TAVR Patient Goes Home Same Day as Procedure
March 31, 2022
UH Clinical Update | April 2022
Success a collaboration of Valve and Structural Heart Disease Center, Hospital@Home, Cardiac Cath Lab, Meds to Beds
University Hospitals Harrington Heart & Vascular Institute has a tradition of innovation when it comes to transcatheter aortic valve replacement (TAVR). Over the past 10 years, a dedicated UH heart team (interventional cardiologists and cardiac surgeons) have pioneered a minimalist approach, performing the procedure while the patient is awake under minimal sedation and local anesthesia. The indications for the procedure have changed dramatically. Low-risk patients with aortic stenosis are now candidates for this procedure, and they demand even more less- invasive procedures and shorter hospital length of stay.
The latest innovation for the UH TAVR team? Partnering with UH’s new Hospital@Home program to send a TAVR patient home the same day as the procedure. The patient arrived home at 3:30 p.m. after a 7:30 a.m. procedure, supported by Hospital@Home, and was discharged after a second visit from Hospital@Home the next morning.
“This allowed the patient to recover in her home post-TAVR with continued hospital-level care,” says Lori Hammer, BSN, RN-BC, Manager of the Valve and Structural Heart Disease Center. “It turned out to be a really great experience for us. It was great collaboration between the teams. Meds to Beds also brought up the prescriptions she needed to go home.”
Hospital@Home care in this case began with a trip to the patient’s home in an ambulance staffed with a medic team. Once in the patient’s home, the medics outfitted the patient with a Masimo remote monitoring device, did a head-to-toe check, checked vitals and initiated the first Zoom call with the care team. This team included a nurse, pharmacist, the provider, the on-site medic and the patient, as well as Hammer, since this was the first TAVR case.
“Everyone was on the same page as far as what orders to do what care to provide for this patient, things to look out for and signs and symptoms of a potential complication,” says Jillian Lavender, MSN, RN, ONC, Assistant Nurse Manager with Hospital@Home.
That’s actually one of the clear advantages of the Hospital@Home model, Lavender says.
“Everybody on the team is hearing the same consistent message at the same time,” she says. “That eliminates a lot of confusion with the team about the plan of care, such as ‘I heard this, but you heard that.’”
The next morning, Hospital@Home sent a portable chest x-ray technician to the patient’s home. The medic collected labs, did a repeat EKG along with the vital signs and a head-to-toe assessment.
“The patient had all her blood work and testing done, we resulted the blood work and the x-ray then we were able to go ahead and proceed with the discharge,” Lavender says. “That is our goal for these patients to discharge next day.”
The Valve and Structural Heart team has very strict clinical criteria to identify the patients who would be the best candidates for Hospital@Home post-TAVR same day discharge -- one reason why this first case went extraordinarily smoothly, Hammer says. Patients excluded from consideration are those who are extremely frail or with an ejection fraction of less than 30 percent. TAVR patients eligible for Hospital@Home must also have adequate kidney function and not have any condition requiring blood transfusions or platelets post-procedure, to minimize any risk of a post-procedure complication. Patients with underlying heart rhythm problems are also not eligible.
Once a potential candidate is identified during the initial consult, the interventional cardiologist Guilherme Attizzani, MD, and cardiac surgeon Cristian Baeza, MD, raise the possibility with the patient, who is scheduled to be admitted as first procedure of the day. A final decision about whether Hospital@Home is a good option is made weighting different clinical criteria during and after the actual TAVR procedure.
In this first case, the patient’s social support at home and willingness to engage with Hospital@Home were also keys to this successful initial result, Hammer says.
Hammer personally followed up with a phone call a few days before the procedure to make sure the patient was on board. She was. That was also followed by an in-depth call from the Hospital@Home team to discuss specific details and alleviate any concerns.
The patient even agreed to pose for a photo with the Structural Heart team before leaving the UH catheterization lab with the Hospital@Home team.
“We asked if she wanted to stand up or be on the stretcher, and she said I'm fine standing up,” Hammer says. “She looked great, and she looked wonderful on the Zoom call the next day with the Hospital@Home team.”
Hammer says that given the pace of innovation with TAVR and the ongoing scarcity of hospital beds, she wouldn’t be surprised if same-day discharge becomes a more common option for patients. Some centers are doing it now, but UH is taking a more conservative approach of starting first with Hospital@Home as a support, she says.
“But hopefully, we'd like to see a quarter to a half of our patients being able to leave the hospital on the same day, whether it's with Hospital@Home or same day.”