In the not-so-long-ago early days of transcatheter aortic valve replacement (TAVR), most eyes focused on the physicians who performed the procedures even as behind-the-scenes contributions from nursing also helped make TAVR a success story. Recognition of their value also is raising nursing’s profile in the cardiovascular community.

Learning by doing

When the Centers for Medicare & Medicaid Services (CMS) released its national coverage determination for TAVR in 2012, it specified that programs establish a heart team with cardiovascular surgeons and interventional cardiologists as well as “additional members … such as echocardiographers, imaging specialists, heart failure specialists, cardiac anesthesiologists, intensivists, nurses and social workers.” The agency took its cue from the aptly named PARTNER (Placement of AoRTic TraNscathetER Valve) studies, Edwards Lifesciences’ pivotal clinical trials that followed a heart team concept.

“In the guidelines, it is embedded as the forced collaboration between cardiac surgery and cardiology,” says Sandra Lauck, PhD, RN, clinical nurse specialist in the Transcatheter Heart Valve Program at St. Paul’s Hospital in Vancouver. She participated in first-in-human TAVR cases, then worked as a cath lab nurse at St. Paul’s with John G. Webb, MD. Webb also contributed to the PARTNER trials and continues as a top investigator.

“One of the things that we learned early on is that the success of the procedure depends on far more than simply getting the valve in and procedural expertise,” Lauck says. “One of the early lessons was that the heart team needed to look quite different depending on where the patient was in his or her journey.” 

Nursing plays a critical role before and after the patient enters an operating room. Preprocedurally nurses may help screen and evaluate potential candidates, ensure they receive necessary diagnostic testing, educate the patient and family about the procedure and discharge, organize heart team meetings and keep everyone abreast of the case. Nurses may contribute to procedure planning and postprocedurally monitor recovery, prepare the patient and family for discharge to a safe setting, arrange follow-up and stay in contact once the patient goes home or to another facility.

Added to that are collecting data for the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy registry (a CMS mandate), overseeing coding, handling financial matters, ensuring efficiencies and participating in patient satisfaction and quality initiatives, all the while serving as a point of contact for patients, families, referring physicians, the heart team and other staff involved in TAVR patients’ care. Titles may vary by institution, but they almost always include the word “coordinator” and often are nurses.

“They are the glue between all of the moving parts that are involved in a transcatheter valve team,” says Marian C. Hawkey, RN, director of clinical research at the Center for Interventional Vascular Therapy at New York Presbyterian/Columbia University Medical Center in New York City, where Martin B. Leon, MD, and Craig R. Smith, MD, were PARTNER’s co-principal investigators.

These nursing pioneers had few good models to guide them at the start. Neither the pathways of care for percutaneous coronary intervention (PCI) nor surgical patients perfectly suited TAVR and a patient population that was on average in their 80s. “Unlike a heart surgery program or a PCI program, the complex stakeholders and the extensive team sport that is involved in TAVR really needs central orchestration,” Lauck says. “We like to think the physicians can do it all, but they have busy schedules. They also sometimes lack that expertise needed to have really good multidisciplinary development. Nurses are well suited to that.”

The team-based approach used in heart failure and transplantation offered some direction. But for the most part, TAVR entered uncharted waters. “We laid the groundwork,” Hawkey recalls. “There was that foundational period where we figured out, ‘How do we do this?’ And then, ‘This is what we need to do, and these are the steps we need to take.’”

Commercialization of TAVR devices in the United States, first with Sapien in 2011 and then with Medtronic’s CoreValve device in 2014, opened the doors for the creation of TAVR centers beyond trial sites. That development prompted Hawkey, Lauck and some other nursing leaders to write recommendations for best practices with a focus on the TAVR program coordinator (Catheter Cardiovasc Interv 2014;84[6]:859-867).

“It was an attempt to bring together the national leaders in this field, recognizing that, first of all, everyone is walking out there in the wilderness not knowing what to do,” Lauck says. The document outlines roles, tasks and competencies needed for the job. “It is not good enough to just tap the nurse on the shoulder and say, ‘Go forth.’ There is a specialized body of knowledge that needs to be outlined and there are specific components of the program that need to be put in place to abide by some of these best practices.”

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Patient-centered care 

Perhaps no one touches the patient more than the TAVR coordinator, from providing functional and psychosocial assessments to determine if he or she is an appropriate candidate to developing a discharge plan with the optimal length of stay tailored to that specific patient. Their ability to steer the patient efficiently from start to finish can affect outcomes. For instance, Lauck and colleagues determined that patients with a lag of six weeks or more between referral and procedure were less likely to be as robust postprocedurally, as measured by decline in gait speed, as patients with shorter wait times (Eur J Cardiovasc Nurs 2015;14[6]:560-569).

TAVR coordinators also may have the best handle on a patient’s wishes, allowing the coordinator to serve as an advocate. Lauck’s group, in exploring TAVR patients’ motivations and expectations, found that quality of life was a universal concern (Eur J Cardiovasc Nurs online Oct. 23, 2015). Knowing that, a TAVR coordinator might question an imaging test that compromises the patient’s kidney function, for example. “Let’s say we do this and give them more contrast and they end up on dialysis: What is that like from a patient’s perspective?”

Lauck and Amy Simone, PA-C, valve clinic coordinator at Emory University Hospital in Atlanta, observe that coordinators look beyond clinical data that informs the procedure such as valve area or artery traits to ensure the program provides patient-centered care. Sometimes that means supporting the patient in declining TAVR.

“Who is driving the impetus of implant? I have seen patients who are motivated by family and they just don’t do as well,” Simone says. “They don’t have

internal motivation. The coordinators are the voice of reason sometimes. ‘I am sure we could do this, but should we? I don’t think we should.’”

Patient-centered care also has translated into cost savings. Both St. Paul’s and Emory have championed shorter-stay TAVRs, building off the recognition that TAVR patients don’t benefit from the long bed rest of traditional surgical aortic valve replacement patients. That required a mind shift among nursing staff, says Patricia Keegan, MSN, NP-C, structural heart coordinator at Emory.

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They achieved that change by emphasizing the need to be open-minded and inviting nursing to help develop protocols and a care decision tree for a minimalist approach. That approach favors local anesthesia and minimal conscious sedation during the procedure and getting the patient out of bed and moving soon after. To educate nurses on various floors, they invited them to observe a TAVR procedure in addition to other instructional events that explained why that information was important.

“We tried to make sure our nurses fully bought in before we brought the first patient to the floor,” Keegan says. “It was not a decision that came from our physicians saying, ‘This was how it was going to be.’ It was a partnership with nursing.”

Emory, also a PARTNER site, initiated its minimalist approach in 2012. In a comparison of minimalist vs. standard transfemoral TAVRs, Keegan, Simone and other Emory researchers reported that 30-day mortality and survival at 435 days follow-up were similar; but lower procedure time, intensive care unit (ICU) time and shorter length of stay created an average savings of $10,000 per procedure (JACC Cardiovasc Interv 2014;7[8]:898-904).

More recently, they calculated that they reduced ICU utilization from 100 percent before the minimalist program to about 20 percent shortly after initiating the program to 3 percent now, with some months recording 0 percent utilization, Simone says.

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Taking on leadership

If nursing has been good for TAVR, TAVR also has been good for nursing. TAVR coordinators at successful programs say their acceptance as part of the heart teams was unequivocal. Successful programs recognize and acknowledge the coordinator’s contributions. Proof in point: Lauck recalls that several years ago she and Hawkey presented a workshop on the TAVR coordinator’s role at a Cardiovascular Research Foundation conference. A room that seated 30 ended up accommodating about 200 people.

“Most of them were physicians who realized they needed to put pieces together for program development,” Lauck says. “It put nurses at that leadership table.”

TAVR, with its quickly evolving technology and a patient population that is likely to change if the risk meter continues to drop, forces nursing to be nimble and adaptable, Hawkey notes. “It is not like it is one of these jobs where you get to a cruising altitude and you are good to go for the duration,” she says.

Some administrators also recognize the acrobatics involved in a TAVR coordinator’s role, which requires a strong understanding of both cardiovascular and structural heart diseases. “There are so many different pieces to this, and it is not MD work and it is not a clinical nurse like an ambulatory nurse job either, because they don’t have the appropriate education,” says Ruth Fisher, a vice president at Henry Ford Hospital’s Heart and Vascular Center in Detroit. “You absolutely need a program coordinator. It was a foregone conclusion. I didn’t have to convince anybody because who else would do all this work to take patients to the point where we could actually do a TAVR?”

Nursing needs to build on this momentum, Lauck argues, with evidence that proves nursing’s value in TAVR. Having a seat at the table adds little if nursing doesn’t pipe in.

“I want to challenge my nursing colleagues to not just be passive members of the heart team,” she says, “but also demonstrate that we can generate the evidence and participate in this rapidly moving area by contributing protocols, standards of care, research findings, that whole gamut that will allow a field to move forward.”    

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