(368) Implementation of a Novel Advanced Practice Provider-Directed Impella Repositioning Program

Introduction: It Is Widely Thought That Impella Percutaneous Ventricular Assist Devices Provide Favorable Hemodynamic Support and Physiologic Benefits in Cardiogenic Shock. Yet Malposition Is Not Uncommon and May Expose the Patient to Hemolysis, Arrhythmias, and Inadequate Support among Other Complications. Repositioning of an Impella Has Historically Been Limited to Select Physicians, Which Often Means a Significant Delay Between Initial Malposition and Resolution. This Leads to Prolonged Exposure to Complications for the Patient as Well as an Unduly High Call Burden for the Physician That May Create Aversion to Pump Placement. We Describe the Safe Implementation of a Process in Which Advanced Practice Providers (APPs) Are Trained and Privileged to Independently Perform Limited Subvalvular Repositioning of Impellas, Resulting in Less Patient Exposure to Complications as Well as a Reduced Call-back Burden for Implanting Physicians.

Methods: Privileging Language and Procedural Scope Were Written and Defined. An Educational Curriculum and Competency Were Generated with Vendor Recommendations for Provider Certification as a Template and Increased per Institutional Recommendations. This Included a Mixture of Online and In-person Education, Mannequin Training, and Completion of 3 Proctored Repositionings. Protocols for Repositioning Were Developed, with Limitations and Hard-Stops Defined. These Were Approved by the Hospital Credentialing Committee, Medical Executive Committee, and Board. The Program Was Then Rolled out to the Cardiovascular ICU.

Results: Over a Period of 2 Months, APPs Were the Primary Proceduralists in the Repositioning of 10 Impellas. Repositionings Were Split Evenly Between Impella CP (5) and 5.5 (5). Access Sites Were Axillary in 6 Cases and Femoral in 4. Repositioning Was Triggered by Console Alarms in 6 Cases, and Surveillance Echocardiography in 4 Cases. All 10 Cases Were Resolved by APPs While in Contact with the Attending Intensivist Without Need for Escalation to Physical Physician Intervention. No Impellas Were Dislodged and No Complications Were Noted in Our First 10 Respositionings.

Conclusions: With Proper Training and Supervision, APPs Can Be Safely Utilized to Provide Limited Bedside Impella Repositioning as a Means to Expedited Resolution of Malpositioning.