August 7, 2023 • 28 mins
In episode 15 of the CardiOhio Podcast, we focus on the role of the cardiovascular team to create innovative programs, and improve patient access and outcomes. We are joined by Andrea Robinson, CNP at OhioHealth and current CV Team liaison for the Ohio ACC Chapter, as well as Kelly Bartsch, PharmD, a Specialty Practice Pharmacist at The Ohio State University. We discussed several innovative programs led by the CV team, including a unique walk in ambulatory clinic for atrial fibrillation.
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Episode Transcript
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(00:08):
So welcome back to the CardioHigh Podcast.
We have a very special topictoday.
We're gonna be focusing on thecardiovascular team.
We'd like to talk a little bitabout using the c v team members
to extend cardiac care, helpimprove outcomes, increase
patient satisfaction as well.
(00:29):
I have the pleasure ofintroducing a couple of guests
who are pretty well known.
I think to our Ohio listeners,they're both C B T members that
have been involved in the Ohio.
Chapter quite a bit recently.
First, I'd like to introducefrom here in Columbus Andrea
Robinson, who's actually thecurrent liaison for our Ohio
(00:51):
chapter for the cardiovascularteam council.
Andrea, welcome.
Thanks, Kenny.
It's a pleasure to be here and Iam excited to talk about this
opportunity with cv, teamliaison and leadership.
Thank you.
Yeah, welcome.
And then I'd also like tointroduce Kelly Barsch Kelly's a
PharmD also here in Columbus atthe Ohio State University.
(01:15):
She's a clinical pharmacist andworks very closely in the
cardiovascular division there.
And she is the chair electincoming chair of our CB team
Council here in Ohio.
Kelly, welcome.
Thanks, Kenny.
Looking forward to ourconversation.
Yeah.
So maybe we can start Andrewwith you.
(01:35):
I really wanted to get you onbecause I know, of course, you,
you have a background inelectrophysiology and you've
been working in EP for severalyears here in Columbus.
And I've had a, the good fortuneto work closely with you here at
Ohio Health.
You know, quite a few years agonow, I think it's been several
that you and your colleaguesproposed.
(01:56):
A walk-in clinic for atrialfibrillation, and I really want
our members to learn a littlebit more about how that clinic
was visualized and conceivedand, and how it's worked.
Obviously, we're all clinicianson the front line and deal with
atrial fibrillation on a dailybasis, inpatient, outpatient,
and all kinds of settings.
(02:16):
But what, what was really therationale that led to
considering this type of clinicversus a traditional way we
deliver cardiac care?
Sure.
So I think, you know, I thinkit, it really was
multifactorial.
I think number one, you know,our initial focus was really on.
Trying to visualize how we couldprovide better access to
(02:39):
patients with atrialfibrillation.
You know, as we know with ouraging and increasingly comorbid
population the number ofpatients diagnosed with AFib is
far outpacing the broadband ofcardiologists or specifically
electrophysiologists.
And, you know, I think with thewealth of data coming out in the
(03:02):
last 10 years on, you know,earlier access to rhythm based
care showing improvement inoutcomes and better cost of
care, we really needed to find away to get these patients
plugged in at the right time tothe right provider.
I think secondarily to that,we've also recognized that AFib
is a really complex disease andit usually takes more than just
(03:27):
a, a quick conversation toreally dig in and educate the
patient on all treatmentoptions.
Talk about risk factormodification and really get them
engaged in their care.
And so we wanted to be able tooffer a clinical model that
would maybe address some ofthose constraints.
(03:48):
So, And third thing I think is,as, as one of the advanced
practice providers, we, wereally wanted to increase our
value to the electrophysiologyteam.
And I, we saw that we couldreally help fill that gap, that
using our advanced practiceproviders to really be the, the
forefront of this clinicalmodel.
(04:10):
We could really sort of Offloadour physician counterparts to
you know, see different types ofpatients or remain in the lab
doing interventions.
And we could really help takeon, you know, the forefront of
treating patients with AFib.
So obviously we know thesepatients are everywhere, right?
(04:32):
They're in the emergency room,they're in the hospital service.
They, they come to our clinicsfor new referrals.
Were you focusing on a specificsubset of AF patients when you
conceive of the clinic, and thenhow did that lead to the actual
structure of the clinic thatyou've created?
Yeah, so initially ours and,other, folks across the country
that have used this model focuson the patients coming in
(04:56):
through the er.
it's really widely accepted thata lot of patients with low risk
AFib are.
Probably unnecessarily admittedto the hospital just because
truly there's no better place tooffer them quick access to care.
And so path of least resistanceis to hospitalize them.
What we found is that, averagelength of stay is two to four
(05:19):
days for these patients.
Really just to get someface-to-face time with an
arrhythmia specialist, maybesome imaging and a
cardioversion.
So on the inpatient side, Ithink that's where we really saw
the need.
When we saw a lot of thesepatients coming in and we
thought, we could, we couldoffer something.
Just as good if not much betterin an outpatient setting to be
(05:41):
able to lower cost of care andincrease patient satisfaction.
So yes, initially we focused onthe acute patients.
So we started off with someemergency department protocols,
helping those colleaguesbasically.
Evaluate patients and determineif they're appropriate for
(06:03):
outpatient care.
Really focusing on, you know,what are the risk factors would
they be able to be ratecontrolled in an acute fashion
anticoagulated, and then ourapproach would be to see them
within two business days in ourclinic.
We also kind of rolled out thatacute algorithm to even our own
(06:25):
practice with cardiology and EPand as well as primary care.
So, previously patients may,call their cardiologist or call
their primary care and.
Report an acute episode of AFib,or it's incidentally found, and
they would be sent to the ERwith these acute protocols.
Patients would instead bypassthe ER altogether and come
directly to our clinic.
(06:47):
Yeah.
So I think that's a prettyaggressive goal, you know, to
take patients who wouldotherwise been admitted into the
hospital and try to see them.
A 24 to 48 hour basis, have youbeen able to accomplish that
turnaround that you intended?
And maybe just talk a little bitabout the logistics of the
clinic in terms of where it'slocated and who staffs it, et
cetera.
(07:08):
Yeah, so, so we have, and that,that's been a really big
priority of ours.
when we, I.
Initially met with, theemergency department providers,
they let us know that, they werea little bit, a little bit
hesitant to adopt this thismodel of care.
they had been burned in the pastby, a lot of people come to the
ERs and say, follow thisprotocol, discharge our
patients, and.
(07:29):
Really there weren't good safetynets in place to see the
patients acutely so patientswould bounce back to the er.
So we really made it our goal toensure that, you know, every
patient referred would be seenwithin two business days.
If it's for an acute episode,so, That's a metric that we
follow very closely.
we're five years into this now.
(07:49):
We look at that, we look at thatmetric, pretty much
continuously.
And if we're ever starting tofall above that line of two
business days, we've been ableto really quickly react, adjust
our access, whether it's addingmore appointment times or
another clinician to be able tobe seen up in clinic.
The providers that we have inclinic, we use advanced practice
(08:11):
providers.
it really is a team-based caremodel.
We, we rely on our clinic nursesas well to help triage a lot of
the patients over the phone tohelp decide when they need to
come in and if they need to comein prepared for a cardioversion
if they need to, come in fastingwith a driver in anticipation of
that.
The apps then do the majority ofthe clinical visit making,
(08:35):
decisions about, rate versusrhythm control, anticoagulation
strategies and the imaging ortesting needed.
And, we're always collaboratingwith our physicians, so, they're
not necessarily coming up andmeeting these patients face to
face.
But, the big part of our, thegoal of our clinic is, Not to
have these patients followedlongitudinally by our clinic.
(08:58):
So if they're coming in for thefirst time, either with a new
episode of AFib or just someonereferred later on in their, in
their diagnosis, but they'venever seen a, a cardiology
Clinician or then sort of makingthe decision should they, or do
they need to be established withep and if so, they'll then, see
(09:19):
them several weeks after followup.
Some of these folks may be moreappropriate to follow with
clinical cardiology and some areeven, okay to follow with their
primary care.
So, you know, we do make sureeveryone's tucked into someone
for follow up in the mostappropriate fashion for them.
Yeah.
So obviously having referredmany patients there, I can vouch
(09:42):
for the the, the, the increasein efficiency and help that you
give all of our generalcardiologists and other
referring providers.
I know obviously, I, I assumemost patients, you're starting
with maybe their antiarrhythmicsor maybe just even an initial
cardioversion with imaging.
Are there some patients thoughthat you're would consider
(10:03):
taking straight to more,invasive.
Like potentially ablation andother things, or is it more of a
stepwise kind of approach?
I mean, it's, you know, inincreasingly there there's been
more data coming out showingearly rhythm control, whether
it's with an antiarrhythmic drugor catheter ablation, and
certain patients is superior toweight control.
(10:25):
And other, you know, otherliterature even suggests that,
you know, catheter ablation canbe more beneficial than an
antirrhythmic drug.
And a subset of population ofpatients.
So we really look at everyone.
Individually, you know, and, Ithink, you know, I think one
thing that makes our clinic workis we do follow kind of
(10:46):
standardized protocols, but,we're, we're, we're still
looking at every patient and thecharacteristics about them
pretty uniquely.
It's also a shared decisionmaking interaction with, with
every clinic visit.
And I think that's part of whatThe biggest benefit to these,
you know, this atrialfibrillation clinic model is
(11:08):
that.
You know, previously we had seenpatients, you know, referred
pretty, pretty late in theirdiagnosis and you know, they may
be persistent AFib orlongstanding persistent.
They'd be referred to EP and youknow, they maybe have never even
heard that ablation is an optionfor them.
And so I.
We're really working to try andsee these patients early on in
(11:29):
the diagnosis and really juststart with really good education
about all treatment options andreally helping them understand
the difference between rate andrhythm control and the risks and
benefits of choosing eachstrategy.
And from there, you know,patients have the knowledge to
sort of, you know, take a, alarger role in the, in their
(11:49):
shared, in their decision makingand participate in their care
and help make those decisionstoo.
Yeah.
And you mentioned education.
I think, you know, one thing wesee when patients are admitted
with an acute episode of af,there's not often a lot of time
to address a lot of thecomorbidity and contributing
factors.
And of course, we all know thatAF tends to cluster with so many
other conditions.
(12:09):
You know, hypertension, sleepapnea, in sedentary lifestyle,
et cetera.
Do you try to address some ofthose things as well with the
patients since you're in alittle bit different scenario
than say, when we're doing aninpatient consultation?
Yeah, a absolutely.
And so that's something elsethat we've sort of hardwired
into every visit.
So, you know, it's ahospital-based clinic.
(12:32):
We sort of pulled it out fromour general clinical setting.
So we could really, design ourappointment slots based off of
what the need of the patientwas.
Not necessarily just trying tofill a template.
So we have 50 minute visits toreally allow for that education.
So everyone gets a goodconversation.
They fill out their own chats,VAs score.
(12:53):
We talk about anticoagulation,we talk about rate and rhythm
control.
But then, you know, we do carveout time each visit to make sure
we go through and we identifyall of the risk factors for
atrial fibrillation.
We, you know, we calculate theirBMIs.
We look at, whether their bloodpressure's at goal.
We screen for sleep apnea, wetalk about alcohol.
(13:14):
And then based off of thefindings, we then help come up
with an individual plan onwhether they need to be referred
for a sleep study.
we'll involve their, you know,primary care if we need further
assistance with, getting theircholesterol or their blood
pressure to goal.
And then we actually do, we, wefollow up with our patients as
well, pretty well, so, We, havecertain metrics when we wanna
(13:37):
refer patients to weightmanagement or sleep management.
And then that's where the nursesreally come in.
we know that that's sort of asensitive topic to talk about
with patients.
And so our nurses do a reallygood job of doing a follow-up
call several weeks later toreally ask and say, Hey, you
know, the referral was put infor sleep.
Or, wait, have you been able to,think about it.
(13:57):
Did you make the decision to goahead and proceed and, you know
sign up for, a weight lossprogram and.
I think that's what, you know,that it's also a nice benefit of
our clinic is that it's asmaller cohort than, than we
follow.
So, you know, our nurses and ourapps are really engaged with
this population.
The patients feel very safe totalk about these things, and so
(14:18):
I think that's where we'vereally been able to see some
success and getting patientscloser to their goals for risk
factor modification.
Yeah.
Well, thanks, you certainly, youand the rest of your, your team
deserve to be commended for youknow, creating a new program
that didn't exist and meeting a.
What are some of the futuregoals, you know, for the clinic
(14:39):
and are there still somechallenges you're trying to
overcome as you try to grow thisand, and care for this growing,
you know, patient population?
Yeah, I mean, so it's, it'salways been evolving, you know,
as I mentioned it, it really wasin the beginning.
Focused on the acute patientsand keeping them outta the
hospital and the er.
(15:00):
And then it slowly evolved to,now we also have a really big
focus on trying to get patientsin after their first diagnosis
of AFib, sort of becoming likethe front door to our EP
practice.
And that's, that's gonnarequire, if, if we're gonna
continue to fulfill that withthis growing population, it's
gonna require, you know,probably expanding the clinic a
(15:22):
little bit to be able to meetthe needs as, as that population
is growing.
We also wanna be able to offerpatients care, close to home.
our, our hospital system spreadsout pretty over, a pretty
diverse geographical range.
So, there's some, that We have asecond.
We have a second.
Location already withinColumbus, but there's gonna be
(15:43):
some considerations of probablyexpanding in the future as well.
Great.
We look definitely look forwardto hearing more about this
project as it grows.
And I assume if some of ourlisteners and their various
institutions want to get moreinformation from you about, the
clinic in terms of logistics ofhow you set it up and so forth,
I, I assume you'd be okay ifthey reach out to you?
(16:06):
I, I absolutely would, and I, I,I'd encourage it, you know, I
would say that, you know, we.
I think one of the things we, wetook on in the beginning was
making sure we collected a lotof baseline data and then data
along the way.
And so five years in, we have alot of good you know, numbers
showing that we have decreasedcost of care, we've got more
patients adhering to in acoagulation and more patients on
(16:29):
appropriate therapy.
So we're happy to share that ifinstitutions are looking to say,
how do we make a business caseto get resources for that.
Well, great thanks Andrea forsharing that information and
educating us a little bit aswell.
And also thanks for serving thestate chapter as chair for the
last couple years.
We look forward to your futurecontributions as well.
(16:50):
Thanks.
So Kelly, as a clinicalpharmacist, I want to continue
the theme of using the entire CVteam to help, extend and
expedite cardiac care.
I know I've talked to you beforeabout some of the programs
you've worked on at Ohio State.
Mm-hmm.
To try to extend care as well.
I mean, obviously for many yearsthere's been a pretty critical
(17:12):
role for pharmacists in cardiaccare given, you know, the
complex.
Pharmacology we use, but I, Ithought I'd just get your input
about some new programs thatyou've been working on that kind
of emphasize the role of theclinical pharmacist.
Could you just start by kind ofdescribing your current role at
O S U and, and what led you toan interest in, in.
Cardiac care specificallycardiac.
(17:33):
Sure.
So I have been at O S U now fora decade and, and when I started
we were purely cardiology.
So I came on board knowing I wasgonna do some anti-coag some
antiarrhythmic med monitoring,which is a little bit different
than the clinic set up thatAndrea's got.
And then also Sublimate clinicas well.
And through the years myself Iwork with a fantastic team of a
(17:57):
bunch of pharmacists.
We've expanded into a lot ofother areas of cardiology, so we
have a smoking cessation clinica transition of care clinic a
heart failure clinic really, andit just continues to grow as
the, the cardiologists identifyareas where we can help
streamline access and educationand making sure patients are
staying compliant for theirmeds.
(18:18):
Yeah, I think lipids are onearea where, of course, you know,
we rely heavily on.
On, on cardiac medications andmm-hmm.
Especially some new and veryevolving set of medicines.
So what are some of the thingsyou're doing there in the lipid
clinic to help the, theclinicians extend their care to
the patients?
Yeah, so we have threephysicians that are part of our.
(18:40):
Our clinic across the system andthen a total of eight
pharmacists across those clinicsas well.
So new patients typically comein to see the physician and the
pharmacist as a tandem visit andthen follow up patients unless
they need to see that samephysician for cardiology care as
well.
Follow actually with thepharmacist and just see the, the
(19:01):
physician every couple of years,which we're able to do under a
collaborative practice that wehave set up with the, the
cardiology practice at OhioState.
So it really allows.
The, the docs to see more of thenew patients and help with that
initial plan and goal setting,and then us to help kind of
execute that along the waywithout backlog their clinic
with all the return patients.
(19:23):
How did you kind of set up acollaborative arrangement, in
which You know you, you're notjust providing information, but
actually helping, assist with,with, with the care of the
outpatients that you're seeing.
Yeah.
So fortunately I actually cameinto that setting, so there were
a few pharmacists that hadstarted before me and, and
started that process.
I.
(19:43):
Actually, I think with our, ananticoagulation clinic and got
the collaborative practice inplace there.
So it's, it's kind of justbecome the expectation when we
start new clinics that therewill be a collaborative practice
in, in place that allows us tomanage to a certain extent.
We also have clinical protocolsfor every clinic that really
outline what.
Is within our scope.
(20:03):
And what's, what's outside ofthat.
And certainly the laws forpharmacists in the state of Ohio
and Ohio is actually prettyprogressive for the practice of
pharmacy.
So we do have the the fortunatecircumstance of being able to do
a bit more than our colleaguesin other states where we're able
to help a little bit more withsome of the ordering and
referrals and things like that.
Yeah, that's great.
(20:25):
I know you wanted to talk alittle bit about smoking
cessation as well.
That's obviously a tremendousneed.
We have clinically and we'reoften understaffed or not really
well staffed to, provide.
Tobacco counseling to thepatients that really need it.
So what areas are you working inthere to help address that need?
(20:48):
Yeah, so that was a, a clinicthat I started actually with one
of our residents several yearsago.
And it's something that if, ifother locations you know, other
practice sites are looking tostart clinics with pharmacy or
that are, are education drivenor, or have such.
Specific medication needs.
Especially if you have pharmacytrainees.
Typically a lot of thosetrainees are interested in
(21:09):
starting clinics and learninghow to do that and being
involved in that.
But it's less of a, a dollarsask upfront to kind of get that
off the ground and pilot it andsee if it's, it's gonna work.
So the clinic started that wayand it's really expanded since
then.
It's set up now thatpractitioners from cardiology,
as well as several otherdisciplines, have their own kind
of branch of, of smokingcessation can refer patients
(21:32):
over or patients can self-referthrough the patient portal or
just by calling in.
To, to schedule an appointmentwith us.
But really the goal is we have alot more time than what our
physicians usually have inpractice or in clinic to spend
digging into the habits of whypeople are smoking, you know,
(21:52):
what their level of dependenceis, what they've tried before,
what.
What might be good options?
And unfortunately a lot of timescoverage is an issue as well, so
it's also taking the time tomake sure we can get these
covered at a cost that's lessthan what they would spend for a
pack of cigarettes to make it a,an appealing cost option as well
to make that quit attempt.
Yeah, that sounds great.
(22:13):
Certainly a unmet need.
So it's great to have some moreresources there.
So, I know, I know at ourinstitution anyways, we, so many
of the cardiac subspecialties doutilize the pharmacist in
different ways.
For example, I know in ep, herewith, they have a big role with
drug monitoring, really doing.
You're basically overtaking alot of the drug monitoring,
(22:37):
office visits for some of theantiarrhythmics.
So do you also, within youroverall team, kind of
subspecialize in a few of thesedifferent areas in terms of each
pharmacist since there's such avaried area within cardiology
where, where you can beutilized.
Yeah.
So Antiarrhythmic Meds, as Imentioned, is, is a, a clinic
that I started in when I startedat O O S U and it's still one
(22:58):
that I staff occasionally.
But yeah, exactly as you said,we do a lot of the med
monitoring.
So especially, with, withSotalol, Tikosyn, amiodarone,
there's such a prescriptive planfor monitoring that needs to
happen.
So it's nice that we're able tosee the patients, get them in at
locations oftentimes a bitcloser to them.
(23:21):
And also just take care of thoseand connect them quickly to EP
if they need it, without theelectrophysiologist needing to
have those on their schedule.
Or even the NPS who are doingnow so many more acute things
just to.
Alleviate some of the burden offtheir schedule to get those more
routine visits done and thenconnect patients to those
resources as needed.
(23:41):
Well, that's great.
I think we, we'd love to hearmore about some of these
programs in more detail as wegrow through some of these
topics on future podcasts.
And congratulations you know, asthe incoming liaison for the
Ohio a c c Cardiovascular TeamCouncil.
We look forward to yourcontributions in the next couple
of years.
(24:01):
Thanks.
I'm gonna try my best to live upto the standard that Andrea
started.
Yeah, so Andrea I obviously we,of course, in our state chapter
we have nurses, we have advancedpractice providers, PAs,
pharmacists.
Do you want to just maybe take aminute and just remind us about
the, the CV Team Council interms of its makeup and maybe
(24:23):
highlight a couple things thatyou've worked on in the last the
last couple years and maybe somefuture goals too.
Yeah, so certainly, it's, I, Ithink you just, you know, went
through and named the majorityof our membership advanced
practice providers, nurses,pharmacists different, whether
it's, it can be a cath lab techor a rad tech.
(24:46):
And you know, really I think thefocus the last several years has
been, sort of making sure thatthere's.
Relevant topics to anon-physician member that are
always at the forefront.
And I think not just from the,within Ohio a, c, c, but the
national A c C as well.
You know, I feel like that hasbeen a big focus of this
(25:09):
team-based care model.
And even, even more so withinthe Ohio chapter, you know, I
just from, your leadership and,you know, Gwen and everyone
else's leadership, I think we'vereally felt valued as a team
member.
And, you don't always get thatwithin an, a big society like
this.
Some of the things over the pastcouple of years we've done is,
(25:30):
held.
A couple of, sessions on, youknow, different clinical topics
where you can share bestpractices and learn about
different topics that you maynot be familiar with.
We had a session about, youknow, kind of demystifying how
do you maybe create a re start,a research project or put
together a case report and thenturn that in to either something
(25:53):
for publication or a poster tobe presented at a regional or
local conference.
And I will make a plug forupcoming, prior to our.
Fall meeting, we're gonna planto have a CV team happy hour
just to get together and kind ofmeet one another.
'cause it's also just been areally great way to network, not
(26:15):
just within your own city, butreally across Ohio with
different, you know, advancedpractice and allied health
providers either within yourspecialty or within a different
specialty.
And really kind of open up someof the pathways to, you know,
learn and grow from each other.
And goals for the future?
(26:35):
I, I have a, I have a a lot ofoptimism that, Kelly comes with
a lot of great clinical andleadership experience already.
And so I know she's just gonnacontinue to, probably look at
some of the things that we'vedone previously and also bring
new ideas into the future withhow we can just continue to make
(26:56):
this a place or place to kind ofcultivate education and
engagement and networking.
Well, that sounds exciting.
I just want to thank you bothfor taking some time to talk
about the programs at yourinstitutions and also the
council itself.
I also want to put in a quickplug myself for our next podcast
(27:18):
episode.
You know, we obviously, we gotsome great insight about the c v
team today, and we're actuallygonna flip to the
electrophysiology perspective.
And we have a couple outstandingand well-known EP docs from
Central Ohio.
Ralph Augustin from Ohio State.
Anisha mean, who's the chief ofVP at Ohio Health, and they're
gonna talk a little bit moreabout the electrophysiologist
(27:40):
perspective for both AFib andsome other arrhythmias as well.
So hopefully you'll be on thelookout for that next episode.
But thank you both for joiningin and hopefully some of our
members will be reaching out toyou to learn a little bit more
about these programs.
Thanks, Kenny.
This has, this has been fun.
Yeah.
Agreed.
Thanks so much and, and pleasedo feel free to reach out to
(28:02):
Andrea or I if, if we don't knowthe answer, we've well
positioned to get you connectedto somebody who does.
Okay.
Well thanks to our audience aswell for joining in this episode
of the Card.
How podcast?
Thank you for joining today'spodcast.
For more information about thespeakers or the topics, please
go to Ohio acc.org,
So welcome back to the CardioHigh Podcast.
We have a very special topictoday.
We're gonna be focusing on thecardiovascular team.
We'd like to talk a little bitabout using the c v team members
to extend cardiac care, helpimprove outcomes, increase
patient satisfaction as well.
(00:29):
I have the pleasure ofintroducing a couple of guests
who are pretty well known.
I think to our Ohio listeners,they're both C B T members that
have been involved in the Ohio.
Chapter quite a bit recently.
First, I'd like to introducefrom here in Columbus Andrea
Robinson, who's actually thecurrent liaison for our Ohio
(00:51):
chapter for the cardiovascularteam council.
Andrea, welcome.
Thanks, Kenny.
It's a pleasure to be here and Iam excited to talk about this
opportunity with cv, teamliaison and leadership.
Thank you.
Yeah, welcome.
And then I'd also like tointroduce Kelly Barsch Kelly's a
PharmD also here in Columbus atthe Ohio State University.
(01:15):
She's a clinical pharmacist andworks very closely in the
cardiovascular division there.
And she is the chair electincoming chair of our CB team
Council here in Ohio.
Kelly, welcome.
Thanks, Kenny.
Looking forward to ourconversation.
Yeah.
So maybe we can start Andrewwith you.
(01:35):
I really wanted to get you onbecause I know, of course, you,
you have a background inelectrophysiology and you've
been working in EP for severalyears here in Columbus.
And I've had a, the good fortuneto work closely with you here at
Ohio Health.
You know, quite a few years agonow, I think it's been several
that you and your colleaguesproposed.
(01:56):
A walk-in clinic for atrialfibrillation, and I really want
our members to learn a littlebit more about how that clinic
was visualized and conceivedand, and how it's worked.
Obviously, we're all clinicianson the front line and deal with
atrial fibrillation on a dailybasis, inpatient, outpatient,
and all kinds of settings.
(02:16):
But what, what was really therationale that led to
considering this type of clinicversus a traditional way we
deliver cardiac care?
Sure.
So I think, you know, I thinkit, it really was
multifactorial.
I think number one, you know,our initial focus was really on.
Trying to visualize how we couldprovide better access to
(02:39):
patients with atrialfibrillation.
You know, as we know with ouraging and increasingly comorbid
population the number ofpatients diagnosed with AFib is
far outpacing the broadband ofcardiologists or specifically
electrophysiologists.
And, you know, I think with thewealth of data coming out in the
(03:02):
last 10 years on, you know,earlier access to rhythm based
care showing improvement inoutcomes and better cost of
care, we really needed to find away to get these patients
plugged in at the right time tothe right provider.
I think secondarily to that,we've also recognized that AFib
is a really complex disease andit usually takes more than just
(03:27):
a, a quick conversation toreally dig in and educate the
patient on all treatmentoptions.
Talk about risk factormodification and really get them
engaged in their care.
And so we wanted to be able tooffer a clinical model that
would maybe address some ofthose constraints.
(03:48):
So, And third thing I think is,as, as one of the advanced
practice providers, we, wereally wanted to increase our
value to the electrophysiologyteam.
And I, we saw that we couldreally help fill that gap, that
using our advanced practiceproviders to really be the, the
forefront of this clinicalmodel.
(04:10):
We could really sort of Offloadour physician counterparts to
you know, see different types ofpatients or remain in the lab
doing interventions.
And we could really help takeon, you know, the forefront of
treating patients with AFib.
So obviously we know thesepatients are everywhere, right?
(04:32):
They're in the emergency room,they're in the hospital service.
They, they come to our clinicsfor new referrals.
Were you focusing on a specificsubset of AF patients when you
conceive of the clinic, and thenhow did that lead to the actual
structure of the clinic thatyou've created?
Yeah, so initially ours and,other, folks across the country
that have used this model focuson the patients coming in
(04:56):
through the er.
it's really widely accepted thata lot of patients with low risk
AFib are.
Probably unnecessarily admittedto the hospital just because
truly there's no better place tooffer them quick access to care.
And so path of least resistanceis to hospitalize them.
What we found is that, averagelength of stay is two to four
(05:19):
days for these patients.
Really just to get someface-to-face time with an
arrhythmia specialist, maybesome imaging and a
cardioversion.
So on the inpatient side, Ithink that's where we really saw
the need.
When we saw a lot of thesepatients coming in and we
thought, we could, we couldoffer something.
Just as good if not much betterin an outpatient setting to be
(05:41):
able to lower cost of care andincrease patient satisfaction.
So yes, initially we focused onthe acute patients.
So we started off with someemergency department protocols,
helping those colleaguesbasically.
Evaluate patients and determineif they're appropriate for
(06:03):
outpatient care.
Really focusing on, you know,what are the risk factors would
they be able to be ratecontrolled in an acute fashion
anticoagulated, and then ourapproach would be to see them
within two business days in ourclinic.
We also kind of rolled out thatacute algorithm to even our own
(06:25):
practice with cardiology and EPand as well as primary care.
So, previously patients may,call their cardiologist or call
their primary care and.
Report an acute episode of AFib,or it's incidentally found, and
they would be sent to the ERwith these acute protocols.
Patients would instead bypassthe ER altogether and come
directly to our clinic.
(06:47):
Yeah.
So I think that's a prettyaggressive goal, you know, to
take patients who wouldotherwise been admitted into the
hospital and try to see them.
A 24 to 48 hour basis, have youbeen able to accomplish that
turnaround that you intended?
And maybe just talk a little bitabout the logistics of the
clinic in terms of where it'slocated and who staffs it, et
cetera.
(07:08):
Yeah, so, so we have, and that,that's been a really big
priority of ours.
when we, I.
Initially met with, theemergency department providers,
they let us know that, they werea little bit, a little bit
hesitant to adopt this thismodel of care.
they had been burned in the pastby, a lot of people come to the
ERs and say, follow thisprotocol, discharge our
patients, and.
(07:29):
Really there weren't good safetynets in place to see the
patients acutely so patientswould bounce back to the er.
So we really made it our goal toensure that, you know, every
patient referred would be seenwithin two business days.
If it's for an acute episode,so, That's a metric that we
follow very closely.
we're five years into this now.
(07:49):
We look at that, we look at thatmetric, pretty much
continuously.
And if we're ever starting tofall above that line of two
business days, we've been ableto really quickly react, adjust
our access, whether it's addingmore appointment times or
another clinician to be able tobe seen up in clinic.
The providers that we have inclinic, we use advanced practice
(08:11):
providers.
it really is a team-based caremodel.
We, we rely on our clinic nursesas well to help triage a lot of
the patients over the phone tohelp decide when they need to
come in and if they need to comein prepared for a cardioversion
if they need to, come in fastingwith a driver in anticipation of
that.
The apps then do the majority ofthe clinical visit making,
(08:35):
decisions about, rate versusrhythm control, anticoagulation
strategies and the imaging ortesting needed.
And, we're always collaboratingwith our physicians, so, they're
not necessarily coming up andmeeting these patients face to
face.
But, the big part of our, thegoal of our clinic is, Not to
have these patients followedlongitudinally by our clinic.
(08:58):
So if they're coming in for thefirst time, either with a new
episode of AFib or just someonereferred later on in their, in
their diagnosis, but they'venever seen a, a cardiology
Clinician or then sort of makingthe decision should they, or do
they need to be established withep and if so, they'll then, see
(09:19):
them several weeks after followup.
Some of these folks may be moreappropriate to follow with
clinical cardiology and some areeven, okay to follow with their
primary care.
So, you know, we do make sureeveryone's tucked into someone
for follow up in the mostappropriate fashion for them.
Yeah.
So obviously having referredmany patients there, I can vouch
(09:42):
for the the, the, the increasein efficiency and help that you
give all of our generalcardiologists and other
referring providers.
I know obviously, I, I assumemost patients, you're starting
with maybe their antiarrhythmicsor maybe just even an initial
cardioversion with imaging.
Are there some patients thoughthat you're would consider
(10:03):
taking straight to more,invasive.
Like potentially ablation andother things, or is it more of a
stepwise kind of approach?
I mean, it's, you know, inincreasingly there there's been
more data coming out showingearly rhythm control, whether
it's with an antiarrhythmic drugor catheter ablation, and
certain patients is superior toweight control.
(10:25):
And other, you know, otherliterature even suggests that,
you know, catheter ablation canbe more beneficial than an
antirrhythmic drug.
And a subset of population ofpatients.
So we really look at everyone.
Individually, you know, and, Ithink, you know, I think one
thing that makes our clinic workis we do follow kind of
(10:46):
standardized protocols, but,we're, we're, we're still
looking at every patient and thecharacteristics about them
pretty uniquely.
It's also a shared decisionmaking interaction with, with
every clinic visit.
And I think that's part of whatThe biggest benefit to these,
you know, this atrialfibrillation clinic model is
(11:08):
that.
You know, previously we had seenpatients, you know, referred
pretty, pretty late in theirdiagnosis and you know, they may
be persistent AFib orlongstanding persistent.
They'd be referred to EP and youknow, they maybe have never even
heard that ablation is an optionfor them.
And so I.
We're really working to try andsee these patients early on in
(11:29):
the diagnosis and really juststart with really good education
about all treatment options andreally helping them understand
the difference between rate andrhythm control and the risks and
benefits of choosing eachstrategy.
And from there, you know,patients have the knowledge to
sort of, you know, take a, alarger role in the, in their
(11:49):
shared, in their decision makingand participate in their care
and help make those decisionstoo.
Yeah.
And you mentioned education.
I think, you know, one thing wesee when patients are admitted
with an acute episode of af,there's not often a lot of time
to address a lot of thecomorbidity and contributing
factors.
And of course, we all know thatAF tends to cluster with so many
other conditions.
(12:09):
You know, hypertension, sleepapnea, in sedentary lifestyle,
et cetera.
Do you try to address some ofthose things as well with the
patients since you're in alittle bit different scenario
than say, when we're doing aninpatient consultation?
Yeah, a absolutely.
And so that's something elsethat we've sort of hardwired
into every visit.
So, you know, it's ahospital-based clinic.
(12:32):
We sort of pulled it out fromour general clinical setting.
So we could really, design ourappointment slots based off of
what the need of the patientwas.
Not necessarily just trying tofill a template.
So we have 50 minute visits toreally allow for that education.
So everyone gets a goodconversation.
They fill out their own chats,VAs score.
(12:53):
We talk about anticoagulation,we talk about rate and rhythm
control.
But then, you know, we do carveout time each visit to make sure
we go through and we identifyall of the risk factors for
atrial fibrillation.
We, you know, we calculate theirBMIs.
We look at, whether their bloodpressure's at goal.
We screen for sleep apnea, wetalk about alcohol.
(13:14):
And then based off of thefindings, we then help come up
with an individual plan onwhether they need to be referred
for a sleep study.
we'll involve their, you know,primary care if we need further
assistance with, getting theircholesterol or their blood
pressure to goal.
And then we actually do, we, wefollow up with our patients as
well, pretty well, so, We, havecertain metrics when we wanna
(13:37):
refer patients to weightmanagement or sleep management.
And then that's where the nursesreally come in.
we know that that's sort of asensitive topic to talk about
with patients.
And so our nurses do a reallygood job of doing a follow-up
call several weeks later toreally ask and say, Hey, you
know, the referral was put infor sleep.
Or, wait, have you been able to,think about it.
(13:57):
Did you make the decision to goahead and proceed and, you know
sign up for, a weight lossprogram and.
I think that's what, you know,that it's also a nice benefit of
our clinic is that it's asmaller cohort than, than we
follow.
So, you know, our nurses and ourapps are really engaged with
this population.
The patients feel very safe totalk about these things, and so
(14:18):
I think that's where we'vereally been able to see some
success and getting patientscloser to their goals for risk
factor modification.
Yeah.
Well, thanks, you certainly, youand the rest of your, your team
deserve to be commended for youknow, creating a new program
that didn't exist and meeting a.
What are some of the futuregoals, you know, for the clinic
(14:39):
and are there still somechallenges you're trying to
overcome as you try to grow thisand, and care for this growing,
you know, patient population?
Yeah, I mean, so it's, it'salways been evolving, you know,
as I mentioned it, it really wasin the beginning.
Focused on the acute patientsand keeping them outta the
hospital and the er.
(15:00):
And then it slowly evolved to,now we also have a really big
focus on trying to get patientsin after their first diagnosis
of AFib, sort of becoming likethe front door to our EP
practice.
And that's, that's gonnarequire, if, if we're gonna
continue to fulfill that withthis growing population, it's
gonna require, you know,probably expanding the clinic a
(15:22):
little bit to be able to meetthe needs as, as that population
is growing.
We also wanna be able to offerpatients care, close to home.
our, our hospital system spreadsout pretty over, a pretty
diverse geographical range.
So, there's some, that We have asecond.
We have a second.
Location already withinColumbus, but there's gonna be
(15:43):
some considerations of probablyexpanding in the future as well.
Great.
We look definitely look forwardto hearing more about this
project as it grows.
And I assume if some of ourlisteners and their various
institutions want to get moreinformation from you about, the
clinic in terms of logistics ofhow you set it up and so forth,
I, I assume you'd be okay ifthey reach out to you?
(16:06):
I, I absolutely would, and I, I,I'd encourage it, you know, I
would say that, you know, we.
I think one of the things we, wetook on in the beginning was
making sure we collected a lotof baseline data and then data
along the way.
And so five years in, we have alot of good you know, numbers
showing that we have decreasedcost of care, we've got more
patients adhering to in acoagulation and more patients on
(16:29):
appropriate therapy.
So we're happy to share that ifinstitutions are looking to say,
how do we make a business caseto get resources for that.
Well, great thanks Andrea forsharing that information and
educating us a little bit aswell.
And also thanks for serving thestate chapter as chair for the
last couple years.
We look forward to your futurecontributions as well.
(16:50):
Thanks.
So Kelly, as a clinicalpharmacist, I want to continue
the theme of using the entire CVteam to help, extend and
expedite cardiac care.
I know I've talked to you beforeabout some of the programs
you've worked on at Ohio State.
Mm-hmm.
To try to extend care as well.
I mean, obviously for many yearsthere's been a pretty critical
(17:12):
role for pharmacists in cardiaccare given, you know, the
complex.
Pharmacology we use, but I, Ithought I'd just get your input
about some new programs thatyou've been working on that kind
of emphasize the role of theclinical pharmacist.
Could you just start by kind ofdescribing your current role at
O S U and, and what led you toan interest in, in.
Cardiac care specificallycardiac.
(17:33):
Sure.
So I have been at O S U now fora decade and, and when I started
we were purely cardiology.
So I came on board knowing I wasgonna do some anti-coag some
antiarrhythmic med monitoring,which is a little bit different
than the clinic set up thatAndrea's got.
And then also Sublimate clinicas well.
And through the years myself Iwork with a fantastic team of a
(17:57):
bunch of pharmacists.
We've expanded into a lot ofother areas of cardiology, so we
have a smoking cessation clinica transition of care clinic a
heart failure clinic really, andit just continues to grow as
the, the cardiologists identifyareas where we can help
streamline access and educationand making sure patients are
staying compliant for theirmeds.
(18:18):
Yeah, I think lipids are onearea where, of course, you know,
we rely heavily on.
On, on cardiac medications andmm-hmm.
Especially some new and veryevolving set of medicines.
So what are some of the thingsyou're doing there in the lipid
clinic to help the, theclinicians extend their care to
the patients?
Yeah, so we have threephysicians that are part of our.
(18:40):
Our clinic across the system andthen a total of eight
pharmacists across those clinicsas well.
So new patients typically comein to see the physician and the
pharmacist as a tandem visit andthen follow up patients unless
they need to see that samephysician for cardiology care as
well.
Follow actually with thepharmacist and just see the, the
(19:01):
physician every couple of years,which we're able to do under a
collaborative practice that wehave set up with the, the
cardiology practice at OhioState.
So it really allows.
The, the docs to see more of thenew patients and help with that
initial plan and goal setting,and then us to help kind of
execute that along the waywithout backlog their clinic
with all the return patients.
(19:23):
How did you kind of set up acollaborative arrangement, in
which You know you, you're notjust providing information, but
actually helping, assist with,with, with the care of the
outpatients that you're seeing.
Yeah.
So fortunately I actually cameinto that setting, so there were
a few pharmacists that hadstarted before me and, and
started that process.
I.
(19:43):
Actually, I think with our, ananticoagulation clinic and got
the collaborative practice inplace there.
So it's, it's kind of justbecome the expectation when we
start new clinics that therewill be a collaborative practice
in, in place that allows us tomanage to a certain extent.
We also have clinical protocolsfor every clinic that really
outline what.
Is within our scope.
(20:03):
And what's, what's outside ofthat.
And certainly the laws forpharmacists in the state of Ohio
and Ohio is actually prettyprogressive for the practice of
pharmacy.
So we do have the the fortunatecircumstance of being able to do
a bit more than our colleaguesin other states where we're able
to help a little bit more withsome of the ordering and
referrals and things like that.
Yeah, that's great.
(20:25):
I know you wanted to talk alittle bit about smoking
cessation as well.
That's obviously a tremendousneed.
We have clinically and we'reoften understaffed or not really
well staffed to, provide.
Tobacco counseling to thepatients that really need it.
So what areas are you working inthere to help address that need?
(20:48):
Yeah, so that was a, a clinicthat I started actually with one
of our residents several yearsago.
And it's something that if, ifother locations you know, other
practice sites are looking tostart clinics with pharmacy or
that are, are education drivenor, or have such.
Specific medication needs.
Especially if you have pharmacytrainees.
Typically a lot of thosetrainees are interested in
(21:09):
starting clinics and learninghow to do that and being
involved in that.
But it's less of a, a dollarsask upfront to kind of get that
off the ground and pilot it andsee if it's, it's gonna work.
So the clinic started that wayand it's really expanded since
then.
It's set up now thatpractitioners from cardiology,
as well as several otherdisciplines, have their own kind
of branch of, of smokingcessation can refer patients
(21:32):
over or patients can self-referthrough the patient portal or
just by calling in.
To, to schedule an appointmentwith us.
But really the goal is we have alot more time than what our
physicians usually have inpractice or in clinic to spend
digging into the habits of whypeople are smoking, you know,
(21:52):
what their level of dependenceis, what they've tried before,
what.
What might be good options?
And unfortunately a lot of timescoverage is an issue as well, so
it's also taking the time tomake sure we can get these
covered at a cost that's lessthan what they would spend for a
pack of cigarettes to make it a,an appealing cost option as well
to make that quit attempt.
Yeah, that sounds great.
(22:13):
Certainly a unmet need.
So it's great to have some moreresources there.
So, I know, I know at ourinstitution anyways, we, so many
of the cardiac subspecialties doutilize the pharmacist in
different ways.
For example, I know in ep, herewith, they have a big role with
drug monitoring, really doing.
You're basically overtaking alot of the drug monitoring,
(22:37):
office visits for some of theantiarrhythmics.
So do you also, within youroverall team, kind of
subspecialize in a few of thesedifferent areas in terms of each
pharmacist since there's such avaried area within cardiology
where, where you can beutilized.
Yeah.
So Antiarrhythmic Meds, as Imentioned, is, is a, a clinic
that I started in when I startedat O O S U and it's still one
(22:58):
that I staff occasionally.
But yeah, exactly as you said,we do a lot of the med
monitoring.
So especially, with, withSotalol, Tikosyn, amiodarone,
there's such a prescriptive planfor monitoring that needs to
happen.
So it's nice that we're able tosee the patients, get them in at
locations oftentimes a bitcloser to them.
(23:21):
And also just take care of thoseand connect them quickly to EP
if they need it, without theelectrophysiologist needing to
have those on their schedule.
Or even the NPS who are doingnow so many more acute things
just to.
Alleviate some of the burden offtheir schedule to get those more
routine visits done and thenconnect patients to those
resources as needed.
(23:41):
Well, that's great.
I think we, we'd love to hearmore about some of these
programs in more detail as wegrow through some of these
topics on future podcasts.
And congratulations you know, asthe incoming liaison for the
Ohio a c c Cardiovascular TeamCouncil.
We look forward to yourcontributions in the next couple
of years.
(24:01):
Thanks.
I'm gonna try my best to live upto the standard that Andrea
started.
Yeah, so Andrea I obviously we,of course, in our state chapter
we have nurses, we have advancedpractice providers, PAs,
pharmacists.
Do you want to just maybe take aminute and just remind us about
the, the CV Team Council interms of its makeup and maybe
(24:23):
highlight a couple things thatyou've worked on in the last the
last couple years and maybe somefuture goals too.
Yeah, so certainly, it's, I, Ithink you just, you know, went
through and named the majorityof our membership advanced
practice providers, nurses,pharmacists different, whether
it's, it can be a cath lab techor a rad tech.
(24:46):
And you know, really I think thefocus the last several years has
been, sort of making sure thatthere's.
Relevant topics to anon-physician member that are
always at the forefront.
And I think not just from the,within Ohio a, c, c, but the
national A c C as well.
You know, I feel like that hasbeen a big focus of this
(25:09):
team-based care model.
And even, even more so withinthe Ohio chapter, you know, I
just from, your leadership and,you know, Gwen and everyone
else's leadership, I think we'vereally felt valued as a team
member.
And, you don't always get thatwithin an, a big society like
this.
Some of the things over the pastcouple of years we've done is,
(25:30):
held.
A couple of, sessions on, youknow, different clinical topics
where you can share bestpractices and learn about
different topics that you maynot be familiar with.
We had a session about, youknow, kind of demystifying how
do you maybe create a re start,a research project or put
together a case report and thenturn that in to either something
(25:53):
for publication or a poster tobe presented at a regional or
local conference.
And I will make a plug forupcoming, prior to our.
Fall meeting, we're gonna planto have a CV team happy hour
just to get together and kind ofmeet one another.
'cause it's also just been areally great way to network, not
(26:15):
just within your own city, butreally across Ohio with
different, you know, advancedpractice and allied health
providers either within yourspecialty or within a different
specialty.
And really kind of open up someof the pathways to, you know,
learn and grow from each other.
And goals for the future?
(26:35):
I, I have a, I have a a lot ofoptimism that, Kelly comes with
a lot of great clinical andleadership experience already.
And so I know she's just gonnacontinue to, probably look at
some of the things that we'vedone previously and also bring
new ideas into the future withhow we can just continue to make
(26:56):
this a place or place to kind ofcultivate education and
engagement and networking.
Well, that sounds exciting.
I just want to thank you bothfor taking some time to talk
about the programs at yourinstitutions and also the
council itself.
I also want to put in a quickplug myself for our next podcast
(27:18):
episode.
You know, we obviously, we gotsome great insight about the c v
team today, and we're actuallygonna flip to the
electrophysiology perspective.
And we have a couple outstandingand well-known EP docs from
Central Ohio.
Ralph Augustin from Ohio State.
Anisha mean, who's the chief ofVP at Ohio Health, and they're
gonna talk a little bit moreabout the electrophysiologist
(27:40):
perspective for both AFib andsome other arrhythmias as well.
So hopefully you'll be on thelookout for that next episode.
But thank you both for joiningin and hopefully some of our
members will be reaching out toyou to learn a little bit more
about these programs.
Thanks, Kenny.
This has, this has been fun.
Yeah.
Agreed.
Thanks so much and, and pleasedo feel free to reach out to
(28:02):
Andrea or I if, if we don't knowthe answer, we've well
positioned to get you connectedto somebody who does.
Okay.
Well thanks to our audience aswell for joining in this episode
of the Card.
How podcast?
Thank you for joining today'spodcast.
For more information about thespeakers or the topics, please
go to Ohio acc.org,
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