A hub-and-spoke model: the role of satellite cardiac electrophysiology laboratory units in mitigating the waiting list pressures for catheter ablation for atrial fibrillation
Authors: Lim V , He H , Lachlan T , Chandan N , Al-Sheikhli J , Ammar A , Foster W , Panikker S , Dhanjal T , Yusuf S , Patel K , Osman F 
Published: May 2023

Abstract

Funding Acknowledgements
Type of funding sources: None.

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 especially catheter ablation for atrial fibrillation (AF). UH serves a catchment area of above 1 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 AF ablation waiting list. This mismatch was compounded by the COVID-19 pandemic.

Aim
To share our experience of how we attempted to mitigate the waiting list pressures on our AF ablation procedures before and during the pandemic by utilising satellite cardiac EP laboratory units.

Methods
Firstly, we made cryoballoon pulmonary vein isolation (PVI) the initial ablation strategy for all of our paroxysmal and persistent AF patients undergoing catheter ablation (due to shorter procedure times and standardised workflow). All cryoballoon PVI cases were performed under local anaesthesia. In 2016, we transitioned from overnight-stay to same-day AF ablation and demonstrated its safety and cost-effectiveness. Finally, we increased our EP laboratory capacity by developing a hub-and-spoke model in collaboration with 2 secondary care centres regionally (WH & StX). From May 2019, cryoballoon PVI cases were performed at 3 sites: UH (hub) and 2 satellite units (WH & StX).
During the pandemic, 3 national lockdowns were declared (23/3/20, 5/11/20, 6/1/21) 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 national lockdown. One of the steps taken to mitigate the impact of the pandemic on our increasing AF ablation waiting list was to collaborate with the private sector (MH) which functioned as a ‘clean’ site for elective EP procedures. Cryoballoon PVI cases resumed within 2 months of the first national lockdown. From September 2020, all 3 sites [UH and its two satellite units (WH & MH)] were performing cryoballoon PVI.
Data from every EP case performed in all centres was entered into an electronic database. Data was extracted from the 1st January 2019 (pre-pandemic) to the 31st December 2021 (post-pandemic). UH was labeled as ‘tertiary unit’ while WH, StX and MH were pooled together and labeled as ‘satellite units’.

Results
The implementation of three national lockdowns led to a transient decrease in the number of electrophysiology procedures (Figure 1). However, the ‘clean’ patient pathway that we rapidly established at our satellite unit (MH) facilitated the sustained delivery of our cardiac electrophysiology service throughout the pandemic from 2020 to 2021. There were no deaths or differences in complication rates between the 2 units (Table 1).

Conclusion
Our hub-and-spoke model is a safe and practical system in tackling the AF ablation waiting list even throughout the pandemic.