Post on 20-Aug-2015
Loyola University Chicago
LOYOLAUNIVERSITYHEALTH SYSTEM
Improving Care of Adult Patients Undergoing Cardiac Surgery at
Loyola University Medical CenterBy:
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
Loyola University Chicago
LOYOLAUNIVERSITYHEALTH SYSTEM
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)
Loyola University Chicago
LOYOLAUNIVERSITYHEALTH SYSTEM
Identify the Problem…….
Historical trend of higher than acceptable risk adjusted complications/mortality as compared to University HealthSystem Consortium data base.
Loyola University Chicago
LOYOLAUNIVERSITYHEALTH SYSTEM
Identify the problem……..
FY 96 Q4 FY 97 Q2 FY 97 Q4 FY 98 Q2
20.0
22.5
25.0
27.5
30.0
32.5
Quarter
Pe
rce
nt
of
Pa
tie
nts
Patients in Major Surgery Risk Pool with Complications
B
Clinical
UHC Rate
Definition: This is a complex measure calculated by University HealthSystem Consortium and reported to the JCAHO in fulfillment of ORYX requirements. In general it reflects potentially preventable complications in those patients undergoing major surgical procedures. Rates are risk-adjusted with UHC methodology. Examples of complications include the following: postoperative hemorrhage, wound infection, pneumonia, myocardial infarction, stroke, hypoxic brain damage, renal failure; procedure related perforation or laceration.Data source: University HealthSystem Consortium calculation based on standard billing form (UB92) data supplied by LUMC.Analysis: Complication rates are significantly above those predicted by the risk adjustment model used by UHC from FY 96 Q4 until the present. The point labeled B indicates that reported events were significantly lower in the third quarter of FY96.. Additional analysis is required to determine the specific types of complications occurring at an unexpectedly high rate and the surgical procedures with which these complications are associated.
This material is confidential and to be used only for quality improvement purposes
FY 97 Q1 FY 97 Q3 FY 98 Q1 FY 98 Q3
Loyola University Chicago
LOYOLAUNIVERSITYHEALTH SYSTEM
LUMC CV-Surgical Team
Surgeons
NursePractitioners
CVAnesthesia
CVO.R.Staff
2-SurgicalICU-Staff
3 NEWS-TelemetryStaff
Cardiac RehabStaff
Surgical Outcomes
RespiratoryCare
Loyola University Chicago
LOYOLAUNIVERSITYHEALTH SYSTEM
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
Loyola University Chicago
LOYOLAUNIVERSITYHEALTH SYSTEM
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
Loyola University Chicago
LOYOLAUNIVERSITYHEALTH SYSTEM
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
Loyola University Chicago
LOYOLAUNIVERSITYHEALTH SYSTEM
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
Loyola University Chicago
LOYOLAUNIVERSITYHEALTH SYSTEM
Solutions – Example - Early Extubation ResultsCABG Patients on a Ventilator for 4 hours or less
16%
27%
0%
5%
10%
15%
20%
25%
30%
Pre_Implementation Implementation
Phase
Per
cen
t o
f P
atie
nt
Po
pu
lati
on
Loyola University Chicago
LOYOLAUNIVERSITYHEALTH SYSTEM
Solutions – Example - Early Extubation ResultsUHC CABG Time on a Ventilator
5.6 5.8
17.0
8.8
0.02.04.06.08.0
10.012.014.016.018.0
UHC High UHC Median UHC Low Loyola
Tim
e (H
ou
rs)
Loyola University Chicago
LOYOLAUNIVERSITYHEALTH SYSTEM
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
Loyola University Chicago
LOYOLAUNIVERSITYHEALTH SYSTEM
ResultsClinical(ORYX)
Definition: This is a complex measure calculated by University HealthSystem Consortium and reported to the JCAHO in fulfillment of ORYX requirements. In general it reflects potentially preventable complications in those patients undergoing major surgical procedures. Examples of complications include the following: postoperative hemorrhage, wound infection, pneumonia, myocardial infarction, stroke, hypoxic brain damage, renal failure; procedure related perforation or laceration.
Data source: University HealthSystem Consortium calculation based on standard billing form (UB92) data supplied by LUMC.
Analysis: Reported complication rates have decreased significantly and are similar to the UHC average. The decline is coincident with multiple interventions including a major quality improvement initiative in Cardiovascular Surgery and improvements in coding policy and practice.
This material is confidential and to be used only for quality improvement purposes
FY 96 Q1
FY 96 Q2
FY 96 Q3
FY 96 Q4
FY 97 Q1
FY 97 Q2
FY 97 Q3
FY 97 Q4
FY 98 Q1
FY 98 Q2
FY 98 Q3
FY 98 Q4
FY 99 Q1
FY 99 Q2
FY 99 Q3
FY 99 Q4
FY 00 Q1
FY 00 Q2
FY 00 Q3
FY 00 Q4
FY 01 Q1
FY 01 Q2
FY 01 Q3
FY 01 Q4
FY 02 Q1
15.0
20.0
25.0
30.0
Quarter
Per
cen
t o
f M
ajo
r S
urg
ery
Pat
ien
tsw
ith
Co
mp
licat
ion
s
Mean = 18.85
Percent of Patients in Major Surgery Risk Pool with Complications
UHC Average Rate
Mean = 27.47
Loyola University Chicago
LOYOLAUNIVERSITYHEALTH SYSTEM
Results
FY 96
Q1
FY 96
Q2
FY 96
Q3
FY 96
Q4
FY 97
Q1
FY 97
Q2
FY 97
Q3
FY 97
Q4
FY 98
Q1
FY 98
Q2
FY 98
Q3
FY 98
Q4
FY 99
Q1
FY 99
Q2
FY 99
Q3
FY 99
Q4
FY 00
Q1
FY 00
Q2
FY 00
Q3
FY 00
Q4
FY 01
Q1
FY 01
Q2
FY 01
Q3
FY 01
Q4
FY 02
Q1
FY 02
Q2
FY 02
Q3
FY 02
Q4
FY 03
Q1
0.0
2.5
5.0
7.5
10.0
12.5
Quarter
CA
BG
Mo
rtal
ity
Rat
e
Patients who die in-hospital after CABG
UHC Expected Rate
Clinical(ORYX)
Definition: Percent of patients who expire in hospital following coronary artery bypass graft surgery.
Data source: University HealthSystem Consortium calculation based on standard billing form (UB92). Expected rates are calculated by UHC based on the entire UHC clinical database.
Analysis: LUMC rates are currently at or below the rate predicted by UHC risk adjustment methodology.
This material is confidential and to be used only for quality improvement purposes
Loyola University Chicago
LOYOLAUNIVERSITYHEALTH SYSTEM
Results
Mor
talit
y R
ate
(Pe
rce
nt)
Post CABG Patient Mortality
CY98 Q
1
CY98 Q
2
CY98 Q
3
CY98 Q
4
CY99 Q
1
CY99 Q
2
CY99 Q
3
CY99 Q
4
CY00 Q
1
CY00 Q
2
CY00 Q
3
CY00 Q
4
CY01 Q
1
CY01 Q
2
CY01 Q
3
CY01 Q
4
CY02 Q
1
CY02 Q
2
CY02 Q
3
CY02 Q
4
CY03 Q
1
CY03 Q
2
CY03 Q
3
0
2
4
6
8
Mean = 3.7
Loyola ExpectedLoyola Observed
Loyola University Chicago
LOYOLAUNIVERSITYHEALTH SYSTEM
4Q 1999-3Q 2000 vs 3Q 2001-4Q 2001
1.020.98
1.06
0.84
1.07
0.15
0
0.2
0.4
0.6
0.8
1
1.2
Mean LOS O/E Mean Case Cost O/E Mortality O/E
4Q 1999 - 3Q 2000 N=383 3Q 2001 - 4Q 2001 N=161
Loyola University Chicago
LOYOLAUNIVERSITYHEALTH SYSTEM
UHC CABG 3Q-4Q 2001 Performance
0.981.06
0.84
1.04
0.15
0.59
0
0.2
0.4
0.6
0.8
1
1.2
M ean LOS O/E M ean Case Cost O/E M ortality O/E
Loyola UHC Top Quartile
Loyola University Chicago
LOYOLAUNIVERSITYHEALTH SYSTEM
CY 2001 STS Comparative Data CABG O/E Operative Mortality Ratio (N=313)
0.33
0.83 0.84
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
Loyola Region STS Overall
Loyola University Chicago
LOYOLAUNIVERSITYHEALTH SYSTEM
CY 1998 - 2001 STS CABG Risk Adjusted Operative Mortality Trends
3.00%
2.30%
1.90%
0.90%
0.00%
0.50%
1.00%
1.50%
2.00%
2.50%
3.00%
CY 1998 CY 1999 CY 2000 CY2001
Loyola University Chicago
LOYOLAUNIVERSITYHEALTH SYSTEM
CY 2001 STS Data CABG Unadjusted Mean LOS N=313
7.86.9 6.8
9.59 8.9
0
1
2
3
4
5
6
7
8
9
10
Post proc. Total
Loyola Region STS Overall
Loyola University Chicago
LOYOLAUNIVERSITYHEALTH SYSTEM
CY 2001 STS Data CABG O/E Ratio Short < 6 days & long >14 days stay N=313
0.78
1.09 1.06
0.9 0.95 0.95
0
0.2
0.4
0.6
0.8
1
1.2
SS O/E ratio LS O/E ratio
Loyola Region STS Overall
Loyola University Chicago
LOYOLAUNIVERSITYHEALTH SYSTEM
CY 2001 STS Pre-procedure Co-morbidity
26.50%
18.40%
16.10% 16%
9.20% 9.90%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
Low EF < 40% Previous Card. Surgery
Loyola Region (STS) National (STS)
Loyola University Chicago
LOYOLAUNIVERSITYHEALTH SYSTEM
CY 2001 STS Pre-procedure Co-morbidity
11.50%
7.30% 6.90%
12.50%
6.30% 5.10%
31.90%
19.10%
15.50%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
CVA Renal Failure PVD
Loyola Region (STS) National (STS)
Loyola University Chicago
LOYOLAUNIVERSITYHEALTH SYSTEM
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
Loyola University Chicago
LOYOLAUNIVERSITYHEALTH SYSTEM
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
Loyola University Chicago
LOYOLAUNIVERSITYHEALTH SYSTEM
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
Loyola University Chicago
LOYOLAUNIVERSITYHEALTH SYSTEM
Patients eligible for 1st day post-op ambulation(Out of bed walking 25-50 ft.)
• Extubated
• Swan-out
• Hemodynamically Stable
Loyola University Chicago
LOYOLAUNIVERSITYHEALTH SYSTEM
Percent of Eligible patients ambulated in ICU 1st Post-op day (Pre)
5%
28%
0% 0%
12%
4%0%
5%
0%
5%
10%
15%
20%
25%
30%
FEB MAR APRIL MAY
AMB CR AMB STAFF
Loyola University Chicago
LOYOLAUNIVERSITYHEALTH SYSTEM
Percent of Eligible patients ambulated in ICU 1st Post-op day (Post)
15%
35%
24%
31%
22%
37%
0%
5%
10%
15%
20%
25%
30%
35%
40%
JUNE JULY AUG
AMB CR AMB STAFF