CARDIOLOGY B
ADVANCED HEART FAILURE & TRANSPLANT
Template for VAD/transplant presentation
Important contacts and Links:
1. There is a Google calendar, which outlines evening schedules as well as clinics, vacations, conferences, etc. Email: cardsbservice and password (case sensitive) HeartFailure.
2. Ensure appropriate follow up for patients you d/c over the weekend:
complete the discharge summary
email post-dc@uw.edu (for transplant patients) or pre-dc@uw.edu (for all others) with a brief overview of the admission and discharge needs.
3. Card B protocols (Transplant med details and more)are available in OCCAM (log in with your UW net ID, see UWMC--Cardiology link on the right.)
https://occam.hsl.washington.edu/category/uwmc/cardiology-b-uwmc/
4. For patients with suspected rejection in whom you are sending stat DSAs, call (206) 689-6580
Introduction:
The Cardiology B Service provides care to patients with severe heart failure, patients referred with unusual heart diseases (amyloid, sarcoid, inflammatory cardiomyopathies, etc), and patients who have undergone heart transplantation. Some patients will be transfers from the CCU following acute decompensation, some are undergoing transplant/LVAD work-up, and others are hospitalized for heart failure “tune-ups” or post-transplant complications.
Learning goals for the rotation:
1. Learn to formulate a treatment plan for acute and chronic heart failure including:
a. Becoming an expert at assessing volume status in patients with heart failure, both by clinical exam, and by non-invasive evaluation with jugular vein ultrasonography.
b. Understanding and be able to calculate a Fick cardiac output from mixed venous blood draws.
c. Becoming an expert in determining optimal medical therapy for treatment of heart failure by understanding the pharmacology and optimal use of medications used in managing patients with heart failure: diuretics, RAAS inhibition, beta-blockade, digoxin, and low dose inotropes.
2. Understand the evaluation of new onset heart failure including the role of:
a. Non-invasive testing such as ECHO and MRI
b. Laboratory testing to rule out reversible causes of cardiomyopathy
c. Ischemic evaluations
3. Understand the indications for primary prevention ICD therapy and CRT
4. Understand the indications, relative and absolute contraindications for advanced heart failure therapies (transplant, MCS) and both the type and quality of evidence associated with screening tests used to establish efficacy.
5. Gain experience in caring for patients following cardiac transplantation including such factors as:
a. Induction and maintenance immunosuppressive regimens
b. Surveillance for rejection
c. Surveillance and treatment of common and uncommon infections
d. Common drug-drug interactions with immunosuppression and use of immunosuppression in patients who are NPO.
e. Role of stress testing
f. Understand the unique physiology of the cardiac allograft in acute management and and chronic surveillance.
6. Observe a heart transplant and/or implantation of a mechanical circulatory support device.
7. Participate in one donor evaluation with an attending using DonorNet.
8. Implement best practices and review evidence to transition patients to the outpatient setting and prevent re-admission.
9. Understand the role of different practitioners in the care of patients with advanced heart disease including: advanced practice providers (ARNP’s, PA’s), pharmacists, social work, and RN’s
10. Understand the role of palliative care in advanced heart disease care planning.
Service Structure:
Staffing:
1. Two to Three ARNPs. They provide primary care for 4-6 patients each.
2. A medical resident will be on the service some months. This is an elective rotation that attracts residents that are usually motivated by an interest in cardiology. On average, they take some vacation and have clinic for one full day/week while on the service.
3. A cardiology fellow (general or AHFTC) who provides consultation/support for ARNP’s and residents. (see expectations below).
4. There is a dedicated pharmacist and a dedicated social worker but no team assistant or coordinating RN.
5. Several nocturnists who cover the service from 8:00 PM – 8:00 AM.
1. While in your continuity clinic, clinic is your responsibility and the Cards B attending will support the ARNP’s and resident: tell your attending or chief if you're paged repeatedly
2. Admissions: Review ALL admissions 8AM-5PM with the ARNP.
You are responsible for notes and orders of patients you seen in post-discharge clinic or Fridays 5-8PM. These patients will transfer to an ARNP the next day
3. Rounds:
a. Help organize rounds to handle acute issues expeditiously.
b. We are moving towards including more providers in rounds to streamline communication, especially the RN. You will get the list of patients by room with RN and their phone # in the AM (the PSS prints it daily.) Call the RN when you are 1 patient away from reaching their patient and invite them to join if available.
4. Learn about cardiac transplant patients. We assume that you have had no previous exposure to this very specialized patient group. Rejection and infection are the two most common reasons for admission. You need to consider cardiac rejection (either cellular or antibody mediated) in patients with dyspnea, shortness of breath, heart failure, arrhythmia, hypotension, unexplained tachycardia, RUQ abdominal pain, or troponin elevation. When in doubt get an echo. There is a stereotypical temporal pattern of infections after transplant: the most frequent infection in the post transplant patient is CMV; half of infections after six months are community acquired. Early imaging is important in the evaluation and management of immunosuppressed patients.
5. Consults on patients with heart failure or cardiac transplantation on other services are performed by the fellow (general or AHFTC) on the MCS service and staffed by the MCS attending with the exception of “fresh” transplants. You will be responsible for consultation on patients undergoing index transplantation and still on CTICU service. These consults will be staffed by the Card B attending.
6. Participation in the biopsy lab was previously a requirement and is now an option. Let us know if you are interested. Biopsies are performed on Monday, Tuesday, Wednesday and Thursday. It is a great option to improve right heart catheterization skills if desired.
7. You will need to help assess patients being admitted from the Emergency Room if there is a question of need for admission vs outpatient follow up, or if the patient is borderline for floor status vs ICU.
Clinic - You may see a few patients that are sufficiently tenous on discharge and cannot be accomodated by the ARNP clinics due to insufficient staffing or special cases of high acuity. You will staff with the inpatient attending--This will not conflict or be an add on to your continuity clinic.
Schedule: (note that rounding format is in flux as inter-professional rounding is introduced in 2016)
8:00 – 8:15: Sign-out from the nocturnist to the team. The second year cardiology fellow is expected to be present at morning sign-out.
8:45 – 9:00 Brief to review any urgent patient needs.
9:00-10:30 Rounds with cardiology attending, ARNPs, cardiology fellow, resident, pharmacist and social worker and, on 5NE at least, the RN.
10:30-12:00 Bedside rounds with attending, review studies, assist ARNP’s in obtaining consults
12:00-12:15 Brief with CCU and MCS fellows to review patients nearing transfer between services
13:00-16:00 Be immediately available for questions and help to ARNP's or residents. See clinic patients prn (max 1 per day).
16:00 – 16:30: Afternoon review, pre-discharge planning on 5NE workroom
17:00 – 20:00: Admissions/ card B pager coverage: Mon-Thur: APP's. Fridays: Weekend on-call card B fellow. There is an upper-level fellow in house until 8PM to support the CCU and Card B teams as needed. Typically Wed is the card B fellow day, with CCU fellows covering other days.
Conferences:
1. The second year fellows are expected to attend all Wednesday Morning Conferences and Friday Cardiology Grand Rounds. Attendance is required
2. Transplant Conference is weekly on Thursday morning from 8:00 – 9:45 in the CT Surgery conference room (AA115K) or Turner Conference Room (E202). Be prepared to present the in-patients who are being considered for advanced heart failure therapies. Clarify with the AHFTC fellow who will be presenting patients who are being discussed. There is an EPIC template that needs to be completed for each patient being presented. Following the presentation, the templated note should be updated with the results of the discussion (list, turn down for X reason or continuing work-up, needs XYZ completed) and cc’d to the patient’s attending. Attendance required
3. MCS Conference is weekly on Thursday from 16:00 – 17:00. Patients being considered for MCS and patients who have received MCS are reviewed. This is an important conference to make sure that any patient who is being worked up for MCS is on the “VADar” of the MCS service. Attendance recommended
4. Transplant Pathology Conference is held monthly on the first Wednesday of the month from 8:30 – 9:30 in the pathology conference room on the second floor (NE 140 G). Endomyocardial biopsy specimens, LVAD core pathology, and explanted heart pathology are reviewed. This is an excellent conference. Attendance required
5. Transplant/HF Educational Conference is held monthly on the last Wednesday of the month from 4:00 - 5:00 in the CT Surgical conference room. Attendance required
Weekends:
The weekends are covered by an attending, a general (second or third year) cardiology fellow, and a moonlighting hospitalist who works from 8 AM-8 PM. The hospitalist should be given >50% of the patients to care for, as the general cardiology fellow will also be covering EP patients and consults. The hospitalist will admit all patients from 8 AM-8PM. The second year fellow should be available for sign-out from the nocturnist at 8:00 AM. Weekend attending rounds generally begin at 9:00 AM.
Tips and Tricks:
AVOID NSAIDS and AMINOGLYCOSIDES under (virtually) any circumstance
SHORTNESS OF BREATH in a POST TRANSPLANT patient is REJECTION UNTIL PROVEN OTHERWISE – this cannot be stressed enough.
All major patient care decisions are to be run by an attending, including titration of vasodilators and inotropes until they are more comfortable with your management style/skill
The attending should be notified at the earliest possible time of notable changes in patient status
There is a great deal of "ART" to management of these advanced heart failure patients--while this can be confusing when attendings are changing, ask them about their practice and learn each of their styles.