Focusing on Each Patient: TAVR Care Protocols at Long Island Jewish Medical Center
Overview
TAVR patients require the highest levels of management and attention from a team of
healthcare providers — not just from a single physician, but an entire multi-disciplinary team that itself must be adequately supported by the hospital system (imaging tests and coordination of information). Systemic practice and management will standardize care for all patients with aortic stenosis who are considered for transcatheter aortic valve replacement (TAVR) or open aortic valve surgery. In this article, you will distinguish and review examples of what is needed for an intra-disciplinary TAVR team, the written protocols, patient screening, and post-op process.
CEE CME/CE Accreditation and Designation
The Center of Excellence in Education (CEE) designates this live activity for a maximum of ONE (1) AMA PRA Category 1 Credit (s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. This credit may also be applied to the CMA
Certification in Continuing Medical Education.
This educational activity has been planned and implemented in accordance with the Institute for Medical Quality and the California Medical Association’s CME Accreditation Standards (IMQ/CMA).
This module is additionally accredited for RNs and other licensed healthcare providers for ONE (1) CE by California Board of Registered Nursing and California EMT-P ~ Pre-Hospital Provider.
Documentation of awarded credit is provided for registered learners in exchange for completed post test and activity evaluations included in the modules.
Target Audience
This journal-based activity is designed for interventional cardiologists, radiologists, clinical cardiologists, vascular medicine specialists, cardiac and vascular surgeons, nurse practitioners, cath lab technologists and other health care professionals with a special interest in the field of interventional and vascular medicine.
Needs Statement
CEE reviews and our activities provide the latest best practice, evidence-based data and science that physicians require to improve patient outcomes.
Activity Goals
The overall goal of this activity is to improve knowledge and competence by the target audience
implementing a TAVR program whose ultimate goal is to improve patient care.
This activity is for those who have not implemented a TAVR program and who want to implement protocols with a consistent multidisciplinary team, track metrics, create a detail-oriented screening process and a focus on post procedure resources that are used to avoid readmission.
Intensive screening and strong patient guidance both pre and post procedure lead to best outcomes for the TAVR patient population.
This experienced, successful TAVR center (Long Island Jewish Medical Center) can advise readers who are beginning a program about care protocols, best practice and the nature of
team involvement necessary for the care of this patient population. Results and protocols shared by this experienced TAVR program will help guide others as to what to expect, resources required, and where to direct energies most efficiently.
Learning Objectives
By the end of this article, participants should be able to:
- Identify the timeframe and likely contributors for developing a TAVR care protocol at their facility.
- Describe the full nature and impact of an intense patient screening process, testing and evaluation pre procedure.
- Apply resources and time necessary for post procedure care over a significant period of time to maximize outcomes and reduce readmission rates.
- Define the depth of patient communication requirements for a very sick and elderly
patient population.
CME/CE Disclosure to the Readers
A review has been conducted by the CEE CME Committee that includes evaluation of objectives, content, faculty qualifications, and commercial supporters (i.e. pharma companies, instrument or device manufacturers) to comply with, and ensure the Institute for Medical Quality (IMQ)/California Medical Association (CMA) and Accreditation Council for Continuing Medical Education (ACCME) standards are met.
In accordance with the standards of commercial support of the IMQ/CME and ACCME, all speakers are asked to disclose any real or apparent conflicts of interest that may have a direct bearing on the subject matter they will be presenting in this article.
It is the policy of The Center of Excellence in Education to ensure balance, independence, objectivity, and scientific rigor in all of its sponsored educational activities. Commercial support from industry does not influence educational content, faculty selection, and/or faculty presentations, and does not compromise the scientific integrity of the educational activity.
Discussion of off-label product usage and/or off-label product use during live cases is made at the sole discretion of the faculty. Off-label product discussion and usage are not endorsed by The Center of Excellence in Education.
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Successful completion of this activity requires a completed post-test and evaluation. You will then print your CME/CE Certificate from the website.
For any CME/CE-related inquiry, please contact donnaconrad@shasta.com.
Activity Sponsorship
This article is sponsored by The Center of Excellence In Education and the educational partner HMP Communications.
Program Support
This article is funded through an educational grant through a commercial supporter. The Center of Excellence in Education ensures that its activities are educational and meet the needs of the target audience.
This educational activity is developed without influence from commercial supporters.
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Disclaimer
This article does not endorse any commercial products.
CME/CE Accreditation for this article expires on December 31, 2014.Can you describe Long Island Jewish Medical Center and the history of your TAVR program?
Effe Mihelis, Valve Clinic Coordinator: Long Island Jewish (LIJ) Medical Center is part of the North Shore-LIJ Healthcare system, and is located in Queens, a borough of New York City. LIJ was the first hospital to offer the Sapien transcatheter aortic valve in Queens and Long Island. It took about 8-9 months of planning before launching our TAVR program, partly due to the construction of a dedicated hybrid room. We performed our first TAVR procedure on January 23, 2012, not long after the Sapien valve FDA approval and local site training. To date, we have performed over 110 cases here at LIJ. Combined with other sites in our healthcare system, North Shore-LIJ has performed more than 290 TAVR procedures. Throughout this time period, the program has successfully incorporated new delivery approaches to safely relieve symptomatic aortic stenosis for patients who otherwise would have been at high risk, or possibly not candidates, for traditional surgical aortic valve replacement.
During the planning process, how did you create a care protocol?
Jose Lam, Director, Department of Cardiovascular & Thoracic Surgery: We reviewed TAVR protocols from Canada, Europe, and U.S. PARTNER trial sites, as well as valve-related information provided by the manufacturer. This data was incorporated with our existing care protocol for surgical aortic valve replacement (SAVR). It took about two to three weeks for us to review and tailor an appropriate care protocol to fit our institution.
Who were the team members involved?
Jose: We have many highly trained individuals that care for our patients. It was natural to continue to use our multi-disciplinary team approach in the planning process and development of a care protocol. This multi-disciplinary team consists of a valve coordinator, cardiac surgeons, interventional cardiologists, echocardiographers, anesthesiologists, intensivists, physician assistants, nurse practitioners, nurses, perfusionists, physical therapists, and radiologists, in addition to other operating room and cardiac cath staff, who are trained to handle the most complex and challenging cases.
Did your initial protocols evolve after seeing your first few cases?
Effe: While we did extensive research to create our TAVR protocols, we were prepared to make adjustments as our program and the field of transcatheter therapies advanced. Our experience has shown us that there are many nuances to cardiac patients, none more relevant than with the TAVR population. While protocols are in place, we take the time to customize a unique plan for each patient. The team meets once a week to review each patient; this is a forum to review past experiences and offer an opportunity to tailor care, given unique clinical presentations. Ultimately, our goal is to guide patients through the process as safely and seamlessly as possible, in order to give them the best clinical outcome and experience.
What is the process of selecting patients for TAVR?
Effe: TAVR is only FDA-approved for high risk and inoperable patients, so this is a very specific and very sick patient population. Typically, a cardiologist refers a patient with a diagnosis of aortic stenosis seen on transthoracic echocardiogram. An extensive, thorough history is obtained, along with a comprehensive physical assessment, which may take 90 minutes. We review medications, social history, electrocardiogram (ECG), lab work, and any other pertinent tests to get a complete understanding of how aortic stenosis has affected the patient’s quality of life and their overall health. If the patient is deemed high risk or inoperable, based on a two surgeon and one interventional cardiologist review, we then proceed with a series of tests to determine if the TAVR procedure is a possibility.
What happens to patients once they are selected as a possible TAVR candidate?
Effe: The safe deployment of the transcatheter valve requires obtaining cardiovascular and thoracic anatomic measurements. A computed tomography (CT) scan of the chest, abdomen and pelvis with intravenous contrast is performed in order to evaluate the aorta, the iliacs, and the femoral arteries for tortuosity, atherosclerosis and size. A comprehensive review of the study, including the non-cardiac organs and structures, is important to ensure there are no findings that would preclude the TAVR procedure. LIJ has an excellent radiology department where accurate measurements and diagnoses are made while maintaining close communication with the department of cardiac surgery and cardiology. If the CT scan results meet criteria, we proceed with scheduling a transesophageal echocardiogram (TEE). This test provides us with measurements of the aortic annulus, necessary to determine valve sizing for surgery, while offering a more accurate analysis of all heart valves, wall motion, and overall heart function. We also perform a cardiac angiogram to determine if a patient has significant coronary artery disease requiring intervention prior to the replacement of the diseased aortic valve. Finally, all this information is reviewed with the cardiac surgeons, interventional cardiologists, echocardiographers, and anesthesiologists so the safest treatment plan can be offered to the patient.
TAVR patients are challenging, because they are often elderly, with multiple co-morbidities. Coordinating care between many medical specialists is extremely important, as each specialist will continue to follow the patient long after the procedure is performed.
As valve coordinator, is it your responsibility to guide the patient through the process from beginning to end?
Effe: Yes, I am with the patients through every stage. Both patients and family members frequently have questions as they are guided through the evaluation process. Not only do I arrange all tests, but I also explain their importance, including the risks and benefits of each procedure. It isn’t uncommon for patients and families to experience anxiety during the process and I do my best to allay their worries and to prepare them for what lies ahead.
Every opportunity is taken to minimize risk throughout the screening process. For example, I am careful to review all patient labs to make sure that the IV contrast given during CT scan or cardiac angiography will not harm the patient’s kidneys. Often we involve medical specialists and make necessary adjustments in scheduling to provide the safest environment for the test to get done. It is not unusual to speak to a patient or family members several times a week. Education is a big component of my role, as many patients, family members and the medical community do not fully understand the benefits of the TAVR procedure and the extent of its screening process. I also follow the patient throughout their hospitalization, and see them multiple times after discharge. I arrange all follow-up appointments, collecting and submitting data, as part of the Society of Thoracic Surgeons (STS)/American College of Cardiology (ACC) TVT Registry.
I find myself building lasting relationships with patients and their families. It is extremely gratifying to see someone who was not able to walk due to their illness now performing tasks they love, like gardening or traveling with family members.
Does LIJ have a target length of stay for TAVR patients?
Jose: Every patient is treated individually, but on average, our patients have a 5-day hospital stay. Usually patients spend one day in the intensive care unit and then are transferred to the telemetry floor prior to discharge. If a patient requires longer hospitalization, by no means do we discharge them.
What kind of discharge planning and materials do you provide?
Effe: I provide the patients pamphlets of information during the initial TAVR consultation. Cardiac models and computer-simulated demonstrations of the procedure are often used as tools to educate and reinforce what is provided in the written materials. From the very beginning, we encourage family support and educate families about what to expect post-operatively. We take a proactive approach to determining a patient’s post-operative course as early as the initial patient assessment by reviewing key markers that might lead to challenges, such as nutritional markers, blood glucose levels, and kidney function. While hospitalized, our multidisciplinary team approach ensures a fluid and comprehensive treatment care plan. At discharge, patients are given written documentation and clear instructions including review of medications, wound care, and follow-up visits. Patients are offered the option of joining Northshore–LIJ Health system’s “Follow Your Heart” program, which was created to ensure seamless continuation of care and reduce readmissions. The program allows a mid-level practitioner, who was previously caring for the patient during hospitalization, to visit them in their home or facility, on the second and fifth day after discharge. During these visits, the physician assistant or nurse practitioner performs a clinical exam, reviews medications, and addresses any medical or psychosocial needs. The assessment and possible changes in care are communicated to the NS-LIJ Homecare agency, and the cardiac surgery department and/or facility, thus maintaining a solid continuum of care. Patients are comforted because they see a familiar face, someone that has cared for them throughout their stay in the hospital, now caring for them at their home or facility.
Jose: We perform a complete pre-op assessment, giving us a good sense of discharge disposition. The team communicates with the patient and family members throughout the hospitalization, adjusting discharge services depending on medical/social needs. We can gauge whether a patient is going home with or without home health care, to a skilled nursing facility, or to a rehabilitation center. In addition, almost all of our patients opt to participate in our “Follow Your Heart” program. This program provides another layer of care, an extra set of eyes, and continues quality care into the community.
How are you evaluating your TAVR program?
Effe: Learning from past experiences is one key to improving the quality of care we deliver. We review best practice models across the world in an effort to streamline and develop our processes for a more efficient and successful program. Important quality metrics include morbidity and mortality, stroke, major vascular bleeding or bleeding events, and pacemaker placement. We are tracking length of stay both pre and post procedure. We are examining the utilization of labor and supplies in the operating room and comparing them to the open AVRs. Cost of pharmaceuticals used during the post-operative period is also reviewed. In addition, we are looking over the utilization of resources post hospitalization, such as a skilled nursing facility, rehabilitation centers, or visiting nurse services. Finally, we are tracking readmission rates within our TAVR population, comparing them to open AVR and other cardiac surgical populations.
Jose: We have been very blessed to have a dedicated team that focuses on every detail. Our mortality rates are very, very low and after 113 TAVR cases, LIJ has had no strokes and no major vascular complications. As a result of the utilization of our “Follow Your Heart” program, our readmission rates have declined, not only for TAVR, but for all cardiac surgery cases. Other institutions in our health system have reported a decrease in readmission rates due to this program.
Effe: In order to have a successful TAVR program, it is very important to have a dedicated and consistent team. Team members must be committed to education, as the field of transcatheter therapies continues to evolve. One needs to take the time to understand this patient population, in order to deliver excellent care and optimize surgical outcomes.
In order to complete this educational activity, please visit the website to answer questions and obtain your certificate:
https://www.cathlabdigest.com/TAVRprogramLIJ
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Check out the first article in Cath Lab Digest's TAVR CME/CUE series: "Planning and Developing a Successful TAVR Program at Maine Medical Center: Economic, Program, and Procedural Considerations"
