Physical Therapy and Occupational Therapy After Transcatheter Aortic Valve Replacement

Study Overview
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Brief Summary
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Implementation of Physical Therapy (PT) and Occupational Therapy (OT) pathway (initiation of services on Post procedure day #1 and continued daily with focus on education and activity progression) for all patients undergoing a transcatheter aortic value repair procedure began on December 2, 2014. Retrospective data was collected from The Society of Thoracic Surgeons/American College of Cardiology Transcatheter Aortic Valve Replacement Procedures (STS/ACC TVT, trademark) Registry - National database for Transcatherter Aortic Valve Replacement Procedures and included subjects from March 2012 through July 31, 2015. Patients included: s/p tAVR via transfemoral catheter approach, with or without minor intra or post procedure events (GI bleeds, minor access bleeds, afib, etc); Exclusions: Major events including stroke, pacemaker placement, other cardiovascular (CV) repair or surgery required, etc). Future data analysis will extend subjects to December 31, 2015 and annually.

Detailed Description
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Rationale: Frequency of transcatheter and other structural heart procedures increased dramatically from 2012 to 2014 and is trending even higher for 2015. Procedures increased from 15 in 2012 to 50 cases in 2013 (233% increase) and to 70 cases in 2014 (40% increase from 2013 to 2014.) -- PT and OT identified a gap in consults and need for specific education targeted for a new surgery population (tAVR) without sternotomy. Often consults were placed on day of discharge to rehab facility or not at all. -- Structural Heart division of CV institute identified increased length of stay (LOS) and decreased activity of their patients in the hospital. -- No literature on this subject found via Henry Ford Hospital Sladen Library PubMed literature review Aim: • Create a standardized pathway for new transcatheter aortic valve replacement patients in the Structural Heart Division (SHD) Improve patient outcomes including increasing the percentage of patients returning to home rather than a rehab facility destination at discharge Decrease length of stay Implementation: Plan: PT and OT identified a gap in consults and need for specific education targeted at a new surgeries population (tAVR); Structural Heart division of CV institute identified an increase LOS and decreased activity of their patients in the hospital. In October 2014 planning began to introduce a SHD tAVR pathway that would include post procedure day number 0 nursing requirements and training, post procedure day number 1-3 PT and OT assessment and interventions. Do: Implemented pathway in November 2014. Check: Order set revision; Patient handouts ; Cardiac Rehab; Weekend criteria; staff training Act: February 2015, order sets in place, patient handouts finalized and full pathway finalized for post op tAVR patients. Continued checks identified additional SHD procedures and team determined that Mitral Clips and LARIATs were not criteria for tAVR pathway but would receive routine PT and OT consults. Intervention: • Added PT and OT to Structural Heart Order Set. PT and OT assessments completed on post procedure day number day 1. PT and OT follow up treatments post procedure day number 2, 3 and beyond as appropriate. Patient education handouts individualized for patient population Pre-op education handouts individualized for patient population Outcome measures: Hospital Length of stay, discharge disposition. Data Analysis: Chi-square tests are used to compare proportions between groups, while Wilcoxon two-sample tests are used to compare distributions of continuous variables between groups. This nonparametric test was chosen due to non-Gaussian distribution of the continuous outcomes within groups. Statistical significance was set at p<0.05. All analyses were performed using SAS 9.4 (SAS Institute Inc, Cary, North Carolina, USA).

Official Title
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Physical Therapy and Occupational Therapy After Transcatheter Aortic Valve Replacement

Conditions
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Transcatheter Aortic Valve Implantation

Intervention / Treatment
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* Other: Post procedure daily PT and OT
* Other: PT post procedure
* Other: OT post procedure
* Other: Routine PT or OT


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: admission to henry ford hospital after March 1, 2012 status post transcatheter aortic valve replacement via transfemoral catheter approach, with or without minor intra or post procedure events (GI bleeds, minor access bleeds, afib, etc) Exclusion Criteria: Occurrence of major events including stroke, pacemaker placement, other CV repair or surgery required, etc) procedure via appropriate other than femoral access (transapical, transcaval)
Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Post procedure routine PT and or OT<br>Routine PT and or OT | Other: Routine PT or OT<br>* Routine PT or OT consulted by physician when identified discharge disposition of home<br>|
| Post Procedure PT and OT pathway<br>Post procedure day zero nursing mobilization; post procedure day one PT and OT assessment and intervention, daily PT and OT intervention | Other: Post procedure daily PT and OT<br>* PT evaluation and treatment on post procedure day zero: Nurses mobility patient using egress testing one time<br>Other: PT post procedure<br>* post procedure day one: PT and OT assessment, education and intervention.<br>Other: OT post procedure<br>* PT and OT Daily until goals met or patient discharge.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Post Procedure Hospital Length of Stay | From date of procedure until date of hospital discharge, assessed up to 50 days. | at discharge | 
| Total Hospital Length of Stay | Days from Hospital admission to Hospital Discharge | at discharge | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Discharge Disposition, Home | Discharge destination at discharge. Home includes those discharge home, Home with assistance or Home with Home care. | on day of hospital discharge | 
| Discharge Destination, Rehab Facility | At hospital discharge, did the patient return Home or were they discharged to a post-acute care Rehab Facility | on day of hospital discharge | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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physical therapy, occupational therapy, tAVR