Teamwork, technology and a can-do attitude come together at a rural community hospital in the Southwest, where an Impella program for cardiogenic shock patients has saved many lives in past years. While many facilities operate successful revascularization programs assisted by Abiomed’s family of Impella left-sided heart pumps, San Juan Regional Medical Center in Farmington, N.M., stands out because of how the nurses manage post-procedure patients. The team at San Juan Regional are confident trailblazers, relying on evidence first as well as well-tooled protocols and staged orientation and training. The success of cardiogenic shock patients here is worth a closer look.
Hear more from the team at San Juan, watch the webinar, Nursing Best Practices: Enabling Success in Protected PCI Patients in Cardiogenic Shock.
The heart team at this 194-bed hospital has been perfecting its work in implanting and managing patients with Impella devices since 2011, says Barbara Charles, BSN, RN, CCCC, the cardiology service line director and a nurse at the facility since 2002. San Juan Regional Medical Center launched its dedicated cardiac care unit in 2006, starting with six rooms and adding 10 more when the hospital opened a new wing in 2010. The plan now is to grow to 24 rooms, as the site has two cath labs, one each shared with electrophysiology and peripheral vascular. They have been a primary PCI hospital and STEMI receiving center since 2010. In 2015, they treated 66 STEMIs and placed 29 Impellas—24 of which were for cardiogenic shock, four were for protected PCI and one for acute myocarditis resulting in a 67% six month survival rate in the cardiogenic shock patient.
This spring, the FDA expanded the options for patients when it approved Abiomed’s family of Impella left-sided heart pumps for treating acute MI patients with cardiogenic shock—which adds up to10 to 12 percent of MI patients who present in-hospital or come through the ER.
“We’re very geographically isolated, and cardiogenic shock patients don’t do well if you have to transport them on a balloon pump,” says Chief of Cardiology Charles Wilkins, MD, who took the reins in 2008 at the launch of the primary PCI and STEMI programs. “Our definition of shock is systolic pressure below 90, not responding to fluid challenge or pressors quickly, and they just look bad…we all know it right away. You have to place [Impella] before the intervention, not after the intervention. Recovery is much better.”
While most facilities maintain a 1:1 nurse to patient ratio of Impella patients through discharge, San Juan Regional has rewritten the rules with a 3:1 ratio. Outcomes are excellent. Patients are cared for in the cardiology unit, rather than the ICU, unless he or she is intubated or has other complications. The secret sauce here is healthy doses of training, mentoring, simulations, well-orchestrated teamwork, and instilling confidence one RN at a time. Training is regimented, organic and utilizes Abiomed’s 24/7 resources.
Wilkins sees it this way: “[N]ursing training is probably the most important part [of the Impella program],” he says. “The device is easy to put in. The physicians are the minor players. It's really the cath lab staff, the nursing staff on the floor, the positioning, the maintenance and troubleshooting that bring good outcomes. It's developed like that and that's good.”
The expanded approval for cardiogenic shock—which comes just a year after the FDA’s greenlighting of the Impella 2.5 device for high-risk PCI patients—enables cardiologists to use Impella devices to help stabilize the shock patient’s hemodynamics, unload the left ventricle, perfuse the end organs and rest the heart enough to, ideally, recover full myocardial function.
The FDA’s updated labeling describes the Impella family of heart pumps as the first and only percutaneous temporary ventricular support devices as safe and effective for the cardiogenic shock indication. The indication states:
The Impella 2.5, Impella CP, Impella 5.0 and Impella LD catheters, in conjunction with the Automated Impella Controller console, are intended for short-term use ( <4 days for the Impella 2.5 and Impella CP and <6 days for the Impella 5.0 and Impella LD) and indicated for the treatment of ongoing cardiogenic shock that occurs immediately ( <48 hours) following acute myocardial infarction (AMI) or open heart surgery as a result of isolated left ventricular failure that is not responsive to