Hospital Care Structure and Self-Care Education Processes of

Ventricular Assist Device Programs: A National Study

S. Brian Widmar PhD, RN, ACNP-BCAnn F. Minnick PhD, RN, FAAN

Mary S. Dietrich PhD

2012 State of the Science Congress on Nursing Research1

Acknowledgements

• Use of the VU REDCap Survey service• Grant support: UL1 TR000445 from NCATS/NIH

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Significance: Why VAD Self-Care Processes?

• ↑prevalence and incidence of CHF• 2007: 5.2 million, 550,000 annually• 2011: 6 million; 670,000 annually

• Increasing indications for VAD therapy• VAD has emerged as HF therapy– 2007: 208 patients 2011: 1,450 patients

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Why Self-Care Processes• VAD care is complicated, continually

demanding and intimidating to patients

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Why Self-Care Processes

• VAD is an exemplar of new technology requiring self-care processes – what is learned about VAD may help with other technologies.

• Professional experience with different methods of VAD education

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Gaps and Unknowns

• How VAD patients learn self-care• How self-care education is provided; resource

utilization• Extent to which type, method, and/or

provider of self-care education influences outcomes

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Aim

• To describe care structures and self-care education processes used in VAD hospitals

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Methods and Analyses• AIM: To describe care structures and self-care

education processes used in VAD hospitals– Concepts: Definitions and measurement– Questionnaire development and testing– AHA Data– Human Subjects Protection

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Administration• Sources of VAD Hospital Addresses• Inclusion criteria• 111 eligible• 3 cycles, 3 weeks apart• Paper or internet option

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Methods

• AIM: To describe care structures and self-care education processes used in VAD hospitals– Response rate: 64%– Generalizability tests

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Results:Organizational Framework

• More than half of VAD programs reported to > 2 departments

• > 75% of VAD Coordinators reported to >2 administrators

• Patient-to-Coordinator census– Median = 15; IQR (10, 20); range 2-40 pts/VC

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Results: Healthcare Structure – Organizational Framework

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Healthcare Provider Assignments in VAD Hospitals (N =71)

Healthcare ProviderAssignment Type*

% of row1 2 3 4

Cardiac Surgeon 4 96 0 0Heart Failure Cardiologist

6 90 3 1

Clinical Nurse Specialist 4 31 17 48

Nurse Practitioner 23 54 11 13Discharge Planner 3 69 13 16Biomedical Engineer 14 45 24 17Pharmacist 7 61 27 6Social Worker 9 86 6 0Physical Therapist 1 70 27 1Clinical Psychiatry 3 47 32 17Clinical Perfusionist 4 61 24 11Home Health Nurse 3 27 47 24Respiratory Therapist 3 41 45 11Dietician 4 76 20 0Chaplain 1 45 44 101 = Works with VAD Program Only2 = Same provider regularly assigned but also works with other kinds of patients3 = Not regularly assigned to VAD program, but is available as needed4 = Provider not currently available to VAD program

Note. Items may not add to 100% due to rounding. *Values in cells are row %s.

Results: Health Care Structures – Caregiver Role Delineation

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Results: Health Care Structures – VAD Coordinator Role Delineation

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Role Components (N = 71)Role Component % Role Component %

Development of VAD nursing education

96 Database entry of clinical data 79

On-call patient care responsibilities

95 Direct care nursing (outpatient) 75

Train staff at Subacute/Rehabilitation Facility

93 Maintain inventory of VAD equipment

74

Emergency Response Personnel (EMS) Education

93 Advanced practice nursing (inpatient) 59

Provide nursing staff education 90 Case Management 58Evaluate nursing staff education 85 Direct care nursing (inpatient) 56Research (Outcomes or Clinical) 85 Advanced practice nursing

(outpatient)55

Train housestaff 82 Other 17

Self-Care Education Processes: LVAD Self-Care Validation (N = 71)

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Skill Return Physical Demonstration

%

Skill Return Physical Demonstration

%Battery Changes 99 Emergency Management 52

Dressing Changes 99 Patient Showering 51

Self-Testing System Controller

94 Recognizing Infection 42

Care of the LVAD Percutaneous Driveline 90

Hemodynamic Monitoring 27

Sterile Technique 89 Medication Management 27

Alarm Troubleshooting 59 CHF Symptom Management

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Power Source Changes 54  

Self-Care Education Processes:% of Programs Using Only 1 LVAD Self-Care

Evaluation Method (N = 71)

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Skill % Using 1 Method

Skill % Using 1 Method

Medication Management 54 Battery Changes 32CHF Symptom Management 52

Hemodynamic Monitoring 31

Dressing Changes 44Care of the LVAD Percutaneous Driveline 30

Sterile Technique 44 Power Source Changes 28Self-Testing System Controller 42 Emergency Management 21

Patient Showering 39 Alarm Troubleshooting 17Recognizing Infection 37  

ResultsCapital Inputs

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Materials Used by Hospitals for VAD Patient Self-Care Education (N = 71)Resource Frequency Used

%Written material developed by device manufacturer/others

96

Verbal Instruction 96Written material developed by hospital or unit 90DVD 89Internet Website(s) 66CD-ROM 21Videotape 18Audio CD 11Podcasts 6Other 17

Self-Care Education Processes: Patient Support

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Organizational Resources for VAD Patients and Family/Caregivers (N= 71)

Resource% of Hospitals with Resources

Available to: Patient Family/Caregiver

Patient Counseling 73 65VAD Support Group Meetings 56 56Hospital Website 45 45Patient-Provider E-mail Correspondence 45 44

Patient Picnics 24 24Facebook/Social Networking 14 14Internet listserv/ Discussion forum 9 9Internet Chat Rooms 6 6

Results: Cluster Analysis (N = 66)

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  Cluster A (N = 29) Cluster B (N = 37)

CapitalInputs

Additional Materials Used for Education

   

Videotape 45% reported use 0% reported useAudio CD 21% reported use 5% reported useInternet Websites 76% reported use 65% reported usePodcasts 14% reported use 0% reported useCD-ROM 14% reported use 30% reported use

       

Support Processes

Additional Resources Used for Patient and

Family/Caregiver

   

Patient Picnics 48% reported use 3% reported useInternet Listserv/Discussion Forums

21% reported use 0% reported use

Internet Chat rooms 14% reported use 0% reported useSocial Networking Sites 35% reported use 0% reported use

       

LaborSum of Healthcare Providers

on VAD Team83% Same providers work regularly with VAD program, others are available as needed

81% Same providers work regularly with VAD program, others are available as needed

       

DemandActual Number of VAD

Implants in Last Fiscal YearMedian = 16, IQR = 10-36 Median =21, IQR = 9-38

Limitations

• Additional VAD hospitals may exist but not likely

• Lack of financial/budget information

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Implications: Clinical

• VAD programs should evaluate their existing care processes and supportive resources• Use > 1 method for validation• Use of simulation?

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Implications: Future Research• Measurement of patient centered care

satisfaction with SCE within VAD hospitals*• Explore relationship of patient satisfaction

with patient service usage and health outcomes

• Explore relationships of VAD program SCE elements and other patient outcomes– Mortality, quality of life, complications

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Implications• Evaluate VAD coordinator preparation to teach

• Evaluation of current staff RN and VAD Coordinator orientation programs– Are current methods of orientation and training

adequate?

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Next Steps

• Describe reports of patient preference for– Methods used for self-care training– Methods used for evaluation of self-care

• Exploration of patient and family/caregiver perceptions of difficulty of VAD care skills

• Exploration of Staff RN and VAD Coordinator orientation programs

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Next Steps

• Apply a similar approach to the cardiac transplant patient population

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Questions?

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