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Reducing TAVR Length of Stay Using a Prescreening Approach
Quick Takes
- Patients identified pre-procedure as low risk for complications from TAVR had length of stay reduced by an average of 12 hours.
- Scheduling a post-TAVR transthoracic echocardiogram prior to admission for the procedure can ensure timely discharge.
- Barriers for discharge within 24 hours post-procedure included delayed entry of discharge orders by internal medicine hospitalist teams, lack of patient transportation home, and new conduction disturbances.
Study Questions:
Would the implementation of a prescreening tool reduce length of stay (LOS) in patients who were scheduled for transcatheter aortic valve replacement (TAVR)?
Methods:
This quality improvement project was conducted in a large Midwest urban hospital in patients who were scheduled for TAVR. The goal of the project was to implement a pre-procedure screening process to determine which patients could be eligible for discharge by 2 pm the day after the procedure, with the goal of reducing LOS. A retrospective chart review was conducted to determine if patients who had been screened for next-day discharge could have been sent home within 24 hours after the procedure and what was their actual LOS. Then during the same 5-month period 1 year later (to control for seasonal impact), the screening tool was used in a prospective group of patients who were scheduled for TAVR to determine which patients would be potentially discharged by 2 pm the day after the procedure. Patients in the prospective group were aware of the potential for discharge within 24 hours and arrangements were made for a post-procedure transthoracic echocardiogram to be obtained the morning after the procedure. Inclusion criteria for next-day discharge were patients >18 years of age, plan for transfemoral or transcaval access, outpatient status before procedure, absence of pre-existing conduction disease without the presence of a permanent pacemaker, and a frailty score of ≤1. LOS was calculated for patients who met criteria for next-day discharge, and for those who did not.
Results:
A total of 122 patients were screened retrospectively (February 1, 2020–July 30, 2020) for discharge by 2 pm the day after the procedure. Based on the screening tool criteria, 51 patients were identified from the retrospective group who would have been eligible for discharge within 24 hours. A total of 126 patients were screened prospectively (February 1, 2021–July 30, 2021) with the screening tool, with 55 patients qualified for discharge by 2 pm the day following the procedure. There was a difference between the retrospective and prospective groups in the LOS among patients who would be eligible for next-day discharge (2.1 days vs. 1.6 days, p = 0.0454). Overall, there was a significant difference in the LOS between all the patients included in the retrospective and prospective groups with an average difference between groups of 1 day (3.4 vs. 2.4 days; p = 0.0016). Patients who qualified for next-day discharge in the prospective group had a transthoracic echocardiogram as scheduled for the morning post-procedure. Patient discharges were delayed in the prospective group due to delayed entry of discharge orders in the electronic health record by the hospitalist internal medicine team (n = 12; 21.8%), delay in cardiac clearance (n = 4; 7%), lack of patient transportation home before the goal of 2 pm discharge time (n = 4; 7%), and development of new conduction disturbances (n = 4; 7%).
Conclusions:
Pre-identification of appropriate patients, prescheduling of post-procedure imaging, and patient expectations for discharge can significantly decrease LOS. The authors recognized that the screening tool had limitations in the prospective group because the frailty score was set high or some pre-procedure conduction disturbances were low risk. It did not identify all patients who were discharged within 24 hours. In addition, the hospitalist internal medicine group did not write discharge orders in time. Lack of cardiac clearance for discharge accounted for 28.8% of the delays in discharge. The quality improvement project team recognized a need to improve the discharge process within the multidisciplinary valve team. The whole prospective group had a significantly lower LOS, which reflected the trend toward reducing LOS for patients who undergo a TAVR procedure.
Perspective:
Using a screening tool pre-procedure can identify patients at low risk for complications from TAVR and can provide large institutions the opportunity to develop and implement order sets and protocols to reduced LOS. Having a process in place to expedite discharge post-TAVR not only reduces LOS but the overall cost of care. This quality improvement project demonstrated the impact of a multidisciplinary valve team working together to reduce cost of care and maintain quality.
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Valvular Heart Disease, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound
Keywords: Cardiac Conduction System Disease, Cardiac Surgical Procedures, Cost Savings, Diagnostic Imaging, Echocardiography, Electronic Health Records, Frailty, Geriatrics, Heart Valve Diseases, Hospitalists, Internal Medicine, Length of Stay, Outpatients, Patient Care Team, Patient Discharge, Quality Improvement, Secondary Prevention, Transcatheter Aortic Valve Replacement
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