Evaluation of a Health Care Performance Improvement Initiative to Facilitate Optimal Clinical Outcomes in Patients Receiving Ventricular Assist Device Support.

BACKGROUND: Ventricular assist device (VAD) patients are at high risk for morbidities and mortality. One potentially beneficial component of the Joint Commission VAD Certification process is the requirement that individual VAD programs select 4 performance measures to improve and optimize patients' clinical outcomes. PROBLEM STATEMENT: Review of patient data after our program's first certification visit in 2008 showed that, compared to national recommendations and published reports, our patients had suboptimal outcomes in 4 areas after device implantation: length of hospital stay, receipt of early (<48 hours) postsurgical physical therapy, driveline infection incidence, and adequacy of nutritional status (prealbumin ≥18 mg/dL). METHODS: Plan-Do-Study-Act processes were implemented to shorten length of stay, increase patient receipt of early physical therapy, decrease driveline infection incidence, and improve nutritional status. With 2008 as our baseline, we deployed interventions for each outcome area across 2009 to 2017. Performance improvement activities included staff, patient, and family didactic, one-on-one, and hands-on education; procedural changes; and outcomes monitoring with feedback to staff on progress. Descriptive and inferential statistics were examined to document change in the outcomes. OUTCOMES: Across the performance improvement period, length of stay decreased from 40 to 23 days; physical therapy consults increased from 87% to 100% of patients; 1-year driveline infection incidence went from 38% to 23.5%; and the percentage of patients with prealbumin within the normal range increased from 84% to 90%. IMPLICATIONS: Performance improvement interventions may enhance ventricular assist device patient outcomes. Interventions' sustainability should be evaluated to ensure that gains are not lost over time.

Bariatric surgery for a patient with a HeartMate II ventricular assist device for destination therapy.

A patient with a HeartMate II left ventricular assist device who had a body mass index of 52 needed gastric bypass surgery in order to qualify for a heart transplant. Unlike previous experience in which the surgery was performed at the implant hospital, the gastric bypass surgery in this case was performed at a bariatric center of excellence that was a separate facility from the implant hospital. The artificial heart program of the University of Pittsburgh Medical Center worked with the bariatric center of excellence in scheduling the gastric bypass surgery using a multidisciplinary team approach at 2 hospitals to coordinate safe, high-quality patient care in a unique situation.

The Joint Commission's disease-specific care certification for destination therapy ventricular assist devices.

The Centers for Medicare and Medicaid Services announced that all hospitals implanting ventricular assist devices are required to have certification from the The Joint Commission for disease-specific care destination therapy with a ventricular assist device effective March 27, 2009, in order to receive Medicare reimbursement for services rendered to patients who have devices implanted for destination therapy. On February 23, 2007, The Joint Commission released the certification requirements for ventricular assist devices implanted for destination therapy in an 8-page document so that hospitals could prepare to meet the 2009 certification deadline. The Artificial Heart Program of the University of Pittsburgh Medical Center undertook a multidisciplinary project, under the guidance of the nurse coordinator, to prepare the hospital and program for a precertification survey by The Joint Commission for disease-specific destination therapy ventricular assist device certification. The Presbyterian Hospital Artificial Heart Program was awarded The Joint Commission's device-specific certification for destination therapy with ventricular assist devices in June 2008.

A rapid hemodynamic monitor of acute ischemia during cardiac procedures: changes in relaxation via a continuous left ventricular pressure-derivative loop.

BACKGROUND: Procedures that induce ischemic pre-conditioning during cardiac surgery will require a rapidly visualized hemodynamic monitor of acute ischemia. This study investigated the utility of a continuous loop tracing of left ventricular pressure (LVP) plotted against its derivative (dP/dt) as a visual beat-to-beat monitor of acute changes in myocardial relaxation due to global ischemia. MATERIALS AND METHODS: In 11 dogs, LVP, recorded via a micromanometer-tip catheter, was plotted against dP/dt as a continuous loop. The angle of the loop during relaxation is inversely related to tau, the time constant of isovolumic relaxation. The angle was measured before and during: infusion of dextran to increase pre-load, infusion of nitroprusside to reduce after-load, and a 30-s occlusion of the left main coronary artery to induce temporary global ischemia. RESULTS: The relaxation angle of the loop did not change with dextran or nitroprusside infusion. During left main occlusion, the angle increased from 57 +/- 7 degrees to 92 +/- 3 degrees (P < 0.001), reflecting markedly impaired relaxation. In five of nine cases, the angle became greater than 90 degrees, rendering the monoexponential model of pressure decay inapplicable. However, the beat-to-beat progression of the angle could easily be followed visually. CONCLUSIONS: The LVP-dP/dt loop is a readily visualized, continuous display of beat-to-beat changes in myocardial relaxation. It provides a dynamic and specific display of immediate changes in relaxation during global ischemia, even when the exponential model of pressure decay is not applicable. The loop may be useful for guiding procedures that induce ischemic pre-conditioning or post-conditioning during cardiac surgery.