1. Staffing Considerations – Effective models for clinic, procedure, and post care
Tricia Keegan DNP, NP-C
Director, Heart and Vascular Strategic and Programmatic Initiatives
Emory Healthcare
Atlanta, GA

2. Disclosures
The information provided is the experience of the Emory Healthcare, 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.
Tricia Keegan is a paid consultant to Edwards Lifesciences

3. What does your staffing model look like?
Pre-procedural
Valve clinic
Organizational
Peri-procedural
Staffing in procedure
Patient management
Post-procedural
Discharge
Follow up

4. What is a VCC?

5. Typical VCC roles

6. How my attending describes me

7. Role of VCC is Evidence Based Practice

8. VCC Job Description Program Development and Support
Marketing
Outreach
In house programs
Research and Data Tracking
TVT
Clinical research
Valve Program Coordination
Scheduling
Processes
Patient flow
Clinical Care Coordination

9. The VCC is evidence based practice!
What is the best role for an Advance Practice Providers (APP)? Is it as a VCC?
The VCC is evidence based practice!
There is no one right answer as to desired educational background for this role
RN, NP, PA, RCIS, MA, Administrative Assistant
Our practice at Emory:
Model was to use APP as VCC to improve consistency throughout patient process

10. Importance of APP Safety
The Quality and Effectiveness of Care Provided by Nurse Practitioners Stanik-Hutt,et al. The Journal for Nurse Practitioners , Volume 9 , Issue 8 , e13
“This systematic review supports previous evidence amassed over the past decade that NPs deliver high quality, safe, and effective care to a large number of patient populations in a variety of settings. NPs practicing autonomously and in partnership with MDs have a very significant role in promoting health and providing care to diverse populations in numerous settings. In this time of health care reform and system evolution, to best meet the needs of Americans, it is essential that future models of care take full advantage of the growing number of NPs to their full potential and capabilities”

11. Importance of APP Financial
Huang, Lucia, "Cost-Effectiveness of Nurse Practitioners" (2015). Social Impact Research Experience (SIRE). Paper 37.
“With robust evidence supporting the ability of nurse practitioners to provide cost effective care and economic value, nurse practitioners are well positioned to meet anticipated physician shortages and increasing patient demand. Evidence from the literature review supports the substitution of nurse practitioners for physicians in their overlapping scopes of practice”

12. Evolution of Program across stages of care- Emory’s growth
Pre
Addition of nurse navigator
Addition of scheduler
Block scheduling with Echo, Radiology, Pulmonary
Peri
Staffing
Relationship with Anesthesia
Post
APP lead clinic

13. What have your staffing ratios strategies been? What are they now?
2007 (one campus, TAVR cases 5)
2 CTS, 2 IC, 1 fellow
2011 (two campus, TAVR cases 117):
3 CTS, 4 IC, 2 fellows, 2 VCC (APPs)
2013 (three campus, TAVR cases 263):
4 CTS, 4 IC, 2 fellow, 3 VCC (APPs), 2 RN
2017 (three campus, TAVR cases 453):
5 CTS, 5 IC, 4 fellows (2 clinical, 2 research), 3 VCC (APPs), 3 RN

14. Pre-procedure planningRN
Triage, TVT registry data gathering, patient education
APP
Clinic, patient flow, H&P, patient education, procedure prep IC
CTS
Structure of clinic
Policies and procedures for patient pathway
Standardized work-up

15. Clinic Structure Dedicated day for new patient consults
Surgeon, Interventional cardiologist, APP, research presence
Patients receive testing (Echo, CT, PFT, Carotid) prior to visit
Real time Heart Team decision

16. Tips and Tricks to make the most of the pre-clinic to pre-procedure evaluation
Triage records
What is the patient’s story?
Block scheduling
Echo, PFT, CT
Work with referring to get LHC
Discuss preference with referring (Do they want to do their own LHC?)
Can save on time for evaluation and limit dye exposure
All hands on deck clinic
CTS, IC, VCC, Research
Nurse navigator educational component
Consistent teaching!
Dedicated materials

17. The Heart Team Meeting Weekly meeting M&M Be consistent
Discuss state of service
Patient presentations
Patient census
Upcoming procedures
New happenings
Personnel
Research
M&M
Be consistent
Flow of meeting
Attendance
Pay attention to time

18. Peri-procedure considerationsIC
Fellow
CTS
Echosonographer
Echocardiographer
Moderate sedation (No anesthesia)
General anesthesia (anesthesia)
Cath lab staff
Monitor
Scrub
Circulator

19. Peri-procedural growth
Staffing:
95% cases done in the cath lab
Personnel: IC, CTS, Fellow, Echo, 1 RN circulator, scrub, monitor, +/- second circulator
Average 3 to 4 cases/day
Most cases are conscious sedation
No anesthesia
No perfusion
No OR staff

20. Post-procedure growth
Patient recovery
PACU
Direct to ward
Standardized order sets
APP lead service

21. Post-Procedure Care Party(ies) responsible for rounding
Standard order sets
Location of patient recovery
Nursing education
Meeting/managing patient expectations

22. Post-procedure staffing at Emory
ICU RN 2:1
Telemetry RN 4 or 5:1
8am-6pm Structural service (Attending, fellow, APP)
Interventional service on nights, weekend
Nurse Navigator does d/c teaching on all patients

23. Follow-up growth Patient growth necessitated additional clinic days
APP lead clinic
Felt important to have patients follow up at implanting site (if possible)
Administrative assistant (1 FTE)
Track patients for follow up
Request records as needed
Schedule appointments
Coordinate testing if unable to return to Emory
Echo
Increase in volume of 1 month and 1 year echo
Should there be yearly surveillance?
Nursing
KCCQ

24. Lessons Learned Don’t assume everyone knows what to do
Know who is collecting registry data and if they are able to access necessary data
Do not rely on non-structural order sets
Need for personalized care within a policy driven service
Consistent patient education
Evaluate Staffing on a rolling basis, predict trends
Evaluate service line baseline- Prepare for Growth! (Mitral and Tricuspid procedures!)

25. Patricia.keegan@emoryhealthcare.org (404) 712-7622

26. Please see the important safety information available at the speaker podium
Edwards and Edwards Lifesciences, are trademarks of Edwards Lifesciences Corporation. All other trademarks are the property of their respective owners.
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