Case Selection and Patient
Throughput Techniques
Marsha Jones, BSN, RN, CCRP
Disclosure Statement of Financial Interest
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Agenda
• Screening and Pre-Procedure Evaluation
• Tools for Case Selection
Referral to Treatment Timeline
48-72 hours
7 days
10 days
Patient/MD
contacted
Consult with TTE
if needed
Obtain done
studies locally
Additional
workup (Baseline
brain imaging,
neuro
assessments)
Presented
w/treatment plan
in place
Pre-auth initiated
Scheduled for
pre-procedure
visit
Within 14-28
days
Patient is
treated/TEE
done on table
Referrals and Scheduling
• Live scheduler/ coordinator receives all
referral calls
• All outside records screened for:
– LAAO suitability
• Diagnosis of atrial fibrillation
• Notes of prior OHS, obtain operative reports
• Does patient meet CHADS/CHADS-VASc requirements
for procedure
• Will tests need to be ordered at time of
consult or have they been done by referring
physician?
Initial Assessment
• History and Physical exam with emphasis on:
• Type of Atrial Fibrillation
• Onset of diagnosis
• Presentation at onset
• CHADS/CHADS-VASc score
• Patient’s functional abilities (Barthel index, Rankin
scale assessments)
• Is the patient on anticoagulant therapy currently?
• Review: TTE, Labs (Labile INR, anemia, blood
transfusion history, liver function, zio study,
pacemaker interrogation readings
• Note dates of prior ablation, cardioversion
CHADS2 Score
Item
Congestive
heart failure
Hypertension
Points
CHADS2
Stroke rate (95% CI)*
1
6
18.2 (10.5–27.4)
5
12.5 (8.2–17.5)
4
8.5 (6.3–11.1)
3
5.9 (4.6–7.3)
2
4.0 (3.1–5.1)
1
2.8 (2.0–3.8)
0
1.9 (1.2–3.0)
1
Age
≥75 years
1
Diabetes
mellitus
1
Stroke/TIA
2
Add points
together
*Per 100 patient-years without antithrombotic therapy
Gage et al, JAMA 2001
CHA2DS2-VASc:
A further refinement of CHADS2
Risk factor
Congestive heart failure/LV dysfunction*
Hypertension
Age ≥75 years
Diabetes mellitus
Previous stroke/TIA/thromboembolism
Vascular disease (MI, aortic plaque, peripheral
artery disease)#
Age 65–74 years
Sex category (female)
Maximum score
Points
+1
+1
+2
+1
+2
+1
+1
+1
9
*Left ventricular ejection fraction ≤40%; #Including prior revascularization, amputation due to peripheral artery
disease or angiographic evidence of peripheral artery disease
Camm et al, Eur Heart J 2010; Lip et al, Chest 2010
Many Stroke Risk Factors Are Also Risk Factors
for Bleeding
Risk factor
for stroke*
Risk factor for
anticoagulant-related
bleeding*
Advanced age14


History of hypertension1,3,4


History of MI or ischemic
heart disease1,3


Cerebrovascular disease1–4


Anemia3,4

Previous history of bleeding3,4

Kidney or liver dysfunction4

Concomitant use of antiplatelets3,4

*Not exhaustive
The relationship between stroke risk and bleeding risk complicates
the evaluation of benefit–risk
1. Lip et al, Chest 2010; 2. Hylek et al, Ann Intern Med 1994; 3. Hughes et al, QJM 2007; 4. Pisters et al, Chest 2010
HAS-BLED Score
Clinical characteristic
Hypertension
(SBP >160 mm Hg)
Abnormal renal or liver
function
Stroke
Bleeding
Labile INRs
Elderly (age >65 years)
Drugs or alcohol
Cumulative score
Points
1
1+1
1
1
1
1
1+1
Range 0−9
Pisters et al, Chest 2010
1-Year Risk of Major Bleeding Increases
with HAS-BLED Score
Score
No.
No. of
Bleeds
Bleeds Per
100 Patient-Years
0
798
9
1.13
1
1286
13
1.02
2
744
14
1.88
3
187
7
3.74
4
46
4
8.70
5
8
1
12.50
6
2
0
0.0
7
0
-
-
8
0
9
0
-
Pisters et al, Chest 2010
Barthel Index
Rankin Scale
Obtain Authorization
• Give complete clinical picture of patient in
consult note
• List CHA2DS2-VASc score
• List patient specific risk factors for bleeding
complications
• Conduct peer to peer reviews over phone first
then appeal only if denied over phone
• Keep patient and family informed of status of
authorization
Obtain Authorization
• Provide FDA approval letter
•
•
•
•
Watchman is not an investigation device
Established safety and efficacy
Physician procedure code (33340)
Baseline TEE code (CPT 93312)
Obtain Authorization
• BSC reimbursement tools and resources
•
•
•
•
Procedural (02L73DK) and diagnosis code
Watchman reimbursement guide
Pre authorization and appeals templates
Physician category III code guide (0281T)
The Pre-Op Visit
• Diagnostic/assessments:
• Pre op Labs-important for registry Hemoglobin, Creatinine
and Albumin
• Patient instructed to hold anticoagulant (warfarin) for 3 days.
INR ~ 2.0 or less
• NOACs held for 48 hours
• NPO for 8 hours
• Hold meds on morning of procedure except inhalers which
should be used
• Assess for infections/injuries that may affect recovery
• Review procedure booklets, procedure animation
Pre-Op Points to Ponder
• Change NOAC to Coumadin 5-7 days prior to procedure
• Anticoagulation: to hold or not to hold
• Meds to be held on morning of procedure (inhalers, HTN
meds, antiplatelets, etc)
• NPO for 8-12 hours
• Assess for infections/injuries that may affect recovery
• TEE in echo suite or on table in lab
• Foley intra-procedure: yes, no, maybe so
• Central line vs peripheral IV
• A-line
Procedure Considerations
•
•
•
•
General anesthesia required with TEE
IV antibiotics prior to start of procedure
Patient is heparinized with goal ACT > 250
Procedure requires contrast, schedule on non
dialysis days
• Foley catheter, yes or no
• Single Perclose for groin hemostasis
• Device prep by trained staff
Procedure Considerations
• Scheduling cases in blocks of 3 or 4 works best
• Patient should arrive at least 2 hours prior to start
time
• Have electronic orders entered in EMR or paper
orders done prior to patient arrival to hospital
• Make sure sufficient device inventory is present
• Staffing to allow for device prep
• Trained cardiac anesthesiologist and
echocardiologist
One Day Hospital Stay
•
•
•
•
•
Extubated in cath lab
Central line Dc’d
Telemetry unit
4 hour bed rest
Resume warfarin
Post-Procedure: Patient Care
• IV hydration 4-6 hours. Hydrate to reduce
renal injury but avoid volume overload.
• Antibiotic therapy (one dose prior to start of
procedure, two doses post procedure given at
6 and 12 hours post).
• Chloraseptic spray
Summary
• Scheduling efficiency leads to growth of
program and number of patients treated.
• Careful attention to pre and post procedure care
is critical to procedural success.
Questions?