CME/CEU Reducing Length of Stay and Enhancing Clinical Outcomes for TAVR Patients with a Focused Clinical Pathway

As hospitals’ transcatheter aortic valve replacement (TAVR) programs evolve, patient length of stay (LOS) and enhanced clinical outcomes have been recognized as opportunities for program optimization. Less invasive, safe, and quality focused care targeting early patient mobility and efficient discharge may enhance patient quality of life while contributing to the success of the TAVR program. “We know the longer the patient stays in the hospital, the more complications they can have,” said Dr. David Brown of The Heart Hospital Baylor. “Decreased LOS can have a significant and positive impact on TAVR quality outcomes.” Recent data from the Society of Thoracic Surgeons (STS) and the American College of Cardiology (ACC) Transcatheter Valve Therapy (TVT) Registry shows the median overall LOS for TAVR procedures at 6 days (5 days for transfemoral access and 8 days for non-transfemoral access routes).¹  

The 2012 Medicare Provider and Analysis Review (MedPAR) data for TAVR procedures revealed several hospitals with a better than average LOS for TAVR patients.² During the summer of 2013, four of these hospitals, including The Queen’s Medical Center (Honolulu, Hawaii), Intermountain Medical Center (Salt Lake City, Utah), The Heart Hospital Baylor (Plano, Texas) and Ochsner Medical Center (New Orleans, Louisiana) came together in a best practice and LOS initiative, participating in a full-day roundtable to share their experiences. “This has been a very successful collaboration between the four centers,” notes Dr. Brown. “It has led to a significant improvement in TAVR quality outcomes resulting from shortened LOS.” From this initiative, a post-procedure care and discharge clinical pathway was developed along with plans for a multicenter, observational study to validate the pathway (currently under development). 

Dr. Christian Spies of The Queen’s Medical Center and Dr. Brian Whisenant of Intermountain Healthcare are two of the physicians involved in the LOS initiative. Cath Lab Digest talks to both physicians about how they achieved success at their centers by implementing several of the shared best practices.

A New Perspective and Partnering for Safe Reduction in TAVR LOS 

Christian Spies, MD, FACC, FSCAI

Tell us about the TAVR program at The Queen’s Medical Center.

We are situated in Honolulu, Hawaii, and are the only TAVR program in the state of Hawaii. We didn’t participate in the PARTNER trials, so we started as a commercial site in May 2012, approximately 6 months following FDA approval in November 2011. Since then, we have done nearly 100 TAVR procedures. 

You participated in a TAVR LOS task force initiative in the summer of 2013. What came out of the meeting?

Most important was the recognition that LOS is probably too long for the TAVR procedure and can be potentially safely shortened. During the meeting, four centers came together to brainstorm the most important factors affecting LOS. Obviously, we recognized that LOS should not only be short, but procedural outcomes should be superb, and readmission should not skyrocket — all of which are connected to each other. Each of us brainstormed items that could affect LOS, finding that several fell in the post-operative period. We eventually arrived at a care pathway and are now looking at its impact on patient care and LOS.

What are some of the most important changes to shorten LOS?

The care pathway is categorized into three different aspects: 1) pre procedural patient evaluation and selection; 2) the procedure itself; and 3) post procedural care (the latter shared in Figures 1-2). The pre procedural evaluation focuses on setting expectations with the patient and family straight from the beginning that we are not anticipating the same LOS as after an open-heart surgical procedure. We don’t want patients or their family to be surprised at discharge 2 or 3 days post procedure. Clearly, selecting the right patients for early discharge is crucial. It is important to make sure patients are capable in terms of their co-morbidities, social support, and so on. One change we have implemented (which several other centers have also started to do) is that we do not admit the patient the day before the TAVR. Instead, the patient comes in the day before the procedure, in the afternoon, to do a pre TAVR visit. We do all the blood work, check x-rays, do a meet and greet, and then have the patient go home and come back the next morning for the procedure. That simple change cuts LOS by one day. So those are some of the pre procedural aspects. During the procedure itself, there were several things we recognized. First is to begin with a very clear-cut understanding of how the procedure will take place. The people in the room are briefed beforehand, so no long discussions take place during the procedure about what to do and what not to do — these discussions happen before TAVR, not during TAVR. The shorter the procedure time on a 90-year-old, the better the outcomes and the better the LOS. Second, we now have protocols in place for certain perioperative aspects, similar to the cath pathway. We will ask, is a Swan-Ganz catheter really necessary? How do we anesthetize the patient? Do we use a narcotics-based anesthetic regimen or a non-narcotic-based regimen? Finally, if at all possible, we extubate the patient in the operating room or hybrid room at the end of the procedure, rather than transporting the patient, still intubated, to the intensive care unit. The patient then has a new care environment, new doctors are taking care of the patient, and the inclination, commonly, is to keep the patient intubated longer, which then again hinders quick recovery. 

Is it standard in the U.S. for patients to receive general anesthesia for TAVR?

There are a few centers that advocate conscious sedation. It depends on the access site and comfort level on the physician side. Our feeling is that we will move toward conscious sedation once smaller access is standard. There was a long discussion on this topic while we were at the LOS meeting. The TAVR procedure takes one hour, and it is debatable whether the patient being under general anesthesia for one hour, versus deep sedation and avoidance of intubation, results in differences in LOS or quickness of recovery. Another possibility discussed was using a laryngeal mask airway (LMA), rather than endotracheal intubation, and using deep sedation, as opposed to general anesthesia. The end result remains in flux, and may be implemented by us locally once smaller sheath sizes are available.

You mentioned setting expectations with the patient for early discharge. Can you share more about what that involves?

Yes, we set the expectations well prior to the procedure. The patient also will meet with a physical therapist, who explains that the patient is expected to be sitting up in a chair after TAVR in four hours, and to potentially be up and ambulating within a few hours after sitting up. 

The post procedural recovery and care pathway now has different expectations, including when the A-line is removed, when the central line is removed, and when the Swan-Ganz catheter is removed (if one was placed at all), as well as weaning the patient off oxygen, getting the patient out of bed, and making him or her ambulatory. At The Queen’s Medical Center, patients have 4 hours of bed rest, and then are expected to be up in a chair and ambulate in the room the day of the TAVR. Early ambulation is key.

The care pathway is determined by access?

Yes, there is one transfemoral and one transapical/transaortic care pathway. 

How does ambulation differ by type of access?

Transapical access patients always lag a few hours behind. The transaortics actually have less pain issues than the transapicals, because a thoracotomy hurts more than a stenotomy. We can ambulate patients with a stenotomy and the transaortic approach in a timeframe equal to transfemorals — after 4 hours. The transapical patients usually take 6-8 hours until ambulation.

What is your percentage of transfemoral access patients? 

About 75% of our patients undergo transfemoral access. At our center, there are more problems with small vessels because of small body size — perhaps due to our Asian population — instead of peripheral arterial disease. Scientifically, data support transfemoral patients doing better overall than transapicals. There is debate as to why that is, whether it is due to co-morbidities or because the procedure is more morbid. We try to do as much transfemoral as possible. Even if the patient is borderline size for the access, at least we will give it a try, and if we cannot get the sheath up, only then will we convert to a transapical or a transaortic approach. If there is a chance we can go transfemoral and it is borderline, we will attempt to do so. 

After implementation of the new care pathways, what have you observed in terms of complications?

We have observed no change in complications. The numbers are not huge, because this is a young project, so take all of that with a grain of salt, obviously. Our LOS was low to begin with, which was one of the reasons we were selected to be part of this initiative. So, for us, it is more difficult to demonstrate a reduction in the LOS. We looked at our transfemoral cases before and after implementation of this care pathway. Pre implementation, our mean LOS for transfemoral cases was 3.0 days, and after implementation, it was 2.3 days, so LOS was reduced by 0.7 days. The average LOS for transfemorals in the U.S. is actually longer, about 5 to 6 days. However, documenting a 0.7-day LOS improvement after starting at 3.0 days is still pretty decent. 

What would you recommend to other labs?

First, a recognition and desire to shorten LOS. TAVR is a costly procedure, and if you are running your cath lab program and want to make sure no one cuts your budget, it is important to show the ability to be cost effective. Second, find a champion, probably either the lead cardiologist or the lead surgeon, and team up with a mid-level provider. Another thing we recognized during the meeting is the critical importance of the mid-level provider. It could be the TAVR coordinator or a nurse who coordinates the valve clinic, or even a nurse practitioner or physician’s assistant who is also part of the clinical TAVR team, and involved in the patient’s care before and after the procedure. Put that person in charge of moving forward with a LOS initiative. Centers can begin with a few basic but significant changes: avoid admission before the day of the procedure and make sure to select the right patients to have a chance for early discharge. For example, a patient who is in acute heart failure should not get TAVR. That person should first be recompensated and then undergo TAVR in a clinically compensated state. Ochnser coined the term “prehab” (rather than rehab). It means the patient is technically a TAVR candidate, but is not fit enough. At Ochsner, these patients go through physical therapy before the TAVR procedure to make them more fit, and then their LOS is shorter. We began to do this ourselves and now do a few weeks of physical therapy before TAVR. 

Is prehab a relatively new development for TAVR programs?

I think so. It was part of the take-home points, and that was why the meeting was so great, because everyone had different ideas, and everyone was able to grab an idea that was new to them and go home with it. One of the ideas I picked up was prehab, and I think it works. 

Aside from helping to lead the charge, how else can the mid-level provider help to shorten LOS?

The mid-level provider is very helpful in making everyone understand that TAVR is not open-heart surgery. It is a common misconception for staff in the hospital to treat TAVR patients according to pathways and order sets from open-heart surgery. For example, the thought that all TAVR patients should automatically get Swans. It has the ultimate impact of making TAVR patients appear sicker than they actually are, with more lines and more complex care protocols than they actually need. 

A possible observational study looking at the care pathways is still in the planning stages?

Yes. It’s a stepwise process. The first step is to demonstrate that the care pathway can be implemented, and it can be implemented safely, and then the next step is to have it tested on hospitals with a long length of stay in order to show it is actually efficient as well.

Any final suggestions? 

We feel very strongly about involving a geriatrician in our multidisciplinary TAVR team. Every patient is seen and evaluated by a geriatrician for appropriateness. The geriatrician will discuss appropriate care, code status and advanced directives. The geriatrician will also follow up with the patient during their hospital stay and with the TAVR team, to address things like delirium, for example. If you give a 90-year-old patient Benadryl, it provokes delirium and that prolongs length of stay. We try to be extremely restrictive with narcotics to avoid delirium in elderly patients. We have found that the involvement of a geriatrician is quite helpful.

Start from the Beginning to Shorten TAVR LOS 

Brian K. Whisenant, MD, FACC

Tell us about the TAVR program at Intermountain Healthcare.

Our first TAVR took place in May 2009 as part of the PARTNER I trial. We have now done nearly 300 total TAVRs as part of either the PARTNER trials or with the commercially available valves. Our structural heart disease team of nurse practitioners, surgeons, cardiologists, and research and program coordinators collaborate closely in the care of our TAVR patients. 

How is length of stay determined?

Our care pathway and LOS are influenced by a combination of the access route, procedural results, and most importantly, the patient’s functional status and comorbidities. Transfemoral procedures are less invasive and have a shorter LOS than the alternative access procedures. Transfemoral procedures that are performed percutaneously without surgical access certainly facilitate early ambulation, which in turn facilitates the shortest LOS.

What has been the impact of the LOS initiative?

We made a concerted effort to reduce our LOS, but this initiative is not just about LOS; it is much more about overall quality of care. LOS is one component of that. The LOS initiative was an opportunity to review our program and think about what we were doing right and what we could do better. After the summit, we implemented many of the changes that were discussed. These changes have clearly shortened our LOS.  More importantly, they have enhanced our overall patient outcomes. 

What were some of the changes that were discussed?

Perhaps the most important change was the focus on early ambulation. As many of these patients are elderly and frail, the longer they stay in bed, the longer it takes them to get up and moving. Simply by focusing on early ambulation, we have found that our patients recover quickly and more fully. They leave the hospital earlier and with more confidence in their ability to accomplish their physical goals.

When patients are evaluated for a TAVR, how important is the ability to get up and walk?

I routinely invite my TAVR candidate patients to walk with me in the halls. The ability to walk and a desire to walk are certainly related to the derived benefit of TAVR. While we do offer TAVR to patients with limited mobility, those with markedly limited mobility, particularly when elderly and frail, cannot always achieve their health goals. Counseling patients regarding their decision to pursue TAVR is an important part of our TAVR evaluation. Cognitive function and a supportive network of family or friends help patients achieve their health goals and are also considered as we evaluate patients.

What about evaluation of frailty?

Frailty is a common reason to consider TAVR as opposed to surgical aortic valve replacement. However, frailty is a broad word that encompasses many factors. We strive to provide patients with durable enhanced quality of life with TAVR. An elderly, mobile, and active patient with a small body mass is the classical frail patient who may derive tremendous benefit from TAVR. Some patients who rely on others for daily care or who demonstrate cachexia also meet our frailty definitions and may not derive a durable quality of life from TAVR. Frail patients by definition have little reserve and benefit from limited periods of immobility.

How did you focus more closely on improving ambulation?

A small group of providers, including other physicians and nurse practitioners, have primary responsibility for our uncomplicated TAVR patients. This small group understands our patients, our care pathway, and prioritizes early ambulation. There was initially some reluctance to depart from more traditional care patterns, but over time, the greater group of intensivists, nurses, therapists, and others who are absolutely essential to our program have also recognized the benefits of early ambulation. Simply establishing a goal of procedure-day ambulation is the most important step. Percutaneous access for transfemoral procedures has certainly helped. Ambulation is difficult for patients and their caregivers when patients are tied up with central and radial lines, IV medications, oxygen, and Foley catheters. If appropriate, we tell patients that we would like them to walk 6 hours after their procedure.  We then work to discontinue lines and provide the patient with the support they need to accomplish this goal.  

How many TAVR patients undergo transfemoral access at your center?

About two-thirds of our patients have a transfemoral procedure, almost all of which have percutaneous access using the Perclose system (Abbott Vascular) for closure. About one-third to a quarter of our patients have alternative access, either transapical or transaortic access. 

Does that proportion hold for the general U.S. population?

Access patterns seem to be institution-specific. There are institutions with a much higher incidence of transapical or transaortic procedures. There are also valves that do not have a transapical option. However, centers using non-transapical valves have a higher rate of transaortic and subclavian access. In Utah, we have a lower smoking population than the U.S. average, which probably helps us have a higher percentage of transfemoral patients. 

In addition to early ambulation, what else has been helpful?

Avoiding narcotics has been helpful. Many elderly patients do not do well with narcotics, which increase their risk of aspiration, limit their ambulation, and create confusion and other problems. Paying attention to aspiration risk is important. Another advantage of percutaneous access and the transfemoral approach is that it tends to not be a very painful procedure, thus making it easier to avoid narcotics.

Do patients receive general anesthesia?

Yes, we use general anesthesia for the large majority of our procedures. On rare occasion, in the setting of severe lung disease, we have used anesthesiologist-administered sedation without intubation. While we have had good outcomes with these rare procedures, we universally extubate in the hybrid OR when we are done with our procedures and have found little reason to move away from this practice. Dr. Steven Ramee and his team from Ochsner use deep sedation without intubation for over 95% of their transfemoral TAVR procedures and he believes that avoiding intubation and general anesthesia improves rapid recovery from transfemoral TAVR. They have observed less delirium and total body malaise as well as less atelectasis and fever after deep sedation than general anesthesia.  Steven credits the use of prehab, day of surgery admission, percutaneous access, and deep sedation without intubation as keys to discharging the majority of their transfemoral TAVR patients 1-3 days post TAVR.

Since you implemented this initiative at your facility, what kind of reduction have you seen in LOS?

There are different ways of counting LOS, and it depends on whether you are looking at entire hospitalization LOS or post procedure LOS. There is more noise in the data for entire LOS that is not as sensitive to the implementation of these changes. If we look at the post procedure LOS for our transfemoral patients, it has decreased from about 4.5 days to about 3 days. 

Have you observed any increase in complications or any issues that you didn’t expect?

We certainly have not seen an increase in complications; while we have not quantified our outcomes, my sense is that our patients have done better with more mobility, have been more likely to achieve their health goals, and overall have done very well since implementing these changes. We have observed a small uptick in the need for skilled nursing facilities and early home health.

How are patients handling the requirement for early ambulation?

Educating patients and managing expectations is key. We advise patients when we first meet them that we encourage early ambulation because it leads to better outcomes, and that they will be discharged when they are walking and feel they have recovered. We won’t send them home until they are confident and comfortable that they are ready to be discharged, and anxious to be discharged. We will make sure patients have the resources they need when they go home. These are concerns for our patients. They have been very receptive and appreciate that we are trying to look after their interests to help them recover quickly and fully. 

What is the role of the TAVR coordinator in this initiative?

Both our coordinators, as well as our nurse practitioners, are absolutely essential. Our coordinators know our patients very well and have a personal relationship with them, which provides confidence. Our nurse practitioners spend a lot of time educating our patients and talking about the procedure, both before patients come into the hospital and after discharge. Our patients know how to reach us and know that we are available and receptive to their concerns following discharge. 

You mentioned an uptick in skilled nursing or home care with the reduced LOS. How is that arranged?

The TAVR team requests consults from a physical therapist and a social worker. We are liberal in using physical and occupational therapy consults, and often have both a physical therapist and social worker evaluate our patients in order to address patients’ concerns in advance of the TAVR procedure. 

It seems a reduction in LOS actually begins while you are first evaluating the patient.

The TAVR community has become more sensitive to identifying patients who will benefit from the procedure. The heart team discusses amongst ourselves, as well as with our patients, the likely outcomes and benefits of our procedures. While the large majority of patients referred for consideration of TAVR proceed with the procedure, TAVR is not the right answer for every patient. We look for patients with good cognitive function, who are engaged with people and activities that provide quality of life. If we feel patients would have an enhanced quality of life independent of their aortic stenosis and aortic stenosis-associated heart failure, then we are anxious to move forward and help them when we can. The patients who are motivated, cognitively intact, and anxious to have an improved quality of life tend to do very well.

With a reduced LOS, what impact have you seen at your center?

Our volumes have increased significantly following the initiation of our practice pathway. I attribute this to referring physicians seeing short, uncomplicated hospital stays with improved patient outcomes.  Maintaining a lower census in the hospital because of shortened LOS has given the structural heart team more bandwidth and the ability to accomplish more things. We have not formally looked at cost since initiating these changes. However, TAVR is associated with a favorable contribution margin at Intermountain Medical Center. n 

References

1. Mack MJ, Brennan JM, Brindis R, Carroll J, Edwards F, Grover F, Shahian D, Tuzcu EM, Peterson ED, Rumsfeld JS, Hewitt K, Shewan C, Michaels J, Christensen B, Christian A, O’Brien S, Holmes D; STS/ACC TVT Registry. Outcomes following transcatheter aortic valve replacement in the United States. JAMA. 2013 Nov 20; 310(19): 2069-2077. doi: 10.1001/jama.2013.282043.
2. Medicare Provider Analysis and Review (MEDPAR) File. Centers for Medicare & Medicaid Services. Available online at https://www.cms.gov/Research-Statistics-Data-and-Systems/Files-for-Order/IdentifiableDataFiles/MedicareProviderAnalysisandReviewFile.html. Accessed March 20, 2014. 

Check out the previous two article in Cath Lab Digest's TAVR CME/CEU series:

From November 2013: "Planning and Developing a Successful TAVR Program at Maine Medical Center: Economic, Program, and Procedural Considerations" 

From December 2013: "Focusing on Each Patient: TAVR Care Protocols at Long Island Jewish Medical Center"

From March 2014: "Adding Value with TAVR at the Oklahoma Heart Institute"