Download Clinical Education for the Ventricular Assist Device

Clinical Education for the
Ventricular Assist Recipient Population
Rachel Anderson, BSN, CCRN, CMC, CSC
University of Virginia Medical Center
Charlottesville, VA
Catherine F. Kane, PhD, RN, FAAN
University of Virginia School of Nursing
Charlottesville, VA
The implantation of ventricular assist devices for the treatment of heart failure is steadily
increasing, in addition to the length of time that the device remains in place. Self-care for this
complex technology can be overwhelming to the patient. To address this problem in patients
discharged home with their device, an evaluation strategy is proposed to identify the patient’s
knowledge obtained through their experience with their device. After this knowledge level has
been identified, teaching can be conducted that is appropriate for the patient’s skill level instead of
their health literacy level alone.
Keywords: Ventricular assist device, educational model
Clinical Education for the Ventricular Assist Device Recipient Population
Heart failure is a chronic condition in which the heart becomes unable to move blood
forward in its normal way. This inadequate movement causes blood to back up in the body and can
affect such major organs as the lungs, kidneys, and liver depending on the side of the heart that is
compromised. This resultant organ dysfunction can have debilitating consequences with high
mortality rates if left untreated. For patients who are in end stage heart failure, transplant is offered
as an option for treatment, however not all patients are candidates to receive a donated heart.
Additionally, not all end stage heart failure patients are well enough to survive the wait to receive a
transplant. For these two categories of patients, one treatment option may be to implant a
ventricular assist device (VAD) as mechanical support to either improve length and quality of life
or to sustain the patient while they await a heart transplant.
The Heartmate II, which is currently the only VAD approved for destination therapy,
reports a total of more than four-thousand devices implanted since the initiation of its clinical
trials in 2005 and current data shows a possible extended five or more years of life 1. For its
implantation, the native heart remains in place and the Heartmate II is placed just below the
diaphragm, with cannulation sites accessing the left ventricle at the apex and ascending aorta. A
cord, called the drive line, tunnels through the patient’s body, and exits the abdomen to connect
to the patient’s system controller 2. Because the VAD off loads the left ventricle using axial, nonpulsatile flow, the patient will not have a pulse unless the native ventricle is able to contribute a
substantial amount of cardiac output, which is most commonly seen with return of ventricular
function.
After five years of being solely used for bridge-to-transplant therapy, in early 2010, the
FDA approved the Heartmate II for long term implantation, also known as destination therapy3.
This approval has increased both the number of VADs, as well as the average length of time
recipients have their devices. As the number of available heart donors has reached a plateau, the number
of those needing a transplant continues to outnumber those available4. This imbalance has placed the
average wait time for a heart transplant to six or more months5 which has also lengthened the time span
for the VAD remaining implanted.
The intent of this paper is to present a strategy for educating patients with VADs to
appropriately manage their health condition based on their level of expertise with their device
instead of their literacy and educational aptitude level alone. Dreyfus and Dreyfus’ model of skill
acquisition6 provides theoretical support for the proposed intervention.
Understanding the challenges of managing a VAD
While a VAD may be the patient’s only treatment option, they do not come without substantial
short and long term risks that need to be addressed through education. One of the obstacles faced by
providers in structuring education is the technological magnitude of the VAD. The patient
handbook for the Heartmate II is an eighty-three page manual2 that comprehensively covers selfcare with the device. Highlights of the education provided by the manual are outlined in Figure
1. Because of the vast amount of knowledge required to provide self-care with device after
discharge, the patient is assessed prior to surgery for their educational abilities. Those who are
not believed to able to understand how to perform self-care are excluded from receiving the
VAD. Upon discharge, the patient is only equipped with the basic abilities to care for themselves
at home with the expectation that a comprehensive knowledge of the device will be learned in
the outpatient setting. Because of limited time allotted for office visits and additional lack of
resources within varying practices, education after discharge has the potential to be insufficient.
Since the Heartmate XVE has been replaced by the newer generation of VAD, the Heartmate II,
the average hospital length of stay has been reduced to from 45 days to 29 days7. While this reduction in
hospital days is beneficial to both the hospital and the patient, it reduces the amount of the time available
to provide patients with a comprehensive education to care for their devices and themselves before
discharge. If patients are to be sent home with their device and be expected to keep the VAD implanted
for increasingly longer periods, excellent continuing education must be provided in the outpatient
setting in order for the recipient to function safely in the community8.
The emotions and fears experienced by both the patient and care giver have been
identified in several articles 9-13.One study used interviews of patients with VADs to establish the
feelings associated with living with their device. During these interviews, one man emotionally
related his life with the VAD to being like the main character in “The Pit and the Pendulum”, by
Edgar Allen Poe14. These feelings of facing the unknown, being confined by the device, living
with fears of what could go wrong, and yet hopeful for the future were experienced by all who
were interviewed for this study.
Literature review
In a review of the literature utilizing CINAHL and PubMed as search engines, the
following phrases where used: ventricular assist device education, Heartmate II education, and
VAD education. Through this review, it was found that no structured educational algorithm has
been proposed for use in VAD patients; however it was found that there is a need for such an
intervention, which was sited in several articles.
In discussing the care of the older generation Heartmate, which is very similar to the outpatient
care of the Heartmate II, Bond, Bolten, and Nelson16 called for nurses to be educated about the
challenges, benefits, daily care, and outpatient preparation of the VAD. Another article that studied
the older model Heartmate, recognized the need for designing a pattern for the patients learning
experience, as well as conducting the education with suitable technique17.
Cournoyer and others9 recognized the growing number of VAD patients discharged home and
called for increased education of patients and their companions for successful outcomes and continued
quality of life.
The general heart failure patient population includes those with VADs, since these devices are
implanted as a mode of treatment, not a cure. While conducting the literature review, several articles
were found that discussed education of those specifically with heart failure. Conclusions were that when
education was effectively implemented, costs could be decreased and quality of life improved 18. Yehle
and Planke19, concluded that something beyond the number or length of sessions improves self-efficacy,
and recommend that self-care education along with ongoing support from health care professionals
needs to be examined in future studies in the heart failure population. Certainly, the knowledge
embedded in the patient’s personal experience with their device is also an area needing further
exploration.
Low health literacy is associated with non-adherence to treatment plans, poor self-care
behaviors, compromised physical and mental health, and increased mortality. Timely recognition of low
health knowledge combined with tailored interventions should be integrated into clinical practice, and
emphasizes the need for an appropriately structured educational program for VAD patients15.
Knowledge Acquisition
In 1980, Dreyfus and Dreyfus6 developed a model of skill acquisition that recognized
knowledge gained through experience instead of structured educational encounters. The process
of skill development is fundamental to the development of learning strategies and has be applied
to nursing, by Patricia Benner From Novice to Expert20. The skill aquisition model provides the
foundation for the advanced practice nurse’s intervention of assessing, not only the knowledge,
but the skills and abilities of persons with VAD, and working with them to continue to learn by
doing.
Five different levels of skill acquisition were identified by Dreyfus and Dreyfus: novice,
advanced beginner, competent practitioner, proficient practitioner, and expert, with all learners
starting as novices. The learner, as a novice, has no practical experience and must base decisions
on principles, rules and specific written instructions. The novice needs hands on coaching and
direct supervision to ensure that the process and procedures are carried out appropriately and that
the rationales for these actions are understood. The learner, now having some experience to draw
from, then progresses to the advanced beginner level where they recognize recurring patterns and
conditions. In this stage the learner begins to differentiate between normal and abnormal
situations and is able to establish priorities, but the learner still reviews written instructions and
requires continued coaching and supervision. In the third level, competent, the learner has about
two years of experience. At this skill level there is more future thinking and development of
plans that are based on conscious, abstract, analytic contemplation of the problem.
The next level is proficient. At this level, situations are seen as a whole picture, rather
than from different perspectives. Actual experience is relied on more heavily to decide how to
problem-solve when slightly different versions of challenging situations are
encountered. Strategies for action are not purposefully designed but rather instinctively
formulated while responding to the challenges as they arise. Develop this level of proficiency
typically takes three to five years.
The highest level is that of expert. The person at this skill level is able to rely on their
vast amount of experience to develop an intuitive grasp of situations. The use of rules written
instructions are no longer necessary to deal with common situations. In managing challenges,
they are highly flexible and proficient and are highly aware of the informative cues in the
situation. However because the expert is drawing from unique and personal experiences, it is
often difficult for them to articulate the rationale for their actions.
Patient education for VAD
Dreyfus and Dreyfus (1986), through studying airplane pilots, chess players, automobile
drivers, and adult learners of a second language captured the richness of knowledge acquired
from doing an activity instead of being formally instructed on its performance. This model of
skill acquisition provides a strategy for conceptualizing the patient’s knowledge and skill
acquired from living with the VAD,.
To provide the appropriate level of education to the VAD recipient, the advanced practice
nurse must evaluate the proficiency level of potential VAD recipient. The structure for the
assessment process is outlined in Figure 2 and has been named the Ventricular Assist Device
Education Delivery Model (VAD ED). The VAD ED is essentially an algorithm that defines the
behaviors of patients in the five levels of learning. Once the patient is assessed at the appropriate
level, the educator utilizes the corresponding educational strategies. Upon each subsequent
encounter the educator then re-evaluates the patient’s level of knowledge to decide if their skill
level has remained the same or progressed to the next level. As the patient’s level of knowledge
and skill progresses, the educator provides the corresponding educational strategies.
Level One Learner
On the initial encounter with the patient, no assessment will be needed to identify the
proficiency level of patient concerning their device as all newly discharged recipients will be at
the level of beginner. However the basic learning capabilities of the patient and their preferred
media for learning should be identified in this phase. In educating at this learning phase, the
nurse will provide step by step rules and basic information about the VAD. It will be important
that the nurse walks the patient through any tasks before asking the patient to do them such as the
dressing change or attachment placement for showering. Patience is important in this stage and
outcome requirements from this stage should only include that the patient is able to repeat basic
facts and simple steps in procedures. It should be the expectation that before discharge the
patient has mastered this level.
Level Two Learner
At the beginning of each new interaction, a dialogue should occur so that the nurse can
assess the patient’s advancement through the skill levels. If upon the next encounter the patient
can articulate how certain actions yield a particular reaction, the skill level for learning can be
progressed to a level two learner. An example of a patient exhibiting this trait is stating, “I’ve
noticed if I forget to take my Lasix ® my pump power always goes up along with my pulse
index.” They may be able to glean from experience how the explicit rules they were sent home
with can be considered more as guidelines to be worked with instead of simply following
instructions.
To address the patient’s needs at this level the nurse should still include in their plan of care
frequent contacts by either phone calls or in office visits as the patient still needs support in
placing the pieces together for care of the VAD. Validation of knowledge obtained from
experiences needs to be confirmed as valid and any miss-associations should also be identified
and corrected. Written materials or video instruction will still be useful at this level.
Level Three Learner
To be classified as a level three learner, the patient will need to be able to discuss their care
in language that is forward thinking. For example the sterile dressing change would be described
by the patient as being done in sterile technique, not to keep them out of the hospital, but to keep
the body healthy and ready for a heart. The patients may report “Ah Ha!” moments where
complex pieces of information may finally make sense or they may finally understand why
certain rules were in place. When discussing their daily living, the patient may express ways they
have altered their self-care to meet the demands of the situation.
In educating the patient in this learning level, the advanced practice nurse can now present
more intuitive and complex questions to the patient. The use of basic materials for instruction
will no longer be useful. Written scenarios and case presentations may be presented to the patient
to work through. The advanced practice nurse will no longer need to plan for scheduled points of
contact outside of the routine office visits. These nurse-patient contacts can be reduced because
the patient is now able to identify what their own needs are and when their own resources for
caring for the VAD are no longer sufficient.
Level Four Learner
When discussing the documented vitals and VAD numbers they have been responsible for,
the patient in the level four learner phase can discuss the interaction of each number to one
another and its relation to such other things as their level of activity for the day or fluid intake.
They are also able to correlate changes in trends to such regimen changes as medication
modification and rehab advancement. These are patients that can usually identify what the
independent licensed care provider will or should prescribe based on what has been occurring
between visits. This class of expertise will be skilled with their VAD to know when something is
going wrong. An example of this knowledge being expressed is by the patient recognizing that
when they eat a lot of salt or take in lots of fluid, that the flows and pump power will increase,
and now that is not the case. The patient would also make the association that when they check
their blood sugar the time required for the bleeding to stop is less than it previously had been.
This patient would have the experiential knowledge to contact someone to rule out a blood clot
in the VAD and also to check on their clotting times (as these patients are on Coumadin ® as
long as the VAD is in). These patients are also seen less in the clinic for miss-association of
clinical pieces or for non-pertinent complaints.
The advanced practice nurse addresses education by role playing scenarios and having the
patient verbalize how they would react. Also eliciting alarms on a demonstration VAD may be
helpful to have the patient physically address the needs of the device during an alarm. Trick
questions and unusual complication presentations are able to be discussed during interactions at
this level. The patient may be asked to be a part of educating other or future VAD recipients.
Level Five Learner
While the hope for a transplant candidate is that a donor will have become available before
the patient can reach the phase of a level five learner, it is not unreasonable that some patients
may obtain this level and it is certainly probable that a destination therapy patient will reach this
final phase of proficiency. This highly skilled level may make some care providers nervous
because the patient will act mainly on instinct and move away from using the rules first given out
during discharge from the hospital. As an expert in their own care, the patient will give highly
analytical interpretations of their clinical findings.
The advanced practice nurse must take care to recognize the knowledge the patient has
obtained from providing their self-care while still providing a safe boundary for the patient.
Though the patient has become an expert in the care and interpretation of the VAD there are still
large pieces of medical care that interplay with the VAD that require medical personal to
interpret. There is very little formal education that can be provided to the patient, though the
practitioner should continue to update the patient on new research or technology pertinent to the
VAD. The opportunity for contact with questions should remain open to the patient.
Providing nurses with a structured educational algorithm that allows them to measure the
patient’s knowledge about their device and tailor education accordingly will help to organize
how instruction and outpatient care is provided. This model can promote continuity of care when
the patient is taught by several different individuals.
Conclusion
In summary, Dreyfus and Dreyfus’ model6 provides the foundation for VAD ED. The VAD
ED provides a structured means by which to identify the skill level of the patient and readiness to
learn. The VAD ED addresses the need for better educational programs that can prepare the patient
to provide optimal self-care in the outpatient setting in order to reduce complications and
unnecessary cost.
References
1.
Thoratec Corporation - VAD Trials & Outcomes - Clinical Outcomes - HeartMate II LVAD .
http://www.thoratec.com/vad-trials-outcomes/clinical-outcomes/heartmate-ll-lvad.aspx.
Accessed 11/7/2010, 2010.
2. Thoratec Corporation. Heartmate II Left Ventricular Assist System. Patient Handbook.
2008;Document No. 103539. http://www.thoratec.com/patients-caregivers/living-withvad/download/82.
3. Heart-Assist System Approved for Severe Heart Failure - US News and World Report .
http://health.usnews.com/health-news/family-health/heart/articles/2010/01/20/heart-assistsystem-approved-for-severe-heart-failure.html. Accessed 11/7/2010, 2010.
4. Heart Failure . http://www.americanheart.org/presenter.jhtml?identifier=1486. Accessed
4/13/2010, 2010.
5. Heart transplantation .
http://www.uptodate.com/patients/content/topic.do?topicKey=~MC9MtunFVPNW2. Accessed
11/7/2010, 2010.
6.
Dreyfus H., Dreyfus S. A Five-Stage Model of the Mental Activities Involved In Directed
Skill Acquisition. California University Berkeley Operations Research Center. 1980;
Technical report.
7. Abstract 3661: Equal Success, but Shorter Length of Stay, With Axial Versus Pulsatile Flow
Left Ventricular Assist Devices (LVAD) as Bridge to Cardiac Transplantation (BTT): The
Columbia Presbyterian Experience -- Sims et al. 120 (10018): S844 -- Circulation .
http://circ.ahajournals.org/cgi/content/meeting_abstract/120/18_MeetingAbstracts/S844-a.
Accessed 11/15/2010, 2010.
8. Barnes K. Complications in patients with ventricular assist devices. DCCN. 2008;27(6):233243.
http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip&db=cin20&AN=201022027
4&site=ehost-live.
9. Cournoyer K, Russo L, Froebe S, Groom R. Successful management of a left ventricular assist
device malfunction in an outpatient setting. J EXTRA CORPOREAL TECHNOL. 2007;39(1):4952.
http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip&db=cin20&AN=200956111
3&site=ehost-live.
10. Bartell LA. Ventricular assist devices: preparing for catastrophic environmental events. Prog
Transplant. 2005;15(3):264-270.
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0&site=ehost-live.
11. Casida J. The lived experience of spouses of patients with a left ventricular assist device
before heart transplantation. Am J Crit Care. 2005;14(2):145-151.
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9&site=ehost-live.
12. Kaan A, Young Q, Cockell S, Mackay M. Emotional experiences of caregivers of patients with a
ventricular assist device. Prog Transplant. 2010;20(2):142-147.
http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip&db=cin20&AN=201068368
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13. Hallas C, Banner NR, Wray J. A qualitative study of the psychological experience of patients
during and after mechanical cardiac support. J Cardiovasc Nurs. 2009;24(1):31-39.
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9&site=ehost-live.
14. Zambroski CH, Combs P, Cronin SN, Pfeffer C. Edgar Allan Poe, "The pit and the pendulum,"
and ventricular assist devices [corrected] [published erratum appears in CRIT CARE NURSE
2010 Feb;30(1):16]. Crit Care Nurse. 2009;29(6):29-39.
http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip&db=cin20&AN=201049786
5&site=ehost-live.
15. Evangelista LS, Rasmusson KD, Laramee AS, et al. Health literacy and the patient with heart
failure--implications for patient care and research: a consensus statement of the heart failure
society of America. J Card Fail. 2010;16(1):9-16.
http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip&db=cin20&AN=201057466
1&site=ehost-live
16. Bond AE, Bolton B, Nelson K. Nursing education and implications for left ventricular assist
device destination therapy. Prog Cardiovasc Nurs. 2004;19(3):95-101.
http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip&db=cin20&AN=200502416
9&site=ehost-live.
17. Andrus S, Dubois J, Jansen C, Kuttner V, Lansberry N, Lukowski L. Teaching Documentation
Tool: Building a Successful Discharge. Crit Care Nurse. 2003;23(2):39.
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18. Velez M, Westerfeldt B, Rahko PS. Why it pays for hospitals to initiate a heart failure disease
management program. DIS MANAGE HEALTH OUTCOMES. 2008;16(3):155-173.
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1&site=ehost-live.
19. Yehle KS, Plake KS. Self-efficacy and educational interventions in heart failure: a review of the
literature. J Cardiovasc Nurs. 2010;25(3):175-188.
http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip&db=cin20&AN=201064450
7&site=ehost-live.
20. Benner P. From Novice to Expert: Excellence and Power in Clinical Nursing Practice. AddisonWesley Publication; 1984.
21. theheart.org: Cardiology news, educational programming, and opinions .
http://www.theheart.org/article/966221.do. Accessed 4/13/2010, 2010.
Initial Clinical Experience with the HeartMate® II Axial-Flow Left Ventricular Assist Device .
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1995046/. Accessed 4/13/2010, 2010.
Figure 1. Understanding how the Heartmate II works
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Warning Lights & Sounds
System Controller Buttons
Battery Fuel Gauge
System Controller Self-Test
System Controller Perc Lock
Changing the System Controller
Battery Module
Replacing System Controllers
The Power Base Unit (PBU)
Power Base Unit (PBU) Warning Lights & Sounds
Display Module
How to Set Up the Display Module
Display Module Alarm Messages
HeartMate Batteries
Power Saver Mode
Recharging HeartMate Batteries
Changing Batteries
Switching Power Sources
Going from Batteries to PBU
Going from PBU to Batteries
Using the Emergency Power Pack (EPP)
How to preform activities of daily living with the Heartmate II
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Keeping Your Home Safe
Activities of Daily Living
Eating
Sleeping
Intimacy
Traveling
Showering
Caring for the Exit Site
Caring for the Percutaneous Lead
Pump Replacement
How to handle emergencies with the Heartmate II
1. What is an Emergency?
2. How to Handle an Emergency when the Pump is Running
3. How to Handle an Emergency when the Pump has Stopped
Thoratec Corporation. Heartmate II Left Ventricular Assist System. Patient Handbook. 2008;Document
No. 103539. http://www.thoratec.com/patients-caregivers/living-with-vad/download/82.
Figure 2.Ventricurlar Assist Device Education Delivery Model (VAD ED Model)
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Level One
Initial encounter with all patients
No assessment needed
Identify learning abilities and preferred
media to learn
o
o
Level Two
Patient can articulate how certain actions
yield a particular reaction.
Sees rules they were sent home with as
guidelines instead of rigid rules to be
followed
o
o
Level Three
Should have achieved by second year with
VAD, though some may achieve this level
earlier.
Patient discusses their care in language
that is forward thinking
Reports “Ah Ha!” moments when complex
pieces of information make sense.
Express ways they have altered their selfcare to meet the demands of a given
situation.
o
o
Level Four
Should have achieved within three to five
years, though some patients will achieve
sooner.
See their self-care in its entirety
Able to correlate changes in trends
Identifies what the independent licensed
care provider will prescribe.
Providers are contacted less for
inaccurate associations
o
o
Level Five
Move away from using the rigid rules
given by the provider
Highly analytical interpretations of their
own clinical findings
o
o
o
o
o
o
o
o
o
o
o
Step by step rules and basic information
Walks through any task before asking the
patient to do them
Patience is important
Expectation that before hospital discharge that
the patient been assessed and at this level.
Frequent contacts
Validation of knowledge obtained from
experiences
Miss-associations should be identified and
corrected
Materials provided based on patients preferred
media
Present more intuitive and complex questions
Move from basic information to written
scenarios and case presentations
No longer need to plan for scheduled points of
contact outside of routine office visits
Role playing
Elicits alarms on demo models and having
patient address them
Trick questions and unusual complication
presentations
The patient may become an educator to future
or new VAD patients
Recognizes the knowledge the patient has
obtained
Providing a safe boundary for patients to work
within
Very little formal education. Remain available
for questions.
Keep patient informed of updates and changes
in device care.
How to Define the Patient’s Skill Level
How to Provide Education Based on the Patient’s
Skill