Loyola University Chicago LOYOLA UNIVERSITY

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



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)



Identify the Problem…….

Historical trend of higher than acceptable risk adjusted complications/mortality as compared to University HealthSystem Consortium data base.



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



LUMC CV-Surgical Team

Surgeons

NursePractitioners

CVAnesthesia

CVO.R.Staff

2-SurgicalICU-Staff

3 NEWS-TelemetryStaff

Cardiac RehabStaff

Surgical Outcomes

RespiratoryCare



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



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



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



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



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



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)



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



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.


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



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.




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



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



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



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



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



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




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




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)



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)



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



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



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



Patients eligible for 1st day post-op ambulation(Out of bed walking 25-50 ft.)

• Extubated

• Swan-out

• Hemodynamically Stable



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



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

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