Reports From the Field

Implementation of a Multidisciplinary Team–Based Clinical Care Pathway Is Associated With Increased Surgery Rates for Infective Endocarditis

Journal of Clinical Outcomes Management. 2023 March;30(2):42-48 | 10.12788/jcom.0125

Author(s):

References

1. Baddour LM, Wilson WR, Bayer AS, et al. Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications: a scientific statement for healthcare professionals from the American Heart Association. Circulation. 2015;132(15):1435-1486. doi:10.1161/cir.0000000000000296

2. Federspiel JJ, Stearns SC, Peppercorn AF, et al. Increasing US rates of endocarditis with Staphylococcus aureus: 1999-2008. Arch Intern Med. 2012;172(4):363-365. doi:10.1001/archinternmed.2011.1027

3. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(23):e521-e643. doi:10.1161/cir.0000000000000031

4. Chambers J, Sandoe J, Ray S, et al. The infective endocarditis team: recommendations from an international working group. Heart. 2014;100(7):524-527. doi:10.1136/heartjnl-2013-304354

5. Habib G, Lancellotti P, Antunes MJ, et al. 2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J. 2015;36(44):3075-3128. doi:10.1093/eurheartj/ehv319

6. Chirillo F, Scotton P, Rocco F, et al. Impact of a multidisciplinary management strategy on the outcome of patients with native valve infective endocarditis. Am J Cardiol. 2013;112(8):1171-1176. doi:10.1016/j.amjcard.2013.05.060

7. Botelho-Nevers E, Thuny F, Casalta JP, et al. Dramatic reduction in infective endocarditis-related mortality with a management-based approach. Arch Intern Med. 2009;169(14):1290-1298. doi:10.1001/archinternmed.2009.192

8. El-Dalati S, Cronin D, Riddell IV J, et al. The clinical impact of implementation of a multidisciplinary endocarditis team. Ann Thorac Surg. 2022;113(1):118-124.

9. Carrasco-Chinchilla F, Sánchez-Espín G, Ruiz-Morales J, et al. Influence of a multidisciplinary alert strategy on mortality due to left-sided infective endocarditis. Rev Esp Cardiol (Engl Ed). 2014;67(5):380-386. doi:10.1016/j.rec.2013.09.010

10. Issa N, Dijos M, Greib C, et al. Impact of an endocarditis team in the management of 357 infective endocarditis [abstract]. Open Forum Infect Dis. 2016;3(suppl 1):S201. doi:10.1093/ofid/ofw172.825

11. Kaura A, Byrne J, Fife A, et al. Inception of the ‘endocarditis team’ is associated with improved survival in patients with infective endocarditis who are managed medically: findings from a before-and-after study. Open Heart. 2017;4(2):e000699. doi:10.1136/openhrt-2017-000699

12. Rotter T, Kinsman L, James E, et al. Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database Syst Rev. 2010;(3):Cd006632. doi:10.1002/14651858.CD006632.pub2

13. Neame MT, Chacko J, Surace AE, et al. A systematic review of the effects of implementing clinical pathways supported by health information technologies. J Am Med Inform Assoc. 2019;26(4):356-363. doi:10.1093/jamia/ocy176

14. Trimarchi L, Caruso R, Magon G, et al. Clinical pathways and patient-related outcomes in hospital-based settings: a systematic review and meta-analysis of randomized controlled trials. Acta Biomed. 2021;92(1):e2021093. doi:10.23750/abm.v92i1.10639

15. Gibbons EF, Huang G, Aldea G, et al. A multidisciplinary pathway for the diagnosis and treatment of infectious endocarditis. Crit Pathw Cardiol. 2020;19(4):187-194. doi:10.1097/hpc.0000000000000224

16. Regunath H, Vasudevan A, Vyas K, et al. A quality improvement initiative: developing a multi-disciplinary team for infective endocarditis. Mo Med. 2019;116(4):291-296.

17. Regunath H, Whitt SP. Multidisciplinary service delivery for the endocarditis patient. In: Infective Endocarditis: A Multidisciplinary Approach. 1st ed. Kilic A, ed. Academic Press; 2022.

18. Durack DT, Lukes AS, Bright DK. New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service. Am J Med. 1994;96(3):200-209. doi:10.1016/0002-9343(94)90143-0

19. Tan C, Hansen MS, Cohen G, et al. Case conferences for infective endocarditis: a quality improvement initiative. PLoS One. 2018;13(10):e0205528. doi:10.1371/journal.pone.0205528

20. Ruch Y, Mazzucotelli JP, Lefebvre F, et al. Impact of setting up an “endocarditis team” on the management of infective endocarditis. Open Forum Infect Dis. 2019;6(9):ofz308. doi:10.1093/ofid/ofz308

21. Camou F, Dijos M, Barandon L, et al. Management of infective endocarditis and multidisciplinary approach. Med Mal Infect. 2019;49(1):17-22. doi:10.1016/j.medmal.2018.06.007

22. Pettersson GB, Hussain ST. Current AATS guidelines on surgical treatment of infective endocarditis. Ann Cardiothorac Surg. 2019;8(6):630-644. doi:10.21037/acs.2019.10.05

23. Mestres CA, Paré JC, Miró JM. Organization and functioning of a multidisciplinary team for the diagnosis and treatment of infective endocarditis: a 30-year perspective (1985-2014). Rev Esp Cardiol (Engl Ed). 2015;68(5):363-368. doi:10.1016/j.rec.2014.10.006

24. Stavi V, Brandstaetter E, Sagy I, et al. Comparison of clinical characteristics and prognosis in patients with right- and left-sided infective endocarditis. Rambam Maimonides Med J. 2019;10(1):e00003. doi:10.5041/rmmj.10338

From the University of Missouri School of Medicine, Columbia, MO (Haley Crosby); Department of Clinical Family and Community Medicine, University of Missouri, Columbia, MO (Dr. Pierce); and Department of Medicine, Divisions of Infectious Diseases and Pulmonary, Critical Care and Environmental Medicine, University of Missouri, Columbia, MO, and Divisions of Pulmonary and Critical Care Medicine and Infectious Diseases, University of Maryland Baltimore Washington Medical Center, Glen Burnie, MD (Dr. Regunath).

ABSTRACT

Objective: Multidisciplinary teams (MDTs) improve outcomes for patients with infective endocarditis (IE), but methods of implementation vary. In our academic medical center, we developed an MDT approach guided by a clinical care pathway and assessed outcomes of patients with IE.

Methods: We compared outcomes of patients with IE and indications for surgery between December 2018 and June 2020 with our prior published data for the period January to December 2016. MDT interventions involved recurring conferences with infectious diseases physicians in team meetings and promoting a clinical care pathway to guide providers on steps in management. Primary outcomes were surgery and in-hospital death.

Results: Prior to the intervention, 6 of 21 (28.6%) patients with indications for surgery underwent surgery or were transferred to higher centers for surgery, and 6 (28.6%) patients died. Post intervention, 17 of 31 (54.8%) patients underwent or were transferred for surgery, and 5 (16.1%) died. After adjusting for age and gender, the odds of surgery or transfer for surgery for patients in the postintervention period were 4.88 (95% CI, 1.20-19.79; P = .027) compared with the pre-intervention period. The odds ratio for death among patients in the postintervention period was 0.40 (95% CI, 0.09-1.69; P = .21).

Conclusion: An MDT team approach using a clinical pathway was associated with an increased number of surgeries performed for IE and may lower rates of in-hospital mortality.

Keywords: infective endocarditis, clinical pathway, quality improvement, multidisciplinary team, valve surgery.

Infective endocarditis (IE) is associated with significant morbidity and mortality.¹ Rates of IE due to Staphylococcus aureus are increasing in the United States.² Reported in-hospital mortality from IE ranges from 15% to 20%.³ Optimal management of IE requires input from a number of specialties, including infectious diseases (ID), cardiology, cardiothoracic surgery (CTS), oromaxillofacial surgery, radiology (eg, nuclear medicine), and neurology, among others, depending on the site of complications. Guidelines from the United States and Europe recommend incorporating multidisciplinary teams (MDTs) in the management of IE.^1,3-5 These recommendations are based on quasi-experimental before-and-after studies that have consistently demonstrated that MDTs reduce in-hospital and 1-year mortality.^6-11 However, implementation of MDTs can be challenging. Successful MDTs require good team dynamics, unified participation, and seamless communication among team members.

Clinical pathways are defined as “structured, multidisciplinary plans of care used by health services to detail essential steps in the care of patients with a specific clinical problem.”¹² In the modern era, these pathways are often developed and implemented via the electronic health record (EHR) system. Studies of clinical pathways generally demonstrate improvements in patient outcomes, quality of care, or resource utilization.^13,14 Clinical pathways represent 1 possible approach to the implementation of a MDT in the care of patients with IE.¹⁵

In our earlier work, we used quality improvement principles in the design of an MDT approach to IE care at our institution.¹⁶ Despite having indications for surgery, 12 of 21 (57.1%) patients with IE did not undergo surgery, and we identified these missed opportunities for surgery as a leverage point for improvement of outcomes. With input from the various specialties and stakeholders, we developed a clinical pathway (algorithm) for the institutional management of IE that guides next steps in clinical care and their timelines, aiming to reduce by 50% (from 57.1% to 28.6%) the number of patients with IE who do not undergo surgery despite guideline indications for early surgical intervention. In this report, we describe the implementation of this clinical pathway as our MDT approach to the care of patients with IE at our institution.

References

4. Chambers J, Sandoe J, Ray S, et al. The infective endocarditis team: recommendations from an international working group. Heart. 2014;100(7):524-527. doi:10.1136/heartjnl-2013-304354

8. El-Dalati S, Cronin D, Riddell IV J, et al. The clinical impact of implementation of a multidisciplinary endocarditis team. Ann Thorac Surg. 2022;113(1):118-124.

16. Regunath H, Vasudevan A, Vyas K, et al. A quality improvement initiative: developing a multi-disciplinary team for infective endocarditis. Mo Med. 2019;116(4):291-296.

17. Regunath H, Whitt SP. Multidisciplinary service delivery for the endocarditis patient. In: Infective Endocarditis: A Multidisciplinary Approach. 1st ed. Kilic A, ed. Academic Press; 2022.

19. Tan C, Hansen MS, Cohen G, et al. Case conferences for infective endocarditis: a quality improvement initiative. PLoS One. 2018;13(10):e0205528. doi:10.1371/journal.pone.0205528

21. Camou F, Dijos M, Barandon L, et al. Management of infective endocarditis and multidisciplinary approach. Med Mal Infect. 2019;49(1):17-22. doi:10.1016/j.medmal.2018.06.007

22. Pettersson GB, Hussain ST. Current AATS guidelines on surgical treatment of infective endocarditis. Ann Cardiothorac Surg. 2019;8(6):630-644. doi:10.21037/acs.2019.10.05

Implementation of a Multidisciplinary Team–Based Clinical Care Pathway Is Associated With Increased Surgery Rates for Infective Endocarditis

References

ABSTRACT

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