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Improving Care of Adult Patients Undergoing Cardiac Surgery at Loyola University Medical Center

Improving Care of Adult Patients Undergoing Cardiac Surgery at Loyola University Medical Center. By: Jeffrey Schwartz, MD, Assistant Professor, Department of Thoracic & Cardiovascular Surgery Derrek Davis, MD assistant Professor, Department of Anesthesiology

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Improving Care of Adult Patients Undergoing Cardiac Surgery at Loyola University Medical Center

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  1. Improving Care of Adult Patients Undergoing Cardiac Surgery at Loyola University Medical Center By: Jeffrey Schwartz, MD, Assistant Professor, Department of Thoracic & Cardiovascular Surgery Derrek Davis, MD assistant Professor, Department of Anesthesiology Michael Jarotkiewicz, Cardiovascular Service Line Administrator Cardiovascular Surgery QI Team

  2. LUMC – Cardiovascular Surgery Department • 5 Cardiovascular/Thoracic Surgeons • Over 600 Open Heart Pump cases/year • Top Center for Mitral and Aortic Valve repair and replacement • Over 583 Heart Transplants since 1984 • Over 250 Lung Transplants since 1990 • 1st successful Heart-lung transplant in Illinois (1986)

  3. Identify the Problem……. Historical trend of higher than acceptable risk adjusted complications/mortality as compared to University HealthSystem Consortium data base.

  4. Identify the problem……..

  5. LUMC CV-Surgical Team Surgeons Nurse Practitioners CV O.R. Staff CV Anesthesia 2-Surgical ICU-Staff Surgical Outcomes 3 NEWS-Telemetry Staff Cardiac Rehab Staff Respiratory Care

  6. These things don’t just happen…….Keys to Success • Multidisciplinary QI Team • DRG specific Cost initiatives • Post-op Primary CV Surgical Service • Dedicated Nurse Practitioner Model • Consolidated Patient Placement 3W Telemetry

  7. More Keys to Success • Dedicated Anesthesiology – 24 Hr. ICU Post-operative patient management • Early awareness, recognition and prevention of post-op complications • Ventilator Weaning/Early Extubation Protocol • Resident accountability

  8. Solutions - Implementations • Aggressive Education of CV – Team • Physicians, Nurses, Respiratory therapists • Aggressive re-warming of patient (OR team) • Reduced utilization of sedation and improved pain management • Implementation of weaning & extubation protocols

  9. Solutions – Implementations Cont. • Implementation of standing orders and integration into Electronic Medical Record (EMR) and Physician Order Entry (POE) Systems • Monitoring and sharing of results with all team members • Nurse Practitioner coordination of project

  10. Solutions – Example - Early Extubation ResultsCABG Patients on a Ventilator for 4 hours or less

  11. Solutions – Example - Early Extubation ResultsUHC CABG Time on a Ventilator

  12. Results • Significant improvement from 4Q 1999 – 3Q 2000 to 3Q – 4Q 2001 • Mean LOS – 9.49 Days • Mean Cost per Case - $24,511 • Mortality – 0.6% (0/E 0.15) identified as best performer in institutions performing >100 CABG procedures

  13. Results

  14. Results

  15. Loyola Expected Loyola Observed Post CABG Patient Mortality 8 6 Mortality Rate (Percent) 4 Mean = 3.7 2 0 CY98 Q1 CY98 Q3 CY99 Q1 CY99 Q4 CY00 Q2 CY02 Q1 CY02 Q2 CY02 Q4 CY03 Q2 CY98 Q2 CY98 Q4 CY99 Q2 CY99 Q3 CY00 Q1 CY00 Q3 CY00 Q4 CY01 Q1 CY01 Q2 CY01 Q3 CY01 Q4 CY02 Q3 CY03 Q1 CY03 Q3 Results

  16. 4Q 1999-3Q 2000 vs 3Q 2001-4Q 2001

  17. UHC CABG 3Q-4Q 2001 Performance

  18. CY 2001 STS Comparative Data CABG O/E Operative Mortality Ratio (N=313)

  19. CY 1998 - 2001 STS CABG Risk Adjusted Operative Mortality Trends

  20. CY 2001 STS Data CABG Unadjusted Mean LOS N=313

  21. CY 2001 STS Data CABG O/E Ratio Short < 6 days & long >14 days stay N=313

  22. CY 2001 STS Pre-procedure Co-morbidity

  23. CY 2001 STS Pre-procedure Co-morbidity

  24. What are our new challenges? • 100% Patient census and capacity issues • CON regulation changes in the State of Illinois • Competition • “Cherry picking” • “Leapfrog” – quality tracking • Interventional Cardiology & Gene Therapy • Reimbursement

  25. Hospital Census – 100% Occupancy Capacity/Bed Availability • Scheduling problems/Delays • Telemetry bed availability • Delays in “Rehabilitation” interventions • Increased ICU LOS • Increase in total LOS • Patient Satisfaction Issues

  26. Hospital Census – 100% Occupancy Bed Availability “What is in our control” • Telemetry bed availability • Trauma Level 1/Increased ED admissions • In-house “Unit renovations” • Increased ICU LOS/Total LOS • Delays in “Rehabilitation” interventions • Patient satisfaction

  27. Patients eligible for 1st day post-op ambulation(Out of bed walking 25-50 ft.) • Extubated • Swan-out • Hemodynamically Stable

  28. Percent of Eligible patients ambulated in ICU 1st Post-op day (Pre)

  29. Percent of Eligible patients ambulated in ICU 1st Post-op day (Post)

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