramatically increased. So did I cover it? Okay. Anyway, it's a great program and I think this is a really excellent, reproducible, safe procedure from a surgical standpoint. So I wish you guys all luck.

Atrial Fibrillation

Patient Care

Inter-disciplinary Collaboration

Program Development

Norton Healthcare

Patient Satisfaction