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Implementing change in your hospital

Hospital shifts in focus from surgical to less invasive procedures must be accompanied by change implementation processes.

About this topic

Transcatheter aortic valve implantation (TAVI) with the SAPIEN 3TM valve (Edwards Lifesciences) has been granted the CE mark for all-risk patients with severe symptomatic aortic stenosis (ssAS) and marks a shift from surgical to less-invasive procedures.

Implementing changes in hospital procedures and processes is complex and challenging, but very much required in order to reduce waiting lists as we enter the next phase of the COVID-19 pandemic where the priority will be addressing the backlog of patients whose care has been placed on hold. It has never been more critical that a hospital display maximum efficiency in delivering best clinical care to their patients – from shortening waiting lists and length of stay (LOS) to lowering re-hospitalisation rates.1

Lauck, Wood and colleagues at the Center for Heart Valve Innovation at St Paul’s Hospital and Vancouver General Hospital, Canada, have demonstrated the role of a multidisciplinary Heart Team in implementing quality innovation that entails minimalist peri-procedure practices and facilitates early discharge for ssAS patients.2 Building on from these results, Wood et al. demonstrated the safety of next day discharge in 80% of TAVI patients, and 48h discharge in 90% of TAVI patients3, and a European FAST-TAVI trial in 2019, showed that a prespecified criteria allows for a safe and timely discharge with no reported risk increase in 30-day complications.4 All three of these studies included patients who underwent TAVI procedures with the Edwards Lifesciences SAPIEN 3TM valve.

The barriers to implementing the TAVI clinical pathway designed by the Heart Team were challenging, and were grounded in historical practices, the complexity and disciplines engaged in the care of TAVI patients, the adoption of LOS as a programme quality indicator and the operational challenges of implementing periprocedure practices.

These barriers were addressed by an expanded Heart Team approach that captured the patient’s journey from admission to discharge, in the form of a TAVI Care Team (below).

This Multidisciplinary Care Team met monthly and reported biannually, and enabled:

  • Communication and discussion of all operational and practice issues related to the clinical pathway initiative
  • Identification of educational initiatives for members of the team
  • Engagement and support of all multidisciplinary stakeholders, all of whom were focused and aligned on the adaptation of new processes, improved outcomes and reduced demand on health service resources
  • Implementation of practice changes involving the transition to minimalist care

Taking these above steps in your hospital will help to implement changes from surgical procedures to the less-invasive TAVI procedure with the Edwards Lifesciences SAPIEN 3TM valve. Doing so will help to shorten waiting lists, which will become imperative as hospitals begin to address the backlog of patients whose care has been placed on hold owing to hospital restructuring to tackle the pandemic.

The Figure is adapted from Wood et al.3

 

  1. ESC guidelines. ESC Guidance for the Diagnosis and Management of CV Disease during the COVID-19 Pandemic. Available from: https://www.escardio.org/static_file/Escardio/Education-General/Topic%20pages/Covid-19/ESC%20Guidance%20Document/ESC-Guidance-COVID-19-Pandemic.pdf (accessed Jun 2020).
  2. Lauck SB, Wood DA, Baumbusch J, et al. Vancouver Transcatheter Aortic Valve Replacement Clinical Pathway. Minimalist Approach, Standardised Care, and Discharge Criteria to Reduce Length of Stay. Circ Cardiovasc Qual Outcomes 2016;9:312–21.
  3. Wood DA, et al. The Vancouver 3M (Multidisciplinary, Multimodality, But Minimalist) Clinical Pathway Facilitates Safe Next-Day Discharge Home of Low-, Medium-, and High-Volume Transfemoral Transcatheter Aortic Valve Replacement Centres. JACC Cardiovasc Interv 2019;12:459–69.
  4. Barbanti M, et al. Optimising patient discharge management after transfemoral transcatheter aortic valve implantation: the multicentre European FAST-TAVI trial. Euro Intervention 2019;15:147–54.
 
This content is sponsored by Edwards Lifesciences