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I am talking about perioperative care of the patient with mitral valve disease, and by that, I mean the care delivered before and after surgery. I am not discussing the operative period today. These are the things I want to talk about and hope to provide an overview of the role of the nurse practitioner at Mount Sinai's Mitral Valve Repair Program. I want to discuss the nursing issues specific to mitral valve repair patients, and at the end touch upon the benefits of a physician-nurse practitioner collaboration in a specialty practice.

So this is one of our patients, status post mitral valve repair. You may think, well that does not look like a typical open heart surgery patient and that is just the point. Our patients are a little different. Dr. Adams was talking about this morning that many of our patients are asymptomatic and that can require a little more education in terms of the nurse practitioner's role in dealing with the patient, the patient who comes in asymptomatic and feels great and is active, needs a little extra education as to why surgery can be beneficial to them

Just a little bit about our program, and specifically as you can see, Dr. Adams came to Mount Sinai in 2002, and the number of mitral valve repairs has almost tripled in that time. So the program has seen steady growth over the past seven years, which again makes a nice role for a nurse practitioner to augment a practice. Our program is growing not only in numbers but in geographic reach as well, and some of you may notice this in your programs too that while most of our patients are still from the New York metro area, with greater frequency are seeing patients from out of state and from out of the country, and as a result, we need to be really efficient in order to streamline the preoperative and operative experience, so hopefully the patient only has to make one visit to Mount Sinai. We also hope that the patient feels confident that we will be able to give them a comprehensive experience even though they live a few time zones away. Just to give you an idea of our weekly patient volume, the nurse practitioners see 10 to 12 patients a week in consultation and Dr. Adams sees these patients as well, but that is about our number. We have done as many as 17 in some weeks, but on average our typical week is 10 to 12. We will see 8 to 10 postoperative patients in followup in the clinic, and in general, he does about 10 to 12 cases a week and to manage this volume we have two NPs; I am an adult health NP and one of my colleagues is an acute care NP and we also work with a clinical nurse specialist.

The initial patient contact is made when the patient calls us for an appointment for a consultation and most of the referrals are still made by cardiologists though with greater frequency we are seeing more and more self-referrals. The patient will be told that they need to see a surgeon regarding an opinion for surgery and maybe they will be given a local referral, but the patients today are often going on to the internet and doing their own research, and sometimes, the patients will find us that way. When they call us to schedule the consultation we will give them the information that we need to have before they come, and if they have not already seen the website, then at this point we will give them that information. We do like for them to go to the website because there is a lot of information available there. They can learn more about their disease process, they can learn about surgery options, and they can watch a video of Dr. Adams doing a surgical procedure. They can read papers that he has published or that his associates have published, and they can also learn more about what to expect before, during, and after surgery. In fact, on the left there is a "what to expect" that they can click on, and they can watch a video which explains to them what to expect at the consultation.

We started this just a few months ago, and I think it is working out really well. We find that patients are more prepared when they come to their consultation, they bring the list of medications, and they have questions ready. It also helps in terms when I go out to greet a patient in the morning, they will say, "Oh, I recognize you from the website" or "Oh, you look familiar," and as we were talking earlier, Dr. Osterman's nice presentation on anxiety, a lot of these patients are very anxious and anything that helps to decrease that level of anxiety is a good thing.

Our goal on the day of consultation is to provide a one-stop process. We want to be able to give the patient a definite indication for surgery on the day of consultation, and this is very important, especially with our patients who come from great distance. So in order to accomplish this, the NPs at least a week prior to the consultation, will review each incoming patient's chart to make sure that it is complete, to make sure that we have not just an echo report but a film as well. If they have been done, we need to have the cardiac cath film and report and chest CT film and report. If the patient is a reop, we would want prior operative notes, and if they have comorbid conditions and see consultants such as pulmonologists or hematologists, we would like reports from them as well.

Our initial assessment includes assessing the impact of disease as indicated by the echo, we are looking at the severity of mitral regurgitation; we are looking at their EF, and their left atrial and left ventricular dimensions. We assess impact on the patient's life as indicated by their symptoms. Are they short of breath, are they having dyspnea on exertion, are they having palpitations, has this changed their level of activity. And then also, we want to know about the existence of comorbid conditions such as diabetes or a prior surgery or renal failure, and we do use the decision tree as published, this is the 2008 update to the 2006 ACC/AHA guidelines published by Dr. Bonow and if you look at the red highlighted areas, most of our patients have severe mitral regurgitation and so the first question is do they have symptoms. If they have symptoms then as long as their EF(ejection fraction) is greater than 30% it is a class-I indication for surgery. It gets a little more complicated if the patient does not have symptoms and then we look at their LV(left ventricular) function, and if their LV function is less than 60 it is becoming compromised, then that again is a class-I indication for surgery. If they have good LV function then we want to look to see are they in atrial fibrillation or do they have pulmonary hypertension because that is a class-IIA indication for surgery.

This is just our consultation form; it is a two-page form that we use when the patient comes. We do our history and physical and we document the echo parameters. We hope to be going electronic sometime in 2010, so hopefully, we will not have these paper forms much longer. Then again back to the decision tree, we can present all of the information to Dr. Adams about what the indications for surgery are, but only he can determine whether a mitral valve repair is likely, and the way he does that is through the echocardiogram and so we have to have an echo film the day of the consultation, and he reviews the echo film with the patient so he can show them their exact disease and the likelihood that he can repair the valve. As it was mentioned earlier this morning, we see more and more asymptomatic patients, and we can kind of tell how busy we are going to be that day or how far behind we will be in the afternoon because asymptomatic patients do require more time to educate. Dr. Adams spends a lot of time with them discussing their disease process and why surgery would benefit them.

The additional goals of consultation are to assess the patient's social situation and to give the patients an idea of what to expect after surgery. It is a time for us to just talk to them about what to expect in terms of length of stay, recovery afterwards, and it is a way to almost begin discharge planning before they have even been admitted to the hospital if they are going to have issues with recovery and convalescence.

The possible outcomes of the consultation are that there is an indication for surgery and the patient schedules a date. When that happens, I would say probably 85% to 90% of our patients schedule that morning after the consultation. Another indication would be that there would be an indication for surgery, but the patient wishes to seek other opinions. We are in New York, people like to shop in New York as they do in Chicago as well I am sure, and so it is not uncommon for people to want to get a second opinion even if there is a very clear indication for surgery, but that does not happen too often. Sometimes, there might be no indication for surgery. I have to say this happens very infrequently, and I think that is because NPs do put so much time into pre-evaluating each patient's file before they come. At times, we do have patients who are very high risk and it is determined that further evaluation is needed before final determination can be made and we will bring them into the hospital, admit them, and have a multidisciplinary evaluation.

After the consultation, we give each patient a booklet. This is relatively new; we started this a few months ago and this I think is also working out well. This booklet contains information about the what to expect preoperatively, preoperative testing, and it has information, most of our patients are day admit surgery patients, and so, there are instructions about that. We give them instructions about what to expect afterwards and instructions for the families about where to wait. They can read articles published by Dr. Adams and his associates, and then, there are also blank sections in this booklet, and we give it to the patients telling them that we would like them to bring this booklet to the hospital when they come in and we will supplement the booklet with their operative notes, with their postoperative echo, with relevant lab results so that when they leave Mount Sinai they leave with full documentation of their experience there, which is a nice thing for them to have and nice for them to share with their cardiologist.

Prior to surgery, we would review any abnormal preoperative tests and results. We will report any abnormal findings to the surgical team and field questions from patients. It is not uncommon for patients to call after the consult. Again, the level of anxiety can be high during that period, and even though certain things were discussed, they may not always remember everything that was talked about so they know that they can feel comfortable calling and asking to speak to one of the NPs. So that covers everything that we do before surgery.

On the day of surgery, we might update the family on the progress or outcome of surgery. Our fellows do a lot of this, but we fill in for them sometimes. We will answer questions from the family regarding ICU care. Again, it is a very anxious time not just for the patients but for the families as well. It is often difficult to see someone you care about in the ICU and often fluid overloaded; they look very different, and so, we try to spend a little time educating them.

Then during the postoperative inpatient period, we do afternoon rounds every day on all the inpatients. So, we go up, it is for a couple of reasons: (1) we do provide clinical update to our surgical team and (2) it is a good time to do a lot of one-on-one education with our patients and families. Dr. Adams does sometimes four cases a day, so there is not a lot of time in the day and for us to be up there and talking to patients and talking to families is really a nice benefit for the patients. Not only do we do one-to-one teaching, but also twice a week we do a formal discharge teaching class on Tuesdays and Fridays. We use our visitors lounge, and we do a PowerPoint presentation and this is very, very nice. We have just found that there is a nice interaction between us and the patients and also between the patients themselves. Somebody might ask a question that someone else was uncomfortable asking and it is usually just a very nice dynamic, and we cover all the topics of what they can expect when they go home, and at this point, we will schedule their followup appointment because they are going to come back to see us in four to six weeks in the clinic, and we also let them know that they can call us anytime after they have gone home from the hospital. In this way, I feel like we have established a relationship with the patient and with the family.

We do provide continued followup after discharge from the hospital. In 24 to 48 hours, we contact each patient at home basically just to see how they are doing to assess recovery, and they know to expect this phone call because we have told that we will be calling. If they had rhythm issues in the hospital, if they were in atrial fibrillation or sinus tachycardia, we assess to see how that is going and make sure that they are having appropriate followup with their cardiologists and are on appropriate medications. Our PAs actually do a good job before the patients are discharged. If someone is going home on Coumadin then the PAs will contact the local cardiologist to follow the INR, but we do get a lot of patients who are from out of state and those patients we do ask to stay in a local hotel for at least a week so that we can keep an eye on them, and for those patients we will make arrangements to have their INR checked and we will dose the Coumadin for them. We also assess to see how their incisions are doing. If they are having any drainage or any sign of infection we bring them right into the office. We assess pain issues, pulmonary status, weight and fluid status.

Our current anticoagulation protocol for our mitral valve repair patients, if someone is in atrial fibrillation for more than two days, they will get Coumadin for three months; if someone has a MAZE procedure they get Coumadin for three months; if there is no atrial fibrillation and there has been no MAZE procedure, then they will go home on aspirin 325 mg. This is our followup phone call sheet that we use for each patient and that just really prompts us to ask about their sternum, remind them we do want them to shower every day to keep their incisions clean, we want them to walk, we remind them about their lifting restrictions and again we remind them that we want them to see their cardiologist 7 to 10 days after they have been discharged from the hospital. They should see the cardiologist at least once before they come back to see us.

We provide continued followup after discharge from the hospital. I think that we provide continued support and reassurance to patients so they continue to feel connected. We definitely triage and streamline flow of care. As I said, if a patient is having any problem either with a wound or shortness of breath we do not hesitate to bring them into the office that day, so those followup numbers I gave you using earlier of 8 to 10 followups, those are scheduled followups. We have unscheduled followups as well that we bring in during the day. I am sure we do help to prevent emergency department visits. Certainly, if there is an emergency and they need to get to a local emergency department, that is fine, but if it is a non-urgent issue we would really prefer that they come into the office and see us.

Then in four to six weeks, our patients all return for a followup clinic appointment. This is one of my other colleagues Joel, and at this time, it is continued education reminding them they still cannot lift anything for about six more weeks, or at least anything over 20 pounds. We do a physical assessment, we do an EKG, we send them to radiology for a chest x-ray, they are seen by the surgeon, and at this point, they are basically, assuming that they are doing well from a surgical standpoint, they are cleared. They will continue to follow up with their cardiologist on a regular basis. At this point too, we also have to remember that we have a lot of reporting in New York State. I am sure it is probably similar in your states as well, but we have to provide New York State with a lot of information about each case.

So, the benefits of an MD-NP collaboration in specialty practice, I do think that in a growing practice like this one has been, NPs can definitely provide an additional resource for patient education and communication. We help to improve continuity and comprehensiveness of patient care. If you are looking for an article, there is a nice article by a Dr. Herrman and Dr. Zabramski that talks about neurosurgery practice with an NP and MD and it just highlights the benefits. It is a nice article.

For me, it has just been a great experience. I love working with Dr. Adams and the entire surgical team. I think that the surgeons really respect our clinical judgment and our autonomy and yet they are always available for questions if we have them and I think the patients also feel connected. They see us as a resource that they can contact if they have questions.

Again, we bring up the ACC/AHA guidelines, and if you look at this last paragraph, it says cardiologists are strongly encouraged to refer patients who are candidates for mitral valve repair to surgical centers experienced in performing mitral valve repair. So, I think this is a definite opportunity for nurse practitioners to work in a center where you can really focus on a particular disease like mitral valve disease and become an expert in an area.

I started with a photo, so I will end with a photo. This is another one of our patients, the guy in the middle who is just touching the alligator; he is an alligator catcher down in Florida. So, again highlighting that our patients are different and it is a good thing he is not holding on to that leash because it would definitely be against rules for postoperative patients.

I hope you have enjoyed this. Thank you.


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