Best Practices in Cardiac Surgery
More efficient operating room process results from first year of cardiac surgery affiliation.
ADVANCE for Nurses
May 31, 2011
by Robin Hocevar
These days, hospital mergers dominate the headlines.
Throughout the country, mergers and clinical affiliations appear to be the magic bullets for facilities looking to improve quality and share the expenses associated with implementing the electronic health record and embrace new initiatives.
Last year, Winfield, IL-based Central DuPage Hospital (CDH) announced a cardiac surgery affiliation with the renowned Cleveland Clinic in Ohio. CDH staff was thrilled, if a little intimidated, by the prospect of collaborating on some of the nation's most complicated cardiac surgery cases. Cleveland Clinic sees approximately 4,000 patients yearly and frequently works with transplantation and support devices. CDH functions on a smaller scale, performing 250-300 heart surgeries annually. Still, the two facilities report a great overlap in coronary and valve surgery.
Surgeons and nurses at this community hospital in the western suburbs of Chicago expected to draw on the expertise of their counterparts at the Cleveland Clinic. In addition to observing processes at the U.S. News and World Report No. 1 ranked center for cardiac surgery, CDH staff has been consulting on a one-on-one basis with Cleveland Clinics nurse management, practice teams and doctors. Conference and seminar invitations from Cleveland Clinic are open to CDH and many have already participated.
For CDH, one pleasant outcome was affirming the commonalities in many of their processes, such as the nurse training program. Also, surprisingly, the advantages aren't necessarily one sided.
Carlotta Netomuceo, MBA, RN, HVI project manager for cardio thoracic surgery affiliate programs, has worked on affiliate programs at Cleveland Clinic since 2008. In addition to CDH, Cleveland Clinic is affiliated with Pikesville Medical Center in Pikeville, KY; Cape Fear Valley Health in Fayetteville, NC; McLeod Regional Medical Center in Florence, SC; Rochester General Health System in Rochester, NY, and Chester County Hospital in West Chester, PA.
"As a result of our clinical affiliations, our best practices have improved across the board. We learn from the affiliate program sites as well. The clinical sharing has been key for us."
OR Reorganization
A 2-day visit to Cleveland, designed as a meet-and-greet for the newly connected professionals, prompted CDH to tackle a substantial reorganization project.
After observing the OR at Cleveland Clinic, CDH cardiovascular surgeon Tim James, MD, and other members of the surgery team recommended changes to the pre-op and OR processes at their home facility.
"We've substantially reorganized how we lay out the instruments and team organization in the OR," he said. "We're talking to the best minds in the field and are working with Cleveland Clinic on protocols for renal failure and kidney injury surrounding heart catheterization. Not that we have a problem, but we're trying to improve our quality indicators in this area. This affiliation allows us to get to a state-of-the-art level."
What impressed James and others during the visit to Cleveland Clinic was the uninterrupted flow in the OR. From surgeons to patient care technicians, everyone was focused on completing the procedure without interruption, said James.
"We decreased the number of people on the [surgery] team and increased the availability of people on the team to participate," James said. "We realized we needed a greater supply chain organization and went through a lean process of our own. Everyone's movements are simplified but access is improved. We didn't do anything high tech, but it involved a lot of thought and organization."
Nursing has plans to put its own stamp on OR process improvement. Though the OR nurses are still in the exploratory phase, Janet Davis, MSN, RN, NEA-BC, has high expectations.
"We're working with the cath lab, telemetry, OR staff and other disciplines to better manage nursing care from pre-admission to discharge," the chief nurse of patient care services said. "Right now, we're focusing on the education and competency processes. The next step will be to study patient's post-op care in the ICU in more detail. There's been no chance to follow up on what happens when patients leave the OR and we're becoming familiar with those steps from the Cleveland team."
Coming Improvements
The more efficient OR is has been the most tangible improvement to date, but many more are on the horizon, said CDH cardiac surgery staff.
Initiatives including an early mobility program, further lessening time a patient spends on the operating table and reducing a patient's overall length of stay, are in the pipeline.
Early investigations into the early mobility program have been promising, said James. Though new, he classified CDH's early mobility program as very sophisticated.
Renal failure is an area in which the Cleveland Clinic consultations are proving invaluable. Ongoing discussions between staff at both locations center on medication at the time of catheterization, the volume of contrast in hydration of a patient and the timing of surgery.
With the affiliation just shy of a year old and many new initiatives not even formally launched, it's impossible to gauge the success of the alliance. In time, CDH's clinical staff is confident that they'll have the data to back up their gut feelings about the relationship's achievements.
"We have assumed some of their mechanisms for quality control," said James. "Cleveland Clinic has a more formal structure for clinically studying metrics. We're looking at our length of stay and cost structures to better track what we do on a monthly basis. Cleveland Clinic staff are all very good communicators and we're fortunate that they've made us a high priority."
Robin Hocevar is senior regional editor at ADVANCE.