Hi everybody. I'll just say before I start, remember before you leave we have this session and then we have another session this afternoon on TVT-centric things. But before you do leave, make sure the person to the right of you, the person to the left of you, you get to know them because we want to make sure that you're going home with Find Your People. Find your, you know, if you want to know who is somebody that you could connect with, ask one of us because we know some of the folks in the room who have been registered for the program. But take the toolkit that you learned from this session, from the previous sessions, from the session this afternoon, and make sure that you keep in contact with those people. We are hashtag Tavernation, soon to be hashtag TVT Nation because of this pesky little tricuspid valve coming aboard. But make sure you get to know some folks because as I keep talking to people and we've said over the years, you are alone back at work but you're not alone because we want to hear from you. We want to know what would work, what would keep you connected. We do at the NCDR continue with our webinars. I did mention yesterday we're working on podcasts and routine quarterly webinars hosted by experts in the field, both our advanced practitioners, our physicians, our steering committee, so that we could kind of be on this journey together. Not only for TAVR, it's still there. It's still important. Again, get ready for what's coming up with regurgitation in addition to stenosis. But also mitral will sort of carry on now with tricuspid because you might be doing those combo cases. So please make sure you introduce yourself and get names and contact from folks in the room and my cell number, my email and the folks on the podium here. So I'm Joan Michaels. I'm the program manager for the TVT registry, the STSACC TVT registry. So I work with Carol Crone at STS who can't be here. She's just coming off her AQO meeting, successful AQO meeting in Nashville. But I'm here to, this is a little bit of a hybrid presentation and what all of the registries are doing is selecting some of the abstracts that were submitted and having a dialogue, a conversation, sort of like a fishbowl, whatever you want to call it, chat. We'll have a little bit of an update of two different abstracts that were presented, poster presentations. And we want you to see if, you know, questions about what about that, knowing one size does not fit all, what about is happening at where Liz Perpetua will talk about, what's happening in San Francisco, what Eric and Kim will talk about, what's happening at Beth Israel. What about that could you possibly take home and introduce to your facilities? So with that, first we're going to talk about nurse-led sedation with the new TVT update which we're planning to start working on in the fall and release next year. We will be including more of the granular ways that folks are getting anesthesia for these procedures. We were kind of right on the cusp with 3.0 about should we include nurse-led sedation. We did not. That was a mistake. We will fix that. But you may or may not be doing it. You may or may not be saying hard stop. My hospital will never do that. But let's just have the conversation and see what Beth Israel has done. I'd like to introduce Eric Harrington who, as of last night, could not speak, but we demanded he gargle with warm salt water, right? And he survived. He is the nurse educator for Beth Israel, Harvard-based facility. And Dr. Kim Gabon who is very active in the ACC General Session. If you attend the annual meeting next year in Chicago, you will see her. And she's an advanced nurse practitioner in charge of the Structural Heart Program there at Beth Israel. So I will be monitoring questions, and they'll talk, and then Dr. Perpetual will talk about how she has turned and helped turned the quality of life awareness and compliance in some of the hospitals that she's consulting in and working with, most currently San Francisco. Thank you. Oh, I have to say, hold on, hold on, hold on. I do have a bias. I'm a huge Red Sox fan. And perhaps if you're interested, maybe that's why I like, that's the only reason why I like Kim. But there may or may not be a tattoo to prove that loyalty to the Red Sox, but I do have a special affinity for all things Boston. So you get extra credit, you get your phone answered quicker, you get your answers quicker if you say you like the Red Sox, okay? Just keep that in mind. There you go, Eric. Oh, thanks. Oh, love it. What an introduction. That was great. Obviously to baseball. I know, it does. You know, sports is my Bible. So thank you for the introduction. Again, my name is Eric Harrington. I'm the unit-based educator for interventional cardiology, specifically the cath lab in Beth Israel Deaconess Medical Center in Boston. I'm joined here, like Joan said, with Kim Gabon. She's our structural heart coordinator. She's actually the brains behind our operation, to tell you the truth. We also have a few names up here that couldn't join us because of some technical travel problems. But Nathan Masterson, he's the assistant nursing director for BI. And Alexander Murphy, he's our technical director for Beth Israel Cath Lab. And so we're looking at nurse-led sedation and transaortic valve replacement. So why do nurse-led sedation? It was actually pretty interesting. We are having an increase in our structural heart, specifically TAVR volume. And we're having a decrease in our anesthesia availability. So we're kind of at a crux or a crossroad of, all right, how are we going to accommodate the increase in this volume? So let's look at our resources. What resources are involved when we're trying to complete one of these TAVRs? We want to look at time savings. So is there any time savings if we take anesthesia out of the picture and introduce nurse-led sedation to this? Is there any associated cost savings in this? And also staff engagement. We want to see if this is actually going to help the staff maybe practice a little higher on their license or are they going to be frustrated and kind of want to give it up? I don't know. We'll see. So the next slide is basically our structural heart volume, specifically TAVR. Year over year, we have an increase of structural heart with TAVR. You can see they're plateaued a little bit during the pandemic, during COVID. And I still like to blame things on COVID, like maybe that's why Nate and Alex aren't here. But there was a little plateau. And then you can see that after that, it kind of steadily increased year over year over year. And so we have in 2023, we've completed 373 TAVRs. And in 2024, our projected volume, because we did our fiscal year October to October, we're targeted for 203 or 204 TAVRs. So roughly 200 TAVRs, I'm sorry, 400 TAVRs a year. So if you look at the chart back in 2022, that's where we implemented this nurse-led sedation. And so you can see after that the volume kind of increased. I'm not sure if that had anything to do with nurse-led sedation specifically. But what I'll say as a staff member and an implementer of this, it gave us a lot of flexibility to do more cases in other procedure rooms. If you look at the graph to the right, we see nurse-led sedation versus anesthesia-led sedation. So we started this with a pilot program back in 2022. We had a nurse-led sedation task force, if you will. And we decided to do 20 patients. And so before we actually did any cases, we had a multidisciplinary meetings with other cardiac anesthesiologists, other cardiac surgeons, other cath lab nurses, other cath lab techs, other structural coordinators who are actually experienced doing nurse-led sedation already. So that was like the backdrop. We did that for about six months to a year beforehand. And then in 2022, we said, all right, we're going to do a pilot program of 20 patients. And then from there, it turned into standard of care. So as of the state of the state right now, we've done 421 nurse-led sedation cases as of July 2022. We've done 431 anesthesia-led sedation cases, roughly 50-50. It's roughly a 50-50 breakdown, depending on what part of the year you actually get the data. But it's roughly 50-50. And I was really concerned about our conversion rate. So all right, we're going to decide this is a nurse-led sedation case. You know, it's large bore sheath. Do you think our cath lab nurses can handle it? But our conversion rate from we decide that it's going to be a nurse-led sedation case, then changing to an anesthesia-led sedation case was less than 1%. Three cases in all of these cases, so 800-plus cases. And I do know one of those cases was for a prolonged procedure where they had to implant a permanent pacemaker and the patient just couldn't tolerate being on the table. So not too bad. I was surprised by that. I thought that conversion rate would actually be a little higher. So every week we have our Structural Heart Team meeting. So it's an interdisciplinary meeting. It consists of cardiac anesthesiologists, cardiac surgeons, interventional cardiologists, the structural coordinator and the structural group, cath lab nurses, cath lab tech and our cath lab fellow. And so this is basically coming up with the procedure details of every case. So every patient that has a TAVR, we go over interdisciplinary team meeting and go over the case to figure out, all right, what are we going to do for access? All right, what are we going to need for equipment? Because not every TAVR is the same. Not every person is the same. It's like a snowflake. So everybody is different. So we try to go over procedure details in this meeting. And one of those is the anesthesia. So are we going to do it with anesthesia-led sedation or are we going to do it with nurse-led sedation? And that conversion rate of less than 1% I think is due to our nurse-led sedation screening tool, which we adopted from a paper out of Emory, Keenan et al. And we kind of morphed it into our own needs. So we go through, you know, step by step. Do they have a reduction in ejection fraction? We earmarked less than 40%. Is their BMI greater than 35%? Difficult airway or have they had a difficult intubation in the past? Do they have complex access issues? Do they have hostile groins? Are we thinking about carotid cut down? Chronic pain and opioid use, that's a big one. We found that if they're on chronic pain meds at home, they're really tough to sedate when they're on the table. And also some recommendations from the Structural Heart team. Are the low coronary height going to be a problem? Calcified, complex aortic annulus? And then there's the TAVRs that actually need TE guidance for sizing. So going forward, or going backwards actually, this is the inception. So this is a picture of what it looked like to complete a TAVR in 2011 at Beth Israel Deaconess Medical Center. It was actually 12 staff plus observers. Everybody was in the room. And it was really crowded. But this was the amount of resources, staff resources it took to complete a TAVR back in 2011. Twelve staff total. So I'm going to ask a question. What are two things that you see wrong with this picture? You don't have to answer it now. But what I see is a waste of resources in terms of staff, equipment, and just to get the job done. We didn't know though back then. But this is what it took to get the job done as we look retrospective. So we had two cardiac anesthesia personnel in the room. We had the attending and the fellow. We had an interventional fellow, cardiac fellow. We had an interventional attending. We had a cardiac surgeon. We had two cardiac cath lab nurses, two cardiac cath lab techs. We had three operating room staff plus our cath lab table and OR table. So the footprint was quite large. All of these cases were done under GA. There's no question. All of these cases were done under GA with TE guidance. They also floated a Swann-Ganz catheter. So all of that time it took to do this case, what I'll say is it took a lot of time to complete these cases. So what we did in 2011 was, all right. Around 2018, 17, 18, so 2011 to 17 or 18 we said, all right, how many times have we actually utilized the operating room staff? And how many times have we actually utilized the TE guidance? Because CAT scans at that time were getting better and better and better. So we utilized the CAT scans for imaging and not so much the TE. So we found that cardiac anesthesia were teaching other fellows how to actually use the TE probe rather than actually looking at the imaging that would make a decision of where the valve would be placed. So in 2018, we had a conversation with our team and we decided to say, all right, we're not going to need the three operating room staff. We're not going to need their operating room table with all their equipment. We still do have cardiac anesthesia, but we're not going to do it under general anesthesia. We're going to do it under monitored anesthesia care, meaning they're not going to put a breathing tube down. They're not going to put a TE probe down. A little less invasive, a little more minimalist. So we brought the staff down from 12 to 9 staff. So we still have the two cardiac anesthesiologists attending and fellow. We have the interventional cardiac attending, the interventional cardiac fellow, still have the cardiac surgeon in the room, and we still have our two cath lab nurses and two cath lab techs in our cath lab table. So now, can we make it even more minimalist? So 2022, we decided, all right, let's see if we can do this. This is our pilot program of 20 patients. We decided, all right, cardiac anesthesia, you don't have to be involved with these cases. So this is our current state right now with our nurse-led sedation cases. We have seven staff members in the room. We still have our interventional cardiac attending, our fellow cardiac surgeon, two cardiac cath lab nurses, two cardiac cath lab techs. So basically we went from 2011, 12 staff in the room down to seven staff back in 2022, basically cutting the staff resources in half. Which is great, right. I think minimalist approach. And now we say, all right, what are we going to do? Are we going to analyze any of this? I think we are doing something other than providing care for these patients. I think there's going to be a cost savings to this. So we looked back and we decided to say, all right, we're going to compare the average cost salary of the two, the cardiac anesthesia attending and the cardiac anesthesia fellow, compared to two seasoned 10-year veteran nurses. Salary.com, we got some information and we got their hourly rate and then broke it down per minute. So if you look at this, you have to remember that even though it's an anesthesia-led sedation case, we still have our two cath lab nurses involved with those procedures as well. They just don't go away. So with that, the average cost of a TAVR with anesthesia-led sedation is $683. Compared to TAVR where anesthesia is not in the room, it's $179. It's an average cost savings of $461 per TAVR, which is a lot, especially if it's a high volume center. So taking it a step further and just to quantify it, what do you save in a year? So we took that $461 and we multiply it by 188 cases. That saves us a little north of $86,000. We look at our projected volume of 2024, 204 cases times 461 gives us about almost $95,000. And I know this is kind of funny money. It's not like I'm going to see any of that money. Kim's not going to see it. The nurses aren't going to get a full time position. There's not going to be a holiday bonus. But it's interesting that we can just display that there is some cost savings involved when we do this minimalist approach. And then I'm like, well, let's look at the time savings. So there's cost savings, which you kind of know. An anesthesiologist makes more than a nurse, right. But let's break it down into the time savings. I actually thought it would have been a lot quicker to do a nurse-led sedation, but there was still some savings there. So the average nurse-led sedation case over a period of time was 118 minutes. Average anesthesia-led sedation case was about 226 minutes. So there was an eight-minute difference between anesthesia-led and nurse-led, nurse-led being a little quicker. So again, looking at our data, we did 188 nurse-led sedation cases in 2023. We multiply that number by eight, and we get about 1500 minutes, which sounds like a lot, and it can be. So it probably gave us the ability to do 12 additional TAFers. I can't really prove that, but it just makes me think that you have the flexibility to increase the amount of volume that you're Remember, we're seeing increased volume, decreased anesthesia. So 2024, with our projected volume at 204, again, multiplying that eight minutes times 204 cases gave us north of 1600 minutes of time, which would allow us to probably accommodate for 14 more additional TAFers in a year. But taking it even a step further, it's amazing that we said, all right, so what is anesthesia doing at that time? They're probably being a little underutilized. They say they're doing their research or using it as a research day. So if you remember, cardiac anesthesia isn't in the room. So they're outside the room. They are available, as with any other anesthesiologist, but they're not actually in the room. So if we look at our projected volume in 2024, and we multiply it by the average time it takes to do a nurse-led sedation case of 118 minutes, we get 400 hours of anesthesia time in a year. So that's a lot of time. And so with these emerging valve therapies such as the tricuspid or the mitral clips that are waiting on a wait list, the anesthesia could be utilized in other areas or other procedures where they absolutely need GA or TE guidance to complete the procedure. So just giving us the flexibility to look at that because we know it's going to be happening in the future. I think the time saved is actually pretty remarkable, you know, cost savings, all that as well. But this is pretty remarkable. And so I wanted to touch on the staff engagement. I can't tell. I mean, I can tell. But are the nurses involved? Are they angry? Are they sad? Are they happy? Are they engaged? What do you feel? How do you feel about giving nurselet sedation, coming out of your comfort zone, maybe practicing at the top of your license? So we surveyed them. And 96% of our staff strongly agree that nurselet sedation for TAVR is within their scope of practice. 91% strongly agree that they would recommend nurselet sedation TAVR to a colleague. And 87% said they're satisfied giving nurselet sedation to TAVR. I'm actually surprised that it was this high. I thought it would be a little lower, 70-80%. Relatively speaking, the staff are satisfied. And they feel they have a little more fulfillment in the job that they're doing. In summary, I feel like nurselet sedation may improve utilization of resources. Nurselet sedation may reduce procedural costs. And I also feel nurselet sedation may empower nurses to practice at the top of their license. The QR code there is of the paper out of Emory if anybody's interested in perusing that. And with that, I'm going to turn it over to Kim to see if you have anything to add or take away, any insights, any questions? »» Yeah, no. Thank you, Eric. It was, Eric did a tremendous amount of work. I can't say enough about all the work that went into this. But I think what was most important is identifying up front who the folks, this is team-based care. What might their concerns be and valuing everybody's concerns, potential barriers, so that everybody had a seat at the table. Everybody was heard, recognized. And then those perceived barriers, concerns, fears, whether or not you agreed, disagreed, were addressed. And a lot of that, as Eric mentioned, was by having like professions with like professions. So anesthesia had a lot of concerns, whether it be safety, territory, timing, et cetera. So we matched our anesthesiologist with another anesthesiologist in a site that does nurse-led sedation, which was very helpful. As Patricia Keegan, who did the Emory paper, we contacted her and she spoke with our cath lab staff for the specifics. Because I think that depending on what your role is, the cath lab staff didn't necessarily care about how much it cost. They wanted to know what drugs did you use? How many milligrams? Where did everybody stand? Very different concerns. And so by addressing each person's concerns and involving each person. So it wasn't as though someone said, we're going to do this and here's how we're going to do it. Eric and his team sat down and said, let's really look at our roles and functions within the room, what everyone's is, and it's time to probably look at that anyways. Does this match our policies within our institution? All those different steps so that we were making sure that everyone is covered, questions were concerned, and just the basics of good team function. »» I will say that some nurses were concerned at first, just to add anecdotally. And I try to encourage them. We take care of these patients, these sick patients. We're putting impellas in, unprotected, left-hand PCI, rota, shockwave. We're doing large-bore access sedation with sicker patients. And everybody's like, oh yeah, I guess you're right. And then we started that pilot program and everybody's like, oh, wow, it's going okay. And then there was like, okay, I want to try it. I want to do it. So there was hesitation on all fronts from nurses, from techs, cardiac anesthesiologists, even some of our interventional attendings. But it took Kim and myself to kind of spearhead the movement and try to foster any questions or complaints I may have before we actually implement. If it was going to be across the board, nobody wants to do this, we would rethink it. But eventually, everybody got on board and it's been, you know, our standard of care. Thank you. Thank you. Open it up. We do have some questions, but I'll hold, maybe I'll hold them and let Liz participate and then we'll, some of the questions have already been answered, but thank you. Great. Thank you. To kick it off with Dr. Perpetua, in planning for this session, if anybody's ever come across my name or it will be on my tombstone, quality of life. Quality of life is my life. KCC is my, I traveled to Nepal and everywhere I went, it was like Nepal loves KCCQ. So it's, even my kids know what that means. So it's a big deal. It is not to scare everybody, it is a bigger deal coming with tricuspid. If you have heard about it, there are two endpoints that everyone, industry, FDA, and the registry will be very interested in with tricuspid, and that is one year, I'll repeat that, one year follow-up of TR, so you need the echo, and quality of life. So if anybody out there knows an easy way to get one year quality of life, you will, you know, be owning an island in St. Barts or something, I mean, it's a big deal. But we're trying to get ideas, we're trying to increase awareness, we're trying to elicit any kind of ideas about how to get one year quality of life for TAVR, Mitral, and again, but most importantly, tricuspid. So we have a prototype of an infographic that some of you have been asked to give your comments on, please take one, look at it, see if it's helpful, we could do it in a couple different formats, and we want your feedback. We're also sharing this with our industry partners, and I got a lot of great feedback showing it to our FDA partners, but we're hoping that this will, and this was done in the approach of heart team, and there's a path for the heart team and there's a path for the patient and the family members, because these procedures, it's a program, not a procedure, and I think if you start at day one, but encouraging the family and the patient to understand it's a program, and that program includes their accountability for the follow-up, we can get there, right? We can get there if they're aware and they're part of the team. So please take one, but with that, and Liz looked at it too, I'll let her talk about the magic she's done in San Francisco specifically, and her thoughts on how to get better compliance. So go ahead, Liz. Well, thank you, Joan. That's quite the introduction. She is so passionate about KCCQ, as you know, and it's funny, because I've been taking care of patients with valve disease since 2008 in programs that were offering transcatheter valve therapies in the clinical trials, and I actually met Joan in 2011, 2012, and our registry site manager, Ben Paul, is actually the one who had like really been curious to talk with Joan about KCCQ, and we still have that picture that Joan was holding up. She's in Kathmandu, and she says, Kathmandu does KCCQ. So that was, I mean, that was a minute ago. So it's been quite a long journey to be able to carry this baton, and I know that the people who are here care so much about data, care so much about our patients, and this is really — I talk about 5-meter walk tests just a little bit, but really KCCQ is the patient-generated outcome that we want to be able to ensure is represented. So with that, thank you for the opportunity to speak on this today. We really want to be foundational about how we continue collecting data for these registries so it doesn't get more foundational than getting KCCQ right. And in my experience, often the easiest things to say are the hardest to do. So my hope is that we will actually show how we can make some of the complexities a little simple. And I just want to also acknowledge the authorship here. So it's a combination of both my company as well as UCSF. We have Rochelle Subba here from UCSF, the Associate Director of Medical Safety and Quality with us today, and then also Diana Ramsey, who is the Director of Nursing Education for my company as well, our company. So these are my disclosures. And first off, why KCCQ and 5-meter walk test? Well these are validated measures that were used in clinical trials, some of which are referenced here. KCCQ in particular is an independent predictor of outcomes in TAVR patients with or without heart failure symptoms. How did we get to know that? From the registry actually. So a 2018 analysis of the registry data and the predictors of outcome, KCCQ, weighed heavily. And that was actually from Arnold and colleagues. And that really helped us to see that quality of life is the only patient-reported measure in the registry. And subsequent studies by Megan Coileride and others have demonstrated that in these domains are really what matters most to patients. 5-meter walk test as well is an independent predictor of outcomes in both TAVR and SAVR, in cardiac surgery in general. And it's actually more prognostic than ejection fraction for patients who are undergoing surgery. So why do we have to do it? I'm just going to start with why. This is why. Because it's coming directly from our patients. And as stated earlier, it's not only important for the assessment of TAVR success for public reporting, which we heard about this morning, but also to evaluate success for these transcatheter mitral and tricuspid therapies. Because as Joan had mentioned, you know, we have TAVR nation, but it really is transcatheter valve therapies nation. So how does KCCQ and 5-meter walk test assessment impact a site's registry star rating? Well eligibility for public reporting requires a rolling three years of 90% data acquisition of the baseline KCCQ and 5-meter walk test. Again easy to say. We know it's important. But it is hard to do. From this, once you meet that threshold, among some other data points, sites can receive a star rating, three-star rating, and understand their risk-adjusted mortality from the registry. What I've learned is that few sites actually meet this threshold. And in Northern California, we actually have one site that meets the threshold that has a star rating. And that's inclusive of a market where we actually have some of the highest volume TAVR programs in the country. And so I started working with and collaborating with University of California San Francisco Medical Center in my company, in which we offer expert consulting and staffing. I will actually come on as a licensed nurse practitioner. My nurse partner, Diana Ramsey, will come on as an expert nurse coordinator. And that way, the people who are on those teams have a sibling that they get to work with and run with and walk with and have all the problems with and be able to actually implement the best practices that we're talking about. So I actually am a nurse practitioner at UCSF as well. And interestingly, we had all of this wonderful medical director leadership who completely were on board with really investing in the staff and the teams. And also interestingly, UCSF Heart and Vascular had previously collaborated with Dr. John Spertus, who is known as the person who really championed and conceived of the KCCQ. And they worked with him to develop an auto-calculating KCCQ flow sheet in their EPICS system. So that was a tool that was already in place. And so using various QI methodology, we wanted to pursue a process improvement initiative to meet that threshold so that we could actually be one of the sites that was publicly reported. And so what we found actually, understanding where we were, how we got there, and where we needed to go, I'm sure it comes as no surprise to you that staffing is often a problem, right. That turnover of coordinator roles and coordinators who are also often the data abstractors for the registry means that often there may be a single point of success or failure program. And as Joan mentioned earlier, it's not just the procedure. It is a program. But when the program, you know, you're either Sisyphus, right, going up the hill, or you're Atlas carrying the whole world on your shoulders, does that resonate with anybody? What happens when somebody resigns? And what we saw actually in this data, thank you so much Dr. Subha, she was able to help us understand that the KCCQ threshold really, as well as the 5-meter walk test threshold, that inflection point really was impacted by the staffing, where an RN coordinator who was a single point of success for that program had resigned, and then there were other resignations through Q1 of 2023, upon which after that our collaboration with UCSF had began. So you can see that here. So when we did a root cause analysis, and when we brought in the patient care coordinators, the MAs, the front desk, the quality teams, the inpatient teams, the physicians, because we had non-invasive valve cardiologists, as well as interventional valve cardiologists in cardiac surgery, during which we're supposed to assess the KCCQ. But as mentioned earlier, a lot of these programs, and this was one, you know, it's very common to have a single process owner versus a programmatic team-based approach. So how do we engage everybody? You know, Kim mentioned earlier just the breadth, right, of the conversations. Because change happens peer-to-peer. A front desk person will change when the other front desk person changes their behavior. And change management, everything that we're doing here when we talk about quality and process, it's behavior change. How am I going to get this person to do something different? And I'm not going to get them to do it. They're going to have to want to. And so that's what we really needed to do in terms of goal setting. So I've talked a little bit about our primary goal, which was to be eligible for public reporting. And we also wanted to hire, train, and hold staff accountable to delineated roles. We wanted to see that all patients, inpatient and outpatient, were assessed for KCCQ and 5-meter walk test, and that it was documented. And Rochelle's been a wonderful partner for our clinical frontline teams to really understand what some of those documentation nuances have been. And we wanted those data to be meaningful. Like if I'm just checking a box, but then in valve conference or your multidisciplinary team meeting, if that information isn't coming forward, like this person has a poor quality of life as evidenced by their KCCQ score, and they would be mostly dissatisfied if they had to continue living at this current quality of life. Sometimes that, which comes from nursing or comes from our coordinators, is the arbiter of decision-making on something about the timing or the if or the when to proceed with TAVR. So from there, we use this operating framework, which comes from the National Academy of Medicine, Five Principles for Effective Team-Based Care. And Eric actually touched on this earlier, because he brought in staff experience. And what happens when people have shared goals, clear roles, mutual trust, effective communication, and then measurable processes and outcomes is that we actually see team members more engaged because they're owners, they're part of the process. And these are also principles that have been demonstrated to reduce clinician burnout and improve retention. So the front line, right, or who's responsible for KCCQ and 5-meter walk test actually had to expand to all of those members of the team. And engaging them meant greater adoption of some new processes that we mapped and planned. So what did we do? We created standard workflow for clinic outpatients. And I'll show you what that looks like in my chart. Appointment notes, huddles for MAs, RNs, and PCCs with a front desk, end of clinic wrap-up, a valve nurse coordinator obtaining the KCCQ on inpatients, and then having these orders in SMART sets. So you can see some of these elements here where the PCC sends a link and documents via MyChart. The patient directly enters into the EHR flow sheet. So they're sent that through MyChart. I'll show you what it looks like. And then in clinic or for inpatients, the team is really along the pathway verifying that those things are in place. So this is what it looks like, the EHR tool for patient direct data entry. So how many of you are using MyChart or delivering this information to patients electronically now? That's so awesome. Was it easy or hard to do? Eh. So maybe we'll talk about that a little bit. But patients actually really enjoy it, right. Because it's not necessarily supposed to be administered by us, truly, right, the KCCQ. So they can actually answer from a link in MyChart. And then these tools, we look at KCCQ like a vital sign, right. So just like you have a vital sign flow sheet, we also have our KCCQ flow sheet. And again, the teams at UCSF already had this wonderful tool, but it wasn't being used. So we had to get the buy-in from the patients, the MAs and the RNs to start using it. Nobody wanted to keep scanning forms. How many still scan their forms in? I'll tell you a secret. We're not fully electronic, too, just to have it as a backup just in case. So we're not fully electronic, we're human, right. We love our paper. But having these options, right, has really improved the efficiency and the ownership that patients and all team members can have. So this is what it looks like, right. If we're seeing a patient, this is April 18th, this is one of their baseline. We realized, oh, it's outside or going to be outside 90 days. So it was assessed again to see if there was any kind of change. That patient actually had a clinical decline from April to June. And then this is their post. So we can actually see it, right, head to head. So it's a beautiful way of actually like even showing the patient and telling the patient their own story. Look what has improved. So how do we make the data meaningful? And then how do we make sure it gets done? So we created a nursing communication for the flow sheets as orders. How many of you have order sets included? This is awesome. So we actually got this tip from another hospital in our system, and they have a star rating and we don't yet. But it was wonderful to know that that was an option. And so we carried that all the way through where if a patient's having a pre-procedure visit with me, we will also ensure that the order of the procedure as well as all of their 30-day and 1-year follow-up orders, KCCQ, are actually put in at the time. The team communicates this with appointment notes. You can see it's just as obvious as it can be, very back to basics. But if you have turnover with the front desk or the MAs or the patient care coordinators, those things fall apart. And so how do we have this language that is consistent and continues regardless of who's in place? So that was really our goal. And then there are team huddles pre- and post-clinic to ensure that the KCQ is obtained for 100% of our intended patients. And here you can see a pre-procedure checklist, which is another checkpoint for KCQ. It captures inpatients prior to TAVR if they've, you know, been transferred in or admitted from clinic because of acuity. And then we end up still ensuring that we know their stated goal. It's written in quotes. We understand what their KCQ is and have the marker that it must be within a 90-day period. Okay. Five-meter walk test is there as well. So our baseline or pre-QI initiative, you can see our KCQ data acquisition was at 76%, 41% for five-meter walk test. And now after this initiative was launched in Q2 of 2023, we now have over 90% on both measures. This is just for rolling Q4 through Q3 of this year. And now zooming out where you can see, okay, where have we been? Where are we going? We want to meet this 90% threshold. Again thank you Rochelle for putting these data together so that we could see it in another depiction in addition to what we get from the registry. This Q12 or 12 quarters, you know, we're nearly there. We're nearly there. Our hope is by Q1 of 2025 we'll have enough washout from this kind of middle period of staff turnover to finally be eligible for public reporting. And we love, love, love, Rochelle actually, she distributes this. So there's, well we have quality meet with the teams every Thursday in a huddle. And Rochelle is also, the quality team is also distributing these data to all the frontline staff in those huddles so they can actually see and feel the impact that they're making for patient care. So conclusions, a multi-modality approach so we can meet people in processes where they truly are. Yes, we're still scanning things. And we have an auto-calculating flow sheet that patients can enter their own data in. And we have a multidisciplinary team approach. The team is not just the interventional cardiologist and the cardiac surgeon. We also have, thank you. I know, I have a loud voice. But it's so far now. So this is my conclusion slide and you're coming up now. Timing is perfect. I love it. Thank you. Thank you. I'll just pretend that it was perfect up until that very moment. But the team approach, right. We always think about the interventional cardiologist, the cardiac surgeon. We think about the coordinator. We think about our advanced practice providers. But it's everyone. It takes a village. Our front desk who's doing check-in, they give the patients the paper still. And it's our patient care coordinators who are actually sending the MyChart link to patients. So it does take a village. And giving people the feedback like, you know, we are like Rochelle is in weekly huddles so they can see, hey, I'm making a big difference for my program. And that engagement also hopefully and may, right, increase our retention and decrease turnover and burnout. And getting it right requires investing in people. It's not just processes, right. It's people. I can have all the tools in the world. But unless I'm engaging the people, it doesn't matter. And so we want to be able to always move forward, engaging people in processes, not just for TAVR but for this future, right, of transcatheter mitral and tricuspid therapies, especially where the outcomes are really, you know, weighted for quality of life. So thank you for your attention. I want to give special acknowledgment to the UCSF team, especially Samuel Maria, Brendan Marr, and previously Lorraine Carroll but now Amanda Brown, as well as Rochelle Zuba, and then Diana Ramsey, Jenna Barrios, and all our MAs, our front desk, they're all here on the authorship because it really is the work of a team of teams. Thank you for your attention. Yep. This is on. So thank you, Liz. That was great. And thank you, Eric. And thank you, Dr. Gabon. A couple of questions. Softballs. The slides will be available. And thanks for including the Emory paper, because if you know Dr. Patricia Keegan, who was at Emory at the time that this was all written, I got a call from Sister Keegan and she yelled at me for not including nurse-led sedation and then sent me the paper. So let's give credit to her as well that this really has started the conversation. And there's a lot of reasons for nurse-led sedation, all the reasons that were mentioned. But again, that little pesky valve, tricuspid, your anesthesiologist will be going in that room, hands down. So where's your backfill? And you don't want these patients to be waiting a longer time to get on the table. So planning ahead or kind of did you think about this, especially if you're a siloed program where maybe the implanter in Taverland is in Taverland and doesn't know the tsunami coming down the street with Evoque and Triclip. So you might be the bearer of interesting news. So with that, the slides will be available. We're happy to share the paper. That's one quick question. And I think, Eric, you answered some of the other questions that came up. If you remove two staff performing anesthesia but did not add nursing staff or additional burden taken over by these nurses, so as you decreased, how did the workload get distributed? Anything? That's a great question. And so Alex was supposed to be here. She's the technical director of the technology staff. But what we did was we got the group together, nurses and techs. And so if a nurse is at the head of the bed delivering nurse-led sedation, we have to reallocate some of the tasks and duties involved for completing a TAVR. So what happened was we took a look at everything that's being done within the TAVR in terms of the nurse, the tech, nurse delivering sedation, and evenly distribute those tasks. So it's an evenly distributed workload to complete a TAVR. And that actually empowered some of the technologists as well. So they were doing things that they weren't really doing before, which I feel like they got really into it. So it was a really positive thing. Yeah. I think a sidebar is, as Dr. Perpetra always, I've heard her speak many times, raise, and I'm going to mess this up, but raise to the level of your license, which English translation is retention, right? That should, okay, so KCCQ is on my tombstone. That'll be on your tombstone when we die. And I think that really embraces the team for retention, which is kind of, how do you put a dollar amount on that, right? Right, you can't. Yeah. Yeah. Hopefully it retains the staff they are interested in, they want to come to work, instead of like, oh my gosh, I have to go to work. There's this interest, a gained interest in actually completing these procedures. Along that line of empowerment, it's not, you know, before we'd have the HART team meeting and here's what we're going to do. Now it's in the hands of the cath lab nurses to say, who do you decide is appropriate for nurse-led sedation? Not the physician telling you, not the team telling you, who do you decide? You tell us which ones are going to be nurse-led. So that's been very empowering as well. Yeah. Yeah. I'd actually be curious because, you know, we have more reports that are available geographically about the turnover of nurses and techs in the lab, right? I mean, it's such that in sonographers has been such a critical area of turnover for every hospital. And I would love to see what the retention, right, the engagement and a lot of those very, you know, like simple but powerful measures that you included in your presentation. I'd love to see what that looks like across a nurse-led sedation cath lab or hybrid OR or, you know, program as compared to a site that doesn't yet offer nurse-led sedation. And there are measures that we can attach to turnover, right? So like on average in the United States, a nurse that turns over, it's like 100K. And an advanced practice provider, it's anywhere from 200 to 300K, that turnover and replacement. So I'd be curious. If you could find the person. Yeah. Right. Right. That's level one. And I think that's where we talk a lot about entanglement strategies as to what embraces you and what keeps you engaged. And I also think based on the fabulous presentation we just saw in the morning session about how does this relate with best in practice, star rating, Nicole, raise your hand. Okay. So she's my hotline to Cleveland Clinic. What are you doing out there? How did you do that? And it's three stars every year. And there's others in the room. But when you ask best practice, what's your best practice to a word, and you could validate this and Misty too from St. Charles, it's awareness and getting people involved and communication and one hospital in particular, even the janitors know what the goal is. Because then it's a piece of them, right. I know I need to get the elevator to run faster. I need to get this room turned over quicker. It's common sense. If everybody knows the end goal, everybody's got a piece of that. It's a team. It's the heart team concept. That really can very nicely translate to a three-star best practice hospital, right. So it's an entanglement of the whole team. I think those are my thoughts in listening to Liz. You're adding value or generating value to the KCQ that wasn't there before. No one knew why or how or that's not my problem, that's not for me. And when you educate and share and engage these folks, I think that's fantastic. I'm hoping, I'm going to take these slides. Yeah, I want the slides. Kim and I have been exchanging those things over the years. How mandatory are follow-up KCCQs and what's the impact on reporting? I think we've probably covered that in that, and there's been sort of comments about, well, you don't have to do the one-year KCCQ anymore, you do. And I mentioned in an earlier session, we provide a national slide set once a year that once everybody and their mother looks at it to make sure Joan didn't make too many mistakes, they will be posted on your resource section of the website. And what's nice about that is the slides, this go-around will show base to one year. Because everybody does a pretty good job with base, right. We've learned that piece of it. But that doesn't mean anything if you drop off and you have a 40% on your one year. So we'll be able to show in the new slide set, what is your, what is the national base to one year? And then you could take that and look at the new dashboard. See, this is, boy, I'm smarter than I think, so it's all kind of making sense to me now. No, we did the Misty Kristen show yesterday about public reporting and the new dashboard, public reporting today and how, you see where we're going with this? It all kind of connects, it's, yeah, it's cool. But anyway, that, please take a look at the slide set when they're posted and we'll put an announcement up when they're up there. But I think it would be nice to say, look at Mr. Doctor, here's where the national benchmark is, and here's where we are. And that's where you, again, get that conversation started. Just post one detail line on your scrub sync. That's what I say. That starts the conversation. Let it be KCCQ, right. And the money saved with the nurse-led sedation. That really, that's a talker, right. For the pilot program with anesthesia, was anesthesia on standby or were they on roller skates like to come out of the lounge real quick? Yeah. When we did our pilot program, they were kind of antsy. So they were on standby. And still now, they're kind of, they are on standby. Not to say that as we peel away and look, the cardiac anesthesiologist being other, used in other procedures, we could just use regular anesthesia for these cases if we had to protect their airway. So they were on standby and they are currently are still now on standby to a degree. But they're not in the procedure room, so they could be doing a procedure right next door. »» Good. »» Yeah. »» Are your patients going to telemetry versus a CCU step down unit having moved the nurses to nurse-led sedation? It seems to be a barrier in this questionnaires facility in moving in that direction. So do they need to be watched at a higher level post-procedure? »» Yeah. I mean, anesthesia, all of our TAVRs were going towards minimalists. And so even when anesthesia gives monitored anesthesia care, they may be giving the exact drugs that we're giving, the reverse end fentanyl. But they're considered monitored anesthesia care for, you know, billing purposes. So a MAC case could be the same as a nurse-led sedation case, except the MAC case was done by a cardiac anesthesiologist and their fellow. So the recovery is very similar. Most of our patients go from our pre-op area to the TAVR, whether it's a MAC case or a nurse-led sedation case, back to our recovery area and then to our inpatient floor. So none of our TAVRs are booked as, you know, going to the CCU afterwards. We streamline that process. And I think the next step is just like thinking about outpatient TAVR too. So that would be somewhere where we kind of free up bed availability, depending on the certain patient population. »» Yeah. So our standard, there's no PACU, there's no CCU. They go right back to cath lab recovery and then to tele-floor. »» Are they done in a hybrid room or regular cath lab or? »» Yeah. So back in 2011, that was strictly done in the hybrid room. We had the CPS machine in the room. Now we are doing them in hybrid and regular cath room. So we are kind of, you know, flipping and flopping in and out of. And we do do them in a regular cath lab room. It does have an anesthesia machine in there, but doesn't have a CPS machine in there. »» And I think every site has their reasons for using the hybrid. Do you use it because you need it or do you use it because you don't want to lose it to someone else? So there's that. »» It's defensive utilization. »» Yeah, exactly. Yeah. Thank you. »» A couple of questions, Liz, about is the checklist publicly available and the cooperation with do you use EPIC or what EMR to use the KCCQ orders? Do you? »» Yeah. So that was EPIC that I showed and the admin and ID teams have been wonderful partners throughout all of it. You can, you know, just get the sense that it takes quite a bit of time. The flow sheet for the KCCQ had been previously established with the advanced heart failure team at UCSF. And they worked with Johns Fertis because it auto calculates. And so that's all coded into the flow sheet. And there was an initial fee to do that. I think it was something in the range of about $7,000 to be able to, you know, ensure that we were above board on all of those processes. »» Are the KCCQs sent out to MyChart at 30 days in one year or they are? »» Yeah. At all. »» Okay. »» Yes. Yeah. And then the nursing order, because it was difficult to get an order that would be able to translate across all settings. And so it's not the nurses who are even obtaining the KCCQ, right? It's actually performed either, you know, self-directed by the patient or it's provided to the patient by the MA, you know, front desk and then MA if it hasn't been completed electronically. And then the MA is actually confirming in the room with the patient and entering at the time. So it really is like a vital sign is, you know, how we think about it. »» In the process. »» Yeah. Because otherwise if it's sent through MyChart then the patient can just enter it right into the flow sheet. It's a patient facing flow sheet. »» There's one other question about how do you sell it that it's, I don't have heart failure. Okay. Wait. I got beat up on that one. »» I know. I remember. It took Sandra's eye. »» Joan has a lot of black and blue marks that she didn't know she was signing up for. Go ahead. »» Yeah. I mean, well, there's two kind of spaces to sell it, right? One I actually pulled up the paper where Suzanne Arnold had done the analysis out of the registry that KCCQ in this patient population was valid. I mean, we had to actually validate it. And if a patient presents with just syncope, right, or presyncope or dizziness and doesn't have your typical heart failure symptoms. So I think even sharing that with not only clinicians but with patients also, and if they have questions like what if I don't have heart failure, then we'll just share, you know, it's really for this population. If you don't have these symptoms, you know, that's okay. And we just want you to answer it to the best, right, fit for you. »» I'll end with one question. I'll answer this last one. We have an increasing number of urgent and emergent tavern mitral cases so we're unable to complete the KCCQ. So Lyra Lyra Pence on fire if you think you're doing more urgent and emergent than the world. Okay. That's my first answer. »» That's why we dropped. Did you see our little drop? »» Yeah. And I'm happy to take that offline. But what a lot of hospitals have started doing is if you have a bump in the road or, you know, whatever, put it on your pre-op checklist. That has worked very well with sites. So they have along their journey to get their program started, that last stop before they hit the table, did you take your teeth out? Did you pee? Did you kiss your wife goodbye? Did you do your KCCQ? »» Do you have your advance directive? »» We're going to do it now. And if that holds up the table time, it won't happen again, right? Think about it. So that is kind of a hard stop for getting that done. If that doesn't work, read what happened at Cape Cod to the tune of $54 or $45 million about not complying. And I'm not the CMS police, otherwise I wouldn't be at St. Bart's. So you want to be aware of it still as part of the CMS requirement. It will be double-dog sure part of the CMS requirement when tricuspid comes out. So don't let your physician say we don't have time for that, we're doing too many urgent emergent cases. You just say to him, Lara, Lara, Pam's on fire. And then St. John's said to say that. »» I just need an option for the intubated patient. Just give us an option for the intubated patient. »» On Tuesdays to be able to say unable, but to give you the blanket, we're too busy for that. We are. And fill in the blank, right? Not acceptable. So with that, I want to thank these fabulous, fabulous speakers. »» Thank you.

medical networks

team-based care

data-driven outcomes

Kansas City Cardiomyopathy Questionnaire

TAVRNation

tricuspid valve procedures

nurse-led sedation

transaortic valve replacement

quality improvement

patient outcomes