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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. http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip&db=cin20&AN=200904296 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. http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip&db=cin20&AN=200901822 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 2&site=ehost-live. 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. http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip&db=cin20&AN=201014856 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. http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip&db=a9h&AN=9457673&sit e=ehost-live. 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. http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip&db=cin20&AN=200995300 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 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 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 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 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) o o o o o o o o o o o o o o o 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