Safety and Quality in the Cardiothoracic Operating Room Engy Hanna, MD Director, Cardiac Anesthesia Abington Jefferson Health April 7, 2017

Objectives Review patient safety and quality initiatives within the Cardiac Surgery Program Discuss safety challenges that are unique to minimally invasive cardiovascular surgery

Cardiac Surgery: Safety and Quality High reliability organization Efficient, safe, consistent care Achieve high quality care for each patient Create a resilient cardiac team Minimize error Continual improvement

Cardiac Surgery: Safety and Quality Team time out at start of each case Each member contributes Formal hand-off between anesthesia and perfusion before going on cardio-pulmonary bypass Formal sign-out to cardiac ICU team Anesthesiologist & RNFA  intensivist, bedside nurse, CT surgery NP

Cardiac Surgery: Safety and Quality Cardiac ICU nurses maintain a secure database to identify issues on arrival to the ICU Metabolic acidosis, uncontrolled glucose, insufficient sedation Real time feedback to the anesthesiologists and OR team Root cause analysis  process & system improvements

Cardiac Surgery: Safety and Quality Complex or unusual cases are discussed in advance with the entire team Surgery, anesthesia, perfusion, RNFAs, OR nursing, CSU Every member of the team is given the opportunity to contribute to the patient’s care Open communication and collaboration

Cardiac Surgery: Safety and Quality Protocols & standardization Bloodless Surgery Antibiotic prophylaxis Perioperative ICD/PPM management Deep hypothermic arrest for aortic surgery Emergency protocols Intraoperative echo assessment for LVADs Percutaneous RVAD insertion

CT Surgery Performance Improvement Multidisciplinary group Goal is to provide infrastructure for team members to improve our system We consider the patient’s journey Preoperative consultation  surgery  ICU  Floor  rehab and home We work to improve steps along the way Make the process smoother & safer for patients Remove unnecessary obstacles for staff

CT Surgery Performance Improvement Examples: ICU nurse identified an issue with excessive noise / conversation during hand off from OR team to ICU team Implemented a “sterile space” for sign-out from anesthesia to ICU TAVR Coordinator identified UTIs as an issue in the TAVR patient population She worked with ID to implement a process for obtaining a urine culture on patients with concerning UAs

Ensuring Safety and Quality in Minimally Invasive Cases New & complex equipment / instruments for proceduralist Technical factors can become a distraction during the case

Ensuring Safety and Quality in Minimally Invasive Cases Standard CT OR team: Surgeon, anesthesiologist, perfusionist, RNFAs, OR nursing For minimally invasive cases: Different setting (Hybrid OR or cath lab) Additional team members (Interventional cardiologists, cath lab nurses & technicians, radiology staff)

Open Cardiac Procedure: Minimally Invasive Procedure: NIBP, Pulse Oximetry, EKG, CO2 monitoring Arterial line Intubated / mechanically ventilated patient Central line CVP PA catheter PA pressures SvO2 CO / CI Cerebral Oximetry TEE

Ensuring Safety and Quality in Minimally Invasive Cases Unique challenges for the team Anesthesia team should always be prepared for emergencies or conversion to an open procedure

Ensuring Safety and Quality in Minimally Invasive Cases Abington TAVR team: Preoperative briefings Frequent (weekly) team meetings to discuss cases Limited team In addition to standard operating room time-out, we use a specific TAVR checklist Regular team retreats to assess progress & discuss future directions

Future Directions for Patient Safety in the Cardiac OR Improved design of operating rooms with focus on workflow / human factors Simulation training to improve team communication and preparation Routine debriefings after every case

Thank you