Is Emory Healthcare still performing TAVR procedures?
Patricia (Tricia) Keegan, DNP, NP-C, AACC, Director, Strategic and Programmatic Initiatives, Emory Heart & Vascular; Lead NP, Structural Heart & Valve: Yes, we are still performing TAVR procedures. In the state of Georgia, they have asked us not to do elective cases, and instead concentrate on urgent and emergent cases. We developed a triage system focusing on those cases that we feel could wait until post-COVID or cases where we have more time, meaning they don’t have to be done in the next 24 to 48 hours. There are a number of things we consider. First, we look at the patient and their symptomology. Have they had a syncopal episode? Have they had repeated heart failure admissions? Have they had angina? Do they feel like they are just kind of dwindling down? The other pieces are the objective criteria from the echocardiogram and the mean gradients in the valve area, which influence our decision as well, and the estimated resource utilization and projected length of stay. We have to consider ventilator usage, ICU bed usage, and staff. These are things we never had to consider before when making patient dispositions, but the situation now requires us to take a step back and evaluate.
Emory has been very progressive in that we have been doing nurse-led sedation since May of 2012. Therefore, our reliance on anesthesia has not been as frequent as a number of other centers that do have anesthesia in every case. We have received calls from a number of these centers regarding our nurse-led sedation process, because they are also interested in figuring out how they can move patients through the system. Part of our streamlining process has been defining nurse-led sedation candidates and those patients that we believe are going to be short stay, meaning that their predicted length of stay is one day. There is data out there to be able to select those patients. We also try to identify patients with anticipated very low 30-day readmission rates. The hope is to identify patients who will not be a large resource utilization for the system. From a leadership standpoint, our administration has been very supportive of our ability to do cases. We have historically shown to be good stewards of resources, and our valve coordinators Alex and Emily do an excellent job of making sure that we have the necessary information to be able to present to administration. Our administration does review our cases to determine eligibility, but we haven’t had a case turned down yet.
How do you evaluate patients in terms of their need for treatment?
Tricia: It is important to talk about frailty in this patient population and not only risk of procedure, but risk of recovery. If patients have high gradients, if they are very symptomatic, these patients typically don’t wait well. On the other hand, we have patients who are low risk for surgery, but who are very symptomatic from their aortic stenosis. Just because they are low risk doesn’t mean that they tolerate waiting any better. It is important to create the general picture of the patient that is not 100% based on their surgical risk. The decision has to be based on their symptoms.
How are you contacting patients and how are they responding to the current crisis in light of their illness?
Alex Hall, RN, Valve Care Coordinator, Emory Structural Heart Program: We have been making regular phone calls and the patients really seem to appreciate it. They like that we are checking up on them, which eases any worries on their part that they are being overlooked or falling through the cracks. I make weekly phone calls to any patients who were not quite ready for procedure prior to the COVID-19 outbreak and the canceled clinic patients as well.
How frequently is the heart team meeting?
Tricia: We continue to meet on a weekly basis, but it is definitely in a different way. We used to all be in a room together, sitting inches apart instead of six feet apart. In terms of having discussions, we would show cases and everybody would be able to converse right then and there. However, with the requirement for social distancing, we instead have created a virtual meeting. We still have the opportunity to meet using online video platforms, and will evaluate patient images and have conversations just as if we all were in the same room. Alex and her colleague, Emily, both our valve clinic coordinators, have a list of patients who we have deferred for the time being, and will alert us if there have been any changes with these patients. As Alex noted, our valve clinic coordinators are calling the deferred patients about once a week to check in on them and see how things are going. It provides a lot of reassurance and then the coordinators are able to report on these patients during our valve clinic meeting.
If a new patient is referred for evaluation, can you describe what happens?
Alex: When I first call the patient, if they sound like they have been more symptomatic, then I will talk to either an advanced practice provider (APP) or the attending physician, and we decide whether that patient needs to come in for testing and a telehealth visit, or if they want to do an in-person visit. Often, the attendings are the ones who make that call. I will relay that information back to the administrative staff and then to the patient as well, and we try to create a plan that works for everyone. Symptomatic patients that we have seen in clinic or in telehealth visits are getting on the schedule quickly. The patients who are not as symptomatic, or not in that urgent or emergent category, have definitely been waiting longer. Normally the timeframe from start to finish is about a month, because we try to get these patients into clinic from referral within two weeks and then we schedule them for their procedure two weeks out from their clinic visit.
Tricia: The attendings typically will call referred patients to get a general idea of how they are doing and their history. We call our referral physicians and get their opinion as well. A referring physician who is sending a patient to us might say, you can probably wait a month before you bring this patient in, or I really think you should get this patient in within the next week. We let that guide the process. As Alex said, we have always tried to have the patient seen within two weeks. However, now we have to consider whether a patient needs to wait a bit longer because of social distancing restrictions in our clinic. When we tell patients that we would like them to come in quickly, that can also be tough, because the patient may say, well, your hospital has X amount of people diagnosed with the virus. We want to respect the process and incorporate shared decision making. It is important to have a conversation with the patient to make sure they have the information necessary to make the best decision for them, but also that the patient’s input is absolutely respected during this entire process.
What might cause any deferred patients that you have been monitoring to be reassessed?
Tricia: If they have any episode where they feel like they have passed out, that would be a red flag. Maybe last week they were able to walk from one end of their house to the other end without difficulty and now they are more short of breath. It is certainly more challenging to evaluate patients, because with people being physically isolated, they don’t get out, they don’t walk around, and they spend a lot of time in their house. It can make it more difficult to elicit changes in symptoms. Our team has done an excellent job of coming up with targeted questions to find out whether anything has changed in the past week. They might ask a patient if they are making their bed. Simple questions like that can offer a clue that the patient is getting more symptomatic.
Tricia, can you tell us about the COVID memo (see Appendix 1) that you helped to put together?
Tricia: This is a memo that was put together by a group of valve coordinators throughout the country, including Joan K. Michaels, MSN, RN, AACC, from the Transcatheter Valve Therapy (TVT) registry. We all had been getting phone calls from other valve programs from across the United States with questions about how we were handling the pandemic. We put together a very quick page of details and some general clarifications about patient selection, process of care, and guidance from the TVT registry that went out to valve coordinators across the United States on March 26th. The goal was to provide guidance but also let valve coordinators know that we understand their concerns and that we are all going through the same thing as well.
Since the COVID memo was created, is there anything you would add?
Tricia: What we provided was a very high-level document. There are certainly more details coming out on a daily basis, whether from the Society of Cardiovascular Angiography and Interventions (SCAI), the Canadian Cardiovascular Association, or the American College of Cardiology (ACC), for example. The challenge is that there are many different documents out there; how do you summarize all of that information? Many documents have discussed TAVR patient selection in light of previous ACC guidance and PARTNER trial results to identify those patients who can be predicted to have poor outcomes. The challenge is that how New York is affected is very different from how Atlanta is affected, which is different than how San Francisco is affected, and which is different from how Ohio is affected. In the memo, we sought to determine any commonalities that could be highlighted as things that you have to consider. For example, many of our hospitals have moved to no-visitor policies. If we are going to do a TAVR procedure on an 85-year-old and their family can’t be present, it has to be a consideration when we are making decisions. How do we streamline that care? Are we going to be taking a respirator away? Who actually needs to be in the room? We have actually looked at how many people we now need to have in a room, the impact of a no-visitors policy, and other changes. Our COVID memo was put together to communicate some of the essential elements to guide patient selection and help centers have those conversations.
How do you discuss the no-visitors policy with patients and family members?
Alex: When we schedule patients, we let them know about the visitation policy ahead of time so that they have the expectation set that there are no visitors. Many of our patients live with their children, who don’t tend to like leaving the parent behind for a one- or two-night stay in the hospital, but we encourage families to plan phone calls or start working on how to use FaceTime with their parent as a way they can check on them.
How do patients feel about coming to the hospital?
Alex: They are definitely more reluctant to come. Family members have let us know they are keeping them at home and being very protective. A high percentage of people are very reluctant right now to come in for any testing unless it is absolutely necessary. The hospital has stations at every entrance and exit, making sure that there are limited visitors. Many of our patients are coming in just for their testing, leaving, and then doing a telehealth visit. It involves minimal interaction with different departments.
What about encouraging ambulation post procedure?
Tricia: Staff gets the patient up when they first come off bedrest. Our policy is that patients have to have a mask on once they step outside their room. Again, it is the consideration of how do we protect our patients? We certainly want to be able to fix a problem that is as life-limiting as an aortic stenosis, but we don’t want to subject patients to a potentially fatal virus, either. It is all part of the conversation about how do we keep patients not only safe during the procedure, but safe during the hospitalization.
Has the use of telehealth affected how follow-up care is handled?
Tricia: We have moved to a mostly telehealth platform for our follow-up patients. The TVT registry requires information about patient status, the New York Heart Association classification, any stroke, and any hospitalizations. Data are typically collected during the video or telephone visit. However, the follow-up imaging is delayed at this point. We do try to get it from a local provider if possible, but many of the local providers are in the same boat as we are. As a result, we have deferred the echocardiogram until post-COVID unless we believe there is a clinical reason to obtain the imaging now. In those cases, we would bring the patient into the clinic.
Alex: The use of telehealth will probably continue, especially for our out-of-town referrals. I think the patients enjoy it, instead of having to travel for an office visit, and it is beneficial for them. I still do see patients either by video or by telephone calls (although Emily and I both miss being present in the clinics with our patients and creating more of a bond than a phone call can provide). Typically we will ask patients if they have blood pressure monitoring and if they take their temperature. I have had a handful of patients who are using an app to measure their EKG and it has been helpful to see that they are in atrial fibrillation, for example, or have been bradycardic. The more information, the better, and the more helpful it is to make decisions about their care, because it is very hard to assess someone’s valve over a video screen.
Is there anything else critical for valve care coordinators to consider during this time?
Tricia: We have all this information out there about patient selection and triage, but it is so important to think about what the next steps are. Once you get permission to do more time-sensitive cases, how do you put those patients on the schedule? Then, even when your hospital decides that okay, we are going to open the doors back up, remember that many centers don’t have dedicated structural heart operating areas. Structural heart may share a room with interventional cardiology, electrophysiology and/or vascular. Everybody is going to have cases to put back on the schedule once the virus becomes less of a threat. What is your strategy to make sure that your patients get taken care of?
This virus has caused a big change in our process. I am impressed with how the team and even our entire healthcare system has responded to this crisis by developing protocols to make sure that our patients know that they are safe. We are reaching out to them and want to provide the best care possible — the same care that we would provide if patients came into the office, even though the situation has changed. The connection that has developed between the valve clinic coordinators, the physicians, and the patients is impressive. Patients feel that we genuinely care about what is happening with them. Similarly, the overall support from Emory Hospital has been essential. Our administration understands that these patients are fairly fragile and that we do have to get them done on a more rapid basis. To be able to develop those relationships during this time, even with each other and our hospital in general, as well as with our patients, has been amazing.
Patricia Keegan, DNP, NP-C, AACC, can be contacted at email@example.com.
Alex Hall, RN, can be contacted at firstname.lastname@example.org.