Protocol To Prevent 30 Day Readmission In Patients Who Receive A Heartmate LVAD with Pre Op Intermacs Profile 1 - 3

Abstract

Background Current average 30 day readmission rate following Left Ventricular Assist Device (LVAD) implantation is 25.1% as per intermacs database. At our single center we aimed to reduce the number of readmissions by instituting a protocol. The protocol has three phases. Phase 1 consists of 5 parts which begin around time of implant. The steps are: 1. LVAD coordinator led multidisciplinary rounds, utilizing rounding time to ensure completeness of care to reduce length of stay. 2. Utilization of mannequin abdomen and driveline for education on sterile techniques. 3. Speed Optimization study prior to discharge. 4. Day prior to discharge, medications with indications, dosing and side effects are reviewed with patient and family. Patient's pharmacy is also called to ensure that medications are received and available for pick up. 5. LVAD coordinator leads verbal and hand's on test prior to discharge for specific education completeness. Phase two is immediate post-discharge phase. It consists of: 1. Early non face to face assessment via phone call the day after discharge to follow up compliance with medications and LVAD driveline dressing. 2. LVAD coordinator provides LVAD emergency management education to EMS agencies and coordinates patient management with rehabs and home care agencies. 3. There are weekly labs and phone calls to evaluate patient volume status, bleeding risk, INR dosing, and any other signs of early decompensation while also evaluating LVAD equipment to ensure safe operating function. Phase three is for more long term following. The LVAD coordinator and heart failure attending see the patient weekly for four weeks, then weekly for one month, then monthly for three months, then every three months. We report on the results of our protocol and outcomes following our policy change. Methods Clinical and LVAD related characteristics (Table 1) of patients who underwent LVAD Implantation in our single center from 2017-2018 (Pre-Protocol / Period 1) and in 2019 (Post Protocol / Period 2) were retrospectively reviewed and cases of readmission were identified. Results During period one, 29.6% of patients (8/27) were re-admitted within 30 days. There were 2 deaths. Reasons for readmission were mainly related to the LVAD; a combination of infection, GI bleed, stroke, and medication confusion. During period two, 16 patients were implanted with Heartmate 3 LVAD and after implementation of the protocol, there were no observed readmissions or deaths within 30 days. Conclusion In the era of cost-efficient medicine, adherence to a strict protocol immediately following LVAD implantation can result in zero 30 day readmissions. Current average 30 day readmission rate following Left Ventricular Assist Device (LVAD) implantation is 25.1% as per intermacs database. At our single center we aimed to reduce the number of readmissions by instituting a protocol. The protocol has three phases. Phase 1 consists of 5 parts which begin around time of implant. The steps are: 1. LVAD coordinator led multidisciplinary rounds, utilizing rounding time to ensure completeness of care to reduce length of stay. 2. Utilization of mannequin abdomen and driveline for education on sterile techniques. 3. Speed Optimization study prior to discharge. 4. Day prior to discharge, medications with indications, dosing and side effects are reviewed with patient and family. Patient's pharmacy is also called to ensure that medications are received and available for pick up. 5. LVAD coordinator leads verbal and hand's on test prior to discharge for specific education completeness. Phase two is immediate post-discharge phase. It consists of: 1. Early non face to face assessment via phone call the day after discharge to follow up compliance with medications and LVAD driveline dressing. 2. LVAD coordinator provides LVAD emergency management education to EMS agencies and coordinates patient management with rehabs and home care agencies. 3. There are weekly labs and phone calls to evaluate patient volume status, bleeding risk, INR dosing, and any other signs of early decompensation while also evaluating LVAD equipment to ensure safe operating function. Phase three is for more long term following. The LVAD coordinator and heart failure attending see the patient weekly for four weeks, then weekly for one month, then monthly for three months, then every three months. We report on the results of our protocol and outcomes following our policy change. Clinical and LVAD related characteristics (Table 1) of patients who underwent LVAD Implantation in our single center from 2017-2018 (Pre-Protocol / Period 1) and in 2019 (Post Protocol / Period 2) were retrospectively reviewed and cases of readmission were identified. During period one, 29.6% of patients (8/27) were re-admitted within 30 days. There were 2 deaths. Reasons for readmission were mainly related to the LVAD; a combination of infection, GI bleed, stroke, and medication confusion. During period two, 16 patients were implanted with Heartmate 3 LVAD and after implementation of the protocol, there were no observed readmissions or deaths within 30 days. In the era of cost-efficient medicine, adherence to a strict protocol immediately following LVAD implantation can result in zero 30 day readmissions.