Developing the Nurse Coordinator Role TAVR Developing the Nurse Coordinator Role With this new technology and procedure comes an entirely new role for the nurse. Fortunately for us, sites such as those in Dallas and Vancouver, who have done hundreds of TAVR procedures through clinical trials, have generously shared their vast experiences and insights with us regarding the role of the TAVR nurse coordinator. From their valuable information we have tailored the nurse coordinator role to our institution here at UC Davis. I am going to take you through the nurse coordinator’s responsibilities as we have developed it here.

Disclosure Statement of Financial Interest I, Janine Carlson, DO NOT have any financial disclosures.

TAVR Nurse Coordinator Primary Goal of the Role: To facilitate seamless care from referral through follow up

TAVR Nurse Coordinator Challenges in Development of the Role: Collaboration Coordination Continuity Fostering collaboration among TAVR team members Coordination of the TAVR program Insuring continuity of care of the patient

Nurse Coordinator Referring physician Hybrid OR staff Echocardiographer Anesthesia Interventional cardiologists, CT surgeons Nurse Coordinator Diagnostics labs staff CCU and cardiology floor nursing Clinic staff The TAVR team involves many disciplines. Everyone on the team is important to favorable outcomes. The coordinator is the hub for initiating and sustaining collaborative relationships and coordinating communication among all team members. Administration Schedulers and authorizations OT and PT

Coordination of Patient Flow Referral Patient Contact Diagnostic Workup Clinic visit Additional Diagnostic Tests Scheduling Peri-Procedure Post-Procedure The coordination of patient flow involves the following progression. Receipt of referral, initial patient contact, diagnostic workup or screening, valve clinic visit, coordination of additional diagnostic testing, scheduling of the TAVR procedure itself, peri-procedure responsibilities and post-procedure responsibilities. I am going discuss each stage in further detail.

Mean gradient > 40 mm Hg Jet velocity > 4 m/sec Referral Be Accessible Manage Expectations Gather prior patient medical records Appropriateness of referral Timelines Confirm a plan Follow Up AVA < 1.0 cm 2 Mean gradient > 40 mm Hg Or Jet velocity > 4 m/sec The TAVR nurse coordinator must be accessible, to all members of the team, referring physicians, and patients and their families: I readily provide my phone number, fax, pager, vocera, and even cell phone. There are several methods of referrals. There is direct referring physician to physician, referring physician to coordinator, self referral and referrals to cardiology clinic. Additionally there are direct transfers of acutely ill patients to our hospital. Ultimately all referrals are reviewed by the TAVR nurse coordinator. When a referral from outside the UC Davis Healthcare system is received, the records that are requested are at minimum: H&P, echo report, cath report, current labs and any other recent diagnostic study reports available. I do my best to get the echo and cath images as well. Appropriateness of the referral is determined by review of the outside records. The patient must have severe symptomatic aortic stenosis. Secondly, on transthoracic echo, the patient must have an AVA < 1.0 cm2 and a mean gradient across the valve of > 40 mm Hg or jet velocity of > 4 m/sec. Does the referred patient even have a qualifying valve? Many referring physicians have just heard of the procedure and do not know the actual indications for TAVR. Referrals have come to our TAVR program for patients that have critical AS but are necessarily high risk or non-operative. Timelines for screening, clinic visit and possible TAVR procedure are projected based on the referral records, insurance authorizations required, patient transportation, etc. Confirm a plan: The plan for the screening process is reviewed with the patient/family Follow up: Plan and timeline conveyed to referring physician

This patient population demands a significant time commitment. Patient factors to consider: Elderly Often hard of hearing Multiple co-morbidities Mental impairment such as dementia Multiple family members involved in the care of the patient

Patient Contact Establish contact and build rapport Explain to the patient that they may be a TAVR candidate but further workup is required Answer questions and dispel myths Review timeline: manage unrealistic expectation Respect patient and family preferences Provide written information The initial step of the patient contact is to build rapport. Much of the communication is with the family. The family is purposely engaged. Patient and family come to us with little knowledge about TAVR and may have unfounded expectations about the benefits and risks of the procedure. They may not understand that it is still has to be determined if they are even a candidate to have the procedure The scheduling is arranged around patient and family preferences bearing in mind the demographics of the AS population. Depend on others for transportation. Come from various distances outside of Sacramento. Those providing transportation often have to work around work schedules and other commitments. Written information is important especially when there are several family members involved in the patient care and medical decisions.

Diagnostic Workup Determine which screening tests need to be completed Help coordinate insurance authorizations Scheduling Assist patient with navigating the institution’s departments Reports and imaging are obtained from the referring physician however most screening related exams are often repeated based on established TAVR imaging protocols. Even though this patient population typically are of Medicare age, many patients have secondary insurances that require authorization or have a managed care insurance handling the patients Medicare benefits. Once authorization has been obtained, the goal is to get all needed diagnostic exams scheduled on the same day prior to the valve clinic visit. A letter listing the screening exams, times and exact locations as well as a UCD campus map is mailed to the patient prior to their visit. The patient is met at the time of the first exam and assisted with navigating the campus in order to get to each of their appointments. All of the screening exams are done at the hospital and often it is confusing for them to get to the Ellison building for the valve clinic visit.

Pre-clinic Diagnostic Testing Transthoracic echocardiogram CT structural heart and CTA of abdomen and pelvis Minimum of spirometry with ABG’s, full PFT’s if underlying pulmonary disease Lab work if none current The transthoracic echo is repeated per a TAVR specific imaging protocol. A structural CT of the heart, and CT angio of the pelvis is done. Aortic annulus and root morphology are obtained with the heart CT. With the CTA of the abdomen and pelvis, The minimal luminal diameters of the aorto-iliac vasculature are measured, as well as the degree of calcification and tortuosity in order to determine if transfemoral approach is possible. Currently transfemoral approach is the only access approved by the FDA. Pulmonary testing is done as part of the operability assessment by the CT surgeon.

Annotated Iliac CTA This is an example of the CTA which has been annotated showing the luminal diameters of the arteries from the common iliacs down to the common femoral arteries.

Facilitate a team approach… Clinic Visit Facilitate a team approach… Perform frailty assessments The TAVR nurse coordinator goal as it relates to the clinic visit is to facilitate a team approach. Upon arrival of the patient to the clinic the TAVR nurse coordinator performs frailty assessment. Frailty assessments are essentially functional assessments which are not only important for screening but for discharge planning as well. Assessment of baseline status will help guide the in-hospital plan of care as well as facilitate discharge planning.

Frailty Assessments 5m Walk Test Exclusions (circle all that apply): o Clinically unstable o Severe neuropsychiatric impairment Non-ambulatory. If checked, specify reason: _____________________________________   Utilized walking aid? Yes / No FiveMWalk 1: __________ s/5m FiveMWalk 2: __________ s/5m FiveMWalk 3: __________ s/5m FiveMWalk AVG: ___________ s/5m Gait speed (circle one) Normal (avg ≤ 6 s/5m) Slow (avg > 6 s/5m) NOTES:____________________________________________________________________________________ Activities of Daily Living /6 as per Katz Index (YES = 1, No = 0)   Independent: Bathing: oYes oNo Dressing: oYes oNo Toileting: oYes oNo Transferring: oYes oNo Continence: oYes oNo Feeding: oYes oNo Total Score:_______/6 as per Katz Index Frailty Assessments are often necessary for determination of the non-operability of the patient. Mobility is assessed and includes the 5 Meter Walk Test. A 5 M distance is marked out in the hallway in the clinic and the patient is timed as they walk from one point to the other. This is done 3 times and averaged. The Katz Index of Independence of Activities of Daily Living is used to further assess the baseline physical functional component. A score of 4 indicates moderate impairment and 2 indicates severe functional impairment. Sometimes a full body photograph is taken for documentation of the “eyeball” or “look test” that may be critical to documentation of non-operability.

Facilitate a team approach… Clinic Visit Facilitate a team approach… Perform frailty assessments Review diagnostic studies Tremendous effort is made to have all non-invasive testing completed and available for review by the cardiologist and CT surgeon at the time of the clinic visit. Imaging is reviewed by surgeon and cardiologist together at the workstation.

Clinic Workstation The workstation in our clinic where the physicians can simultaneously view echo imaging, CT images, cath images and the patients EMR. This fosters the collaborative environment.

Facilitate a team approach… Clinic Visit Facilitate a team approach… Perform frailty assessments Review diagnostic studies Determine operability vs. inoperability Make clinical decisions and treatment plans Patient and family education Send the patient home with a clear plan Follow up with the referring provider Patient is then seen by surgeon and cardiologist together and plan is formulated. Is the patient too sick for TAVR, is the patient not sick enough and a candidate for surgical AVR, does the patient have adequate femoral iliac access and if not what is the plan. Education is critical for decision making support as well as to optimize pre-procedure preparation. Patients receive written education materials again important for decision making and involvement of patients other involved family members. Referring provider contact information is available at the clinic visit and the referring physician is typically contacted directly by the cardiologist at the end of the visit.

Additional Diagnostic Tests As determined to be necessary in clinic visit… Schedule cardiac cath with possible PCI or BAV Schedule TEE Patients will need an angiogram if one has not been done within the past 6 months. Aortic root may be visualized and IVUS may be used to further evaluate the common femoral and iliacs if needed. Is there obstructive coronary disease that needs to be addressed? Balloon aortic valvuloplasty is a consideration for patients that are 1) too sick to have TAVR and offered as a palliative measure, 2) to be used as a bridge to TAVR when femoral access is not an option, or 3) as a diagnostic tool to determine if the patient would even benefit from TAVR as in the case of patient with confounding co-mordibities such as COPD. Aortic annulus size is determined by measurement of the TTE as well as the heart CT. The TEE is the gold standard for annulus measurement. If there is a big discrepancy between the TTE and CT or if the annulus measurement is borderline small, borderline large or there is not a clear delineation of the prosthetic valve size needed, the patient will need a TEE.

Valve Size to Annulus Diameter Valve Sizing Valve Size to Annulus Diameter The approved transcatheter heart valve is currently available in 23 mm and 26 mm sizes. The valves will accommodate native annular size ranges of 18 mm - 25 mm. The small valve is used when the annular size is 18mm - 20 mm. The 26 mm valve is used when the annular size is 23mm - 25 mm. When the annular size falls between 21mm and 22mm the valve prosthesis size is determined by taking into account various factors related to the morphology of the native valve and ascending aorta. (procelain aorta, severe annular calcificaiton, narrow root and low coronary ostia, mitral annular calcification) 18 mm 19 mm 20 mm 21 mm 22 mm 23 mm 24 mm 25 mm 23 mm or 26 mm valve The Edwards SAPIEN transcatheter heart valve accommodates an annular size range of 18 mm to 25 mm

Scheduling Upload all screening imaging to ValvePoint for manufacturer review Notify out-patient cath coordinator, all physicians, admin assistants and supervisors Notify valve company for clinical support during the case Valvepoint is Edwards Lifesciences web based data tool process which allows the company to review the diagnostic exams as part of the eligibility process. CT exams, echo exams, angiogram, annotated annulus measurement and screening form are uploaded for review by Edwards clinical staff. Once a date for the procedure is determined, a group e-mail is sent out to key members of the team. The valve company provides clinical support during the case so they are notified of the date as well.

Peri-Procedure Discuss what to expect Review advanced directives and code status Bright pink - REFUSES conversion Bright green - AGREES to conversion Bright yellow - AGREES to emergency vascular repair Collect data for TVT Registry Keep family up to date Post-op daily rounding There is further discussion with the patient and family regarding the procedure itself. The hybrid OR room staff is fully set up and prepared for conversion to open chest in case of emergency. The attending cardiologist has discussed with the patient his/her desire for conversion to open procedure in case of emergency. The chart is clearly labeled with the patient’s conversion desires. The patient’s conversion decision is also stated during the surgical time-out. A stipulation for CMS coverage is that every site participate in the TVT registry which is a benchmarking tool developed to track patient safety and real-world outcomes related to the TAVR procedure. Procedural data is collected as well as outcome data at 1 month and 12 months post procedure. The family is kept apprised of the patients status throughout the hospitalization. The TAVR nurse coordinator participates in post-op daily rounding on the patient. The high risk of functional decline associated with the hospitalization of elderly patients warrants close and team oriented care post-operatively. Early mobilization is key to achieving the goal of returning these patients to optimal functional status.

Post Procedure Set realistic expectations about recovery Symptoms Quality of Life Functional status Meds Resume care with primary cardiologist Weekly phone follow up until stable One month valve clinic follow up The patient and family are educated regarding signs and symptoms of congestive heart failure. Quality of life and functional status post TAVR is discussed. Medications are reviewed. Before patient leaves the hospital a follow up appointment is made to see the CT surgeon in 7-10 days for groin check. Additionally, a one month follow up appointment with echo is scheduled for our TAVR clinic. The patient is instructed to follow up with their primary cardiologist in 1-2 weeks. After discharge the TAVR nurse contacts the patient by phone at least weekly until the patient comes for the 1 month follow up or the patient is considered stable. A follow up letter, CD of the procedure imaging, TAVR procedure report, post procedure echo report and discharge summary are mailed to the referring physician. Follow up with referring physician

UC Davis TAVR Team Every member of the TAVR team is important to the positive outcome.

However the real focus is not on the superhero TAVR team, but the patients and the awesome opportunity to give them a chance to enjoy their golden years.

Unity is strength…when there is teamwork and collaboration, wonderful things can be achieved. -Mattie Stepanek Thank you