FEATURE
Left Ventricular Assist Device: Care On Inpatient Rehabilitation Facility George Forrest1, MD, Gabriel Radu1, MD, Kathleen Rifenburg1, RN, Evelyn Shields1, RN & Sarah Clift1 1 Department of Physical Medicine and Rehabilitation, Albany Medical College, Albany, NY, USA
Keywords
Abstract
Cardiac; nurses; outcomes; left ventricular assist device. Correspondence George Forrest, Department of Physical Medicine and Rehabilitation, Albany Medical College, 43 New Scotland Ave, Albany, NY 12208. E-mail: [email protected] Accepted October 4, 2014. doi: 10.1002/rnj.192
Purpose: Investigate the outcomes of patients admitted to an inpatient rehabilitation facility (IRF) after placement of a left ventricular assist device (LVAD). Design: Retrospective review of records. Method: Authors reviewed records of patients admitted to the IRF after cardiac surgery or admission to the hospital with either acute myocardial infarction, congestive heart failure, or placement of an LVAD. The study reports improvement in function, length of stay (LOS), and location of discharge. Findings: The patients in the LVAD group made as much progress in terms of improvement in function as the other groups. None of the patients in the LVAD group required transfer back to medical or surgical units. All were discharged to home. Length of stay (LOS) of the LVAD group was not significantly longer than that of the other cardiac patients. Conclusions: Patients who have had placement of an LVAD can be safely cared for in an IRF. Clinical Relevance: This paper provides information about the indications for LVAD, the nursing care of patients with an LVAD, and the outcomes of care in an IRF.
Introduction According to the American Heart Association, 5.7 million residents of the United States have congestive heart failure (CHF). CHF is the most common reason that people 65 years or older are admitted to the hospital. Twenty percent of patients with Medicare who are admitted to the hospital have a diagnosis of congestive heart failure (Jessup & Bronzena, 2003; Khan, Gheorghiade, Dunn, Pezalla, & Fonarow, 2008). The main symptoms of CHF are shortness of breath, fatigue, and edema. Over the last 20 years, there have been many advances in the treatment of CHF. Primary care physicians are encouraged to be proactive in reducing risks of heart disease including hyperlipidemia, hypertension, glucose intolerance, smoking, and sedentary life style. Recognized treatments include use of diuretics, angiotensin-converting enzyme inhibitors, and aldosterone inhibitors. Cardiac resynchro-
378
nization with the use of biventricular pacemakers and placement of automatic implantable cardioverter defibrillators are indicated for selected patients with reduced ejection fraction. While each of these treatments has been shown to improve outcome, CHF still has a worse prognosis than most forms of cancer. A patient who presents with CHF has a 45% chance of dying within a year and a 75% chance of dying within 5 years (Jessup & Bronzena, 2003; Jhund et al., 2009; McMurray, 2010). The best treatment for advanced heart failure is heart transplantation. The median survival after heart transplantation is 10 years. The number of patients who can benefit from heart transplantation greatly exceeds the number of hearts that are available for transplantation (Toyoda, Guy, & Kashem, 2013). Left ventricular assist devices (LVAD) have been developed to serve as a bridge to heart transplantation (Abraham & Smith, 2013; LaFranca et al., 2013; Slaughter et al., 2009). An LVAD can prolong © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2014, 40, 378–383
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Rehabilitation After LVAD
Figure 1 Thoratec Heartmate II left ventricular assist device.
survival and improve the quality of life of a patient who does not qualify for heart transplantation. This is referred to as destination therapy. The line between use of an LVAD as a bridge to transplant or as a long-term treatment for heart failure may not always be clear. There will never be enough hearts available for all of the patients waiting for a donor heart. There are approximately 2,500 heart transplants per year in the United States. The number of hearts available for transplant has remained constant for 10 years. Factors that may prevent a patient from moving high enough on the waiting list for transplant to actually receive a heart include age, pulmonary hypertension, renal insufficiency, impaired hepatic function, chronic obstructive pulmonary disease, obesity, difficult to control diabetes, or inability to tolerate the immunosuppressive therapy required to prevent rejection of a transplanted heart (Costanzo et al., 1995). A significant © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2014, 40, 378–383
increase in the availability of implants to replace failed hearts must come from use of mechanical devices or from stem cell technologies that are not currently available for clinical use. The most commonly implanted left ventricular assist system is the Heart Mate II (Thoratec Corporation, Pleasanton, CA, USA). The Heart Mate II LVAD is implanted below the diaphragm either in a pocket created within the abdominal muscles or in the left upper quadrant of the abdomen. One end is inserted into the left ventricle and the other into the ascending aorta. The components of the LVAD are displayed in Figures 1 and 2. The pump is a small rotor that propels blood from the left ventricle to the ascending aorta. A percutaneous lead or drive line connects the pump with the system controller. A Perc Lock secures the connection between the drive line and the system controller. The system controller is a computer
379
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that controls the operation of the pump. It controls the speed of rotation of the rotor, which is usually between 8,000 and 10,000 rpm. The cardiac output is directly related to the rate of rotation. The system controller is connected to the power source and to the pump. It supplies power to the pump. The system controller has a computer that monitors the function of the pump and has warning lights or icons that indicate if cardiac output has dropped below 2.5 L/min, if the connection between the drive line and the pump is loose, if the battery charge is low, or if the fixed power source is not providing enough energy to the system. In addition, the system controller has a system test button that activates a program to test all key functions of the system. The newest feature of the system controller is a screen that provides instructions directing proper response to any malfunction that it detects. The power module is the power source for what is called tethered operation of the system. The power module is connected to a grounded outlet in the patient’s room and to the system controller. The LVAD may also be powered by two batteries that are placed in a vest that the patient wears or in a carrying case. This is called untethered use of the LVAD. The batteries provide 8–10 hours of charge before needing to have power renewed in a recharger that comes with the system. The number of recipients will increase every year as more surgeons and more facilities are trained to implant and care for the LVAD. Patients have a 70%, 2-year survival rate and markedly improved quality of life (LaFranca et al., 2013; Lee, Fukamachi, Golding, Moazami, & Starling, 2013). Many patients go to inpatient rehabilitation facilities (IRF) before discharge. The purpose of this article is to describe the outcomes of patients treated at a
G. Forrest et al.
university medical center and to discuss the role of rehabilitation nurses in caring for the patients and educating the families of the patients. Method The authors reviewed the charts of all patients admitted to the IRF in 2012 and 2013 after admission to acute medical surgical units for cardiac surgery, congestive heart failure, or myocardial infarction. The records were identified by selecting the charts of all patients in the Centers for Medicare and Medicaid Services impairment group nine which is the designation for patients admitted with cardiac problems. The authors recorded the age, sex, score on Functional Independence Measure (FIM) at admission and at discharge, length of stay, and place to which patient went at time of discharge from the rehabilitation unit. The FIM is a reliable instrument to measure patient function. It contains 18 scales that measure aspects of mobility, self-care, communication, and cognition. The maximum score is 126 and the minimum score is 18 (Cohen & Marino, 2000). Six patients who were admitted after transcatheter aortic valve replacement were excluded from the study as that is another relatively new procedure deserving of its own independent investigation. Fisher’s exact test was used for categorical data (sex and place of discharge) and Student’s t test was used to compare items measured on a continuous scale when there were two groups. One-way ANOVA was used when there were more than two groups. Data were analyzed with MiniTab statistical software or using the Vassarstats.net website. Results
Figure 2 System controller for left ventricular assist device.
380
Sixty-five patients were transferred to the IRF after admission to acute medical surgical services for cardiac care. Thirty-eight patients had coronary artery bypass surgery and/or operative valve replacement. The average patient age was 70.8. The average admission FIM was 76.7, and the average FIM gain was 22.8. Average LOS was 8.9 days, with the proportion discharged to home 94.7%, and 5.3% transferred back to acute care services. Nineteen patients were transferred to the IRF after admission for CHF or myocardial infarction. The average age among these patients was 80.3. The average admission FIM was 76.8, and the average improvement in FIM was 19.6. The average LOS was 8.1 days, and the percent of patients discharged to home was 78.9 while 21.1% being © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2014, 40, 378–383
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Table 1 Outcomes for coronary artery bypass surgery (CABG), myocardial infarction (MI)/congestive heart failure (CHF), and left ventricular assist device (LVAD) CABG/Valve Replacement Number of patients Percent male (n) Average age (SD) Admission FIM (SD) Discharge FIM (SD) FIM change (SD) LOS (SD) Discharged to home (n)
38 63.2 (24) 70.8 (11.3) 76.7 (8.7) 99.5 (11.0) 22.8 (9.5) 8.9 (4.5) 94.7 (36)
p-value
MI/CHF
LVAD
19 63.2 (12) 80.3 (7.9) 76.8 (9.5) 96.4 (19.1) 19.6 (13.8) 8.1 (5.1) 78.9 (15)
8 87.5 (7) 64.8 (8.6) 83.8 (8.0) 107.6 (7.3) 23.8 (6.9) 12.3 (7.6) 100.0 (8)
.45 .001 .12 .20 .55 .13 .11
FIM, Functional Independence Measure; LOS, length of stay.
transferred back to acute services. Eight patients were admitted to the IRF after placement of an LVAD. Their average age was 64.8. Among these patients, the average admission FIM and average improvement in FIM were 83.8 and 23.8. All patients were discharged to their homes after an average hospital LOS of 12.3 days. Comparing the patients in the surgical group and medical group, there were no significant differences in age, sex, admission FIM, improvement in FIM, discharge FIM, LOS, or place of discharge. The only significant difference between the patients in the LVAD group and the other two groups was that the patients in the LVAD group were younger (see Table 1). If the medical and surgical groups are combined and compared to the LVAD group, then the age of the patients in the LVAD group is significantly less than the age of the other patients. Moreover, the admission FIM scores and discharge FIM scores of the patients in the LVAD group were significantly higher than the scores of the other patients, but the change in FIM score was not statistically different (see Table 2). Discussion Survival of patients with class IV congestive heart failure is improved by use of an LVAD. Survival rates for patients with continuous flow pumps are 80% at 1 year and 70% at 2 years (LaFranca et al., 2013). Quality of life is improved with placement of the LVAD (MacIver & Ross, 2012). Three articles have looked at a small series of patients admitted to an IRF after placement of an LVAD. Nissinoff, Tian, Therattil, Salvarrey and Lee (2011) reported on a series of three patients. Average gain in FIM was 17 and average LOS was 5.7 days. All three patients were discharged to home. English and Speed (2013) reported on a series of 20 patients treated at the University of Utah Medical Center. The average admission FIM was © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2014, 40, 378–383
Table 2 Outcomes for left ventricular assist device (LVAD)
Number patients Percent male (n) Average age (SD) Admission FIM (SD) Discharge FIM (SD) FIM change (SD) LOS (SD) Percent discharged to home (n)
Non-LVAD
LVAD
57 57 (36) 74.0 (11.1) 76.8 (8.9) 98.6 (14.1) 21.8 (11.1) 8.6 (4.7) 81.0 (51)
8 88 (7) 64.8 (8.6) 83.8 (8.0) 107.0 (7.3) 23.3 (6.9) 12.4 (7.6) 100 (8)
p-value
.250 .020 .047 .017 .614 .207 .00
FIM, Functional Independence Measure; LOS, length of stay.
79.5, the average improvement in FIM was 22.05, and the average LOS was 11.6 days. Sixteen of the 20 patients were discharged to home and four to acute services. Nguyen and Stein (2013) reported on 11 patients treated at New York Presbyterian Hospital. The average admission FIM was 63.2, the average improvement in FIM was 28.6, and the average LOS was 17.5 days. Seven of the 11 patients were discharged to home and four to acute medical service. The data from those three articles and this report indicate the patients can be cared for with no higher risk of adverse medical event than is customary for an IRF. Improvement in function and LOS are similar to other patients with cardiac impairment. All patients in this study were discharged to their own homes. An IRF that wants to treat patients who have had an LVAD needs to provide special training to the nursing staff. Stahovich, Chillcott, and Ferber (2004) described the protocol at Sharp Memorial Hospital. The nurses must understand the components of the LVAD and be able to train the patients and the patients’ families in caring for the device at home. Patients and their families must understand how the pump functions. They must learn how to clear the drive
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Key Practice Points
G. Forrest et al.
Left ventricular assist devices help patients with stage IV congestive heart failure by acting as a bridge to cardiac transplantation or as a means of prolonging survival of patients who are not candidates for heart transplant or for whom no heart is available.
This article is written with great appreciation for the care and teaching provided by the rehabilitation nurses on the rehabilitation unit. The important role played by the nursing service in caring for this patient group is highlighted. The limitation of this study is the small number of patients in the LVAD group that makes statistical analysis difficult.
The left ventricular assist device is a small motor that propels blood from the left ventricle to the aorta.
References
Patients with left ventricular assist devices can be safely cared for in an inpatient rehabilitation unit. Rehabilitation nurses have a key role in caring for the patients and educating the caregivers.
line and secure the connection to the system controller, a sterile technique for dressing changes, and to shower using a carrier case to keep the system dry. In addition, the patients need to learn the meaning of the icons and warnings on the system controller. They need to learn to use the system controller test system and also the display module, which is a second check on the function of the system. Plus, patients must learn to change from use of the power module to battery power or from battery power to power module without interrupting the electric flow to the pump. Discharge from rehabilitation to home is based upon the patient meeting customary criteria for discharge from an IRF an criteria specific to understanding the function and care of an LVAD as described by MacIver et al. (2009). Other activities the patients much learn prior to discharge are how to transfer and ambulate household distances, perform actions including showering with a special carrying case that keeps the system controller and battery pack dry, and finally, how to dress, feed, and wash independently or with help available at home. At the medical center, the rehabilitation nurses work with the nurses from the cardiology service to make sure that the patients and their families understand the system and can recognize and respond to system malfunctions or medical emergencies. In this study, the patients in the LVAD group had higher admission FIM scores than the patients in the congestive heart failure/myocardial infarction group or the cardiac surgery group. There is not yet literature to explain this finding. Possible reasons are that the LVAD ensures adequate cardiac output, and that the incision to install the device is less painful and less limiting than a median sternotomy. Another possible explanation is that the patients in the LVAD group are younger.
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Abraham, W.T., & Smith, A.S. (2013). Devices in the management of advanced chronic heart failure. Nature Reviews Cardiology, 10, 98–110. Cohen, M.E., & Marino, R.S. (2000). The tools of disability outcomes research functional status measures. Archives of Physical Medicine and Rehabilitation, 81(Suppl. 2), S21–S29. Costanzo, M.R., Augustine, S., Bourge, R., Britostow, M., O’Connell, J.B., Driscoll, D., & Rose, E. (1995). Selection and treatment of candidates for heart transplantation. Circulation, 92, 3593–3612. English, M.L., & Speed, J. (2013). Effectiveness of acute inpatient rehabilitation after left ventricular assistive devices. American Journal of Physical Medicine and Rehabilitation, 92, 621–626. Jessup, M., & Bronzena, S. (2003). Heart Failure. The New England Journal of Medicine, 348, 207–2016. Jhund, P. S., Macintyre, K., Simpson, C. R., Lewsey, J. D., Stewart, S., Redpath, A., McMurray, , & J.J. , (2009). Longterm trends in first hospitalization for heart failure and subsequent survival between 1986 and 2003: A population study of 5.1 million people. Circulation, 119, 515–523. Khan, S.S., Gheorghiade, M., Dunn, J.D., Pezalla, E., & Fonarow, G.C. (2008). Managed care interventions for improving outcomes in acute heart failure syndromes. American Journal of Managed Care, 14(Suppl.), S273–S285. LaFranca, E., Iacona, R., Ajello, L., Sansone, A., Caruso, M., & Assenato, P. (2013). Heart failure and mechanical circulatory assist devices. Global Journal of Health Science, 14 (5), 11–19. Lee, S., Fukamachi, K., Golding, L., Moazami, N., & Starling, R.C. (2013). Left ventricular assist devices: From bench to the clinic. Cardiology, 125, 1–12. MacIver, J., & Ross, H.J. (2012). Quality of life and left ventricular assist device support. Circulation, 126, 866–874. MacIver, J., Ross, H.J., Delgado, D.H., Cusimano, R.J., Yau, T.M., Rodger, M., . . . Rao, V. (2009). Community support of patients with left ventricular assist device: the Toronto General Hospital experience. Canadian Journal of Cardiology, 25, e377–e381. McMurray, J.V. (2010). Systolic Heart Failure. The New England Journal of Medicine, 362, 228–238.
© 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2014, 40, 378–383
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Nguyen, E., & Stein, J. (2013). Functional outcomes of adults with left ventricular assist devices receiving inpatient rehabilitation. PM & R: The Journal of Injury, Function, and Rehabilitation, 5, 99–103. Nissinoff, J., Tian, F., Therattil, M., Salvarrey, R.M. & Lee S.W. (2011). Acute inpatient rehabilitation after left ventricular assist device implantation for congestive heart failure. PM & R: The Journal of Injury, Function, and Rehabilitation, 3, 586–589. Slaughter, M.S., Rogers, J.G., Milano, C.A., Russell, S.D., Conte, J.V., Feldman, D., . . . Frazier, O.H. (2009).
© 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2014, 40, 378–383
Rehabilitation After LVAD
Advanced heart failure treated with continuous–flow left ventricular assist device. The New England Journal of Medicine, 361, 2241–2251. Stahovich, M., Chillcott, S., & Ferber, L. (2004). Management of adult patients with a left ventricular assist device. Rehabilitation Nursing, 29, 100–103. Toyoda, Y., Guy, S., & Kashem, A. (2013). Present status and future perspectives of heart transplantation. Circulation Journal, 77, 1097–1110.
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Left Ventricular Assist Device: Care On Inpatient Rehabilitation Facility George Forrest1, MD, Gabriel Radu1, MD, Kathleen Rifenburg1, RN, Evelyn Shields1, RN & Sarah Clift1 1 Department of Physical Medicine and Rehabilitation, Albany Medical College, Albany, NY, USA
Keywords
Abstract
Cardiac; nurses; outcomes; left ventricular assist device. Correspondence George Forrest, Department of Physical Medicine and Rehabilitation, Albany Medical College, 43 New Scotland Ave, Albany, NY 12208. E-mail: [email protected] Accepted October 4, 2014. doi: 10.1002/rnj.192
Purpose: Investigate the outcomes of patients admitted to an inpatient rehabilitation facility (IRF) after placement of a left ventricular assist device (LVAD). Design: Retrospective review of records. Method: Authors reviewed records of patients admitted to the IRF after cardiac surgery or admission to the hospital with either acute myocardial infarction, congestive heart failure, or placement of an LVAD. The study reports improvement in function, length of stay (LOS), and location of discharge. Findings: The patients in the LVAD group made as much progress in terms of improvement in function as the other groups. None of the patients in the LVAD group required transfer back to medical or surgical units. All were discharged to home. Length of stay (LOS) of the LVAD group was not significantly longer than that of the other cardiac patients. Conclusions: Patients who have had placement of an LVAD can be safely cared for in an IRF. Clinical Relevance: This paper provides information about the indications for LVAD, the nursing care of patients with an LVAD, and the outcomes of care in an IRF.
Introduction According to the American Heart Association, 5.7 million residents of the United States have congestive heart failure (CHF). CHF is the most common reason that people 65 years or older are admitted to the hospital. Twenty percent of patients with Medicare who are admitted to the hospital have a diagnosis of congestive heart failure (Jessup & Bronzena, 2003; Khan, Gheorghiade, Dunn, Pezalla, & Fonarow, 2008). The main symptoms of CHF are shortness of breath, fatigue, and edema. Over the last 20 years, there have been many advances in the treatment of CHF. Primary care physicians are encouraged to be proactive in reducing risks of heart disease including hyperlipidemia, hypertension, glucose intolerance, smoking, and sedentary life style. Recognized treatments include use of diuretics, angiotensin-converting enzyme inhibitors, and aldosterone inhibitors. Cardiac resynchro-
378
nization with the use of biventricular pacemakers and placement of automatic implantable cardioverter defibrillators are indicated for selected patients with reduced ejection fraction. While each of these treatments has been shown to improve outcome, CHF still has a worse prognosis than most forms of cancer. A patient who presents with CHF has a 45% chance of dying within a year and a 75% chance of dying within 5 years (Jessup & Bronzena, 2003; Jhund et al., 2009; McMurray, 2010). The best treatment for advanced heart failure is heart transplantation. The median survival after heart transplantation is 10 years. The number of patients who can benefit from heart transplantation greatly exceeds the number of hearts that are available for transplantation (Toyoda, Guy, & Kashem, 2013). Left ventricular assist devices (LVAD) have been developed to serve as a bridge to heart transplantation (Abraham & Smith, 2013; LaFranca et al., 2013; Slaughter et al., 2009). An LVAD can prolong © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2014, 40, 378–383
G. Forrest et al.
Rehabilitation After LVAD
Figure 1 Thoratec Heartmate II left ventricular assist device.
survival and improve the quality of life of a patient who does not qualify for heart transplantation. This is referred to as destination therapy. The line between use of an LVAD as a bridge to transplant or as a long-term treatment for heart failure may not always be clear. There will never be enough hearts available for all of the patients waiting for a donor heart. There are approximately 2,500 heart transplants per year in the United States. The number of hearts available for transplant has remained constant for 10 years. Factors that may prevent a patient from moving high enough on the waiting list for transplant to actually receive a heart include age, pulmonary hypertension, renal insufficiency, impaired hepatic function, chronic obstructive pulmonary disease, obesity, difficult to control diabetes, or inability to tolerate the immunosuppressive therapy required to prevent rejection of a transplanted heart (Costanzo et al., 1995). A significant © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2014, 40, 378–383
increase in the availability of implants to replace failed hearts must come from use of mechanical devices or from stem cell technologies that are not currently available for clinical use. The most commonly implanted left ventricular assist system is the Heart Mate II (Thoratec Corporation, Pleasanton, CA, USA). The Heart Mate II LVAD is implanted below the diaphragm either in a pocket created within the abdominal muscles or in the left upper quadrant of the abdomen. One end is inserted into the left ventricle and the other into the ascending aorta. The components of the LVAD are displayed in Figures 1 and 2. The pump is a small rotor that propels blood from the left ventricle to the ascending aorta. A percutaneous lead or drive line connects the pump with the system controller. A Perc Lock secures the connection between the drive line and the system controller. The system controller is a computer
379
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that controls the operation of the pump. It controls the speed of rotation of the rotor, which is usually between 8,000 and 10,000 rpm. The cardiac output is directly related to the rate of rotation. The system controller is connected to the power source and to the pump. It supplies power to the pump. The system controller has a computer that monitors the function of the pump and has warning lights or icons that indicate if cardiac output has dropped below 2.5 L/min, if the connection between the drive line and the pump is loose, if the battery charge is low, or if the fixed power source is not providing enough energy to the system. In addition, the system controller has a system test button that activates a program to test all key functions of the system. The newest feature of the system controller is a screen that provides instructions directing proper response to any malfunction that it detects. The power module is the power source for what is called tethered operation of the system. The power module is connected to a grounded outlet in the patient’s room and to the system controller. The LVAD may also be powered by two batteries that are placed in a vest that the patient wears or in a carrying case. This is called untethered use of the LVAD. The batteries provide 8–10 hours of charge before needing to have power renewed in a recharger that comes with the system. The number of recipients will increase every year as more surgeons and more facilities are trained to implant and care for the LVAD. Patients have a 70%, 2-year survival rate and markedly improved quality of life (LaFranca et al., 2013; Lee, Fukamachi, Golding, Moazami, & Starling, 2013). Many patients go to inpatient rehabilitation facilities (IRF) before discharge. The purpose of this article is to describe the outcomes of patients treated at a
G. Forrest et al.
university medical center and to discuss the role of rehabilitation nurses in caring for the patients and educating the families of the patients. Method The authors reviewed the charts of all patients admitted to the IRF in 2012 and 2013 after admission to acute medical surgical units for cardiac surgery, congestive heart failure, or myocardial infarction. The records were identified by selecting the charts of all patients in the Centers for Medicare and Medicaid Services impairment group nine which is the designation for patients admitted with cardiac problems. The authors recorded the age, sex, score on Functional Independence Measure (FIM) at admission and at discharge, length of stay, and place to which patient went at time of discharge from the rehabilitation unit. The FIM is a reliable instrument to measure patient function. It contains 18 scales that measure aspects of mobility, self-care, communication, and cognition. The maximum score is 126 and the minimum score is 18 (Cohen & Marino, 2000). Six patients who were admitted after transcatheter aortic valve replacement were excluded from the study as that is another relatively new procedure deserving of its own independent investigation. Fisher’s exact test was used for categorical data (sex and place of discharge) and Student’s t test was used to compare items measured on a continuous scale when there were two groups. One-way ANOVA was used when there were more than two groups. Data were analyzed with MiniTab statistical software or using the Vassarstats.net website. Results
Figure 2 System controller for left ventricular assist device.
380
Sixty-five patients were transferred to the IRF after admission to acute medical surgical services for cardiac care. Thirty-eight patients had coronary artery bypass surgery and/or operative valve replacement. The average patient age was 70.8. The average admission FIM was 76.7, and the average FIM gain was 22.8. Average LOS was 8.9 days, with the proportion discharged to home 94.7%, and 5.3% transferred back to acute care services. Nineteen patients were transferred to the IRF after admission for CHF or myocardial infarction. The average age among these patients was 80.3. The average admission FIM was 76.8, and the average improvement in FIM was 19.6. The average LOS was 8.1 days, and the percent of patients discharged to home was 78.9 while 21.1% being © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2014, 40, 378–383
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Rehabilitation After LVAD
Table 1 Outcomes for coronary artery bypass surgery (CABG), myocardial infarction (MI)/congestive heart failure (CHF), and left ventricular assist device (LVAD) CABG/Valve Replacement Number of patients Percent male (n) Average age (SD) Admission FIM (SD) Discharge FIM (SD) FIM change (SD) LOS (SD) Discharged to home (n)
38 63.2 (24) 70.8 (11.3) 76.7 (8.7) 99.5 (11.0) 22.8 (9.5) 8.9 (4.5) 94.7 (36)
p-value
MI/CHF
LVAD
19 63.2 (12) 80.3 (7.9) 76.8 (9.5) 96.4 (19.1) 19.6 (13.8) 8.1 (5.1) 78.9 (15)
8 87.5 (7) 64.8 (8.6) 83.8 (8.0) 107.6 (7.3) 23.8 (6.9) 12.3 (7.6) 100.0 (8)
.45 .001 .12 .20 .55 .13 .11
FIM, Functional Independence Measure; LOS, length of stay.
transferred back to acute services. Eight patients were admitted to the IRF after placement of an LVAD. Their average age was 64.8. Among these patients, the average admission FIM and average improvement in FIM were 83.8 and 23.8. All patients were discharged to their homes after an average hospital LOS of 12.3 days. Comparing the patients in the surgical group and medical group, there were no significant differences in age, sex, admission FIM, improvement in FIM, discharge FIM, LOS, or place of discharge. The only significant difference between the patients in the LVAD group and the other two groups was that the patients in the LVAD group were younger (see Table 1). If the medical and surgical groups are combined and compared to the LVAD group, then the age of the patients in the LVAD group is significantly less than the age of the other patients. Moreover, the admission FIM scores and discharge FIM scores of the patients in the LVAD group were significantly higher than the scores of the other patients, but the change in FIM score was not statistically different (see Table 2). Discussion Survival of patients with class IV congestive heart failure is improved by use of an LVAD. Survival rates for patients with continuous flow pumps are 80% at 1 year and 70% at 2 years (LaFranca et al., 2013). Quality of life is improved with placement of the LVAD (MacIver & Ross, 2012). Three articles have looked at a small series of patients admitted to an IRF after placement of an LVAD. Nissinoff, Tian, Therattil, Salvarrey and Lee (2011) reported on a series of three patients. Average gain in FIM was 17 and average LOS was 5.7 days. All three patients were discharged to home. English and Speed (2013) reported on a series of 20 patients treated at the University of Utah Medical Center. The average admission FIM was © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2014, 40, 378–383
Table 2 Outcomes for left ventricular assist device (LVAD)
Number patients Percent male (n) Average age (SD) Admission FIM (SD) Discharge FIM (SD) FIM change (SD) LOS (SD) Percent discharged to home (n)
Non-LVAD
LVAD
57 57 (36) 74.0 (11.1) 76.8 (8.9) 98.6 (14.1) 21.8 (11.1) 8.6 (4.7) 81.0 (51)
8 88 (7) 64.8 (8.6) 83.8 (8.0) 107.0 (7.3) 23.3 (6.9) 12.4 (7.6) 100 (8)
p-value
.250 .020 .047 .017 .614 .207 .00
FIM, Functional Independence Measure; LOS, length of stay.
79.5, the average improvement in FIM was 22.05, and the average LOS was 11.6 days. Sixteen of the 20 patients were discharged to home and four to acute services. Nguyen and Stein (2013) reported on 11 patients treated at New York Presbyterian Hospital. The average admission FIM was 63.2, the average improvement in FIM was 28.6, and the average LOS was 17.5 days. Seven of the 11 patients were discharged to home and four to acute medical service. The data from those three articles and this report indicate the patients can be cared for with no higher risk of adverse medical event than is customary for an IRF. Improvement in function and LOS are similar to other patients with cardiac impairment. All patients in this study were discharged to their own homes. An IRF that wants to treat patients who have had an LVAD needs to provide special training to the nursing staff. Stahovich, Chillcott, and Ferber (2004) described the protocol at Sharp Memorial Hospital. The nurses must understand the components of the LVAD and be able to train the patients and the patients’ families in caring for the device at home. Patients and their families must understand how the pump functions. They must learn how to clear the drive
381
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Key Practice Points
G. Forrest et al.
Left ventricular assist devices help patients with stage IV congestive heart failure by acting as a bridge to cardiac transplantation or as a means of prolonging survival of patients who are not candidates for heart transplant or for whom no heart is available.
This article is written with great appreciation for the care and teaching provided by the rehabilitation nurses on the rehabilitation unit. The important role played by the nursing service in caring for this patient group is highlighted. The limitation of this study is the small number of patients in the LVAD group that makes statistical analysis difficult.
The left ventricular assist device is a small motor that propels blood from the left ventricle to the aorta.
References
Patients with left ventricular assist devices can be safely cared for in an inpatient rehabilitation unit. Rehabilitation nurses have a key role in caring for the patients and educating the caregivers.
line and secure the connection to the system controller, a sterile technique for dressing changes, and to shower using a carrier case to keep the system dry. In addition, the patients need to learn the meaning of the icons and warnings on the system controller. They need to learn to use the system controller test system and also the display module, which is a second check on the function of the system. Plus, patients must learn to change from use of the power module to battery power or from battery power to power module without interrupting the electric flow to the pump. Discharge from rehabilitation to home is based upon the patient meeting customary criteria for discharge from an IRF an criteria specific to understanding the function and care of an LVAD as described by MacIver et al. (2009). Other activities the patients much learn prior to discharge are how to transfer and ambulate household distances, perform actions including showering with a special carrying case that keeps the system controller and battery pack dry, and finally, how to dress, feed, and wash independently or with help available at home. At the medical center, the rehabilitation nurses work with the nurses from the cardiology service to make sure that the patients and their families understand the system and can recognize and respond to system malfunctions or medical emergencies. In this study, the patients in the LVAD group had higher admission FIM scores than the patients in the congestive heart failure/myocardial infarction group or the cardiac surgery group. There is not yet literature to explain this finding. Possible reasons are that the LVAD ensures adequate cardiac output, and that the incision to install the device is less painful and less limiting than a median sternotomy. Another possible explanation is that the patients in the LVAD group are younger.
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Rehabilitation After LVAD
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