Vancouver Transcatheter Aortic Valve Replacement Clinical Pathway

Abstract

Abstract-We describe the development, implementation, and evaluation of a standardized clinical pathway to facilitate safe discharge home at the earliest time after transfemoral transcatheter aortic valve replacement. Between May 2012 and October 2014, the Heart Team developed a clinical pathway suited to the unique requirements of transfemoral transcatheter aortic valve replacement in contemporary practice. The components included risk-stratified minimalist periprocedure approach, standardized postprocedure care with early mobilization and reconditioning, and criteria-driven discharge home. Our aim was to reduce variation in care, identify a subgroup of patients suitable for early discharge (≤48 hours), and decrease length of stay for all patients. We addressed barriers related to historical practices, complex multidisciplinary stakeholder engagement, and adoption of length of stay as a quality indicator. We retrospectively reviewed the experiences of 393 consecutive patients; 150 (38.2%) were discharged early. At baseline, early discharge patients had experienced less previous balloon aortic valvuloplasty, had higher left ventricular ejection fraction, better cognitive function, and were less frail than the standard discharge group (>48 hours). Early discharge was associated with the use of local anesthesia, implantation of balloon expandable device, avoidance of urinary catheter, and early removal of temporary pacemaker. Median length of stay was 1 day for early discharge and 3 days for other patients; 97.7% were discharged home. There were no differences in 30-day mortality (1.3%), disabling stroke (0.8%), or readmission (10.7%). The implementation of a transcatheter aortic valve replacement clinical pathway shifted the program's approach to combine standardized processes and individual risk stratification. The Vancouver transcatheter aortic valve replacement clinical pathway requires a rigorous assessment to determine its efficacy, safety, and reproducibility. Goals and Vision of the ProgramTranscatheter aortic valve replacement (TAVR) is a recommended treatment for inoperable and select higher surgical risk patients with severe aortic stenosis. [1][2][3] In the first decade of therapy development, careful case selection, increased periprocedural expertise, and enhanced technology have contributed to improved outcomes and patient access to TAVR. 4,5 Interest is shifting from "How we do TAVR" to "How we care for TAVR patients" to further optimize outcomes, reduce health service utilization, and contribute to the sustained success of transcatheter heart valve therapies. 6 Duration of hospital stay is an indicator of quality of care and a predictor of outcome in the elderly population. 7 There is a significant variation in reported postprocedure length of stay (LOS) after TAVR, ranging from 1 to >10 days.8-10 Similar variation exists in patients' disposition at the time of discharge; for example, the US Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy registry reported i...

Factors associated with length of stay following trans-catheter aortic valve replacement - a multicenter study

“…Indeed, other groups are evaluating the use of conscious sedation in combination with a care pathway to facilitate next day discharge post TAVR [29–31]. Conscious Sedation and non- surgical access have been associated with less delirium and might explain the shorter LOS.…”

Incidence, determinants and consequences of delirium in older patients after transcatheter aortic valve implantation

“…Severity of delirium was defined by the delirium observation score [ 26 ]. In case of delirium, patients were treated according to current national guideline ‘Delirium in adults’, Dutch Geriatrics Society [ 16 ].…”

Exploring the Reduction in Hospitalization Costs Associated with Next-Day Discharge following Transfemoral Transcatheter Aortic Valve Replacement in the United States

“…24 Single site studies have reported savings of $10,000 to $16,000 for patients treated with a minimalist approach and discharged within shorter LOS without compromising patient safety. [25][26][27] The recent publication of the Multimodality, Multidisciplinary but Minimalist TAVR (3M TAVR) study demonstrated the safety and reproducibility of the Vancouver TAVR Clinical Pathway 23 to facilitate NDD home in over 50% patients screened at 13 TAVR centers of varying procedural volume and program maturity while achieving excellent clinical outcomes. 13 Careful attention to all components of patients' journey of care is essential to consistently achieve similar results.…”