The Approach to the Psychosocial Evaluation of Cardiac Transplant and Mechanical Circulatory Support Candidates.

PURPOSE OF REVIEW: We update evidence underlying the recommendations of a 2018 multi-society consensus report regarding the psychosocial evaluation of individuals for cardiothoracic transplantation and mechanical circulatory support (MCS). In the present review, we focus on heart transplantation and MCS. RECENT FINDINGS: Expert opinion and new evidence support the inclusion of ten core content areas in the psychosocial evaluation. Prospective data indicate that psychosocial factors can predict post-transplantation/post-implantation outcomes. Such factors include treatment adherence history, mental health and substance use history, cognitive impairment, knowledge about treatment options, and social factors such as socioeconomic status. For other factors (e.g., coping, social support), new evidence is weaker because it derives largely from cross-sectional studies. Concerning evaluation process issues, expert opinion remains consistent with consensus recommendations, but there is a dearth of empirical evidence. The psychosocial evaluation can identify factors relevant for candidacy for heart transplantation and MCS implantation. It enables the provision of interventions to improve patients' viability as candidates, and facilitates care planning.

The 2018 ISHLT/APM/AST/ICCAC/STSW Recommendations for the Psychosocial Evaluation of Adult Cardiothoracic Transplant Candidates and Candidates for Long-term Mechanical Circulatory Support.

The psychosocial evaluation is well-recognized as an important component of the multifaceted assessment process to determine candidacy for heart transplantation, lung transplantation, and long-term mechanical circulatory support (MCS). However, there is no consensus-based set of recommendations for either the full range of psychosocial domains to be assessed during the evaluation, or the set of processes and procedures to be used to conduct the evaluation, report its findings, and monitor patients' receipt of and response to interventions for any problems identified. This document provides recommendations on both evaluation content and process. It represents a collaborative effort of the International Society for Heart and Lung Transplantation (ISHLT) and the Academy of Psychosomatic Medicine, American Society of Transplantation, International Consortium of Circulatory Assist Clinicians, and Society for Transplant Social Workers. The Nursing, Health Science and Allied Health Council of the ISHLT organized a Writing Committee composed of international experts representing the ISHLT and the collaborating societies. This Committee synthesized expert opinion and conducted a comprehensive literature review to support the psychosocial evaluation content and process recommendations that were developed. The recommendations are intended to dovetail with current ISHLT guidelines and consensus statements for the selection of candidates for cardiothoracic transplantation and MCS implantation. Moreover, the recommendations are designed to promote consistency across programs in the performance of the psychosocial evaluation by proposing a core set of content domains and processes that can be expanded as needed to meet programs' unique needs and goals.

Nursing patients with ventricular assist devices: an interpretive description.

CONTEXT-Although researchers have studied the experience of caring for patients with ventricular assist devices from the perspective of family caregivers, few reports address the experience of nursing patients with such devices. OBJECTIVE -To investigate the experience of nursing patients who have a ventricular assist device. DESIGN -A qualitative approach called interpretive description was used to conduct semistructured, 1-on-1 interviews. PARTICIPANTS-Six registered nurses with a range of clinical experiences were interviewed in a 1-year period from 2009 to 2010. Data were transcribed and analyzed by the researcher in conjunction with a research team. RESULTS-Four distinct themes were interpreted from the interview data: exclusive knowledge, human connection, ethics, and interdisciplinary stress and technology. CONCLUSION -Nursing patients who have a ventricular assist device is a complex experience. Nurses develop expert knowledge that is related to direct exposure to patients; this unique knowledge should be formally considered in team decision making. Nursing care of patients who have a ventricular assist device also has features that might result in overconnected nurse-patient relationships. Closely connected nurse-patient relationships intensified the emotional difficultly of experiences of exposure to illness or suffering, or exposure to an unpredictable dying trajectory. Nursing patients with ventricular assist devices can be difficult, and nursing leaders should be aware of the emotional reactions that can result from direct exposure to patients who might be perceived as very ill or suffering. Institutions with ventricular assist device programs should consider providing emotional support for health care workers who find this type of work emotionally difficult.

The development and evaluation of a competency-based program for patients with a ventricular assist device.

The ventricular assist device (VAD) is a mechanical device that is used to provide long term support either as a bridge or as an alternative to transplantation for patients suffering from end stage heart failure. While in hospital, patients with a VAD have traditionally been taught by an educator nurse with VAD expertise in preparation for discharge. In 2004, our centre implemented a successful competency-based patient education program in post-heart transplant patients and thought that a similar program may provide increased confidence for bedside nurses to actively participate in VAD patient education prior to discharge. The purpose of this quality improvement project was to create a competency-based education program that would provide consistency in patient teaching. A questionnaire was developed and completed by 13 bedside nurses. This pre-test questionnaire indicated the need for a systematic and organized approach to VAD patient teaching. Furthermore, adequate resources, consistency in teaching methods, and feedback were seen to be essential. A pilot competency-based program was designed to lead bedside nurses and patients through a series of learning phases and has successfully been implemented. Since its implementation, the questionnaire has been repeated with results reflecting satisfaction with the revised competency-based program. Our findings and evaluation of the program through pre- and post-testing reflect an increase in organization in our teaching methods and has led to improved confidence and satisfaction for bedside nurses using this program. By redeveloping the current method of VAD education, our goal has been to improve the ways in which we deliver teaching to our patients. It is thought that, as with our experience in the post-heart transplant population, bedside nurses and team members will feel more empowered to provide teaching to patients with a VAD.

Assessment of an Interactive Digital Health-Based Self-management Program to Reduce Hospitalizations Among Patients With Multiple Chronic Diseases: A Randomized Clinical Trial.

Importance: Digital health programs may have the potential to prevent hospitalizations among patients with chronic diseases by supporting patient self-management, symptom monitoring, and coordinated care. Objective: To compare the effect of an internet-based self-management and symptom monitoring program targeted to patients with 2 or more chronic diseases (internet chronic disease management [CDM]) with usual care on hospitalizations over a 2-year period. Design, Setting, and Participants: This single-blinded randomized clinical trial included patients with multiple chronic diseases from 71 primary care clinics in small urban and rural areas throughout British Columbia, Canada. Recruitment occurred between October 1, 2011, and March 23, 2015. A volunteer sample of 456 patients was screened for eligibility. Inclusion criteria included daily internet access, age older than 19 years, fluency in English, and the presence of 2 or more of the following 5 conditions: diabetes, heart failure, ischemic heart disease, chronic kidney disease, or chronic obstructive pulmonary disease. A total of 230 patients consented to participate and were randomized to receive either the internet CDM intervention (n = 117) or usual care (n = 113). One participant in the internet CDM group withdrew from the study after randomization, resulting in 229 participants for whom data on the primary outcome were available. Interventions: Internet-based self-management program using telephone nursing supports and integration within primary care compared with usual care over a 2-year period. Main Outcomes and Measures: The primary outcome was all-cause hospitalizations at 2 years. Secondary outcomes included hospital length of stay, quality of life, self-management, and social support. Additional outcomes included the number of participants with at least 1 hospitalization, the number of participants who experienced a composite outcome of all-cause hospitalization or death, the time to first hospitalization, and the number of in-hospital days. Results: Among 229 participants included in the analysis, the mean (SD) age was 70.5 (9.1) years, and 141 participants (61.6%) were male; data on race and ethnicity were not collected because there was no planned analysis of these variables. The internet CDM group had 25 fewer hospitalizations compared with the usual care group (56 hospitalizations vs 81 hospitalizations, respectively [30.9% reduction]; relative risk [RR], 0.68; 95% CI, 0.43-1.10; P = .12). The intervention group also had 229 fewer in-hospital days compared with the usual care group (282 days vs 511 days, respectively; RR, 0.52; 95% CI, 0.24-1.10; P = .09). Components of self-management and social support improved in the intervention group. Fewer participants in the internet CDM vs usual care group had at least 1 hospitalization (32 of 116 individuals [27.6%] vs 46 of 113 individuals [40.7%]; odds ratio [OR], 0.55; 95% CI, 0.31-0.96; P = .03) or experienced the composite outcome of all-cause hospitalization or death (37 of 116 individuals [31.9%] vs 51 of 113 individuals [45.1%]; OR, 0.57; 95% CI, 0.33-0.98; P = .04). Participants in the internet CDM group had a lower risk of time to first hospitalization (hazard ratio, 0.62; 95% CI, 0.39-0.97; P = .04) than those in the usual care group. Conclusions and Relevance: In this study, an internet-based self-management program did not result in a significant reduction in hospitalization. However, fewer participants in the intervention group were admitted to the hospital or experienced the composite outcome of all-cause hospitalization or death. These findings suggest the internet CDM program has the potential to augment primary care among patients with multiple chronic diseases. Trial Registration: ClinicalTrials.gov Identifier: NCT01342263.

Emotional experiences of caregivers of patients with a ventricular assist device.

CONTEXT: Little is known about the stresses experienced by caregivers of patients discharged home with a ventricular assist device. OBJECTIVE: To describe the lived experience of caregivers of patients who were discharged home with a ventricular assist device. DESIGN: The study used a phenomenological framework to conduct semistructured interviews guided by 2 psychologists using a focus group setting. PARTICIPANTS: Interviews of 13 caregivers of 9 patients discharged to home with a ventricular assist device between March 2004 and June 2007 were recorded, transcribed, and analyzed. RESULTS: Four themes emerged during the interviews: anxiety, initially exhibited as profound shock; loss of a loved one, of their lives, of freedom and independence; burden, both the physical burden and the burden of responsibility; and finally coping through faith, acceptance, empathy, and social support. CONCLUSION: Caregivers of patients discharged home with a ventricular assist device experienced significant pressures that changed over the duration of support with the ventricular assist device. Caregivers described their coping mechanisms in dealing with shock, loss, and burden. Understanding the fluctuating needs of caregivers will enable teams to provide interventions based on the situation. Future care guidelines should address the significant stresses placed on caregivers of recipients of a ventricular assist device.

The use of the Internet to remotely monitor patients with heart failure.

Heart failure (HF) results in high hospitalization rates and healthcare costs. Telemonitoring of HF has been shown to result in improved outcomes but usually involves the use of expensive equipment. A more feasible alternative may be the use of a Web site. The purpose of this study is to investigate the use of a Web site designed for HF telemonitoring. Patients newly referred to a heart function clinic were screened for eligibility. Twenty participants were recruited and entered their weight and symptoms onto the Web site for 6 months. A nurse monitored the Web site for changes in participant health status and telephoned the participants as necessary. Self-care, quality of life, 6-minute walk test, and N-terminal prohormone brain natriuretic peptide (NT-proBNP) were assessed. Interviews were conducted to assess intervention uptake. Seventeen participants completed the study. A significant change was observed on the maintenance subscale of the Self-Care of Heart Failure Index (p = 0.039). There was a trend toward improvement on the confidence subscale of the Self-Care of Heart Failure Index (p = 0.069), Minnesota Living With Heart Failure((R)) Questionnaire (p = 0.337), 6-minute walk test (p = 0.124), and NT-proBNP (p = 0.210). Participants and nurses demonstrated a favorable uptake of the Web site. A Web site that facilitates the telemonitoring of patients with HF was favorably accepted and its use in this pilot study was associated with improved self-care skills. However, further investigation is warranted in a larger study population.

Medical Management of Left Ventricular Assist Device Patients: A Practical Guide for the Nonexpert Clinician.

Left ventricular assist devices (LVADs) provide short- or long-term circulatory support to improve survival and reduce morbidity in selected patients with advanced heart failure. LVADs are being used increasingly and now have expanded indications. Health care providers across specialties will therefore not only encounter LVAD patients but play an integral role in their care. To accomplish that, they need to understand the elements of LVAD function, physiology and clinical use. This article provides a concise overview of the medical management of LVAD patients for nonexpert clinicians. Our presentation includes the basics of LVAD physiology, design, and operation, patient selection and assessment, medical management, adverse event identification and management, multidisciplinary care, and management of special circumstances, such as noncardiac surgery, cardiac arrest, and end-of-life care. The clinical examination of LVAD patients is unique in terms of blood pressure and heart rate assessment, LVAD "hum" auscultation, driveline and insertion site inspection, and device parameter recording. Important potential device-related adverse events include stroke, gastrointestinal bleeding, hematologic disorders, device infection, LVAD dysfunction, arrhythmias, and heart failure. Special considerations include the approach to the unconscious or pulseless patient, noncardiac surgery, and palliative care. An understanding of the principles presented in this paper will enable the nonexpert clinician to be effective in collaborating with an LVAD center in the assessment, medical management, and follow-up of LVAD patients. Future opportunities and challenges include the improvement of device designs, greater application of minimally invasive surgical implantation techniques, and management of health economics in cost-constrained systems like those of Canada and many other jurisdictions.

Canadian Cardiovascular Society/Canadian Cardiac Transplant Network Position Statement on Heart Transplantation: Patient Eligibility, Selection, and Post-Transplantation Care.

Significant practice-changing developments have occurred in the care of heart transplantation candidates and recipients over the past decade. This Canadian Cardiovascular Society/Canadian Cardiac Transplant Network Position Statement provides evidence-based, expert panel recommendations with values and preferences, and practical tips on: (1) patient selection criteria; (2) selected patient populations; and (3) post transplantation surveillance. The recommendations were developed through systematic review of the literature and using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The evolving areas of importance addressed include transplant recipient age, frailty assessment, pulmonary hypertension evaluation, cannabis use, combined heart and other solid organ transplantation, adult congenital heart disease, cardiac amyloidosis, high sensitization, and post-transplantation management of antibodies to human leukocyte antigen, rejection, cardiac allograft vasculopathy, and long-term noncardiac care. Attention is also given to Canadian-specific management strategies including the prioritization of highly sensitized transplant candidates (status 4S) and heart organ allocation algorithms. The focus topics in this position statement highlight the increased complexity of patients who undergo evaluation for heart transplantation as well as improved patient selection, and advances in post-transplantation management and surveillance that have led to better long-term outcomes for heart transplant recipients.

A systematic review of telemonitoring technologies in heart failure.

AIMS: Heart failure (HF) results in characteristic signs and symptoms including oedema and breathing difficulties. Heart failure is particularly suited to telemonitoring, because patients' signs and symptoms can be assessed remotely by healthcare providers, and deterioration can be quickly detected and addressed. In this paper, we review studies conducted in HF telemonitoring, to describe the nature of the modality, the methods, and the results. METHODS AND RESULTS: Articles were obtained through a MedLine search, utilizing the term heart failure in conjunction with the terms telehealth, telecare, telemonitoring, web, Internet, remote monitoring, and self-monitoring. Studies utilizing various modalities, including telephone touch pad, specialized hardware, and websites for participants to enter data were found, with various benefits being reported. Most studies demonstrated improvements in outcome measures, including improved quality of life and decreased hospitalizations. However, not all studies reported the same improvements and in several cases the sample sizes were relatively small. CONCLUSION: Telemonitoring appears to be an acceptable method for monitoring of HF patients. Controlled, randomized studies directly comparing different modalities and evaluating their success and feasibility when used as part of routine clinical care, are now required.