Left ventricular assist devices (LVADs) are rapidly becoming commonplace treatment for end-stage heart failure, either as a bridge to transplant or as destination therapy alone.1,2 More and more patients are surviving with LVAD therapy and going on to live longer, fuller lives. As a result, unfortunately, more LVAD patients are being admitted and readmitted to the hospital for common non-cardiac illnesses.
For five years, Bon Secours St. Mary’s Hospital in Richmond, Va., has been one of the few community hospitals with an advanced heart failure and LVAD program. Historically, when LVAD patients presented for admission with noncardiac complaints, they were deemed too complex for general care and admitted by their cardiothoracic surgeon or cardiologist. Over a year ago, the hospitalist group at St. Mary’s met with leadership of our advance heart failure program to try to improve and streamline care for these patients. This conversation spawned our LVAD medical management program.
At the outset, more than 80% of our hospitalists had hands-on experience with LVAD management. Although there was a good base of understanding of cardiac functioning and the physiology of mechanical assistance, the nuances of such subspecialized care created a great deal of anxiety. To create a knowledge base to build up, we developed a training curriculum that included online didactics and hands-on training with an LVAD. All hospitalists at St. Mary’s underwent three hours of training online through the Thoratec provider portal for the HeartMate II left ventricular assist device, and, subsequently, an in-person education session by heart failure coordinators. All new hospitalists complete the same training within six months of their hire date.
As we moved forward with the program, we set clear expectations. Our hospitalists are not expected to manage the LVAD directly; however, knowledge of the device parameters (i.e., rotor speed, power, and pulse index) is necessary for diagnosis and management of patients. The heart failure team is consulted on every LVAD patient who is admitted to the hospital for device management and LVAD-related complications.
A hospitalist attending admitted the first LVAD patient more than a year ago. Patients admitted under the hospitalist service are at least six months post-LVAD implantation. In review, we believe that six months was a conservative starting point. Our hospitalists' confidence and comfort with this population has grown over the year and allowed us to consider taking on these patients much sooner after implantation.
Since initiating the program, we have admitted 15 unique patients for 33 separate encounters. The hospitalist team has provided care for illnesses commonly experienced by LVAD patients, such as GI bleeding and drive-line site infection, as well as general medicine complaints (concussion, septic arthritis, lung cancer, and pneumonia).3,4
Our team manages more than 90% of the St. Mary's non-surgical adult patients, and in reality, the role we play for these patients is much the same as for other complex medical and surgical patients. We provide first point of contact, diagnosis and treatment, coordination of subspecialty care, and safe discharge.
The program of hospitalist care for LVAD patients at St. Mary’s has passed its first birthday. It’s an innovation that we’re very proud of. Since the outset of our care for these patients, we have been collecting data about patient outcomes, length of stay, and resource utilization. Moving forward, we plan to begin identifying places where we can improve the general medical care for this specialized group of patients. TH
Dr. Thistlethwaite is an adult hospitalist at Bon Secours St. Mary’s Hospital in Richmond, Va. Dr. Mbanu is chief of the adult hospitalist department at St. Mary’s Hospital and medical director of clinical integration at Bon Secours Health System, Inc.
Editor's note: this article was updated Feb. 3, 2016.
- Lampropulos JF, Kim N, Wang Y, et al. Trends in left ventricular assist device use and outcomes among Medicare beneficiaries, 2004–2011. Open Heart. 2014;1(1):e000109. doi:10.1136/openhrt-2014-000109.
- Jorde UP, Kushwaha SS, Tatooles AJ, et al. Results of the destination therapy post-food and drug administration approval study with a continuous flow left ventricular assist device: a prospective study using the INTERMACS registry (Interagency Registry for Mechanically Assisted Circulatory Support). J Am Coll Cardiol. 2014;63(17):1751-1757.
- Stern DR, Kazam J, Edwards P, et al. Increased incidence of gastrointestinal bleeding following implantation of the HeartMate II LVAD. J Card Surg. 2010;25(3):352-356.
- Fischer SA, Trenholme GM, Costanzo MR, Piccione W. Infectious complications in left ventricular assist device recipients. Clin Infect Dis. 1997;24(1):18-23.