Across the nation, more than one in 10 patients who undergo bypass surgery are readmitted to the hospital within 30 days of their operation. Common reasons for readmission include complications from the procedure or infection. But for recent patients at Christiana Care’s Center for Heart & Vascular Health, the need for hospital readmission has been drastically lower — closer to 1 in 20.
These good results didn’t happen by chance. Through a focused, multidisciplinary campaign to prevent re-hospitalizations, Christiana Care has demonstrated extraordinary improvement on rates that at one time were slightly worse than the national average. These readmission rates aren’t merely numbers — they represent patients and family members who experience better health and a better quality of life because of the intense focus that Christiana Care has put on their safety and quality of care.
“It’s a nice example of how multidisciplinary teams can have a real and positive impact,” said Kirk Noel Garratt, M.D., MSc, chief of Cardiology and associate medical director of the Center for Heart & Vascular Health. He explained how physicians and leaders partnered with patient care teams in the hospital, skilled nursing facilities, the Visiting Nurse Association and others to understand what was causing readmissions. They then put in place specific measures to help head off those problems.
“Part of our responsibility is to do all we can to prevent patients from coming to the hospital,” Dr. Garratt said. “We achieve this by forming strong partnerships with outside providers and our community.”
This kind of big-picture thinking is the hallmark of today’s Center for Heart & Vascular Health. The team is working on all fronts to embrace the most advanced, most effective techniques and technologies to diagnose and treat heart disease, while at the same time reaching out across the community to help people take control of their heart health and potentially prevent the need to ever see a heart surgeon or a cardiologist.
“Innovation arises from a culture that values communication, collaboration and a sense of unity among team members,” said Timothy J. Gardner, M.D., medical director of the Center for Heart & Vascular Health and executive director of Christiana Care’s Value Institute. “We’ve worked to create a structure that fosters the circulation of new ideas that bring cutting-edge technology to our facilities and form partnerships that help our patients stay healthy in their communities.”
The disappearing stent
That spirit of innovation is evident in Christiana Care’s participation in a study of the first absorbable coronary scaffold, a stent-like device that dissolves into carbon dioxide and water over about two years.
“I think the technology sounds brilliant,” said principal investigator Wasif Qureshi, M.D., medical director of the Structural Heart Program at the Center for Heart & Vascular Health. “Who wants something in their heart or arteries that will last forever?”
Since the introduction of intracoronary stents in the mid-1980s, these tube-shaped devices have been implanted in millions of Americans. They are wrapped around balloon catheters and inserted into blood vessels through small incisions, often in the leg. Once the stent is in place, the balloon is inflated, causing the wire mesh to expand, compressing plaque and restoring blood flow. These stents stay inside the patients for the rest of their lives.
Since regulatory approval in July 2016 following the ABSORB III trial, which included about 20 Christiana Care patients, biodegradable scaffolds that absorb into the body are a new option. Data from the trial show that the absorbable scaffolds performed similarly to traditional stents.
New heart surgery technology changes lives
Most new medical devices offer gradual improvement, but some advances disrupt their field and change the way care is delivered. One such disruptive technology goes by the acronym TAVR, which stands for transcatheter aortic valve replacement. At Christiana Care, TAVR technology and innovative partnerships among care teams together are transforming care — and patients’ lives.
Aortic stenosis is a heart condition in which calcium accumulates on the aortic valve, the main pumping chamber through which all of the body’s blood travels. The effect is akin to putting your finger over a garden hose — blood that travels through a narrowed aortic valve has to speed up tremendously to get through a smaller hole.
“People live probably no more than one to three years with severe aortic stenosis,” said cardiologist Neil J. Wimmer, M.D.
In the past, open-heart surgery was the only treatment option for this condition. But TAVR has given new hope to patients for whom open-heart surgery presents too many risks.
The procedure is well suited to higher-risk patients primarily because it is less invasive. The artificial valve is attached to a small balloon and inserted through a blood vessel, usually in the leg, similar to a stent procedure. The catheter and balloon are positioned inside the calcified valve, and the balloon is inflated to implant the artificial valve. Often, the patient can go home the day after the procedure.
At the same time, doctors know that TAVR is not for everyone, including those whose quality of life won’t dramatically increase even with a new valve.
“We often have very frank conversations with patients,” Dr. Wimmer said. “I ask, ‘If I could fix your heart valve by magic, how would you feel tomorrow?’”
Dr. Wimmer consults with his colleagues at Christiana Care’s Swank Memory Care Center to help answer patient quality-of-life questions. This collaboration helps the care team to understand whether the patient’s symptoms are caused by the faulty valve or by an unrelated condition. Often, the core question isn’t whether TAVR would fix the valve, but whether it would truly improve the patient’s daily life.
“It’s another example of how taking care of these patients is a team effort across the institution,” Dr. Wimmer said. “It’s a nice model for an integrated service line.”
Just as TAVR is an effective alternative for those who can’t undergo open-heart surgery, Christiana Care doctors are using a new left atrial appendage occluding device to help patients at risk of stroke who can’t take blood-thinning medications.
“There were many patients coming into the hospital with bleeding issues, but previously there were no options for them,” Dr. Qureshi said. Preventing stroke is a high priority for these patients, many of whom have seen friends and family debilitated by the condition.
For people with a typical heartbeat, blood is regularly pumped out of a small pouch in the upper left chamber of the heart called the left atrial appendage. But for people with atrial fibrillation, or an irregular heartbeat, blood can pool here and form clots, which may eventually travel to the brain. Patients with this condition are several times more likely than others to have a stroke.
Christiana Care doctors can now implant the parachute-shaped device through a blood vessel in the leg and guide it to the entrance of the left atrial appendage, where it expands and prevents blood from entering the chamber, reducing the risk of stroke.
Robot assistance makes surgery less invasive
Innovation can take the form of devices, but sometimes it means learning how to perform familiar procedures in a new way. For cardiothoracic surgeon Paul K. Davis, M.D., that meant using robotic technology to help him perform bypass surgery through incisions much smaller than he could perform by hand.
“Being able to operate through a small, 2.5 cm incision is exceedingly useful, especially in patients who are not good candidates for standard open-heart surgery,” Dr. Davis said.
Most patients who undergo robotic surgery are out of the hospital in two or three days and back to work within three weeks. The back-to-work time for open-heart surgery is typically closer to two months.
Robotic surgery, at least in the cardiac realm, is a bit of a misnomer, according to Dr. Davis. A more descriptive term would be robotic-assisted surgery. The robot, called the da Vinci Surgical System, is controlled by a surgeon at a console; it is not programmed to act autonomously.
At the same time, traditional surgery without robotic assistance continues to be a vital part of Christiana Care’s program. Michael K. Banbury, M.D., W. Samuel Carpenter III Distinguished Chair of Cardiovascular Surgery, said patient care improves with the interrelation of robotic and non-robotic surgery at Christiana Care, supporting optimal care for each patient.
“Careful use of new technologies in cardiac surgery is helping many patients live healthier lives with better quality outcomes,” Dr. Banbury said.
New option for heart failure
Technological innovation is changing treatment for heart failure, and Christiana Care is bringing it closer to home.
There are only about 2,000 heart transplants a year in the United States. For those with heart failure who can’t get a transplant, there are few long-term options.
“Heart failure patients are managed with lifestyle modifications, diet, exercise, medications and surgery,” said heart surgeon Ray A. Blackwell, M.D. “Despite these treatments, some patients will develop advanced heart failure. There are other options for these patients.”
One of those options is called LVAD, which stands for left-ventricular assist device. This battery-powered machine is implanted during open-heart surgery and replaces the heart’s pumping action. For some LVAD recipients, the device is a way to be healthy while they’re waiting for a transplant. For others, the LVAD is itself a destination. In either case, the LVAD is a major responsibility for the patient and family. At least one family member must learn how to take care of the device and the patient, and must join the patient for weekly hospital visits after the surgery.
“LVAD requires a lot of education for both patients and family members,” Dr. Blackwell said. “Being able to do it in Delaware reduces stress for the family.”
Since the program began in 2011, 24 LVADs have been implanted at Christiana Care. In addition, Christiana Care cares for about 15 LVAD patients whose devices were implanted at other institutions.
First in heart health across the First State
Health care innovation isn’t always about technology. Sometimes it means reaching beyond the hospital walls to find partners who can help people where they live. Christiana Care’s Blood Pressure Ambassadors are a shining example of how these kinds of partnerships can improve the health of a community.
Cardiovascular disease is the leading cause of death in the United States for both men and women. High blood pressure is often the silent harbinger of heart problems, especially for African-Americans, about two in five of whom have the condition. The ailment is often asymptomatic, so a high reading may be the first sign that something is wrong. It is nonetheless serious — about 70 percent of people having their first heart attack have high blood pressure, according to the American Heart Association.
The Blood Pressure Ambassadors are volunteers trained to be peer-to-peer educators for their communities, said Angela M. Parker, MSN, RN-BC, project manager. Since July 2015, Christiana Care’s Blood Pressure Ambassadors have performed more than 4,300 blood pressure screenings in the community. They also partner with Christiana Care health guides to help people connect to a primary care provider if they don’t already have one.
Another successful community partnership, Project Connect, links hospital patients with free tobacco-cessation counseling and medication.
“There’s nothing you can do that’s worse for your coronary arteries than smoke,” said Dr. Davis. “Everybody talks about the risk of getting lung tumors, but your chances of getting a cardiovascular blockage are much higher.”
Hospitalization presents a key opportunity to help smokers to quit. They are required to quit while they’re in the hospital, and people who are undergoing a health crisis are often motivated to make changes in their life, said Denise Taylor, MS, RD, project manager for Project Connect.
Tobacco cessation often requires multiple attempts, and Project Connect aims to overcome the barriers to care that arise after discharge from the hospital. Preliminary results of a pilot study are promising. Of patients who were connected to the smoking-cessation service Delaware Quitline by Project Connect, one in three enrolled in services.
A culture of innovation
Clear and obvious heart-health messaging throughout Delaware will continue to be a focus for the Center for Heart & Vascular Health, Dr. Garratt said.
“We’ve launched initiatives aimed at demonstrating to Delawareans that we have their heart health in mind,” he said.
Meanwhile, patients at Christiana Care can expect to benefit from innovations across the spectrum of cardiac technology, as long as they provide real value to patients. The culture of innovation is about more than staying current. It’s about curiosity and a willingness to change.
As Dr. Qureshi put it, “We embrace new technology, and we love to learn.”