Interact CardioVasc Thorac Surg 2009;8:84-88. doi:10.1510/icvts.2008.187377
© 2009 European Association of Cardio-Thoracic Surgery
Institutional report - Assisted circulation |
Multidisciplinary approach decreases length of stay and reduces cost for ventricular assist device therapy
Margaret A. Murraya,
Satoru Osakia,
Niloo M. Edwardsa,
Maryl R. Johnsonb,
Joseph L. Bobadillaa,
Elizabeth A. Gordona,
Mark Sanderfoota and
Takushi Kohmotoa,*
a Department of Surgery, Division of Cardiothoracic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, 600 Highland Avenue, WI 53792, USA
b Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
Received 1 July 2008;
received in revised form 2 October 2008;
accepted 6 October 2008
 Presented at the 42nd Annual Meeting of the Society of Thoracic Surgeons, January 30–February 1, 2006, Chicago, IL.
*Corresponding author. Tel.: +608-262-3858; fax: +608-263-0547.
E-mail address: kohmoto{at}surgery.wisc.edu (T. Kohmoto).
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Abstract
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High implantation costs and long postoperative length of stay (LOS) in debilitated patients complicate ventricular assist device (VAD) therapy. Between July 2000 and February 2005, 30 patients received a VAD at our institution. Of those, 20 patients were successfully discharged from the hospital with VADs. In August 2003, a multidisciplinary team was formed consisting of all services for VAD patients to replace a single-discipline (cardiac surgery) system. This team evaluated potential VAD candidates and identified optimal timing for implantation. These 20 VAD patients were divided into two groups according to the initiation of multidisciplinary team; the traditional group (n=7, July 2000–July 2003) and the multidisciplinary group (n=13, August 2003–February 2005). Patient demographics were not different. The LOS decreased from 61 to 15 days (P<0.01), especially LOS on the floor decreased from 35 to 7 days (P=0.03). The floor cost was significantly reduced ($47,111 vs. $8742, P<0.01), leading to a decrease in total postoperative cost ($202,238 vs. $161,744, P<0.01). The 30-day readmission rate decreased (5/7 patients vs. 1/13 patients, P<0.01). A multidisciplinary approach significantly decreased LOS and cost after VAD therapy, mostly by decreasing the cost of routine non-ICU care, without increasing the readmission rate.
Key Words: Mechanical circulatory support; Ventricular assist device; Congestive heart failure
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1. Introduction
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Multidisciplinary approach has been proposed to improve staff communication, patient outcomes and satisfaction, and reduce length of hospital stay (LOS) [1, 2]. Multidisciplinary approach is resource intensive but provides a comprehensive approach to caring for patients. There are contradicting results from studies on the effectiveness of this approach in various patient populations [2–5].
Over the years, ventricular assist device (VAD) therapy has become an increasing option for patients in end-stage heart failure. High implantation costs as well as long postoperative length of stay in debilitated patients complicate VAD therapy [6–9]. Therefore, it is important for each VAD program not only to improve outcomes, but also to reduce hospital LOS and cost. Transplant centers offer VAD therapy for patients as a bridge to transplant, bridge to recovery, or as a destination therapy. In 2003, HeartMate XVE VAD (Thoratec Corp, Pleasanton, CA) was approved by the food and drug administration for destination therapy. Prior to October 2003, the patients on Thoratec P-VAD with TLC-II device (Thoratec Corp, Pleasanton, CA) could not be discharged from the hospital. These patients significantly increased the overall length of stay and cost for institutions until they were transplanted.
In the past, the VAD patients at our institution were managed by a single discipline team within the cardiac surgery division. In August 2003, we created a multidisciplinary team to streamline care for VAD patients. The purpose of this study was to examine the impact of the multidisciplinary approach in the hospital LOS and cost in patients who underwent VAD therapy, compared with the traditional single discipline approach.
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2. Patients and methods
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Between July 2000 and February 2005, 30 patients received a VAD at our institution. Of those, 20 patients were successfully discharged from the hospital with VADs in this study period. In order to compare the cost and length of hospital stay, these 20 patients with VAD supports were included in this study. The cohorts were divided into two groups according to the implementation of our institutional multidisciplinary VAD patient care program; the traditional group (n=7, July 2000–July 2003) and the multidisciplinary group (n=13, August 2003–February 2005). All patients in these series received the VADs as a bridge to transplant. The details of the devices are listed in Table 1 and include the HeartMate XVE, Thoratec P-VAD and MicroMed DeBakey LVAS (MicroMed Technology, Inc. Houston, TX).
Preoperative diagnosis, preoperative risk factors, preoperative and postoperative LOS, cost after VAD implant and hospital readmission rate within 30 days of discharge were analyzed. In the analysis of the preoperative risk factors, the lab data, such as arterial blood gasses, creatinine and INR, were obtained from the samples immediately prior to going to the operation room (OR). Cardiogenic shock was defined as cardiac index below 1.8 l/min/m2. Recent/acute MI was defined as MI within seven days of VAD implant. Emergent VAD implant was defined as VAD implant surgery within 24 h of admission to our institution. Data were collected prospectively and analyzed retrospectively. The Institutional Review Board committee approved this retrospective study.
2.1. Multidisciplinary team
A multidisciplinary team was developed to streamline the care provided to our VAD patients in August 2003. The team consists of: staff nurses in the cardiothoracic surgery ICU and floor, cardiac surgeons, heart failure cardiology, clinical nurse specialist (device coordinator in our institution), clinical nurse manager, case management and social work, anesthesia, perfusion, pharmacy, respiratory therapy, nutrition, cardiac rehabilitation, physical and occupational therapy, inpatient rehabilitation, and decision support of this institution.
2.2. Evaluation of VAD candidates and preoperative managements
In the multidisciplinary approach, the cardiac surgeons and heart failure team evaluated potential VAD candidates together, starting immediately after admission to our institution, to identify optimal timing for VAD implantation. Special attention was paid not to delay VAD implantation to prevent end-organ dysfunction, such as renal failure, hepatic failure and intubation. Any potential postoperative concerns about VAD implantation, such as lack of social or financial support, lack of compliance, ability to learn and handle each potential devices, etc. were discussed prior to VAD implantation as much as possible, even for the emergent VAD implantation cases. We tried to address these concerns, if present, as much as possible prior to implant. However, no patient was declined VAD implant due to the lack of social or financial support. Once a patient was identified as a potential candidate for VAD implantation, the clinical nurse specialist met with the patient and the family, if available, and explained the device, postoperative course and restrictions after VAD implant. A demo pump was shown to the patient and the family (if time is allowed) to facilitate understanding the device and expectation of postoperative treatment including daily wound care. Thus, VAD teaching started preoperatively in selected patients.
2.3. Postoperative managements
The postoperative medical treatment was co-managed by heart failure cardiology and cardiothoracic surgery teams. The multidisciplinary team rounded together three times per week to discuss patients' progress and any potential discharge issues. Patient and family education began in the ICU setting on postoperative day (POD) one. The education continued daily with the patient and family until discharge. Patients were provided with an educational binder containing information on: device specific handbook, heart failure, medications, therapies, nutrition, and vital signs and VAD reading logs. Education focused on components of the device using 1:1 technique. Occasionally, a patient education CD-ROM (Thoratec Corp, Pleasanton, CA) was used for reinforcement. An enormous amount of time was spent on troubleshooting alarms and ‘what if’ situations. Patients were encouraged to identify people who should have knowledge about the device including family, friends, neighbors, or co-workers. Education and reinforcement continued at outpatient visits. In addition, the clinical nurse specialist contacted the local emergency medical service and local hospital within 24–48 h of VAD implant to notify them of the patient returning to their community and potential discharge date.
Physical, occupational and cardiac rehabilitation therapies assessed the patient and started appropriate therapies on POD 1. The goal is to begin these therapies early because most of these patients need reconditioning. These therapists worked with the patients daily to help them attain a level of conditioning prior to discharge. If necessary, they were transferred to our inpatient rehabilitation program for reconditioning and this was defined as discharge from our service. In addition, upon discharge, they were referred to an outpatient cardiac rehabilitation program. If patients stayed locally, they worked with our cardiac rehabilitation team once or twice prior to going home. These visits helped reinforce the activity goals and exercises and allowed the team to assess the patient's progress prior to going home.
Nutritional assessment started on POD 1. The following methods were used to facilitate the nutrition needed for these patients to recover. Implantable VAD patients tend to have appetite loss from surgery or from mechanical compression of the stomach by placement of the device. In this series of patients, all HeartMate XVE devices were placed in the preperitoneal position. When the patient began eating, calorie counts were started. Patients ate six small meals each day to facilitate total intake and appetite. The patients were encouraged to eat high protein shakes, drinks or bars as indicated. We monitored prealbumin and albumin levels to better understand nutritional status. If the patient was unable to swallow, enteral tube feedings were started as soon as possible.
2.4. Outpatients managements
In both the traditional and multidisciplinary approach, upon discharge from the hospital, patients with more than a 30-min drive to the hospital stayed in a local hotel. If the drive was <30 min, the patient went directly home. One of the differences between the two approaches was the length of time at the hotel. The traditional approach required up to 2 weeks vs. <1 week, mostly 2–4 days, for the multidisciplinary approach. It facilitated education, transition and one clinic visit prior to going home. When the patients went home, the clinical nurse specialist called their home to assess the patient condition and to answer any additional questions the patient and family may have.
2.5. Statistical analysis
The data were expressed as median and range. Categorical data were analyzed by means of Fisher's exact test. Continuous variables were analyzed with the Mann–Whitney U-test. A P<0.05 was considered significant.
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3. Results
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Seven out of 17 VAD patients (41%) were discharged prior to initiating this approach and 13 of 13 patients (100%) after initiating this approach (P<0.01). Therefore, seven patients in the traditional group and 13 patients in the multidisciplinary group were included in this analysis (note: in the multidisciplinary period, all patients who received VAD were discharged from the hospital and there were no hospital mortalities). Out of 13 patients, 12 were successfully transplanted. One patient was removed from transplant list due to high value of his panel reactive antibody and died at 764 days after LVAD implantation.
Preoperative diagnoses in those patients are listed in Table 2. Preoperative risk factors are summarized in the Table 3. Although the multidisciplinary group had a relatively younger patient population (median age, 57 vs. 50 years, P=0.06) there were no differences in the other various systemic parameters such as the respiratory, renal and surgical factors as listed in Table 3.
The preoperative LOS (from admission to surgery) in the traditional group tended to be longer than the multidisciplinary group [21 days (range 0–85) vs. 2 days (range 0–8), P=0.07].
The postoperative LOS as well as the hospital readmission rate within 30 days of discharge is summarized in Table 4. Although there were no statistically significant differences in ICU stay in hours, the total postoperative LOS significantly decreased in the multidisciplinary group from a median of 61 days to 15 days. This was mostly due to the shortening of days on the general care floor. There was a significant decrease in the 30-day readmission rate although the patients in the multidisciplinary group were discharged sooner than the traditional group (Table 4). The reasons for readmission are listed in Table 5. Infection, such as sepsis and LVAD driveline infection, was the most frequent reason for readmission.
The postoperative cost analysis data are shown in Table 6. Operating room cost and ICU cost were not different. With this approach, the floor cost was significantly reduced leading to a decrease in total postoperative cost.
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4. Discussion
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As the use of VAD increases worldwide, the economics of VAD therapy have become an important focus of concern [10, 11]. Therefore, VAD programs can put a financial strain on a hospital unless an efficient and safe outpatient program is developed [6]. A multidisciplinary approach has been proposed to improve staff communication, patient outcomes and satisfaction and results in reduction of hospital LOS and cost [2, 5]. Therefore, the purpose of this study was to retrospectively study the impact of the multidisciplinary approach in the cost and length of stay reduction in patients who underwent VAD therapy.
As described in the results section, the preoperative LOS in the traditional group ranged from 0 days to 85 days. The reasons of this longer preoperative stay were the following: 1) medical management tried first for acute myocardial ischemia and then failed; 2) OR scheduling; 3) waited for heart transplant on intra-aortic balloon pump but donor heart was not available for 30 days; 4) heart transplantation evaluation done as inpatient; 5) infection such as pneumonia. Considering those findings, in the multidisciplinary treatment, the heart transplant evaluation was done as outpatient as much as possible. Also, the patient was taken to the OR as soon as the patient was determined as a candidate for VAD therapy. The OR time was not delayed in order to prevent end-organ failure, infection, and intubation. After establishing the multidisciplinary team, communication between cardiac surgery and heart failure cardiology became more frequent and this improvement communication, in part, may have resulted in shortening the preoperative LOS.
The reasons for longer postoperative LOS in patients in the traditional treatment group were the following: 1) family member not available for VAD education; 2) family member not available for go out on pass; 3) family member not available to accompany the patient at hotel; 4) training kit not immediately available; 5) poor nutrition; 6) infection; 7) right heart failure in patients with LVAD; 8) The inpatient rehabilitation was not accepting VAD patients; 9) renal failure; 10) pain control associated with device, patient excessively sedated with narcotics and patient unable to learn about device; 11) ventricular arrhythmias. Considering those factors, in the multidisciplinary group, patient and family education started as soon as possible, even prior to surgery if time allowed. The go out on pass was eliminated. Training kits, including demo pumps of each device, were obtained and immediately available for demonstration (note: after extensive meeting with the physicians and nurses from inpatient rehabilitation, the inpatient rehabilitation started admitting the VAD patients to their floor and service, beginning on December 2004). This significantly shortened the postoperative LOS in selected patients in the multidisciplinary group, especially if the patients had cerebro-vascular event.
The OR cost did not differ at all between the groups, since the cost of the device is the major component of the total OR cost. The cost of the device itself accounts for up to 30% of overall cost in the previous literature [10]. As the LOS on the floor decreased by 80%, from a median of 35 days to 7 days, there was an associated reduction in the cost while patients on the floor. The reduction was by 78%, from a median of $47,111 to $8742. Our mean total postoperative cost in the multidisciplinary group was slightly less than the previously published costs for VAD therapy [7, 10, 12, 13]. In order to further reduce the cost for VAD implant, there are several targets for improvements. Oz and colleagues [12] analyzed the patients enrolled in the REMATCH trial and identified sepsis as the most important predictor of increased cost. The second predictor was pump housing infection. In their study, sepsis added roughly $140,000 to the cost of the stay. The newer devices currently under investigation or development are smaller than those currently approved and available, and can eliminate creating preperitoneal or intraperitoneal device pocket. Moreover, totally implantable VADs, which do not have percutaneous driveline, can potentially eliminate this problem. Therefore, these device improvements may further decrease the risk of infection in VAD recipients. The other predictor of cost was perioperative bleeding. Again, improved surgical proficiency and innovative approaches to management of bleeding, such as newer anticoagulants, would reduce the current rate of postoperative bleeding, leading to the reduction of the cost. Patient selection is another important factor assessing the cost. Oz and colleagues [12] found that survivors' cost was on average $156,000 less to manage than non-survivors. Furthermore, considering the long-term cost of this VAD therapy, improvements in device durability is a crucial key to minimize the cost of readmissions for device failure and replacement. As the number of devices implanted increases, the price of the device may be reduced in the future [14].
There are some limitations in this study. This is a single institution study and the number of patients is relatively small in our study. However, it is comparable to other studies on LOS and cost in VAD patients [7, 10, 15]. Only three devices were used in our current series and the number of patients who received the Thoratec P-VAD and Micromed DeBakey VAD were small, two and one, respectively. There were changes and additions in the members of surgical and medical teams over the period.
In conclusion, the multidisciplinary approach was able to significantly decrease overall LOS and total cost after VAD therapy. This was due mostly to decreases in cost and time of routine non-ICU care. Furthermore, there was an actual reduction in 30-day readmission rates, thus showing that ‘bounce-back’ admissions were not a problem with this streamlined care practice. As a result of this study, multidisciplinary teams tailored to the special care needs of VAD patients can be implemented in a cost effective and safe manner that allows for overall cost reduction, shorter hospital stay, and no observable adverse effect on patient care. Efforts need to be continued to further decrease LOS and cost.
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Abstract
1. Introduction
