1. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM Improving Care of Adult Patients Undergoing Cardiac Surgery at Loyola University Medical Center By: 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

2. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM 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 1 st successful Heart-lung transplant in Illinois (1986)

3. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM Identify the Problem……. Historical trend of higher than acceptable risk adjusted complications/mortality as compared to University HealthSystem Consortium data base.

4. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM Identify the problem……..

5. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM LUMC CV-Surgical Team Surgeons Nurse Practitioners CV Anesthesia CV O.R. Staff 2-Surgical ICU-Staff 3 NEWS-Telemetry Staff Cardiac Rehab Staff Surgical Outcomes Respiratory Care

6. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM 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

7. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM 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

8. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM 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

9. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM 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

10. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM Solutions – Example - Early Extubation Results CABG Patients on a Ventilator for 4 hours or less

11. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM Solutions – Example - Early Extubation Results UHC CABG Time on a Ventilator

12. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM 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

13. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM Results

14. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM Results

15. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM Results

16. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM 4Q 1999-3Q 2000 vs 3Q 2001-4Q 2001

17. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM UHC CABG 3Q-4Q 2001 Performance

18. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM CY 2001 STS Comparative Data CABG O/E Operative Mortality Ratio (N=313)

19. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM CY 1998 - 2001 STS CABG Risk Adjusted Operative Mortality Trends

20. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM CY 2001 STS Data CABG Unadjusted Mean LOS N=313

21. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM CY 2001 STS Data CABG O/E Ratio Short 14 days stay N=313

22. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM CY 2001 STS Pre-procedure Co-morbidity

23. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM CY 2001 STS Pre-procedure Co-morbidity

24. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM 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

25. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM 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

26. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM 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

27. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM Patients eligible for 1 st day post-op ambulation (Out of bed walking 25-50 ft.) Extubated Swan-out Hemodynamically Stable

28. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM Percent of Eligible patients ambulated in ICU 1 st Post-op day (Pre)

29. Loyola University Chicago LOYOLA UNIVERSITY HEALTH SYSTEM Percent of Eligible patients ambulated in ICU 1 st Post-op day (Post)