Care Management for VAD Patients
Lynn Cardona, RN
Tricia Shustock, BSN, RN
Christyna Zalewski, BSN, RN
Silverstein 10 Nursing Team
Penn Medicine VAD Coordinator Team
Innovation Accelerator Program
Cardiac patients who undergo the placement of ventricular assistance devices (VADs) for heart failure are at high-risk for anticoagulation complications. Frequent and close monitoring of these patients’ international normalized ratio (INR), a measure of how long it takes for a patient’s blood to clot, is crucial for safety, as poor management can lead to readmissions and even death.
Conventional anticoagulation management restricts and inconveniences patients because it requires frequent trips to the lab or the doctor’s office for INR testing.
We partnered with a team of nurses from the Penn Medicine Heart and Vascular Center to explore ways to optimize anticoagulation management for VAD patients and the providers charged with managing their care.
Point-of-care testing kits were distributed to VAD patients, and training on how to conduct INR testing at home was implemented. Care teams kept in contact with patients via text message after discharge to collect contextual information about things like symptoms, changes in diet, and medication adherence, along with INR results.
Home INR testing allowed for more independence and improved quality of life among patients. It also freed up valuable hospital and health system resources and improved care delivery and patient outcomes.
In the initial pilot, we observed a reduction in missed or delayed tests and a shorter turnaround time to receive results. The 30-day readmission rate among non-enrolled patients hovered around 50 percent in the control group, compared to 17 percent in the pilot population. The 90-day mortality rate clocked in at 20 percent among non-enrolled patients compared to 0 percent among enrolled patients.
Instead of relying on a verbal recount of experience, ask users to show you how they use a product or service. What people say they do is often quite different than what they do.
Observing users in action will help you understand the spectrum of experiences users can have with the same product or service.
Surveys, interviews, questionnaires, and focus groups don’t tell you what you need to know. Prompting users to show instead of tell often reveals what others have missed.
We needed to understand what information was collected during in-person visits at the Anticoagulation Management Clinic and how providers used it to make decisions about care.
We spent several days observing clinic visits and documenting conversations and care decisions. We also conducted real-time interviews with patients and providers to learn more about their decision-making processes. This helped reveal patient-reported data - in addition to INR results - that providers would need on hand if patients were not coming into the office to complete testing.
We used the insights from this work to inform the structure for text message encounters with patients completing testing at home.
Fake front end
Fake front end
Fake front end
Fake front end
Before piloting home INR testing with text-based support, we distributed paper prototypes to patients in the waiting room at the Anticoagulation Management Clinic.
The prototypes prompted patients to provide the information we planned to collect via text message in the pilot. Completed forms were presented to providers, who were asked to make clinical recommendations before seeing the patient.
After the provider spoke with the patient, we compared before and after clinical recommendations to determine if the remote-monitoring approach impacted patient care. The fact that providers felt confident making clinical recommendations based on the patient-reported data on the forms helped us gain buy-in to pilot at-home testing.
A journey map is a visualization of a user's process to accomplish a task. Journey mapping involves plotting user actions onto a timeline.
Details on users' thoughts, emotions, and feedback are then added to the timeline to provide a holistic view of the experience or journey. Journey mapping will help you uncover what's working well in the current state and identify key pain points that need addressing.
You can build a journey map based on several users' observations, creating an archetype user journey, or you can use a template in real time as you conduct individual observations of users.
The experience for VAD patients is complex. Several care teams are involved with keeping these patients safe, and there are many steps along the way - from VAD placement to, hopefully, transplant.
We plotted all of the patient and provider touchpoints on a journey map. The map helped various stakeholders understand the complexity of the process and enabled us to discuss where care could be streamlined to improve the experience.