Cardiovascular  Surgery

Early Extubation Best Practices, presented to the COAP Management Committee by Daniel Mumme, MD FACS, May 2017

Background:  Early extubation within COAP and STS has been defined as extubation <6 hours after cardiac surgery.   The definition of < 6 hours is somewhat arbitrary and early literature defined early extubation with an 8-hour cutoff.   Early extubation is an integral part fast-track post-operative cardiac surgery care, designed to help reduce health care resources while preserving optimal patient outcomes.  Other aspects of fast-track cardiac surgical care including lower dose, faster-acting opioid based anesthesia, specific vent weaning protocols, and direct admission to a cardiac stepdown ward (no ICU stay) will not be covered in this review.

Currently there are no society guidelines (STS, AATS) or consensus statements surrounding early extubation.   Early extubation is not a portion of the STS composite rating nor the star rating system.  Currently COAP considers early extubation a level II metric.   While early extubation does not have long-term implications such as stroke, renal failure, or mortality, we have felt that it serves as a surrogate for the coordination of post-operative care amongst the entire surgical and ICU teams.    There continues to be a wide variation of early extubation rates amongst hospitals in Washington state.  The state average for early extubation is 69% (2014—2016).

Summary of Data Behind Early Extubation:  

(See Early Extubation Literature for more detail on individual studies)

–There are no society guidelines (STS, AATS) for early extubation.

–Early extubation is safe as there is no difference of mortality or morbidity.

(Silbert, Cheng, Karaman,  van Mastright, Wong (Cochrane Review))

–Early extubation reduces ICU LOS.

(Arom, Cheng, van Mastright, Wong (Cochrane Review))

–Early extubation may be cost effective.

(Arom, van Mastright)

–Early extubation probably does not reduce overall LOS.

(Silbert, van Magistright, Wong (Cochrane Review))

–The reintubation rate is low.

(Arom, Cheng, Crawford, Silbert, Wong (Cochrane Review))

–Fast-track cardiac surgery can be safe when applied to select patients.

(van Magistright, Wong (Cochrane Review), Youssefi)

–Dexmedetomidine based sedation may reduce intubation time

(Curtis, Karaman)

— Some data suggests there is a greater morbidity and mortality when extubation extends beyond 12 hours and that there is no difference between extubation <6 hours and <12 hours. (Crawford)

Strength of Data:   The Cochrane review of 28 randomized clinical trials gave a low level of evidence to the primary outcome of mortality and the secondary outcome of morbidity.  ICU LOS and overall LOS were downgraded to low level of evidence.   Some of the initial studies were performed in the 1990s and may be outdated.

Tacoma General Hospital/Pulse Heart Institute experience with improving early extubation:

Prior to 2015, early extubation rate at Tacoma General for CABG only was 47%.  In an effort to improve our early extubation times, a CABG collaborative group was created which sought input from all potential responsible parties.  This group included cardiothoracic surgery, pulmonary, cardiac anesthesia, nurse manager, data manager, quality manager, IT/EPIC support, respiratory therapy, physician assistant, cardiac care line manager, and organizational effectiveness manager.    Input from each member of the group was sought.  Retrospective CABG only data of surgeon specific ventilator times as well as anesthesiologist and surgeon narcotic usage was obtained.  Prospective data was collected and presented to all cardiac surgeons and all members of the CABG Collaborative group on a bi-weekly basis initially to assess and correct problems as quickly as possible.  Since then the meetings have spaced out to quarterly and now bi-annually.

Various actions taken over the next few months included:

Nursing/RT efforts:

–Education of Cardiac ICU nurses of goal of early extubation.  Creating a culture of early extubation

–Marking the 6 hour and 24 hour extubation times on a whiteboard in the patient’s ICU room to alert all members of the team

–Respiratory therapy signing out at bedside

–Rewriting the post-operative EPIC order set to include less narcotic use and encourage non-narcotic alternatives

–Creating a 2 hour post-operative “huddle” to decide to proceed with early extubation

–Willingness on all members of the team to extubate patients with IABP in place

–More liberal use of pulmonary consult

–More stringent use of extubation protocol

–Citing which patients did/did not meet extubation mark at nursing sign-out of 07:00 and 19:00.

–ICU nurse to send email to surgeon and nurse manager if patient failed the 6-hour mark.

Data efforts:

–Attempt to create real-time data review to understand why patients were failing early extubation

–Weekly vent reports sent out to all cardiac surgeons, RT, nursing manager, quality manager, and cardiac ICU nurses

–Vent data reviewed at monthly Quality meeting and Coronary COE meeting

Compensation efforts:

–Early extubation as one of four metrics used for Pulse cardiac surgery quality bonus

–Early extubation also one of several metrics cited for LEM bonus of Pulse administration.

Over the past two years, early extubation at Tacoma General has improved for all open heart operations.  In 2016, the CABG only early extubation rate was 79%.   Improvement in blood product usage, another goal of the above collaborative, has also occurred.   The results have thus far been sustainable.   Attempts to make the data analysis more real-time, actionable, and accountable are felt to have contributed to the improved results.   Multi-disciplinary efforts to improve early extubation have created a culture of early extubation.

For further questions, please contact:

Jeannie Collins-Brandon, Program Director COAP; jcollinsbrndon@qualityhealth.org

Daniel Mumme, MD FACS Pulse Heart Institute; daniel.mumme@multicare.org

Reducing Post-CABG 30 Day Readmissions – Best Practices, presented to COAP Management Committee by Ryan Foresman, MD, May 2017

Background:  CABG ranked as having the highest potentially preventable readmission rate within 15 days following discharge (13.5%)

• Second highest average Medicare payment per readmission ($8,136)(MedPAC, 2007).

• $151 million:  The estimated annual cost to Medicare for potentially preventable CABG readmissions

CMS update 2017

• Penalties for <30 day readmission following CABG
• It is projected that penalties for total readmissions will increase to $528 million in 2017, $108 million more than in 2016.
• HRRP (Hospital Readmission Reduction Program) hospitals with readmission rates that exceed the national average are penalized by a reduction in payments across all of their Medicare admissions—not just those which resulted in readmissions.

Most importantly, the significant cost to the patient both from a financial and emotional perspective cannot be dismissed.  Although the cost to the patient is difficult to quantify, it remains undoubtedly significant.

Unfortunately, there is a paucity of literature addressing the issue of post-CABG 30 day readmission.

Harrison Medical Center Post-CABG readmission reduction:

In 2016, Harrison Medical Center (HMC) was able to decrease post-CABG 30 day readmissions to 3.6%.  For comparison, National Range: 12-24%, STS: 10% (2016), COAP (WA state) average: 7.9%.   Prior to 2017 HMC had post-CABG 30 day readmission rates of 16.3% in 2014 and 8.9% in 2015.  In an effort to significantly reduce our readmission rates several key steps were taken.  These steps are listed below along with how each step was addressed.

1. Identification of patients with greatest risk of readmission

According to STS  the most frequent causes of readmission are fluid overload (often presenting as pleural effusion) 23%, infection 20%, and arrhythmia (most commonly atrial fibrillation) 8%.

According to NIH / CIHR Cardiothoracic Surgical Trials Network the patients most at risk for readmission are female gender, diabetes mellitus, COPD, elevated creatinine, low hemoglobin, long duration of surgery (Ann Thorac Surg. 2014 October ; 98(4): 1274–1280.).

Once we understood which patients pose the risk, the following steps were taken; incorporating a full-time heart failure ARNP, direct surgical team involvement with optimizing patients in preoperative acute heart failure, and early establishment of true baseline weight as a goal for discharge.

1. Teaching

ICU and PCU nursing education/re-education regarding acute heart failure with focus on signs of fluid overload postoperatively.

Patients were taught the Heart Zone tool.

Beta blocker doses were not increased and ACE inhibitors were  held until patients were close to baseline weight.

1. Observation vs readmission

Discussions with ER physician director were held to utilize observation status on some “readmissions” especially those that were related to heart failure or stable rhythm changes.  This was done to allow for 24 hours of evaluation without admitting the patient.  ED physician would then notify the surgeon on call and the surgical team then rounds on the patient the next day.

1. Early post-operative follow-up (within 3 days post-discharge)

The single most important change was the implementation of having our Advance Practice Clinicians begin seeing patients in clinic on the 3rd day post-discharge.  This allowed for very early recognition of heart failure symptoms, knowledge that the patients were not correctly taking medication, and a lack of patient understanding of their recovery process.

The Literature:

1. Ann Thorac Surg. 2014 Oct; 98(4): 1274–1280

1. JAMA, 2003 Aug; 290(6): 773-780

1. J Thorac Cardiovasc Surg 1999;118:823-32

1. J Thorac Cardiovasc Surg. 2001 Aug;122(2):278-86

1. January 26, 2016 – Scientific presentation at the 52nd Annual Meeting of

The Society of Thoracic Surgeons. John P. Nabagiez, MD

1,185 patients who received visits from PAs on days 2 and 5 following hospital discharge had a significantly lower rate of readmission (10%) compared to (17%). This represents a 41% reduction in the rate of readmission within the first 30 days following cardiac surgery. It cost $23,500 to make house calls to 363 patients, which saved $977,500 in readmission costs.

This translated to $39 in healthcare savings for every $1 spent.

Interventional Cardiology 

Transradial Access for Coronary Angiography Best Practices, presented to the COAP Management Committee by Kim Koegel, MN, RN, CNML, clinical nurse manager; Sunil Rao, MD, FSCAI, technical advisor; Peter Krebs, ARRT, cath lab supervisor; Chris Anderson, ARRT, cath lab tech. June  2017  

Transradial access for coronary angiography can help a cath lab’s progress towards achieving triple aim goals.  Improved quality, reduced cost and improved patient satisfaction are seen in cath labs with a high degree of transradial access.  Quality is improved through reduced bleeding and vascular access site complications.  Cost is reduced through decreased length of stay and utilization of hospital resources.  Patients who have experienced transfemoral and transradial prefer transradial due to increased mobility and function and decreased discomfort.

There are several keys to starting a transradial program that are integral to success.   First is having a physician champion.  Just like any change process there are early adopters and late adopters when starting up a transradial program.  Having a physician champion that can speak with peers about concerns and can offer guidance and support during the training period is helpful to the overall successful adoption of a transradial program.

Recently there have been increases in observational and randomized control studies that help establish best practice for transradial programs.  The Society for Cardiovascular Angiography and Intervention (SCAI) put forth a consensus report on best practice for transradial programs.  The consensus recommendations include (a) adequate anticoagulation during transradial procedures; (b) use of low profile system catheters; and (c) patent hemostasis technique when removing the sheath (1).

Adequate anticoagulation during the procedure:
Adequate procedural anticoagulation reduces the risk of radial artery thrombosis and occlusion.   Heparin can be given intravenous or intra-arterial and is cost effective.  Bivalirudin and low molecular weight heparin may also be considered.

Use of low profile catheters:
Choosing the lowest profile catheter that will allow good imaging is another important measure to reducing the risk of radial artery occlusion/injury.  Use of 5-French or 6-French introducing sheaths that have a tapered tip and are hydrophilic have been shown to create less vascular trauma and potentially better long-term radial artery patency (2).

Patent hemostasis technique when removing the sheath:
There have been many trials and observational studies that have demonstrated statistically significant reductions in bleeding and access site complications when using the transradial approach (2).  The radial artery is easily compressed and there is collateral circulation to the hand from the ulnar artery.  SCAI recommends patent hemostasis technique using a hemostatic compression device (1).  A radial artery compression device is inflated to just past pulsatile bleeding.  After remaining inflated for two hours post procedure the air is removed from the compression device according to the manufacturer guidelines.

Other considerations when establishing a transradial access program:

Radiation exposure:  During the learning curve phase there is an increased radiation exposure to physicians.  To help mitigate this several things can be done.  Position the patient with the arm next to the torso.  Use a radiolucent arm board to help position the patient with arm to the side.  The board can be articulated at an angle to the table to allow radial artery cannulation and then moved parallel to the body to allow better positioning of the lead shielding.  For left radial access you can bring the arm across the body after radial access and support with pillows, bath blankets, or gel molds.  This allows the physician and scrub tech to stand in usual positions tableside.  Using extension tubing to increase the distance from the image intensifier to the manifold is another way to decrease radiation exposure.  Once providers have become proficient in the transradial technique radiation exposure significantly reduces.

Clearly established standards of care and team training:  Having a clearly defined transradial standard of care that the team is well versed on will reduce early confusion among team members when establishing a transradial program.  Things to consider are patient selection, appropriate positioning, establishing IV access away from the distal part of the arm being used for radial access, and spasmolytic therapy. Patient selection includes consideration of hemodynamic stability, age, prior transradial procedures, planned dialysis access in the extremity and potential need for bypass graft surgery.  Previously it was thought the ideal transradial patient was less than 70 years and had a simple coronary lesion.   Newer studies show that transradial access is feasible in older patients, as well as those with complex lesions, bypass grafts, and difficult coronary anatomy (3).

Patient positioning to reduce radiation exposure was discussed earlier.   It is helpful in the ordering template to have the provider indicate transradial or trans femoral access so the team can have the patient appropriately positioned for the procedure and to reduce waste in supplies picked for the case.  Early in the development of a transradial program it is advised to prep both radial and femoral sites to ease the transition to femoral access if the radial site is unable to be accessed.  Communicating proper IV placement to the prep and recovery team will allow ease of access to the IV line during the procedure and not impede IV infusions when the radial access hemostatic device is inflated post procedure.  Letting the ED know about proper IV site placement is important when starting radial access for STEMI.

Another standard of care consideration is the prophylactic use of spasmolytic therapy.  Calcium channel blockers (verapamil or nicardipine) and/or nitrates (nitroglycerin) are typically used right after radial artery access to reduce arterial spasm (2).  This will reduce the potential for vascular trauma during catheter manipulation.   Recent attention has been given to spasmolytic therapy at the end of the procedure before the sheath is removed (4).  Use of nitroglycerin at the end of the procedure was shown to decrease the incidence of radial artery occlusion, thus preserving the site for possible future use in the setting of bypass surgery.

Special considerations for radial access and STEMI:

Transradial access for STEMI should not be considered until the team is well accustomed to doing this with elective procedures.  SCAI recommendation is at least 100 elective PCI procedures using the transradial approach (1).  Both radial and femoral sites should be prepped and a pre-determined time limit for when to switch to femoral access if radial access is difficult to achieve are beneficial towards keeping door to balloon times down.  The cath program should monitor door to balloon time to prevent it from creeping up and allow timely correction if needed.

There is growing preference for transradial approach across the nation.  The reduced risk of complications and improved patient satisfaction are among the top reasons for this.  The COAP database has shown a steady rise in the use of transradial access, increasing from just 3.5% in 2012 to 31.7% in 2016.  Taking advantage of the lesions learned from centers that have higher transradial access for diagnostic and interventional cardiac cases can help new programs with a sound foundation to launch their own program.

Page Break

REFERENCES

1.  Rao SV, Tremmel JA, Gilchrist IC, et al.  Best practices for transradial angiography and intervention: A consensus statement from the Society for Cardiovascular Angiography and Intervention’s Transradial working group.  Catheterization and Cardiovascular Interventions 2014; 83:228-236.
2. Caputo RP, Tremmel JA, Rao S, et al.  Transradial arterial access for coronary and peripheral procedures: Executive summary by the Transradial Committee of the SCAI.  Catheterization and Cardiovascular Interventions 2011; 78:823-839.
3. Amin AP, Patterson M, House JA, et al.  Costs associated with access site and same-day discharge among Medicare beneficiaries undergoing percutaneous coronary intervention:  An evaluation of the current percutaneous coronary intervention care pathways in the United States.  JACC: Cardiovascular Interventions 2017; 10:324-351.
4. Dharma, S., Kedev, S., Patel, T., Kiemeneij, F. and Gilchrist, I. C. A novel approach to reduce radial artery occlusion after transradial catheterization: Postprocedural/prehemostasis intra-arterial nitroglycerin. Catheterization and Cardiovascular Interventions 2015; 85: 818–825.