Nursing leadership of the transcatheter aortic valve implantation Heart Team

Introduction

Valvular heart disease is the next epidemic of cardiovascular disease in industrialized countries. ¹ Disease prevalence is estimated at 2.5% and increases markedly to over 7% after the age of 65 years. Impaired valve functioning is associated with debilitating symptoms, heart failure, poor quality of life, repeat hospitalization, and poor prognosis. Valve replacement or repair is required to alter disease progression. ²

In 2005, the treatment of valvular heart disease was permanently transformed by the successful and reproducible development of transcatheter aortic valve implantation (TAVI) pioneered in British Columbia (BC). ^3,4 Today, most patients who are debilitated by severe aortic stenosis and whose advanced age, frailty, and comorbidities increase their surgical risk are referred for TAVI eligibility in specialized cardiac centres. Programs are growing rapidly, creating significant challenges for clinicians, administrators, and health policy leaders and funding agencies.

The concept of the multidisciplinary “Heart Team” approach is foundational to best TAVI practices. Beyond the minimum requirement of interventional cardiology and cardiac surgery recommended by international guidelines, ⁵ nursing leadership can further strengthen the TAVI Heart Team by promoting patient-centred program development and evidence-based practices in this innovative and rapidly evolving area of patient care.

In this article, we discuss the paradigm shift to the transcatheter management of valvular heart disease and the opportunities for nursing administrative and clinical leadership to sustain the successful implementation of innovation in cardiac care as members of the TAVI Heart Team.

Transcatheter heart valve interventions: A paradigm shift in the management of cardiac care

Valvular heart disease encompasses multiple conditions that affect the four valves that separate the cardiac chambers and large vessels. Aortic stenosis (narrowed) and mitral regurgitation (leaking) are the most prevalent valvular heart diseases and account for three of four cases. ⁶ Aortic stenosis is caused by the progressive accumulation of calcium within the valve leaflets and is primarily associated with aging. Once patients experience symptoms, including heart failure, angina, or syncope, quality of life deteriorates rapidly, repeat hospitalizations are often required, and life expectancy is reduced to 2 to 4 years. Timely treatment is essential to improve prognosis. ² Surgical aortic valve replacement (SAVR) offers a definitive treatment for eligible patients, but challenges are associated with the treatment of higher surgical risk patients, sternotomy, cardiopulmonary bypass, and lengthy recovery. In 2010, the findings of the Placement of Aortic Transcatheter Valve (PARTNER) clinical trial established TAVI as the standard of care for inoperable patients. ⁷ Since then, further research has supported the increasing use of TAVI as a safe and effective treatment for select patients. ⁸

In 2012, the Canadian Cardiovascular Society (CCS) outlined the indications for TAVI and strongly endorsed the importance of a multidisciplinary Heart Team approach inclusive of cardiology, cardiac surgery, imaging, cardiac anaesthesia, and nursing. ⁵ Given the advanced age, frailty, and comorbidities of most people with aortic stenosis, the journey of care of TAVI patients can be lengthy and onerous. ⁹ The eligibility for TAVI requires multiple diagnostic testing and consultations in a specialized cardiac centre and results in varying treatment decisions. Further, the peri- and post-procedural team has unique requirements, including the engagement of cardiac imaging, anaesthesiology, cardiac catheterization, operating room personnel, critical care, and the discharge planning team. ¹⁰ Although relatively low volume compared to other cardiac procedures (eg, heart surgery, cardiac catheterization, and cardiac implantable electronic devices), the complexity of program development, processes of care, and stakeholder engagement can render TAVI uniquely resource intensive. Thus, an efficient, effective, and sustainable TAVI program hinges on operational and clinical leadership that contributes to the development of best practices.

In BC, there was an 88% increase in the volume of TAVI procedures completed between 2005 (N = 40) and 2015 (N = 332). During that time, the proportion of BC patients treated with TAVI compared to SAVR grew from 8% to 32%. Importantly, the volume of SAVR grew similarly from 511 to 698 (27%). Overall, demand for treatment of aortic stenosis increased by over 50% in the past decade in BC (Cardiac Services BC; see Figure 1). ¹¹ Many Canadian centres have experienced similar growth. In 2014, over 1,600 TAVI procedures were performed at 25 Canadian centres. ¹²

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Figure 1.

Trends in the management of aortic stenosis in British Columbia (2003-2014). A, Proportion of patients treated with Surgical Aortic Valve Replacement (SAVR) and Transcatheter Aortic Valve Implantation (TAVI). B, Growth in the treatment of aortic stenosis (SAVR and TAVI).

The Centre for Heart Valve Innovation at St. Paul’s Hospital has completed over 1,500 TAVIs since 2005. Learning from its early pioneering accomplishments and the challenges encountered, the team questioned the restricted view of the Heart Team as limited to a collaborative relationship between cardiology and cardiac surgery. Rather, an expanded Heart Team concept was embraced as a strategy to promote patient-centred program development and support excellence, planning, and sustainability (see Figure 2). This strengthened the team’s common vision to accelerate innovation while attending to the complex operational and practice imperatives of a successful TAVI program. The capacity of nurses to provide administrative and clinical leadership augmented the Heart Team’s expertise by offering varying perspectives and skill sets grounded in the scope of practice of registered nurses.

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Figure 2.

Expanded Heart Team approach for Transcatheter Aortic Valve Implantation (TAVI) patients.

Joining the Heart Team: Nursing administrative leadership

It is imperative that administrators grasp the planning and operational complexities of managing the growing demand for TAVI and other transcatheter heart valve procedures. Nursing administrative leadership is well suited to understand patient and clinical needs, redesign models of care, secure appropriate resources, and monitor patient access and quality of care.

A grasp of the disease progression of valvular heart disease, the discernment of treatment options, and the anticipation of the clinical shifts afoot with the rapid emergence of transcatheter therapies are assets to TAVI program development. Nursing expertise in cardiovascular care strengthens administrators’ capacity to orchestrate the multiple services and areas of care required to consolidate the moving parts of a TAVI program and manage the demands of surgical and transcatheter treatments. This “clinical literacy” increases the ability to learn about rapidly evolving devices, procedural approaches, clinical requirements, and scientific evidence and to engage the multidisciplinary stakeholders with an enhanced awareness of priorities, risks, and needs.

Significant change management is associated with the administration of services, human and operational resources, and funding requirements of TAVI programs. For example, the unique and diverse requirements for TAVI include intensive multimodality diagnostic imaging, “hybrid” models of peri-procedural staffing that combine operating room and cardiac catheterization expertise, and access to critical care services that may be unaccustomed to the post-procedure admission of elective patients (eg, cardiac intensive care unit). Further, bridging the operational requirements for SAVR and TAVI resources can be informed by an in-depth understanding of patient and clinical needs to avoid potential competing demands and silos of care. Nursing expertise can enhance administrators’ complex task of redesigning models of care and engaging with medical leadership with a common clinical understanding of the issues at hand.

The task of administrators whose responsibilities include TAVI program is further complicated by the need to secure additional resources to meet patient needs and support the quality of services. TAVI programs are poorly served by an extension of the triage coordination model of cardiac surgery and interventional cardiology. Unique clinical and clerical staff is required to manage referrals, support case selection, coordinate procedure planning, facilitate discharge, conduct follow-up, and attend to the often onerous data collection needed for evaluation and funding purposes. Advocacy for procedure time and resources must balance the competing demands of other services and the imperative need for sustainability. Close collaboration with senior leadership teams and funding agencies is essential to communicate program needs and plan accordingly.

Lastly, nursing leadership is well positioned to monitor patient access and quality of care. There are no established Canadian TAVI wait time benchmarks. ¹³ In view of the current growth in demand for the procedure across the country and the poor prognosis associated with disease progression, the clinical interpretation of wait lists, wait time, and urgency of patients’ status (eg, elective outpatient vs urgent inpatient) is pivotal to plan health services. Similarly, the critical evaluation of outcomes and other quality indicators enables administrators to engage the clinical team to support quality of care. The recent publication of the CCS quality indicators for TAVI will assist administrators and their Heart Team to review their quality report and participate in a national quality improvement strategy to promote best practices across the country. ¹²

Joining the Heart Team: Nursing clinical leadership

Nursing leadership contributes to the development of clinical best practices to support the innovations in the treatment of valvular heart disease. The role of the Clinical Nurse Specialist (CNS) is best used to support novel and complex program development and ongoing quality assurance. ¹⁴ This skill set can accelerate the development of TAVI processes of care, help develop best practices and a TAVI clinical pathway, and implement a multidisciplinary forum to address program issues and quality improvement.

In our experience, the joint partnership of the CNS and the medical director has enabled the development of TAVI-specific and patient-centred processes of care and support for clinical teams along the continuum of care within the cardiac program. This collaborative relationship has promoted the implementation of evidence-informed protocols, standardized physician order sets, and risk-stratified clinical pathways. ^9,15 The CNS also supports the pivotal role of the TAVI nurse coordinator and the transcatheter heart valve clinic staff. This clinical leadership can facilitate significant efficiencies gained through centralized referral, standardized processes for case selection and protocols, and streamlined clinic infrastructure.

There is a paucity of evidence to guide nursing practice of TAVI patients. To date, limited experience, low procedural volumes, and the rapid pace of innovation have precluded the study of clinical pathways and other interventions aimed at reducing variation in care. Yet, opportunities exist for nurses to lead practice changes and contribute to improved outcomes. In our experience, focused quality assurance initiatives led by the CNS and aimed at mitigating the risks of the “geriatric giants” of in-hospital deconditioning have improved our program. For example, the implementation of a standardized post-procedure clinical pathway focused on rapid mobilization, avoidance of invasive devices (eg, urinary catheter), and facilitated discharge has contributed to decreasing length of stay to less than 48 hours for most TAVI patients. ¹⁵ Similarly, nursing leadership has facilitated a standardized process to help patients transition to palliative care when TAVI is not an option to promote continuity of care. ¹⁶

Lastly, the CNS is tasked with facilitating the engagement of the Heart Team. The multidisciplinary Transcatheter Heart Valve Program Care Team is a monthly forum aimed at discussing the program’s operational and practice issues to determine action items and promote quality of care and sustainable program development. The distinct expectations of Heart Team members who are accustomed to processes of care designed for the unique needs of their clinical areas (eg, interventional cardiology, cardiac surgery, or imaging) can lead to complex team dynamics. Internal competition for resources (eg, procedural and clinic time), increased demand for specialized services (eg, transesophageal echocardiography and anaesthesiology services), and shared responsibility for multiple aspects of the program (eg, case selection, procedure planning, and emergency intervention requirements) can exacerbate communication issues. In our experience, the joint management of these challenges at the Care Team meeting is an effective means to mitigate the risks inherent to this complex program and identify creative solutions to evolving problems and changing needs. In addition, the CNS coordinates a biannual program quality report meeting to examine outcomes and quality indicators, discuss adverse events, and identify opportunities for quality assurance initiative.

Conclusion

The contributions of nursing administrative and clinical leaders in developing efficient, effective, and sustainable approaches to support the TAVI program exemplify the role that nurses can assume to promote innovation in cardiac care. The expertise and perspectives of nurse leaders are well matched to the complexity of managing the paradigm shift in the treatment of valvular heart disease. The competencies outlined in the LEADS framework are particularly salient to supporting innovation in cardiac care. ¹⁷ The TAVI program development is an exemplar of how nurse leaders are guided by the principles of systems transformation, development of coalitions, achieving results, leading self, and engaging others to support a paradigm shift in healthcare. The effectiveness of this framework in measuring the contributions of nurse leaders warrants further study.