Initiation of DT LVAD Programs at Non-transplant Centers

Rohinton J. Morris, MDAbington Health Systems

DT Program

Reasons Logistics Process Results

Abington Hospital

600 bed capacity Cardiac surgery since 1996 –

3-400 cases/year Two cardiac surgeons All cases done, except for

transplant 17 & 8 member Cardiology

groups 6 cardiac cath labs Heart Failure Service Community of the Elderly

Reasons

Abington, PA

COMPETING FORCES

4 surrounding transplant centers

22 cardiac surgery centers in 20 mile radius

Population of 8 million in surrounding Phila area

Local population of 800K in primary service area

LOCOREGIONAL NEEDS

15 miles from Philadelphia

Acceptance that VAD is one part of Rx for Advanced HF

Why a VAD program?

Primary Belief:

Why a VAD program at__(Abington)

__?

Service of community – elderly, inadequacy of HF support

Complementary HF services – to cath lab, EP service

High-risk cardiac surgery Satellite to a transplant program

Why a VAD program? –Ext/Int

HEART FAILURE

Primary cause of death in the U.S.

#1 DRG for admissions

Advanced HF is its own specialty – board certification by ACC

Demographics of US population leading to…greater prevalence of HF

SURGICAL/CARDIOLOGY COLLABORATION

Team approach to chronic disease

Clinicians at front line-but everybody in hospital involved – administration, social work, ER, primary care, subspecialties.

Why should LVAD management be performed in the community

1. Better appreciation of the natural history of heart failure will improve outcomes clinically

Treatment options offered to local patients

Utilization of resources efficiently

Earlier recognition of advanced heart failure

134HTx centers

Advanced Heart Failure Care: An “Ivory Tower” at Academic Centers

• Heart failure, as a specialty, has lagged significantly behind other areas of cardiology in diffusing to the community– CABG– PCI– ICD -> Biventricular pacing -> afib ablations

• Heart failure outcomes in the community are poor– 30 day readmission rates up to 25%– Average LOS nearly 7 days

Advanced Heart Failure Care: An “Ivory Tower” at Academic Centers

• Heart failure, as a specialty, has lagged significantly behind other areas of cardiology in diffusing to the community– CABG– PCI– ICD -> Biventricular pacing -> afib ablations

• Heart failure outcomes in the community are poor– 30 day readmission rates up to 25%– Average LOS nearly 7 days

Hypothesis:

Poor penetration of advanced HF care Poor clinical outcomes

are driven (largely) by failure to identify stage D HF

DT programLogistics

Elements of a Successful Program

INFRASTRUCTURE

Surgical, cardiologic focus

Special people – VAD coordinator, HF social worker

Involvement of multiple departments- Nutrition, Phys Ther, echo, ID, Psych,

Administrative belief

EMOTIONAL COMPONENTS Mission buy-in Culture of a village Nursing specialization

Identify Timeline

Begin w End –goal : Implantation Work backwards – from Patient

identification Identify team components Start with basic elements of team

#1

Basic team members

Committee formation

Pt identification

Simulation – FMEA process

FMEA –Failure Mode & Effects Analysis

Identify personnel needed Identify equipment/space/peripherals What departments are involved?

Who needs education? What are weak links? What are likely failure modes?

FMEA

FAILURE MODE VAD coordinator sick Device malfunction Slow timing of lab

results Lack of blood

products Multiple pt

requirements Operative

misadventure Caregiver stress

CHANCE OF OCCURRENCE/EFFECT – SOLUTIONS??

Likely/ Moderate Unlikely/ Drastic Very likely / Serious Possible/ Serious Likely / Mild (Abstain)/ Serious Likely/ Moderate

FMEA Process___(Failure Mode &Effects Analysis)

•Mock VAD Implant

•Interdisciplinary team involvement

•Debriefing after 1st LVAD implant – 1/24/2012

•Guided by Center for Patient Safety and Healthcare Quality

• Maria Wilson & Nancy McMann

Timeline

FMEA

VAD Surgeon(2010)

VAD Coordinator(2011)

Heart Failure Clinic

Establish Administrative & Clinical Committee

Identify Candidates

1st VAD Implant

Joint Commission Destination Therapy Certification

Heart Failure specialist to start Jan 2013

Continued Program Growth

DT Program - InfrastructureProcess

The VAD Team

PRIMARY

Cardiac Surgeon Heart Failure

Cardiologist VAD coordinator Social Worker Heart Failure Nurses Financial manager Administrative

support Echocardiographers

ESSENTIAL

Nutritionist Physical Therapist Rehab Outpatient Nursing

Laurence MerlisPresident & CEO

Margaret McGoldrickExecutive Vice

President & COO

Terry O’ReillySenior Vice President, Patient Safety & CNO

Dr. John J. KellyChief of Staff

Marni GubaDirector, Cardiovascular

Service Line

Theresa ReillyDirector, Critical care Services

Dr. Richard EisenstaedtChairman, Department of Medicine

Dr. John KukoraChairman, Department of Surgery

Dr. Robert WatsonChief of Cardiology

Director, Comprehensive Heart Failure Program

To Be NamedCo-Director, CHFP

Medical Director, MCAP

Dr. Rohinton MorrisChief, Cardiothoracic Surgery

Medical Director, Cardiovascular Service Line

MCA ProgramKevin Hagan, VAD Coordinator

Education VAD Inpatient VAD OutpatientVAD Committee

Performance Improvement Research INTERMACS

•Cardiology

•Cardiac Surgery

•Anesthesia

•Perfusion

•OR Staff

•Nursing

•Social Work/Case Management

•Physical/Occupational/Speech Therapy

•Nutrition

•Finance

•Palliative Care

Mechanical Cardiac Assist Program –Organizational Structure

MCAP Team Members Chief, Cardiothoracic Surgery Chief of Cardiology VAD Coordinator HF Nurse Practitioner CT Surgeon HF Cardiology Social Work –HF dedicated Financial Coordinator Nutrition Physical/Occup/Speech Therapy Palliative Care HFU, CICU Nursing Staff CNS (Clin Nurse Spec) Heart

Failure Unit Critical Care Educator

• Home care• Rehab• Anesthesia• CT Surgery Team – OR RNs,

RNFAs, CT NPs• Perfusion • Pharmacy• Echocardiography• Cardiovascular Service Line

Director• Nursing Administration• Hospital Senior Leadership

“We asked each segment to send at least one designated person to the FMEA process”

Mechanical Cardiac Assist Program

Interdisciplinary team meetings Operations group meeting – includes

administration Outpatient VAD Clinic

Combined with Comprehensive Heart Failure Program

Overlap with Aquapheresis Program Collaboration with multiple transplant

centers Participate in INTERMACS Registry

Patient Flow

Majority of patients present via Comprehensive Heart Failure Program

Major focus on PCP education & referral Self-referred Hospital units impacted:

OR - Cath Lab CSU - Acute Rehab Unit HFU ETC

Staff Education Nursing competency

Specialized nursing units: CSU, HFU Annual unit competencies New user training class Sim Lab – in development

Physical & Occupational Therapy competency Specialized for VAD pt care Annual requirement

Rehab unit competency Thoratec online training

Follow-Up Care

Transplant Center

Community Goals

“SHARED CARE” New Paradigm of care Greater access of care

for patients Multiple practice

involvement Relief on implanting

site for followup care Revenue sharing

Complication Management

Local Volume issues / flows Minor perc site

infection Gout Fracture in drive line

casing local help from Thoratec engineer

Acute pulmonary edema local ER

Routine alarms Mild anemia Blood pressure

Referred Profound anemia

GIB Drive line infection

with sepsis VT + MV endocarditis

ICD generator change

Cataract surgery Hyperkalemia

DT ProgramResults

Program growth

2012 2013 2014 2015 2016

4 12 16 9… ???

--Yearly growth

--Total referrals : 131

--Following 43 patients

--One-year mortality:9.7%

--Two VAD changeouts

IM-1 IM-2 IM-3 IM-4 IM-5

1 17 11 12 0

Administrative concerns“Besides payment”

Performance Improvement Plan

The Mechanical Cardiac Assist Program created a Performance Improvement (PI) Plan to: Monitor the process and outcome of patient care

Promote safe, quality and timely provision of care

Improve the knowledge and skills of the MCAP team Provide the structure that supports performance

improvement

The MCAP PI plan is integrated with AMH’s

organization-wide PI activities

Profitability

Patient selection –biggest driver of outcomes

LOS –everybody contributes Readmission blues

Medical issues Psychosocial issues

Administration pitfalls Coding/Billing/Collecting Staffing

Program Growth Goals

Advanced Heart Failure specialist joined team Jan 2013

Community outreach Chairman’s Forum Primary Care Update

Physician outreach / in-reach Internet promotion Large DT population in service area –

Culture of the Elderly

–Program Growth- ”Keep track”

September 2011 – Present (Apr 2015): VAD/Tx Evals: 129 Recommended VAD/Tx: 47 VAD Implants: 46 (41 @ AMH) TxListed/Potentially Listed (But not

VADed): 5

Outcomes

JACC (Jun 2011) – Showed outcomes were no different in 55 pts that were BTT or DT (split by age 70) at a 386 bed community hospital Lead author Robert Adamson –Medical

director of cardiac transplantation program at Sharp Memorial Hosp, S.D.

Outcomes

Ann Thor Surg – (John, Oct 2011)- PMA study.

Compared outcomes of 486 pts @ 36 centers during clinical trial, to 1496 pts @ 83 centers posttrial. Kaplan-Meier survival increased (76 to 85%) in 2nd group. Presented at AATS-First discussant: “That new

VAD technology that utilizes continuous flow. . .can be taught along with appropriate patient selection and disseminated to a broad range of clinical centers.” M. Acker –Chief of Cardiac Surgery -UPenn

Conclusions

DT is no longer the “future”—It’s here.

More DT/advHF programs are needed for the community.

A team approach—including hospital administration & staff– is necessary.

Careful construction, continuous monitoring and PASSION give great outcomes.

Thank YouQuestions?