Novel Acute Care Nurse Practitioner–Led Prehabilitation Protocol in a Mechanical Circulatory Support Program

Advanced heart failure is often associated with multiorgan failure, frailty, and poor quality of life. It represents 10% of the 6.7 million adults in the United States afflicted with heart failure—a chronic, progressive, and debilitating syndrome.1,2 Within the first year of diagnosis of advanced heart failure, a heart transplant or an insertion of mechanical circulatory support (MCS), such as a left ventricular assist device (LVAD), must be employed to prolong a patient’s survival with improved quality of life. However, due to multiple organ failure, frailty is common in advanced heart failure, particularly in those who are candidates for an LVAD, and is a predictor of poor postoperative outcomes.3–5 Candidates for LVAD therapy are typically frail, encompassing deficient functional capacity and, to some extent, cachexia, which significantly contribute to long intubation time, prolonged critical care stay and hospitalization days, and high mortality rates.4,5In recent years, there has been increased interest in exploring various strategies to reverse frailty before and after hospitalization for LVAD implantation. Research data from the cardiac and general surgery populations show that implementing comprehensive preoperative and postoperative rehabilitation programs reverses frailty.4,6–9 Preoperative rehabilitation, referred to as prehabilitation, is a process aimed at optimizing patients’ functional capability, general health, and well-being and enabling them to withstand the systematic stress of a major surgery (eg, abdominal and cardiac), resulting in improved postoperative outcomes.10–12 In 2023, the International Society for Heart and Lung Transplantation published a consensus statement recommending frailty assessment as essential for diagnosing and evaluating advanced heart failure and/or candidacy for LVAD therapy. Moreover, prehabilitation before implantation of a durable LVAD is highly recommended in the statement.6This article describes the development of a novel prehabilitation LVAD protocol led by an acute care nurse practitioner (ACNP) in an MCS program on the West Coast of the United States. It presents an initial implementation and outcome evaluation as used with a patient requiring the implantation of a durable LVAD and discusses implications for research and practice.The ACNP team in the MCS program initiated the conceptualization and development of the prehabilitation protocol program. A doctorally prepared ACNP convened, led, and collaborated with a multidisciplinary team that began by exploring ways to further understand the characteristics of frailty among patients with advanced heart failure. This exploration included literature synthesis and multiple discussions with the multidisciplinary team, leading to the development of the LVAD prehabilitation protocol. The ACNP leader was responsible for presenting the protocol to essential stakeholders, subsequently gaining collective support in implementing the protocol on a patient described later in this article.The overarching goals of the prehabilitation program were to support LVAD candidates in developing healthy dietary habits, avoiding a sedentary lifestyle, and beginning a tolerated exercise program with expert guidance by a member of the multidisciplinary MCS team, such as a physical or occupational therapist. The program sought to enhance the patient’s physical function capability and general health before scheduling the surgical implantation of the LVAD. The Figure illustrates the prehabilitation protocol, comprising 4 steps: assessment, education, interventions, and reassessment. With each, the MCS multidisciplinary team’s collaboration and engagement are paramount.An initial frailty assessment for LVAD candidates is conducted, focusing on physical and cognitive functions, nutritional status, and risk stratification. This step is crucial for establishing baseline data for identifying types of frailty and determining eligibility for enrollment in the prehabilitation LVAD program.LVAD coordinators provide educational materials to patients enrolled in the prehabilitation program. Comprehensive patient education is instrumental in providing patients with knowledge and understanding about contributory or risk factors of frailty. Additionally, information regarding the overall benefits of prehabilitation empowers patients and increases their motivation to actively engage in the self-management process to optimize their health before LVAD implantation.Through a multidisciplinary approach, a prehabilitation care plan tailored to the initial frailty assessment completed during step 1 is implemented. Led by the ACNP, this team collaboration aims to optimize the patient’s physical, cognitive, and nutritional functions through the support of various disciplines in the MCS program, including nutritionists and physical and occupational therapists. Such rich multidisciplinary collaborative efforts are intended to mitigate risks identified through patient risk stratification conducted in preparation for LVAD implantation.Patient frailty is assessed immediately before implantation and at 3 months after LVAD implantation hospitalization. This step aims to evaluate frailty markers (eg, positive or negative changes), informing the multidisciplinary team to monitor progression and address any persistent issues to ensure ongoing optimization of the patient’s health and quality of life.The initial recipient of the prehabilitation LVAD protocol was a 62-year-old Asian-American male with a history of nonischemic cardiomyopathy secondary to methamphetamine use disorder and chronic systolic heart failure with a left ventricular ejection fraction of 20%. He developed decompensated heart failure, eventually leading to cardiogenic shock, which required a temporary MCS. Due to the severity of his advanced heart failure, he was evaluated for and eventually received an LVAD implant.The patient was enrolled in the prehabilitation program to reverse his frailty and optimize his physical function before the LVAD implant. During the initial evaluation for LVAD and before implant, the patient exhibited profound frailty, as evidenced by poor performance in 6-minute walk distance (6MWD) and short physical performance battery (SPPB), as well as grip strength test results typical of patients with advanced heart failure (Table). Additionally, the patient had cognitive impairment and very poor quality of life, as exhibited by a Montreal Cognitive Assessment (MoCA) score of 12 and a Kansas Cardiomyopathy Questionnaire (KCCQ) summary and clinical score of 6.3 and 8.4, respectively.13,14 In recent years, these data have been critical in determining eligibility for LVAD implants.After 21 days with the prehabilitation protocol, the patient’s physical function and nutrition status improved. Substantial improvement was noted, particularly in the patient’s SPPB score, suggesting readiness to withstand highly stressful LVAD surgery. The patient then successfully underwent a durable LVAD implantation without significant intraoperative complications. Immediately after LVAD implantation, the team continued the prehabilitation protocol as the patient tolerated it. After the fourth postoperative day in the critical care unit, the patient was transferred to a progressive care unit and discharged from the hospital on postoperative day 14.At a 3-month postimplantation hospitalization follow-up visit, the patient continued showing functional and nutritional status improvement without any adverse events or complications necessitating postimplantation hospitalization readmission. The patient’s physical function had significantly improved, with more than a four-fold increase in 6MWD from the initial evaluation (Table). Notably, the patient’s cognitive function improved from the first assessment, from the initial MoCA score of 12 to a score of 29, suggesting the absence of cognitive impairment.13 Also, his quality of life showed improvement through his respective KCCQ summary and clinical scores of 62 and 62.6.14 These 3-month data suggest a reversal of frailty leading to the patient’s referral to a cardiac rehabilitation program for continued optimization of physical and nutritional function. The patient successfully received a heart transplant 15 months after implantation hospitalization.This article briefly described the development and implementation of a multidisciplinary prehabilitation protocol led by an ACNP in an MCS program. Initial implementation outcomes supported the extant literature about prehabilitation in the cardiac and general surgery population.6,10–12 However, the data were limited to 1 patient. Therefore, a well-designed research study with sufficient sample size is warranted to generate data regarding reversing frailty and improving outcomes before, during, and after implantation of durable LVADs. Longitudinal study designs are certainly needed, beyond 3 months after implantation hospitalization, to elicit data corroborating the evidence that quality of life and cognitive function significantly improve at 6 months or more after implantation of durable LVADs.15–17 Also needed are data regarding the MCS team’s intervention fidelity (eg, clinician and/or patient adherence to prehabilitation protocol), enrollment timing, and other factors that need to be controlled to achieve rigor with internal validity.An ACNP with a doctorate in nursing practice is well suited to lead an implementation science team to further provide evidence-based clinical management practices in the LVAD population. More importantly, ACNPs in MCS programs must continue to be innovative in developing and testing care delivery models responsive to nursing outcomes. Since the early use of MCS in outpatient settings more than 3 decades ago, advanced practice nurses have been known to create, innovate, and improvise care processes tailored to the unique needs of patients and their family caregivers.18 This novel prehabilitation protocol is another example of that tradition, where ACNPs in the twenty-first century continue to demonstrate their leadership and impact on increasing survival and optimizing the quality of life for individuals living with LVADs.