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 optimal medical management and conventional treatment measures with or without an intra-aortic balloon pump. The intent of the Impella system therapy is to reduce ventricular work and to provide the circulatory support necessary to allow heart recovery and early assessment of residual myocardial function.
“Because the patient is more stable, we feel comfortable tackling lesions we otherwise would defer or consider sending the patient for bypass or even to a tertiary hospital,” says Interventional Cardiologist Faraz Sandhu, MD. “Objectively, the patient's parameters improve. There is less ischemia. The left ventricular filling pressures drop. Data support complete revascularization and show high-risk patients do better with the Impella in place.”
Rural and confident
San Juan Regional Medical Center is unique for a variety of reasons. This nonprofit, community-owned, Level III trauma center is nestled in the northwest corner of New Mexico where the geography is very remote and catchment area immense, including some 350,000 to 400,000 people. New Mexico is the 5th largest state, but its population is just twice that of Rhode Island. Patients often travel long distances by helicopter, ambulance, car, truck or foot to the facility.
The hospital serves a largely Native American population while the rest of the patient base is predominantly Hispanic or Caucasian. Widely prevalent risk factors include obesity, renal disease and acute renal injury. Many are smokers. Registry data show that greater than 42 percent of patients have some form of diabetes, Charles notes. Additionally, multivessel disease, diffuse disease, diabetic vasculopathy and congestive heart failure are common.
With complex anatomy, procedures tend to be more complex as well. “The lesions are more calcified requiring atherectomy or further higher risk interventions,” Sandhu says. “The vessels in Native Americans and Hispanics tend to be smaller, which also is challenging.”
Patients, too, tend to be sicker at presentation. Fewer than 40 percent call EMS for transport, while the rest either drive themselves to the hospital or have a family member drive them. Access is the biggest challenge for patients, with many living in small towns or on a reservation, most quite far from Farmington. For regular appointments, patients are known to walk up or hitch hike 20 miles from home—and back.
Complete confidence in care is a must. Due to its remote location, the hospital is too far away to rely on backup hospitals to save patient lives. The team has been very successful in getting patients in quickly from Northern Navajo Medical Center. Door to door to reperfusion times are consistently below 120 minutes.
“Being remote helps build our confidence,” Sandhu says. “We have to be independent because we don’t have cardiothoracic surgeons to back us up or bail us out. We try to salvage as much myocardium here, supporting them hemodynamically.”
“As soon as we started using Impella, everyone on the team saw the difference it could make,” Charles chimes in. “That inspired our nursing staff, at all levels of experience, to do the extra work it takes to train in, and get very good at, working with Impella patients. They can see that this is saving lives.”
Cath Lab Supervisor Tammie Herrera, RT(R), RCIS, seconds Charles on what a difference it makes to be a firsthand witness to Impella in action. Thanks to the device, she says, “about 90 percent of our patients are off pressors by the time they leave the cath lab. So Impella has the ability to both save lives and impact the post-procedure management once the patient gets to the floor.”
Unity on the unit
When San Juan Regional launched the Impella program, they also crafted a careful plan to train nurses during as well as after the procedure. They created a protocol and flow sheets and continue to refine them over time. New nurses are trained while veterans are retrained periodically, always staying current under the guidance of Staff Educator Rebekah French, RN, BSN, RCIS.
When a procedure is complete, two cath lab nurses bring the patient to the cardiology unit. Together they give bedside report, sharing patient details with the floor RN, reviewing stats, step by step and filling out the flow sheet together to make sure there were no changes. An echo tech joins them to be sure the patient gets an echo exam to verify correct Impella placement. The patient also has a knee immobilizer on to avoid any leg movement and avoid bleeds. The hourly checklist guides nurses in monitoring waveforms, pump placement, groin management and meds.
“Impella patients start on 2 to 1 nursing care,” says Cardiology Patient Care Manager Terry Chapman, RN, BSN. “There's no set time, but when we see the [Impella] patient is more stable, we will move him or her to 3 to 1. Usually, the patient becomes very stable and you're really just monitoring him or her after that.”
Inspired nurses build expanded skill sets
Nursing training has made the difference for patients, the team agrees. Every nurse who touches an Impella patient receives comprehensive, staged training that combines in-house programs of didactic, lecture and hands-on components along with Abiomed resources. An internally built staged orientation program lasts 8 to 12 weeks for graduate to experienced nurses.
Stage 1 is basic nursing care: admissions, discharges, getting used to the documentation system, looking at policies and procedures. Stage 2 incorporates more complex patients such as PCI and cath lab as well as diagnostic procedures, noninvasive procedures and caring for the cardiology patient. Stage 3 gets more intense, adding more advanced skills such as working with temporary pacers, cardioversions and pressors. Stage 4 is where Impella is introduced along with more advanced nursing skills. In Stage 4, nurses first learn about Impella via Abiomed online education that takes a couple of hours, all of which are compensated. For patients with an Impella still in place, nurses learn to use the flow sheets that document care steps, groin management, blood pressure and the checks that are needed and the data to document. After initial training, French meets with nurses routinely and provides hands-on, simulated training with a mannequin.
“Nursing is a hands on career,” French says. “You need to learn with your hands. You have to know your equipment. If they have that experience before going into a patient's room, they are more comfortable. They feel more in control.”
This hands-on learning is not just for new hires. The entire cardiology nursing staff goes through refreshers every other month. It’s mandatory and nurses are paid. Once a year, Abiomed does a house-wide training that is mandatory for all nurses. Twice a year, the nursing staff—cath lab, air care, intensive care and cardiology
—attend training on Impella by an Abiomed clinical educator. Other times, French creates simulations using case studies based on actual patients they have had on the floor.
“Our training program really stems from the support we receive from our physicians, the cath lab as well as our leadership team,” French says. “We also receive a lot of support from the Abiomed clinical educators as well and the 24/7 support from the 800 number.”
At the end of the day, it’s all about the outcomes, Chapman says. “And that flows down from the top. Dr. Wilkins and Barbara Charles are very passionate about the technology, and all of us just want to do what’s best for the patient.”
Rightly ordered ROI
They also want to do what’s best for the hospital—and an Impella program lets them do so, says Charles.
“On a quarterly basis, I get direct communication back from the coders to make sure the account was coded appropriately to the correct DRG, because if it’s not the correct DRG, reimbursement is going to be an issue,” says Charles. “This and other proactive communications between the cath lab supervisor, myself and our finance team has helped make our protected PCI program make sense on the financial side. If you chase quality, the reimbursement will follow.”
“The importance of having this level of care can't be underestimated,” Wilkins says. “It brings a service to this area that wasn't here before. It's the result of a lot of people's efforts and hard work. It's really remarkable how well this has worked out.”