Fast Track Protocol for TAVR Feasible, Efficient
Identifying TAVR patients who will benefit from a fast track care pathway after the procedure is feasible and results in shorter and less expensive hospital stays without compromising quality of care, according to a small study published online November 29, 2014, ahead of print in Catheterization and Cardiovascular Interventions.
For the study, 2 institutions initiated fast track care pathway programs with inclusion and discontinuation criteria designed to foster early extubation, fewer ICU days, and early ambulation in select patients.
Howard C. Herrmann, MD, of the Hospital of the University of Pennsylvania (Philadelphia, PA), and colleagues analyzed data on the 99 patients (mean age 85) who underwent transfemoral TAVR at 2 centers from June to December 2013:
- Site A, a large academic tertiary hospital, used an organized pathway approach in which an interdisciplinary team determined who would follow the program preprocedurally.
- Site B, a moderate-sized academic community hospital, used an inclusive systematic pathway approach in which the fast track pathway was attempted on most patients who received transfemoral TAVR.
Roughly 40% of patients (n = 39) met fast track inclusion criteria.
Site A employed more exclusion criteria than site B. The fast-track protocols were similar at both institutions except regarding where patients were sent after TAVR. At site A, patients were moved to a postanesthesia care unit where they underwent testing and then transferred to a cardiac intermediate step-down unit after 2 hours until discharge. At site B, patients were moved to a cardiothoracic ICU for up to 4 hours while tests were reviewed, and after being examined by a cardiac anesthesia intensivist, they were transferred to a floor bed.
By study design, fast-track patients had fewer comorbidities than those who were ineligible for the program.
Most Eligible Patients Complete Program
Of the 39 patients who started the fast track protocol, 28 (72%) finished it. More patients at site A than site B successfully completed the program (94% vs 57%). The patient from site A who did not complete the protocol was unable to continue because of respiratory failure and complete heart block with eventual pacer implementation and required prolonged inotropic support. At site B, reasons for discontinuation included tamponade, ventricular perforation, prolonged use of vasopressor or inotropic support, severe hypertension, and vascular complications.
Of those who started the fast track program, 15 patients required home health services, 2 assisted living, 2 inpatient rehabilitation, 5 skilled nursing, and 15 no additional services at hospital discharge.
Program Less Expensive Than Standard Care
At 30-day follow-up, 14 patients (88%) from site A and 10 (77%) from site B who completed the fast track program were alive and at home. The 1 patient who was discontinued from the fast track from site A died within 6 weeks of TAVR, but 6 of the 10 patients from site B who discontinued were “doing well” at 30 days, the paper notes.
Patients who started fast track treatment had lower direct hospital costs and shorter ICU and postoperative hospital stays than those who did not, regardless of whether they completed the program (table 1).
Furthermore, ICU and postoperative length of stays were shorter while direct costs were lower among those who completed rather than discontinued the fast track program.
Of the patients who discontinued fast track treatment, “there was no evidence that the care [they received] was compromised,” say the study authors.
Enrollment Criteria Expected to Evolve
The higher number of discontinuations at site B than site A can be attributed to the fewer number of exclusion criteria employed, they explain, potentially making bed occupancy planning more challenging. Moreover, as “a number” of the fast track discontinuations were due to procedural complications, the authors expect these to decline as device technology improves. Some of the reasons for discontinuation at site B also could be “managed in some hospitals with a ‘step-down’ unit, which is not available” at the site, they suggest
Despite site A having more stringent enrollment criteria than site B, the average frailty score of patients fast-tracked at site A was lower than those of both enrolled and excluded patients at site B. Because both sites had similar outcomes after TAVR, “it is possible that [fast track] care with early ambulation may benefit the frail patient,” they say, proposing that frailty alone should not be a barrier to participation.
The postanesthesia care unit employed at site A “was crucial to the initiation and expansion” of the fast track program, as bed use and costs are likely less expensive there than in an ICU, they note. Revisions in enrollment criteria may also be necessary in order to encourage adoption and efficacy of the protocol.
Marcantuono R, Gusche J, Burke-Julien M, et al. Rationale, development, implementation, and initial results of a fast track protocol for transfemoral transcatheter aortic valve replacement (TAVR). Catheter Cardiovasc Interv. 2014;Epub ahead of print.
- Dr. Herrmann reports owning equity in Microinterventional Devices and receiving research funding to his institution from Abbott Vascular, Boston Scientific, Edwards Lifesciences, Gore, Medtronic, Siemens, and St. Jude Medical and honoraria from Edwards Lifesciences, GlaxoSmithKline, Merck, and Siemens.