Practice Management: Timely Extubation in Cardiac Surgery: A Team Sport?

In this installment of STS News, Dr. Paul Levy describes his institution’s approach to increasing value in the care of cardiac surgery patients. By incorporating a team approach to postoperative management, NEA Baptist Memorial Hospital has been able to demonstrate remarkable improvement in extubation times.
--Frank L. Fazzalari, MD, MBA, Chair, Workforce on Practice Management

Paul S. Levy, MD, MBA, Director of Surgical Services, NEA Baptist Memorial Hospital, Jonesboro, Ark.

STS News, Summer 2017 -- With recent efforts by the Centers for Medicare & Medicaid Services to bundle payments for cardiac surgical services, alternative payment models (APMs) are now front and center in health care reform. An emphasis has been placed on coordination of care and stakeholder collaboration. Payer demand for value is here to stay.

At our institution, we heard this message loud and clear. We have aggressively focused our efforts toward driving cardiac surgery production costs down. The high-cost environments of the operating room and intensive care unit were targeted.

The ability to extubate patients expeditiously following open heart surgery is dependent upon a multitude of factors. Many stakeholder groups are involved, with each having its own entrenched practice patterns. Needless to say, there are many moving parts. Organizational culture and stakeholder “tribal knowledge” can stall the most driven change agents.

In 2015, we investigated the current state of our post-cardiac surgery extubation times and were surprised to find that only 9% of patients were extubated within 8 hours of their surgery (the average extubation time was 14 hours). Additionally, 65% of our patients had a 2-day ICU length of stay (LOS). Certainly, we could do better. Identifying our barriers was fundamental to achieving our goals, which were to reduce the average extubation time to 8 hours or less, reduce ICU LOS, and maintain patient safety.

The first steps involved educating stakeholder groups—anesthesia, ICU RN, respiratory therapy, and step-down RN staff—on how our current state compared to STS National Database benchmark data and describing the potential negative clinical impact of prolonged mechanical ventilation. Our initiative’s goals were then clarified, and each stakeholder group developed plans to close performance gaps.

Our anesthesia group adopted a best practice, standardized approach to cardiac anesthesia. As a result, patients arrived at the ICU less sedated. ICU RN and respiratory therapy staff members developed a “protocol-driven” extubation process and, as a result, fewer arterial blood gas (ABG) tests were required with no reintubations. Educational in-services helped the step-down RN staff close clinical care gaps in the postoperative day #1 cardiac care pathway. Deming’s scientific method was employed to monitor the initiative’s progress and help stakeholders make appropriate adjustments.

The financial impact was a substantive decrease of at least $650/case.

In 2016 (12 months after taking these steps), 62% of our patients were extubated within 8 hours, compared to only 9% in 2015. In fact, in the last quarter of 2016, average time to extubation was 6.1 hours.

ICU LOS has similarly improved, with 78% of patients having a 1-day LOS in 2016 compared to only 35% in 2015. The collaboration between the ICU RN and respiratory therapy staffs also has resulted in improved collegiality, a reduction in the average number of ABG tests per case (3.4 in 2016 versus 7.0 in 2015), and preserved patient safety. The financial impact was a substantive decrease of at least $650/case.

As is evident by our win, teamwork with clear, unified goals is an effective strategy to cost reduction in cardiac surgery.