Heart Failure Care Outside of ICU Can Lower Cost

Select patients with heart failure fitted with an implantable left ventricular assist device can be safely moved to a stepdown unit (SDU) from intensive care unit (ICU), reducing costs, reported investigators evaluating almost 2 years of follow-up data.

More than 60% of patients qualified for stepdown care, reducing costs by a median of $13,442 per patient without any apparent increase in adverse outcomes, according to Anthony P. Carnicelli, MD, assistant professor in the Department of Medicine at the Medical University of South Carolina in Charleston, South Carolina.

Over the course of the 20-month study, patients with a left ventricular assist device in Carnicelli’s institution spent 1114 days in a stepdown unit rather than in an ICU, which worked out to a saving of $1.36 million.

“The prevalence of device-related adverse events was low, with more than 50% of patients experiencing no adverse events over their SDU course,” reported Carnicelli, who presented these results during a late-breaker session at the recent Cardiovascular Research Foundation Technology and Heart Failure Therapeutics meeting. The data were published simultaneously in JACC: Heart Failure.

The study was initiated at the beginning of 2021, after a protocol was developed and stepdown-unit personnel were trained. In all patients, a transcatheter approach was used to implant the Impella 5.5 device (Abiomed) into the left ventricle. The device helps the ventricle to move blood into the aorta.

Most Patients Bridged to Transplantation

The strategy was used as a bridge to transplantation in 65% of the 91 patients who received the left ventricular assist device during the study period. Nearly 20% of patients had previously received a temporary mechanical support device. The median age of the study population was 59 years, approximately 20% of participants were women, and 77% had nonischemic cardiomyopathy.

Of the 60 patients (66%) who met criteria for a transfer to the stepdown unit, 23 (38.3%) experienced an adverse event. Only three (5%) experienced more than one adverse event, producing a total of 27 events. The most common adverse event was major hemolysis (11 events), followed by bleeding (six events), bacteremia (four events), and major vascular injury (three events).

The most serious events were two neurovascular events (stroke or transient ischemic attack) and one case of heparin-induced thrombocytopenia. One patient died after care was withdrawn when no appropriate advanced care options could be identified.

The study was not designed to compare the risks of adverse events for those deemed to be eligible for transfer to the stepdown unit with those who remained in the ICU, but most stepdown-unit patients who developed an adverse event were able to proceed to a definitive therapy.

Among the 23 patients who experienced any adverse event, 15 (65.2%) underwent heart transplantation, four (17.4%) underwent durable left ventricular assist device implantation, two (8.7%) were discharged alive with native heart recovery, and two (8.7%) died during hospitalization.

The cost savings depended on the length of stay in the stepdown unit rather than the ICU. These ranged on a per-patient basis from about $1200 to more than $98,000. In addition, there are other advantages to being transferred to a stepdown unit, Carnicelli pointed out.

Advantages Beyond Cost Savings

“The SDU offers a quieter environment than the ICU,” he said. In addition to the patient experience that was evaluated in this study, other data have shown an association between the stepdown unit and patient well-being relevant to improved outcomes, including a lower susceptibility to nosocomial infections and improved sleep.

By itself, “ICU-related sleep disturbance is associated with detrimental effects on cardiopulmonary physiology, susceptibility to infection, and metabolic, as well as endocrine, disturbances,” he said, citing previously published evidence.

There are also potential efficiencies for the hospital. When ICU throughput is increased, beds are freed up and surgical volume can increase. Care in the stepdown unit might also be less labor-intensive, Carnicelli added. At his own institution, the study protocol allowed up to four patients to be managed at one time by stepdown-unit staff.

This was a single-institution study, so not definitive, but the experience was positive and should be evaluated elsewhere because of the advantages that extend beyond cost savings, including better patient well-being, he said.

The protocol for stepdown transfers and stepdown-unit care developed at the Medical University of South Carolina are available upon request, Carnicelli said.

Stepdown-unit management has relative advantages over ICU management, and not necessarily because of the cost savings, said Wilbert S. Aronow, MD, professor of medicine and director of Cardiology Research at the Westchester Medical Center and the New York Medical College, in Valhalla, who did not hear the presentation, but was a co-author of a review article on the Impella device.

“I think a stepdown unit would be preferable to an intensive care unit for managing Impella-fitted patients if this was proven safe in a large-controlled trial,” he said, adding that patients are more comfortable in calmer setting.

Carnicelli reported a financial relationship with Acorai. Aronow reported no conflicts of interest.