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A Team Approach to Cardiac Surgery Performance Improvement and Rapid Cycle Change

Arnar Geirsson, Hossam Tantawy, Ryan Strouse, Laurie Devin, Diane Collins, Jeptha Curtis, Nihar Desai, Matthew Gordon, Mary Pierson,
Patricia Byrne, Kelly Howe, Catherine Alvarez, Sarah Kenyon, Maureen Roussel, Manuel Fontes, Francine LoRusso, Keith Churchwell,
Eileen Taylor, Maureen Legenos, Lorna Steele, Christine Picklo, Elizabeth Peters, Pauline Acorda, Lynne Maccubbin, Betsy Hine, Diana Grilo, Ritu Agarwal

Objective Discussion
Improve preoperative and The engagement of leadership of
postoperative management of all CT disciplines has created a
patients undergoing cardiac surgery culture that supports and expects
to reduce variation, increase use of improvement and excellence. A
guideline recommended therapy, multifaceted approach with the
and improve clinical outcomes. use of reports, feedback and
interdisciplinary team has allowed
Methods
for quick tests of change and an
Based on review of YNHH data in the accelerated improvement process.
Society for Thoracic Surgery (STS) Over a brief period, we have seen
Registry, the process measures of focus substantial improvements in pre-
were: op beta blocker use, guideline
1. Use of pre-op beta blockade. directed therapy at discharge, and
2. Standardized assessment of shortened intubation times. Two
Results additional areas of focus have
patients post-op for extubation.
In the STS Registry, CABG prolonged ventilation (greater than 24 hours) been identified – post-op A Fib and
3. Use of guideline directed medical
started with a mean time of 16.0 hours. The mean time is now 13.7 hours sternal wound infection
therapy at discharge including
with a median time of 8.9 hours. 94% of CABG patients are extubated within prevention. Taken together, these
aspirin, beta blocker, ACE inhibitor,
24 hours. Also, additional intubation hours and re-intubation have efforts will improve the outcomes
and statin.
simultaneously decreased. achieved for patients and reduce
4. Future star rating metric of STS cost. The ability to share success
The administration of Pre op Beta Blockers has also shown improvement
score documentation with risk and and opportunities in a transparent
from 81.2% to 88.9% of eligible cases. Discharge medications such as beta
benefits. manner has allowed for open
blocker, ACE and lipids among eligible cases have maintained 97-99%
The above measures are part of the compliance. Imbedding the STS risk score into the discussion with potential discussion and creative
STS Star rating metrics. Our methods CT surgery patients has allowed providers to explain in simple terms the improvement interventions.
included: An interdisciplinary team risks and benefits for surgery. Compliance has gone from 0-71%. YNHH has a Implications for Yale New Haven Health
including surgeons, anesthesiologists, The development of a
higher than benchmark average of post-op a fib and post-op sternal wound
cardiologists, quality managers, nurse multidisciplinary performance
infections. These two improvement opportunities are underway with the
managers, respiratory therapists, improvement team for CT surgery
engagement of the consulting experts in electrophysiology and infection
advance practitioners (APP) data will enable YNHH to provide
prevention. These groups are developing strategies to standardize processes
abstractors, Joint Data Analytic team uniformly excellent care for all
to optimize best practices and improve patient safety.
(JDAT) and staff from all areas caring patients. The development of the
for cardiac surgery patients was put STS dashboard and reports will
together. With active participation of support continuous improvement
all team members, a dashboard was efforts moving forward. In sum,
created to facilitate feedback and these efforts will facilitate YNHH
increase transparency. becoming a three star facility
based on STS Star Ratings.

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