1. The Use of Vascular Quality Initiative Strategies to Decrease Length of Stay After Elective Carotid Endarterectomy
Joyce Peralta, DNP, ACNP-BC, Fred A. Weaver, MD, MMM,
Sung Wan Ham, MD
University of Southern California, Los Angeles
Keck Medicine of USC

2. Disclosure
No financial or other disclosures

3. Problem Statement
Length of stay (LOS) rate >1 day and use of intravenous antihypertensive medications following elective carotid endarterectomy (CEA)
Far exceeded our region and Vascular Quality Initiative (VQI) overall since 2011.

4. Observed Length of Stay > 1 day
Background
Observed Length of Stay > 1 day Us
Everyone else

5. Use of IV Antihypertensive Medications
Background
Use of IV Antihypertensive Medications
As A Risk Factor for LOS >1 day
VQI Center Opportunity for Improvement (COPI)
USC: 45.5% vs. Region:19.3% vs. VQI overall 25.6%
Unavailability of a step-down unit
Increased ICU utilization
Contributed to LOS > 1 day
Use of IV Antihypertensive Medications
VQI COPI report identified use of IV antihypertensive medications as a risk factor for LOS > 1 day

6. Goals
Our facility aimed to decreased LOS > 1 day after elective CEA by:
Decreasing the use of IV antihypertensive medications
Implementing LOS improvement strategies
ICU utilization
And implementing other LOS improvement strategies related to ICU over utilization

7. Improvement Strategies
Blood Pressure Management
Post-operative CEA order set standardization
Change in post-operative SBP parameter goal
SBP < 140mmHg to < 160mmHg
Pre-operative hypertensive medication assessment
Four-hour recovery stay
Timely resumption of all oral blood pressure medications
All surgeons agreed to liberalize post op BP parameters

8. Improvement Strategies
ICU Utilization
Streamlined protocol for discharge direct from ICU
Early identification of mobility deficits
Protocol to wean off IV antihypertensive medications
Resident engagement
ICU nurse education/buy-in
No step down, patients who did require IV BP meds get sent to ICU. Streamlined protocol to DC patients directly from ICU which included early ID of mobility deficits, protocol to wean off IV BP meds, resident engagement and ICU nurse buy-in for discharge direct from ICU. This was a challenge since it is unusual for a patient to be discharged home from ICU

9. Methods: Key Components
Physician
Champion
Chief of Vascular Surgery
FFellow
Resident
Intern
Inpatient Nurse Practitioner
Dedicated Case Manager
JVascular Surgery Junior Attending

10. Results: LOS > 1 Day
All of us
Yay!

11. Results Fiscal Year Goal O:E is <1.0 O:E Ratio
What are the units? Is this O:E ratio for LOS?
Goal O:E is <1.0
Fiscal Year

12. Results

13. Results: Financial Impact
Per Patient
CEA

14. Challenges/Lessons Learned
Standardization of post-operative goal SBP
All surgeons
Unavailability of a step-down unit
Direct ICU discharge
Accurate medication reconciliation

15. Success Factors
Commitment to the importance of applying VQI data for institutional quality improvement
Chief of Vascular Surgery and Vascular Surgery junior attending
Resident engagement
Dedicated inpatient nurse practitioner
Dedicated case manager
Physician champion commitment sets the tone and culture for the importance of QI
Dedicated NP is paramount since residents come and go