TAVR Program Efficiency Bobby Leonardi West Columbia, SC

Disclaimer The information provided is the experience of  Lexington Medical Center, and Edwards Lifesciences has not independently evaluated these data. Outcomes are dependent upon a number of facility and surgeon factors which are outside Edwards’ control. These data should not be considered promises or guarantees by Edwards that the outcomes presented here will be achieved by an individual facility. I am a paid consultant to Edwards Lifesciences.

Background Your TAVR (structural heart) program is getting busier, and there are only so many hours in a day, procedure suites in the hospital, beds in the ICU, etc. Outcomes as good or better than surgery have contributed to expanded indications for TAVR in recent years, contributing to a more than 340% increase in annual TAVR volume over the first 4 years of commercialization. And, double-digit growth is projected for several more years. Time is money.

Efficiency “state or quality of being able to accomplish something with the least waste of time and effort; competency in performance” Dictionary.com

The TAVR Process TAVR Day Referral Evaluation Admission Pre-Procedure Care TAVR Day TAVR Post-procedure Care Discharge Follow-Up

Carolina Products, Inc. Google images “Identify the problem. Formulate a plan. Take corrective action.” If you’re having trouble… Barriers to efficiency often are allowed to persist because they have not been identified. “We’re not building the space shuttle here.” This isn’t open heart surgery. Google images

Barriers to Efficiency Referral process complexity Pre-TAVR evaluation requirements Hospital (ICU?) bed availability OR > lab availability Procedural complexity Turnover time Post-operative “bottlenecks” Discharge planning Bottlenecks include

Referral Efficiency Text message from referrer with name and # MD calls patient directly MD emails team with plan Appointments made Patient called again with detailed instructions MD replies to referrer to close loop

Pre-TAVR Evaluation TAVR Need diagnostic coronary angiography? Yes No Local? No Yes Same-day OVs and CTA Cath - Admit - CT - Surgeon Outpatient Angiography Home with TAVR Plan Plan “Pre-TAVR” Angiography at TAVR Home with TAVR Plan Same-day OVs and CTA TAVR

Admission and Pre-procedural Efficiency Why admit the day before? Why not same day? Scheduling First case where? Can we “bounce?” Patient preparation (PIVs and groin clipping) before arrival in procedure area Staff aware of procedure plans/details? Best if all equipment immediately available

The Glue

Intra-Procedural Efficiency Use lab (not OR) when appropriate. Better availability of infrequently used equipment. Minimize staff requirements in room. 1 RN/circulator 1 lab technician to assist 1-2 lab/OR technicians to crimp

Advantages of Minimalist TAVR Increases scheduling flexibility Less dependence on OR availability Facilitates same-day admission (no anesthesia consultation) Saves OR and lab time Less pre-procedure set-up + less post-procedure clean-up = less turnover time Less patient time on the table Facilitates more rapid recovery Less delirium and anesthesia-related voiding difficulty (and Foley catheters) Shortens length of stay Saves roughly $1 million per 100 TAVRs Patients like it. May be able to stay out of OR entirely. Happy patients = happy referring providers.

Criteria for Minimalist TF TAVR Catheterization Laboratory with no Cut-down, TEE, Anesthesiologist, or CBP Option Is the patient cooperative? Is the risk of vascular injury low? Consider feasibility of percutaneous management. Is the risk of respiratory failure low? Consider baseline respiratory status and airway. Is the risk of needing MCS low? Consider baseline LV/RV function, comorbid valvular disease, comorbid CAD, and pulmonary hypertension.

Criteria for Transfer from Lab to PCU Is the patient hemodynamically stable? Is the patient’s respiratory status stable? Does the patient have a TVP wire?

Inter-procedural Efficiency Minimize “skin to next skin” (turnover) time. Should be similar to time between PCIs Engage and empower lab/OR staff in identifying and eliminating unnecessary delays. “Terminal clean” by lab/OR technician may help Ideal to “bounce” between two rooms Turnover time can be < 5 minutes. Helps to achieve operator equivalency in TF cases Ideal if neither room is routinely the hybrid OR

Inter-procedural Efficiency Not Bouncing Bouncing 7:00 patient #1 in room #1 7:15 stick - 8:15 done 9:00 patient #2 in room #1 9:15 stick - 10:15 done 11:00 patient #3 in room #1 11:15 stick - 12:15 done 1:00 patient #4 in room #1 1:15 stick - 2:15 done 3:00 patient # 5 in room #1 3:15 stick - 4:15 done 7:00 patient #1 in room #1 7:15 stick - 8:15 done 8:00 patient #2 in room #2 8:15 stick - 9:15 done 9:00 patient #3 in room #1 9:15 stick - 10:15 done 10:00 patient #4 in room #2 10:15 stick - 11:15 done 11:00 patient #5 in room #1 11:15 stick - 12:15 done Assume all patients take 15 minutes to prepare after room entry, all procedures take 60 minutes, and room turnover always takes 45 minutes. Bouncing reduces stick to next stick time by 50%!

Post-procedural Efficiency Protamine given? Sheaths out in holding area. To post-PCI care unit, not ICU. Generally more open beds than ICU. Happy to take TAVR patients. Not afraid of groins. Familiar with admit/discharge processes. Post-TAVR echo on POD #0 (evening).

Discharge and Follow-Up Efficiency Discharge appointments done before TAVR APRN visit at 30 days with echo for TVT registry PPD, SW, PT consults at admission? (STR) Post-TAVR echo on POD #0 Discharge orders in place by 8:00 am

Necessity is the Mother…

Percutaneous First 1 TAo, 1 TA 1 cut-down Currently more than half of cases being done in Cath Lab.

TAVR in the Cath Lab *1st 3 months

Journey: 2/Day to 5 by 1:00 pm Streamline referral and pre-procedure processes. Admit the same day. Schedule intelligently. “Bounce” if you can. Simplify the TAVR. Transfer to post-PCI unit when appropriate. Minimize turnover (ideally 2 rooms; 2 labs OK). Anticipate discharge delays.

Who cares? Your patients Your hospital leadership Your partners, staff, and family/friends

What’s in it for the patient? Shorter procedure Less post-operative pain (groin, throat) Less anesthesia “hangover” Less time in ICU More rapid mobilization Earlier discharge Less cost?

What’s in it for your hospital? Lower cost Lower procedural cost Shorter LOS No need for another hybrid OR More productivity More cath/PCI volume per TAVR day More OR availability More “esprit de corps” for TAVR team More referrals?

Minimalist TAVR Reduces Cost Hospital costs during the initial procedure hospitalization in the minimalist approach transfemoral transcatheter aortic valve replacement (TF TAVR) group compared with standard approach TF TAVR group. Hospital costs include the cost of the trans-catheter valve ($32,500) but not physician fees. J Am Coll Cardiol Intv 2014;7:898–904

Aren’t you cutting corners?!?

Minimalist TAVR J Am Coll Cardiol Intv 2014;7:898–904

Efficiency is an ideal. Just keep identifying problems, formulating plans, and taking corrective action. You can always get better. If your trying to get better, you probably will.

Thank You

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