News & Media

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.

STS News, Summer 2017 -- STS is partnering with the European Association for Cardio-Thoracic Surgery (EACTS) on a new educational program in Latin America that is designed for all members of the cardiac surgical team. “A key goal of the Society’s new strategic plan is to foster collaboration and connection, especially among the global cardiothoracic surgery community,” explained STS Immediate Past President Joseph E. Bavaria, MD. “During a recent workforce meeting, surgeons from Latin America noted the lack of an all-inclusive cardiovascular surgery educational program held in their region of the world. STS and EACTS jumped on the opportunity to provide that education.” EACTS Past President Jose Luis Pomar, MD, PhD said that the collaboration was a natural fit. “Sharing experiences from different parts of the world will help improve our knowledge and better serve our patients,” Dr. Pomar said. “It also will help strengthen relations at a personal level; the face-to-face contact will be crucial.” The STS/EACTS Latin America Cardiovascular Surgery Conference is planned for September 21-22 at the Hilton Cartagena in Cartagena, Colombia. It will highlight the management of coronary artery disease, valvular heart disease, thoracic aortic disease, and atrial fibrillation, as well as the surgical management of heart failure. In addition to Drs. Bavaria (from Philadelphia) and Pomar (from Barcelona), Program Directors include Juan P. Umana, MD (from Bogota) and Vinod H. Thourani, MD (from Washington, DC). The faculty will be a mix of experts from North America, Europe, and Latin America. The Hilton Cartagena offers ocean views, secluded beach access, an expansive swimming pool complex, and tennis courts. The 2-day conference will begin with general sessions on management of the mitral valve before splitting into separate tracks on adult congenital, heart failure, atrial fibrillation, and the tricuspid valve. The second day starts off with dual tracks of “Stump the Professor,” followed by general sessions on the aortic valve and quality initiatives, and in the afternoon will feature tracks on coronary artery disease and the aorta and aortic arch. The program closes with another general session on the aortic root. “The program covers a wide array of topics, with special emphasis on valvular disease. We believe this is an area that holds great potential in Latin America, particularly as it pertains to valvular preservation and repair,” Dr. Umana said. “The program design highlights the importance of the Heart Team approach as a means to offer patients the best possible treatment available, regardless of geographic location.” Scientific abstracts and panel discussions will be incorporated into each session. “This course features a heavily case-based format,” said Dr. Thourani. “Our goal is for it to be very interactive.” An exciting component of the program will be invited technical videos displaying procedural expertise in these disease processes, which Dr. Umana described as “very powerful teaching tools.” The session on quality and outcomes initiatives will explore the history of the STS National Database, the challenges of implementing multicentric registries in Latin America, and how to maintain quality in a surgical program. “As quality initiatives and registries become increasingly important, a specific session dedicated to performing research and measuring quality will look at the cross-pollination of what’s been done in Europe and the United States,” Dr. Thourani said. To learn more about the conference and register, visit www.CardiovascularSurgeryConference.org. If you have questions, contact STS Education Manager Michelle Taylor or (312) 202-5864.

STS News, Summer 2017 -- Surgeons and data managers from 25 Adult Cardiac Surgery Database (ACSD) sites participated this spring in a month-long pilot aimed at developing an online reporting dashboard that would offer interactivity and more detailed analyses of data from the national report PDF than participating sites currently receive. The Society is making adjustments to the dashboard based on the pilot group’s feedback, and the dashboard is expected to be released to all ACSD participants this fall. General Thoracic Surgery Database and Congenital Heart Surgery Database participants should receive access to the dashboard next year. Once participants log in, they will see an executive summary showing 3-year overall numbers of procedures, post-procedure length of stay, and unadjusted mortality by procedure for all participating sites. A menu on the left-hand side allows users to drill down into their specific institution’s data, including star ratings, National Quality Forum measures, comorbidities, demographics, operative information, outcomes, postoperative events, and more. This draft mockup of the new dashboard homepage displays a snapshot of national data. “It’s a lot easier to navigate than trying to scroll through a PDF,” said pilot tester Gaetano Paone, MD, MHSA, Division Head of Cardiac Surgery at Henry Ford Hospital in Detroit and Chair of the STS Task Force on Quality Initiatives. “For example, if I want to look at our blood transfusion rate for coronary bypass surgery in the current report, I have to find it on, let’s say, page 127; if I then want to see the same data for aortic valves, I might have to scroll through another 70 pages before I get there. With the new dashboard, all I have to do is unclick the CABG box and click the valve box, and the same dataset pops up. That’s an enormous improvement.” More Frequent Data Updates Another advantage of the dashboard is the speed with which new data will be incorporated. Site data will be refreshed daily; analytics will be updated once per quarter. Being able to access data so quickly, rather than waiting for quarterly reports, is a big plus for Mary Barry, Database Coordinator for the ACSD at the University of Michigan, who also participated in the pilot. “I anticipate using the dashboard to more quickly query our data,” she said. “I also like being able to download reports that show the specific Record ID associated with a selected variable.” Tool for Quality Improvement The dashboard will make it even easier for participating sites to improve quality and patient outcomes at their institutions. “I generally know how our division is doing day to day, but there are some specific things I don’t know—Have we been transfusing more patients or having more patients with longer times on the ventilator? The dashboard allows me to quickly assess these variables,” Dr. Paone said. “You also can create aggregate subsets of patients with specific morbidities and see the rate of major complications and operative mortality outcomes that occurred within that group. It’s a much more granular way of assessing where your problem areas might be.” "It’s a much more granular way of assessing where your problem areas might be." Gaetano Paone, MD, MHSA Other pilot testers agreed. “We like the ability to see the benchmarks easily,” said Amy Geltz, Quality Data Manager at the University of Michigan Health System. “I think if we ever do continuous harvesting at our site, the dashboard would be even more helpful. I also could see us using this dashboard in quality improvement meetings, allowing us to quickly look at certain data points.” Barry added that the interactivity of the dashboard will help her track ongoing projects. “I anticipate that I will use it to assist in monitoring work related to a quality project, as well as checking consistency of data abstraction,” she said. More information on the dashboard will be shared in future issues of STS News and STS National Database News. If you have questions about the dashboard, contact Carole Krohn, STS National Database Manager, Adult Cardiac Surgery, at Carole Krohn or (312) 202-5847.