Hello, my name is Ileah Reichert. I'm an acute care nurse practitioner at Riverside Methodist Hospital in Columbus, Ohio. I have a lot of roles and responsibilities in my program, and one of them that pertains to this discussion is obviously that of data collector. It's not a very popular role, but it's one that I took on and continue to work at daily because I know the value that up-to-date, relevant data can bring to programs and to patients and to clinical outcomes. Our program is a high-volume interventional cardiology structural heart program. We perform over 600 procedures a year, 400 of those being TAVR alone, and follow all of our patients closely post-op out from between one and two years. We're an outpatient and inpatient service line and report to the TBT registry on all of our patients regardless of what valvular intervention was performed. A majority of my time is spent at the bedside of patients, either in clinic or inpatient, and the remainder is split between administrative roles for our program and data collection. I do not report to the registry myself. That is performed by a separate individual whose office is located off-site of our clinic. She obtains all of her information that she's going to report to the TBT registry by chart review. Now, recently, she has started sending me all data prior to submission to ensure accuracy, but this was not always the standard protocol. I would say for anyone listening that if this is the case for your institution as well, I would highly recommend close contact and open communication between providers who care for the patients and those who report on what happened during their procedural course. The last thing that any program wants is to unintentionally false report data, particularly as we transition to a value-based model of health care and as outcomes become more publicly reported. Our program started in 2014, and we have grown exponentially in the last five years. Our first year, we performed about 120 transcatheter aortic valve replacements, and last year, we were near 400. We also do left atrial appendage occlusion with The Watchman, which has grown from about 20 patients in 2015 to 72 patients last year, and we're set to surpass that this year. We also perform mitral and tricuspid clipping. We started out with 10 procedures in 2014 and completed 72 clips last year. We also are a research center, so we have lots of new clinical trials, new therapies, new valves coming, so our volume only continues to grow. When I started in late 2017, despite having EMR, our program relied 100% on paperwork and, in particular, large three-ring binders to track patients from referral to procedure. These binders were everywhere in our clinic and only increased as our volume soared. Our amazing coordinator at that time had a very efficient way of knowing where each patient was in her process, but unfortunately, no one else did. When she took time off or was sick, there was virtually no way for anyone else to step into the process efficiently and continue patient throughput. She actually took a lot of work home with her because there was no one else who knew how to streamline the process. An Excel spreadsheet was used to track when patients should return for follow-up, which for TAVR alone was at 30 days and, again, at one year according to registry requirements. Obviously, no program should be completely dependent on a single person running the flow because, inevitably, that person will need or want to step away, and this transition should be seamless. In addition, the only way that we were able to retrospectively review our program compared to national averages was through the STS registry, which was lagging several months behind actual day-to-day program happenings. We also, as I stated before, had someone giving registry data who was not really affiliated with true patient outcomes. And so when we looked back, we could see that some of the things that we were reporting to the STS registry maybe was not all that accurate. We had a lot of needs as our program continued to grow. Our most pressing was patient tracking and throughput, but there was pushback from the staff because their system worked for them. So that need was placed in the proverbial parking lot for some time. We also had the physicians really pushing for real-time data collection so we could focus on quality improvement and getting our program where we really knew it could be. I asked around to other institutions about how they were tracking patients and how they were tracking data, and I also asked about what data tracking vendors were being utilized. But after many discussions with our IT department, it really became apparent that there was no room for any third-party vendors to come into our program to help with this. So I had to look around at what was already existing within our program. So what I found was this healthcare data capture program called REDCap. And maybe some of you have heard or are using this program yourselves. It's certainly not limited to our healthcare organization alone. This program basically tracks and organizes data with good old-fashioned zeros and ones. If a box is checked, the program will pull all the data that has that box checked and separate that data seamlessly. First step with REDCap was capturing our current trends. The TBT registry has, for several years, reported on a quarterly basis. Now I hear that that's going to be changing in the next coming months, but our TBT reporting will still not occur on a very consistent, timely basis. Now we, meaning our entire program, nurse practitioners, interventional cardiologists, cardiothoracic surgeons, we review complications on a weekly basis at our heart team meeting. And we provide year-to-date data every two to three months so everybody throughout the program knows where we are. We really pride ourselves on recognizing current trends and monitoring our interventions to improve quality. After speaking with our cardiologists, we determined what quality indicators we wanted to track and monitor, and then created a data instrument form which would be used on each patient. Our forms look like this one. Every patient who undergoes a procedure has their information placed into this protected health care form. You can see on this section of the form we are able to input the patient's demographics, pre-echo findings, indication for treatment, valve, implanting physician, and so on. So after I've input all of the patient's data into the form, including everything that happened intra- and postoperatively, I create reports which basically allow me to separate the data based on what I'm looking for. So I can see how many patients year-to-date have had any procedure by going to my all data report. That's indicated with the red arrow here. I can also pull how many patients had required a new pacemaker after their procedure, had an access site complication, required blood transfusions. Anything that I put into my initial form, I can pull out if I've clicked that box. As long as the data is kept up to date, which is through manual entry, these reports will pull the data relatively quickly. REDCap also allows me to run stats and charts relatively quickly and can also export data to an Excel spreadsheet. Here I have an example of statistics on access sites for our procedure. Every data element that I input can be organized in this manner. We can review average STS of our patient population, which valves have more complications compared to the others, and a lot of registry data as well, like stroke and death rates, access site complications, and so on. An added benefit that I have found is I can actually run a report and find who is deficient in their post-op follow-up appointments, which organizations are held accountable to the TBT-4. We have schedulers in our program in charge of our follow-ups. But if they're unable to reach a patient, they move on to the next patient, leaving voids in our follow-up data. So now I can see who's not followed up, and we can evaluate why this occurred. And even more recently, if they're not able to come into our clinic, even getting them on for a virtual visit. So data collection and analysis is really only worthwhile if it leads to some type of significant change. Now we've been monitoring this data now this way for three years. And in that time frame, we have seen some significant changes. One, we've reduced vascular complications. So by reviewing our trends as frequently as we do, we have made necessary changes, things such as implantation technique, even closure. We've also ensured that what we're reporting to the registry is 100% accurate. We've also reduced the need for unnecessary testing. Left bundle branch blocks are very common after our procedures, and many of our patients used to undergo EP studies. And we realized that this was not really an added test that brought much benefit to our patients. And so what we instituted was patients with new conduction abnormalities would be placed on a heart monitor for discharge. And this would be on for 30 days. We were able to reduce the length of stay for these patients and reduce hospital costs. Now not all can be attributed to data review, but I certainly believe that these changes took place after recognition of the data and our purposeful intent to make changes to our processes given that data. It's also, again, making sure that we are compliant and correct in our programs reporting to the registry. This will be publicly reported soon, so this will become an even more important feature in program monitoring in the near future. And now I don't need to go to each individual's charts. I'm able to pull up my data rather quickly to make sure that everything that our TBT registry reporter is going to report is factual. Here's another look at where statistically we grew since 2018 when data tracking was implemented. We're very proud of these changes and very proud of how our program has continued to evolve. Next was organization of patient throughput. Our coordinator, who had her own way of tracking patients, did indeed leave, so we were left with a huge need for radical change to our process. Again, no third-party vendor was allowed to assist. I had to work with what we had. Believe me, I asked. So after keeping this post-op data through REDCap for nearly a year and a half, I realized that this program could also be formatted to help track our patients through their workup. The new coordinator and I sat down, we looked at the data elements that were needed, and we again created reports. Our coordinator now has several reports related to her patient intake process. So here's an example. After referral, the first thing that our coordinator needs is a CREAT level. Once that level is obtained, they will be scheduled for their CT scan and screen date where they will meet our staff and get educated on their procedure. She's able to quickly see which patients after referral still need their CREAT obtained and which patients are ready to be scheduled for their screen date just by keeping up with the data and running a quick report. The patients also need to obtain a left heart cath and see a cardiothoracic surgeon. And once these are obtained and checked off through the system, she can run a report of who is ready for their procedure. Not only have the three ring binders disappeared, now any one of our staff members can jump into her spot in her absence and pick right up where she left off. This makes our office manager extremely happy. There's no confusion about where patients are in the process. We can see, based on the purple arrows, you can click on whatever report you need to see which patient is where, and we can see who has been scheduled and what their date will be. This process has dramatically streamlined our referrals. We are now 90% electronic with no further waste of resources or staff time and effort to print out and check off every item needed and work up. We have reduced clinic material cost without those binders and printed paperwork, and we have increased staff availability while reducing staff workload on patient tracking. We also always have a bird's eye view of our program. How long is referral to table? Do we need additional procedure days? Can we get an additional cardiothoracic surgeon and interventionalist to jump into procedures? Do we need more TAVR days, et cetera? All can be answered with a few simple clicks. The downside, this is not Epic-based. That's what we use for our EMR. There's no communication, and it all has to be manually entered by someone. This is obviously cumbersome and time-consuming in and of itself. If this would auto-populate data, our coordinator and myself, our efforts, it would all be way more efficient. Now, this is really, I know where the future is headed, where we can track patients through our EMR, we can see where they are, and we can see how they did post-operatively for TBT reporting. In the meantime, we're going to continue to use what we have available through our system because we can see that it is radically changing our program for the better. Thank you for the opportunity to speak about our data collection. It certainly has changed our program. I have left my email here in case anyone has any follow-up questions. Thank you. Thank you.

data collection

interventional cardiology

structural heart program

REDCap

patient outcomes