May 21, 2016

yael maxwellThis is the third of a 3 part look at the Heart Team by CHMP Media Fellow Yael Maxwell looking at the Heart Team in practice: what works, what doesn’t, and what the future may hold. This story originally appeared on TCTMD.com. Read part 1 here and part 2 here.

 

 

On the first Tuesday in March, several people sat facing each other in an eighth-floor conference room in one of Michigan’s highest volume cardiac centers. The sun had barely risen, its first rays inching through the east-facing window as if to help illuminate the discussion that had begun some 20 minutes earlier.

 

Of those present—advanced heart failure physicians, interventional cardiologists, noninvasive cardiologists, surgeons, an anesthesiologist, a physician assistant, a coordinator, and a nurse manager—about half were clad in scrubs, having already rounded on patients or prepped the cath lab for the day’s cases.

 

Each knew the weekly routine. They flipped through the binder in front of them and glanced at the echocardiograms and cardiac MRIs playing on a screen at the front of the room as Richard McNamara, MD, presented the third case of the morning.

 

A 68-year-old outpatient had been complaining of weakness and shortness of breath since eating a jalapeno dish on Super Bowl Sunday. It was originally thought he was having a heart attack. But after testing revealed a blood clot in the left descending coronary artery, the course of treatment became less clear.

 

Within 10 minutes, the group had decided on a course of action, and by 8:30 that morning, McNamara had communicated the plan to the patient.

 

creative commons lic.
creative commons lic.

Let’s Give It a Try

 

While the Heart Team concept evolved to bridge the often steel-walled siloes within the specialty, cardiologists, surgeons, and non-physician staff openly admit its use in practice is inconsistent and needs improvement. Some hospitals, however, have been creative in making it work for their practitioners and their patients.

 

For the team at Spectrum Health (Grand Rapids, MI), the management of their cardiac patients was not always so streamlined. Before the fall of 2014, “our process was very chaotic,” said McNamara, an interventional cardiologist who serves as co-director of Spectrum Health’s Heart Team.

 

“What tended to happen before is you’d have part of the conversation,” McNamara explained. “You’d say ‘What’s plan B?’ And we’d never have plan B very well worked out.”

 

Spectrum Health cardiothoracic surgeon and Heart Team co-director, Theodore J. Boeve, MD, said that cardiologists and surgeons “had more head butting before we had the Heart Team than we do now.”

 

McNamara originally spearheaded the effort to start Heart Team meetings at Spectrum out of pure frustration. That the 2014 American Heart Association/American College of Cardiology guidelines lists the Heart Team as a “should do” process for trans catheter aortic valve replacement  (TAVR), helped to “put a little bit of structure and muscle behind it,” he said, but “we have always been absolutely dedicated to [excellent outcomes]. Once we had identified this as a problem . . . we said, ‘This looks like a potential solution. Let’s give it a try.’”

 

At first, meetings were held monthly. Practitioners submitted their cases to McNamara for presentation. Someone recorded minutes. But many of the cardiologists and surgeons who were most wanted didn’t show up, explained David Wohns, MD, director of Spectrum Health’s catheterization, or cath lab.

 

“We had a lot of skepticism about its value,” said Wohns, Finding a time that worked for everyone was the hardest logistical issue, since surgeons start doing rounds on patients earlier than the cardiologists do. They eventually settled on 6:45 am.

 

Comprehensive Standardization

 

From there, the hospital hosted a multiday roundtable event in February 2015 to comprehensively delve into all of the inconsistencies and miscommunications in cardiac care from diagnosis through follow-up. In addition to Boeve and McNamara, there was a quality control manager, nurse managers, rounding nurses, midlevel providers, pharmacists, cath lab techs, and even representatives from the emergency department. “We brought everyone involved that had a little bit of a stake in this,” McNamara said. “What we found was that everyone was doing something different . . . and we never had standardized work.”

 

They decided that the meetings would be weekly and urged all cardiology and cardiovascular surgical personnel present in the hospital to attend.

 

Another resolution that came from this event was the need for a full-time Heart Team coordinator to assist in prepping case files for meeting attendees, curating imaging needs, and documentation. DeeAnn Stickland, who had worked as a clinical cardiology nurse at Spectrum Health for many years and had been helping out with the Heart Team as a favor to McNamara, was chosen for the position in October 2015.

 

Treating cardiac patients can often pit cardiology and surgery teams against each other, Stickland said, and “crossing over into this role, it’s interesting to see the other side. [We are] trying to get both sides to buy into this and really function more as a team.”

 

Revolutionary Change

 

In 2015, the Spectrum Health Heart Team reviewed 265 patients and averaged 17-20 providers in attendance at each meeting. Diagnoses have ranged from severe aortic stenosis to heart failure, and recommendations included surgeries, medications, and interventions alike.

 

The importance of this exercise is not only about the recommendations, McNamara said, but “really trying to get everybody’s opinion. One of our challenges has always been that surgeons and interventional cardiologists tend to dominate the conversation, and we’re [now] trying to get [others] in there.”

 

Wohns agreed, commenting that the Heart Team “breaks down traditional disciplinary barriers and brings in a variety of opinions and perspectives for the care of the patient. I’d say our program has been revolutionary in accomplishing that for us.”

 

In a survey taken of the Spectrum cardiology and surgery staff last fall, almost all respondents reported that they valued the Heart Team highly and that poor communication was the biggest issue they faced before its implementation.

 

Patients seem to appreciate the new process as well. Stickland said the feedback she receives from patients is very positive. She ensures that each patient knows when and how they are going to be presented during the Heart Team meeting and that they can expect a consultation with their doctor soon after to discuss the ultimate recommendation. Still, she is careful to stress that the final decision lies with the patients and that “they are an active player in the team.”

 

There’s still pushback, McNamara said, adding that some providers “like the way that they make their decisions, and they really don’t prefer to have a lot of other input.” No one specifically complains about attending Heart Team meetings, he reported but a small number of critics—mostly referring cardiologists based off-site—simply do not come.

 

When asked why, usually the response has something to do with timing, Stickland said, although she acknowledged that morsels of politics and animosity might also come into play. “Let’s face it. No one wants to go to a 6:45 meeting in the morning. You just have to believe in it and think it’s important,” she said.

 

Show Me the Data

 

The team does not yet have enough data to show an improvement in patient outcomes since commencing the meetings, but the recommendations and outcomes of all patients reviewed are being catalogued in a database so that the team might analyze them at a later date.

 

These details will be pivotal in supporting the continuance of Spectrum’s Heart Team, according to McNamara. “I don’t want this to be another academic exercise,” he said. “I’d like this to be important and truly beneficial.”

 

“The beauty of the Heart Team is [that] you just can’t get that group of minds together to sit down and have an intense review and conversation about patients to that level otherwise,” Stickland commented.

 

Despite his initial skepticism, Wohns said that for him personally the Heart Team is “empowering” and has helped him feel that he now brings “the collective wisdom of a very experienced group” to his patients. “We’re totally dependent on it now,” he said. “I think it’s here to stay.”