Task Force 4: Inpatient Management of Patients with MCSD - The ...

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Recommendations for Inpatient MCS Care by a Multidisciplinary Team: Class I: 1. A multidisciplinary team lead by cardiac surgeons and cardiologists, and composed of subspecialists (i.e., palliative care, psychiatry, and others as needed), MCS coordinators, and other ancillary specialties (i.e., social worker, psychologist, pharmacist, dietitian, physical therapist, occupational therapist, and rehabilitation services) is indicated in the in-hospital management of MCS patients. Level of Evidence: C. Quality of Life Assessment Patients have reported that they were quite satisfied with their health-related quality of life (HRQOL) while still hospitalized after MCS implantation. 54,55 Patients further reported that they were quite satisfied with the outcome of MCS and were doing quite well after surgery. 54,55 These reports on “overall” HRQOL may reflect a “honeymoon phase”. Importantly, when specific domains of HRQOL were examined, MCS patients were least satisfied with their health and functioning and most satisfied with significant others. 54 Health status, energy level, and independence were specific areas of more dissatisfaction. 54 When compared to MCS outpatients, the HRQOL of MCS inpatients was significantly worse. 53 This finding was supported in a small sample of MCS patients whose HRQOL improved from before to after discharge. 67 Small sample sizes, missing data, and use of first generation pulsatile devices limit the findings from these observational studies. HRQOL is collected as part of the INTERMACS registry at 3 months, 6 months, and at 6 month intervals through 2 years after implant and yearly thereafter. Recommendations for Routine Assessment of HRQOL While Hospitalized Post MCSD Implantation: Class IIb: 1. Routine assessment of HRQOL while hospitalized after MCS implantation may be reasonable, but its usefulness is unknown. Hospitalized patients are beginning to adjust to living with MCS, and as such require MCS team support as they recover from surgery and rehabilitate. Assessment of specific problems that are related to 20
domains of HRQOL (e.g., depression, anxiety, or pain) based on symptomatology may be more reasonable. Level of Evidence: B. Discharge Preparations The literature is limited on transitioning MCS patients from hospital to home. Discharging a MCS patient from the hospital requires a multi-disciplinary approach and good communication across settings to ensure that the patient and their caregiver are competent in device management in the community setting. 68 Prior to discharge, specific outpatient monitoring and management needs to be organized, including referrals for anticoagulation monitoring and dosing, with clear instructions for the patient and caregiver regarding anticoagulation management. 46 The patient and caregiver should be aware of the outpatient management plan, including MCS clinic appointments for medical follow-up (with labs and tests), physical therapy classes and ongoing education refresher sessions. Also, a source for dressing supplies needs to be identified. A clear algorithm for when and how to seek help, including contact numbers for MCS staff at the hospital, emergency services, and the general practitioner is essential for appropriate response to urgent and emergency situations. Transitioning to the outpatient environment is further discussed elsewhere in these guidelines. Recommendations for Successfully Discharging a MCS Patient Class I: 1. Patient and caregiver education and discharge instructions, as well as preparation of community providers on the safe management of the device and the MCS patient, is recommended. Level of evidence: C. Management of the MCS Inpatient During Subsequent Hospitalization As the duration of support increases in the era of DT, patients with MCS will likely require re-hospitalization at some point. These hospitalizations may be for MCS related 21
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Page 5 and 6: Recommendations for Neurohormonal B
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Page 29 and 30: 6. Discontinuation or reversal of a
Page 31 and 32: Infectious Issues The classificatio
Page 33 and 34: Level of Evidence: B. 3. A possible
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Page 41 and 42: Level of Evidence: C. Class II: 1.
Page 43 and 44: 19. Holman WL, Rayburn BK, McGiffin
Page 45 and 46: 60. McGrady A, McGinnis R, Badenhop
Page 47 and 48: 98. Cadeiras M, Nagaraj H, Kirklin
Page 49 and 50: Table 1. Causes of Deviation from N
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Page 53: B. Deep MCSD-specific Percutaneous

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