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October 15, 2013
9:00:00 AM - 10:00:00 AM
Room Room 104-Area E
Improving Team Performance and Patient Outcomes During Transcatheter Aortic Valve Replacement (TAVR) Through Simulation
Samata Paidy, M.D., Ntesi Asimi, M.D., Sugam Bhatnagar, M.D.,M.P.H., Robert Poston, M.D.
University of Arizona, Tucson, Arizona, United States
Introduction: Transcatheter Aortic Valve Replacement (TAVR) is a highly promising treatment of severe aortic stenosis but has an early “learning curve” that can dramatically alter patient safety and hospital costs. It is well known that communication and teamwork failures are common triggers for adverse events during established surgical procedures. The TAVR learning curve mandates an even greater degree of collaboration between cardiology, CT surgery and cardiac anesthesia to improve patient clinical outcomes. Therefore, we hypothesized that TAVR training in our hybrid catheterization laboratory directed at teamwork and communication would likely shorten the learning curve and improve early patient outcomes.

Methods: The primary TAVR team (two interventional cardiologists, two cardiac surgeons, cardiac anesthesiologist, a non-invasive cardiologist, perfusionist, TEE technician, three cath lab nurses and three CT surgery nurses) participated in 5 cadaver TAVI simulations over a 4-month period prior to 5 clinical cases. Each cadaver and clinical case involved a didactic briefing session, videotaping of performance in the hybrid OR, and a debriefing session to review selected case highlights. Two raters independent of the TAVR team reviewed the videos for non-technical/team endpoints and technical performance - time to complete and knowledge of tasks, motion efficiency of the support staff (quantified by pedometers). The incidence of mortality and major STS morbidity and length of stay for the first 10 clinical TAVR cases was analyzed from a de-identified dataset obtained from a quality assurance database (TVT registry).

Results: The first simulations were characterized by a high incidence of major errors, largely related to misunderstanding of individual roles/duties not addressed during initial briefing sessions (see table), followed by improvements in the later simulations (13,13,12,9,7 major errors/case). These improvements translated into the first clinical TAVR cases (2,1,0,0,0 major errors/case). Moreover, there was a 70% increase in the use of closed loop communication and 50% reduction in wasted motion over the course of the simulations and clinical cases. Amongst the initial 10 TAVR patients there was no mortality (average STS risk 8.4%) and 1 major morbidity (STS risk 44%). Feedback scores about the training ranged from satisfied to extremely enthusiastic amongst the participants.

Conclusion: Our simulation experience suggests that there may be a benefit when it comes to multidisciplinary team training in reducing errors, which may translate, in better patient outcomes. Further studies are required to confirm these findings.
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