Readmissions after left ventricular assist device implantation: Considerations for nurse practitioners

Association between psychosocial factors and left ventricular assist device implant outcomes: A systematic review

BACKGROUND

Psychosocial assessment is a core component of the multidisciplinary evaluation for left ventricular assist device (LVAD) implantation. The degree to which psychosocial conditions are considered a contraindication to LVAD implantation continues to be debated. This systematic review examines modifiable psychosocial factors as predictors of outcomes in patients undergoing LVAD implantation.

METHODS

We conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. The search resulted in 2509 articles. After deduplication, abstract and full-text review, 20 relevant articles were identified.

RESULTS

Included studies evaluated socioeconomic status (n = 6), caregiver characteristics (n = 6), non-adherence (n = 6), substance use (n = 13), and psychiatric disorder (n = 8). The most commonly measured outcomes were all-cause death, readmission rate, and adverse events. Studies varied widely in definition of each psychosocial factor and selected outcomes. No psychosocial factor was consistently associated with a specific outcome in all studies. Socioeconomic status was generally not associated with outcomes. Non-adherence, psychiatric disorder, and substance use were associated with higher risks of mortality, adverse events, and/or readmission. Findings on caregiver characteristics were mixed.

CONCLUSION

Of the psychosocial factors studied, non-adherence, psychiatric disorder, and substance use were the most consistently associated with an increased risk of mortality, readmission, and/or adverse events. Heterogeneity in research methodology and study quality across studies precludes firm conclusions regarding the impact of psychosocial factors on long-term patient outcomes. The results of this review reveal a need for adequately powered studies that use uniform definitions of psychosocial factors to clarify relationships between these factors and outcomes after LVAD implantation.

Healthcare consumption of patients with left ventricular assist device: real-world data

BACKGROUND

A left ventricular assist device (LVAD) is a life-saving but intensive therapy for patients with end-stage heart failure. We evaluated the healthcare consumption in a cohort of LVAD patients in our centre over 6 years.

METHODS

All patients with a primary LVAD implantation at the University Medical Centre Utrecht in Utrecht, the Netherlands from 2016 through 2021 were included in this analysis. Subsequent hospital stay, outpatient clinic visits, emergency department visits and readmissions were recorded.

RESULTS

During the investigated period, 226 LVADs were implanted, ranging from 32 in 2016 to 45 in 2020. Most LVADs were implanted in patients aged 40-60 years, while they were supported by or sliding on inotropes (Interagency Registry for Mechanically Assisted Circulatory Support class 2 or 3). Around the time of LVAD implantation, the median total hospital stay was 41 days. As the size of the LVAD cohort increased over time, the total annual number of outpatient clinic visits also increased, from 124 in 2016 to 812 in 2021 (p = 0.003). The numbers of emergency department visits and readmissions significantly increased in the 6‑year period as well, with a total number of 553 emergency department visits and 614 readmissions. Over the years, the annual number of outpatient clinic visits decreased by 1 per patient-year follow-up, while the annual numbers of emergency department visits and readmissions per patient-year remained stable.

CONCLUSION

The number of patients supported by an LVAD has grown steadily over the last years, requiring a more specialised healthcare in this particular population.

Socio-economic position, multimorbidity, and health care utilization among Danish left ventricular assist device patients

AIMS

Increasing numbers of patients with advanced heart failure and significant comorbidity and social barriers are considered for left ventricular assist devices (LVADs). We sought to examine health care utilization post-LVAD implantation, including the influence of individual-level socio-economic position and multimorbidity.

METHODS AND RESULTS

We conducted a Danish nationwide cohort study linking individual-level data from clinical LVAD databases, the Scandiatransplant Database, and Danish national medical and administrative registries. Socio-economic position included cohabitation status, educational level, and employment status. Multimorbidity was defined as two or more chronic conditions from at least two chronic disease groups. Health care utilization (hospital activity, general practice activity, and redeemed medical prescriptions) within 2 years post-discharge after LVAD implantation was evaluated using descriptive statistics at 0.5 year intervals. We identified 119 patients discharged alive with first-time LVAD implanted between 2006 and 2018. The median age of the patients was 56.1 years, and 88.2% were male. Patients were followed until heart transplantation, LVAD explantation, death, 31 December 2018, or for 2 years. The median follow-up was 0.8 years. The highest median use of health care services was observed 0-0.5 years post-LVAD discharge compared with the subsequent follow-up intervals: 0.5-1, 1-1.5, and 1.5-2 years, respectively. The median (interquartile range) number of hospitalizations was 10 (7-14), bed days 14 (9-28), outpatient visits 8 (5-12), telephone contacts with a general practitioner 4 (2-8), and total redeemed medical prescriptions 26 (19-37) within 0-0.5 years post-LVAD discharge compared with the median utilization within the consecutive follow-up periods [e.g. within 0.5-1 year: hospitalizations 5 (3-8), bed days 8 (4-14), outpatient visits 5 (3-8), telephone contacts 2 (0-5), and redeemed medical prescriptions 24 (18-30)]. The median use of health care services was stable from 0.5 years onwards. The median number of hospitalizations and bed days was slightly higher in patients living alone with a low educational level or low employment status within 0-0.5 years post-LVAD implantation. Finally, the median number of in-hospital days and redeemed prescriptions was higher among patients with pre-existing multimorbidity.

CONCLUSIONS

Among patients who underwent LVAD implantation, health care utilization was high in the early post-LVAD discharge phase and was influenced by socio-economic position. Multimorbidity influenced the number of in-hospital days and redeemed prescriptions during the 2 year follow-up.

Validity and reliability of the self-care behaviour scale for patients with left ventricular assist device

AIMS

To evaluate the validity and reliability of the self-care behaviour scale for patients with left ventricular assist devices.

DESIGN

Methodological study.

METHODS

The English version of the scale was translated into Korean, and it was then back-translated into English. Survey data were collected from 32 patients with left ventricular assist device in South Korea, and construct validity, content validity and reliability were analysed.

RESULTS

The original self-care behaviour scale comprises three domains and 33 items, whereas the Korean self-care behaviour scale comprises 27 items and five domains: device management, wound management, symptom monitoring, activated healthcare system and self-care management. Cronbach's alpha for the overall scale was 0.94, and that for the five domains ranged from 0.36 to 0.90. The intraclass correlation coefficient for the overall scale was 0.89, and the five domains ranged from 0.71 to 0.88.

CONCLUSION

The newly evaluated scale would be valid and reliable in measure self-care behaviour for patients with a left ventricular assist device.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Patients can manage the left ventricular assist device on their own based on evidence and use it as a tool for effective communication with medical professionals.

Perceptions of Bedside Nurses Caring for Patients with Left Ventricular Assist Devices (LVAD): A Qualitative Study

Introduction

Bedside nurses in the intensive care units are exposed to multiple challenges in their regular practice and recently have taken in ventricular assist device care in Lebanon since its introduction as a fairly new practice.

Objectives

To explore the experiences of nursing staff who work in Lebanese hospitals with Left Ventricular Assist Devices (LVAD).

Methods

This study employed a qualitative phenomenological research design, where semi-structured interviews were carried out among fifteen LVAD nurses in an acute care hospital.

Results

The qualitative data analysis produced six main themes. The first theme prevalent was "LVAD incompetence and shortage" and it reflected the deficit in properly structured training and the number of specialized LVAD nurses. The second theme that resulted from the analysis was titled, "Patient and family knowledge", which indicated the misconceptions that families and patients usually hold about LVAD which usually sugarcoats the situation. This was followed by "Burden of complications", "LVAD patient selection", "Perception of the LVAD team as invulnerable", and "High workload and patient frailty" which reflected the perspectives of LVAD nurses.

Conclusion

This study shows that the Lebanese LVAD nurses who participated in this study perceived inadequate competence, yet lacked proper training and induction. The nurses reported multiple challenges relating to care tasks, workload, and patient and family interactions which need to be addressed by coordinators.

The History of Durable Left Ventricular Assist Devices and Comparison of Outcomes: HeartWare, HeartMate II, HeartMate 3, and the Future of Mechanical Circulatory Support

The utilization of left ventricular assist devices (LVADs) in end-stage heart failure has doubled in the past ten years and is bound to continue to increase. Since the first of these devices was approved in 1994, the technology has changed tremendously, and so has the medical and surgical management of these patients. In this review, we discuss the history of LVADs, evaluating survival and complications over time. We also aim to discuss practical aspects of the medical and surgical management of LVAD patients and future directions for outcome improvement in this population.

The Preimplantation Psychosocial Evaluation and Prediction of Clinical Outcomes During Mechanical Circulatory Support: What Information Is Most Prognostic?

BACKGROUND

Psychosocial evaluations are required for long-term mechanical circulatory support (MCS) candidates, no matter whether MCS will be destination therapy (DT) or a bridge to heart transplantation. Although guidelines specify psychosocial contraindications to MCS, there is no comprehensive examination of which psychosocial evaluation domains are most prognostic for clinical outcomes. We evaluated whether overall psychosocial risk, determined across all psychosocial domains, predicted outcomes, and which specific domains appeared responsible for any effects.

METHODS

A single-site retrospective analysis was performed for adults receiving MCS between April 2004 and December 2017. Using an established rating system, we coded psychosocial evaluations to identify patients at low, moderate, or high overall risk. We similarly determined risk within each of 10 individual psychosocial domains. Multivariable analyses evaluated whether psychosocial risk predicted clinical decisions about MCS use (DT versus bridge), and postimplantation mortality, transplantation, rehospitalization, MCS pump exchange, and standardly defined adverse medical events (AEs).

RESULTS

In 241 MCS recipients, greater overall psychosocial risk increased the likelihood of a DT decision (odds ratio, 1.76; P = 0.017); and postimplantation pump exchange and occurrence of AEs (hazard ratios [HRs] ≥ 1.25; P ≤ 0.042). The individual AEs most strongly predicted were cardiac arrhythmias and device malfunctions (HRs ≥ 1.39; P ≤ 0.032). The specific psychosocial domains predicting at least 1 study outcome were mental health problem severity, poorer medical adherence, and substance use (odds ratios and HRs ≥ 1.32; P ≤ 0.010).

CONCLUSIONS

The psychosocial evaluation predicts not only clinical decisions about MCS use (DT versus bridge) but important postimplantation outcomes. Strategies to address psychosocial risk factors before or soon after implantation may help to reduce postimplantation clinical risks.

A systematic review of psychosocial design considerations for the next generation of mechanical circulatory support

BACKGROUND

Biomedical engineers are developing new mechanical circulatory support pumps. Clinicians are generating and analysing new evidence for their prescription and management. Industrial designers are generating usable solutions for wearable components and controllers. However, psychosocial considerations may be falling between the cracks of the three disciplines because of their multi-faceted nature.

OBJECTIVES

This article seeks to identify psychosocial needs raised in previous work, re-frame them as needs for future products and services, and discuss routes to solutions.

METHODS

SLR extracted 225 statements on psychosocial considerations from 42 included articles. 23 codes were inductively generated and applied to relevant datapoints. Codes were consolidated under 4 main themes and re-framed as solvable problems.

RESULTS

Identified themes: expanded remote care, improved multidisciplinary management tools, creating easier interactions; and extending patient engagement.

CONCLUSIONS

Design-driven methods have been used to solve analogous problems in other contexts and can address the identified psychosocial problems if implemented fully.

Risk factors of readmission to acute care hospital among individuals with heart failure and left ventricular assist device (LVAD) at inpatient rehabilitation setting (STROBE compliant article)

In post-acute care hospital setting, the heart failure (HF) individuals with left ventricular assist device (LVAD) have about 30% of transfer to acute care hospitals which requires readmission. There is relative increase in cost and mortality due to the readmission.The goal of this study is to identify possible risk factors at Inpatient Rehabilitation Unit (IRU) to decrease the rate of readmission to acute care hospitals.This study is retrospective study at the Inpatient Rehabilitation Unit (IRU)Twenty one individuals with HF and LVAD were admitted to IRU. We determined 2 subgroups. One is the readmission group (Readmission) and the other is the control group (Control). Readmission (n = 6) is the individuals who were transferred to acute care hospital, and Control (n = 15) is the individuals who were discharged.To compare Readmission group with Control group and evaluate demographic, laboratory, and functional outcome parameters. Main Outcome Measures are Body Mass Index (BMI), International Normalized Ratio (INR), and Functional independence measure (FIM).At admission, INR in Readmission group was 3.4 ± 1.2 and in Control group was 2.2 ± 0.5 with a statistically significant p value (P = .004) and FIM score in Readmission group was 81.2 ± 15.9 and in Control group was 96.3 ± 11.5 with a statistically significant p value (P = .023).The study showed the individuals with HF and LVAD at IRU had high INR and low FIM which may be the cause for readmission and need more attentive care. This data can help identify the factors causing readmission and help reduce the rate of readmission. Further evaluation is necessary to determine the cause for readmission.

The Approach to the Psychosocial Evaluation of Cardiac Transplant and Mechanical Circulatory Support Candidates

PURPOSE OF REVIEW

We update evidence underlying the recommendations of a 2018 multi-society consensus report regarding the psychosocial evaluation of individuals for cardiothoracic transplantation and mechanical circulatory support (MCS). In the present review, we focus on heart transplantation and MCS.

RECENT FINDINGS

Expert opinion and new evidence support the inclusion of ten core content areas in the psychosocial evaluation. Prospective data indicate that psychosocial factors can predict post-transplantation/post-implantation outcomes. Such factors include treatment adherence history, mental health and substance use history, cognitive impairment, knowledge about treatment options, and social factors such as socioeconomic status. For other factors (e.g., coping, social support), new evidence is weaker because it derives largely from cross-sectional studies. Concerning evaluation process issues, expert opinion remains consistent with consensus recommendations, but there is a dearth of empirical evidence. The psychosocial evaluation can identify factors relevant for candidacy for heart transplantation and MCS implantation. It enables the provision of interventions to improve patients' viability as candidates, and facilitates care planning.