Hi, my name is Misty Terrio. I'm the valve clinic coordinator for the TAVR program at Lake Charles Memorial Hospital in Lake Charles, Louisiana. I want to thank you so much for tuning in. Today I'll be talking to you about riding out the storm, how our program has been able to push through with all the struggles we have faced the past couple of years by the ACC's help through transcatheter valve certification. Throughout this presentation I'll be talking to you about how we were able to achieve and maintain our certification through all the disasters we faced and has been quite a few the past couple of years and also how the certification process positioned us to be able to bounce back quickly from those experiences. A little about our facility, we are an acute care community hospital located in southwest Louisiana. We started TAVR a little over four years ago and we have three TAVR physicians, all of which share the role of co-program medical director. That includes two interventional cardiologists and one CBT surgeon. All four of us have been together since we started the program. At our facility I'm the only coordinator and I'm also the TBT registry site manager. Our annual volume is 50 to 75 cases, but I will say in 2020, in addition to dealing with the COVID pandemic, our area has been greatly devastated by two hurricanes, a freeze and a flood, which I'll talk about throughout this presentation. The past two years we really have focused on rebuilding, restructuring and outreach and we are finally seeing an increased trajectory regarding our volumes, so we are excited about that. Lastly, our program was the first in the nation to obtain the transcatheter valve certification back in September 2019. We were also the first program to become recertified in January of this year. I'll start by explaining a little bit about the transcatheter valve certification, also mentioned as TCV here. So this is an external review process that provides a foundational platform for TAVR and TIER. TIER was included in the V1.1 update that went live last year, but you do not have to do both at your facility in order to obtain this. The TBT registry also plays a large part in the certification to help identify areas for program improvement. An ACC navigator or review specialist will be assigned to the facility going through this and they really help to provide best practices and guide and facilitate the process. We decided to go through with this in 2019 because our top commitment is to patient care, so anything that we could do to further improve the process and the outcome for the patient that is what we were looking forward to. Additionally, we wanted to streamline processes in order to become more efficient. I know I'm not alone in saying that it's overwhelming when you're starting and maintaining a TAVR program. There's so many great areas and so much that goes into it. So anything that we could do to make all of our lives easier is really, again, what we were looking forward to. I love this picture of the cat herder that is included in here at the top because I feel like as a VCC, this is what so much of our day looks like, trying to keep everything on track. So having the additional guidance of the ACC in this process was something that we knew would only further improve our program. Lastly, at the end of the day, we wanted to be recognized for having a proficient program. We wanted patients to know that when they come to our facility, they're being treated by a team that truly values shared decision-making, follows the best practices, has great patient outcomes, and truly provides a patient-centered, focused care. And that's what we felt the certification would exemplify. I wanted to show a visual of how long the certification process took for us. From submitting the application to receiving the certification was within two months. The ACC does allow one year from access to the tool to completing all of the requirements. I think six months is a realistic timeframe to get all of this done. And I would definitely strive to get it done before one year, just in case you have something that comes up and you're unable to work on it so much at a certain point. The first step is the baseline gap analysis, which is a good assessment for you and the ACC navigator to be able to see where your program is, the gap that exists, to get your program to where the potential of what it could be. You then start uploading the documents that meet the various requirements. We set the goal date of completion to be within 30 days to do all of the requirements. I know, a little crazy. So I think just make sure whatever goal date you select, make sure it's something realistic and attainable for you. Overall, I would definitely make sure that you're making this a team effort and not just an individual effort. And once the certification is granted, it is good for three years. You do get access to the tool one year before your certification expires. And they do provide you with a list of ongoing requirements that must be met in order to maintain the certification, but it's extremely manageable. Throughout the certification and recertification processes, it became apparent how vital it is to utilize the strengths of your team. I really can't stress that part enough. It's so important that you go directly to those individuals and departments when you're looking at certain processes, such as TAF or inventory management, and really get their feedback, see what they like about the process, ideas they have on how you can improve upon that to make it more efficient. Not only does this help with overall buy-in and support, but it helps with compliance as well. We found that we had a lot of processes in place, but they weren't properly documented. So having the ACC's guidance to be able to come up with those necessary documents really did help solidify the overall foundation of our program. By looking so closely at our TVT metrics, we were able to identify a lot of ways that we can improve upon by doing a deep dive and really figuring out what we were doing and brainstorming how we can improve. We did see a lot of improvement in our metrics regarding patient outcomes and program outcomes by doing this. Lastly, our TAF or staff education process needed to be streamlined. We didn't know that we would have the staffing issues that we're having now. So having the training process so ironed out and outlined really has helped along with having the ongoing education requirements listed as well. After certification, life was going really well. We had a lot of momentum and excitement. We were focusing on marketing efforts and doing different commercials and articles. And at that same time, the FDA had also approved for low risk, which we know was game changing for TAFers. So we were seeing increased referrals, and the trajectory for our program just appeared to be really promising. That momentum and excitement came crashing down very quickly in 2020 when the COVID-19 pandemic began. This slide provides a quick snapshot on what was to come for the next couple of years for our program. And you can see it was quite eventful. We then were devastated with a Category 4 near Category 5 hurricane, Hurricane Laura, and it caused such widespread disaster. It really looked like a bomb went off in this area. Our facility was closed for two and a half weeks. I personally was without power for 70 days, mainly due to all of the downed power lines. We had a lot of family members living in our backyard and campers because they had completely lost their homes. So it was a very challenging time. We then had another hurricane hit our area just a couple miles apart from where the original hurricane hit. It was not quite as strong, but it was still concerning because there was so much loose debris everywhere. We then had a freezing event that happened. And at that time, there were still a lot of people who were living in campers and tents. So a lot of people were put in danger. And it resulted in a lot of broken and busted water pipes. We then had a flash flooding event. Some people had just started to move back in their home when this happened. I remember looking out of the window at the hospital and there were boats going on the main road in front of the hospital trying to evacuate people from their homes. So just a very scary, difficult, challenging past couple of years, but we really have all come together to help each other through it. I wanted to show a timeline so you could really visualize what really has happened the past couple of years. So in 2019, we were able to obtain the certification. Then the COVID pandemic began. We were devastated by Hurricane Laura and then Hurricane Delta. A couple months later, had the freeze and then the flood. While all of these natural disasters were happening, we were still having to meet the ongoing requirements by the ACC, but it was still very manageable. After the flood is when we started focusing on our recertification and we were able to get that in January of this year. Just to recap, downed power lines were definitely one of the main stressors that we were faced with. This top left picture shows what so many areas around our facility looked like. So you can imagine how it was difficult to travel around this area. Also, getting supplies was an issue. Not having internal telephone lines working within the hospital system. It affected Wi-Fi and just a lot of the essential things that you need to be able to run a facility. The running water was another issue, and then patients losing their home, transportation. All of this just took a while for us to be able to recover and rebuild from. The aftermath of all of these events really resulted in a decreased population. Prior to these events happening, our area was really booming. The population was increasing. More people were moving to this area, and afterwards, people moved away and did not come back. According to the U.S. Census Bureau, they estimate at least 5% of patients left this area, and they really think this is grossly underestimated and is really closer to about 10%. So you could see how this would affect a TAVR program, for instance, as a lot of patients we had tracking and monitoring for TAVR and also scheduled and set up had moved and relocated to other areas. After reviewing all of those obstacles, you may be asking, how are we able to maintain certification? Well, it continued to be a team effort, and having to focus on time management and prioritization were really key. So many of our processes had become so streamlined throughout this process that it made it very simple to maintain. It really didn't seem like any extra work because it is what we were already doing on a regular basis. So why did we continue? I know that would probably be another question. Why didn't we just stop when all these obstacles were happening and just say, this is too much? Well, we saw the positive effects that this had on our program. We saw the improved patient outcomes and program metrics, and we knew this was important to continue. Also, all of these updated processes had become integrated in our daily lives, and so it really didn't present to us as though it was more work. It was just part of the way that we did things now. So that question never came up for us. Also, we were searching for a sense of normalcy, and that is really what this brought for us. This was one thing we did not have to really worry about while we were being hit from all these different directions with all of this other chaos around us. So sense of normalcy and the positive effects are the main reasons why we continued. The next two slides, I wanted to be able to show examples of the positive effects that I've mentioned. These resulted from us looking closely at all of our processes with the ACC's guidance to really make sure we were becoming as efficient as possible. One of our main focuses was having decreased procedure time. By really improving on our vascular complications, this helped tremendously, along with using moderate sedation instead of general anesthesia and making a couple of other adjustments. We were able to make sure that we were done with three cases generally by noon on a regular basis. We're limited in doing more than three cases on a TAVR day, mainly due to the cardiologist needing to do clinic that afternoon, and they're in satellite clinics the remainder of the week. So Tuesday morning is generally the only time that we have, so we have to make it as efficient as possible. I have an example of the very first TAVR day that we did where we thought it would be a great idea to do three cases, and you can see how long of a day that was for us. Improving on our program throughput was another focus of ours and really goes along with the last slide as well to make sure that we're treating patients in a more timely manner. In 2018, we had a huge backlog of patients that were waiting for us to start our program, so our total throughput at that time was 50 days, and we were not okay with that. So even with COVID and all of the disasters that we were faced with, we were continuing to be able to improve upon this by doing more cases in a day, adding more Tuesdays within a month to be able to make sure that we were treating patients quicker. Additionally, when I get a referral for a patient, I try to make sure I have them scheduled for testing within seven days and then be able to get them scheduled if they're appropriate for TAVR after that. So just making sure we're going through the process quicker. This year, our total throughput is right at 17 days. I mentioned the aftermath from all of these events that resulted in the decreased population and also how we were able to bounce back quickly from the obstacles we were faced with. This allowed us to really focus on rebuilding our program and making sure that we were reaching as many patients as possible that were left within our community. We focused a lot on outreach efforts and doing a lot of education on both the community and physician level increasing our marketing efforts and going through prior ECHO reports to make sure we were treating as many patients as possible. Overall, the certification and recertification processes were extremely beneficial for our program and helped to set us up for success. Little did we know all of the obstacles that we would be faced with, but it really allowed us to bounce back quickly so that we could focus on rebuilding our program. We continue to look very closely at our TBT metrics to further find ways that we can improve upon because I don't feel like you should ever be complacent. There's always room to improve upon and continue to make this a team effort. Make sure you're continuing to involve your entire team and don't let this stop when you get your certification. Let it continue beyond that. I want to thank the ACC for this opportunity and for their ongoing support the past couple of years along with thanking our TAVR physicians, hospital administration, and TAVR team at Lake Charles Memorial for their continued resilience and dedication to patient care while riding out the storms the past couple of years. Thank you so much for tuning in and I really hope this information has been helpful for you and your program.

TAVR program

transcatheter valve certification

disasters

rebuilding

patient-centered care