Programmatic Specialization and Pathway Development Improves Outcomes in Mechanical Circulatory Support

Abstract

Cardiac surgery continues to transform into areas of sub-specialization and expertise. With increasing complexity of cases and scrutiny of outcome-based reimbursement, it is imperative that these cases are performed with reduced variability and superior outcomes. This can be achieved by introducing sub-specialization in mechanical circulatory support (MCS) therapies, implementing clinical care pathways and using standardized protocols during various stages of patient care. We analyzed the impact of protocol and clinical pathway-driven sub-specialization on MCS outcomes. A single center retrospective analysis was conducted of patients undergoing long term MCS device placement between 2002-2018. The analysis was conducted comparing management of patients before (Era 1: 2003-2011) vs. after (Era 2: 2012-2018) introduction of MCS sub-specialization. Since 2012, multiple initiatives were introduced in our program, namely recruitment of specialized MCS/transplant surgeons, multidisciplinary team rounds, establishment of a shock team, development of clinical care pathways, electronic medical record order sets and clinical practice guidelines. Quality metrics were analyzed every month, and process improvement projects were initiated during this era. During Era 1, five cardiac surgeons implanted LVADs in 181 patients, while in Era 2, three MCS/transplant trained surgeons implanted LVADs in 326 patients. Era 2 included higher number of INTERMACS 1 and 2 profile patients (66% vs. 85%) reflecting higher-acuity patient population. With implementation of the sub-specialization services, 1-year survival improved from 58% to 96%. Median ICU stay decreased from 13 to 8 days and percent of patients discharged to home increased from 62% to 95%. Standardized protocols for management of high LDH, GI bleeding, and blood pressure management resulted in significant reduction in overall hospital length of stay. With introduction of clinical care pathways, the average time for workup from admission to LVAD implant decreased from 27.6 days to 8.5 days. With improved outcomes in Era 2, the program grew 200%. Introduction of sub-specialization services, with use of clinical pathways and protocols in managing patients with LVADs can help improve survival, reduce variability in medical care, and reduce ICU length of stay.