Table 2.
Results care delivery process analysis
| Treatment | Process Phase | Potential improvement intervention | Impact on outcome |
|---|---|---|---|
| SAVR | Monitoring and preventing | Identify high-risk patients by measuring a Frailty Score | Mortality, Quality of Life |
| Organize a specific pre-operative screening for older patients | None* | ||
| Diagnosing | Introduce a frailty protocol | Quality of Life, mortality | |
| Discuss older patients in a multidisciplinary team | Quality of Life, Mortality | ||
| Introduce a checklist for uniform imaging | Quality of Life, Mortality | ||
| Screen abdominal vascular disease | Mortality | ||
| Screen for long-vein narrowing | Mortality | ||
| Preparing | Adjust the anticoagulation protocol | Mortality | |
| Intervening | Standardize with a protocol for the blood or crystalloid cardioplegia | Mortality | |
| Use of MECCa and improve experience of the operation team | Mortality | ||
| Implant the long-term pacemaker as fast as possible after operation | Mortality | ||
| Recovery/Rehab | Conduct an echocardiography only with indication | Quality of Life | |
| Improve nightly supervision at the ICUb (cultural change) | Mortality, valve re-intervention | ||
| Offer every patient heart rehabilitation program | Quality of Life | ||
| Raise more attention to diet of the patient, practice spirometry | Quality of Life | ||
| Introduce a checklist for the exit consult | Re-intervention | ||
| Monitoring/ Managing | Adjust the medication protocol | Quality of Life | |
| TAVR | Monitoring and preventing | Optimize Frailty identification | None* |
| Introduce home monitoring system for measuring blood pressure (E-Health) | Quality of Life | ||
| Diagnosis | Introduce more frequent TAVR team meetings to discuss patients | Mortality, Quality of Life | |
| Improve hospital logistics (with the support of the Lean method) | Mortality, Quality of Life | ||
| Assure that an echo is always available before diagnosis | Complications | ||
| More frequent TAVR Team meetings to discuss patients | Mortality | ||
| Digitalize the treatment plan | Mortality | ||
| Involve an anesthetist in the TAVR Team meetings | Mortality | ||
| Introduce a diagnosis checklist for treatment choices | None* | ||
| Preparing | Conduct pre-operative check-up and CT-scan on the same day | Waiting-times | |
| Introduce a checklist for the check-up | Mortality | ||
| Involve an anesthetist much more this phase | Complications | ||
| More local anesthesia | Mortality | ||
| More procedures in one day or another day for TAVI procedure to shorten the waiting times | None* | ||
| Intervening | Introduce the presence of a surgeon, cardiologist and anesthetist during the procedure | Complications | |
| Use ACIST Pumpc (control of injection rate) | None* | ||
| Only use the new generation of valves (replaceable valves) | Mortality | ||
| Use of a debris catch device | Stroke | ||
| Recovery/Rehab | Introduce clinical pathway | Quality of Life | |
| Ensure removal of the pacemaker the following day and directly implant the long-term pacemaker if needed | Infections | ||
| Apply telemetry monitoring for full period until dismissal | None* | ||
| Monitoring/Managing | Define targets for medication | Re-intervention |
*The proposed potential improvement intervention is not expected to have considerable impact on one of the patient-relevant outcome measures, but process or structure measures
aMECC is minimal extracorporeal circulation
bICU is intensive care unit
cACIST Pump simplifies contract injection for procedures