How Soon Is Too Soon? A Quality Improvement Approach to Postoperative Length of Stay Following Transcatheter Aortic Valve Replacement

BACKGROUND: Heart valve disease prevalence is expected to rapidly increase over the next twenty years. Aortic stenosis, the most common valvular disorder, is a significant cause of heart failure hospital admissions and high mortality if left untreated. Treatment options include surgical aortic valve replacement (SAVR) and the more popular transcatheter aortic valve replacement (TAVR). The rapid increase of TAVR procedures generates hospital bed capacity issues, and there is no recommendation defining the minimum length of stay (LOS) following TAVR.

LOCAL PROBLEM: The setting was a 1,100-bed academic medical center in southeastern Pennsylvania with an average annual TAVR volume of 400 and growing. The median LOS was double the national database benchmarked data. This quality improvement project aimed to increase the percentage of TAVR patients discharged on the first postoperative day (POD) by implementing a next-day discharge (NDD) protocol.

METHODS: The Model for Improvement guided this project with plan-do-study-act (PDSA) cycles assessing compliance with NDD screening, education, and communication. A retrospective cohort was compared to the prospective cohort to understand the effect of implementing an NDD protocol.

INTERVENTIONS: The electronic health record (EHR) implemented an NDD screening tool, patient education materials, pathway continuity status, and adverse event tracking documentation. All elective TAVR patients were screened, and a patient satisfaction questionnaire was implemented for inclusion patients.

RESULTS: Of those meeting inclusion criteria, 43.9% of the prospective cohort versus 8.3% of the retrospective group were successfully discharged on POD 1, representing a statistically significant difference following the implementation of the NDD protocol. Thirty-day readmissions of the early discharges revealed no statistically significant differences between cohorts. Patient feedback revealed significant satisfaction.

CONCLUSIONS: Using an NDD screening tool resulted in a statistically significant increase in TAVR patients discharged on POD 1. This identification will reduce bed capacity issues, increase patient access, and contribute to a positive total contribution margin.