Vancouver Transcatheter Aortic Valve Replacement Clinical Pathway: Minimalist Approach, Standardized Care, and Discharge Criteria to Reduce Length of Stay.
We describe the development, implementation, and evaluation of a standardized clinical pathway to facilitate safe discharge home at the earliest time after transfemoral transcatheter aortic valve replacement. Between May 2012 and October 2014, the Heart Team developed a clinical pathway suited to the unique requirements of transfemoral transcatheter aortic valve replacement in contemporary practice. The components included risk-stratified minimalist periprocedure approach, standardized postprocedure care with early mobilization and reconditioning, and criteria-driven discharge home. Our aim was to reduce variation in care, identify a subgroup of patients suitable for early discharge (≤48 hours), and decrease length of stay for all patients. We addressed barriers related to historical practices, complex multidisciplinary stakeholder engagement, and adoption of length of stay as a quality indicator. We retrospectively reviewed the experiences of 393 consecutive patients; 150 (38.2%) were discharged early. At baseline, early discharge patients had experienced less previous balloon aortic valvuloplasty, had higher left ventricular ejection fraction, better cognitive function, and were less frail than the standard discharge group (>48 hours). Early discharge was associated with the use of local anesthesia, implantation of balloon expandable device, avoidance of urinary catheter, and early removal of temporary pacemaker. Median length of stay was 1 day for early discharge and 3 days for other patients; 97.7% were discharged home. There were no differences in 30-day mortality (1.3%), disabling stroke (0.8%), or readmission (10.7%). The implementation of a transcatheter aortic valve replacement clinical pathway shifted the program's approach to combine standardized processes and individual risk stratification. The Vancouver transcatheter aortic valve replacement clinical pathway requires a rigorous assessment to determine its efficacy, safety, and reproducibility.
From the Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, Canada (S.B.L., D.A.W., D.S., L.A., P.B., R.H.B., A.C., D.D., J.A.G., B.L., J.L., R.M., G.P., K.R., J.Y., J.G.W.); University of British Columbia, Vancouver, Canada (S.B.L., D.A.W., J.B., J.-Y.K., R.H.B., A.C., J.A.G., B.L., J.L., R.M., K.R., J.Y., J.G.W.); Vancouver General Hospital, Vancouver, Canada (D.A.W.); Alfred Hospital, Western Health, Baker IDI Heart and Diabetes Institute, Melbourne, Australia (D.S.); and Cardiac Services BC, Vancouver, Canada (J.P.). slauck@providencehealth.bc.ca.
Sandra B
SB
Lauck
From the Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, Canada (S.B.L., D.A.W., D.S., L.A., P.B., R.H.B., A.C., D.D., J.A.G., B.L., J.L., R.M., G.P., K.R., J.Y., J.G.W.); University of British Columbia, Vancouver, Canada (S.B.L., D.A.W., J.B., J.-Y.K., R.H.B., A.C., J.A.G., B.L., J.L., R.M., K.R., J.Y., J.G.W.); Vancouver General Hospital, Vancouver, Canada (D.A.W.); Alfred Hospital, Western Health, Baker IDI Heart and Diabetes Institute, Melbourne, Australia (D.S.); and Cardiac Services BC, Vancouver, Canada (J.P.).
David A
DA
Wood
From the Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, Canada (S.B.L., D.A.W., D.S., L.A., P.B., R.H.B., A.C., D.D., J.A.G., B.L., J.L., R.M., G.P., K.R., J.Y., J.G.W.); University of British Columbia, Vancouver, Canada (S.B.L., D.A.W., J.B., J.-Y.K., R.H.B., A.C., J.A.G., B.L., J.L., R.M., K.R., J.Y., J.G.W.); Vancouver General Hospital, Vancouver, Canada (D.A.W.); Alfred Hospital, Western Health, Baker IDI Heart and Diabetes Institute, Melbourne, Australia (D.S.); and Cardiac Services BC, Vancouver, Canada (J.P.).
Jennifer
J
Baumbusch
From the Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, Canada (S.B.L., D.A.W., D.S., L.A., P.B., R.H.B., A.C., D.D., J.A.G., B.L., J.L., R.M., G.P., K.R., J.Y., J.G.W.); University of British Columbia, Vancouver, Canada (S.B.L., D.A.W., J.B., J.-Y.K., R.H.B., A.C., J.A.G., B.L., J.L., R.M., K.R., J.Y., J.G.W.); Vancouver General Hospital, Vancouver, Canada (D.A.W.); Alfred Hospital, Western Health, Baker IDI Heart and Diabetes Institute, Melbourne, Australia (D.S.); and Cardiac Services BC, Vancouver, Canada (J.P.).
Jae-Yung
JY
Kwon
From the Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, Canada (S.B.L., D.A.W., D.S., L.A., P.B., R.H.B., A.C., D.D., J.A.G., B.L., J.L., R.M., G.P., K.R., J.Y., J.G.W.); University of British Columbia, Vancouver, Canada (S.B.L., D.A.W., J.B., J.-Y.K., R.H.B., A.C., J.A.G., B.L., J.L., R.M., K.R., J.Y., J.G.W.); Vancouver General Hospital, Vancouver, Canada (D.A.W.); Alfred Hospital, Western Health, Baker IDI Heart and Diabetes Institute, Melbourne, Australia (D.S.); and Cardiac Services BC, Vancouver, Canada (J.P.).
Dion
D
Stub
From the Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, Canada (S.B.L., D.A.W., D.S., L.A., P.B., R.H.B., A.C., D.D., J.A.G., B.L., J.L., R.M., G.P., K.R., J.Y., J.G.W.); University of British Columbia, Vancouver, Canada (S.B.L., D.A.W., J.B., J.-Y.K., R.H.B., A.C., J.A.G., B.L., J.L., R.M., K.R., J.Y., J.G.W.); Vancouver General Hospital, Vancouver, Canada (D.A.W.); Alfred Hospital, Western Health, Baker IDI Heart and Diabetes Institute, Melbourne, Australia (D.S.); and Cardiac Services BC, Vancouver, Canada (J.P.).
Leslie
L
Achtem
From the Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, Canada (S.B.L., D.A.W., D.S., L.A., P.B., R.H.B., A.C., D.D., J.A.G., B.L., J.L., R.M., G.P., K.R., J.Y., J.G.W.); University of British Columbia, Vancouver, Canada (S.B.L., D.A.W., J.B., J.-Y.K., R.H.B., A.C., J.A.G., B.L., J.L., R.M., K.R., J.Y., J.G.W.); Vancouver General Hospital, Vancouver, Canada (D.A.W.); Alfred Hospital, Western Health, Baker IDI Heart and Diabetes Institute, Melbourne, Australia (D.S.); and Cardiac Services BC, Vancouver, Canada (J.P.).
Philipp
P
Blanke
From the Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, Canada (S.B.L., D.A.W., D.S., L.A., P.B., R.H.B., A.C., D.D., J.A.G., B.L., J.L., R.M., G.P., K.R., J.Y., J.G.W.); University of British Columbia, Vancouver, Canada (S.B.L., D.A.W., J.B., J.-Y.K., R.H.B., A.C., J.A.G., B.L., J.L., R.M., K.R., J.Y., J.G.W.); Vancouver General Hospital, Vancouver, Canada (D.A.W.); Alfred Hospital, Western Health, Baker IDI Heart and Diabetes Institute, Melbourne, Australia (D.S.); and Cardiac Services BC, Vancouver, Canada (J.P.).
Robert H
RH
Boone
From the Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, Canada (S.B.L., D.A.W., D.S., L.A., P.B., R.H.B., A.C., D.D., J.A.G., B.L., J.L., R.M., G.P., K.R., J.Y., J.G.W.); University of British Columbia, Vancouver, Canada (S.B.L., D.A.W., J.B., J.-Y.K., R.H.B., A.C., J.A.G., B.L., J.L., R.M., K.R., J.Y., J.G.W.); Vancouver General Hospital, Vancouver, Canada (D.A.W.); Alfred Hospital, Western Health, Baker IDI Heart and Diabetes Institute, Melbourne, Australia (D.S.); and Cardiac Services BC, Vancouver, Canada (J.P.).
Anson
A
Cheung
From the Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, Canada (S.B.L., D.A.W., D.S., L.A., P.B., R.H.B., A.C., D.D., J.A.G., B.L., J.L., R.M., G.P., K.R., J.Y., J.G.W.); University of British Columbia, Vancouver, Canada (S.B.L., D.A.W., J.B., J.-Y.K., R.H.B., A.C., J.A.G., B.L., J.L., R.M., K.R., J.Y., J.G.W.); Vancouver General Hospital, Vancouver, Canada (D.A.W.); Alfred Hospital, Western Health, Baker IDI Heart and Diabetes Institute, Melbourne, Australia (D.S.); and Cardiac Services BC, Vancouver, Canada (J.P.).
Danny
D
Dvir
From the Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, Canada (S.B.L., D.A.W., D.S., L.A., P.B., R.H.B., A.C., D.D., J.A.G., B.L., J.L., R.M., G.P., K.R., J.Y., J.G.W.); University of British Columbia, Vancouver, Canada (S.B.L., D.A.W., J.B., J.-Y.K., R.H.B., A.C., J.A.G., B.L., J.L., R.M., K.R., J.Y., J.G.W.); Vancouver General Hospital, Vancouver, Canada (D.A.W.); Alfred Hospital, Western Health, Baker IDI Heart and Diabetes Institute, Melbourne, Australia (D.S.); and Cardiac Services BC, Vancouver, Canada (J.P.).
Jennifer A
JA
Gibson
From the Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, Canada (S.B.L., D.A.W., D.S., L.A., P.B., R.H.B., A.C., D.D., J.A.G., B.L., J.L., R.M., G.P., K.R., J.Y., J.G.W.); University of British Columbia, Vancouver, Canada (S.B.L., D.A.W., J.B., J.-Y.K., R.H.B., A.C., J.A.G., B.L., J.L., R.M., K.R., J.Y., J.G.W.); Vancouver General Hospital, Vancouver, Canada (D.A.W.); Alfred Hospital, Western Health, Baker IDI Heart and Diabetes Institute, Melbourne, Australia (D.S.); and Cardiac Services BC, Vancouver, Canada (J.P.).
Bobby
B
Lee
From the Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, Canada (S.B.L., D.A.W., D.S., L.A., P.B., R.H.B., A.C., D.D., J.A.G., B.L., J.L., R.M., G.P., K.R., J.Y., J.G.W.); University of British Columbia, Vancouver, Canada (S.B.L., D.A.W., J.B., J.-Y.K., R.H.B., A.C., J.A.G., B.L., J.L., R.M., K.R., J.Y., J.G.W.); Vancouver General Hospital, Vancouver, Canada (D.A.W.); Alfred Hospital, Western Health, Baker IDI Heart and Diabetes Institute, Melbourne, Australia (D.S.); and Cardiac Services BC, Vancouver, Canada (J.P.).
Jonathan
J
Leipsic
From the Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, Canada (S.B.L., D.A.W., D.S., L.A., P.B., R.H.B., A.C., D.D., J.A.G., B.L., J.L., R.M., G.P., K.R., J.Y., J.G.W.); University of British Columbia, Vancouver, Canada (S.B.L., D.A.W., J.B., J.-Y.K., R.H.B., A.C., J.A.G., B.L., J.L., R.M., K.R., J.Y., J.G.W.); Vancouver General Hospital, Vancouver, Canada (D.A.W.); Alfred Hospital, Western Health, Baker IDI Heart and Diabetes Institute, Melbourne, Australia (D.S.); and Cardiac Services BC, Vancouver, Canada (J.P.).
Robert
R
Moss
From the Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, Canada (S.B.L., D.A.W., D.S., L.A., P.B., R.H.B., A.C., D.D., J.A.G., B.L., J.L., R.M., G.P., K.R., J.Y., J.G.W.); University of British Columbia, Vancouver, Canada (S.B.L., D.A.W., J.B., J.-Y.K., R.H.B., A.C., J.A.G., B.L., J.L., R.M., K.R., J.Y., J.G.W.); Vancouver General Hospital, Vancouver, Canada (D.A.W.); Alfred Hospital, Western Health, Baker IDI Heart and Diabetes Institute, Melbourne, Australia (D.S.); and Cardiac Services BC, Vancouver, Canada (J.P.).
Gidon
G
Perlman
From the Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, Canada (S.B.L., D.A.W., D.S., L.A., P.B., R.H.B., A.C., D.D., J.A.G., B.L., J.L., R.M., G.P., K.R., J.Y., J.G.W.); University of British Columbia, Vancouver, Canada (S.B.L., D.A.W., J.B., J.-Y.K., R.H.B., A.C., J.A.G., B.L., J.L., R.M., K.R., J.Y., J.G.W.); Vancouver General Hospital, Vancouver, Canada (D.A.W.); Alfred Hospital, Western Health, Baker IDI Heart and Diabetes Institute, Melbourne, Australia (D.S.); and Cardiac Services BC, Vancouver, Canada (J.P.).
Jopie
J
Polderman
From the Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, Canada (S.B.L., D.A.W., D.S., L.A., P.B., R.H.B., A.C., D.D., J.A.G., B.L., J.L., R.M., G.P., K.R., J.Y., J.G.W.); University of British Columbia, Vancouver, Canada (S.B.L., D.A.W., J.B., J.-Y.K., R.H.B., A.C., J.A.G., B.L., J.L., R.M., K.R., J.Y., J.G.W.); Vancouver General Hospital, Vancouver, Canada (D.A.W.); Alfred Hospital, Western Health, Baker IDI Heart and Diabetes Institute, Melbourne, Australia (D.S.); and Cardiac Services BC, Vancouver, Canada (J.P.).
Krishnan
K
Ramanathan
From the Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, Canada (S.B.L., D.A.W., D.S., L.A., P.B., R.H.B., A.C., D.D., J.A.G., B.L., J.L., R.M., G.P., K.R., J.Y., J.G.W.); University of British Columbia, Vancouver, Canada (S.B.L., D.A.W., J.B., J.-Y.K., R.H.B., A.C., J.A.G., B.L., J.L., R.M., K.R., J.Y., J.G.W.); Vancouver General Hospital, Vancouver, Canada (D.A.W.); Alfred Hospital, Western Health, Baker IDI Heart and Diabetes Institute, Melbourne, Australia (D.S.); and Cardiac Services BC, Vancouver, Canada (J.P.).
Jian
J
Ye
From the Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, Canada (S.B.L., D.A.W., D.S., L.A., P.B., R.H.B., A.C., D.D., J.A.G., B.L., J.L., R.M., G.P., K.R., J.Y., J.G.W.); University of British Columbia, Vancouver, Canada (S.B.L., D.A.W., J.B., J.-Y.K., R.H.B., A.C., J.A.G., B.L., J.L., R.M., K.R., J.Y., J.G.W.); Vancouver General Hospital, Vancouver, Canada (D.A.W.); Alfred Hospital, Western Health, Baker IDI Heart and Diabetes Institute, Melbourne, Australia (D.S.); and Cardiac Services BC, Vancouver, Canada (J.P.).
John G
JG
Webb
D001021:Aortic Valve / Q000503:physiopathology / Q000601:surgery*; D001024:Aortic Valve Stenosis / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D001955:British Columbia; D019091:Critical Pathways / Q000458:organization & administration*; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D004059:Diffusion of Innovation; D006350:Heart Valve Prosthesis; D006801:Humans; D007902:Length of Stay; D017146:Models, Organizational; D010351:Patient Discharge; D061214:Patient Safety; D011183:Postoperative Complications / Q000209:etiology / Q000628:therapy; D017064:Process Assessment, Health Care / Q000458:organization & administration*; D015397:Program Evaluation; D012307:Risk Factors; D013997:Time Factors; D065467:Transcatheter Aortic Valve Replacement / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D016896:Treatment Outcome
critical pathways; length of stay; postoperative care; quality improvement; transcatheter aortic valve implantation