A hub-and-spoke model for cardiac ablations: utilising satellite units to tackle the challenges from the pandemic and beyond
Authors: Lim V G , He H , Lachlan T , Chandan N , Ashok V , Al-Sheikhli J , Siang R , Ammar A , Foster W , Panikker S , Dhanjal T , Yusuf S , Patel K , Osman F 
Published: November 2023

Abstract

Background
Since setting up the cardiac electrophysiology (EP) service at our tertiary centre (UH) in 2010, there has been a significant increase in referrals for EP procedures. We currently serve a large catchment area (&gt;1.6 million people) and the increasing demand coupled with limited resources in a publicly funded health system has led to a huge supply-demand mismatch in our EP waiting list. This mismatch was compounded by the COVID-19 pandemic.

Aim
To share our experience of how we set up a hub-and-spoke model to mitigate the EP waiting list pressures before and during the pandemic by utilising satellite EP laboratory units.

Methods
Single shot cryoballoon pulmonary vein isolation (PVI) became the initial ablation strategy for all paroxysmal and persistent atrial fibrillation (AF) patients undergoing catheter ablation (due to shorter procedure times/standardised workflow). Almost all EP cases were performed under local anaesthesia. We transitioned from overnight-stay to same-day EP cases (all standard ablation and some complex ablation procedures) and demonstrated its safety and cost-effectiveness. We increased our EP laboratory capacity by developing a hub-and-spoke model in collaboration with 2 regional secondary care centres (WH & StX).
During the pandemic, 3 national lockdowns were declared (Figure 1) and national healthcare services were restructured. Urgent inpatient cardiac EP cases were still performed at UH but elective EP procedures across all three sites (UH, WH & StX) were cancelled during the first lockdown. One of the steps taken to mitigate the impact of the pandemic on our EP waiting list was to collaborate with the private sector (MH) which functioned as a ‘clean’ site for elective EP procedures. Cryoballoon PVI and other EP cases resumed at our centre within 2 months of the first lockdown.
Data from every EP case performed were routinely entered into an electronic database. Data was extracted from the 01/01/2018 (pre-pandemic) to 31/12/2022 (post-pandemic). UH was labelled as ‘tertiary unit’ while WH, StX and MH were pooled together (labelled as ‘satellite units’). Graphpad Prism was used for analysis (Chi-squared test for categorical variables and t-test for continuous variables).

Results
3695 EP cases were performed over 5 years. Satellite units performed predominantly standard ablation and cryoballoon PVI cases (Table 1). The implementation of three national lockdowns led to a transient decrease in the number of EP procedures (Figure 1). However, the ‘clean’ patient pathway that we rapidly established at our satellite unit (MH) facilitated the sustained delivery of our cardiac EP service throughout the pandemic from 2020 to 2021. The higher complication rates in the tertiary unit likely reflected the higher proportion of complex ablation cases.

Conclusion
Our hub-and-spoke model is a safe and novel system in tackling the EP waiting list even throughout the pandemic.Figure 1Table 1