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A dedicated cardioversion unit for the treatment of atrial fibrillation

Reducing costs by optimizing processes

Aufbau einer Spezialambulanz zur ambulanten Kardioversion von Vorhofflimmern

Kostenreduktion durch Prozessoptimierung

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Abstract

Background

Atrial fibrillation (AF) is the most frequent arrhythmia seen in man. Many patients are admitted to the hospital to undergo transesophageal echocardiography (TEE) for thrombus exclusion and subsequent electrical cardioversion (ECV) under deep sedation to restore sinus rhythm. The present study investigated prospectively how workflow optimization can contribute to reducing time and costs in AF patients scheduled for ECV in an outpatient setting.

Methods

A cardioversion unit (CU) was established and equipped to perform all ECV-associated procedures. Between November 2007 and January 2009, ECV was performed in 115 patients in an outpatient setting. Three different settings were tested for ECV: (1) usual care (n = 19): preparation/follow-up in the outpatient clinic, blood testing in the central hospital laboratory (CHL), TEE in the echocardiography laboratory, and ECV in the intensive care unit; (2) optimized process 1 (n = 41): preparation/follow-up, TEE + ECV during one sedation in the CU, blood testing in the CHL; (3) optimized process 2 (n = 55): preparation/follow-up, TEE + ECV and point of care (POC) blood testing in the CU. All procedure-related costs were listed and classified according to material, human resources, and infrastructure.

Results

From setting 1 to 3, there was a significant decrease in procedural time from 480 ± 105 min to 205 ± 85 min (p < 0.001). Likewise, ECV-associated costs could be reduced from 683 ± 104 € to 299 ± 63 € (p < 0.001).

Conclusion

Establishing a CU for AF enables a more than 50% reduction in procedural time and costs. A combination of TEE and ECV in one sedation and POC testing in the CU were the major contributors to this time and cost reduction.

Zusammenfassung

Hintergrund

Vorhofflimmern (VHF) ist die häufigste Rhythmusstörung des Menschen. Als eine mögliche Strategie wird bei einem Teil der Patienten versucht, einen Sinusrhythmus wiederherzustellen. Hierzu erfolgt oft ein Thrombusausschluss per transösophagealer Echokardiographie (TEE) mit anschließender elektrischer Kardioversion (EKV) in Kurznarkose. Da eine stationäre Aufnahme zur Behandlung von Patienten mit VHF oft mit hohen Kosten verbunden ist, sollte dies im ambulanten Bereich erfolgen. Ziel dieser prospektiven Studie war es zu untersuchen, wie unterschiedliche Konzepte und eine iterative Prozessoptimierung einer spezialisierten Ambulanz für EKV sich auf die verursachten Kosten auswirken.

Methodik

Eine Spezialambulanz (Kardioversionsambulanz, KA) wurde zur Durchführung ambulanter, elektrischer Kardioversionen technisch und personell ausgerüstet. Zwischen November 2007 und Januar 2009 wurde bei 115 Patienten eine ambulante EKV durchgeführt. Drei unterschiedliche organisatorische Abläufe wurden konsekutiv getestet [historischer Ablauf (n=19): Vorbereitung und Nachsorge in der KA, Blutanalyse im Zentrallabor, TEE im Echokardiographielabor und EKV auf der Intensivstation; 2. optimierter Ablauf 1 (n=41): Vorbereitung und Nachsorge in der KA, Blutanalyse im Zentrallabor, TEE und EKV im Rahmen einer Kurznarkose auf der KA; 3. optimierter Ablauf 2 (n=55): Vorbereitung und Nachsorge in der KA, Blutanalyse (Elektrolyte, Gerinnungsstatus) per „point of care“ (POC) in der KA, TEE und EKV im Rahmen einer Kurznarkose auf der KA]. Alle mit der Prozedur verbundenen Material-, Personal- und Infrastrukturkosten sowie Zeiten wurden dokumentiert und ausgewertet.

Ergebnisse und Schlussfolgerung

Durch die iterative Umsetzung vom historischen Ablauf zum optimierten Ablauf konnte eine signifikante Reduktion der Dauer einer EKV von 480±105 min auf 205±85 min (p<0,001) erzielt werden. Gleichzeitig zeigte sich auch eine Abnahme der mit der EKV verbundenen Kosten von 683±104 Euro auf 299±63 Euro (p<0,001). Der Aufbau einer speziellen KA zur Durchführung von EKV bei VHF führte somit zu einer mehr als 50%igen Reduktion von Zeit- und Kostenaufwand. Die wichtigsten Einsparungsfaktoren waren eine kombinierte Durchführung von TEE und EKV innerhalb einer Sedierung sowie die POC-Blutanalyse in der KA.

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Abbreviations

AF:

Atrial fibrillation

AFL:

Atrial flutter

CU:

Cardioversion unit

DRG:

Diagnosis-related groups

EBM:

“Einheitlicher Bewertungsmaßstab” (uniform assessment standard)

ECV:

Electrical cardioversion

ICD:

Implantable cardioverter–defibrillator

ICU:

Intensive care unit

ICD-10-GM:

International Classification of Diseases, German Modification

INR:

International normalized ratio

IV:

Intravenous

J:

Joule

n.s.:

Not significant

POC:

Point of care

TEE:

Transesophageal echocardiography

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Acknowledgment

We are especially thankful to Inge Hoesch and Daniela Mock who carefully registered patients, equipment used, and time spent.

Conflict of interest

The corresponding author states that there are no conflicts of interest.

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Authors and Affiliations

  1. Department of Cardiology, University Hospital Maastricht, Maastricht, The Netherlands

    C. Knackstedt & H.P. Brunner-La Rocca

  2. Department of Cardiology, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Deutschland

    M. Becker, K. Mischke &  P. Schauerte M.D.

  3. Financial Controlling, RWTH Aachen University, Aachen, Deutschland

    R. Pauling

Authors
  1. C. Knackstedt
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  2. M. Becker
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  3. K. Mischke
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  6. P. Schauerte M.D.
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Correspondence to P. Schauerte M.D..

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Knackstedt, C., Becker, M., Mischke, K. et al. A dedicated cardioversion unit for the treatment of atrial fibrillation. Herz 37, 518–526 (2012). https://doi.org/10.1007/s00059-011-3546-0

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