International Journal of Nursing and Health Care Research (ISSN: 2688-9501)

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Nursing-Guided Pre-Procedural Preparation In Patients Undergoing Transcatheter Aortic Valve Replacement

Miryam González-Cebrian1*RN, MSN, PhDc ;Marta Alonso-Fernández-Gatta1,2 MD,PhD; Rosa Carreño Sánchez 1 RN; Elena Olaya González Egido1 RN; Sara Alonso Meléndez1 RN; Cristina Ferrín Prieto3, Elena Calvo Barriuso 4RN,MSD,PhD; Beatriz de Tapia Majado 1 MD; Rosa Ana López Jiménez1MD; Ignacio Cruz-González1,2, MD, PhD;Pedro L Sánchez1,2 MD,PhD.

1 Cardiology Department, University Hospital of Salamanca, Salamanca, Spain. IBSAL.

2 CIBER-CV Instituto de Salud Carlos III (ISCIII), Madrid, Spain.

3 Medtronic Ibérica, Madrid, Spain

4 Cardiology Department, University Hospital of Bellvitge, Barcelona, Spain.

*Corresponding author: Miryam González-Cebrian, Cardiology Department, University Hospital of Salamanca, Salamanca, Spain.

Received Date: 12 October, 2022

Accepted Date: 26 October 2022

Published Date: 29 October, 2022

Citation: . González-Cebrian M, Alonso-Fernández-Gatta M, Sánchez RC, González Egido EO, Meléndez SA, et al. (2022) Nursing-Guided Pre-Procedural Preparation In Patients Undergoing Transcatheter Aortic Valve Replacement. Int J Nurs Health Care Res 5: 1354. DOI: https://doi.org/10.29011/2688-9501.101354

Abstract

Background: Transcatheter Aortic Valve Replacement (TAVR) has become the treatment of choice for many patients with severe symptomatic aortic stenosis (AS). For TAVR candidate a multidisciplinary evaluation is necessary where nursing currently has an anecdotal participation. Our objective was the development and implementation of a TAVR program nurse led including a pre-TAVR assessment protocol for the patient and caregiver based in patient-centered approach. Methods: A multidisciplinary working group was created to develop the necessary contents for the TAVR nurse program and the TAVR pre-implantation nursing guide. A retrospective analysis of the preliminary single-center experience on pre-implantation assessment was performed.Results: A Pre-TAVR nurse clinic was launched to be carried out approximately 7-15 days before the intervention, focusing on training and education and a global patient assessment on geriatric features, frailty, cognitive impairment, dependence, quality of life and social support. 40 patients were evaluated in the preprocedural outclinic and subsequently the interventions were performed from March 2022 to July 2022. Regarding patient satisfaction with the pre-TAVR nurse consultation a mean score of 9,8 points was achieved for all items evaluated. Conclusion: Implementing a TAVR nurse program with a patient-centered approach is feasible and could help to improve the patient preparation, education and coaching, maintain continuity of care, and increase patient satisfaction throughout the TAVR process.

Keywords : Aortic stenosis; Frailty; Nurse; Transcatheter Aortic Valve Replacement.

Introduction

Severe aortic stenosis (AS) is the most common primary heart valvular disease in developed countries. Its growth is related to a higher life expectancy and increasing ageing of the population [1-3]. Its estimated prevalence is significant, being 2.5% in the general population, reaching up to 7% in the population over 65 and to 13% in those over 75 [4-5]. Patients might remain asymptomatic for many years, but once symptoms appear, the associated 3-year mortality rate without intervention can reach up to 50% [6-7]. In the last two decades, Transcatheter Aortic Valve Replacement (TAVR) has transformed the management of severe symptomatic AS[8], positioning as a less invasive alternative to traditional surgical (SAVR) with equivalent or even better outcomes [3].

TAVR was started as an alternative in inoperable or high surgical risk patients, but this therapeutic option has grown very rapidly during last years. This growth and the associated success are the result of technological progress, increased operator expertise, improved safety, and the reduction of intraprocedural complications. The combination of these factors allowed for the expansion of indications including lower risk patients in whom TAVR confirmed favorable outcomes compared to SAVR [3-8]. This represents a paradigm shift in the treatment of valvular heart disease, with a transition to minimally invasive procedures which allow to reduce the in-hospital length of stay, to optimize the use of healthcare resources and to improve patient health outcomes without increasing mortality and complications [9-12].

For TAVR candidate a multidisciplinary evaluation is necessary where nursing currently has an anecdotal participation. It is necessary to develop TAVR programs that place the patient at the very center of the process and ensure multidisciplinary decision-making with the nurse playing a key role in case management and preparation before intervention (which include undertaking the necessary tests and providing proper information and education resources to the patient and its family), to ensure an adequate adherence to the treatment and faster recovery. Patient education and coaching provided by the nurse staff helps to improve patient satisfaction, anticipate and prevent complications, plan an early discharge, and maintain continuity of care [4,13-16].

We aimed to develop and implement a process led by nursing in patients undergoing TARV including a pre-TAVR assessment protocol for the patient and caregiver to improve their preparation and knowledge and to help reduce patient anxiety, complications, and in-hospital length of stay.

Methods

A multidisciplinary working group was created, consisting of interventional, clinical, and imaging cardiologists together with the team of nurses familiar with the TAVR procedure (TAVR nurse). The team also included a process engineer acting as a facilitator and ensuring that the team worked applying lean management methodology. The purpose of this team was to reach a consensus on the essential aspects to be included in the nursing TAVR assessment protocol and, to subsequently validate and implement the protocol. To this end, regular team meetings have been scheduled. A protocol called TAVR nurse was developed for use in our center, including prior nursing assessment, during admission and follow-up.

An exhaustive literature review was conducted which, combined with the knowledge and experience of the multidisciplinary team, was key to develop the necessary contents for the TAVR pre-implantation nursing guide (focusing on description and management of the disease, the TAVR procedure, the patient's pathway and the discharge care plan).

In our center, the pre-TAVR assessment includes an angio-computed tomography (CT) of the aorta and the feasibility of vascular access (transfemoral choice), the size of the aortic annulus for prosthesis selection, and the coronary arteries by non-invasive coronary angiography. Elective TAVR is performed according to the Hospital protocol with admission of the patient on the same day of the procedure at the Cardiac Day Care Unit. TAVR is then performed under conscious sedation in cases of transfemoral access or under general anesthesia in other types of access (subclavian, transapical or transcava...). After the procedure, the patient is transferred to the Intensive Cardiac Care Unit (ICCU) for a minimum of 24 hours, with a total length of stay of 2-4 days depending on the risk of atrioventricular (AV) block and in the absence of major complications.

Once the TAVR nurse program was developed and implemented, we performed a retrospective analysis of the preliminary single-center experience on pre-implantation assessment of TAVR by nurses in patients with severe AS with indication for intervention and accepted for TAVR by the Heart Team. The data collection was conformed to the principles outlined in the Declaration of Helsinki and were properly anonymized.

Statistical analysis was performed using the IBM SPSS Statistics for Windows package, version 22 (IBM Corp., Armonk, N.Y., USA). The qualitative variables were expressed as absolute frequency (n) and percentage (%) and the continuous ones by mean and standard deviation (SD) or median and interquartile range (IQR) depending on the distribution according to the normality.

Results

TAVR nurse protocol

As a result, a protocol for nursing assessment throughout the whole TAVR process was established, together with the development of specific material.

Once the indication for aortic valve intervention is established and is decided by the Heart team that the patient is candidate for TAVR, a group of nurses, experienced in Cardiology and with experience in the different phases of TAVR, assess patients in different phases (pre-TAVR consultation, during hospitalization and post-TAVR consultation follow-up), in parallel with the established medical follow-up.

Pre-TAVR nurse consultation

A face-to-face clinical assessment by a nurse in a outclinic is carried out approximately 7-15 days before the intervention, which could be adapted depending on the urgency of the procedure. The consultation has a duration of 45 minutes and pursues three main objectives, for which different specific materials were elaborated:

Information about the disease and the TAVR procedure

An educational guide was developed to facilitate the retention of information, including oral and written materials consisting of:

  • Slide show oriented to health education which includes different aspects: definition of AS, cardiac anatomy, most common symptoms of the disease and TAVR procedure (accesses, anesthesia/conscious sedation, prosthesis, explanation of the technique). Also, it includes a virtual tour of all the units of the patient pathway from admission to discharge: Day care unit (for the preparation before the procedure), catheterization laboratory, ICCU and cardiology ward. (Figure 1)
  • Brochure for handing out to patients and caregivers which includes information about the admission process, the care plan provided in each unit, important reminders for the day of the procedure (fasting, medication, etc.) and contact details to resolve doubts or ask questions. (Figure 2)

Figure 1: TAVR patient education slides presentation;Slides presentation showed in pre-TAVR nurse consultation; TAVR= Transcatheter aortic valve aortic replacement; Sources: http://cardiosaudeferrol.com, Edwards Lifes science, Abbott laboratories, Medtronic, Boston scientific, Virgen del Rocio Hospital.