Problem Solvers

 







Problem Solvers: Taking a New Cardiac Surgery Path



by Marlene Goldman

Richard Johnson remembers well his first brush with heart surgery 21 years ago. Stricken with what he says felt like a ten-ton weight on his chest, the 52-year-old engineer turned to Emory for quadruple bypass surgery. After 11 days in the hospital and a breathing tube for "what seemed like forever," he went home.

This past July, well beyond the average lifespan of a bypass, Johnson came back for a "redo." Same place, same doctor, but what a difference two decades of experience and creative problem-solving make.

The second time around, Johnson, now 73, spent just four days at Emory Hospital. After surgery on a Monday, he was breathing by himself in less than eight hours and went from intensive care to the floor within a day. By Wednesday, he was strolling the halls, and on Thursday, he left the hospital to visit his daughter in Stone Mountain. By August, he and his wife, Virginia, (shown above) were taking mile-long walks every morning near their home in Warner Robins.

Johnson's seemingly remarkable recovery is not that unusual today by Emory Hospitals' standards. More than a third of the 3,000 patients who come to Emory University Hospital and Crawford Long Hospital each year for similar procedures are discharged within four days; more than 60% are discharged within five days. Fast-track approaches to surgery and aftercare through "clinical pathways" get patients in and out of the hospital faster and back into their daily routines. While economics, along with technology and new drugs, have driven much of the change, patients say they feel better in the process. They also have fewer complications and are more personally involved in their care.

Setting the pace

Clinical pathways have reduced length of stay and costs of care.

Cardiac surgery pathways are success stories that have set the pace for other services at both Emory and Crawford Long hospitals. Five years ago, charges for open heart surgery at Emory University Hospital were among the highest in the Atlanta area.

"That's partly because of the higher acuity level of patients we see," says cardiothoracic surgeon Joe Craver, noting that on the day alone that Momentum interviewed him, he had seen three patients referred by other heart surgeons. "We're also a major academic center with people in training who sometimes want additional examinations or tests to document that a patient is doing well after surgery. Extrapolate $250 for frequently ordered tests or as much as $700 for each echocardiogram then multiply it by about 3,000 patients per year - that can add up to a whole lot of money."

While insurance companies picked up all hospital costs in the past, today the surgery team and the hospital must live within predetermined reimbursements for procedures. With its cardiac surgery pathway and a growing host of others, Emory Hospitals have forged ahead in the nationwide push for hospitals to reduce costs while maintaining highest quality of care.

In a clinical pathway, a team identifies a standard of care and practice and sets a timed sequence of diagnostic tests, care interventions, and a recovery program. The pathway is outcome rather than task-oriented and requires that all disciplines involved in providing care help develop the guidelines. Pathways usually target high-volume patient populations who need similar care.

Because extended hospital stays are often neither cost-effective nor critical to patient recovery, an important outcome of clinical pathways has been to reduce length of stay (LOS) and thereby costs of care. Achieving that has strengthened Emory's edge in an increasingly competitive health care marketplace that demands changes in overall patient management.

"Third-party payers, including Medicare, are much more stringent today in how much hospitalization they will pay for," says anesthesiologist James Ramsay, who co-led the EUH cardiac surgery team with Craver. "We're being judged for contracts with all our competitors with regard not only to our quality of care, but also to our costs. Length of stay is a major determinant of cost."

"Sending people home early isn't something we necessarily wanted," Craver adds. "This was mandated by the payer community. If they find that individual surgeons or hospitals are outside the norm, they reserve the right to investigate and withhold payment or send their patients elsewhere. That means we have to comply or be investigated, which gives all hospitals added impetus to standardize procedures. One way we did that was by reducing or eliminating the pre-op hospital stay, and another was by accelerating the post-op recovery."

Everyone at the table


We all got together and challenged every member of the team to examine their practices for what was really necessary.

Since heart surgery patients comprise one of the largest groups in the Emory system, Ramsay and Craver, in consultation with cardiac surgery chief Robert Guyton and others, helped spearhead a move six years ago to get the heart team to sit down together and talk about their practices. That meant bringing the entire team to the table - heart surgeons, cardiologists, anesthesiologists, nurses, respiratory therapists, physical therapists, pharmacists, dietitians, social workers, and hospital administrators - to brainstorm about better ways to care for heart surgery patients.

"We got together for months and challenged every member of the team to examine their practices for what were really necessary," Ramsay says. For almost a year, they talked, and they listened. The rules? Two comments were not allowed: "No, it can't be done," and "It's always been done this way." The goal was to provide timely, efficient, and high-quality care that was cost-effective. The ultimate question the pathway committee asked as they put their practices under the microscope was "How does this affect patient care?"

The team considered every step, from admission to the hospital for surgery to discharge and aftercare at home. And they ended up with a multidisciplinary protocol that called for compromise from all services.

For Craver, it was hard to give up admitting patients the day before surgery. Today, patients undergoing elective surgery visit a preadmission area for final tests and instructions the day before surgery, then check into a motel or return home for the night. These patients come to the hospital the morning of their surgery at 6:30 am. That puts more responsibility on patients and their families and means they must be educated up front.

The team decided to get patients through the recovery process faster by shortening anesthesia so patients could wake up easier and earlier on the day of surgery. Breathing tubes are removed earlier, and if possible, the patient is moved earlier from intensive care to a regular post-op floor.

To do that, the seven cardiac anesthesiologists agreed to use shorter-acting medications in the operating room. "We decided we'd treat a cardiac patient the same way - from an anesthesia point of view - as we'd treat any other patient," Ramsay says, "because there is no proven benefit of high-dose opioid anesthesia. We changed our follow-up management in the ICU so patients are not kept sedated. We allow them to wake up and we wean them off the respirator as early as possible."

Breathing easier



Clinical pathways are not cookbook medicine, says cardiothoracic surgeon Joe Craver. They are guidelines that are helping patients such as Richard Johnson get out of the hospital earlier and back to their daily routines.
Ongoing close contact helps make early discharge more acceptable to patients and families.

Fast-tracking patients sometimes requires using more expensive drugs, such as propofol, for postoperative sedation, which allows patients to awaken more predictably an hour or two after surgery versus 12 to 24 hours. The drug's higher cost has been more than offset by reducing time spent in the $1,200-a-day ICU.

Patients are delighted to get off the ventilator sooner. "Patients have told us for years that what bothers them the most about open heart surgery is the breathing tube in their throat and the chest tubes for drainage. These are now often pulled within 24 hours as soon as drainage slows rather than 'routinely' in three days," says Gabriella Mitchell, nursing director of the cardiovascular ICU.

The changes have proven positive psychologically as well. "It's been much better for the patient and family for the patient to be awake and talking within a few hours of surgery than to be in a sedated state with a ventilator overnight. We can get patients out of the ICU quicker and into a private room where they are happy to be with their family and loved ones and usually return to their normal activities quicker," Mitchell says.

Changing drug therapy has had other benefits, adds pharmacist Linda Pine. Antibiotics are now given immediately before surgery and for 24 hours after, rather than for three days as in the past - with no increase in infection rates and fewer fungal infections, especially in women. Aspirin therapy has become standard practice. And based on evidence that normal saline solution is just as effective as albumin for fluid replacement, saline now is the first-line fluid given in the OR and ICU. The resulting savings are close to half a million dollars a year.

Lab tests were also scrutinized. "Before, we didn't worry about frequent lab tests," Craver recalls. "If there was any advantage of having a lab test every four hours, we'd get it whether we absolutely needed it or not. But now we look at what tests we really need and how often we need them. Blood gases, for example, are one of the most expensive tests, and we've gone from getting blood gas results every four hours for the first day and a half to one blood gas test, period. We use other monitoring to insure adequate oxygen saturation rather than the more expensive blood gas test."

The self-scrutiny also extended into the operating room. Surgical and nursing teams standardized OR supplies and instruments to capitalize on bulk ordering and cut out anything that was done just because it was "routine." Such was the case with the use of cell savers, an expensive process that saves patients' shed blood, cleans it, and makes it available for reinfusion. Today cell savers are used only in cases in which the expected blood loss statistically warrants the cost of running the equipment, staffing it, and buying supplies.

The team challenged other routine practices, such as using invasive monitoring devices like pulmonary artery catheters which measure how much blood the heart is pumping. Because studies have shown that such evaluations can be done clinically and that the monitor often encourages unnecessary treatment, those catheters are used now at Emory Hospitals only on high-risk patients with poor heart function.

With patients waking up earlier, breathing tubes removed faster, and reduced reliance on pulmonary catheters, many patients didn't need to stay in the ICU overnight, especially if they were resting comfortably and didn't require intensive care nursing. Because of these changes, about 20% of cardiac surgery bypass patients go to the floor on the day of surgery. By the next day, all patients are sitting on the side of the bed ("dangling") within four hours of extubation, and are encouraged to get out of bed, walk, and eat.

A hard sell

Patients do best when they know what to expect. Some are surprised, some are shocked, most are elated.

Working out a plan to streamline care was the easy part of fast-tracking. Overcoming the anxiety of patients, their families, referring doctors, and our own clinicians and staff is another story.

Patients can still be sore and in many cases don't have all their body's systems up and running after three days in the hospital, Craver points out. "If the patient isn't walking well but can walk safely, the patient can go home and walk. If the patient's bowels haven't moved but there are no problems, the patient can take a laxative and go home. If there's some fever, but no other signs of infection, it can be watched at home. Medication is prescribed to treat residual pain and soreness. Sometimes patients are doing well but just don't want to go home, or their spouse or caregivers at home may feel imposed on and want to delay the patient's leaving the hospital."

The team has found that patients do best under the fast-track system when they and their families know up front what to expect - that they will come in the day of surgery and if all goes well, they should be ready to go home in three or four days to continue the healing process. Some are surprised, some are shocked, most are elated.

Mary Zellinger, EUH clinical coordinator for cardiovascular services, counsels patients before surgery and during the hospital stay and calls them at home on a regular schedule to see how they're doing and answer their questions. This postdischarge contact also has eased the strain on referring doctors who may not be accustomed to caring for open heart surgery patients.

Such ongoing close contact by nurse coordinators has helped fast-track systems nationwide survive, and Emory is no exception. Craver says it's the single most important thing in making early discharge acceptable to patients and their families, and that it makes them feel comfortable calling back if they have any problems.

Most who leave early don't have problems, a recent study by nurse-researcher Christi Deaton and cardiologist Bill Weintraub shows. They found that patients who stay longest in the hospital, in fact, have the highest incidence of readmission.

"We work on discharge planning from the moment a patient comes in," says Zellinger. "Some patients, particularly elderly patients, on day five don't need an acute care hospital, but their spouse isn't ready to take care of them at home. Our social workers work closely with them to work out the support they need."

Physicians and staff themselves pose another hurdle. "I remember our first meeting," Ramsay says. "Joe Craver and I were very gung ho, but some other members of the team felt that we had had superior results with the status quo, so why question a good thing? But everybody agreed that we needed to control costs and reduce length of stay in order to stay an active player in cardiac surgical health care in Atlanta."

Enforcing such changes in practice has required ongoing diligence, especially with consultants unfamiliar with the clinical pathway or people in training who want to conduct tests to answer curiosity questions. "We have to continually stop those extra tests and procedures. We have to teach these people to be clinical doctors and not only number readers. We get tests when we need them, not if they are just convenient," Craver says.

Accelerating the pace of recovery also has had enormous impact on nursing. Moving patients sooner from the ICU to the floor has required increased skill levels on the floor. Nurses now cross-train to move seamlessly between EUH and CLH to accommodate floor and ICU nursing needs as they change, says Mitchell.

Fine tuning


Today, five years after that first get-together, the team continues to meet quarterly, tweaking the cardiac surgery pathway as it would any fine product. Members of the EUH team have worked closely with their counterparts at Crawford Long, which has had similar positive results. The two teams have now consolidated their membership and care plans.

Besides standardizing practice, the pathway has allowed the cardiac surgery team to collect data on how it's doing. It keeps a close watch on variances - or deviations from the clinical path. If, for example, LOS is a day longer one month than others, the team takes that variance back to the meetings, to individual physicians, to nursing services, or units, and tries to pinpoint its cause and look for remedies.

The team's advice to other services getting on the clinical path bandwagon? Get all your medical specialists and ancillary support services on board. Physician leadership and participation are key to the success of the streamlining effort. Put any recalcitrant colleagues on the committee so that they can understand all the issues and advocate for change.

Checking results

The cardiac surgery clinical pathway has been healthy for both patients and the hospital's bottom line. About 60% of patients are now extubated within six hours of surgery, and 90% of bypass surgery patients spend less than 18 hours in the ICU. Since the cardiac surgery clinical pathway first was implemented at EUH, average length of stay has dropped 39%, from 11 days to 6.7 days. And the savings have been huge - hundreds of thousands of dollars per year.
In this Issue


From the Director  /  Letters

From Mind to Market

Emory Start-Ups and Licensees

Grow West, Entrepreneur

Preparing for the Year 2000

Cardiac Pathways

Learning On-line

Moving Forward  /  Noteworthy

A Question of Service

Cap Worn Around the World

One important measure of success is that readmission rates are the same as before the fast-track program - a fact that the team attributes to the continued high quality of Emory's heart surgery program at all stages.

Other services at the hospitals are developing their own clinical paths. Pathways have been implemented for 49 different conditions, diseases, or procedures; ten more are under development. Teams learn from each other and in some cases, implement other service's successes. Revised sedation regimens, for example, developed for open heart surgery patients, have been implemented in all ICUs.

Is this cookbook medicine? Craver says no. "This is highly ordered and prescribed medicine taking advantage of individual patients' resources and their abilities to respond to a fast-track program. Our pathway is a guideline, not an end in itself, and won't be successful for all patients."

While admittedly not all patients are as enthusiastic about shorter stays and more personal responsibility for their recovery or are too ill to take advantage of new practices, the best testimony to clinical pathways' successes comes from patients like Richard Johnson.

"The first time, I wasn't scared," he says. "I was terrified. But my experience was totally different this time around. Even though I thought I knew what to expect this time, it was much better than I imagined."


Marlene Goldman is editor of Momentum.

 


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